ARTICLEInvestigating the recording and accuracy of fluid b.docx

ARTICLE
Investigating the recording and accuracy of fluid balance
monitoring in critically ill patients
A Diacon, MCur; J Bell,' 3 MCur, BCur, PGDN
1 Division o f Nursing, Faculty o f Medicine and Health
Sciences, Stellenbosch University, Cape Town, South Africa
3 TASK Applied Science, Karl Bremer Hospital, Bellville, Cape
Town, South Africa
3 Department o f Nursing Science, School o f Clinical Care
Sciences, Faculty o f Health Sciences, Nelson Mandela
Metropolitan University,
Port Elizabeth, South Africa
Corresponding author: A Diacon ([email protected])
Background. The accurate assessment o f fluid balance data
collected during physical assessment as well as during m
onitoring and
record-keeping forms an essential part of the baseline patient
information that guides medical and nursing interventions aimed
at
achieving physiological stability in patients. An informal audit
o f 24-hour fluid balance records in a local intensive care unit
(ICU) showed
that seven out of ten fluid balance calculations were incorrect.
Objective. To identify and describe current clinical nursing
practice in fluid balance m onitoring and measurement accuracy
in ICUs,
conducted as part of a broader study in partial fulfilm ent of a
Master o f Nursing degree.

Methods. A quantitative approach utilising a descriptive,
exploratory study design was applied. An audit of 103 ICU
records was
conducted to establish the current practices and accuracy in
recording o f flu id balance m onitoring. Data were collected
using a
purpose-designed tool based on relevant literature and practice
experience.
Results. Of the original recorded fluid balance calculations,
79% deviated by more than 50 mL from the audited
calculations. Further-
more, a significant relationship was shown between inaccurate
fluid balance calculation and administration of diuretics
(p=0.01).
Conclusion. The majority o f fluid balance records were
incorrectly calculated.
S AfrJCrit Care 2014;30(2):55-57. DOI:10.7196/SAJCC.193
M ainta in ing a balance between flu id intake and
output plays an im portant role in the management
o f a critica lly ill patient. The accurate assessment
o f the flu id balance data collected during physical
assessment as well as during m onitoring activities
and record-keeping forms an essential part o f the baseline
patient
in fo rm ation tha t guides medical and nursing in terventions to
achieve physiological stability in a patient. Changes in a
critically ill
patient's fluid balance can complicate the patient's clinical
condition.
It is, therefore, necessary that flu id balance parameters are
accu-
rately monitored and recorded for all patients in intensive care
units

(ICUs).111
A daily observation sheet is used to record all vital signs,
nursing
interventions, medical procedures and the fluid balance for each
24-h period of a day. The fluid balance record comprises
records of
the intake and output of fluids by a patient over a 24-h period.
The
difference between the volumes is calculated to provide the 24-
h
fluid balance.121 The monitoring of a patient's fluid balance is
of great
importance in understanding and managing a patient's clinical
status
and, as such, accurate monitoring and recording of fluid balance
data
plays an essential role in patient care management.131
Several studies have considered the relationship between
fluid imbalances and patient outcomes in critical care. The
Sepsis
Occurrence in Acutely III Patients (SOAP) study by Vincent et
al.,m
conducted across 198 ICUs in Europe in 2002, determined that a
positive fluid balance is a strong prognostic factor for death in
criti-
cally ill patients. Similarly, research by Alsous et a/.,151 Boyd
et al.m
and Payen et o/.I7] concluded that a more positive fluid balance
is associated w ith an increased risk of m ortality in patients
with
septic shock or acute renal failure. Furthermore, Rosenberg et
a/.181
determined that a cumulative negative fluid balance in patients

w ith acute lung injury is associated with lower mortality. The
conclusions offered by these studies require that monitoring and
recording of fluid balance data must be complete and accurate,
w ith assessment of a patient's fluid balance being recognised as
an
important component of nursing any critically ill patient.
In South Africa (SA), the practice of a registered nurse is
regulated
by the Scope of Practice drawn up by the SA Nursing
Council.191
Chapter 2, section 2(i) of these regulations identifies that fluid
balance
monitoring is part of the scope of practice of a registered nurse.
Therefore, a registered nurse working in a critical care
environment
is responsible and accountable for the accurate recording and
calculation of fluid balance when caring for and managing a
critically
ill patient. Managing a patient's fluid balance is as equally
important
as carrying out any other patient care activity for the critically
ill, such
as administering a medication prescription or providing
nutrition.121
Fluid balance management in ICU patients is complex.
Monitoring
and measurement of fluid balance requires close attention to
ensure
that current methods are applied accurately and consistently to
provide the most complete data, upon which patient
management
decisions can be based.
Based on practice experience and underpinned by an informal

