Improving Hydration and Fluid Management in Fife Bateson M, McDougall M, Peacock K, Dick K, Bendowski A, Hadoke J. Victoria Hospital, Kirkcaldy Contact: [email protected] Why focus on fluids? Suboptimal hydration is common and contributes to morbidity and mortality amongst hospitalised patients1,2. Prompt detection and appropriate action are required to prevent harm. Fluid balance charts, the purpose of which is to monitor intake and output, have been identified as an area for improvement in 10 out of the 14 Care of Older People in Acute Hospitals inspections across NHS Scotland since 2013 ᶟ. Similarly, NICE⁴ highlighted intravenous fluid prescribing as a complex process which required guidance and governance. NHS Fife baseline data reflected these concerns, demonstrating variation in approaches to fluid management. It was identified as priority for improvement. Methods What started as a conceptually simple change in fluid prescription and fluid balance documentation has become a complex project. The driver diagram below illustrates some of the change concepts which have been co-created by a multidisciplinary, multilevel team. Testing was initially confined to one ward and has now progressed to a four ward collaborative to facilitate the development of standardised documentation which is fit for purpose. Primary Drivers Hydration as a Strategic Priority Secondary Drivers What we’re testing Engage Senior Management and Leadership Integration with organisational and national priorities Develop senior multidisciplinary engagement Appointment of Fluid Lead Intravenous fluid prescription chart with decision support NHS Fife’s aim Every adult inpatient will receive the right volume of the right fluid at the right time by October 2014 Point of Care: Person Centred Hydration Management Reliable hydration assessment and planning Person centred goal setting for hydration Person centred hydration provision Criteria for commencing fluid balance monitoring Reliable detection and escalation of suboptimal hydration Seamless transitions in care Measures: Process: % patients with documented fluid intake ≥75% of goal (30ml/kg/24hrs if not stated) Outcome: Rate of deaths with fluid related critical incident (as defined by NICE 2013) Infrastructure Education for patients, relatives, staff and students Sustainable Measurement Results NICE (2013) recommends a daily fluid intake of 25-30ml/kg/24hrs. The run chart below illustrates % of patients with a documented fluid intake of ≥75% of 30ml/kg/24hrs. Each data point represents five patients. The median of 40% demonstrates that this work is at an early stage. Documented Fluid Intake in Ward A % of patients with a documented fluid intake of ≥75% of 30ml/kg/24hrs 100 Aim : 95% 90 80 70 60 Testing fluid balance and prescription charts separately 50 Median: 40% 40 30 Testing hydration goals 20 Combined chart implemented 10 0 30.01.14 27.01.14 03.02.14 12.02.14 21.02.14 27.02.14 04.03.14 14.03.14 06.04.14 23.04.14 29.04.14 06.05.14 15.05.14 Conclusions • • Optimising hydration through effective fluid management is fundamental to excellent clinical practice. Providing a consistent and pragmatic approach will reduce unwarranted variation in care. However, practical implementation is complex. NHS Fife is working towards a process which is fit for purpose and delivers for every patient every time. Total intake and output more than once per day Trigger on fluid balance chart to identify at risk patients Standardisation of documentation: content & timing Embedding outcome measure into hospital mortality review process Key Learning 1. Listen first. • Front line staff know where the operational challenges are and what we could test to solve them. 2. Develop a clear, shared ‘why’ which underpins the aim. 3. Be patient and persistent. • Unexpected opportunities for improvement which must be addressed will appear. 3. Culture is core to patient care. • New guidelines, education and documentation cannot, alone, advance care. • Culture + Structure + Processes = Improvement in Care Next Steps •Culture: • From bedside to board room: developing momentum in optimal hydration management as an achievable essential. • Structure: • Finalise documentation within the collaborative. • Implement systematic and sustainable education plan. •Processes: • Support local testing and sharing of process changes to improve hydration e.g. reliable hydration goal setting. References 1. Callum KG, Gray AJ, Hoile RW, et al. Extremes of age: the 1999 report of the National Confidential Enquiry into Perioperative Deaths. London: NCEPOD. 1999 2. Walsh SR, Walsh CJ. Intravenous fluid-associated morbidity in postoperative patients. Annals Royal College of Surgeons England. 2005;87:126-130 3. Healthcare Improvement Scotland www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/nhs_hospitals_and_s ervices/care_of_older_people/care_of_older_people_reports.aspx 2014 [Accessed 15.05.14] 4. NICE. Intravenous Fluid Therapy in Adults in Hospital NICE clinical guideline 174. NICE 2013