PM2032: Closing the Fluid Gap- improving Isotonic Maintenance Intravenous Fluid Use in a Community Hospital Network

Purpose/Objectives:

Background:
Hyponatremia is reported in up to 30 percent of hospitalized children secondary to SIADH, and can worsen with use of hypotonic maintenance intravenous fluids (IVF). Early symptoms of hyponatremia are nonspecific and difficult to recognize. Hyponatremic encephalopathy, although rare, can occur acutely, and can be fatal or cause irreversible brain injury.
Administration of hypotonic maintenance IVF was standard practice in pediatrics for over 60 years. A recent American Academy of Pediatrics (AAP) clinical practice guideline (CPG) published in December 2018 recommends the use of isotonic IVF for maintenance needs to decrease the risk of hyponatremia. Continued use of hypotonic IVF in 42-93 percent of admitted patients at three sites in our community hospital network several months after the release of AAP guidelines prompted this quality improvement project.

Objective:
Increase median use of isotonic maintenance IVF in patients age 28 days to 18 years admitted to three sites in a community hospital network from a baseline rate of 8 – 42 percent to >85 percent over 12 months.

Design/Methods: The project started at one network site in October 2019 and was expanded to the two other sites in Feb 2020 and Nov 2020 respectively. We used improvement methodology to identify critical drivers of continued hypotonic fluid use. We included all patients aged 28 days to 18 years that received maintenance IVFs at the rate >10 mL/hour. Patients with active chronic medical conditions were excluded. Interventions included 1) discussions among the providers about the risks from use of hypotonic fluids, 2) education on the AAP CPG, 3) new electronic medical record (EMR) order sets to encourage isotonic IVF use, and 4) clinical decision support (link to AAP CPG & clinical pathway from the associated tertiary care children’s hospital). Additionally, notices in work areas served as reminders and pharmacy helped by stocking the Pyxis adequately to facilitate appropriate IVF administration. Balancing measures were adverse events from hypo and hypernatremia. Data were analyzed using statistical process control charts.

Results: The isotonic IVF use at all 3 sites surpassed the goal of > 85 percent. The percent use of isotonic fluid at Site 1 increased from 37.8 percent at baseline to 96.4 percent, at Site 2 from 41.7 percent to 89.4 percent and at Site 3 from 7.7 percent to 93.8 percent. All 3 sites have sustained the improvement for at least one year. There were no reports of hypo or hypernatremia or other adverse outcomes related to the use of isotonic IVF.

Conclusion/Discussion: The use of improvement methods helped standardize the use of maintenance isotonic IVF in children admitted to the three community hospitals in the network. The education and EMR order sets were critical to successful adoption of the new AAP guideline.