audit of 24-h fluid balance charts in a local ICU, where seven
out of
ten calculated totals were incorrect, the research question posed
was:
What are the current practices of registered nurses in ICUs with
regard
to fluid balance monitoring?
SAJCC November 2014, Vol. 30, No. 2 55
Methods
A quan tita tive approach u tilis ing an
exploratory, descriptive study design was
applied. The study was conducted in ICUs
across three purposively selected hospitals
of one private sector hospital group. The
ICUs of these hospitals were similar in terms
of their patient admission profiles, with the
same nursing documentation and policies
applied at all three hospitals.
An audit tool was developed from
relevant literature and clinical experience
to assess particular aspects of the sampled
fluid balance records. Two critical care nurse
experts evaluated the content and face
validity of the audit tool; no changes were
required. A pretest of the audit tool was
conducted at one additional ICU of the same
hospital group to determine the accuracy
and relevance of the measurements;
no changes were required. The pretest
data were not included in the study data.
A statistician determined the tool to be

appropriate and adequate for data collection
and analysis purposes.
Ethical approval for the study was
obtained from the Human Research Ethics
Committee at the Faculty of Medicine and
Health Sciences, Stellenbosch University,
as well as the relevant committee of the
hospital group.
The population for this study was critical
care patient records. The study sample was
drawn from fluid balance records according
to the following inclusion criteria:
• Nursing records of admissions to ICUs for
the first 48 h of the patient's stay, from
1 July to 31 December 2011
• Patients over the age of 18 years as per
the definition of an adult in the Children's
Act No. 38 of 20051'01
• Patients classified as 'intensive care':
activity 1 or 2 on the patient classification
system o f th is hospital group. This
classification was used by the doctor
to determine financial charges to the
patient. No w ritten policy regarding
this classification was available from the
hospitals.
A simple random sampling technique was
implemented to select patient records for
the audit: all the admission numbers of

patients meeting the inclusion criteria were
identified through the hospital informa-
tion system and admission record book
of the ICU. The patient record file that
was connected with every third patient
admission number was drawn until the
required sample was achieved. The sample
size was calculated to ensure adequate
precision in population estimates, using 95%
confidence intervals (CIs). A sample size of 80
fluid balance records would have resulted in
6% precision in the 95% Cl width, assuming
a 10% error rate in the calculation ofthefluid
balance. This was well within the accepted
precision of between 5% and 10%. A sample
size of N= 103 was selected and divided
specifically among the various units under
the guidance of the statistician (Table 1).
Descriptive statistics were recorded and
the Mann-Whitney U-test was used to test
associations between recorded variables
and fluid balance calculation accuracy.
Data were recorded on the study audit
tool by the researcher and a field worker
together in the three hospitals. The fluid
balance calculation recorded in each
patient record for a 24-h period during
the first 48 h of a patient's stay was noted
on the audit tool. A control calculation of
each recorded fluid balance total was done
by the researcher and verified by the field
worker. These audited calculations were
recorded in the audit tool. The deviation
between the original calculations and the

audited calculations was determined and
recorded.
In addition to the fluid balance
calculation, baseline vital sign data, modes
of fluid output (e.g. diarrhoea), specific
data regarding the administration of blood
products, and the number of continuous
intravenous infusions were recorded on
the audit tool.
Results
24-h calculated fluid
balance totals
The original recorded 24-h fluid balance
total was compared with the audited fluid
balance total performed by the researcher
and field worker. The difference in calcula-
tion was referred to as the deviation in fluid
balance calculation, and is presented in
Table 2 for descriptive reasons.
In the audit of 103 fluid balance
documents, a total of 71 (68.9%) recorded
calculated fluid balance totals were within
a 500 mL deviation from the fluid balance
calculated by the researcher. Fourteen
recorded calculations (13.5%) were found
Table 1. Sam pling fram ew o rk
Hospital Intensive-care beds, n
Admissions:
July - December 2011 , n Records sampled, n
A 26 1 020 34

