The New NICE Quality Standard
for Intravenous Fluid Therapy in
adults in hospitals
Marlies Ostermann
Consultant in Critical Care & Nephrology
Content
•
The New Quality Standard
• Implementation of the quality statements in practice
• Monitoring and demonstrating competence
• IV fluid management plan
• Implications for community IV services
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
Background: Amount of fluid
Critical Care Medicine 2012;40(6)
Background: Risks of fluid overload
Cerebral oedema
Myocardial
oedema
Pulmonary
oedema
Fluid overload
Hepatic
congestion
Gut oedema
Renal oedema
risk of multi-system
dysfunction
Tissue
oedema
Prowle J et al. Nat Rev Nephrol 2010;6
Background: Types of fluids
Na+
Cl-
K+
Ca2+
mmol/L
mmol/L
mmol/L
mmol/L
Plasma
140
100
4
0.9% NaCl
154
154
Hartmann’s
Solution (CSL)
131
Plasma Lyte
HCO3mmol/L
pH
mosmol/L
2.4
24
7.4
280
-
-
-
5
308
111
5
2
29
5.0-7.0
278
140
98
5
-
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
as lactate
27
as acetate
Osmol
Background: Types of fluids
9g NaCl =
36 bags of crisps
or 1 bag of saline
Background: Fluid charts
• often inaccurate
• uncertain which patients need a
catheter
• what does OTT plus wet++ equal?
Background
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.
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.
NICEStandards:
AKI guideline
NICE Quality
Fluid therapy
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
Guidance
from the National Institute for
professionals
Acute
kidneycompetent
injury in assessing patients' fluid and electrolyte needs,
Health and
Care
prescribing and administering
IV fluids,
andExcellence
monitoring patient response.
NICE pathway and information for the public
August
2013
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
Anne-Louise
Clayton
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
AKI guideline
NICE
Quality
Standards
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.
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
NICE
Quality
Standards
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.
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
NICE
Quality
Standards
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.
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
NICE
Quality
Standards
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.
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
NICE
Quality
Standards
4. For adults who receive IV fluid therapy in hospital, clear
incidents of fluid mismanagement are reported as critical incidents.
• 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)