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Ludwig L, Seifert R. How does pharmacological and toxicological knowledge evolve? A case study on hydrogen cyanide in German pharmacology and toxicology textbooks from 1878 to 2020. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03227-z. [PMID: 38900251 DOI: 10.1007/s00210-024-03227-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/06/2024] [Indexed: 06/21/2024]
Abstract
Little is known about how pharmacological and toxicological knowledge evolves. The aim of this study was to investigate the changes in the presentation of the poison hydrogen cyanide in sixteen German-language pharmacology and toxicology textbooks from 1878 to 2020. The categories of structure, molecular mechanism of action, occurrence, effects, resorption, areas of application, lethal dose, acute symptoms of intoxication, treatment of hydrogen cyanide poisoning, and recommended therapeutic preparations were evaluated. The knowledge on the structure, lethal dosage, and occurrence of hydrogen cyanide has remained constant. In contrast, knowledge on molecular mechanism of action and recommended preparations of the poison has changed dramatically. Until 1944, the binding of hydrogen cyanide to hemoglobin was considered the mechanism of action, whereas from 1951 onwards, the interaction of hydrogen cyanide with the Fe3+ of cytochrome oxidase was described. The number of preparations containing hydrogen cyanide decreased into obsolescence until 1951. The areas of application of hydrogen cyanide also show a change, as from 1919 onwards, mainly industrial areas of application of the poison are described instead of medical ones, and from 1951 onwards, criminalistic areas of application are also mentioned. Thus, pharmacological and toxicological knowledge develops non-linearly, molecular mechanism and uses being the most dynamic areas, whereas the knowledge about hydrogen cyanide's chemical structure, lethal dose, and occurrence remained constant. Older pharmacology and toxicology textbooks were better than newer ones at discussing changes in scientific concepts. Pharmacology and toxicology textbooks also mostly failed to discuss the misuse of hydrogen cyanide (Zyklon B) during the Nazi regime, missing an important opportunity to showcase the ethical responsibility of pharmacology and toxicology. Thus, future pharmacology and toxicology textbooks should improve on discussing the development of pharmacological and toxicological concepts and the ethical responsibility of the discipline.
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Affiliation(s)
- Laureen Ludwig
- Institute of Pharmacology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Roland Seifert
- Institute of Pharmacology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
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Wuyts SCM, Scheyltjens S, Hubloue I, Dupont AG, Cornu P. Interdisciplinary knowledge gaps on intravenous fluid management in adult patients: Survey among physicians and nurses of a university hospital. J Eval Clin Pract 2022; 28:599-606. [PMID: 35080261 DOI: 10.1111/jep.13663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
RATIONALE Intravenous (IV) fluids are frequently involved in iatrogenic complications in hospitalized patients. Knowledge of IV fluids seems inadequate and is not covered sufficiently in standard medical education. METHODS Two surveys were developed, based on the 2016 British National Institute for Health and Care Excellence guideline 'IV fluid therapy in adults in hospital', to provide insight on the learning needs and expectations of physicians and nurses. Each survey focused on profession-specific practice and consisted of three parts: demographics, knowledge questions and evaluation of current habits. Physicians and nurses practicing in a Belgian university hospital were invited to complete the survey electronically, respectively, in January and May 2018. RESULTS A total of 103 physicians (19%) and 259 nurses (24%) participated. Although every indication for fluid therapy may require a specific fluid and electrolyte mixture, and hence, knowledge of their exact composition, most physicians and nurses did not know the composition of commonly prescribed solutions for IV infusion. Senior physicians did not score better than juniors did on questions concerning the daily needs of a nil-by-mouth patient. The availability of an IV fluid on the ward guides physicians to prescribe IV fluids (17%). Nurses (56%) feel they share responsibility in fluid management as they frequently intervene in urgent situations. More than half of participants (70% of physicians, 79% of nurses) indicated a need for additional information. CONCLUSIONS A clear need for more structured information on IV fluids was identified. Both physicians and nurses struggle with fluid therapy. Continuing education on IV fluid management, emphasizing multidisciplinary collaboration, and monitoring evidence-based practice is essential to support the clinical decision process in daily practice.
