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 “Fluid management…should be accorded the same status as drug prescription” (NCEPOD) (GMC EQUIP)

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

Initial research 1)Questionnaire Weight- 56% never check Fluid status- only 12% always check U+Es- only 28% always check 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% 3) Appropriateness

Developing the Aim

Driver Diagram

Effectiveness Safety Timeliness and Efficiency Patient centeredness

Developing a Fluid Prescribing Tool

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

Feedback Indication Clinical assessment box Continue/stop/review U+Es Guidance on the back Clarify ‘clinical assessment’ box More space to write fluid/additive Space for 2 nd nurse to countersign It doesn’t need to be perfect because it is a huge improvement on what we have at the moment We often waste time bleeping the doctor because the bag has finished when they didn't want more fluids anyway!

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

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 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 THANK YOU ANY QUESTIONS?