B 28 1 027 34
C 38 1 022 35
D 12 300 Pilot study
Table 2. Deviation in fluid balance (A/=103)
Calculated deviation
Overall
0 - 3 706 0 - 50 51 - 500 501 - 1 000 1 001 - 2 000 >2001 No
record
n 98 22 49 14 7 6 5
Percentage 95.1 21 48 13.5 6.8 5.8 4.9
Median deviation (mL) 167 20 146 754 1 249 3 310 -
Mean deviation (mL) 493 21 184 754 1 371 3 116 -
Range (mL) 0 - 3 706 0-46 61 -463 501 - 984 1 008- 1 928 2
260 - 3 706 -
56 SAJCC November 2014, Vol. 30, No. 2
Table 3. Comparison of accurate and inaccurate fluid
calculation
Inaccurate flu id calculation, median (IQR)
Variable Yes No p-value

Received blood products 180.5 (60- 1 312) 167 (61 -530) 0.95
CVP measured 202.5 (90 - 764) 119 (41 -320) 0.09
Matched doctor's prescription 155 (60 - 530) 201 (63 - 708)
0.61
Diuretic administered 279(102-996) 106 (46 - 350) 0.01
Received >2 intravenous drugs 257 (75 -708) 138 (60-435) 0.16
IQR = in te rqua rtile range; CVP = central venous pressure.
to deviate between 500 mL and 1 000 mL,
while seven recorded calculations (6.8%)
were found to deviate between 1 000 mL
and 2 000 mL. Six recorded calculations
(5.8%) were found to have a deviation of
>2 000 mL.
There was a significant association
between the administration of diuretics
and inaccurate fluid balance calculation
(p=0.01), but there was no association
between other variables and the outcome
of interest (Table 3).
Discussion
The definition of a net positive fluid balance
as a volume >500 mL used in the study by
Alsous eta/.151 was applied in this study. Of
great concern were the 27/103 documents,
more than 25% o f the sample, w ith a
deviation of >500 mL between the recorded
calculation and the control calculation.
Equally of concern were the five patient
records where no fluid balance calculation
was available at all. These findings repres-
ent a risk for the critically ill patient when

one considers the findings of previous
studies related to positive fluid balance and
patient mortality.14'81 The findings of this
study showed that fluid balance calculation
is not treated as a priority in the nursing
management of a critica lly ill patient.
The incorrect calculation of fluid balance
means that every patient management
decision utilising these fluid balance data
was influenced by inaccurate information.
Perren et al.1" 1 performed a similar study in
Switzerland and expressed their concern
about the accuracy of fluid balances in
critically ill patients.1111
Additionally, the significant association
between inaccurate fluid balance calcula-
tion and diuretic administration (p=0.01)
suggests that when diuretics are adminis-
tered, there is a higher chance of the
calculated fluid balance being incorrect.This
finding supports the researcher's concern
that a careful and accurate approach to
fluid balance does not enjoy high priority
in managing critically ill patients in this
context. Diuretic therapy is a commonly
prescribed therapeutic modality; in this
study, 38.8% (40/103) of critically ill patients
had diuretics recorded as being adminis-
tered during the first 48 h of their admission.
Inaccurate fluid balance data may result in
inappropriate application of diuretic therapy,
resulting in fluid imbalances that affect the
haemodynamic stability of patients.

The findings of this study are limited by
the focus on one hospital group and may
be regarded as a pilot study for further
development.
Conclusions
in this study, the majority of audited 24-h
fluid balance calculations were shown to
be incorrect; 79% (81/103) of the original
recorded fluid balance calculations deviated
by >50 mL from the audited calculation. The
accuracy of the 24-h balance calculated is
questionable, with only 21% of the original
fluid balance totals deviating by <50 mL
from the audit calculations. This is of great
concern. Several studies14'81 have noted
a relationship between fluid imbalance
and mortality in critically ill patients. The
findings indicate that treatment decisions
are often based on inaccurate fluid balance
information, which may lead to negative
consequences for the patient.
A significant association was shown
between the administration of diuretics and
inaccurate 24-h fluid balance calculations.
With diuretics prescribed specifically to
manage fluid imbalance, this finding
indicates that the accuracy of the calculated
fluid balance must be confirmed prior to
diuretics being prescribed or administered.
Within the context of limited resources, any
clinical recommendations must be realistic
and practical. One suggested example
is instituting a system of checking fluid

