There is a lot to say, but I’ve tried to be as concise as possible. Having just met with our medical director this afternoon to discuss this, it is a red hot topic. He certainly had absolutely no opposition towards anything I was discussing with him…an engaging session, from which we are going to ensure changes are made and that importantly, they can last!
So why is this such an issue?!
We prescribe IV fluids every day, particularly in anaesthesia and ITU! The problem is that the evidence suggests that it is rarely done correctly. We get into that ‘mirror, signal, manoeuvre’ mindset with them. ‘They are harmless’, ‘we can just duplicate what the last doctor did!’
Another issue is that the prescription falls to the most junior members of the medical teams, as it is seen as rather ‘menial’. But, observing the ‘prescribers’, is certainly an eye opener! Elements such as reviewing weight, latest U&E’s, fluid balance and status were often overseen and rarely documented.
Fluids are drugs, and we cannot emphasise that enough! The concept of the 4D’s of IV fluid therapy gives clarity to this issue. The concept was conceived by Prof. Manu Malbrain and has been widely taught by him, as well as many others, since its conception in 2015.
The 4D’s resonate far more clearly than many of the archaic and out-of-date teachings on IV fluid therapy, which often lead to attrition in good prescribing habits. We all deliver thanks to Manu for his dedication to this cause over many years!
There is clear guidance out there within (NICE CG174), but the worrying thing is that there is a lack of knowledge and experience, which often breeds confusion and places patients at increased risk of harm. It may also incur unnecessary costs to Trusts throughout the UK, Europe and beyond.
So, something so harmless can actually cause devastation to many patients when it is in the wrong hands….just don’t let those hands be yours!
So what did we see going on at ‘our place’?
- We weren’t adhering to NICE guidance
- Generally, patients were prescribed:
- Too much water
- Too much sodium and chloride
- Inadequate potassium and glucose
- There were issues with patient’s prescriptions including:
- Poor management of electrolyte disturbances
- Too many prescriptions based on outdated urea and electrolytes (U&E’s)
- Mismatch between the indications for IV fluids and the actual prescription
- Assessment was poor:
- Patients’ fluid balances were not being assessed correctly, or at all
- Losses were not being accounted for
So, patients were being fluid overloaded, some were technically dehydrated and unsurprisingly, many had electrolyte disturbances. Within critical care, we were seeing increasing numbers of patients coming up to us with severe fluid overload requiring extensive removal via CVVH and some with AKI, often as a result of dehydration.
What did the doc’s know about IV fluids??
We looked at 40 junior doctors (FY1-ST6) and assessed what they knew about fluids.
What we asked:
“This is a question about normal physiology”
For a 70kg male:
- What is the total body water in litres? 42 litres (accept 40-45) (1)
- What is the intravascular volume? 5 litres (1)
“This is a question regarding the Daily Requirements of your average patient”
For a patient who is nil by mouth, what is the requirement for:
- Fluid in ml/kg/hour? 1-2 (1)
- Sodium in mmol/kg/day? 1 – 2 (1)
- Potassium in mmol/kg/day? .5 – 1 (1)
“So, do you know what is in each of the following bags of fluid?”
The results demonstrated poor knowledge, yet we were hanging bags of the stuff up on our patients every day!
What we got:
So interesting! No one had a clue about Hartmanns (a safe physiological fluid in our eyes!) Many knew about 5% dextrose though (a completely unsafe fluid in our eyes, well, certainly for maintenance outside of special circumstances!) Knowledge of (Ab)normal saline was poor and no one had a clue what was in a bag of your average colloid, (copious amounts of sodium!)
A quality improvement project was born!
We had to do something about this, so with the support of the Trust, we set about making some changes on the back of a 4 year audit cycle period. Your good old PDSA cycle! Dr Abdul Gomaa was my safety fellow at the time, and I must thank him for a massive amount of hard work in development of the bundle, and for his persistence with the work. Much of what you see here is taken from a rather comprehensive management report he wrote, after working with us on the project.
So, we wanted to ensure that IV fluid prescriptions were:
- Adhered to evidence-based NICE guidance
We went about this by implementing a broad range of interventions:
- Educational programme initiation
- Changing prescribing habits
- Raising global awareness of IV fluid safety
Before undertaking a project, its worth doing a SWOT analysis to see where you are, where you want to go and where you may end up:
The situation in 2012!
The results below are rather scary! There was a clear divide between medical and surgical directorates:
- They favoured 0.9% Saline followed by Dextrose (64.2% and 21.2% fluids prescribed)
- They tested U+Es more frequently than the surgeons (Average 0.85 days compared to 1.19 days since last checked)
- More of their patients received fluid which was inappropriate to their most recent U+E results (32.6% vs 10.3% of those with clear trends)
- Their patients received an average of 943% of their daily requirement!
