Introduction to Fluid Stewardship

Abstract

Intravenous (IV) fluids are commonly prescribed drugs in healthcare. However, inappropriate fluid administration is associated with higher morbidity and mortality. Fluid stewardship is defined as a series of coordinated interventions for judicious IV fluid administration, with a primary goal of limiting the deleterious effects of inappropriate fluid prescription and fluid overload or accumulation and optimizing the clinical outcomes. The success of Stewardships in healthcare can achieve success by strategy and policy development, designing overarching systems, encouraging collaboration and ensuring robust governance and accountability processes. The components of fluid stewardship are optimum fluid prescription (5Ps of the fluid prescription), comprehensive fluid guidelines, continuous staff education and an audit or quality improvement framework. The optimum fluid prescription includes the 6 D’s (definitions, diagnosis, drug, dose, duration, de-escalation and documentation at discharge) of IV fluid administration.

FormalPara IFA Commentary

Intravenous (IV) fluid are the most commonly prescribed drugs in healthcare and needs stewardship. Fluid stewardship is an appropriate use of IV fluids, optimizing clinical outcomes. It requires an in-depth understanding of pharmacokinetics and pharmacodynamics, indications and contraindications (4 D’s—drug, dosing, duration and de-escalation), and adverse effects of various IV fluids. It also requires a review of the IV fluid prescription for appropriateness using the 5 P’s (prescriber, prescription, pharmacy, preparation and patient). Fluid stewardship should be part of healthcare quality and needs overhauling in the systems to ensure efficiency and effectiveness. To produce a change in the system (implementation of fluid stewardship), one needs to collaborate and engage stakeholders, formulate a plan and policy collectively, training, leadership alignment and robust governance with accountability.

FormalPara Learning Objectives

After reading this chapter, you will:

• 1. Learn the processes of stewardship in healthcare under a quality improvement framework.

• 2. What is fluid stewardship? How can we implement fluid stewardship in the hospital or intensive care unit?

• 3. The principles (the 5P’s) of fluid prescription,

• 4. The 7 D’s (definitions, diagnosis, drug, dose, duration, de-escalation and documentation at discharge) of fluid therapy.

• 5. How to audit the fluid prescription using hospital- or ICU-based fluid guidelines?

FormalPara Case Vignette

42-year male with hypertension has undergone emergency laparotomy for perforation peritonitis. The patient was kept nil-per-oral status and prescribed intravenous (IV) 5% dextrose 0.9% normal saline (5% DNS) at 150 ml/h by the surgery trainee. On day 4, the patient’s serum sodium was 153 mmol/L, potassium 3.1 mmol/L and chloride 123 mmol/L, serum creatinine 142 μmol/L. His arterial blood gas showed metabolic acidosis with an anion gap of 9. He developed anasarca and acute kidney injury.

Questions

• Q1. Was the prescription for IV fluid, correct? Why did the patient develop non-anion gap acidosis or hyperchloremic acidosis?

• Q2. How to initiate fluid stewardship in my hospital/ICU?

Introduction

The primary goal of fluid stewardship is to optimize clinical outcomes, while minimizing unintended consequences of intravenous fluid (IV) administration. This requires an in-depth understanding of the indications, contra-indications, toxicity, adverse events, fluid dynamics, and kinetics of IV fluids. Put simply, the physician needs to understand fluid physiology (see Chaps 2 and 3). The appropriate use of IV fluids is essential to patient safety and deserves careful oversight and guidance. Given the association between fluid (mis)use and the deleterious effects on patients’ morbidity and mortality, the frequency of inappropriate fluid prescription could play a role as a surrogate marker for the avoidable impact on iatrogenic fluid overload, and the subsequent end-organ dysfunction and failure [1].

A secondary goal of fluid stewardship is to reduce healthcare costs, without adversely impacting the quality of care. In patients with septic shock, the administration of fluids for resuscitation during initial hemodynamic stabilization remains a major therapeutic challenge, because we are faced with many open questions regarding the type, dose, rate, and timing of fluid administration. In addition, fluids are used for maintenance of intravascular volume, replacement of losses and to cover any unmet daily caloric needs. In this document, we provide definitions of different terms pertaining to fluid therapy in hospitalized patients, the sickest of whom are those with septic shock. We discuss different fluid management strategies, including early adequate goal-directed fluid management, late conservative fluid management, and late goal-directed fluid removal. In addition, we expand on the concept of the “four D’s” of fluid therapy (namely drug, dosing, duration and de-escalation) into the 7 D’s adding “definitions”, “diagnosis” up front and “documentation at discharge” at the very end [2]. In treating patients with shock (of any kind), one should consider the phases of fluid therapy—resuscitation, optimization, stabilization and evacuation. Chap. 28 will discuss A Logical Prescription of Intravenous Fluids

Definitions

Appropriate Fluid Prescription

The process of IV fluid therapy is divided into several stages, based on an audit framework developed by NICE.

