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NATIONAL INSTITUTE FOR HEALTH AND CARE
EXCELLENCE
Health and social care directorate
Quality standards and indicators
Briefing paper
Quality standard topic: Intravenous fluid therapy in adults in hospital
Output: Prioritised quality improvement areas for development.
Date of Quality Standards Advisory Committee meeting: 27 January 2014
Contents
1 Introduction .......................................................................................................... 2
2 Overview .............................................................................................................. 2
3 Summary of suggestions ..................................................................................... 6
4 Suggested improvement areas ............................................................................ 7
Appendix 1: Additional information ........................................................................... 21
Appendix 2: Key priorities for implementation (CG174)............................................ 28
Appendix 3: Suggestions from stakeholder engagement exercise ........................... 32
1 Introduction
This briefing paper presents a structured overview of potential quality improvement areas for IV fluid therapy in adults in hospital. It provides the Committee with a basis for discussing and prioritising quality improvement areas for development into draft quality statements and measures for public consultation.
1.1 Structure
This briefing paper includes a brief description of the topic, a summary of each of the suggested quality improvement areas and supporting information.
If relevant, recommendations selected from the key development source below are included to help the Committee in considering potential statements and measures.
1.2 Development source
The key development source referenced in this briefing paper is:
Intravenous fluid therapy in adults in hospital. NICE clinical guideline 174 (2013).
2 Overview
2.1 Focus of quality standard
This quality standard will cover the assessment and management of adults’
intravenous fluid needs in hospital. Intravenous fluid therapy is the provision of fluid
and/or electrolytes directly into the vein. This quality standard will not cover the use
of blood or blood products.
2.2 Definition
Intravenous (IV) fluid therapy is a way of replacing fluids in the body by giving them
straight into the bloodstream (intravenous means 'into a vein', and is often called a
drip). IV fluid contains water, electrolytes (called salts) and glucose (a type of sugar).
It is given to stop people becoming dehydrated and to make sure they have the right
amount of fluid, salts and sugars in their blood that they need for normal health.
Many adult hospital inpatients need intravenous (IV) fluid therapy to prevent or
correct problems with their fluid and/or electrolyte status. This may be because they
cannot meet their normal needs through oral or enteral routes (for example, they
therefore wide variation in clinical practice. Many reasons underlie the ongoing
debate, but most revolve around difficulties in interpretation of both trials evidence
and clinical experience, including the following:
Many accepted practices of IV fluid prescribing were developed for historical reasons rather than through clinical trials. Trials cannot easily be included in meta-analyses because they examine varied outcome measures in heterogeneous groups, comparing not only different types of fluid with different electrolyte content, but also different volumes and rates of administration and, in some cases, the additional use of inotropes or vasopressors. Most trials have been undertaken in operating theatres and critical care units rather than admission units or general and elderly care settings. Trials claiming to examine best early therapy for resuscitation have actually evaluated therapy choices made after initial resuscitation with patients already in critical care or operating theatres. Many trials inferring best therapy for resuscitation after acute fluid loss have actually examined situations of hypovolaemia induced by anaesthesia.
See appendix 1 for the associated algorithms from NICE clinical guideline 174. See appendix 2 for key priorities for implementation from NICE clinical guideline 174.
2.3 National Outcome Frameworks
Tables 1–2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.
Table 1 NHS Outcomes Framework 2014/ Domain Overarching indicators and improvement areas 1 Preventing people from dying prematurely
Overarching indicator 1a Potential Years of Life Lost (PYLL) from causes amenable to healthcare* i Adults 4 Ensuring that people have a positive experience of care
Overarching indicators 4b Patient experience of hospital care Improvement areas Improving hospital’s responsiveness to personal needs 4.2 Responsiveness to in-patient’s personal needs 5 Treating and caring for people in a safe environment and protecting them from avoidable harm
Overarching indicators 5a Patient safety incidents reported 5b Safety incidents involving severe harm or death 5c Hospital deaths attributable to problems in care Improvement areas Reducing the incidence of avoidable harm 5.4 Incidence of medication errors causing serious harm Alignment across the health and social care system
- Indicator shared with Public Health Outcomes Framework (PHOF)
Table 2 Public health outcomes framework for England, 2013– 2016 Domain Objectives and indicators 4 Healthcare public health and preventing premature mortality
Objective Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities Indicators 4.3 Mortality rate from causes considered preventable* Alignment across the health and social care system
- Indicator shared with NHS Outcomes Framework (NHSOF)
4 Suggested improvement areas
4.1 Prescribing of IV fluids
4.1.1 Summary of suggestions
Algorithms for IV fluid therapy
Stakeholders highlighted that prescribing of IV fluids should be as part of a clear management plan and follow the 3 algorithms: resuscitation, replacement or redistribution. They highlighted that prescribers may be unfamiliar with fluid and electrolyte requirements for different clinical situations, leading to inappropriate fluid prescribing. Stakeholders commented that staff should know what regime of treatment they are delivering and deliver it in accordance with the recommended algorithm. Stakeholders commented that standardised fluid prescription algorithms will lead to less variation in practice and would specifically aid junior doctors in consistency of fluid prescribing.
