The New NICE Quality Standard for Intravenous Fluid Therapy in

adults in hospitals

Marlies Ostermann Consultant in Critical Care & Nephrology

• The New Quality Standard

• Implementation of the quality statements in practice

• Monitoring and demonstrating competence

• IV fluid management plan

• Implications for community IV services

Content

Background

Reasons for iv fluid therapy

To resuscitate circulation and ensure organ perfusion

To correct hypovolaemia

To maintain euvolaemia when patients are “nil by mouth”

To replace ongoing losses and oral intake is inadequate

To replace essential electrolytes

To provide nutrition

For drug administration

Critical Care Medicine 2012;40(6)

Background: Amount of fluid

Fluid overload risk of multi-system dysfunction

Prowle J et al. Nat Rev Nephrol 2010;6

Cerebral oedema

Pulmonary

oedema

Renal oedema

Tissue

oedema

Gut oedema

Hepatic

congestion

Myocardial

oedema

Background: Risks of fluid overload

Na+

mmol/L Cl-

mmol/L K+

mmol/L Ca2+

mmol/L HCO3- mmol/L pH Osmol

mosmol/L

Plasma 140 100 4 2.4 24 7.4 280

0.9% NaCl 154 154 - - - 5 308

Hartmann’s Solution (CSL)

131 111 5 2 29 as lactate

5.0-7.0 278

Plasma Lyte 140 98 5 - 27 as acetate

4 – 6.5 294

NaHCO3 1.2% 150 - - - 150 8.17 300

Dextrose 5% (50g/L)

- - - - - 3.5–5.5 278

8.4% NaHCO3 1000 0 0 0 1000 14 2000

Gelofusine 154 120 - - - 7.1–7.7 290

Background: Types of fluids

9g NaCl =

36 bags of crisps

or 1 bag of saline

Background: Types of fluids

Background: Fluid charts

• often inaccurate

• uncertain which patients need a

catheter

• what does OTT plus wet++ equal?

Problems with solutions: drowning in the brine of an inadequate knowledge base Telephone questionnaire to determine fluid prescribing practices and knowledge among 200 surgical preregistration house officers (PRHOs) and senior house officers working in 25 UK hospitals. RESULTS • PRHOs were responsible for prescribing in 89% of instances. • 56% stated that fluid charts were checked on morning ward rounds. • <50% knew the Na content of 0.9% NaCl or the daily Na requirement. CONCLUSIONS Inadequate knowledge and suboptimal prescribing of fluid is common.

Background

Lobo DN et al. Clin Nutr. 2001;20(2):125-30

NICE guideline

28 recommendations Aims: Guidance on iv fluid therapy for general hospital practice to reduce morbidity and mortality associated with fluid therapy and to improve patient outcomes Exclusion of patient groups with more

specialised fluid prescribing needs.

Acute kidney injury

NICE pathway and information for the public

Anne-Louise Clayton

Guidance from the National Institute for Health and Care Excellence

August 2013

NICE AKI guideline

1. Hospitals have an IV fluids lead who has overall responsibility for training, clinical governance, audit and review of IV fluid prescribing, and patient outcomes.

2. Adults receiving IV fluid therapy in hospital are cared for by healthcare

professionals competent in assessing patients' fluid and electrolyte needs, prescribing and administering IV fluids, and monitoring patient response.

3. Adults receiving IV fluid therapy in hospital have an IV fluid management plan,

determined by and reviewed by an expert, which includes the fluid and electrolyte prescription over the next 24 hours and arrangements for assessing patients and monitoring their plan.

4. For adults who receive IV fluid therapy in hospital, clear incidents of fluid mismanagement are reported as critical incidents.

NICE Quality Standards: Fluid therapy

NICE AKI guideline

1. Hospitals have an IV fluids lead who has overall responsibility for training, clinical governance, audit and review of IV fluid prescribing, and patient outcomes.