balance calculations at specific intervals,
such as during patient handover at shift
change, during the patient assessment
process or during patient management
discussions. Awareness around the poten-
tial consequences of calculation errors must
be reinforced during patient discussions
and continuing education sessions.
The requirement to provide accurate,
correct fluid balance monitoring and
recording as part of the patient's vital sign
data must be established as a fundamental
standard of practice for every nurse
practising in an ICU. Regular outcome-
driven audits will assist in identifying
where and when errors occur, allowing for
specific interventions to be designed and
implemented.
Further studies may assist in refining
the particular challenges of accurate fluid
balance recording, for instance cumulative
fluid balance over more than 24 h.
References
1. Culleiton AL, Simko LC. Keeping electrolytes and fluids in
balance. Nursing2013 Critical Care 2011;6(2):30-35. [http://
dx.doi.org/10.1097/01 :CCN.0000394395.67904.4d]
2. Scales K, Pilsworth J. The importance of fluid balance
in clinical practice. Nursing Standard 2009;22(47):50-57.
[http://dx.doi.org/10.7748/ns2008.07.22.47.50.c6634]
3. Elliot D, Aitken L, Chaboyer W. ACCCN's Critical Care

Nursing, 1st ed. Marrickville, Australia: Mosby Elsevier,
2007:440,445-446.
4. Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European
intensive care units: Results of the SOAP study. Crit Care
Med 2006;34(2):344-353.
5. Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong
Y, Manthous CA. Negative fluid balance predicts survival
in patients with septic shock: A retrospective study. Chest
2000;117(6):1749-1754.
6. Boyd JH, Forbes J, Nakada T, Walley K, Russell JA. Fluid
resuscitation in septic shock: A positive fluid balance
and elevated central venous pressure are associated with
increased mortality. Crit Care Med 2011;39(2):259-265.
[http://dx.doi.Org/10.1097/CCM.0b013e3181 feebl 5]
7. Payen D, de Pont AC, Sakr Y, et al. A positive fluid balance
is associated with a worse outcome in patients with acute
renal failure. Crit Care 2008;12(3):R74. http://ccforum.com/
content/12/3/R74 (accessed 27 October 2014). [http://
dx.doi.org/10.1186/cc6916]
8. Rosenberg AL, Dechert RE, Park PK, Bartlett RH, National
Institutes of Health-National Heart, Lung, and Blood
Institute Acute Respiratory Distress Syndrome Network. A
review of a large clinical series: Association of cumulative
fluid balance on outcome in acute lung injury: A
retrospective review o f the ARDSnet tidal volume study
cohort. J Intensive Care Med 2009;24(1):35-46. [http://
dx.doi.org/10.1177/0885066608329850]
9. South African Nursing Council. R2598, Regulations relating
to the scope of practice o f persons who are registered
or enrolled under the Nursing Act, 1978. Regulation of

the Nursing Act, 2005 (Act No. 33 of 2005). Pretoria:
Government Gazette, 491,2006:34.
10. South African Government. Children's Act 38 o f 2005.
http://www.justice.gov.za/legislation/acts/2005-038%20
childrensact.pdf (accessed 27 October 2014).
11. Perren A, Markmann M, Merlani G, Marone C, Merlani P.
Fluid balance in critically ill patients. Should we really rely
on it? Minerva Anestesiol 2011;77(8):802-811.
SAJCC November 2014, Vol. 30, No. 2 57
Copyright of Southern African Journal of Critical Care is the
property of Health & Medical
Publishing Group and its content may not be copied or emailed
to multiple sites or posted to a
listserv without the copyright holder's express written
permission. However, users may print,
download, or email articles for individual use.
Chapter 10
Mandatory Minimum Staffing Ratios
Copyright © 2016 Wolters Kluwer Health | Lippincott Williams
& Wilkins
Copyright © 2020 Wolters Kluwer • All Rights Reserved

