GUIDANCE NOTES
NICE CG 174: Intravenous fluid therapy in adults in hospital
Background IV fluid therapy has become an essential part of modern health care. It has been estimated that more than 90% of hospital patients receive some form of IV therapy (Corrigan, 2001). However, despite the established and routine use of IV fluid, it is not without its complications. It is estimated that 1 in 5 patients receiving IV fluids and electrolytes experience complications or even death as a result of inappropriate IV fluid administration (National Confidential Enquiry into Perioperative Deaths (NCEPOD),1999; NICE, 2013a). Harm from IV fluid therapy is significantly under-reported because health professionals often fail to appreciate the role that IV fluid has played in a patient’s morbidity and mortality. For example, from the author’s clinical experience, an elderly patient may receive too Katie Scales
Consultant Nurse, Critical Care, Imperial College Healthcare NHS Trust, Charing Cross Hospital and Nurse Member, NICE Guideline Development Group for IV Fluids and NICE Quality Standards Group for IV Fluids, London
S6
much IV fluid and go on to develop acute pulmonary oedema. Pulmonary oedema often leads to pneumonia, which may ultimately be the cause of death. The over-administration of IV fluid will rarely be identified as causation and is unlikely to appear on the death certificate. Equally, the failure to adequately hydrate patients can lead to acute kidney injury, admission to intensive care and a prolonged hospital stay; patients may then go on to develop chronic renal failure and risk becoming dialysis-dependant. The patient’s evolving ill health becomes progressively divorced from the original episode when the patient was allowed to become dehydrated. Despite the potentially devastating effects of over- or under-hydration, scant attention is paid to fluid management within either the nursing or medical curriculum. Nurses receive training in IV therapy but the focus is usually on medication administration, drug calculations and the care of vascular access devices—IV fluid therapy rarely features. Surveys have shown that prescribers of IV fluids have little knowledge of the fluid and electrolyte needs of patients and are unfamiliar with the composition of the different IV fluids that are available (NICE, 2013a). Errors in IV fluid prescribing are most commonly found in general medical and surgical wards where fluid prescribing is often left to the most junior member of the team. The NICE guideline aims to help prescribers to understand the (NICE, 2013a): ■■ Physiological principles that underpin fluid prescribing ■■ Pathophysiological changes that affect fluid balance in disease states ■■ Indications for IV fluid therapy ■■ Reasons for the choice of the various fluids available ■■ Principles of assessing fluid balance. This is one of the most practical guidelines ever produced by NICE and includes four algorithms to guide assessment and prescribing (NICE, 2013b). CG 174 also includes a helpful and informative diagram that explains the fluid and electrolyte losses associated with different clinical situations (NICE, 2013c). These are available as posters for use in the clinical area and can be downloaded from the NICE website. There is also a poster summarising the electrolyte content of the most commonly used IV fluids (NICE, 2013d), which should help
prescribers to select the most appropriate fluid for the patient’s clinical condition. Too often, IV fluid prescribing is an ad hoc event because the current bag of fluid is about to finish. The next bag of fluid may be prescribed without clinically reviewing the patient, their fluid balance, their observations or their blood results. CG 174 requires doctors and nurses to pay greater attention to fluid prescribing and clinical monitoring. Prescribing must be based upon the clinical needs of each individual patient and nurses should know whether the prescription they are following is clinically appropriate. IV fluid prescribing can be protocolised under four broad headings (NICE, 2013a): ■■ Fluid resuscitation ■■ Regular maintenance fluid ■■ Replacement of losses ■■ Fluid redistribution. Fluid redistribution generally refers to patients who have developed oedema or effusions from excess salt and water. In order to determine the correct protocol for each patient, the prescribing process should start with a comprehensive assessment. Having administered IV fluid, it is essential to reassess the patient as their needs may have changed. CG 174 (NICE, 2013a) describes this process as the 5 Rs: ■■ Resuscitation ■■ Routine maintenance ■■ Replacement ■■ Redistribution ■■ Reassessment. CG 174 contains evidence-based recommendations about the general principles that underpin the prescription and monitoring of IV fluid therapy; it does not cover the practical aspects of fluid administration.