NICE Quality Standards

Rationale

• To promote best practice

• To ensure that healthcare professionals are trained in prescribing and

administering IV fluid

• To review learning from 'near miss' and critical incident reporting

• To ensure continuity of care in relation to fluid management

NICE AKI guideline

1. Hospitals have an IV fluids lead who has overall responsibility for training, clinical governance, audit and review of IV fluid prescribing, and patient outcomes.

NICE Quality Standards

Role of IV fluids Lead

• overall responsibility for the quality of care relating to IV fluid therapy

• should be somebody in a senior position

• may delegate specific functions through normal governance structure

• not expected to be the person who delivers the training, clinical

governance, audit and review of IV fluid prescribing

NICE AKI guideline

2. Adults receiving IV fluid therapy in hospital are cared for by healthcare professionals competent in assessing patients' fluid and electrolyte needs, prescribing and administering IV fluids, and monitoring patient response.

NICE Quality Standards

Background: 1. At the end of medical training, new doctors feel unprepared for fluid prescribing. (Coombes et al. 2008)

2. Interns feel unprepared in iv fluid management on commencement of clinical roles. (Kelly et al, 2011)

3. Retrospective review of 250 fluid charts showed large discrepancy in quality. (Chung et al, 2002)

NICE AKI guideline NICE Quality Standards

Competency Need to establish systems to ensure that all healthcare professionals involved in prescribing and delivering IV fluid therapy are trained and formally assessed and re-assessed at regular intervals to demonstrate competence in: • understanding the physiology of fluid and electrolyte balance in patients with normal physiology and during illness • assessing patients' fluid and electrolyte needs • assessing the risks, benefits and harms of IV fluids • prescribing and administering IV fluids • monitoring the patient response • evaluating and documenting changes and • taking appropriate action as required

NICE AKI guideline NICE Quality Standards

Competency Need for training and formal assessment at undergraduate level during early medical training during nursing training during specialist training (as directed by specialty)

Examples from other areas:

Benefits of protocol led care (ie. sepsis bundles)

Simulation training to improve knowledge and allow competency assessment

NICE e-learning tools

NICE AKI guideline NICE Quality Standards

Competency needs to be tailored to the professional role

Responsible authorities for delivery and competency review: Deans of Medical Schools Training Programme Committees GMC Nursing Council

NICE AKI guideline

3. Adults receiving IV fluid therapy in hospital have an IV fluid management plan, determined by and reviewed by an expert, which includes the fluid and electrolyte prescription over the next 24hrs and arrangements for assessing patients and monitoring their plan.

NICE Quality Standards

IV fluid management plan fluid and electrolyte prescription over the next 24-hour period including type, rate and volume of fluid Assessment evaluation of response to IV fluid therapy specific checks for adverse effects of IV fluid therapy Monitoring of the plan monitoring and review within appropriate timescales initially, daily review by an expert in stable patients on longer-term IV fluid therapy, less frequent reviews

NICE AKI guideline

4. For adults who receive IV fluid therapy in hospital, clear incidents of fluid mismanagement are reported as critical incidents.

NICE Quality Standards

• not all adverse consequences of IV fluid therapy are due to fluid mismanagement • clinically significant problems caused by IV fluid mismanagement should be reported as critical incidents, even when well-managed Adverse events: hypovolaemia pulmonary oedema hyponatraemia (Na <130mmol/L) hypernatraemia (Na ≥155mmol/L) peripheral oedema

NICE Quality care standards

• central to supporting the Government's vision for a health and social care system focused on delivering the best possible outcomes for people who use services • consider the complete care pathway • set out aspirational but achievable care and are not targets

• should be integrated when planning services, as part of a general duty to secure continuous improvement in quality

NICE Quality care standards

Implementation: • will be challenging • at present limited to hospital based care

• will require change of “traditional dogmas”

• will only be effective through multidisciplinary approach

• likely to cost money (at least in beginning)