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Affiliation(s)
- Stephanie C M Wuyts
- Research Group Clinical Pharmacology and Clinical Pharmacy, Centre for Pharmaceutical Research, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Pharmacy Department, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Simon Scheyltjens
- Department of Emergency Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Ives Hubloue
- Department of Emergency Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Research Group in Emergency and Disaster Medicine, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Alain G Dupont
- Research Group Clinical Pharmacology and Clinical Pharmacy, Centre for Pharmaceutical Research, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Pieter Cornu
- Research Group Clinical Pharmacology and Clinical Pharmacy, Centre for Pharmaceutical Research, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Information and Communication Technologies, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Clinician Attitudes and Concordance with Self-Assessed and Actual Intravenous Fluid Prescribing Patterns: A Single-Institution Evaluation of Survey and Electronic Prescribing Data. Am J Med Sci 2022; 364:36-45. [DOI: 10.1016/j.amjms.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/01/2022] [Accepted: 03/29/2022] [Indexed: 11/23/2022]
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McDougall M, Guthrie B, Doyle A, Timmins A, Bateson M, Ridley E, Drummond G, Vadiveloo T. Introducing NICE guidelines for intravenous fluid therapy into a district general hospital. BMJ Open Qual 2022; 11:bmjoq-2021-001636. [PMID: 35115322 PMCID: PMC8814811 DOI: 10.1136/bmjoq-2021-001636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 01/15/2022] [Indexed: 11/30/2022] Open
Abstract
Background National Institute for Health and Care Excellence (NICE) guidelines on intravenous fluid prescribing for adults in hospital, issued in 2013, advised less use of 0.9% sodium chloride than current practice, provided a logical system for prescribing and suggested further study of electrolyte abnormalities. Aims To describe the steps taken to establish and monitor guideline introduction and to assess effects on clinical biochemistry results, in a general hospital setting. Methods We used established principles of change to modify education, teaching, record keeping and audit throughout the hospital, changed the availability of intravenous fluid preparations in the wards and monitored the use of intravenous fluids. We anonymously linked local clinical chemistry records to nationally available patient records (NHS Scotland SMR01). We chose specified medical emergencies, and major emergency and elective general and orthopaedic surgery, where management would require intravenous fluids, for a two-phase cross-sectional study between 2007 and 2017, spanning the change in prescribing. Primary outcomes were abnormal bicarbonate, sodium, potassium and incidence of acute kidney injury (AKI), and secondary outcomes were mortality and length of stay. Results Over the study period, sodium chloride 0.9% use decreased by 75%, and overall intravenous fluid use decreased from 0.65 to 0.40 L/occupied bed day. The incidence of acidosis decreased from 7.4% to 4.8% of all admissions (difference −2.7%, 95% CI −2.1 to −3.0). No important changes in other electrolytes were noted; in particular, plasma sodium values showed no adverse effects. Stage 1 AKI increased from 6.7% to 9.0% (difference 2.3%, 95% CI 1.6 to 3.0), but other causes for this cannot be excluded. Mortality and length of stay showed no adverse effects. Conclusions and implications Effective implementation of the guidelines required substantial time, effort and resource. NICE suggestions of fluid types for maintenance appear appropriate, but prescribed volumes continue to require careful clinical judgement.
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Affiliation(s)
| | - Bruce Guthrie
- University of Edinburgh, Community Health Sciences, Edinburgh, Midlothian, UK
| | - Arthur Doyle
- Renal Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alan Timmins
- Pharmacy Department, Victoria Hospital, Kirkcaldy, UK
| | - Meghan Bateson
- Institute of Healthcare Policy and Practice, University of the West of Scotland, Blantyre, South Lanarkshire, UK
| | | | - Gordon Drummond
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Thenmalar Vadiveloo
- Health Services Research Unit, School of Medical Sciences, University of Aberdeen, Aberdeen, UK
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Kingsmore SF. 2022: a pivotal year for diagnosis and treatment of rare genetic diseases. Cold Spring Harb Mol Case Stud 2022; 8:a006204. [PMID: 35217563 PMCID: PMC8958907 DOI: 10.1101/mcs.a006204] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The start of 2022 is an inflection point in the development of diagnostics and treatments for rare genetic diseases in prenatal, pediatric, and adult individuals-the theme of this special issue. Here I briefly review recent developments in two pivotal aspects of genetic disease diagnostics and treatments: education and equitable implementation.