RN Skill Mix
Economics as the driving concern for changes
Trend: reduction in RNs in staffing mix; replacement with less
expensive personnel
Research: number of RNs in staffing mix directly affecting
quality of care and patient outcomes
National movement to mandate minimum staffing ratios
As of 2017, 14 states addressed nurse staffing in hospitals in
law/regulations
California is the only state that stipulates in law; regulations for
required minimum nurse-to-patient ratios to be maintained at all
times by unit
Staffing Ratios and Patient Outcomes
Research findings (see Table 10.1)
Questions about cost-effectiveness of statewide mandatory
nurse staffing ratios
Greater RN skill mix and fewer cases of sepsis and failure to
rescue
Benchmark research
Needleman et al. (2002)
Aiken et al. (2002)
Direct link between nurse-to-patient ratios and mortality from
preventable complications
Mandatory Minimum Staffing Ratios: Needed? #1
ANA with concern related to effect of poor staffing on nurses’
health and safety and patient outcomes
Proponents
Absolutely essential for patient safety and outcomes

Use of standardized ratios for consistent approach
Critics
Exponentially increased cost with no guarantee of quality
improvement or positive outcomes
AONE agrees and does not support mandated nurse staffing
ratios
Question #1
Is the following statement true or false?
Few states have enacted staffing laws.
Answer to Question #1
False
As of 2017, 14 states addressed nurse staffing in hospitals in
law/regulations.
Evidence of benefits mixed, contradictory
No accounting for education, experience, and skill level
Risk of actual decline in staffing—used as a ceiling or absolute
criteria without accounting for patient acuity or RN skill level
Cost as the major deterrent—not financially attractive to
hospitals
Mandate for specific staffing ratios and current shortage leading
to reduction in hospital services, increased emergency room
diversions, increased unit closures, increased expenses

Ohio Hospital Association: benefit of staffing ratios is mixed
and sometimes contradictory
Corbridge (2017): argues that mandating inflexible nurse
staffing ratios or stringent meal and rest break requirements do
not improve patient care or outcomes
Silber et al (2016): better-staffed facilities had a formula for
excellent value as well as better patient outcomes (see Box
10.2)
California Prototype #1
First state to implement mandatory minimum staffing ratios
Maximum number of patients an RN could be assigned to care
for under any circumstances (see Table 10.2)
Issues in determining appropriate ratios
Lack of data about nurse staffing distribution
Patient classification system (PCS) data problematic
Unknown cost
Recommendation: 1 nurse to every 6 patients in med/surg units
Delays in implementation
Problems with interpreting the meaning and intent of language
related to “licensed nurses”
Issues related to cutting nonlicensed staff
Questions if adequate number of RNs available to meet ratios
Emergency regulation in 2004; overturned in 2005

Hospitals and nursing unions’ responses
Struggle to implement
Mandate effective 1/1/2004
Larger hospitals versus smaller hospitals to meet mandate
Need for legal clarification for “at all times” (i.e., breaks,
lunches)
Question #2
California implemented mandatory minimum staffing ratios
fairly quickly.
False
There were significant delays in implementing the California
mandatory minimum staffing ratios.
Improvement in RN staffing and patient outcomes?
Reduction in number of patients per licensed nurse
Increase in number of worked nursing hours per patient day in
hospitals

No significant impact on measures of nursing quality and
patient safety indicators
No increase in adverse outcomes despite increasing patient
acuity
Lower risk-adjusted mortality (Aiken, 2010)
No improvement in quality of care (HC Pro, 2009)
Similar Initiatives: Other States
Minimum standards for licensed nursing in certified nursing
homes but not in acute care hospitals
Several attempts, but none enacted
Adequate numbers requirement for Medicare-certified hospitals
Many states actively pursuing minimum staffing ratio
legislation
Other Alternatives
Pursuit of alternatives to improve nurse staffing without
legislated minimum staffing ratios
Lack of support for legislated minimum staffing ratios
The Joint Commission
ANA against fixed nurse–patient ratios; recommendation of
three general approaches (see Box 10.3)
Question #3
The ANA supports legislation for fixed nurse–patient ratios.

