OBJECTIVES:

Maintenance intravenous fluids (IVFs) are routinely used in the care of hospitalized children. The American Academy of Pediatrics (AAP) published clinical practice guidelines in November 2018 that recommended the use of isotonic maintenance IVF. Our primary aim was to increase the proportion of hospital days pediatric inpatients were exclusively administered isotonic maintenance IVF to ≥80% by May 2020 at our institution.

METHODS:

We conducted a single-center quality improvement (QI) study as part of an AAP collaborative. An interdisciplinary team led QI interventions including providing targeted education to clinicians, integrating guideline recommendations into the electronic medical record, engaging hospital leaders, and providing performance data to clinicians. Our study population included children ages 28 days to 18 years admitted to inpatient wards. Our primary outcome was the proportion of hospital days with exclusive isotonic maintenance IVF use. Balancing measures included transfers to the ICU, ordering of serum sodium laboratory tests, and adverse events. Data were analyzed by using statistical process control.

RESULTS:

We analyzed 500 hospital admissions and found a significant increase in exclusive isotonic IVF use (63% to 95%) within 9 months of starting our QI intervention. We found no significant changes in balancing measures (serum sodium laboratory tests [24% to 25%], ICU transfer [0.3% to 1%], adverse events [0.3% to 1%]).

CONCLUSIONS:

Our interdisciplinary QI team led interventions that were associated with significant improvements in isotonic IVF use, in accordance with AAP clinical practice guidelines. With our study, we provide detailed guidance on successful interventions for implementing this evidence-based guideline.

Maintenance intravenous fluids (IVFs) are routinely used in the care of hospitalized children who are acutely ill and unable to receive sufficient fluids via enteral administration. Historically, hypotonic maintenance IVFs have been used in the care of hospitalized children, but there is growing evidence that practice is associated with iatrogenic hyponatremia.15  Iatrogenic hyponatremia can occur when hypotonic IVFs are used in children with increased antidiuretic hormone secretion and impaired free-water excretion. This is common in the setting of acute illness because elevated antidiuretic hormone secretion can occur from pulmonary disease, pain, nausea, central nervous system disorders, gastroenteritis, or a postoperative state.1,57  Inappropriate use of IVFs may cause several hospital-acquired harms, including iatrogenic dysnatremia, pain and discomfort from IV insertions, and inadequate or inappropriate monitoring for adverse effects.1,2,8,9 

The American Academy of Pediatrics (AAP) published clinical practice guidelines on maintenance IVFs in November 2018 to address inappropriate variability in IVF prescribing practices nationwide and provide an evidence-based approach to choosing tonicity of maintenance IVF. These guidelines recommend using isotonic, rather than hypotonic, maintenance IVFs in medical and surgical patients 28 days to 18 years old without neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns.5 

Our pediatric hospital medicine (PHM) division leadership was committed to improving evidence-based care of children on maintenance IVF. Consequently, our hospital joined an AAP Value in Inpatient Pediatrics (VIP) national quality improvement (QI) collaborative and used best practices in pathway implementation to try to improve IVF prescribing practices.1012  The primary aim of our QI initiative was to increase the proportion of hospital days with exclusive isotonic maintenance IVF use to ≥80% by May 2020 at our local institution.10 

The study took place from May 2018 to May 2020 in a single large, urban, academic tertiary medical center, which is the largest children’s hospital in the county. The hospital serves a total catchment area of 1.9 million children from 9 counties; it has ∼15 000 emergency department (ED) visits and 2100 pediatric admissions to the PHM service annually. Ordering providers for the PHM and ED services include attending physicians, fellows, residents, and advanced practice providers.

This study was part of the VIP Network’s Standardization of Fluids in Inpatient settings (SOFI) QI collaborative.10  Our institution had previously participated in national QI collaboratives and published on proposed best practices for implementation of clinical pathways.11  We planned to integrate these best practices: using a QI and data-driven approach, committing to shared goals, integrating tools into the electronic medical record (EMR), leveraging interdisciplinary teams, and engaging hospital leaders. We created an interdisciplinary study team of physicians (3 from PHM and 1 from the ED), 1 nursing leader, 2 pharmacy leaders, and 1 business management analyst. Our team met in large and small group settings during the preintervention phase (May 2018 to July 2019), followed by small group settings during the intervention phase (August 2019 to May 2020).

