Fluid Guidelines: Who needs them? Dr. Marcia McDougall Fluid Lead - - PowerPoint PPT Presentation
Fluid Guidelines: Who needs them? Dr. Marcia McDougall Fluid Lead NHS Fife Disclosure I have received honoraria from Baxter for educational talks about fluid guideline development (FORTE education meetings). Acknowledgements Professor
I have received honoraria from Baxter for educational talks about fluid guideline development (FORTE education meetings).
Professor Dileep Lobo, Professor Robert Hahn
Is there a problem? What should we be doing? Guidance around fluid management Action in Fife Demonstrating impact
Is there a problem?
Elderly patients are dying as a result of
(New) doctors have inadequate knowledge
Fluid prescription must be given the same
NICE draft Quality Indicators March 2014
Usually done by juniors with little support Regarded as a task of low importance Pile of fluid charts to ‘fill in’ Poor knowledge of fluid content/requirements Juniors felt teaching on fluids is poor Confidence in prescribing was poor
Powell, Drummond 2011 Unpublished survey, Edinburgh
(1493-1541)
Varadhan & Lobo, Manual for Fast-track Recovery in Colorectal Surgery 2011
2 x 5%glucose to 1 x 0.9% saline Quickly becomes saline saline saline Potassium generally not prescribed Saline for resuscitation/replacement in A&E and medicine Balanced crystalloids in use in anaesthetics/critical care Do we use balanced crystalloids correctly?
c
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients GIFTASUP 2007 (Revised 2011)
Jeremy Powell-Tuck (chair)1, Peter Gosling2, Dileep N Lobo1,3 Simon P Allison1, Gordon L Carlson3,4, Marcus Gore3, Andrew J Lewington5, Rupert M Pearse6, Monty G Mythen6 On behalf of1BAPEN Medical - a core group of BAPEN,2the Association for Clinical Biochemistry,3the Association of Surgeons of Great Britain and Ireland,4the Society of Academic and Research Surgery,5the Renal Association and6the Intensive Care Society.
Consensus Statement on Acute Kidney Injury November 2012 RCPE website All hospitals must have fluid prescribing guidelines Recommend balanced salt solutions for replacement and
resuscitation
Fluids are important and require careful prescribing Changes in fluids
Standardise maintenance fluid: should be mostly water
e.g. 0.18%NaCl/4%Glucose +/- KCl for ADULTS
Dose maintenance according to weight Use balanced solutions for replacement/resuscitation Some evidence building against 0.9% NaCl (acidosis,
renal vasoconstriction)
Reassessment is important
80 kg man needs:
2400 ml H2O 80 mmol Na+ 80 mmol K+ 80 mmol Cl-
40kg man needs:
1200 ml H2O 40 mmol Na+ 40 mmol K+ 40 mmol Cl-
have been trained and assessed for knowledge and competence in fluid management.
for fluids given and reviewed by a senior clinician including prescription, assessment and monitoring.
as critical incidents and learning is applied.
There is a long way to go in the UK!
Fife Strategy 2010-15
Mean daily post-
fluid intake: 3021 ml* Standard deviation: 1256 ml
2 4 6 8 10 12 14 16 Too little Recommended (+/- 500ml) Too much
Number of patient days
2 4 6 8 10 12 14 Number of patient days Na (mmol/day) 2/3 get excess Na 1 patient >800mmol D. Hall SHDU 2010
5 10 15 20 25 Number of Patient Days K (mmol/day) Excess losses not replaced D. Hall SHDU 2010
May-Oct 2014 13% deaths had a contribution from poor
fluid management
Poor fluid balance chart completion Frail elderly coming to harm from too much/too little fluid Senior input lacking to fluid therapy More monitoring needed Beware fluid restriction – often get <500ml/day
Adult guidelines only Maintenance, replacement, resuscitation Hyponatraemic <132, use PL 148 for maintenance. Hyponatraemia Guideline on intranet Give Potassium routinely in maintenance unless rising or high Diabetes: HHS and DKA protocols unchanged On IV insulin: use 0.18%NaCl/4% Glucose +KCl for
maintenance by weight
Manchester, Stirling, Aberdeen, Glasgow, Sheffield (some of these as part of Baxter educational programme)
Prescription Administration Assessment
Meghan Bateson supported by R&D grant Education of nurses Liaison with nursing and medical management, dieticians Introduction and monitoring of combined fluid
prescription/fluid balance charts: QI methods
Posters: fluid volumes, criteria for fluid balance chart,
guidelines, fasting
Supporting junior doctors OPAH report – high level management engagement
Current completion unreliable Ward culture: fluid balance low priority Documentation varied between wards Goal setting where appropriate Triggering escalation when appropriate Prescription and Fluid balance together
Baseline audits prior to chart use Testing of charts on wards Education: ANPs, pharmacists nurses, doctors:
Changing fluid stocks in wards Posters Consultant mandatory training Leadership support
10 20 30 40 50 60 70
ml/kg/24 hours Total Fluid Intake (ml/kg/24hrs) Implementation
1000 2000 3000 4000 5000 6000 7000 8000 9000 Jan-09 Apr-09 Jul-09 Oct-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11 Apr-11 Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Litres Month
Fluid use NHS Fife
SODIUM CHLORIDE 0.9% INFUSION Viaflo
SODIUM LACTATE COMPOUND INFUSION (Hartmans)
Plasmalyte
SODIUM CHL 0.18%/ GLU 4% Guidelines Start of fluid work Charts PL change
Very busy month
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 May-14 Jul-14 L/OBD Month
Litres/OBD
Start of fluid work Guidelines Charts
Very busy month
=cost saving of £82000/year on fluids cf 2008 Quality improvement saving not quantifiable
In progress:
Monitoring of biochemistry across hospital Difficult to look at patient outcomes LOS a possibility for surgical patients
Incident reporting for fluid problems Culture change around fluids has occurred
20 40 60 80 100 120 140 160
2008 2011 2013
SHDU MHDU ICU Ortho
5 10 15 20 25 30 35 40 2008 2011 2013 ICU MHDU SHDU
Sodium: a minor drop in mean Na 137-136 mmol/l across
hospital
Mean Potassium stable or increased 4.2-4.3 mmol/l Calcium slightly lower (Plasmalyte) Mg higher or same Renal function improving in some wards So far no reports of dangerous iatrogenic hyponatraemia Awaiting figures for 2014-15 after charts introduced
100% Referred to the guidelines when in Fife 80% Guidelines have improved my ability to prescribe
fluids safely
70% I have changed how I prescribe fluids 55% Fluid management is part of ward rounds with
seniors
‘The guidelines and structure of the chart are extremely
helpful and provide a clear and concise framework’.
‘The fluid charts make me think about fluid in much more
detail and I take more care when prescribing it now’
Second fluid nurse now appointed from savings Nurse education a priority Learnpro modules in development Teaching video for FYs and students Continued junior doctor education (induction and in
tutorials/bedside teaching)
App Paper