• 1. The physician must assess the patient’s IV fluid needs and decide on the right treatment (indication). Only the three major indications need to be examined thoroughly for the purpose of a clinical audit: resuscitation, maintenance and replacement or redistribution.

• 2. Every IV fluid prescription has to be detailed in order to ensure safe administration, with a fluid management plan to aid continuity of care.

• 3. The information in the hospital’s fluid guidelines should be focussed upon to develop quality standards.

• 4. These standards represent the necessary elements for a complete and qualitative check of appropriateness.

If all standards are met, the IV fluid therapy will be deemed as appropriate for that patient. A key factor in appropriate empiric fluid therapy, is the consideration of patient risk factors (fluid balance, fluid overload, capillary leak, source control, acid-base status, comorbidity, electrolyte status, kidney function and organ function).

The 5 P’s of Fluid Prescription

• Prescriber: makes a clinical decision regarding fluid management

• Prescription: is written, accounting for drug, dose and duration

• Pharmacist: checks the prescription for inconsistencies

• Preparation: prescribed fluid is prepared with any necessary additions (e.g. electrolytes)

• Patient: fluid is administered to the patient; the process, response and follow-up management are handled by fluid stewards

Fluid Management in the ICU as a Quality Improvement Project

IV fluids are some of the most commonly prescribed day-to-day therapies in modern healthcare. Like any drug, they have their indications, contra-indications, benefits, risks, toxicity, adverse side effects and complications. Often, the task of fluid prescribing is delegated to the most junior members of the healthcare team. Evidence suggests that even when clear guidelines are available, fluid prescriptions can be inappropriate or incorrect [3,4,5].

Given the association between fluid (mis)use with patient morbidity and mortality, the frequency of inappropriate fluid prescription could be used as a surrogate marker for the quality of care delivered.

The combination of effective fluid management (led with multi-disciplinary involvement), comprehensive fluid guidelines, continuous staff education and an allied quality improvement programme, may limit the deleterious effects of inappropriate fluid prescription and fluid overload [6, 7].

Quality Improvement in Healthcare

In healthcare systems worldwide, patients are exposed to risks of avoidable harm and unwarranted variations in practice and hence outcomes.

In 1999, the Institute of Medicine (IOM) in Washington, DC, USA, released To Err Is Human: Building a Safer Health System [8], a report that brought much public attention to the crisis of patient safety in the United States. In 2001, the IOM issued a second report, Crossing the Quality Chasm: A New Health System for the twenty-first century [9], introducing the STEEEP acronym, which outlines six overarching “Aims for Improvement” for healthcare:

• Safe: Avoid injuries to patients from the care that is intended to help them.

• Timely: Reduce waiting for both patients and carers

• Effective: Match care to science; avoid overuse of ineffective care and underuse of effective care

• Efficient: Reduce waste

• Equitable: Close racial and ethnic gaps in health status

• Patient-Centred: Prioritize the individual and respect choice

Quality improvement (QI) is a systematic, formal approach, to analyzing practice, performance and efforts to improve performance, beginning with a clear and agreed aim [10]. Many organizations use the six IOM aims above to help them develop their individualized aims. These should be time-specific and measurable; the specific population of patients that will be affected should also be defined.

There are several existing QI models which include:

• Model for Improvement (Plan-Do-Study-Act [PDSA] cycles (www.ihi.org) (Fig. 27.1): The Institute for Healthcare Improvement’s Model for Improvement combines two popular QI models: Total Quality Management (TQM) and Rapid-Cycle Improvement (RCI).

• Six Sigma (asq.org): Six Sigma is a method of improvement that strives to decrease variation and defects in practice.

• Lean (www.ihi.org) is an approach that drives out waste and improves efficiency in work processes so that all work adds value.

