Order Substitutions and Education for Balanced Crystalloid Solution Use in an Integrated Health Care System and Association With Major Adverse Kidney Events

Bledsoe, Joseph; Peltan, Ithan D.; Bunnell, R J; Brown, Samuel M.; Jephson, Al; Groat, Danielle; Levin, Nicholas M.; Wilson, Emily L.; Newbold, Jon; Fontaine, G; Frandsen, Joe; Hasleton, David; Krakovitz, Paul; Brunisholz, Kim; Allen, Todd L.

doi:10.1001/jamanetworkopen.2022.10046

Cited by 7 publications

(7 citation statements)

References 37 publications

(87 reference statements)

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“…In 2019, as a response to the lack of real-world effectiveness data as well as a dearth of implementation methodology for this practice, we performed a prospective type II hybrid implementation-effectiveness study across 22 hospitals' general emergency departments (EDs) and adult inpatient units within the Intermountain system *. We demonstrated an improvement in both clinical outcomes, with a 2.2% absolute reduction in major adverse kidney events at 30 days, and implementation outcomes, with a significant increase in the percentage of balanced crystalloid fluids prescribed from 28% to 75% 5. Implementation methods included traditional education with fact sheets, presentations at department meetings, and order substitutions and a just-in-time alert embedded in the electronic health record (EHR).…”

Section: Case 1: Changing Fluid Resuscitation From Normal Saline To L...mentioning

confidence: 96%

The Importance of Organizational Structure in Implementing Evidence-Based Best Practice

Sakata

Fowles

Knighton

et al. 2023

Quality Management in Health Care

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Section: Case 1: Changing Fluid Resuscitation From Normal Saline To L...mentioning

confidence: 96%

The Importance of Organizational Structure in Implementing Evidence-Based Best Practice

Sakata

Fowles

Knighton

et al. 2023

Quality Management in Health Care

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“…Bledsoe and colleagues provide an excellent example of how a large, integrated health system can break the inertia of “the way we’ve always done it” and effectively implement the slightly better of two available therapies, at scale. In just 16 months, their implementation was associated with changes in the care of nearly 150 000 patients.…”

Section: What Is the Role Of Health Systems In Generating And Impleme...mentioning

confidence: 99%

“…Currently, pharmaceutical companies do not have the incentive and national clinical trial networks do not have the capacity or resources to conduct acute care trials at this scale—but health systems could. In just 16 months with only institutional funding, Bledsoe and colleagues used tools within the electronic health record to (1) enroll nearly 150 000 eligible patients, (2) separate the two study groups with regard fluid receipt (balanced crystalloids vs saline), and (3) collect, analyze, and report clinical outcomes. Had the health system applied these exact same methods, but replaced the before-and-after design with a parallel-group, cluster-randomized, or cluster-crossover design, the results would have provided rigorous evidence on the effect of fluid choice on outcomes at a scale unprecedented for any comparative effectiveness question in acute care.…”

Section: What Is the Role Of Health Systems In Generating And Impleme...mentioning

confidence: 99%

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Intravenous Fluids—A Test Case for Learning Health Systems

Semler

2022

JAMA Netw Open

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Bledsoe and colleagues 1 present the results of the I USE LR study. This before-and-after study evaluated the outcomes associated with an implementation intervention promoting use of lactated Ringer solution rather than saline solution among nearly 150 000 patients across 22 hospitals. The intervention used education and changes to the electronic order entry system to affect which fluid patients received beginning immediately at hospital presentation. The proportion of intravenous fluid administered that was lactated Ringer increased (from approximately 25% to 75%) and the use of saline decreased (from approximately 75% to 25%). In interrupted time series analysis, implementation of lactated Ringer was associated with a 2% absolute risk reduction in death, new receipt of kidney replacement therapy, or persistent kidney dysfunction. This effect size was greater for patients with sepsis and patients who received more fluid. This study raises important questions about the choice between lactated Ringer and saline and, more broadly, how we should make evidence-based choices between widely available, commonly used treatment alternatives in acute care. What Magnitude of Difference in Clinical Outcomes Should Determine the Choice Between Two Available Treatments?Explanatory trials evaluating the efficacy and safety of adding a new drug or device to current clinical care (A vs A-plus) are traditionally powered to detect the smallest difference in clinical outcomes that would justify incorporating the new treatment into care, considering its added risks, costs, and burdens. For example, the median minimal clinically important difference in mortality targeted by acute care trials has been approximately 8%, implying that smaller differences in mortality might not justify incorporation of the new treatments into care. These types of trials ask, "is this new treatment better than current care by enough to offset the added cost and risk?" In contrast, when attempting to select between two treatments (A vs B) that are already extensively used in current care, widely available, and similar in cost, the concept of a minimal clinically important difference is less relevant.If availability and cost are similar, then the clinical question is simply, "which treatment is more likely to produce a better patient outcome?" The choice between balanced crystalloids and saline exemplifies such a comparative effectiveness question, and the unique challenges faced in determining which of two common treatments is better when essentially any difference in patient outcomes would be sufficient to drive practice.Balanced crystalloids (like lactated Ringer) and saline are the two commonly available options for intravenous isotonic crystalloid infusion. Both have been used for over a century, are widely available, and cost approximately $1 per liter to manufacture. More than 30 million patients in the United States receive these fluids each year. Because treatment with these fluids is so ubiquitous, differences in outcomes that might seem small at t...

