Risks of Intravenous Fluid Therapy by First Year Residents – A Prospective Study

Abstract

Aims: Intravenous fluid prescriptions are common in hospitals and most are written by junior doctors. Despite the frequency in which clinicians prescribe IV fluids, the burden from mortality and morbidity related to IV fluids is huge with an estimate that 1 in 5 patients are harmed by inappropriately prescribed fluids. We wished to identify the deficiencies in foundation year 1 doctors’ (FY1s, first year of clinical practice after graduation) knowledge and practice of IV fluid prescribing and to identify barriers to good prescribing practice that they had encountered on the wards. FY1s are in their first year of internship after graduating from medical school and this UK experience may be mirrored across the world. Study Design: A prospective, mixed methods study was carried out, using questionnaires, educational interventions and post-interventional evaluation. Place and Duration of Study: Royal Liverpool & Broadgreen University Hospitals NHS Trust, Prescott Street, Liverpool, UK. The study took place over 2015. Methodology: A 53 point questionnaire was designed and used to sample data. An educational intervention was designed after a gap analysis and post-intervention sampling to assess the efficacy of the interventions was also carried out. Results: Significant deficiencies were revealed in the ability to prescribe maintenance fluids. 33% of doctors (n = 8) had not read any guidance about IV fluid prescribing. 42% (n = 10) of participants adhered to fluid prescribing guidance. 17% (n=4) doctors stated that they did not know the contents of fluid bags they prescribed. Only 25% (n = 6) of first year residents indicated that they adhered to weight based prescribing and 4% and 16% felt they at times prescribed too much sodium or water, or too little potassium, for maintenance. Most residents (92%, n=22) reported checking patient’s latest urea and electrolyte values prior to prescribing IV fluids and 54% (n=13) indicated that they reviewed the patient clinically prior to prescribing fluids, However, 67% (n = 16) reported not documenting IV fluid therapy and fluid status in the case notes. The analysis of the narrative data showed system barriers, such as nurses not weighing patent weight, as contributing to the deficiencies in prescribing correctly. The intervention was successful in reversing the deficiencies to a large extent. However cultural and system barriers were also identified. Conclusion: Cultural and system barriers are significant in any learning and need to be taken into account when designing healthcare improvements.