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Development and validation of an audit tool for fluid management in non-critically ill adults in the emergency department

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Abstract

Especially in the emergency department (ED), it is critical to identify weaknesses in prescribing behavior of IV maintenance fluids to ensure a qualitative 24-h fluid management plan. The primary aim of this study was to develop an audit instrument to assess the pitfalls in documentation and prescribing habits of IV fluid therapy for non-critically ill patients admitted to the ED. In this study, an expert panel initially designed the tool. During different phases, adaptations were made to optimize inter-rater agreement (Fleiss’ kappa, κ) and validity was determined based on the application of the tool on randomly selected electronic ED patient records. Second, the IV fluid prescription’s appropriateness was addressed. The final tool consists of three parts: fluid status assessment, evaluation of maintenance fluid needs and, if present, a limited appropriateness check of the fluid prescription. A manual enhanced inter-rater agreement. κ-values achieved the target value (0.40) after three adaptation rounds, except for the category of ‘clinical observations’ in the assessment part (κ = 0.531, 95% CI 0.528–0.534), which was acceptable. A check of the IV fluid’s indication and volume was only possible with an additional expert evaluation to conclude on prescription appropriateness. Criterion related validity of the final version was high (93.4%). To conclude, the instrument is considered reliable and can be used in clinical practice to evaluate ED fluid management. Thorough documentation is essential to evaluate the appropriateness of the IV fluid prescription, to improve information transfer on IV fluid therapy to the ward and to facilitate retrospective chart review of ED prescribing behavior.

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Acknowledgements

The authors thank all colleagues who participated as raters or as part of an expert team during the development and validation of this audit tool. We thank the hospital’s Pharmacy and Therapeutics Committee, especially Prof. Dr. Alain Dupont and Prof. Dr. Manu Malbrain for their contribution to the implementation of a fluid stewardship program in UZ Brussel. This initiative is important for daily fluid management and has encouraged the researchers to develop this tool.

Funding

None declared.

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Authors and Affiliations

  1. Emergency Department, Universitair Ziekenhuis Brussel, Brussels, Belgium

    Sabien Vleeschouwers, Simon Scheyltjens, Maarten Vandendriessche & Ives Hubloue

  2. Pharmacy Department, Universitair Ziekenhuis Brussel, Brussels, Belgium

    Stephanie C. M. Wuyts

  3. Research Group Clinical Pharmacology and Clinical Pharmacy, Faculty of Medicine and Pharmacy, Centre for Pharmaceutical Research, Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels, Belgium

    Stephanie C. M. Wuyts & Pieter Cornu

  4. Department of Medical Informatics, Universitair Ziekenhuis Brussel, Brussels, Belgium

    Pieter Cornu

  5. Research Group Emergency and Disaster Medicine, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium

    Ives Hubloue

Authors
  1. Sabien Vleeschouwers
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  2. Stephanie C. M. Wuyts
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  3. Simon Scheyltjens
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  4. Maarten Vandendriessche
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  5. Pieter Cornu
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  6. Ives Hubloue
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Contributions

VS and WS contributed equally to this paper: study concept, study design, data collection, data analysis and interpretation, writing and revision. SS: study design, data collection, analysis and interpretation, VM: data collection, CP: writing and revision, HI: contributed to the study concept, the study design and revision. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Stephanie C. M. Wuyts.

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The authors declare that they have no conflict of interest.

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The authors obtained ethical approval from the Ethical Committee of UZ Brussel (B.U.N. 1432020000235).

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A waiver of consent was acquired from the Ethics Committee.

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Vleeschouwers, S., Wuyts, S.C.M., Scheyltjens, S. et al. Development and validation of an audit tool for fluid management in non-critically ill adults in the emergency department. Intern Emerg Med 18, 241–248 (2023). https://doi.org/10.1007/s11739-022-03103-9

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  • DOI: https://doi.org/10.1007/s11739-022-03103-9

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