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Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric
Sahar N Rooholamini1, Brittany Jennings2, Chuan Zhou1,3
1Department of Pediatrics, University of Washington, Seattle.
Insights
A quality improvement intervention increased the use of isotonic maintenance intravenous fluids (IVF) in pediatric hospitals. The intervention did not increase adverse events or laboratory testing, but further efforts are needed to reduce unnecessary lab tests.
Area of Science:
- Pediatric hospital quality improvement
- Intravenous fluid management
- Clinical practice guideline implementation
Background:
- Hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm.
- The American Academy of Pediatrics recommends isotonic IVF for pediatric patients.
- Unnecessary laboratory tests contribute to healthcare waste and patient harm.
Purpose of the Study:
- To evaluate a quality improvement intervention bundle's effect on increasing exclusive isotonic IVF use.
- To assess the intervention's impact on decreasing laboratory tests obtained during hospitalization.
Main Methods:
- A stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) involving 106 US pediatric hospitals.
- Intervention components included educational materials, a clinical algorithm, electronic medical record interventions, and "harms of overtesting" cards.
- Outcomes were analyzed using linear mixed-effects regression models, comparing baseline and intervention periods.
Main Results:
- The intervention bundle led to a 5.4% absolute increase in exclusive isotonic IVF use.
- No significant change was observed in the proportion of hospital days with laboratory test values obtained (0.1% difference).
- There was a 4.4% increase in daily patient weight measurements while receiving IVF, with no increase in adverse events or electrolyte testing.
Conclusions:
- The intervention effectively improved isotonic maintenance IVF use in pediatric settings.
- The study highlights the need for further strategies to deimplement unnecessary laboratory testing.
- The findings support the adoption of evidence-based practices to enhance patient safety and reduce healthcare waste.
Importance:
Given that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients.
Objective:
To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained.
Design, Setting, And Participants:
This stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020.
Interventions:
Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards.
Main Outcomes And Measures:
Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models.
Results:
A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF.
Conclusions And Relevance:
In this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing.
Trial Registration:
ClinicalTrials.gov Identifier: NCT03924674.
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