The VIP Network and the SOFI project provided our site with sample key driver diagrams, EMR templates, a maintenance IVF visual algorithm and pathway, QI training (eg, plan-do-study-act cycles), and proposed pharmacy interventions.10  Our team reviewed these SOFI tools and previous literature and then discussed potential barriers to improvement. Although attending physicians in the hospital medicine division expressed a desire to adhere to the new AAP guidelines, we identified several potential barriers. These included multiple ordering providers with varying levels of training, difficulty accessing EMR orders for isotonic IVF, and lack of awareness regarding our ordering variability. These discussions resulted in the creation of our own site-specific key driver diagram (Fig 1) and selection of site-specific interventions. We developed local consensus on interventions using this key driver diagram, interactive discussions, and review of local data.

The target population was defined by the SOFI collaborative and the AAP guideline.5,10  It included children age ≥28 days and ≤18 years at the time of admission who were admitted to or comanaged by the PHM service and received maintenance IVF at a rate >10 mL/hour on hospital day 2 at 12:01 am. This population included medical, surgical, and specialty patients admitted to inpatient or observation status and cared for on inpatient non-ICU units. Exclusion criteria included specific comorbidities detailed in Table 1 as defined by the SOFI collaborative and the AAP guideline.5,10 

Targeted Education

Targeted education was provided by the level of training for physicians (residents versus fellows and attending physicians), with separate sessions for nursing and pharmacy staff. Resident-level education was performed as part of the intern core lecture series, then once per 8-week block rotation during the intervention period. This resulted in all 29 pediatric interns, 10 of 23 third-year residents, no second-year residents, and all 4 chief residents receiving this in-person education. All 87 residents received the educational materials electronically. Similarly, an in-person session was held at the PHM division meeting and educational materials were disseminated electronically, reaching all 4 fellows and 26 attending physicians that staff the hospital. All 125 acute care nurses that staff the hospital unit to which the majority of patients are admitted also received education and materials. We chose to stratify groups in this way to promote open discussion among clinicians with different levels of training. The sessions included a review of the AAP guidelines for use of isotonic maintenance IVF in the inpatient pediatric population, our site’s current performance (based on baseline data), and the rationale for implementing an IVF pathway, EMR changes, and educational interventions. Attendees were encouraged to ask questions regarding the supporting literature and review examples of patients who would meet inclusion and exclusion criteria. Pharmacy used an internal educational tool, that is, a pharmacy clinical update that was electronically sent out to the 45 pharmacists and pharmacy residents at our institution (see Supplemental Information). This tool was disseminated to pediatric residents and was published on the internal pharmacy Web site accessible to all providers.

Modifications to the PHM Pathway and Clinical Guidelines

Our division had a preexisting IVF pathway and guideline that largely aligned with the recommendations of the AAP guideline. However, our local pathway and guideline did not recommend isotonic fluid for children ages 28 days to 1 year. In May 2019, the PHM division and affiliated sites discussed and agreed to edit the pathway and guidelines to recommend isotonic fluid for children 28 days to 1 year.

Implementation of Admission Order Set Modifications

A general admission order set for hospital admissions previously existed at our institution and was used for all admissions to the PHM service. We modified our Epic EMR system admission order set to include text-based guidance on the AAP recommendations for isotonic fluid usage, patients at risk for increased antidiuretic hormone secretion, and patient populations meeting exclusion criteria. It included a link to our local guidelines and associated IVF pathway. The order set listed isotonic fluid options at the top of the IVF section. No fluid orders were preselected or defaulted because of a high proportion of patients meeting exclusion criteria admitted to our facility, and hypotonic fluids were listed in a separate drop-down menu.

Ease of Access for Ad Hoc Orders

Methods for ordering maintenance IVF were evaluated at our site. We found that only 6.5% of orders for maintenance IVF were placed via the admission order set, and the remainder were placed as independent ad hoc orders. We also received feedback that potassium-containing isotonic fluids were difficult to find via Epic’s order search functions, which resulted in hypotonic fluids being ordered. To promote the use of isotonic fluids via ad hoc orders, we added all stocked isotonic fluids as an “Orders Preference List” for each resident. This resulted in increased accessibility of these previously difficult-to-find orders. Residents were chosen for this intervention because they are the primary ordering providers at our institution.

