Improving the Safety and Efficiency of Intravenous Fluid Prescribing for Adults

E. Tenison, K. Leonard, A. Cumpstey, S. de Courcy, A. Foster, H. Mackinnon, K. Nelson-Smith, S. Walter, H. Yilmaz, E. Greig, M. Walburn Wednesday 12 th June 2013 NACT/UKFPO Foundation Programme Sharing Event

Fluid Prescribing

• Morbidity + mortality • 9% of prescription errors (GMC EQUIP) “Fluid management…should be accorded the same status as drug prescription” (NCEPOD)

Our Experience

• Undergraduate teaching • “Learn as you go along” • Life as an F1

Initial research

Weight 56% never check Fluid status only 12% always check U+Es only 28% always check 11% indicated not indicated 89% 2) On call survey 55% could safely have been prescribed by day team 22% - could have been stopped prior to OOH request ’

EXCESS Na+

83%

INSUFFICIENT K+ 85%

Developing the Aim

Driver Diagram

Effectiveness Effectiveness Patient centeredness Safety Timeliness and Efficiency

Developing a Fluid Prescribing Tool

BATCH NUMBER removed

Current Progress

• Changing culture • Education • Widespread hospital involvement • Trialing fluid chart • Feedback • Further PDSA cycles

• • • • • Indication Clinical assessment box Continue/stop/review U+Es Guidance on the back

Feedback

We often waste time bleeping the doctor because the bag has finished when they didn't want more fluids anyway!

• Clarify ‘clinical assessment’ box • More space to write fluid/additive • Space for 2 nd countersign nurse to It doesn’t need to be perfect because it is a huge improvement on what we have at the moment

The next steps…

• Measure the impact of intervention • Teaching • Future plans – Fluid balance chart – IV fluid teaching programme for FY1s – – Paediatrics Other trusts?

THANK YOU ANY QUESTIONS?

• • • • • •

References

The Health Foundation: Quality improvement made simple- what every board should know about healthcare quality improvement Dorman et al. EQUIP study. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. Powell-Tuck, J et al. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients . GIFTASUP. March 2011.

Thong Lim et al. Intravenous fluid prescribing practices by foundation year one doctors – a questionnaire study. R Soc Med Sh Rep 2012;3:64.

Extremes of Age: the 1999 National Confidential Enquiry into Peripoperative Deaths Intravenous fluid therapy in adults in hospital. NICE guidance: draft for consultation. May 2013.