Rachael Worthington - A Point Prevalence Study of Paediatric IV Fluids

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A presentation given by Rachael Worthington at the 2012 CHA Conference, The Journey, in the 'Innovations in Supporting Acutely Unwell Children, Young People & Their Families' stream.

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  • aAtleast 50 case reports of serious morbidity including at least 27 deaths amongst children who developed hospital acquired hyponatraemia whilst receiving iV fluids (Moritz ML, Ayuz JC. Pediatrnephrol 2005;20:1687-1700Add in image of patient safety alert 22 from NPSAArmon et al paper of audit Arch Dis child 2008 – point prevalence in 17 hospitals (10 DGHs, 3 patients each; 7 university teaching hospitals, 7 patients each, total 99 patients reviewed). Reviewed… in 2 audits, one prior to and the other after change in practice
  • Screen shots of these papers….Normal sodium requirement in children – orally 20-27mmol/L (similar to 30mmol/L in N/5) – see paper by MG Coulthard Arch Dis Child 2008, which describes why and has an algorithmGlobal concern about type of fluids and methods of prescribing Rubbing salt in the wound – M Hatherill – Traditional reccommendations for maintenance fluid volume exceed actual requirements and may contribute to the development of hyponatraemiaM Coulthard audit published in January 2012 – prospective, randomised open label study. 82 children, hartmanns and 5% dex or 0.45% saline and 5% dex.RBH PICU post spinal instrumentation, craniotomy or cranioplasty surgery – 7 patients in 0.45% group hyponatraemic 16-18 h post-op, cf none in hartmanns group Not fluid restrictive, saltier solution admin safer and more practical approach – urinary sodium same in both groups Neville papers – fluid type rather than rate determines post-op risk for hyponatraemiaRef 24 – Yung – greater fall in sodium with N/5/dexcf NS/dex, and that fluid admin at full maintenance greater fall than restricted rate.
  • Add in graph to show Iv fluids number one, but nature of these incidents is around administration (line/pump issues, wrong rate/fluid based on what prescribed/used outside policy/extravasation injuries etc) – administration without consideration of ideal fluid type
  • Add in IV fluid image and IV fluid management policy screen shotA working party was convened to implement the new fluid guidelines into practice. The data was used to inform the development of a new IV fluid order chart, local guidelines and educative strategies used.
  • On a single day in 2010 (pre-change) and again in 2012 (post change – incident numbers rising)
  • Demographic table for pre and postAgeTeam underDiagnoses – neuro/gastroCo-morbidsDuration IV fluidsType (graph)% requirements (dehydinc if documented)Electrolytes in preceding 24 hours? (P and ur)Na levelsdocumentation
  • Combine this with slide above
  • 104 out of 215 patients were receiving IV fluids100% of the patients received IV fluid volumes calculated in accordance with the new guidelines, and titrated to oral intake and output. 34% had mild hyponatraemia documented as their sodium level on the day of or within a week of the audit.Complex patients in post audit: One patient with DI had sodium levels between 145-154mmol/L managed with desmopressin and fluids were appropriate. Compliance with monitoring electrolytes increased, but weights decreased in patients receiving >48 hours IV fluids as per protocol – new protocol allows for more clinical judgement after the first 24 hours – explore this further. The orders themselves were incomplete and the prescriber unclear in 90%. Quality of prescribing – real estate tight on form, all should be completed, guidance on backWhat was missing – calculation in the main, prescriber clarity, weight, abbreviations used for sodium choride and strengths and glucose as dex or D
  • Hyponatraemia is observational – audit did not allow for detailed evaluation of clinical status and parameters for each patientN/4 not used pre-change in fluids – may need more than N/2 – guidelines expected to change in next iterationPatients tx fromED/PICU – not transcribed to ward charts (similarly from theatres)Rates not matching what is prescribed – sometimes documented in progress notes but not on fluid orderFluid balance chart difficult to interpretAudit – small, regular, as part of daily ward rounds (aka Lester) or via EOC – audit app in development to make this easySimulation exercises for practical application of IV fluid management – all disciplines (inc pharmacists) -
  • For sustainability in reducing adverse drug events or maintaining the quality of what we do …important to use a multifaceted approach
  • IV fluids in Top 5 incidents each month – mix of administration and prescribing – continued vigilance.Statewide guidance – 500ml bags and neonatal guidance included.Policy into practice changes and sustaining – Hurdowar et al paper from Healthc Q 2009. Canada. ‘Active’ ImplementationHow do we educate – enough, more hands on, prescribing expectations clear?Change of fluids again – awaiting results of trial at RCH melbourne comparing standard to BSS – recruitment slow but ongoingOne size does not fit all – care with population unable to adapt to low sodium fluids.
  • Rachael Worthington - A Point Prevalence Study of Paediatric IV Fluids

