FIGURE 3
Baseline audit results of indications for fluid prescriptions
are now generated weekly by pharmacy assistants , which are topped-up when the regular stock medicines are ordered for each ward . This has resulted in time efficiencies because each ward now typically only receives one fluid order / week , which in most cases can be accommodated on the ward because fluids used infrequently have been removed . If a patient has a genuine need for a less frequently supplied fluid , this must now be screened by a ward pharmacist to sense-check it is appropriate , and , if necessary , an individual supply will be ordered .
With the introduction of Maintelyte ® , members of the pharmacy team took the opportunity to review , with each ward manager , what their wards empirically needed . This included removing some fluids that did not appear to have an indication and adding Maintelyte ® on to each stock list . Initially the amount stocked of each fluid was a best guess , and we have monitored each ward ’ s usage
FIGURE 4
Type and frequency of fluid prescribed and their recorded indications
10 9 8 7 6 5 4 3 2 1 0
4 %
13 %
13 %
50 %
Resuscitation Redistribution Indication not stated in notes
Plasma-Lyte 148 ® Sodium
chloride 0.9 %
20 %
Resuscitation Redistribution Routine maintenance Replacement Indication not stated in the notes
Routine maintenance Replacement
Maintelyte ®
|
Other |
NaCl 0.18 % |
|
|
Gluc 4 % |
|
|
KCl 0.15 % |
with subsequent tailoring of quantities . Figure 2 shows the effect on the two fluids that Maintelyte ® ostensibly replaces ; however , its use across the Trust far exceeds what was replaced , possibly suggesting the ease of prescribing has led to increased usage . However , the baseline prescribing audit shows things in a different light .
First prescribing audit With all these changes we wanted to get an idea of how well fluids were being prescribed , prior to further developments being introduced . We were fortunate to have a fourth-year medical student with an interest in fluid stewardship , and in need of an audit , so an audit was designed and tested on two medical wards in February 2021 .
The primary aim was to collect and analyse Trustwide baseline data on fluid prescribing in relation to the standards in NICE CG174 . It was also hoped to identify any barriers to appropriate fluid prescribing and evaluate the impact of education on fluid prescribing standards .
Figure 3 shows the audit ’ s findings of whether the indication for a fluid prescription was recorded in the notes . In half the prescription charts examined no clear indication was documented ; what was not examined , and might feature in a future audit , is whether the indications that were captured were accurate and appropriate for the clinical situation of the patients . Our current prescription chart does not provide space to capture an indication for a fluid , although it does for other regular or whenrequired medicines . The audit provided evidence of patients ’ weights being recorded ( 70 % were recorded ; 30 % were not ) which has a significant bearing on a pharmacist ’ s ability to clinically check the appropriateness of the volume of fluid prescribed for routine maintenance , redistribution , and resuscitation .
The audit examined the frequency of types of fluid prescribed ( Figure 4 ) and correlated this with the indication . As well as reinforcing the lack of indication in half of the prescriptions we found that fluids were being prescribed for an inappropriate indication ; for example , Plasma-Lyte 148 ® was used as routine maintenance in one patient ; sodium chloride 0.9 % had been erroneously used , where the indications were recorded , when our guidance was to use Plasma-Lyte 148 ® prescribed for redistribution and resuscitation and Maintelyte ® for routine maintenance ; and Maintelyte ® had been used for redistribution when its sole indication is routine maintenance .
The volumes prescribed were recorded , with 93 % ( n = 28 ) being 1000ml and 7 % ( n = 2 ) being 250ml . A tailored volume should be prescribed for replacement , redistribution , and routine maintenance such that , when rounded to the nearest 100ml , volumes other than 1000ml prescribed in many cases would be expected .
Junior doctors were asked to complete a questionnaire in the same period the audit took place to capture their perceptions and understanding of fluid stewardship . The results are shown in Table 1 and perhaps explain the audit findings , with junior doctors confident in their prescribing of fluids , although the audit shows this is starkly misplaced ; feeling they receive good training as an undergraduate , while slightly less so on the job ; and that they would benefit from further training … although none of them had watched the films on the intranet .
Clearly there is much work to do regarding the education and engagement of junior doctors .
18 | Issue 99 | 2021 | hospitalpharmacyeurope . com