Introducing NICE guidelines for intravenous fluid therapy into a district general hospital

Abstract

Background: National Institute for Health and Care Excellence (NICE) guidelines on intravenous fluid prescribing for adults in hospital, issued in 2013, advised less use of 0.9% sodium chloride than current practice, provided a logical system for prescribing and suggested further study of electrolyte abnormalities.

Aims: To describe the steps taken to establish and monitor guideline introduction and to assess effects on clinical biochemistry results, in a general hospital setting.

Methods: We used established principles of change to modify education, teaching, record keeping and audit throughout the hospital, changed the availability of intravenous fluid preparations in the wards and monitored the use of intravenous fluids. We anonymously linked local clinical chemistry records to nationally available patient records (NHS Scotland SMR01). We chose specified medical emergencies, and major emergency and elective general and orthopaedic surgery, where management would require intravenous fluids, for a two-phase cross-sectional study between 2007 and 2017, spanning the change in prescribing. Primary outcomes were abnormal bicarbonate, sodium, potassium and incidence of acute kidney injury (AKI), and secondary outcomes were mortality and length of stay.

Results: Over the study period, sodium chloride 0.9% use decreased by 75%, and overall intravenous fluid use decreased from 0.65 to 0.40 L/occupied bed day. The incidence of acidosis decreased from 7.4% to 4.8% of all admissions (difference -2.7%, 95% CI -2.1 to -3.0). No important changes in other electrolytes were noted; in particular, plasma sodium values showed no adverse effects. Stage 1 AKI increased from 6.7% to 9.0% (difference 2.3%, 95% CI 1.6 to 3.0), but other causes for this cannot be excluded. Mortality and length of stay showed no adverse effects.

Conclusions and implications: Effective implementation of the guidelines required substantial time, effort and resource. NICE suggestions of fluid types for maintenance appear appropriate, but prescribed volumes continue to require careful clinical judgement.

Keywords: clinical practice guidelines; health professions education; quality improvement.

Conflict of interest statement

Competing interests: MMD has been a member of advisory panels on intravenous fluids for Baxter Healthcare and has given educational talks on fluid guidelines for Baxter Healthcare and Teva Healthcare.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

Monthly fluid use over the study period. (A) Changing use of total fluid, 0.9% sodium chloride, balanced electrolyte solutions (Hartmann’s solution and Plasma-Lyte) and the introduction of 0.18% sodium chloride and 4% glucose as a maintenance fluid. (B) Changes in the pattern of maintenance fluid use and potassium supplements over the same period. Before time mark B, all fluids containing potassium are shown, that is, 0.9% sodium chloride with potassium and 5% glucose with potassium. Note the different scale for fluid volume. Time marks apply to both panels and indicate: A: start of fluid education, B: Guidelines introduced and C: sustained campaign to encourage 0.18% sodium chloride and 4% glucose solutions with potassium.

Figure 2

Association between the use of 0.9% sodium chloride (solid line) and the quarterly incidence of acidosis (filled circles), over the early study period. Time marks indicate: A: start of fluid education and B: guidelines introduced.

Figure 3

Proportional usage of intravenous crystalloid fluids in Scottish health boards, ranked in decreasing order of proportional use of 0.9% sodium chloride, for the financial years 2017 and 2018. The effect of implementing the NICE guidelines is clear, comparing NHS Fife to the pattern of use in other health boards. Note the greater use of 0.18% sodium chloride and 4% glucose, the limited use of 5% glucose and a smaller proportion of use of 0.9% sodium chloride, indicating maintenance prescribing based on the NICE guidelines. The two columns adjacent to NHS Fife show the start of similar prescribing in these hospital boards. NHS, National Health Service; NICE, National Institue for Health and Care Excellence.