Fig. 27.1

Model for qualitty improvement using Plan-Do-Study-Act (PDSA) cycle (adapted from [8])

QI can also involve specific interventions intended to improve processes and systems, ranging from checklists and “care bundles” of interventions (a set of evidence-based practices applied consistently) to invasive procedures and clinical care pathways.

Regardless of the specifics, all QI models share common values and themes [11]:

• Establish a culture of quality in the team that is aligned with the organization’s values, processes and procedures.

• Determine and prioritize potential areas for improvement, including identification of the potential barriers to change.

• Collect and analyze data. Data collection and analysis lie at the heart of quality improvement. Improvements can only be made if the current situation is known and understood.

• Communicate results. QI efforts require the involvement and support of the entire team. Transparent and regular lines of communication should be encouraged. The team’s efforts and hard work should be acknowledged.

• Commit to ongoing evaluation. Quality improvement is an ongoing process. A high-functioning practice will continually strive to improve performance, revisit the effectiveness of interventions, and regularly seek feedback from patients and staff.

• Share and celebrate successes. Share lessons learned with others to support wide-scale, rapid improvement, that benefits all patients and healthcare.

Despite the theoretical benefits provided by the various QI models, there are no randomized controlled trials demonstrating the value of QI processes in improving outcomes [12]; equally, no single QI model has been demonstrated to be superior to others [13]. Hence an in-depth understanding and proper implementation of the chosen technique, as well as a commitment to the cause, is probably more important than a specific QI model.

Stewardship (or Champions in Healthcare)

How to Mandate Change?

Change in healthcare is a time- and resource-consuming process. Stewards (or champions), in healthcare systems, can increase the likelihood of success through:

• Strategy and policy development

• Designing overarching systems

• Encouraging collaboration

• Ensuring robust governance and accountability processes

Strategy and Policy Development

Strategy formulation means setting a clear vision for quality, specifying activities that would lead to achieving that goal, and assigning responsibilities to execute those activities. It provides an overarching framework for other roles. The goal should be ‘SMART’—specific, measurable, achievable, relevant and timely. Specific and clearly defined goals are more likely to be achieved.

Once the goals have been determined, the various workstreams required to support the goal can be identified, and a strategy developed. Formal designation and implementation of policies to tackle the various pathways are important. These provide a clear, transparent, robust framework for operational issues and outline the necessary monitoring and governance requirements.

Such policies may require the development of tools such as checklists and protocols to support colleagues in day-to-day tasks. Recommendations in clinical practice guidelines are often lengthy, complex, and easy to forget. Tools such as checklists, flowsheets, protocols and reminders simplify the adoption of guidelines into a step-by-step approach. For example, a well-designed prescription chart with cognitive aids, can promote adherence to prescribing guidelines.

Designing Overarching Systems

A high-quality health system depends on the availability of staff, equipment, infrastructure and supplies in the right location. Also, smooth coordination of care as the patient moves through different stages of illness and encounters different parts of the health system is paramount. A system to ensure best practices are applied consistently and organizational cultures prioritizing quality of care, including patient safety and patient experience, are also essential.

With such a complex set of requirements, it is necessary to view each project across all of the teams and processes involved. Mapping out the various pathways can be helpful, as they may not be apparent initially. For example, in changing a policy of drug administration, the clinician and nursing teams are not the only parties involved—pharmacists, the procurement department and even the personnel responsible for restocking the drugs also need to be considered.

Encouraging Collaboration

Engagement with the relevant stakeholders is crucial; failure to engage and communicate the vision effectively leads to a lack of buy-in and hence resistance/indifference to the project. A project is more likely to succeed if the team shares a common vision and a sense of purpose. This way, attrition can be minimized.

As with most QI projects in the healthcare system, a collaboration between teams is vital. Collaboration relies on formal mechanisms to bring stakeholders together, with mutually agreed objectives, clear roles and responsibilities. Poorly defined individual and team responsibilities result in misunderstandings about the assigned tasks, redundant efforts and gaps in the work done. Clear agreements between the steward and the collaborating organizations can minimize these risks.

The individual (and skill-set) should be matched to the role and task requirements. It is naïve to think that any individual can simply slot into a role without considering their strengths and weaknesses. Effective leadership will maximize the potential of the individuals and foster seamless working of the entire team. Part of achieving and maintaining this goal is to ensure adequate and continuous training is available for individuals and the team.

