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Abstract
Introduction Intravenous fluids are one of the most commonly prescribed drugs in the hospital setting and yet the practice continues to fall short of National Institute for Health and Care Excellence (NICE) guidelines, with significant gaps in staff knowledge exposing patients to heightened morbidity and mortality.
Aim Following the 2013 publishing of updated NICE guidelines on intravenous fluid prescribing, an intravenous fluid team was formed within the Royal Liverpool University Hospital (RLUH). Their role has been (and continues to be) to overhaul the culture of suboptimal intravenous fluid prescribing within the hospital and, ultimately, to improve patient outcomes. A framework to engender this change has been developed and is offered as an example to other Trusts within which improvement of guideline-compliant intravenous fluid prescribing remains stagnant.
Method There have been three principal stages of the project to this point which are best demonstrated in a chronological manner. The period of 2010–2014 allowed for assessment of the issue of intravenous fluid prescribing and analysis of its causes through serial audits and a staff-wide survey. From 2015, there has been implementation of several measures (educative, managerial, administrative and technological) within the hospital to foster reproducible and positive change with regards to intravenous fluid prescribing. Finally, between 2016 and 2017, three cycles of a rolling audit based on NICE guidelines have been completed to allow measurement of improvement in intravenous fluid prescribing practice.
Conclusion Results have demonstrated a significant improvement in the appropriateness of the intravenous maintenance and replacement fluids prescribed in the hospital since the March 2016 audit. Moreover, a 29-fold increase has been observed in the use of 4% dextrose/0.18% sodium chloride as maintenance fluid (gold standard as per NICE guidelines) since the staff-wide survey of 2015. Despite progress however, adherence to NICE guidelines remains below the recommended 100% and therefore further work remains to be done.
- audit and feedback
- clinical practice guidelines
- continuous quality improvement
- medical education
- quality improvement methodologies
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Footnotes
Contributors JF: author and foundation doctor, Helen Campbell, Nageshwaran Vaitehi, Alex Trevaskis, Daniel Gibney, Sid Srinivas, Jenika Patel, Jennifer Chalmers, Louise Zammit, Ashley Holt, Sarah Beresford, Simon West, Rosie Conroy. David Corness member of RLUH audit team, VM: consultant chemical pathologist and director. All listed names were involved in data collection. DC was responsible for collation and initial analysis of data. HC and VM supervised study design and interpretation. VM oversaw and was involved directly in data collection from the audits, progress to date on the recommendations from those audits, data analysis and data interpretation. VM is also responsible for revisions of the manuscript. JF also carried out data analysis, interpretation and wrote the manuscript, responding to revisions from VM.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.