    1. 1. A Little more salt with that order? IV Fluids in Paediatrics Rachael WorthingtonThe Children’s Hospital at Westmead
    2. 2. Background• The danger of intravenous hypotonic saline administration, to acutely ill or post-operative children has been well documented over the past decade.• Children’s Hospitals Australasia (CHA) Medication safety SIG Intravenous Fluids Working Party, in line with other safety organisations, released intravenous fluid guidelines which addresses this.• Local intravenous fluid types for use in children and adolescents across a range of settings, including maintenance fluids, the perioperative period, dehydration and resuscitation, were reviewed. Moritz ML and Ayuz JC Pediatr nephrol 2005 Armon et al Arch Dis Child 2008
    3. 3. Questions raised• Is there really harm from hypotonic saline?• Is maintenance fluid Na+ volume too much?• How should we be monitoring?• Sodium Chloride 0.45% vs 0.9% vs balanced salt solution Hatherill Arch Dis Child 2004 Coulthard MG Arch Dis child 2008
    4. 4. Local incident data - 2011• Graph showing IV fluids up there over last 4 years
    5. 5. Ongoing trend
    6. 6. CHW Incident dataIV Fluid Prescribing Incidents 2011 N=25 4% 8% IV Fluid Administration Incidents 2011 Documentation Not prescribed N=91 28% Policy and procedure Unclear/ambiguous 48% Wrong IV fluids Extravasation 14% 8% Wrong patient ID No order 4% Ceased incorrectly 38% Expired stock 13% IV incompatibility Line issues Omission Policy and procedure 11% Wrong order administered Wrong IV Fluids 1% 12% Wrong rate 4% 3% 2% 1% 1%
    7. 7. IV fluidmanagement policy
    8. 8. IV fluid order form
    9. 9. Educational materials• JMO lunchtime teaching• PrInt students• Undergraduates• Nursing orientation
    10. 10. Method: Audits• IV fluid data was collected, from current fluid order charts, patient notes, and the clinical documentation system (PowerchartTM) on a single day in February 2010 (pre-change) and in October 2012 (post change) from every hospital ward, with the exception of the Neonatal Nursery.• Data collected included demographic patient data (diagnosis, co-morbidities and factors associated with non osmotic ADH secretion), IV fluids, additives and rate prescribed, fluid balance and serum electrolytes.• The quality of prescribing of IV fluids was also documented.• Data was analysed for type of fluid used (maintenance and bolus), appropriateness (met patient requirements), presence of hypo or hypernatraemia (and any action taken) and quality of prescribing.• Hyponatraemia was defined as mild (Sodium <135mmol/L) or moderate/severe (Sodium <130mmol/L)• Hypernatraemia was defined as mild (Sodium > 145mmol/L) and moderate/severe (Sodium >150mmol/L)
    11. 11. DemographicsMean (Range) Audit 1 n=95 Audit 2 n=104Age 6.54 (9 days-18 years) 6.44 (7 days-18 years)Male 58 58Weight (Kg) 25.75 (3.5-69.8) 23.53 (2.83-87)Medical/surgical 59/36 53/51Duration of IV Fluids (dys) 8.92 (<1 – 70) 10.3 (<1-80)Sodium Range (mmol/L) 127-144 121-154Number fluid boluses 37 29
    12. 12. Audit 1 (2010) Results
    13. 13. Audit 1 and 2 results compared Audit 1 n=98 Audit 2 N=104Fluids met requirements 100% 100%Hypernatraemia? 0% 1%Hyponatraemia? 32% 34%Sodium Chloride 0.225% 0% 0%prescribedSodium Chloride 0.9% 97% 100%used as bolus fluid (crys)Daily weights as per 38% 35%protocol?Electrolytes monitored 27% 32%as per protocol?Quality of prescribing: No-84% No-90%orders clear/complete?
    14. 14. Discussion• No change in hyponatraemia or hypernatraemia observed – but fluid types used only marginally changed.• Use of sodium chloride 0.9% plus 5% glucose as maintenance is slowly increasing (PICU).• Documentation needs to be tightened across the board.• Regular cycle of audit.• Educational input to date (JMO lunches, PrInt students, undergraduates, nursing orientation) – enough?
    15. 15. Multi faceted approachover 4 years• Clinician engagement• Multi D communication• Interactive education• Timely feedback
    16. 16. In summary• IV fluids still feature in the top 5 Medication/IV fluid incident reports every month.• Statewide NSW paediatric IV fluid guidelines have been developed based on CHA recommendations.• Maintaining/sustaining policy into practice – ‘active’ implementation, ongoing education, ‘living’ policy with timely review, safety culture, audit and feedback, changing educational strategy.• Change to sodium chloride 0.9% or balanced salt solution in the near future• One size does not fit all.
    17. 17. Questions

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