Prescribing after initial assessment
Stakeholders highlighted that the quality of initial assessment prior to prescribing is in need of improvement. They acknowledged that the accuracy of the initial prescription is vital to prevent exacerbation of existing complications and occurrence of future complications. They commented that initial assessment of the fluid and electrolyte needs of patients should be standardised.
4.1.2 Selected recommendations from development source
Table 4 below highlights recommendations that have been provisionally selected from the development source(s) that may support potential statement development. These are presented in full after table 4 to help inform the Committee’s discussion.
Table 4 Specific areas for quality improvement Suggested quality improvement area
Suggested source guidance recommendations Algorithms for IV fluid therapy Principles and protocols for intravenous fluid therapy NICE CG174 Recommendation 1.1.3 (KPI) NICE CG174 Recommendation 1.1.4 (KPI) (Algorithms for IV fluid therapy 1-4) Prescribing after initial assessment Initial assessment NICE CG174 Recommendation 1.2. NICE CG174 Recommendation 1.2.2 (KPI)
Algorithms for IV fluid therapy
Principles and protocols for intravenous fluid therapy
NICE CG174 – Recommendation 1.1.3 (key priority for implementation)
When prescribing IV fluids, remember the 5 Rs: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment.
NICE CG174 – Recommendation 1.1.4 (key priority for implementation)
Offer IV fluid therapy as part of a protocol (see Algorithms for IV fluid therapy) [appendix 1 of this briefing paper]:
Assess patients' fluid and electrolyte needs following Algorithm 1: Assessment.
If patients need IV fluids for fluid resuscitation, follow Algorithm 2: Fluid resuscitation.
If patients need IV fluids for routine maintenance, follow Algorithm 3: Routine maintenance.
If patients need IV fluids to address existing deficits or excesses, ongoing abnormal losses or abnormal fluid distribution, follow Algorithm 4: Replacement and redistribution.
Prescribing after initial assessment
Initial assessment
NICE CG174 – Recommendation 1.2.
Assess whether the patient is hypovolaemic. Indicators that a patient may need urgent fluid resuscitation include:
systolic blood pressure is less than 100 mmHg
heart rate is more than 90 beats per minute
capillary refill time is more than 2 seconds or peripheries are cold to touch
respiratory rate is more than 20 breaths per minute
National Early Warning Score (NEWS) is 5 or more
passive leg raising suggests fluid responsiveness
were still areas of poor performance and the overall IV fluid guideline bundle of care compliance rate was only 22.9%.
4.2 Reassessment and monitoring of IV fluids
4.2.1 Summary of suggestions
Stakeholders highlighted that improved monitoring of fluid requirements was required and prescribing should take into account several key indicators of clinical assessment. They reported that prescribers often do not undertake a clinical assessment including key clinical indicators, and prescribing is often done by junior doctors who have the least experience.
Stakeholders reported that patients receiving fluids need regular monitoring including initial daily assessments of clinical indicators and that this is currently not done consistently.
Stakeholders highlighted that effective and accurate recording and monitoring of fluid requirements ensures prescriptions can be adapted to meet the patient’s individual needs. They noted that electronic patient records specifically would assist in improving this practice.
4.2.2 Selected recommendations from development source
Table 5 below highlights recommendations that have been provisionally selected from the development source(s) that may support potential statement development. These are presented in full after table 5 to help inform the Committee’s discussion.
Table 5 Specific areas for quality improvement
Suggested quality improvement area
Selected source guidance recommendations Reassessment and monitoring of IV fluids
Reassessment NICE CG174 Recommendation 1.2. NICE CG174 Recommendation 1.2. (KPI)
Reassessment
NICE CG174 Recommendation 1.2.
If patients are receiving IV fluids for resuscitation, reassess the patient using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure), monitor their respiratory rate, pulse, blood pressure and perfusion continuously, and measure their venous lactate levels and/or arterial pH and base excess according to guidance on advanced life support (Resuscitation Council [UK], 2011).
4.3 IV fluid management plan
4.3.1 Summary of suggestions
Stakeholders suggested that fluid balance charts should be completed accurately and contemporaneously to increase their usefulness. This should be done at regular intervals over a 24 hour period to enable corrections to fluid prescribing before an imbalance occurs.
These plans should be reviewed by experts in IV fluid management initially. Stakeholders stated that if plans are formalised and reviewed then prescriptions can be adjusted following changing patient needs. They also suggested that an IV fluid management plan could be combined with an early warning system to aid consistency of completion and allow earlier recognition of complications.
Stakeholders acknowledged that IV fluid management plans should be communicated clearly between healthcare professionals in order to ensure that assessment and monitoring is followed through and reviewed regularly.
4.3.2 Selected recommendations from development source
Table 6 below highlights recommendations that have been provisionally selected from the development source(s) that may support potential statement development. These are presented in full after table 6 to help inform the Committee’s discussion.
Table 6 Specific areas for quality improvement
Suggested quality improvement area
Selected source guidance recommendations IV fluid management plan Principles and protocols for IV fluid therapy NICE CG174 Recommendation 1.1.6 (KPI)
Principles and protocols for IV fluid therapy
NICE CG174 Recommendation 1.1.6 (key priority for implementation)
Patients should have an IV fluid management plan, which should include details of:
the fluid and electrolyte prescription over the next 24 hours
the assessment and monitoring plan.
