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Adherence to Daily Weights and Total Fluid Orders in the Pediatric Intensive Care Unit
Marshall A Ahearn1, Danielle E Soranno2, Timothy Stidham3
1Department of Pediatrics, Graduate Medical Education, School of Medicine, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado.
Insights
Fluid overload (FO) in critically ill children is common and linked to poor outcomes. A quality improvement program improved daily weight monitoring, suggesting simple interventions can enhance fluid management practices.
Area of Science:
- Pediatric critical care medicine
- Quality improvement initiatives
- Fluid management in children
Background:
- Fluid overload (FO) is a significant concern in critically ill children, associated with increased morbidity and mortality.
- The Volume Status Awareness Program (VSAP) was developed to address iatrogenic FO through quality improvement.
- Baseline data collection focused on fluid management practices in a pediatric intensive care unit (PICU).
Purpose of the Study:
- To evaluate baseline fluid management and monitoring practices in a PICU.
- To assess the impact of the initial phase of the VSAP on fluid management practices.
- To identify opportunities for reducing iatrogenic fluid overload in pediatric patients.
Main Methods:
- Retrospective cohort study of diuretic-naive patients admitted to the PICU in 2014.
- Furosemide administration served as a proxy for provider-perceived FO.
- Data collected included daily weight orders, total fluid (TF) orders, and adherence to TF limits.
Main Results:
- Only 10% of patients had daily weight orders at baseline.
- Despite 84% having TF orders, 63% experienced >5% FO by day 1 and 51% had >10% cumulative FO by day 3.
- Following VSAP phase 1, daily weight order frequency increased from 6% to 88%.
Conclusions:
- Fluid monitoring tools were inconsistently and infrequently used in the PICU prior to VSAP.
- Early results indicate that simple interventions can improve fluid ordering and monitoring practices.
- Further quality improvement cycles are needed to confirm the reduction of iatrogenic FO.
Background:
Fluid is central to the resuscitation of critically ill children. However, many pay limited attention to continued fluid accumulation. Fluid overload (FO) is associated with significant morbidity and mortality. The Volume Status Awareness Program (VSAP) is a multi-phase quality improvement initiative aimed at reducing iatrogenic FO. For baseline data, the authors examined a retrospective cohort of patients admitted to the pediatric intensive care unit.
Methods:
Cohort included diuretic-naive patients admitted to the pediatric intensive care unit at a tertiary care children's hospital in 2014. Furosemide-exposure was used to indicate provider-perceived FO. Variables included daily weight and total fluid (TF) orders, and their timing, frequency, and adherence. Implementation of VSAP phase 1 (bundle of interventions to promote consistent use of patient weights) occurred in June 2017.
Results:
Forty-nine patients met criteria. Five (10%) had daily weight orders, and 41 (84%) had TF orders-although 7 of these orders followed furosemide administration. Adherence to TF orders was good with 32 (78%) patients exceeding TF limits by < 10%. Thirty (63%) had > 5% FO by day 1, and 22 (51%) had > 10% cumulative FO by day 3. Following phase 1 of the VSAP, the frequency of daily weight orders increased from 6% to 88%.
Conclusions:
In our institution, use of fluid monitoring tools is both inconsistent and infrequent. Early data from the VSAP project suggests simple interventions can modify ordering and monitoring practice, but future improvement cycles are necessary to determine if these changes are successful in reducing iatrogenic FO.
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