Intelligent Fluid Management Bundle Lyn McIntyre Head of Clinical Quality & Patient Safety & Regional QIPP Safe Care Lead NHS East of England

Context and overview of the East of England Intelligent Fluid Management Bundle Project Share progress with the development on the nursing contribution

NHS East of England We work with 40 local NHS organisations across Bedfordshire, Cambridgeshire, Essex, Hertfordshire, Norfolk and Suffolk East of England Ambulance Service across the region We also operate with a number of private and voluntary organisations. Visit eoe.nhs.uk to find out more Change to new map from crb/annie or jpeg of counties Add scroll of names at bottom, ie orgs 3

Getting the Basics Right.. A nursing observation audit ….. was an initiative to improve the reliability of patient observations, which is a fundamental component of reducing harm from deterioration..

The key issues you found – an example from one trust from EoE baseline assessment November % compliance 1. All observation documentation provides details of ward, patient number, date of birth, hospital number, consultant and frequency of observations. 10/158 6.3% 2 all patients receive twice daily observations of temperature, pulse, blood pressure and respirations, level of consciousness and oxygen saturations 152/158 96% 3 MEWS in accordance with trust policy 155/157 99% 4. 24 hour cumulative balances will be evident on all fluid balance observations 26/52 50% 5. There is evidence of documentation of referrals to medical staff for the patients assessed as being at risk 7/12 58% 6 the patient was weighed on admission to the ward 121/159 76% All 6 components completed How often do you think fluid charts be added up? 1hrly, 6 hrly, 12hrly-24hrly; as and when, if the patient deteriorates When would you start a patient on fluid chart? Start on IV fluids; on admission; when NBM When would you stop fluid balance monitoring? Discharge; when they are well; IV therapy stops; Urine catheter removed Do all patient on IV fluids require fluid chart? 5 out of 21 said No What is a cumulative balance? Total balance in 24 hrs; all out puts; whole records from admission; balance at the end of the shift; Where would you find the fluid balance chart? In filling; in the folder; at the end of the bed; in the patient notes

Issues that we are trying to resolve Inconsistent volumes in cups/beakers – cups of tea Patients unable to reach their water jugs Monitoring patients who use the toilet – how do you monitor effectively? Inconsistency when fluid charts are used and assessed Poorly completed charts Estimating output for incontinent patients Lack of standardization of approach across all clinical settings Lack of clear guidance and criteria for patients requiring fluid management Challenge of helping vulnerable often elderly patients receiving optimal hydration Detecting clinical deterioration including over hydration Supervision of care provided being adequate Identifying effective indicators for outcomes of care Improving the nursing contribution in community and acute care

Root cause of poor fluid management Inadequate staff knowledge and competence in the effective management of volume assessment leading to over or under hydration within the overall context of holistic clinical assessment and care of the patient Weaknesses in the systems and processes that support effective fluid management Insufficient governance of and accountability for effective fluid management

Project Brief An Intelligent Fluid Management Bundle, that contains; policy guidance for assessing, planning, delivering, evaluating and recording intelligent care; and to support its implementation with tools including those for auditing and teaching.

What do we know…what we do now does not work effectively….. that monitoring of input and output will always be an inadequate way of determining hydration state or whether someone is hypovolaemic it is inappropriate to say or imply that the patient with fluid input equal to urinary output is in zero fluid balance – they are inevitably (because of insensible losses) in negative fluid balance someone with a charted positive balance of less than 500 mL / day will almost certainly be in negative overall fluid balance. nurses waste hours completing charts that we know are inaccurate, and never can be made accurate, and which docs don’t take notice of is clearly not sensible

Fluid Chart Issues to consider The twenty four Hour fluid management plan (treatment goal and rationale) is rarely clearly written on the fluid chart or forms part of the care plan Patients requiring IV fluids rarely have a written clear rationale for requirements The totalling of twenty four balances are inconsistently completed throughout the day and night, often no action is taken as a result of totalling The cumulative seven day balance is rarely presented Hydration Status rarely forms part of the routine clinical handover Intake: The section for oral fluids is always the first column on the Fluid Balance Charts (FBC) The size of the ‘cell’ is the same for all the other fluid intakes e.g. I/V; enteral; NG All the FBCs have only one cell per hour ( the only difference being North Tees and Hartlepool NHS Trust have divided the cell into two smaller sections per hour.) Output: Urine is nearly always in the first column The cell size is the same for all output The same as for oral fluids Generally do not visually present the deterioration of clinical condition Is there a need for a basic and complex fluid chart?  

What we do know… good nursing care will comprise measures to ensure that each patient has an adequate water intake, unless there are good medical reasons for restricting water intake Good nursing will detect deterioration in a patient's condition Good nursing will involve the patient and family Will ensure effective escalation Retain the accountability for patients safety

We could…… Consider not charting fluids routinely Nurses / Carers could offer and help all patients (not NBM) to have a drink regularly so that over the course of every three hours during the day a cupful (200mls) is consumed Hourly rounding could focus on fluid management Handover tools could incorporate hydration status Recording postural BP could be done once daily in all patients – a fall indicates likely intravascular volume depletion Recording body weight once per day in all patients – fall of more than 0.2Kg per day indicates likely dehydration. Agree that 1500 mls is the optimal fluid intake (unless clinically indicated)

We could also... Agree that a positive balance of 500mls (unless clinically indicated) is a trigger for escalating care Agree that an input of 2500 mls or more (unless clinically indicated) triggers escalation of care Routinely include liquid in food as part of charted fluid intake Agree principles of effective charting Use colour charts for assessment of urine concentration Use estimating techniques for incontinent patients as per the Hartlepool Model Share all this information with patients and families so they can be involved in the care and hold us to account Redesign fluid charts and incorporate visual risk cues

Critical Questions for the WebEx Have we understood the issues – we are not trying to create a medical consensus on the medical management – but recognise that the medical management drives the care Have we identified the right changes to improve the nursing contribution? If we do these things will we be doing something that will result in different outcomes for community and acute care? What else do we need to consider?