Interdisciplinary Collaboration, Audit, and Feedback

In line with best practices for pathway implementation, this was an interdisciplinary collaboration that involved members of the PHM and ED divisions, nursing leadership, pharmacy leadership, and business management.11,12  In collaboration with hospital leadership, we added this project as a quality and safety metric on the True North board displayed on the hospital unit to which the majority of patients are admitted.13  A monthly e-mail update was sent out to ordering providers that included progress toward our goal, any changes they may expect, and requests for feedback to the study group.

Lists of potentially eligible patients for the baseline and intervention period were obtained by the business management analyst and filtered by service, age, and select comorbidities by using International Classification of Diseases, 10th Revision codes. We reviewed 15 months of baseline data (May 2018 to July 2019) and 10 months of intervention period data (August 2019 to May 2020). All eligible charts were reviewed chronologically in order of date of discharge until a maximum of 20 charts were entered per month. One month of baseline data was reviewed collaboratively with the study team to reach a consensus on chart review methods. All charts were subsequently reviewed by the project leader with a midpoint chart audit to ensure data accuracy.

The primary outcome measure was the proportion of hospital days with exclusive isotonic maintenance IVF use, with a goal of reaching ≥80% by May 2020. This measure was selected in accordance with the SOFI collaborative and AAP guideline recommendation that all patients should receive isotonic maintenance IVF unless they had specific medical conditions precluding isotonic fluid use.5,10  Data were collected separately for each of 3 hospital days (hospital days 2–4), starting on hospital day 2 at 12:01 am. Day 1 was excluded to focus on inpatient care practices and to capture a population of likely euvolemic patients. Exclusive isotonic fluid use was determined by calculating the proportion: hospital days patients received exclusive isotonic IVF/total eligible hospital days.

Balancing measures were selected in accordance with the SOFI collaborative and included the ordering of serum sodium laboratory tests, transfers to ICUs, and adverse events prompting one of the following changes in clinical management: hypertension or edema requiring diuretic, hypertension requiring antihypertensive medication, or acute kidney injury requiring renal replacement therapy or dialysis.10  Serum sodium ordering was monitored because of concerns that providers might increase laboratory draws after the proposed change to using isotonic IVF. Other balancing measures were selected because of concerns that isotonic IVF use could theoretically lead to hypernatremia, fluid overload, and/or hypertension.14  Process measures included a monthly review of project data at True North board meetings with unit leaders, completion of educational sessions with clinicians, and distribution of monthly project update e-mails with run charts reviewing current and past performance. These process measures were tracked and updated monthly on the unit True North board.

We used t tests to evaluate for differences in age or length of stay between the pre- and postintervention cohorts. Statistical process control was used for analyses of the primary and balancing measures. P charts were used to analyze the proportion of hospital days with exclusive isotonic maintenance IVF use and the proportion of admissions with serum sodium laboratory tests ordered. For the other balancing measures (ICU transfers and adverse events), T charts and Fisher’s exact tests were used, given these were rare events. Common versus special cause variation was determined by using established definitions.15 

The institutional review board determined this project was not human-subjects research and provided a QI exemption waiver.

We analyzed 500 hospital admissions that occurred from May 2018 through May 2020 (of the total 4392 eligible), with 300 patients in the preintervention period and 200 patients in the postintervention period. Patient characteristics were similar in the pre- and postintervention periods. Mean ages of pre- and postintervention cohorts were 10 and 10.4 years, respectively (P = .6). Mean lengths of stay of pre- and postintervention were 3.6 and 3.5 days, respectively (P = .8).

Our interventions began in August 2019, and we found special cause variation in our primary outcome after these interventions (9 points above the centerline; Fig 2). Mean performance in exclusive isotonic maintenance IVF usage increased from 63% to 95% by May 2020, above our aim of ≥80%. During the baseline data collection phase of the project, we found our median usage of exclusive isotonic fluids only increased from 58% to 67% after guideline publication, which did not meet criteria for special cause variation (Fig 2).

