Out of hours intravenous fluid therapy: a prompt to guide prescribing

Abstract

Recent NICE guidance has highlighted the importance of appropriate and safe intravenous fluid use. We aimed to improve the quality of out of hours fluid prescription in a Bristol hospital by ensuring that indications and cautions for fluid therapy were clearly documented at the time of initiation.Time-pressured on-call doctors need quick access to information regarding patients' care. A documented “fluid plan” allows doctors to undertake a more informed assessment of the patient's fluid balance, leading to safer prescriptions.Our ideal was for 100% of out of hours intravenous fluid prescriptions to be appropriate. Our process measures included the proportion of patients on intravenous fluids who had a documented fluid plan in the medical notes or on the prescription chart on Friday, prior to the weekend on call period. This was defined as mention of indications and/or cautions to fluid therapy.The introduction of a sticker to prompt fluid plan documentation did marginally improve use of fluid plans. It was notable that 96% of these were followed where plans were documented (n=23). Initiation of IV fluid with an accompanying plan is likely to make subsequent fluid prescriptions safer.Rapid turnover of staff and stationary proved significant barriers to consistent implementation of the sticker. Despite these challenges we demonstrated a “proof of concept”, suggesting system modification to include fluid plans is safe and effective.

Learning to prescribe intravenous fluids: A scoping review

“…There have also been educational quality improvement projects targeting completion of fluid balance charts and prescriptions, particularly in out-of-hours settings, where junior doctors were poorly supervised [ 71 – 75 ]. The transferability of these findings was limited by being very context-specific, influenced by local variations in practice, and lacking long-term follow-up.…”

Impact of resuscitation fluid bag size availability on volume of fluid administration in the intensive care unit

“…For example, vegetarian meal options at the top of a restaurant menu make more people, including non‐vegetarians, to choose this option . Nudging has also been reported to appear in medicine, for example, by increasing cognitive effort in decisions on antibiotic treatment and by increasing awareness on the importance of fluid administration by interventions (ie, making it an active decision) increases adherence to guidelines …”

Redesigned intravenous fluid order form with more perceived safety and accuracy for after-hours doctors​

“…During the trial period, medical and nursing staff (n=84) were approached to complete surveys, and all participated with their informed consent. The qualitative surveys with ‘yes/no’ responses from medical and nursing staff (n=84) assessed the following: whether the revised IVF order form was easy to use, whether the new sections of the revised form were useful and if having the indication helped doctors chart IVF more safely 6. Compliance with filling out the new sections of the revised IVF order form was also audited over the 2-week trial period.…”