Building the team requires careful consideration. The team composition will vary according to the task, but team members must be familiar with all aspects of the project. An effective team usually consists of team members representing the three different tiers of expertise within the organization: system leadership, technical expertise and day-to-day leadership. This can take the form of individuals each possessing expertise in one area or perhaps individuals skilled in overlapping areas of expertise.

Ensuring Robust Governance and Accountability Process

Measurement is critical to testing and implementing changes; such indicators or outcomes inform a team if the changes are actually bringing any improvement. Regular indicators to monitor implementation, processes and outcomes, ensure that all steps are measured and addressed. It is important that attention is not fixated upon final outcomes alone—it is crucial that all steps in the process are measured, with analysis and learning from any detected inefficiencies. Where more complex systems are in operation, new ways of providing constructive oversight, guidance and monitoring must be developed. Robust accountability processes are crucial tools for the standardization of governance tasks—especially true for ensuring patient safety.

The setting of the project’s vision should be followed by the designation of outcome measures. Ideally, stewards should measure quality across multiple dimensions (safety, effectiveness, patient experience, efficiency, equity, and timeliness), using a mix of structure, process, and outcome variables. Measurement activities should include monitoring changes over time, drawing comparisons between institutions, regions, and countries and setting benchmarks or targets for performance.

Activities to map, measure and improve processes, overcome resistance to change, and build strong organizational cultures require strong leadership and technical skills. Failure to invest in the development of these skills may lead to the failed implementation of any of the ideas above.

Fluid Stewardship

Goals

As stated previously, fluid stewardship can be defined as a series of coordinated interventions. These are introduced to select the optimal type of fluid, as well as the dose and duration of therapy, that will result in the best clinical outcome, prevent adverse events, and reduce costs.

The primary goal of fluid stewardship is to optimize clinical outcomes while minimizing unintended consequences of intravenous fluid administration. Ensuring the appropriate use of IV fluids is complex. It requires good theoretical and practical knowledge on the part of the prescriber, alongside clear operating procedures and oversight to ensure that various outcomes are measured, with recognition and learning from any adverse events.

A secondary goal of fluid stewardship is to reduce healthcare spending, without adversely impacting on the quality of care.

These goals can be broken down into several overlapping workstreams:

• Improvement of fluid prescribing practice

• Development of robust guidelines on fluid prescription and management, with regular updates when new scientific knowledge becomes available

• Rolling programme of education across the multidisciplinary team

• Regular quality assurance exercises—defining the key performance index (KPI) or outcomes measured

Like other healthcare QI projects, fluid stewardship is a team effort. Examples of the composition of a fluid stewardship team are shown in Table 27.1.

Table 27.1 Roles and responsibilities of a fluid team

The roles and desired qualities of stewards can be summarized in Table 27.2.

Table 27.2 Role and qualities of a fluid steward

Previous chapters have already discussed the 4 Questions and the 7Ds of Fluid Therapy. Taking each in terms, aims and hence KPIs can be defined as follows.

The 4 Questions of Fluid Therapy

When to start IV fluids (pertaining to the benefits of fluid administration)

• Aim: To guide fluid resuscitation based on macro-hemodynamics e.g. thorough history and examination to determine the volaemic status of the patient. Additional use of dynamic measures to assess volume tolerance–e.g. passive leg raises, POCUS.

• KPI: Understanding clinical signs and symptoms of true hypovolemia and the function/utility of different monitoring tools

When to stop IV Fluids (pertaining to the potential risks of ongoing fluid administration)

• Aim: Guidance based on the absence of volume tolerance.

• KPI: Understanding the signs of absence of volume tolerance and resolution of shock

When to start Fluid removal (pertaining to the benefits of active fluid removal, using diuretics or renal replacement therapy with net ultrafiltration)

• Aim: Monitoring hypervolemia based on impact of fluid overload on organ function

• KPI: Understanding the deleterious effects of GIPS and consequences of fluid overload on organ function

When to stop fluid removal (pertaining to the risks of removing excessive volumes of fluid)

• Aim: Avoiding hypoperfusion

• KPI: Understanding different techniques for mobilizing and evacuating fluid and signs of hypoperfusion

The 7 D’s of Fluid Therapy

Definitions

Comparison of fluid prescription habits and practices is only possible when universal definitions are applied regarding maintenance, replacement or resuscitataion fluids, hypovolemia or hypervolemia etc.

