Improving the prescribing of IV Fluids
CCCF ePoster library. Gomaa A. Oct 4, 2017; 198132; 82
Dr. Abdul-Rahman Gomaa
Dr. Abdul-Rahman Gomaa
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Improving the prescribing of IV Fluids

Gomaa, Abdul-Rahman1; Wilkinson, Jonathan1

1 Northampton General Hospital, Northampton, Northamptonshire, UK

Intravenous (IV) fluids are some of the most commonly prescribed day-to-day drugs. They have their indications, benefits, side-effects and complications. Evidence suggests that such prescriptions are rarely ever done correctly despite the presence of clear guidelines [1,2]. This is thought to be due to lack of knowledge and experience, placing patients at increased risk of harm, also incurring unnecessary costs to the hospital.

To ensure that all IV fluid prescriptions are safe, appropriate and adhere to NICE guidance by August 2017.

Review and improve the prescribing process of “IV fluid prescribing” via three simultaneous approaches (figure 1). 

Teaching sessions were delivered to all junior doctors in order to improve knowledge and awareness of appropriate IV fluid prescribing and promote familiarity with the current NICE IV fluid guidelines. This included a ‘feature session’ at our local hospital Grand Round.

A point-of-care aide-memoire containing a summary of the information needed for correct prescription was designed and printed. This complimented the teaching sessions and supported good clinical practice.

Using serial Plan-Do-Study-Act (PDSA) cycles, a novel “IV fluid bundle” (figure 2) was developed, fine-tuned and trialled on five wards, (three surgical, two medical). The aim of the bundle was to ensure that patients were clinically reviewed in order to assess their volaemic status in order that appropriate IV fluids could then be selected and prescribed safely.

The impact of these interventions was assessed on the trial wards via a weekly point prevalence audit of the IV fluid bundles for the duration of the trial. Parameters looked at were: incidence of deranged U&E’s, incidence of AKI and the number of days between the latest U&E’s and the patient’s IV fluid prescription.

With only a 50% uptake we were able to significantly improve outcomes. Of all of the patients on the IV fluid bundle, 100% had a documented review of both fluid status and balance. The incidence of deranged U&E’s decreased from 48% to 35%. Incidence of AKI decreased 14% to 10%. The average number of days between the latest U&E’s and a fluid prescription decreased from 2.2 days to 1.0 day.

Prescribing IV fluids is a complex task. It is an area of clinical practice that requires significant improvement both locally and nationally.
The project included carefully structured interventions geared towards tackling the confounding issues (education, awareness and organisational systems) identified from previous audits and process mapping.

Changing prescribing habits is an extremely challenging goal for many reasons. The introduction of a change that incorporates something clear and simple has a minimal effect on compliance. The design of a simple IV fluid bundle ensured minimal interference.

Since commencing the project, we have seen an improvement in the knowledge base around IV fluid safety. We have also noticed a clear improvement in the prescription of IV fluids in our trust.

Even though only a small representative sample of wards were selected for the fluid bundle trial, feedback was highly positive and reports were that the bundle was a help, not a hindrance.

We anticipate that further improvements will be achieved once the bundle has been incorporated into the hospital’s electronic prescribing system eliminating confusion as to where fluids should be prescribed. Fluids are drugs and should be safely prescribed as such.

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