Key priorities for implementation The guideline development group (GDG) identified ten priorities for implementation. These have been summarised below (further detail is available on the NICE website): ■■ When prescribing IV fluids, remember the 5 Rs (listed in previous section) ■■ Offer IV fluid therapy as part of a protocol (see Algorithms for IV fluid therapy in adults (NICE, 2013b)) ■■ Patients should have an IV fluid management plan, which should include details of the fluid and electrolyte prescription over the next 24 hours and the required monitoring. This
© 2014 MA Healthcare Ltd
T
he National Institute for Health and Care Excellence (NICE) produces evidence-based guidelines and advice for health care, public health and social care practitioners (NICE, 2014a). If a topic such as intravenous (IV) fluid therapy in adults has received a referral for the development of a NICE Quality Standard, an independent group within NICE will develop Quality Standards to help drive and measure the recommended quality improvements (NICE, 2014a). Quality standards are intended for use by both providers and commissioners of health and social care services. The IV fluid therapy guideline (CG 174) was commissioned by the Department of Health (DH) and the Welsh Assembly Government in February 2010 to improve the quality of IV fluid prescribing in hospital (NICE, 2014b). The scope of the guideline was developed in consultation with registered stakeholders and a guideline development group was appointed in 2011. The guidance was released for stakeholder consultation in May 2013 and the final guideline was published in December 2013. The Quality Standards associated with the guidance are under development and are scheduled for publication in August 2014 (NICE, 2014c).
British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 8
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 7, 2015. For personal use only. No other uses without permission. . All rights reserved.
GUIDANCE NOTES ■■ Hospitals should establish systems to ensure that
all health professionals involved in prescribing and delivering IV fluid therapy are trained on the principles covered in this guideline, and are then formally assessed and reassessed at regular intervals to demonstrate competence ■■ Hospitals should have an IV fluids lead, responsible for training, clinical governance, audit and review of IV fluid prescribing and patient outcomes. CG 174 is accompanied by a baseline assessment tool that can be used to assess whether practice meets the recommendations set out by NICE (2013e). A clinical audit tool is also available from the NICE website. An ‘information for the public’ leaflet has been produced to help patients understand the recommendations and ask questions about their IV fluid therapy (NICE, 2013f). Nurses will need a good understanding of IV fluid and electrolyte therapy to respond appropriately to questions from patients and carers. Undergraduate and postgraduate education needs to change to meet the requirements of CG 174. Nurses must know the fluid and electrolyte requirements of their patients and must be confident to challenge poor prescribing. Clear guidance on the prescription and
monitoring of IV fluids and electrolytes and on the education and training of hospital staff was long overdue. This guideline will be challenging to deliver but its impact on care for hospital BJN patients should be far reaching. Corrigan A (2001) History of Intravenous Therapy. In: Hankins J, Waldman RL, Henrick C, Perdue M, eds. Infusion Therapy in Clinical Practice, 2nd edn. WB Saunders, Philadelphia National Confidential Enquiry into Perioperative Deaths (1999) Extremes of age. The 1999 Report of the National Confidential Enquiry into Perioperative Deaths. NCEPOD, London National Institute for Health and Care Excellence (2013a) Intravenous fluid therapy in adults in hospital (CG174). NICE, London. http://guidance.nice.org.uk/CG174 (accessed 8 April 2014) National Institute for Health and Care Excellence (2013b) Algorithms for IV fluid therapy in adults. NICE, London. http:// tinyurl.com/o7e6csy (accessed 8 April 2014) National Institute for Health and Care Excellence (2013c) Diagram of ongoing losses. http://tinyurl.com/qggtugn (accessed 8 April 2014) National Institute for Health and Care Excellence (2013d) Composition of commonly used crystalloids. http://tinyurl. com/q6p7hrg (accessed 8 April 2014) National Institute for Health and Care Excellence (2013e) CG174 