The document describes efforts by the Bay Pines Veterans Administration Healthcare System to improve fluid balance measurement and documentation. Specifically: - Ward 4A formed a work group to incorporate a new charting method and computerized calculation process to improve accuracy of intake-output documentation from 29% to 87%. - The new process integrated a module in the Computerized Patient Record System to automatically calculate fluid balances entered by staff, eliminating common errors. - Based on the success in Ward 4A, the new process was expanded to additional wards and intensive care units to standardize fluid balance monitoring across the facility.

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Bay Pines Veterans Administration Healthcare System
Formalized Effort Improves Fluid Balance Measurement and Documentation Consistency
A
Problem
Background
Beyond UBC…
Refining Ward 4A’s process consisted
of:
forming a multi-disciplinary work
group
incorporating a new method of
charting
integrating a computer-calculating
process through a branch of
Computerized Patient Record System
(CPRS), CPFlowsheets.
1. Informatics created a connection
with CPFlowsheets with all 4A
computers.
2. Approximately 80 staff members
were trained on this new procedure
and program.
Acknowledgements
Results
 Use of CPFlowsheets eliminated 2 of the 3 errors described above by automatically
and correctly calculating the data entered.
Staff comments include “entering data is far easier than the previous procedure” and
“I like that it totals the I/O’s for you.”
Patient outcomes and length of stay can be improved by better calculated physicians’
plans of care being more precise.
We went from 29% to 87% of all I/O’s being documented and calculated accurately!
That is 66% improvement from baseline!
Trial Pilot
Conclusion
References
Albert, N. (2012). Fluid management strategies in
heart failure. Critical Care Nursing, 32(2), 20-32.
Diacon, A. & Bell, J. (2014). Investigating the
recording and accuracy of fluid balance
monitoring in critically ill patients. South Africa
Journal of Critical Care. 30 (2), 55-57.
Ling, W.W., Ling, L.L., Chin, Z.H., Wong, I.T.,
Wong, A.Y., Nasef, A., & Zianuddin, A. (2011).
Improvement in documentation of intake and
output chart. International Journal of Public
Health Research Special Issue, 152-162.
Shepherd, A. (2011). Assessing hydration status
and measuring fluid balance can ensure
optimal hydration: Measuring and managing
fluid balance. Nursing Times, 107(28), 12-16.
During 2016 ward 4A’s Unit Based
Council (UBC) took definitive steps
improving their I/O practice in support
of our Congestive Heart Failure team’s
daily rounding. While 4A greatly
improved the process, it still suffered
due to human error of compliance and
calculation. Only 23% of the physician
orders resulted in completed 24-hour
I/O data thus indicating that even with
a physician order, 24-hour I/O’s are not
completed for all patients. Seventy-one
percent of these have at least one of
three types of errors including:
no 24-hour total and missing I/O data
no 24-hour total, but I/O data was
recorded for all shifts
24-hour totals but with missing shift
data
Authors: Sherry Philbrook RN,BSN, Alma Begovic RN, Harold Campbell RN, Neil David RN, Michelle Marengo RN, BSN, Germain Orteneau RN,BSN,CNOR,
Suzzette Seril RN,MSN,CNS-BC, Laura Sink RN,MSN,CNS-BC, Kristie Van Gaalen RN-BC, Anna Paszczuk, MD
Inaccurate intake and output (I/O)
documentation can lead to delayed
detection of intervention of abnormalities
and errors in medical decisions increasing
the risk of inpatient complications
including:
 hypervolemia
 hypovolemia
 electrolyte imbalance
Medical personnel use fluid status to
make decisions regarding fluid orders and
diuretic prescriptions. (Diacon & Bell,
2014 and Ling et al, 2011.) Practice of
patient I/O documentation at this facility
currently differs from unit to unit.
Additional potential hurdles include:
 changes in staff caring for patients
 staff communication
 patient understanding
I/O’s can be incorrectly calculated,
communicated, reported and documented.
Use of CPFlowsheets is an improved
communication and calculation system
over our prior I/O procedure.
Establishing a standardized I/O practice to
be utilized in all acute arenas will greatly
improve accurate documentation, thus
facilitating timely, precise physician
prescriptions regarding fluid intake and
diuretics as required.
A pilot program was conducted on Ward
4A from February 12 to 25, 2018.
Upon obtaining a physician order nursing:
1. provides a manual worksheet to ease
communication
2. places I/O signage over the patient’s
bed for easy identification
3. provides patient education
4. Provides the patient a handout,
“What Counts as a Fluid?”.
5. Nursing then documents I/O’s in
CPRS’s CPFlowsheet which:
a. totals data entered
b. then transfers to CPRS notes every
24 hours
CPFlowsheets and the I/O bundle process
is being expanded to include wards 3D,
5B, 5A, MICU’s Boarders to determine if
other populations will benefit from this
new process.