Initially, the IV fluid management plan should be reviewed by an expert daily. IV fluid management plans for patients on longer-term IV fluid therapy whose condition is stable may be reviewed less frequently.
4.3.3 Current UK practice
In 2011, The National Confidential Enquiry into Preoperative Deaths (NCEPOD)^3 reported that fluid management was a common problem. A review of 30 day mortality highlighted that 20.5% of patients were considered to have had inadequate pre-operative fluid management compared with 4.7% mortality in those with adequate pre-operative fluid therapy. This report reinforces previous evidence outlining the beneficial effects on outcome of optimisation of fluid status prior to surgery.
(^3) NCEPOD report (2011) ‘Knowing the risk, A review of peri-operative care of surgical patients’
Training and education
NICE CG174 Recommendation 1.6.1 (key priority for implementation)
Hospitals should establish systems to ensure that all healthcare professionals involved in prescribing and delivering IV fluid therapy are trained on the principles covered in this guideline, and are then formally assessed and reassessed 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 (the 5 Rs: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment) 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 CG174 Recommendation 1.6.
Healthcare professionals should receive training and education about, and be competent in, recognising, assessing and preventing consequences of mismanaged IV fluid therapy, including: pulmonary oedema peripheral oedema volume depletion and shock.
4.4.3 Current UK practice
No published reports relating to current practice were highlighted by stakeholders for this quality improvement area.
4.5 IV fluids lead
4.5.1 Summary of suggestions
Stakeholders suggested that all hospitals should have an IV fluids lead. This lead should be responsible for training, clinical governance, audit and review of IV fluid prescribing and patient outcomes. They acknowledged that an IV fluids lead will enable standards to be raised, educational programmes to be mandatory and drive the uptake of the NICE clinical guideline. They stated that the IV fluids lead should be a responsible individual, who is accountable to the Trust Board as this will be most likely to ensure implementation of standards and continuous improvement of IV fluid therapy. A stakeholder noted that regular auditing will identify and highlight issues at board level, enabling corrective action plans to be put in place. Local auditing can then be used to benchmark clinical practice and this in turn could be developed into a national registry.
4.5.2 Selected recommendations from development source
Table 9 below highlights recommendations that have been provisionally selected from the development source(s) that may support potential statement development. These are presented in full after table 9 to help inform the Committee’s discussion.
Table 9 Specific areas for quality improvement
Suggested quality improvement area
Selected source guidance recommendations IV fluids lead Training and education NICE CG174 Recommendation 1.6. (KPI)
Training and education
NICE CG174 Recommendation 1.6.3 (key priority for implementation)
Hospitals should have an IV fluids lead, responsible for training, clinical governance, audit and review of IV fluid prescribing and patient outcomes.
4.5.3 Current UK practice
No published reports relating to current practice were highlighted by stakeholders for this quality improvement area.
4.7 Incident reporting
4.7.1 Summary of suggestions
Stakeholders stated that IV fluid related complications should be routinely reported. They highlighted that the incidence of IV fluid related complications is unknown due to lack of reporting. Increased scrutiny and the associated learning from clinical incidents could further drive improvements in practice, reduce the morbidity and mortality, which will bring improvements for patients and reduced costs for the NHS generally.
Stakeholders suggested that routine auditing of incidents for IV fluid therapy could ensure issues are highlighted at board level and enable benchmarking of clinical practice. They also suggested that routine registries could be used to drive up standards.
Stakeholders highlighted that appropriate reporting of fluid-therapy related complications should enable organisations to reflect on the care provided to patients and to optimise their care pathways and ensure staff training and competency. They acknowledged that there is considerable variation in the type of adverse events which are currently reported, how these are investigated, how trends are identified and organisation responses. They stated that development of standards in this area should help to reduce patient harm.
Stakeholders also highlighted that although IV fluids status is that of a prescription only medication they are often not treated in clinical practice as a drug, a consequence of which is a low level of adverse event reporting and lack of understanding of safety considerations associated with IV fluid therapy.
4.7.2 Selected recommendations from development source
Table 10 below highlights recommendations that have been provisionally selected from the development source(s) that may support potential statement development. These are presented in full after table 10 to help inform the Committee’s discussion.
Table 10 Specific areas for quality improvement Suggested quality improvement area
Selected source guidance recommendations Incident reporting Reassessment NICE CG174 Recommendation 1.2. (KPI)
Reassessment
NICE CG174 Recommendation 1.2.6 (key priority for implementation)
Clear incidents of fluid mismanagement (for example, unnecessarily prolonged dehydration or inadvertent fluid overload due to IV fluid therapy) should be reported through standard critical incident reporting to encourage improved training and practice (see appendix 1 of this briefing paper on Consequences of fluid mismanagement to be reported as critical incidents).
4.7.3 Current UK practice
The National Reporting and Learning System (NRLS) managed by NHS England reported over 700 IV medication incidents between 2012 and 2013.