False
The ANA does not support fixed nurse–patient ratios but
advocates for a workload system that takes into account the
many variables that exist to ensure safe staffing.
End of Presentation
Chamberlain College of Nursing NR439: Evidence-
Based Practice
Week 6: Reading Research Literature Worksheet
Directions: Complete the following required worksheet using
the required article for the current session.
Name:
Date:
Purpose of the Study:
Research & Design:
Sample:
Data Collection:

Data Analysis:
Limitations:
Findings/Discussion:
Reading Research Literature:
3/2020 ST
1
Hello everyone! I want to welcome you to your final
assignment you have due for your NR439 course! Can you
believe it? This is your last one, so Kudos to you! I have
created for you a short tutorial for your week 6 reading research
literature worksheet.
Your week 6 assignment is located in your week 6 module; if
you click on the link it will take you to your guidelines and
directions. As always, you will find your rationale and purpose
for completing the learning activity. I created this worksheet
assignment to help you demonstrate your understanding of how
to read an original research article that has been assigned for
you and then answer specific questions about the research
study. The worksheet is designed to help you appreciate and
value the importance of reading research literature. As a take
away, you can use this worksheet to help you critique any
research literature of interest in your future.
The week 6 reading research literature assignment is based off
of a culmination of your learning so far in your course. Please
refer back to your learning in the course to help you with the

questions for the activity. I designed this learning activity
using your AACN standards for professional practice which
requires a BSN to appreciate, read, and understand original
nursing research literature as this is an essential for creating an
evidence-base practice.
The assignment directions and rubric are located under your
week six assignment. It is essential that you read over the
directions as these have key instructions and helpful hints to
complete the required week 6 reading research literature
worksheet. The worksheet is located here and you must use the
worksheet that is assigned in your session you are taking the
course. The worksheet can change from session to session and
so it is important that you use the one that is assigned during
the session you are taking the course. This assignment requires
that you read an assigned research article that is located here
and then answer the questions after you have read the article.
Be sure you are using the assigned article for the session you
are taking the course. The article can change from session to
session so it is important you access the assigned article that is
linked in the course located here. I encourage you to read all the
directions first, and then read over your grading rubric which is
located beneath the assignment directions. Be sure that you are
using your grading rubric to complete the required assignment.
Your instructor will use the grading rubric to evaluate each of
the criteria you will be completing. You want to use the first
column to be sure you are capturing all available points for that
criteria.
All assignments at Chamberlain require Academic Integrity
which means the work that you produce is your own. As you
know in practice and in school, integrity matters. Therefore, it
is imperative you are using your own words to answer the
questions after you have read the assigned article. You want to
pay attention to the scholarly writing area and the APA area for
the assignment. You can paraphrase some of the information
you will discuss from the article. Paraphrasing means you are
using your own words to describe what the author has

discussed. You can use 1-2 short direct quotes but I highly
encourage you to paraphrase instead in order to prevent any
academic integrity concerns. You must use APA in-text
citations which means you must cite the sentence you
paraphrased using your own words. You can use other scholarly
sources to support your answers to demonstrate your knowledge
of how to read a research article. If you use an outside
scholarly source or any other source, please list the resource
below the worksheet. Listing the resource at the end without
citing does not demonstrate integration of the resource. Be sure
you are fully citing the resource; posting a link will not be
accepted as a scholarly source as your instructor can not
determine from a link the quality of the resource.
The assignment is worth 200 points. I want to point out that you
need to use scholarly writing, spelling, grammar, and complete
sentences. Again, use your own words to write about the
criteria to demonstrate your understanding of the article and use
in-text APA citations for any sentences that you use from
resources. It is important that you are using the assigned
worksheet and article in the session you are taking the course; if
you do not, points will be deducted from the elements listed
here in your grading rubric. Resources: You can find APA
resources as well as writing assistance in your resources tab and
your Chamberlain library. Your Chamberlain library is a great
database to find current evidence to support your writing. The
link to the library is located here.
Students, again Kudo’s to each of you for your persistence and
all of your valuable work you are doing in NR439. We
appreciate each of you and know that you are expanding your
knowledge and skill set related to practicing as a BSN. The
course was created to help support your knowledge, skills, and
awareness of how to utilize and practice with an evidence-based
approach and way of thinking as you move towards achieving
your BSN. As always, please contact your NR439 instructor if
you have any questions. Enjoy your final assignment!

ARTICLEInvestigating the recording and accuracy of fluid b.docx

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