Future Direction
Special thanks for all of your support with this
continuing project to: Joanne Albertson, Alexsy
Anderson, Mike El Haje, Dr. Dennis Hall, Michelle
Jans, Diane Johnstone, Teresa Kumar, Laurie Laurino,
Anne Mallen, Kim Manganiello, Cynthia Neavins
and Magda Vargas-Agostini

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Bay Pines Veterans Administration Healthcare System
Ensuring Sufficient Hydration in Enteral Tube-fed Patients Decreases Nosocomial Complications
Author: Sherry Leah Philbrook RN, BSN, CMSRN
Problem
If tube-feed hydration is not delivered in
adequate quantities and in a timely
manner dehydration can occur within
days. Dehydration can lead to multiple
complications which can include:
 Altered mental status
 Skin break down (decubitus ulcers)
 Urinary tract infections
 Constipation
 Kidney or liver malfunction
 Abnormal body temperature
Another complication with lack of flushes
includes avoidable problems with tube
patency. (Guenter et al, 2011).
Rationale for Changes to Inpatient Practice and Impact on Patient Care
Current Practice
C.W. Young Veteran’s Administration Medical Center (CWYVAMC) has
43 Kangaroo “924” feeding pumps that can provide continuous feed of
prescribed liquid nutrition only.
These pumps have been in commission roughly 7 years. The prior
Kangaroo pumps were in use for 15 years. Flushes are ordered for
nurses to do manually, intermittently. While nursing has a good
awareness of the dangers of dehydration, water flushes can be delayed
due to patients competing for care and fitting them around feeding and
medication regimes.
Kangaroo “924” pumps and their replacement parts are no longer
manufactured. Yet, there were no plans to update the “924” feeding
pumps, opting to rely on manual flushing to ensure hydration and tube
patency.
Conclusion and Future Direction
The Call for Change Based on Best Practice
References
 The concern for adequate hydration through an automated flush system was initially
introduced at an April 2017 Skin Care Committee (SCC) meeting. The SCC member was
provided support and direction of fellow members to begin the arduous task obtaining
approval for a facility wide equipment purchase.
 In addition to the presentation of the noted benefits, positive testimony was provided by
nursing who has worked with the Kangaroo ePump in community hospitals and family of
patients who have used the Kangaroo Joey at home to assist in justifying this equipment
purchase.
Acknowledging the increasing demands
on nursing related to higher acuity of
today’s patients warrants organizational
support of providing pumps with the
capacity to deliver automatic,
programmed flushes by removing the
prospect of human delay in providing
timely flushes. (Best, C. & Lecko, C.
2013).
Acknowledgements
On a multi-disciplinary level staff will
be assured that our patients are
receiving all ordered hydration
preventing unnecessary nosocomial
complications.
Patients and family can be better
prepared to handle their home Joey
pumps by having a longer period
during their hospital stay to become
familiar with working with the
compatible ePump.These potential hazards were identified as risks for patients who are
tube fed upon returning home. CWYVAMC began providing a personal
home pump that was designed to provide intermittent automatic
flushes as often and as much as programmed by the pump user.
Changes in Outpatient Practice
Description of Innovative Best Practice
Use of a pump capable of programed flushes will ensure:
 Patients are receiving all duly ordered hydration.
 Patients’ tubes will remain patent thus preventing time lapses in receiving needed nutrition
and hydration.
 Added protection against nosocomial injury and infections.
 Patient education can begin at the hospital bedside as the Kangaroo ePumps for hospital use
have the same screen face as the Joey personal pumps.
 This may also give patients added confidence in working with their feeding tubes,
especially in cases of newly placed enteral feeding tubes.
Our facility has approved for purchase 58
ePumps that will be utilized in wards 3D,
4A, 5A, 5B, 5C, MICU, SICU, and all
CLC’s (East, West and Central).
The bedside Kangaroo ePump
The Kangaroo “Joey”
Kangaroo “924”
Outcome Achieved
Best, C. & Lecko, C. (2013). Survey findings show
that health professionals need to give more
consideration to hydration when
administering enteral tube feeding to
patients: Maintaining hydration in enteral
tube feeding. Nursing Times, 109(26). 16-17.
Guenter, P., Brantley, S., Lord, L., McGinnis, C.,
Pash, E. (2011). Panel discussion: Fluid
management in enteral feeding. Safe
Practices in Patient Care, 5(2). 2-4.
Lord, L. (2011). Maintaining hydration and tube
patency in enteral tube feedings. Safe
Practices in Patient Care, 5(2). 1, 5-12.
Sincere appreciation for all of your support
with this positive change and new practice to:
Audrey Ferguson, Shelby Jones, Anne Mallen,
Cynthia Neavins, Koa Viravong, Eileen
Welling, Debra Williams