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Affiliation(s)
- Stephen F Kingsmore
- Rady Children's Institute for Genomic Medicine, Rady Children's Hospital, San Diego, California 92123, USA; Keck Graduate Institute, Claremont Colleges, Claremont, California 91711, USA
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A cross-sectional survey of knowledge pertaining to IV fluid therapy and hyponatraemia among nurses working at emergency departments in Denmark. Int Emerg Nurs 2021; 57:101010. [PMID: 34139392 DOI: 10.1016/j.ienj.2021.101010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 03/17/2021] [Accepted: 04/04/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Inappropriate fluid therapy may induce or worsen existing hyponatraemia with potentially life-threatening consequences. Nurses have an important role in assisting physicians in IV fluid prescribing. However, research is lacking in Denmark about nurses' knowledge pertaining to IV fluid therapy and hyponatraemia. METHODS An explorative cross-sectional survey was performed among Danish emergency department nurses in Spring 2019. Knowledge about IV fluid therapy was assessed for three common clinical scenarios, and multiple-choice questions were used to measure knowledge about hyponatraemia. RESULTS 112 nurses responded to all scenario questions corresponding to 6.2% (112/1815) of the total population of nurses working at emergency departments in Denmark. In two of the three scenarios, a minority of nurses (8-10%) inappropriately selected hypotonic fluids. Nearly one third (31%) selected a hypotonic fluid for a patient with meningitis, which is against guideline recommendations. The study revealed limited knowledge about severe symptoms of hyponatraemia, patients at high risk, and hyperglycaemia-induced hyponatraemia. CONCLUSION In accordance with guideline recommendation, the majority of nurses did not select hypotonic fluids in three clinical scenarios commonly encountered in the emergency department. However, when setting up an educational program, further awareness is needed regarding symptoms of hyponatraemia, high-risk patients, and hyperglycaemia-induced hyponatraemia.
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Sindahl P, Overgaard-Steensen C, Wallach-Kildemoes H, De Bruin ML, Leufkens HGM, Kemp K, Gardarsdottir H. Are Further Interventions Needed to Prevent and Manage Hospital-Acquired Hyponatraemia? A Nationwide Cross-Sectional Survey of IV Fluid Prescribing Practices. J Clin Med 2020; 9:jcm9092790. [PMID: 32872460 PMCID: PMC7565867 DOI: 10.3390/jcm9092790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/16/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hyponatraemia is associated with increased morbidity, increased mortality and is frequently hospital-acquired due to inappropriate administration of hypotonic fluids. Despite several attempts to minimise the risk, knowledge is lacking as to whether inappropriate prescribing practice continues to be a concern. METHODS A cross-sectional survey was performed in Danish emergency department physicians in spring 2019. Prescribing practices were assessed by means of four clinical scenarios commonly encountered in the emergency department. Thirteen multiple-choice questions were used to measure knowledge. RESULTS 201 physicians responded corresponding to 55.4% of the total population of physicians working at emergency departments in Denmark. About a quarter reported that they would use hypotonic fluids in patients with increased intracranial pressure and 29.4% would use hypotonic maintenance fluids in children, both of which are against guideline recommendations. Also, 29.4% selected the correct fluid, a 3% hypertonic saline solution, for a patient with hyponatraemia and severe neurological symptoms, which is a medical emergency. Most physicians were unaware of the impact of hypotonic fluids on plasma sodium in acutely ill patients. CONCLUSION Inappropriate prescribing practices and limited knowledge of a large number of physicians calls for further interventions to minimise the risk of hospital-acquired hyponatraemia.
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Affiliation(s)
- Per Sindahl
- Danish Medicines Agency, Division of Pharmacovigilance and Medical Devices, 2300 Copenhagen, Denmark;
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584CG Utrecht, The Netherlands; (H.G.L.); (H.G.)
