Improving intravenous fluid prescribing

Midwives' perspectives of intravenous fluid management and fluid balance documentation in labour: A qualitative reflexive thematic analysis study

AIM

To describe current practice, examine the influences and explore barriers and facilitators to accurate documentation, for the administration of intravenous fluids during labour.

DESIGN

A descriptive qualitative study was performed.

METHODS

Qualitative semi-structured interviews were conducted with Registered Midwives working across Australia. Midwives were recruited via email and social media advertisements. A maximum variation sampling strategy was used to identify potential participants. Interview questions explored four main areas: (i) understanding of indications for IV fluids in labour; (ii) identification of current practice; (iii) barriers to documentation and (iv) benefits and complications of IV fluid administration. Reflexive thematic analysis of recorded-transcribed interviews was conducted.

RESULTS

Eleven midwives were interviewed. Clinical practice variation across Australia was recognized. Midwives reported a potential risk of harm for women and babies and a current lack of evidence, education and clinical guidance contributing to uncertainty around the use of IV fluids in labour. Overall, eight major themes were identified: (i) A variable clinical practice; (ii) Triggers and habits; (iii) Workplace and professional culture; (iv) Foundational knowledge; (v) Perception of risk; (vi) Professional standards and regulations; (vii) The importance of monitoring maternal fluid balance and (viii) barriers and facilitators to fluid balance documentation.

CONCLUSION

There was widespread clinical variation identified and midwives reported a potential risk of harm. The major themes identified will inform future quantitative research examining the impact of IV fluids in labour.

IMPACT

The implications of this research are important and potentially far-reaching. The administration of IV fluids to women in labour is a common clinical intervention. However, there is limited evidence available to guide practice. This study highlights the need for greater education and evidence examining maternal and neonatal outcomes to provide improved clinical guidance.

Introducing NICE guidelines for intravenous fluid therapy into a district general hospital

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.

Efficacy and Safety of Isotonic and Hypotonic Intravenous Maintenance Fluids in Hospitalised Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Hyponatraemia is a known complication in hospitalised children receiving maintenance intravenous fluid. Several studies have been published to investigate the efficacy and safety of intravenous fluids in children. However, there is still an ongoing debate regarding the ideal solution to be used in the paediatric population. Therefore, the aim of this meta-analysis was to investigate the safety and efficacy of administering isotonic versus hypotonic intravenous maintenance fluid in hospitalised children. An extensive search was undertaken on PubMed, Web of Science, Scopus, ScienceDirect, Google Scholar and Cochrane Library on 28 December 2020. Only randomised controlled trials (RCTs) were included. We used the random-effects model for all analyses. Risk ratio (RR) and mean difference with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. The quality of each study was assessed using the Joanna Briggs Institute critical appraisal tool for RCTs. This study is registered with PROSPERO (CRD42021229067). Twenty-two RCTs with a total of 3795 participants were included. The studies encompassed surgical and medical patients admitted to intensive care unit as well as to general wards. We found that hypotonic fluid significantly increases the risk of hyponatremia at both ≤24 h (RR 0.34; 95% CI: 0.26–0.43, p < 0.00001) and >24 h (RR 0.48; 95% CI: 0.36–0.64, p < 0.00001). Isotonic fluid increases the risk of hypernatraemia at ≤24 h (RR 2.15; 95% CI: 1.24–3.73, p = 0.006). The prevalence of hyponatraemia was also higher in the hypotonic group at both ≤24 h (5.7% vs. 23.3%) and >24 h (6.0% vs. 26.3%). There was no statistically significant difference in the risk of developing adverse outcomes between the two groups. Mean serum and urine sodium as well as serum osmolality/osmolarity was lower in the hypotonic group. Isotonic solution is protective against the development of hyponatraemia while hypotonic solution increases the risk of hyponatraemia.

Detailed analysis of 'work as imagined' in the use of intravenous insulin infusions in a hospital: a hierarchical task analysis

OBJECTIVE

Variable rate intravenous insulin infusions (VRIII) is a high-risk medication that has a potential to cause significant patient harm if used in error. Complex preparation of VRIII in clinical areas and the need for frequent monitoring and adjustment increase the complexity of using VRIII. An emerging approach, called Resilient Healthcare, proposes understanding complexity of work by exploring how work is assumed to be done and compare it with everyday work. This study aimed to explore how VRIII is perceived to be used by healthcare practitioners, focusing on one aspect of Resilient Healthcare: understanding how work is assumed to be done, using a method called hierarchical task analysis (HTA).

DESIGN

A qualitative study using document analysis and focus groups.

SETTING

A vascular surgery unit in an acute National Health Service teaching hospital in the UK.

PARTICIPANTS

Stakeholders/users in different professional roles involved in the process of using VRIII.

RESULTS

The HTA showed the complexity of using VRIII and highlighted more than 115 steps required to treat elevated blood glucose. The process of producing hospital-specific guidelines was iterative. Careful consideration was taken to coordinate the development and implementation of guidelines. Documents provided detailed clinical instructions related to the use of VRIII but practitioners selectively used them, often in deference to senior colleagues. Intentional adaptations, for example, proactively asking for a VRIII prescription occurred and were acknowledged as part of providing individualised patient care.

CONCLUSION

Using VRIII to treat elevated blood glucose is a complex but necessary process mediated by a range of factors such as organisational influences. Adaptive strategies to mitigate errors were common and future research can build on insights from this study to develop a broader understanding of how VRIII is used and to understand how adaptations are made in relation to the use of VRIII.