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Safer fluid prescribing at North Bristol Trust: Bringing practice in line with NICE Guidance with a redesign of the fluid prescription chart.

ABSTRACT: The National Institute of Clinical Excellence (NICE) released new fluid guidelines following data suggesting 20% of patients receiving fluids suffer adversely (2013). This quality improvement group assessed fluid prescribing in a tertiary teaching centre and introduced a new fluid- prescribing chart to align practice with NICE recommendations. Notes and corresponding fluid prescription charts were reviewed for evidence of (1) indication, (2) co-morbidities, and (3) further management as surrogate markers of safe prescribing in accordance with NICE. Overall, the data showed practice fell short and prompted a redesign of the Trust fluid prescription chart. Three different variations of the chart were issued consecutively using a PDSA method (plan, do, study, act) over a 6-month period. They all included indication, co-morbidities and further management plans as constant design features. Suggestions from interested parties were incorporated and an educational programme was implemented to promote awareness. Prior to our intervention, an indication for fluids was documented in 26% of notes, it took an average of 4.6 minutes to find co-morbidities, and further management plans were rarely documented. Following the new prescription chart, an indication was recorded in 72% of cases, co-morbidities noted on 63% of charts with 93.1% accuracy, and further management documented in 100% of cases. The new fluid prescription chart encourages prescribers to incorporate NICE recommendations when prescribing fluids. The new fluid prescription design has since been rolled out Trust wide.

SUBMITTER: Andersson J

PROVIDER: S-EPMC4645836 | biostudies-other | 2015

REPOSITORIES: biostudies-other

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Project description: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.

Project description:BackgroundThere is growing interest internationally in linking reimbursement decisions with recommendations for further research. In the UK, the National Institute for Health and Clinical Excellence (NICE) can issue guidance to approve the routine use of a health intervention, reject routine use or recommend use within a research programme. These latter recommendations have restricted use to 'only in research' (OIR) or have recommended further research alongside routine use ('approval with research' or AWR). However, it is not currently clear when such recommendations are likely to be made.ObjectivesThis study aims to identify NICE technology appraisals where OIR or AWR recommendations were made and to examine the key considerations that led to those decisions.MethodsDraft and final guidance including OIR/AWR recommendations were identified. The documents were reviewed to establish the characteristics of the technology appraisal, the cost effectiveness of the technologies, the key considerations that led to the recommendations and the types of research required.ResultsIn total, 29 final and 31 draft guidance documents included OIR/AWR recommendations up to January 2010. Overall, 86 % of final guidance included OIR recommendations. Of these, the majority were for technologies considered to be cost ineffective (83 %) and the majority of final guidance (66 %) specified the need for further evidence on relative effectiveness. The use of OIR/AWR recommendations is decreasing over time and they have rarely been used in appraisals conducted through the single technology appraisal process.ConclusionNICE has used its ability to recommend technologies within research programmes, although predominantly within the multiple technology appraisal process. OIR recommendations have been most frequently issued for technologies considered cost ineffective and the most frequently cited consideration is uncertainty related to relative effectiveness. Key considerations cited for most AWR recommendations and some OIR recommendations included a need for further evidence on long-term outcomes and adverse effects of treatment.

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Safer fluid prescribing at North Bristol Trust: Bringing practice in line with NICE Guidance with a redesign of the fluid prescription chart.

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