Diagnosis

Correct fluid therapy starts with an adequate assessment of the patient’s fluid or volume status.

• Aim: Standardizing and driving adoption of hypovolemia screening and assessment tools, including hemodynamic monitoring

• KPI: Systematic process in place for evaluating volume status in 100% of applicable patients

Drug

Inappropriate fluid therapy should be avoided. Clear and careful documentation of the choice, dose and duration of fluid therapy are expected, ideally including the indication for fluid therapy.

• Key considerations:

  • Approach an IV fluid the same way as any other drug

  • Select the type of IV fluid with the most suitable composition for the patient

  • Think about the indication of why you are using the fluid

  • Consider contraindications, comorbidities and side effects

• Aim: Appropriate indication, choice and route of fluid administration

• KPI: Correct fluid administered, on time, to the correct patient according to institutional guidelines

Dose

As Paracelsus nicely stated: “All things are poison, and nothing is without poison; only the dose permits something not to be poisonous.”

• Key considerations:

  • Consider timing, the starting dose, the rate of administration and cumulative dose:

    • Fluid bolus: 4 ml/kg/15 min

    • Mini-fluid challenge: 1 ml/kg/5 min

    • SSCG: 30 ml/kg/1–3 h

  • Determine the daily need for

    • Water: 1 ml/kg/u or 25 ml/kg/day

    • Glucose: 1–1.5 g/kg/day (to prevent starvation ketosis)

    • Sodium: 1–1.5 mmol/kg/day

    • Potassium: 1 mmol/kg/day

    • Chlorine: 1 mmol/kg/day

  • Consider pharmacodynamics and pharmacokinetics

    • Infusion: Same volume effect of crystalloids vs colloids as long as infusion is running

    • Distribution: decreased in shock, hypotension, during surgery, after induction and sedation

    • Elimination: decreased in shock, hypotension, during surgery, after induction and sedation

• Aim: Meeting daily fluid volume targets, fluid under/overload and considerations for special patient populations

• KPI: Volume, water, glucose and electrolyte targets achieved in accordance with guidelines

Duration

The duration of fluid therapy is important. There is an imbalance in clinical research. The mainstay of focus remains on the type of fluid administered, Vs. the far less studied therapeutic maneuver of withholding/removing fluid.

• Key considerations:

  • Always ask yourself the 4 basic questions

    • When to start with IV fluid?

    • When to stop giving IV fluid?

    • When to start fluid removal?

    • When to stop fluid removal?

  • Stop IV infusion if the patient no longer responds to fluid administration due to an increase in stroke volume (or blood pressure)

  • Monitor for hypo- and hypervolemia

  • Use dynamic indices of fluid responsiveness

  • Perform passive leg raising test

• Aim: Correct timing of fluid therapy, including initiation, speed, rate, length and transition of each modality

• KPI: Average cumulative fluid status no greater than 2.5–5% at day 7

De-escalation

The final step in fluid therapy is to consider withholding or withdrawing resuscitation fluids when they are no longer required.

• Key considerations:

  • Limit IV fluids as soon as the patient can drink again

  • Give concentrated enteral nutrition

  • Start fluid removal in case of fluid accumulation syndrome

  • Fluid accumulation causes increased morbidity and mortality

• Aim: Avoiding and mitigating complications (e.g. hypervolemia, fluid overload, electrolyte/metabolic disturbances, CLABSI) and stopping

• KPI: Zero complications from IV Fluid Management

Documentation

• Aim: Correct discontinuation of fluid therapy

• KPI: Post-discharge fluid intervention plan actioned

Different Phases During Implementation of Fluid Stewardship

A multidisciplinary panel of leading practitioners and experts recently published best practices for ongoing staff education, intravenous fluid therapy, new training technologies, and strategies to track the success of institutional fluid stewardship efforts. Fluid leads should be identified in every hospital to ensure consistency in fluid administration and monitoring. The different phases during implementation of fluid stewardship is summarized in the following steps [14]:”

Start-up Phase

Step 1: Composition of the Fluid Stewardship Core Team

In order to achieve, implement and maintain the best results, the hospital needs a multidisciplinary fluid team. The composition is discussed with the medical and nursing management as well as the head pharmacist and the members of the medical pharmaceutical committee. Ideally, the fluid stewardship (FS) core team consists of:

• ER physician

• Intensivist

• Internist (endocrinologist, cardiologist, nephrologist)

• Surgeon or OR manager (anaesthetist)

• Pharmacist

• Nurse

• Member of quality team

Step 2: Determination of the Targets for Baseline Measurement

The collection of data at the start of the FS program can be used as a benchmark to set strategic goals. A number of questions can be discussed here:

• What is the infusion-related incidence of electrolyte disturbance and acute renal failure?

