The Royal Liverpool IV Fluid Team

To assess knowledge and clinical practice of staff across the hospital wards on prescribing of IV fluids in a large acute teaching hospital and to analyse these findings and present them to our colleagues and the medical director at the Grand Rounds.

To educate and raise awareness of IV fluid prescribing and best practice to medical staff with respect to NICE guidance on IV fluid therapy.

To educate and raise awareness of IV fluid prescribing and administration to nursing staff and relevant allied healthcare professionals.

To educate staff about the NICE guidelines and trust IV fluid policy which summarises the NICE Guidance on IV fluid therapy. Our aim was to roll out the IV fluid prescribing poster/ chart across all wards and to educate staff on using this to supplement IV fluid prescribing.

To train nurses doctors and medical students across many grades and departments on IV fluid therapy.

 To then continue the work and perform audit following the teaching events to see whether the NICE guidelines were being met and whether patients were having a 24 hour IV fluid management plan, in line with recommendation 1.1.6 in NICE CG174 which advises that patients should have an IV fluid management plan, which should include details of:

• the fluid and electrolyte prescription over the next 24 hours
• the assessment and monitoring plan

The recommendation also advises that initially, the IV fluid management plan should be reviewed by an expert daily. IV fluid management plans for patients on longer-term IV fluid therapy whose condition is stable may be reviewed less frequently. 

IV fluid prescribing has long been an area in need of improvement. The Research shows up to ¼ of all IV fluids are incorrectly prescribed or maladministration in hospital, a seriously alarming statistic considering this puts a large number of patients at significant risk of iatrogenic harm (source: NICE CG174).

Since the CG174 guidelines release in 2013 and subsequent trust guideline publication, there were still unacceptable levels of poor IV fluid prescribing. Generally speaking, patients were receiving too much sodium-containing fluids without other electrolyte replacement, and at times getting either too little or too much fluid. The link with morbidity and mortality is an alarming one. The iatrogenic harm is avoidable and improving practice on IV fluid therapy prescribing and administration was felt to be a patient safety priority within the trust. The Royal Liverpool Hospital is a busy inner-city acute teaching hospital with approximately 750 beds.

A tertiary centre for several specialities such as haematology, renal medicine and transplantation, hepato-pancreaticobiliary, vascular and ophthalmic surgery and a variety of others. Initially our IV fluid trust policy was updated following the introduction of the new NICE guidelines. The clinical biochemistry department were aware that IV fluid prescribing could be improved. Additionally, they were aware that NICE guidelines were not being followed and that staff training and understanding was a potential cause.

Having dealt with patients with hypokalaemia, hyper/hyponatraemia, it was sometimes incorrect IV fluid prescribing that had caused or compounded some of these issues. The IV fluid chart was developed to simplify the fluid prescribing and to be used as a sport of reference for ward staff. The IV fluid chart was developed with the illustrations department and distributed to all wards.

In 2015 we formed a team consisting of several foundation doctors, a pharmacist and a specialist nurse. Led by Dr Mishra, Consultant Clinical Biochemist, we aimed to change culture and attitude towards IV fluid whilst educating staff on the NICE guidelines on IV fluid therapy. The IV fluid policy and flowchart was printed and placed on all wards on ward round trolleys or in clean utilities, on the trust emergency medicine handbook app, intranet and emails.

Many teaching sessions and lectures were given to doctors, nurses and students on IV fluids and on the IV fluid policy. We then marked National Pathology Week by being on the trust screensaver, national pathology week website, a biochemistry department stall in the foyer and with more teaching sessions. We designed a two-page survey on IV fluids and went across 30 wards including the A&E department and over 150 members of clinical staff completed the survey. A “drop-in” stall was set up in the education centre where we spoke with more staff and students. We distributed our trust flow chart and gave information to staff and asked more of them to complete our survey.

Whilst we asked staff to complete the survey, we also gave ad-hoc teaching on IV fluids and went over the answers to the questions afterwards to go over the gaps in their knowledge. The results from the survey were inputting into excel and analysed. The results were then presented to the trust’s Medical Director’s Grand Round in November 2015. From this we identified the gaps in staff knowledge and continued to focus on certain areas. There were no real problems faced although a shift in culture in any organisation is difficult. However having guidelines as a reference and a workforce keen to improve meant this hasn’t been too difficult. There were no costs incurred and this was all done voluntarily in our own time or through study leave. No services have been discontinued. 

 In 2016 we decided to formulate an audit tool based on the NICE guidance on IV fluid therapy audit tool. We are now going to audit every ward in the hospital over the next few months following all the training we have been doing. Our plan would be to redesign the IV fluid charts and incorporate the fluid balance charts in one chart so that a “24-hour IV fluid plan” is commonplace across the trust, to be signed off by a senior doctor and t have this incorporated as part of the regular ward round. 

Our initial survey of over 150 staff identified that there was a general poor knowledge of IV fluid prescribing and administration. This was with doctors as well as nurses and many were unaware of the risks of excess sodium and of failing to replace potassium. There was also a poor understanding of the principles of IV fluid prescribing, “The Five Rs”:

• Reassessment
• Routine maintenance
• Resuscitation fluid
• Replacement of abnormal losses
• Redistribution

Not all staff could identify correctly signs of fluid overload or hypovolaemia and some staff didn’t know the difference between the theory of replacement/maintenance/resuscitation fluids. The teaching events and drop in stall during National Pathology Week and future teaching events have all increased awareness and confidence with IV fluid prescribing. The trust has invested in stocks of “Dextro-saline”, a less sodium rich fluid.

There has been noticeable increase in attitude regarding IV fluids and more consultant input regarding these. We feel patient safety is increased with these changes and are currently in the process of an audit for this with regards to a 24 hour IV fluid management plan which will look at whether this was part of the ward round.

This shift in culture has also introduced an awareness amongst senior clinicians to be involved with IV fluids and they are more attentive to them on a ward round.

A team led approach supported by the NICE guidance and supportive seniors within the trust has been helpful and led to positive change within the organisation. Involving a variety of clinical staff and hosting several interactive events and informal teaching helped get our message across.