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark;
- Correspondence:
| | | | - Helle Wallach-Kildemoes
- Section for Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark;
| | - Marie Louise De Bruin
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark;
| | - Hubert GM Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584CG Utrecht, The Netherlands; (H.G.L.); (H.G.)
| | - Kaare Kemp
- Danish Medicines Agency, Division of Pharmacovigilance and Medical Devices, 2300 Copenhagen, Denmark;
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584CG Utrecht, The Netherlands; (H.G.L.); (H.G.)
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, 3584CX Utrecht, The Netherlands
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Fluid and electrolyte balance-establishing the knowledge base of Foundation Year One doctors. Ir J Med Sci 2018; 188:1047-1055. [PMID: 30484067 DOI: 10.1007/s11845-018-1937-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Fluid and electrolyte management for hospital inpatients has been identified by multiple reports to be suboptimal, with delegation of this task to the most junior members of a medical team, Foundation Year One (FY1) doctors, also known as interns or house officers, being identified as a contributing factor. METHODS An online survey was distributed nationally via social media to FY1 doctors between 21st August 2018 and 19th September 2018. Questions focused around cohort characteristics, team behaviours around fluid and electrolyte prescribing, as well as teaching and knowledge. RESULTS Two hundred eighty-six doctors participated. 67.13% knew the daily water requirement of a healthy adult. 58.39 and 79.72% knew the daily requirements of potassium and sodium, respectively. 41.26 and 33.57% knew the potassium and sodium composition of Hartmann's solution (1 L), respectively, with only 31.12% of candidates knowing the correct sodium content of 1 L of normal saline 0.9%. FY1 doctors were the principle prescribers of fluid therapy (97.55%); senior house officers, registrars, and consultants were only actively involved in the process 51.75, 20.98, and 5.59% of the time, respectively. 30.77 and 23.43% of FY1s received guidelines and/or teaching on the topic within their firms or as part of their foundation teaching, respectively. At undergraduate level, 52.44% of doctors reported the teaching to be "neither poor or good," "poor," or "very poor." CONCLUSION The principle knowledge base underlying fluid and electrolyte management is still poorly understood by FY1 doctors, with poor teaching of the subject at both undergraduate and post-graduate level potentially contributing.
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McCrory RFR, Gormley GJ, Maxwell AP, Dornan T. Learning to prescribe intravenous fluids: A scoping review. PERSPECTIVES ON MEDICAL EDUCATION 2017; 6:369-379. [PMID: 29119469 PMCID: PMC5732109 DOI: 10.1007/s40037-017-0386-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
INTRODUCTION Prescribing intravenous (IV) fluid therapy is a core skill expected of qualified doctors at the point of graduation, but medical graduates often feel ill-equipped to perform this task. This lack of preparedness contributes to treatment-related patient harm. This scoping review maps the current state of published evidence about how junior doctors prescribe IV fluid therapy and learn how to do it. METHODS We searched five electronic databases and grey literature from 1994 until June 2016 for articles describing any aspect of IV fluid prescribing practice or its education. A total of 63 articles were selected for analysis. Using the WHO Guide to Good Prescribing to categorize the extracted findings, our review focuses on prescribing IV fluids in adult generalist settings. RESULTS Most articles studied IV fluid prescribing from the perspective of the doctor. Junior clinicians struggled to conceptualize IV fluid prescribing as a 'whole task' in authentic work settings and lacked support. Educational interventions to improve IV fluid prescribing often focused on enhancing prescriber knowledge about fluid and electrolyte balance rather than execution of the prescribing task. CONCLUSIONS Our understanding of IV fluid prescribing as a holistic integrated skill is patchy, as is its performance. Current IV fluid prescribing education appears insufficient to foster safe and effective practice. For education to achieve the ultimate goal of safer prescribing in workplaces, we need a clearer understanding of how healthcare professionals prescribe IV fluids in real world practice.
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Affiliation(s)
- Richard F R McCrory
- Centre for Medical Education, Queens University Belfast, Belfast, Northern Ireland, UK.