• Is the body weight and fluid balance tracked correctly?

• Are the international NICE guidelines followed?

• Where can we have the fastest and biggest impact?

• Is there a problem with moisture overload?

All this is to gain a better understanding of the current situation in the hospital as well as to record the benchmarks (peers compare) for improvements.

Step 3: Baseline Measurement

It should be ensured that the baseline measurement contains all the information necessary to achieve and support the intended goal. This is related to the data that will be collected in the future during periodic assessments (tracers). Consultation and coordination is done with the fluid team.

• Snapshot/baseline measurement of the current consumption of the different infusion fluids

  • Data available from pharmacy

  • Compare data with those available via lump sum medication.

• Thinking about and determining future data collection:

  • Population-level biochemical lab data as surrogate markers for change: mean sodium, mean creatinine, and chloride

  • Follow-up logistical problems in prescribing and administering IV fluids such as the lack of infusion pumps or difficulties in weighing patients or monitoring daily fluid balance

  • Follow-up of the number of infusion-related incident reports

  • Analysis of morbidity and mortality

Step 4: Calculation Consumption and KPI

• Action analysis: Excel file with determination of indicators (KPIs) (Query via pharmacy and compare with government data):

  • Total number of litres of consumption on an annual basis per infusion fluid

  • Ratio of total litres of balanced fluid to number of litres of physiological NaCl

  • Ratio of liters of balanced (or buffered) maintenance fluid to number of liters of Gluc

  • Number of litres of infusion fluid per admission/stay

  • Number of liters of infusion fluid per day hospitalization (bed occupancy day)

  • Calculation of total cost of infusion fluids and percentage of lump sum

  • If possible: split between acute vs. chronic services (rehabilitation)

  • If possible: split between OR vs. ICU vs. ER

  • If possible: split between pediatric vs. Adult patients

  • If possible: split between physical vs. Mental illness

Step 5: Benchmarking Snapshot

• Mutual comparison of the figures from different hospitals (peers compare)

• Comparison with international literature data, e.g. from Fife (Scotland – conducted by Marcia McDougall and colleagues)[15].

• Simulation of cost-economic impact based on standard amounts per liter (or real amounts per infusion bag)

• Calculation of possible savings (cf. percentage decrease as observed in Fife and other hospitals)

Knowledge Phase

Step 6: Knowledge Survey of Doctors and Nurses

• Have a separate questionnaire completed by doctors and nurses

• Separate survey of pediatricians and pediatric nurses

• Call for interested doctors and nurses to choose 2 “fluid stewards” per department or ward

Step 7: Performing Medical Audit (Optional)

• File analysis of the appropriateness of the infusion prescribing behavior.

  • Through retrospective research of about 100 files (50 internist and 50 surgical).

  • Possibility of participating in multicentric research

Strategy Phase

Step 8: Determining the Change Objectives

Identification of the short- and long-term changes required using the results of the baseline measurement and determination of clear targets for this change. Breaking down the targets into a series of small chunks to make them more manageable.

Examples may include:

• We want a measured body weight in X% of all admitted patients

• We want a correct fluid balance in X% of the admitted patients

• We want a complete fluid prescription in X%

• We want to decrease in laboratory with kidney function and electrolytes within 24 h of an infusion administration at X%

• We want an increase in incident reports around IV fluids by X%

Step 9: Identification of Stimulators and Blockers of Change

Starting a fluid stewardship implies a change in the current way of working. This often encounters resistance and that has to do with culture. The need for change must be demonstrated by a clear vision and leadership.