Intravenous fluid therapy in adults in hospital: baseline assessment tool. http://tinyurl.com/pd7ezfw (accessed 8 April 2014) National Institute for Health and Care Excellence (2013f) Intravenous fluid therapy for adults in hospital. About this information. http://tinyurl.com/p9vk9uw (accessed 15 April 2014) National In stitute for Health and Care Excellence (2014a) What we do. http://tinyurl.com/7lheccn (accessed 8 April 2014) National Institute for Health and Care Excellence (2014b) Intravenous fluid therapy. http://tinyurl.com/q2d5akg (accessed 8 April 2014) National Institute for Health and Care Excellence (2014c) NICE quality standards. http://tinyurl.com/p3aqyk7 (accessed 8 April 2014)
© 2014 MA Healthcare Ltd
plan should be reviewed daily by an expert until the patient is stable ■■ Assess the patient’s likely fluid and electrolyte needs from their history, clinical examination, current medications, clinical monitoring and laboratory investigations ■■ All patients receiving IV fluids need regular monitoring. This should initially include at least daily reassessments of clinical fluid status, laboratory values (urea, creatinine and electrolytes) and fluid balance charts, along with weight measurements twice weekly ■■ Clear incidents of fluid mismanagement (e.g. unnecessarily prolonged dehydration or inadvertent fluid overload as a result of IV fluid therapy) should be reported through standard critical incident reporting to encourage improved training and practice ■■ If patients need IV fluid resuscitation, use crystalloids that contain sodium in the range 130–154 mmol/litre, with a bolus of 500 ml over less than 15 minutes ■■ If patients need IV fluids for routine maintenance alone, restrict initial prescription to: 25–30 ml/kg/day water, approximately 1 mmol/kg/day potassium, sodium and chloride, and approximately 50–100 g/day glucose to limit starvation ketosis
S8
British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 8
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 7, 2015. For personal use only. No other uses without permission. . All rights reserved.
NICE CG 174: Intravenous fluid therapy in adults in hospital
Background IV fluid therapy has become an essential part of modern health care. It has been estimated that more than 90% of hospital patients receive some form of IV therapy (Corrigan, 2001). However, despite the established and routine use of IV fluid, it is not without its complications. It is estimated that 1 in 5 patients receiving IV fluids and electrolytes experience complications or even death as a result of inappropriate IV fluid administration (National Confidential Enquiry into Perioperative Deaths (NCEPOD),1999; NICE, 2013a). Harm from IV fluid therapy is significantly under-reported because health professionals often fail to appreciate the role that IV fluid has played in a patient’s morbidity and mortality. For example, from the author’s clinical experience, an elderly patient may receive too Katie Scales
Consultant Nurse, Critical Care, Imperial College Healthcare NHS Trust, Charing Cross Hospital and Nurse Member, NICE Guideline Development Group for IV Fluids and NICE Quality Standards Group for IV Fluids, London
S6
much IV fluid and go on to develop acute pulmonary oedema. Pulmonary oedema often leads to pneumonia, which may ultimately be the cause of death. The over-administration of IV fluid will rarely be identified as causation and is unlikely to appear on the death certificate. Equally, the failure to adequately hydrate patients can lead to acute kidney injury, admission to intensive care and a prolonged hospital stay; patients may then go on to develop chronic renal failure and risk becoming dialysis-dependant. The patient’s evolving ill health becomes progressively divorced from the original episode when the patient was allowed to become dehydrated. Despite the potentially devastating effects of over- or under-hydration, scant attention is paid to fluid management within either the nursing or medical curriculum. Nurses receive training in IV therapy but the focus is usually on medication administration, drug calculations and the care of vascular access devices—IV fluid therapy rarely features. Surveys have shown that prescribers of IV fluids have little knowledge of the fluid and electrolyte needs of patients and are unfamiliar with the composition of the different IV fluids that are available (NICE, 2013a). Errors in IV fluid prescribing are most commonly