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“…This implies that there is a high probability that balanced fluids reduce mortality in adults, but the effect size is very small. However, for an intervention as frequently used as IV fluid therapy, even very small effect sizes could be important (14). For example, a true 0.1% absolute reduction mortality between balanced fluids and 0.9% saline in children admitted to PICU would equate to at least 200 preventable deaths annually in the United States alone (15).…”

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confidence: 99%

Balancing Fluid Resuscitation in Pediatric Sepsis*

Branco

2023

Pediatric Critical Care Medicine

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F luid resuscitation remains a mainstay of sepsis treatment in children and adults. Historically, pediatric guidelines endorsed early, "aggressive" fluid resuscitation for children with sepsis. Compliance with these guidelines, that often-included large amount of fluid resuscitation, led to early recognition of sepsis and significant reductions in mortality in both developed and developing countries (1). More recently, however, there is growing recognition that IV fluids are not innocuous. Both quantitative and qualitative aspects of fluid resuscitation are being questioned, and concerns over issues such as fluid overload or fluid-induced hyperchloremic acidosis are being increasingly debated. These changes were reflected on the most recent pediatric Surviving Sepsis Campaign recommendations, that now support a more individualized approach to the use of fluid boluses and recommend the use of balanced/buffered crystalloids over 0.9% saline for the initial resuscitation of children with septic shock (2).The latter recommendation on balanced fluids was based on "very low quality of evidence" and the Campaign appropriately called for further high-quality pediatric data. In this issue of Pediatric Critical Care Medicine, Fernández-Sarmiento et al (3) make their important contribution to this topic. The authors assessed glycocalyx disruption associated with balanced and unbalanced fluid boluses in children with sepsis. The authors measured perfused boundary region (PBR) on sublingual video microscopy to assess endothelial glycocalyx thickness and blood levels of syndecan-1 as a biomarker for glycocalyx degradation. The study found that glycocalyx thickness decreased significantly 6 hours after fluid bolus in children receiving unbalanced fluids, while it remained mostly unchanged in children receiving a balanced fluid. The glycocalyx thickness reduction was associated with chloride and albumin levels, as well as markers of infection and inflammation. This is a very interesting topic because the glycocalyx regulates many of the key pathophysiological processes associated with sepsis and organ dysfunction. The glycocalyx is a ubiquitous protective layer lining the luminal surface of endothelial cells. It functions as more than just a physical barrier, it regulates essential aspects of microvascular homeostasis, helping to control microvascular permeability, mediate shear-induced vasorelaxation, and modulate cellwall interactions (4, 5). Glycocalyx loss exposes the endothelium and leads to increased fluid shift, edema, loss of vascular responsiveness, and leukocyte/ platelet endothelial interaction with increased inflammation and hypercoagulability. Controlling these processes would likely have a massive effect on the management and outcome of patients with sepsis.Although the glycocalyx was first visualized more than 50 years ago, its direct visualization in vivo remains a challenge. In the study by Fernández-Sarmiento et *See also p. 213.

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Order Substitutions and Education for Balanced Crystalloid Solution Use in an Integrated Health Care System and Association With Major Adverse Kidney Events

Abstract: This comparative effectiveness research study investigates the association of order substitutions and education for the use of lactated Ringer solution with major adverse kidney events in an integrated health care system.

Cited by 7 publications

References 37 publications

The Importance of Organizational Structure in Implementing Evidence-Based Best Practice

The Importance of Organizational Structure in Implementing Evidence-Based Best Practice

Intravenous Fluids—A Test Case for Learning Health Systems

Balancing Fluid Resuscitation in Pediatric Sepsis*

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