HPE 99 – October 2021 Issue | Page 17

FIGURE 1

East Lancashire Hospitals ’ Fluid Stewardship Committee ’ s list of areas to optimise fluid management

• Assessment of fluid requirements – oral or IV

• Prescribing fluids appropriately

• Administration of fluids , including use of smart pumps

• Monitoring patients receiving fluids

• Monitoring range and turnover of fluids on wards

• Procurement of fluids and giving sets

• Storage – bulk store and ward storage

• Ordering fluids by wards – process , and wards ’ stocklists

• Education of doctors , nurses , pharmacists , advanced clinical practitioners , other non-medical prescribers , health care assistants - on induction and for existing staff

• Audit – figuring out what , and how we check everything is ‘ just so ’

pharmacists , and nurses . To achieve consistency of message , and to ensure all important elements of fluid management were covered , we decided to produce a suite of short films describing :

• the concept of fluid stewardship

• fluid resuscitation

• routine maintenance fluid

• fluid replacement and fluid redistribution . The films were made with the assistance of Dr

Justin Roberts ( ICU Consultant with a fluid interest ), who is also a key member in the Fluid Stewardship Committee and has helped drive the prescribing effectiveness side of the programme .

A fifth film examining fluid balance in more detail is now included in the suite .

Our films were uploaded to a new fluid stewardship page of the intranet , with additional summary points under each embedded film to act as aide memoirs once each film had been viewed . The films have also been posted on the Trust ’ s internet , so a wider audience can view them and perhaps use them as educational tools , or inform their own fluid stewardship programmes .

FIGURE 2

Number of bags of routine maintenance fluids issued ( Jul 2020 – June 2021 )

1600

1400

1500

1000

800

600

400

Maintelyte 1L NaCl 0.18 % / Gluc 4 % / KCl 0.3 % 1L NaCl 0.18 % / Gluc 4 % / KCl 0.15 % 1L

There is a paucity of education in Schools of Medicine , Pharmacy and Nursing surrounding the teaching of fluid prescribing

Nurse practice educators were charged with informing the nursing staff ; the critical care directorate consultant training lead took responsibility for doctors , and I arranged a series of education events for pharmacists and preregistration pharmacists , with our induction programme for new pharmacists including a fluid stewardship element . Since July 2021 , I have also delivered a fluid stewardship training session to the new FY1 intake as part of their core induction .

We are fortunate in that the Trust has made significant investment in the pharmacy team through our Dedicated Ward Pharmacy service . This means most wards have a dedicated pharmacist , with enhanced pharmacy technician resource , so pharmacists can routinely participate in the daily consultant-led , multi-disciplinary ward rounds where they can actively influence all aspects of prescribing ( including fluids ), as well as being proactive in discharge planning ( which was historically an oxymoronic term ). ^{6 , 7} Pharmacists , empowered with the knowledge of our fluid stewardship programme , have become , in effect , ‘ practice educators ’ and ‘ fluid stewards ’ for the pharmaceutical aspects of fluid management on each ward .

Introduction of a new maintenance fluid The recommendation of CG174 for routine maintenance fluid is to use a ‘ balanced fluid ’ that delivers the basic daily water and electrolyte requirements for an adult . That is :

• 25ml / kg / day of water – in practice rounded to the nearest 100ml , and only 20ml / kg / day for patients who are : frail ; have renal impairment or cardiac failure ; or who are malnourished

• 1mmol / kg / day of potassium , sodium , and chloride

• 50 – 110g glucose / day to limit starvation ketosis ( NB that this amount of glucose does not meet a person ’ s nutritional needs ).

Historically we had used sodium chloride 0.18 % in glucose 4 % with potassium chloride ( 0.15 % or 0.3 %), which is complicated to prescribe , and get right on a paper prescription chart ( the Trust does not yet have electronic prescribing ). Our fluid supplier ( Baxter ) recently introduced a product called Maintelyte ^® , ⁸ that closely matches CG174 ’ s recommendation for maintenance fluid content . The shorter , memorable , and more meaningful name was an attractive way to make prescribing for this indication easier , safer , and effective , so we sought and gained approval to use it in the Trust from the Medicines Management Board .

It was launched at the beginning of December 2020 with communications through the various professions ’ channels within the Trust , and posters in treatment rooms , and was referred to in our engagement film on routine maintenance fluid .

Reassessment is an important aspect of routine maintenance fluid monitoring , and we recommend checking electrolyte serum concentrations two to three times a week . Maintelyte ^® contains 20mmol KCl in each litre bag , which equates to around 0.5mmol / kg / day potassium if dosed correctly , so occasional supplementation of additional potassium with our original maintenance fluid is required .