found in general medical and surgical wards where fluid prescribing is often left to the most junior member of the team. The NICE guideline aims to help prescribers to understand the (NICE, 2013a): ■■ Physiological principles that underpin fluid prescribing ■■ Pathophysiological changes that affect fluid balance in disease states ■■ Indications for IV fluid therapy ■■ Reasons for the choice of the various fluids available ■■ Principles of assessing fluid balance. This is one of the most practical guidelines ever produced by NICE and includes four algorithms to guide assessment and prescribing (NICE, 2013b). CG 174 also includes a helpful and informative diagram that explains the fluid and electrolyte losses associated with different clinical situations (NICE, 2013c). These are available as posters for use in the clinical area and can be downloaded from the NICE website. There is also a poster summarising the electrolyte content of the most commonly used IV fluids (NICE, 2013d), which should help
prescribers to select the most appropriate fluid for the patient’s clinical condition. Too often, IV fluid prescribing is an ad hoc event because the current bag of fluid is about to finish. The next bag of fluid may be prescribed without clinically reviewing the patient, their fluid balance, their observations or their blood results. CG 174 requires doctors and nurses to pay greater attention to fluid prescribing and clinical monitoring. Prescribing must be based upon the clinical needs of each individual patient and nurses should know whether the prescription they are following is clinically appropriate. IV fluid prescribing can be protocolised under four broad headings (NICE, 2013a): ■■ Fluid resuscitation ■■ Regular maintenance fluid ■■ Replacement of losses ■■ Fluid redistribution. Fluid redistribution generally refers to patients who have developed oedema or effusions from excess salt and water. In order to determine the correct protocol for each patient, the prescribing process should start with a comprehensive assessment. Having administered IV fluid, it is essential to reassess the patient as their needs may have changed. CG 174 (NICE, 2013a) describes this process as the 5 Rs: ■■ Resuscitation ■■ Routine maintenance ■■ Replacement ■■ Redistribution ■■ Reassessment. CG 174 contains evidence-based recommendations about the general principles that underpin the prescription and monitoring of IV fluid therapy; it does not cover the practical aspects of fluid administration.
Key priorities for implementation The guideline development group (GDG) identified ten priorities for implementation. These have been summarised below (further detail is available on the NICE website): ■■ When prescribing IV fluids, remember the 5 Rs (listed in previous section) ■■ Offer IV fluid therapy as part of a protocol (see Algorithms for IV fluid therapy in adults (NICE, 2013b)) ■■ Patients should have an IV fluid management plan, which should include details of the fluid and electrolyte prescription over the next 24 hours and the required monitoring. This
© 2014 MA Healthcare Ltd
T
he National Institute for Health and Care Excellence (NICE) produces evidence-based guidelines and advice for health care, public health and social care practitioners (NICE, 2014a). If a topic such as intravenous (IV) fluid therapy in adults has received a referral for the development of a NICE Quality Standard, an independent group within NICE will develop Quality Standards to help drive and measure the recommended quality improvements (NICE, 2014a). Quality standards are intended for use by both providers and commissioners of health and social care services. The IV fluid therapy guideline (CG 174) was commissioned by the Department of Health (DH) and the Welsh Assembly Government in February 2010 to improve the quality of IV fluid prescribing in hospital (NICE, 2014b). The scope of the guideline was developed in consultation with registered stakeholders and a guideline development group was appointed in 2011. The guidance was released for stakeholder consultation in May 2013 and the final guideline was published in December 2013. The Quality Standards associated with the guidance are under development and are scheduled for publication in August 2014 (NICE, 2014c).
British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 8
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 7, 2015. For personal use only. No other uses without permission. . All rights reserved.
