Are Further Interventions Needed to Prevent and Manage Hospital-Acquired Hyponatraemia? A Nationwide Cross-Sectional Survey of IV Fluid Prescribing Practices

Abstract

Background: Hyponatraemia is associated with increased morbidity, increased mortality and is frequently hospital-acquired due to inappropriate administration of hypotonic fluids. Despite several attempts to minimise the risk, knowledge is lacking as to whether inappropriate prescribing practice continues to be a concern. Methods: A cross-sectional survey was performed in Danish emergency department physicians in spring 2019. Prescribing practices were assessed by means of four clinical scenarios commonly encountered in the emergency department. Thirteen multiple-choice questions were used to measure knowledge. Results: 201 physicians responded corresponding to 55.4% of the total population of physicians working at emergency departments in Denmark. About a quarter reported that they would use hypotonic fluids in patients with increased intracranial pressure and 29.4% would use hypotonic maintenance fluids in children, both of which are against guideline recommendations. Also, 29.4% selected the correct fluid, a 3% hypertonic saline solution, for a patient with hyponatraemia and severe neurological symptoms, which is a medical emergency. Most physicians were unaware of the impact of hypotonic fluids on plasma sodium in acutely ill patients. Conclusion: Inappropriate prescribing practices and limited knowledge of a large number of physicians calls for further interventions to minimise the risk of hospital-acquired hyponatraemia.

Impact of a Treatment Guide on Intravenous Fluids in Minimising the Risk of Hospital-Acquired Hyponatraemia in Denmark

“…(1) Although the response rate was moderate in both the pre-and post-intervention surveys (55% and 42% of the total population of physicians working at emergency departments in Denmark [37], respectively), compared to physicians' general low response rate in surveys [35,38,39], the non-probability sample design may limit the generalisability of our results. However, our previous study did not find any predicting factors of prescribing practice [8]. Additionally, our results did not change after adjustment for imbalances of background characteristics.…”

“…We conducted a survey to assess prescribing practices before and after distribution of a treatment guide aimed at minimising the risk of hospital-acquired hyponatraemia in Denmark. In this before-and-after cross-sectional study, the pre-measurement was performed in spring 2019 (from March through May) [8]. The treatment guide was distributed two times.…”

“…To investigate the national need for risk minimisation measures beyond the regular product information, the Danish Medicines Agency conducted a survey in 2019 [8]. About a quarter of the 201 responding health care professionals reported that they would use hypotonic fluids in patients with increased intracranial pressure, and 29.4% would use hypotonic maintenance fluids in children, both of which are against guideline recommendations [9][10][11][12][13].…”

“…Moreover, only 29.4% selected the correct fluid, a 3% hypertonic saline solution, for a patient with hyponatraemia and severe neurological symptoms, which is a medical emergency [10, [14][15][16]. Hence, the Danish Medicines Agency concluded that further interventions to minimise the risk of hospital-acquired hyponatraemia were warranted in Denmark [8]. Subsequently, in June 2020, the Danish Medicines Agency decided together with the Danish Patient Safety Authority to distribute a treatment guide (pocket-folder) with basic information on IV fluids and hyponatraemia to all emergency departments in Denmark (see Supplementary Materials).…”

“…Characteristics of the emergency departments (EDs) were based on a report of EDs by the Danish Ministry of Health[18] 7. Complexity of services they provide 8. Combined general population EDs provide care for all patients in one area, while separate general population EDs provide care to children and adults in separate locations within a facility.…”