Improving Isotonic Maintenance Intravenous Fluid Use at a Tertiary Children’s Hospital

Abstract

OBJECTIVES: Maintenance intravenous fluids (IVFs) are routinely used in the care of hospitalized children. The American Academy of Pediatrics (AAP) published clinical practice guidelines in November 2018 that recommended the use of isotonic maintenance IVF. Our primary aim was to increase the proportion of hospital days pediatric inpatients were exclusively administered isotonic maintenance IVF to ≥80% by May 2020 at our institution. METHODS: We conducted a single-center quality improvement (QI) study as part of an AAP collaborative. An interdisciplinary team led QI interventions including providing targeted education to clinicians, integrating guideline recommendations into the electronic medical record, engaging hospital leaders, and providing performance data to clinicians. Our study population included children ages 28 days to 18 years admitted to inpatient wards. Our primary outcome was the proportion of hospital days with exclusive isotonic maintenance IVF use. Balancing measures included transfers to the ICU, ordering of serum sodium laboratory tests, and adverse events. Data were analyzed by using statistical process control. RESULTS: We analyzed 500 hospital admissions and found a significant increase in exclusive isotonic IVF use (63% to 95%) within 9 months of starting our QI intervention. We found no significant changes in balancing measures (serum sodium laboratory tests [24% to 25%], ICU transfer [0.3% to 1%], adverse events [0.3% to 1%]). CONCLUSIONS: Our interdisciplinary QI team led interventions that were associated with significant improvements in isotonic IVF use, in accordance with AAP clinical practice guidelines. With our study, we provide detailed guidance on successful interventions for implementing this evidence-based guideline.

Closing the Fluid Gap: Improving Isotonic Maintenance Intravenous Fluid Use in a Community Hospital Network

“…Other recent publications have described the use of targeted education, clinical support in the EHR, and order set revisions as we used, as well as performance practice review in successfully making the transition to isotonic IVF in children in a pediatric emergency department (ED), 16 at an urban academic tertiary medical center, 17 on a resident-led inpatient unit, 18 and as part of a large multicenter AAP-sponsored project. 19 To our knowledge, this is the first report of IVF guideline implementation in a community hospital setting.…”

Control charts for evaluation of quality of low-dose-rate brachytherapy for prostate cancer

“…Statistical process control is used in multiple fields of medicine, including infectious disease and preventive medicine [ 20 , 21 ], orthopedics [ 22 ], pediatrics [ 23 ], and for improving bio-pharmaceutical manufacturing processes and operations [ 24 ]. In radiation oncology, it was described in multiple publications, including investigating energy variations in tomotherapy [ 25 ], and for assessing the quality of high-dose-rate (HDR) brachytherapy treatment delivery [ 26 ].…”

Fluid management of the critically Ill child

“…This recommendation, published as evidence-based consensus guidelines, excludes patients with cardiac disease, neurosurgical disorders, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhoea or severe burns [17]. As these guidelines were published, centres have shown success in increasing use of isotonic maintenance IVF in children in the emergency department [18] and admitted to the hospital [19,20] by means of quality improvement interventions.…”