Stimulus:

• Responsibility: assigning clearly defined roles. It is best to appoint 2 fluid stewards for each (nursing) department (a doctor and a nurse)

• Information: Provide on the definition of an incident and encourage reporting

• Education: via information sessions

• Restructuring the medication prescribing process with the introduction of mandatory steps that make prescribing the right fluids easier

• Limitation of choice and compliance guidelines: encouraging reporting of all errors

• Getting important services on board: dialogue with doctors who have experience with change

• Fluid stewards (and other key figures) lead by example

Resistance to change:

• Culture/customs/habits

• Time and pressure

• Lack of knowledge

• Other priorities

• Organizational problem

• Financial misconceptions: IV fluid bags are relatively inexpensive, so the perception may be that there is no financial need for FS

• Fragmented care: no clear policy

Step 10: Target Audience Identification

Identifying the target audience and how the message is best conveyed is an important step in achieving the objectives. We strive for unambiguous transparent communication.

Preparation Phase

Step 11: Coordination by Clinical Pharmacist

It is important that there is a single point of contact (best the clinical pharmacist) who follows up on the FS program. Check which products are available and where. Provide additional education in training. Follow-up core team. Finalizing one's own directive. Increasing visibility and publicity.

Step 12: Feedback results baseline measurement

• First to fluid core team (fluid stewards)

  • Use this to develop fluid bundles and guidelines for hospital

    • Clear regulations on which fluid can be used in which phases (feeding, maintenance, resuscitation and replacement).

• Followed by explanation to all doctors

  • Results and fluid bundle/guidelines

Step 13: Increase awareness

• By means of posters, screensavers, educational lectures, flyers, etc.

Education Phase

Step 14: Preparation of Training and Education Tool

• Introduction to IV fluid management, including a practical test for nurses such as filling in a fluid balance and for doctors such as correctly prescribing an IV fluid

• Presentation overview of errors in prescribing IV fluids from medical record analysis

• Bedside teaching in the departments

• Weekly workshops

• Train pharmacists and quality team staff to perform routine fluid prescription checks

• Adjusting guidelines for specific patient populations

Implementation Phase

Step 15: Roll out new guidelines

Post-Implementation Phase

Step 16: Follow-up

• Performing quick scans/tracers in the various departments regarding the correctness of infusion prescription.

• Follow up on KPIs (as defined above)

• PDCA or PDSA cycle

Case Vignette

• Q1. Was the prescription for IV fluid, correct? Why did the patient develop non-anion gap acidosis or hyperchloremic acidosis?

• A:  The patient developed hyperchloremic acidosis because of the IV fluid prescription of 5%DNS.The prescription of IV fluid 5% DNS at 150 ml/hour does not meet the 6D’s of fluid management. The right diagnosis helps decide the need for fluid administration, resuscitation, replacement and maintenance. In the initial phase, a balanced crystalloid would be required for resuscitation. However, the fluid prescription should be reviewed daily, based on the patient’s need and hospital guidance on IV fluids. The duration and de-escalation of IV fluids at the earliest when they are no longer required to avoid fluid creep and its deleterious effects.

• Q2. How to initiate fluid stewardship in my hospital/ICU?

• A:  The implementation of fluid stewardship is divided into four stages,

  • Firstly, the development of the hospital’s fluid guideline or bundle based on the recent evidence to create quality standards.

  • Secondly, various stakeholders (5 P’s) should be involved in the program and education of the staff about the program.

  • Thirdly, the prescription of every IV fluid in the hospital has to be detailed (based on the 6 D’s) to ensure proper administration and warrant the continuity of care.

  • Finally, audit prescriptions to the quality standards for a qualitative check of appropriateness.

Conclusion

In summary, improved fluid management in healthcare requires engagement and commitment from the multi-disciplinary team to maintain the ethos of continued change and improvement. Such a culture embraces the principles of quality improvement and creates the mindset required to ensure the best possible care within IV fluid management. Fluid stewards provide the necessary vision and leadership to coordinate such a project across the multidisciplinary team, working in separate but overlapping pathways.

Take Home Messages

• Fluid stewardship can optimize patient outcomes by reducing the unintended consequences of IV fluid administration and healthcare costs.

• Components of fluid stewardship include the development of comprehensive hospital-based fluid guidelines, a fluid stewardship team, continuous staff education and an audit or quality improvement framework.

• The optimum fluid prescription includes considering the 6 D’s (diagnosis, drug, dose, duration, de-escalation and discharge) of IV fluid administration.

• The audit framework for fluid prescription should include the 6 P’s (physician, prescription, pharmacy, preparation and patient).

• Use a validated model of improvement (e.g., PDSA: plan-do-study-act) to assess the quality of the fluid stewardship program.