- Very few of their patients received their daily potassium requirement (16%)
- Surgeons used Hartmann’s solution more than Saline (58% and 25.3% respectively)
- Their patients received 378% of their daily requirement
- Very few of their patients received their daily potassium requirement (7%)
So, most patients received adequate Na+ to meet daily requirements (92% of medical patients, 98% of surgical). Have a look below…
There are always some!
- One medical patient with low and falling Na+ (117), received three consecutive litres of dextrose with no added salts.
- Likely re-prescribing error without reference to electrolyte result!
- One medical patient with Na+ level of 154 and rising (last checked 3 days prior) received two consecutive bags of saline.
- Two medical patients were given fluids with added KCl despite high and rising K+ levels!
- A patient came up to us on ITU having received 9 litres of fluid over a rather short period..developed AKI and required filtration!
Interventions…we needed to break poor control of the process!
So now, in come the changes. It was paramount to do something that was palatable, wouldn’t lose its inertia and was repeatable for the staff involved. We are all too often strangled by protocols in medicine….and introducing something complex merely irritates people and they will bypass it for what they ‘already know’.
The Bundle was born:
You can click it to download it here
We created this poster – click on it to download – if you use it, just acknowledge us!
What effect did the bundle have??
The sample size, although not huge, demonstrated a marked improvement over the time period from the start of the investigation into this area.
How do we keep this up though!?
Intellectual stimulation plays a large role within this transformational change, since we are challenging the existing norms of prescribing IV fluids and aspiring to change it. This was done initially in closed controlled environments within lecture theatres through case-based teaching sessions. These sessions encouraged the followers to think deeply, reflect on their current habits and offer better ways of achieving the same task whilst simultaneously realising the project’s goals. Inspirational motivation was easy to initiate, but difficult to sustain, since it’s very easy for the followers to revert to old habits. I must say, I have had a lot of fun over the years teaching various cohorts of doctors, from junior to senior, nurses and allied health professionals. No one realised how much there was to this!
Get the word out there
In order to keep the punters stimulated and to go on ‘pushing the cause’, we kept the interest going. This was done via engaging with the Trust’s quality improvement team, social media team and placing computer screensavers out there for all to see. We have created ward-based “champions”, who are there to make sure everyone is aware on the shop floor.
Get some cash for more help!
The biggest and most important step now is to secure funding via a business case for an IV fluids nurse. We now have electronic prescribing in effect, so this platform is an ideal opportunity to build the bundle in. This ensures a forcing function for continuity and familiarity with the clearer bundle.
Find credible experience and passionate individuals
Finally, idealised influence is the provision of role models that are credible, respected and trusted by all stakeholders and followers. We hope this can be achieved by placing credible consultants, (who are deemed as the experts within this field), as the role models, advisors and supporters to the project. One of those happens to be me! I have the daunting title of, NGH IV fluid lead. This is a role that holds some importance to me and all of the patients, particularly as it lies within an area I am passionate about.
Meet like minded people!!
Networking within our speciality is vital. When I travel around and talk at meetings, act as part of faculty at meetings etc., I get to meet some amazing people. The International Fluid Academy meeting is one such congress where we can all get together and spread really important messages regarding this key area of critical care medicine. Prof. Manu Malbrain introduced many of us to this forum….thanks again! One of those was Dr David Lyness (@gas_craic). He runs a fabulous site called propofology.com. He uses imagery and infographics to convey messages, and teach and discuss poignant stuff. I ran the bundle past him and together, we came up with this poster!
Download yours here – just acknowledge us if you can!
It’s all about promoting the vital 4D’s and ROSE!
Prof. Marcia McDougall (@marciamcdougall) was another. She has fought for the safe IV fluid cause in her trust too. The 3 of us are going to continue our collaboration and build on it. See her fluid protocol here. Again, please acknowledge her if you use it.
We also podcasted this out at iFAD 2017. You can listen below:
Listen to what we had to say!
Dave and I talked yesterday about all of this and the importance of safe IV fluid prescription. Click the picture to take you to the podcast.
- Future collaboration with Propofology.com
- Podcasts and video casts regarding IV fluid safety
- Building business cases for IV fluid nurses
- Initiation of early teaching with the Universities so the medical students are ‘jump started’ into IV fluid safety
- Development of a fluid early warning scoring system
- Development of an IV fluid App.
WATCH THIS SPACE!!