REVIEW
Fluid stewardship in East Lancashire hospitals : Part 1
The creation of a Fluid Stewardship Committee at Royal Blackburn Hospital in the UK has led to better systems , processes and innovations to support effective intravenous fluid prescribing and management
Alistair Gray BSc ( Hons ) MRPharmS DipClinPharm Clinical Services Lead Pharmacist , East Lancashire Hospitals NHS Trust , Lancashire , UK
I first heard the term ‘ fluid stewardship ’ in a corridor conversation with our Acute Care Team lead nurse , Jane Dean , in 2019 ; who , in turn , had only recently come across it in a tweet from the International Fluid Academy . 1 The term struck a chord ; it sounded like ‘ antimicrobial stewardship ’, so surely must be about everything to do with the safe and effective management of fluids in hospitals ?
The term appears to have been coined in the mid-2010s , with most definitions focusing on the clinical aspects of fluid management . For example , ‘ the primary goal of fluid stewardship is to optimise clinical outcomes while minimising unintended consequences of intravenous fluid administration ’. 2 However , the outcome of the corridor conversation resulted in a more holistic description for my Trust – we wanted to cover all aspects of fluid management and developed a list ( Figure 1 ) that we circulated to some like-minded , ‘ fluid-thinking ’ colleagues . Within a fortnight , the Trust ’ s Fluid Stewardship Committee was formed , with multidisciplinary membership from the consultant body , nursing , pharmacy , and Quality & Safety . Our aim was to examine and optimise all the areas on our list .
The remainder of this article describes our journey so far ; a follow-up article will describe how the developments mentioned have progressed .
The Fluid Stewardship Committee The committee initially met fortnightly while we assessed what was required , and who should take responsibility for what . The professional leads took responsibility for the educational elements for their respective professions , although there was much overlap . The pharmacy elements were led by me with support from two colleagues . Our Quality & Safety lead kept us all in check ; sticking to the agenda and helping figure out how we could measure outcomes .
NICE Clinical Guideline 174 The National Institute for Health and Care Excellence ( NICE ) published Intravenous fluid therapy in adults in hospital 3 in 2013 , and which was the standard used to develop our educational programme and support materials . It describes how to assess and prescribe fluids for the most common indications ( with caveated exclusions for patient groups with more specialised fluid prescribing needs ). It introduces the concept of ‘ The 5 Rs ’: Resuscitation fluid ; Routine maintenance fluid ; Replacement fluid ; and Redistribution fluid ; showing algorithms for each element covering assessment and prescribing , with the fifth ‘ R ’ Reassessment underpinning them all .
On one level , this is all one needs to know to manage those scenarios ; however , there are many myths perpetuated from the time before the guidance , with many having been developed through the perceived wisdom of practice rather than being taught . There is a paucity of education in Schools of Medicine , Pharmacy and Nursing surrounding the teaching of fluid prescribing , with mnemonics such as ‘ one bag of salt to two bags of sugar ’… or is it ‘ two bags of salt to one of sugar ?’ persisting with some of the more experienced clinicians . And this custom gets passed down the years , resulting in large volumes of sodium chloride 0.9 % being inappropriately prescribed and administered , giving patients ( irrespective of their body weight and fluid requirements ) 154mmol of sodium and chloride with every litre infused : which is more than twice the daily requirements for a 70kg individual .
Harm can and does occur . The National Confidential Enquiry into Perioperative Deaths reported that up to one in five patients who had received IV fluids suffered from complications or morbidities due to inappropriate prescribing or administration . 4
Our first task was therefore to try to break this cycle of ‘ fluid learning ’.
Staff engagement and education Key to improving fluid stewardship was disseminating the right knowledge to the doctors ,
16 | Issue 99 | 2021 | hospitalpharmacyeurope . com