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Optimising renal replacement therapy: evaluating the impact of a formalised prescription chart on fluid balance management in critical care
Ali, Muzzamil Mewse, Lorna Park, Stevie Bhalla, Harry Kouka, Athanasia Ramchandani, Priyanka Panchumarthy, Pragna Arshad, Mohammed Patel, Jaimin
Ali, Muzzamil
Mewse, Lorna
Park, Stevie
Bhalla, Harry
Kouka, Athanasia
Ramchandani, Priyanka
Panchumarthy, Pragna
Arshad, Mohammed
Patel, Jaimin
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Affiliation
University Hospitals Birmingham NHS Foundation Trust; University of Birmingham
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Publication date
2024-10-10
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Abstract
Background
A previous audit within our tertiary centre's critical care units highlighted significant issues with suboptimal dosing of renal replacement therapy (RRT), particularly at weight extremes, and fluid balance ambiguities. These issues were largely attributed to the lack of dedicated prescription charts, raising concerns about the consistency and safety of RRT delivery. A subsequent staff survey revealed consistent discrepancies between RRT prescription and actual delivery, further underscoring the need for improvement in clinical practice.
Aim
In response to these findings, a formalised RRT paper prescription chart was developed and trialled over four months in one of the four critical care units (Unit A). The trial aimed to assess whether the formalised chart could effectively reduce discrepancies between RRT prescription and delivery.
Objectives
The study aimed to determine if the correct dose of RRT was prescribed based on patients' ideal body weight, to evaluate whether the prescribed fluid balance was achieved or if there were statistically significant discrepancies between prescribed and achieved fluid balances, to identify and quantify clinical reasons contributing to any discrepancies, to assess the completeness of the formalised prescription charts across all units, and to evaluate the completion rate of the night shift section of these charts for patients on continuous therapy.
Methods
This prospective observational study was conducted over one month, eight months after the formalised RRT paper prescription chart was implemented across all four critical care units (Units A, B, C, and D). Data were collected from 89 patients receiving RRT, with 53 patients having completed formalised prescription charts. Statistical analyses included Chi-square tests for categorical variables and paired t-tests for continuous variables to assess discrepancies in fluid balance.
Results
Of the 53 patients with completed charts, 69.81% received the correct RRT dose based on their ideal body weight. However, 30.19% received incorrect doses, with 22.64% under-dosed and 7.55% over-dosed for valid clinical reasons. Fluid balance analysis revealed a significant median discrepancy of -767.0 ml (p = 0.00206) between prescribed and achieved balances across all patients. After excluding patients with valid clinical reasons, the median discrepancy remained significant at -600.0 ml (p = 0.0064). The completeness of prescription charts varied, with 40.45% of charts missing or incomplete, and 58.00% of night shift sections for continuous therapy patients were not completed.
Conclusion
This study underscores the ongoing challenges in RRT dosing and fluid balance management in critical care, even with a formalised paper prescription chart. Significant discrepancies, particularly underdosing, continue to pose risks to patient outcomes, while vague fluid balance targets like "2L negative" lead to inconsistencies in achieving intended results. To enhance patient care, it is essential to standardise fluid prescriptions into clear categories, improve documentation through targeted staff training, address night shift challenges with focused interventions, and consider
transitioning to electronic charts with automated alerts for discrepancies.
Citation
Ali, M., Mewse, L., Park, S., Bhalla, H., Kouka, A., Ramchandani, P., Panchumarthy, P., Arshad, M. and Patel, J. (2024) 'Optimising renal replacement therapy: evaluating the impact of a formalised prescription chart on fluid balance management in critical care'. FICM Conference. Churchill House: London; 10 October.
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Conference Output