Interdisciplinary knowledge gaps on intravenous fluid management in adult patients: Survey among physicians and nurses of a university hospital

Intravenous fluid therapy: an audit and discussion of improvements required for prescribers and administrators

BACKGROUND

Foundation doctors and nurses are the clinicians most closely involved in fluid assessment, intravenous (IV) fluid prescription and administration. However, both groups report challenges regarding IV fluids. At a large NHS trust in England, adherence to the National Institute for Health and Care Excellence (NICE) guideline CG174, regarding IV fluids, was largely unknown.

AIMS

To assess the baseline adherence, within the hospitals, to CG174 and identify areas for improvement.

METHODS

A set of 12 audit standards were developed and used to collect data across 29 clinical areas between September 2022 and May 2023, with 255 patients receiving IV fluids at any time during their inpatient stay included.

FINDINGS

For two standards target adherence of 95% was achieved, with an adherence less than 50% in most. Areas of particularly poor adherence included assessing and meeting fluid and electrolyte requirements, patient reassessment and developing IV fluid management plans.

CONCLUSION

Trust baseline adherence to NICE CG174 requires improvement, particularly regarding patient assessment and reassessment, and meeting electrolyte requirements.

Multidisciplinary expert panel report on fluid stewardship: perspectives and practice

Although effective and appropriate fluid management is a critical aspect of quality care during hospitalization, the widespread adoption of consistent policies that ensure adequate fluid stewardship has been slow and heterogenous. Despite evidence-based guidelines on fluid management being available, clinical opinions continue to diverge on important aspects of care in this setting, and the consistency of guideline implementation is far from ideal. A multidisciplinary panel of leading practitioners and experts convened to discuss best practices for ongoing staff education, intravenous fluid therapy, new training technologies, and strategies to track the success of institutional fluid stewardship efforts. Fluid leads should be identified in every hospital to ensure consistency in fluid administration and monitoring. In this article, strategies to communicate the importance of effective fluid stewardship for the purposes of education, training, institutional support, and improvement of patient outcomes are reviewed and recommendations are summarized.

Development and validation of an audit tool for fluid management in non-critically ill adults in the emergency department

Especially in the emergency department (ED), it is critical to identify weaknesses in prescribing behavior of IV maintenance fluids to ensure a qualitative 24-h fluid management plan. The primary aim of this study was to develop an audit instrument to assess the pitfalls in documentation and prescribing habits of IV fluid therapy for non-critically ill patients admitted to the ED. In this study, an expert panel initially designed the tool. During different phases, adaptations were made to optimize inter-rater agreement (Fleiss' kappa, κ) and validity was determined based on the application of the tool on randomly selected electronic ED patient records. Second, the IV fluid prescription's appropriateness was addressed. The final tool consists of three parts: fluid status assessment, evaluation of maintenance fluid needs and, if present, a limited appropriateness check of the fluid prescription. A manual enhanced inter-rater agreement. κ-values achieved the target value (0.40) after three adaptation rounds, except for the category of 'clinical observations' in the assessment part (κ = 0.531, 95% CI 0.528-0.534), which was acceptable. A check of the IV fluid's indication and volume was only possible with an additional expert evaluation to conclude on prescription appropriateness. Criterion related validity of the final version was high (93.4%). To conclude, the instrument is considered reliable and can be used in clinical practice to evaluate ED fluid management. Thorough documentation is essential to evaluate the appropriateness of the IV fluid prescription, to improve information transfer on IV fluid therapy to the ward and to facilitate retrospective chart review of ED prescribing behavior.