1. Intelligent Fluid Management Bundle
Lyn McIntyre
Head of Clinical Quality & Patient Safety & Regional QIPP Safe Care Lead
NHS East of England

2. Context and overview of the East of England Intelligent Fluid Management Bundle Project
Share progress with the development on the nursing contribution

3. NHS East of England
We work with 40 local NHS organisations across Bedfordshire, Cambridgeshire, Essex, Hertfordshire, Norfolk and Suffolk
East of England Ambulance Service across the region
We also operate with a number of private and voluntary organisations.
Visit eoe.nhs.uk to find out more
Change to new map from crb/annie or jpeg of counties
Add scroll of names at bottom, ie orgs 3

5. Getting the Basics Right.. A nursing observation audit
….. was an initiative to improve the reliability of patient observations, which is a fundamental component of reducing harm from deterioration..

6. The key issues you found – an example from one trust from EoE baseline assessment
November
% compliance
1. All observation documentation provides details of ward, patient number, date of birth, hospital number, consultant and frequency of observations.
10/158
6.3%
2 all patients receive twice daily observations of temperature, pulse, blood pressure and respirations, level of consciousness and oxygen saturations
152/158
96%
3 MEWS in accordance with trust policy
155/157
99%
4. 24 hour cumulative balances will be evident on all fluid balance observations
26/52
50%
5. There is evidence of documentation of referrals to medical staff for the patients assessed as being at risk
7/12
58%
6 the patient was weighed on admission to the ward
121/159
76%
All 6 components completed
How often do you think fluid charts be added up? 1hrly, 6 hrly, 12hrly-24hrly; as and when, if the patient deteriorates
When would you start a patient on fluid chart? Start on IV fluids; on admission; when NBM
When would you stop fluid balance monitoring? Discharge; when they are well; IV therapy stops; Urine catheter removed
Do all patient on IV fluids require fluid chart? 5 out of 21 said No
What is a cumulative balance? Total balance in 24 hrs; all out puts; whole records from admission; balance at the end of the shift;
Where would you find the fluid balance chart? In filling; in the folder; at the end of the bed; in the patient notes

7. Issues that we are trying to resolve
Inconsistent volumes in cups/beakers – cups of tea
Patients unable to reach their water jugs
Monitoring patients who use the toilet – how do you monitor effectively?
Inconsistency when fluid charts are used and assessed
Poorly completed charts
Estimating output for incontinent patients
Lack of standardization of approach across all clinical settings
Lack of clear guidance and criteria for patients requiring fluid management
Challenge of helping vulnerable often elderly patients receiving optimal hydration
Detecting clinical deterioration including over hydration
Supervision of care provided being adequate
Identifying effective indicators for outcomes of care
Improving the nursing contribution in community and acute care

8. Root cause of poor fluid management
Inadequate staff knowledge and competence in the effective management of volume assessment leading to over or under hydration within the overall context of holistic clinical assessment and care of the patient
Weaknesses in the systems and processes that support effective fluid management
Insufficient governance of and accountability for effective fluid management

9. Project Brief
An Intelligent Fluid Management Bundle, that contains; policy guidance for assessing, planning, delivering, evaluating and recording intelligent care; and to support its implementation with tools including those for auditing and teaching.

10. What do we know…what we do now does not work effectively…..
that monitoring of input and output will always be an inadequate way of determining hydration state or whether someone is hypovolaemic
it is inappropriate to say or imply that the patient with fluid input equal to urinary output is in zero fluid balance – they are inevitably (because of insensible losses) in negative fluid balance
someone with a charted positive balance of less than 500 mL / day will almost certainly be in negative overall fluid balance.
nurses waste hours completing charts that we know are inaccurate, and never can be made accurate, and which docs don’t take notice of is clearly not sensible

11. Fluid Chart Issues to consider
The twenty four Hour fluid management plan (treatment goal and rationale) is rarely clearly written on the fluid chart or forms part of the care plan
Patients requiring IV fluids rarely have a written clear rationale for requirements
The totalling of twenty four balances are inconsistently completed throughout the day and night, often no action is taken as a result of totalling
The cumulative seven day balance is rarely presented
Hydration Status rarely forms part of the routine clinical handover
Intake:
The section for oral fluids is always the first column on the Fluid Balance Charts (FBC)
The size of the ‘cell’ is the same for all the other fluid intakes e.g. I/V; enteral; NG
All the FBCs have only one cell per hour ( the only difference being North Tees and Hartlepool NHS Trust have divided the cell into two smaller sections per hour.)
Output:
Urine is nearly always in the first column
The cell size is the same for all output
The same as for oral fluids
Generally do not visually present the deterioration of clinical condition
Is there a need for a basic and complex fluid chart?

12. What we do know…
good nursing care will comprise measures to ensure that each patient has an adequate water intake, unless there are good medical reasons for restricting water intake
Good nursing will detect deterioration in a patient's condition
Good nursing will involve the patient and family
Will ensure effective escalation
Retain the accountability for patients safety

13. We could…… Consider not charting fluids routinely
Nurses / Carers could offer and help all patients (not NBM) to have a drink regularly so that over the course of every three hours during the day a cupful (200mls) is consumed
Hourly rounding could focus on fluid management
Handover tools could incorporate hydration status
Recording postural BP could be done once daily in all patients – a fall indicates likely intravascular volume depletion
Recording body weight once per day in all patients – fall of more than 0.2Kg per day indicates likely dehydration.
Agree that 1500 mls is the optimal fluid intake (unless clinically indicated)

14. We could also...
Agree that a positive balance of 500mls (unless clinically indicated) is a trigger for escalating care
Agree that an input of mls or more (unless clinically indicated) triggers escalation of care
Routinely include liquid in food as part of charted fluid intake
Agree principles of effective charting
Use colour charts for assessment of urine concentration
Use estimating techniques for incontinent patients as per the Hartlepool Model
Share all this information with patients and families so they can be involved in the care and hold us to account
Redesign fluid charts and incorporate visual risk cues

15. Critical Questions for the WebEx
Have we understood the issues – we are not trying to create a medical consensus on the medical management – but recognise that the medical management drives the care
Have we identified the right changes to improve the nursing contribution?
If we do these things will we be doing something that will result in different outcomes for community and acute care?
What else do we need to consider?