We found no significant changes in balancing measures (serum sodium laboratory tests [24% to 25%], ICU transfer [0.3% to 1.0%], adverse events [0.3% to 1.0%]). For adverse events, no patients required renal replacement therapy throughout the study period, no patients required diuretics preintervention and 1 patient required diuretics postintervention, and 1 patient required an antihypertensive medication in both the pre- and postintervention periods. During the intervention period, there were no other projects or system changes that would have affected our interventions or results.

Using QI methodology and pathway implementation best practices,11  we achieved our aim of increasing the proportion of hospital days with exclusive isotonic maintenance IVF use to ≥80% within 9 months. At our institution, and as is often true across the country, the release of a clinical practice guideline did not result in a significant change in practice.12,16,17  This study provides detailed guidance on how to use QI methodology and implementation best practices to increase adherence to AAP clinical practice guidelines.

Ordering providers at our facility vary in their levels of training and include resident physicians, advanced practice providers, fellows, and attending physicians. We observed that targeted education, as part of a multifaceted intervention, can improve guideline adherence.12,18  We provided education by level of provider with separate sessions for nursing and pharmacy staff. This interdisciplinary education and engagement proved to be immediately impactful, as it was after these interventions that we started to see special cause variation (Fig 2).

We used multiple EMR interventions to promote ease of ordering of isotonic IVF and increase adherence. The initial planned EMR intervention of modifying the admission order set was thought to be insufficient given low rates of maintenance IVFs being ordered via this route. Additionally, through outreach to our ordering providers, it was clear that difficulty finding specific isotonic fluids when orders were placed ad hoc occasionally resulted in hypotonic fluids being selected. This Lean concept of listening to the customer13  proved to be valuable because it resulted in the creation of order preference lists to promote isotonic fluid selection when orders were placed ad hoc. These interventions may have played a role in our sustained success because we noted a decrease in use in February 2020 that subsequently increased after the release of the above EMR changes in March 2020. Given the growing complexity of EMR systems, it is important to evaluate local EMR workflows to identify unanticipated barriers to change.

We leveraged our health system’s strong culture of QI and support from hospital leadership to increase the visibility of this project by adding it as a quality and safety metric to the True North board13  on the unit to which the majority of PHM patients are admitted. Leadership support is important for promoting the use of clinical practice guidelines as well as pathway implementation.11,12  This visibility tool (True North board) reinforced the institutional support for this change in practice, provided real-time feedback to providers, and facilitated a data-driven approach to our QI interventions.

Although we were able to achieve significant changes in practice at our institution, our study had several limitations. Our QI initiative took place at a single tertiary children’s hospital with a robust institutional commitment to and support of QI projects, which may limit generalizability. Additionally, it is possible that these improvements could reflect the delayed effects of passive dissemination of the AAP guidelines. However, we saw only random variation in the 6 months after guideline publication and special cause variation soon after our QI intervention began. Only a subset of patient charts was reviewed each month, and it is possible that these charts were not representative of all patients admitted to the PHM service. To address this, the method for chart selection was in chronological order based on time of discharge and was consistent throughout the study. Given low concerns of monthly patterns in admission type or severity, this method of convenience sampling had a low likelihood of selection bias. Lastly, the study period ended in May 2020, and we were unable to continue to collect and analyze data beyond that time. This limited our ability to assess the sustainability of improvements we achieved. Efforts to sustain our improvements are continuing with an IVF lecture embedded into the resident curriculum.

Our interdisciplinary QI team showed significant improvements in the local rates of isotonic IVF use, in accordance with the AAP clinical practice guidelines. Our key interventions included targeted education by clinical role, integrating guideline recommendations into the EMR, engaging hospital leaders, and providing performance data to clinicians. Our study provides detailed guidance on successful interventions for implementing this evidence-based guideline.

We thank the members of the QI team and specifically key members Israel Green-Hopkins, MD; Mansi Desai, MD; Barbette Murphey, RN, MSN, CPNP; Sarah Lucas Scarpace, PharmD, BCPS, BCPPS, FCSHP, FPPA; Lulu Jin, PharmD, BCPPS, BCPS; and Hanae Casseras for their assistance in the planning and implementation of this QI project.

Dr Nordstrom conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection, conducted the initial analyses, and drafted the initial manuscript; Dr Kaiser conceptualized and designed the study, supervised data analysis, and critically reviewed the manuscript; Drs Landman and Pfaff conceptualized and designed the study and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.