GUIDANCE NOTES ■■ Hospitals should establish systems to ensure that
all health professionals involved in prescribing and delivering IV fluid therapy are trained on the principles covered in this guideline, and are then formally assessed and reassessed at regular intervals to demonstrate competence ■■ Hospitals should have an IV fluids lead, responsible for training, clinical governance, audit and review of IV fluid prescribing and patient outcomes. CG 174 is accompanied by a baseline assessment tool that can be used to assess whether practice meets the recommendations set out by NICE (2013e). A clinical audit tool is also available from the NICE website. An ‘information for the public’ leaflet has been produced to help patients understand the recommendations and ask questions about their IV fluid therapy (NICE, 2013f). Nurses will need a good understanding of IV fluid and electrolyte therapy to respond appropriately to questions from patients and carers. Undergraduate and postgraduate education needs to change to meet the requirements of CG 174. Nurses must know the fluid and electrolyte requirements of their patients and must be confident to challenge poor prescribing. Clear guidance on the prescription and
monitoring of IV fluids and electrolytes and on the education and training of hospital staff was long overdue. This guideline will be challenging to deliver but its impact on care for hospital BJN patients should be far reaching. Corrigan A (2001) History of Intravenous Therapy. In: Hankins J, Waldman RL, Henrick C, Perdue M, eds. Infusion Therapy in Clinical Practice, 2nd edn. WB Saunders, Philadelphia National Confidential Enquiry into Perioperative Deaths (1999) Extremes of age. The 1999 Report of the National Confidential Enquiry into Perioperative Deaths. NCEPOD, London National Institute for Health and Care Excellence (2013a) Intravenous fluid therapy in adults in hospital (CG174). NICE, London. http://guidance.nice.org.uk/CG174 (accessed 8 April 2014) National Institute for Health and Care Excellence (2013b) Algorithms for IV fluid therapy in adults. NICE, London. http:// tinyurl.com/o7e6csy (accessed 8 April 2014) National Institute for Health and Care Excellence (2013c) Diagram of ongoing losses. http://tinyurl.com/qggtugn (accessed 8 April 2014) National Institute for Health and Care Excellence (2013d) Composition of commonly used crystalloids. http://tinyurl. com/q6p7hrg (accessed 8 April 2014) National Institute for Health and Care Excellence (2013e) CG174 Intravenous fluid therapy in adults in hospital: baseline assessment tool. http://tinyurl.com/pd7ezfw (accessed 8 April 2014) National Institute for Health and Care Excellence (2013f) Intravenous fluid therapy for adults in hospital. About this information. http://tinyurl.com/p9vk9uw (accessed 15 April 2014) National In stitute for Health and Care Excellence (2014a) What we do. http://tinyurl.com/7lheccn (accessed 8 April 2014) National Institute for Health and Care Excellence (2014b) Intravenous fluid therapy. http://tinyurl.com/q2d5akg (accessed 8 April 2014) National Institute for Health and Care Excellence (2014c) NICE quality standards. http://tinyurl.com/p3aqyk7 (accessed 8 April 2014)
© 2014 MA Healthcare Ltd
plan should be reviewed daily by an expert until the patient is stable ■■ Assess the patient’s likely fluid and electrolyte needs from their history, clinical examination, current medications, clinical monitoring and laboratory investigations ■■ All patients receiving IV fluids need regular monitoring. This should initially include at least daily reassessments of clinical fluid status, laboratory values (urea, creatinine and electrolytes) and fluid balance charts, along with weight measurements twice weekly ■■ Clear incidents of fluid mismanagement (e.g. unnecessarily prolonged dehydration or inadvertent fluid overload as a result of IV fluid therapy) should be reported through standard critical incident reporting to encourage improved training and practice ■■ If patients need IV fluid resuscitation, use crystalloids that contain sodium in the range 130–154 mmol/litre, with a bolus of 500 ml over less than 15 minutes ■■ If patients need IV fluids for routine maintenance alone, restrict initial prescription to: 25–30 ml/kg/day water, approximately 1 mmol/kg/day potassium, sodium and chloride, and approximately 50–100 g/day glucose to limit starvation ketosis
S8
British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 8
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 7, 2015. For personal use only. No other uses without permission. . All rights reserved.