- Regional Nephrology Unit, Belfast City Hospital, Belfast, Northern Ireland, UK.
| | - Gerard Joseph Gormley
- Centre for Medical Education, Queens University Belfast, Belfast, Northern Ireland, UK
| | | | - Tim Dornan
- Centre for Medical Education, Queens University Belfast, Belfast, Northern Ireland, UK
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Gao X, Huang KP, Wu HY, Sun PP, Yan JJ, Chen J, Chen X. Inappropriate prescribing of intravenous fluid in adult inpatients-a literature review of current practice and research. J Clin Pharm Ther 2015; 40:489-495. [PMID: 26096723 DOI: 10.1111/jcpt.12295] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/07/2015] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE It is known that mismanagement of intravenous (IV) fluid therapy may cause serious complications. The 2013 NICE guideline on intravenous fluid therapy in hospitalized adults also emphasizes the importance of appropriate prescribing of IV fluid. So far, no systematic review of the incidence and types of inappropriate prescribing of IV fluid has been conducted. Therefore, this study was undertaken to review the research literature on inappropriate prescribing of IV fluid in adult patients and develop corresponding strategies for improving practice. METHODS A comprehensive literature search was performed. Critical appraisals were conducted on the articles drawn from the search, and an analysis was performed on the results. RESULTS AND DISCUSSION Incorrect volumes and types of IV fluids prescribed, classified as misprescribing, was the most common type of inappropriate prescribing. Commonly, patients on IV fluid therapy were prescribed a greater volume of fluid and amount of sodium in excess of normal requirements. Doctors did not always check the body weight, serum electrolyte level and serum creatinine before prescribing IV fluid for patients. The other common type of inappropriate prescribing was incomplete/incorrect prescription writing. These common inappropriate prescribing of IV fluid could be caused by insufficient knowledge and training of the prescribers. In addition, the ignorance of the importance of IV fluid prescribing also contributed to this behaviour. WHAT IS NEW AND CONCLUSION There is an urgent need to make doctors aware of these problems and enhance appropriate training on IV fluid prescribing, especially on the appropriate volume and amount of electrolytes. Pharmacists could exert a role in reviewing the fluid prescription chart for improving clinical practice.
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Affiliation(s)
- X Gao
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - K-P Huang
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - H-Y Wu
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - P-P Sun
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - J-J Yan
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - J Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - X Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Sansom LT, Duggleby L. Intravenous fluid prescribing: Improving prescribing practices and documentation in line with NICE CG174 guidance. BMJ QUALITY IMPROVEMENT REPORTS 2014; 3:bmjquality_uu205899.w2409. [PMID: 26734287 PMCID: PMC4645880 DOI: 10.1136/bmjquality.u205899.w2409] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 10/31/2014] [Indexed: 11/10/2022]
Abstract
Intravenous (IV) fluid prescribing is a common occurrence in inpatient settings; it has been repeatedly demonstrated that high levels of mortality and morbidity are associated with inappropriate IV fluid prescribing. IV fluid prescriptions are often completed by the most junior and inexperienced members of the clinical team. In recognition of the issues surrounding IV fluid prescribing and in an effort to combat the issues surrounding current practice, the National Institute for Health and Care Excellence (NICE) published guidance in December 2013 - ‘Intravenous fluid therapy in adults in hospital (CG174)’. At our hospital the approach to IV fluid prescribing amongst junior doctors was highly variable with poor awareness of the NICE guidance. We defined necessary components for the documentation of IV fluid prescriptions based upon the NICE guidance. Our initial data showed that these components were infrequently documented, with prescriptions often having no indication for IV fluid, no 24 hour plan / review, no documentation of patient weight or request for further weights, and no current or requested fluid balance charts. Lanyard cards emphasising the necessary components of an appropriate IV fluid prescription along with a copy of the NICE fluid prescribing algorithm were distributed to junior doctors on the acute admissions units. Following the introduction of the lanyard cards there was a significant increase in the documentation of the defined prescription components. Significant increases in the documentation of indication for IV fluid and patient weight, which are essential components of accurate fluid prescription, were demonstrated on both medical and surgical admissions units. Subsequently, as a result of improved documentation and consideration given to fluid prescriptions, we were able to increase the percentage of maintenance IV fluid prescriptions that conformed to NICE guidelines. As an endpoint to this intervention all new Foundation Year 1 doctors at our hospital were issued with IV fluid prescribing lanyard cards at Trust induction; the authors believe that this intervention will lead to a unified approach and a sustained improvement in IV fluid prescribing practices and prescription documentation at this hospital site.
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