From the 2021 HVPAA National Conference
Sri Lalitha Garimella (Richmond University Medical Center), Sireesha Aleti, Hina Fatima, Aishwarya Palorath, Kristen Roy, Lenny Shats, Kelly Reinhold, Jean Gordon, Joann Stuart, Ellen Heinrich, Jiliu Xu, Teresa Lemma, Kevin McDonough, Melissa Grageda
In 2018, the American Academy of Pediatrics (AAP) published guidelines on maintenance IV fluids (IVF) in pediatric patients, recommending isotonic (instead of hypotonic) fluid use to significantly decrease the risk of developing hyponatremia. Our quality improvement (QI) team sought to improve and sustain the exclusive use of isotonic maintenance IVF in our inpatient pediatric unit, and joined a national QI collaborative led by the AAP Value in Inpatient Pediatrics (VIP) Network.
The aims of the collaborative were to increase the proportion of hospital days with exclusive isotonic maintenance IVF use to ≥ 80%, to decrease the number of routine labs per hospital day by 20% from baseline, and to decrease the proportion of time (hours) on maintenance IVF during hospitalization by10% from baseline by May 2020.
Our QI team submitted an application to, and was selected to be part of the national collaborative, Standardization of IV Fluids in Inpatient Settings (SOFI). The SOFI Collaborative included 114 sites from 34 states. The project took place at the inpatient pediatric unit of an academic community hospital. Champions from the departments of pharmacy, nursing, emergency medicine and pediatrics led the QI initiative. Each champion educated their staff about the updated guidelines, ongoing project and interventions. The study occurred over 14 months (April 2019-May 2020). During the intervention period, harm cards were distributed to staff to remind clinicians of the potential harm from “routine” blood draws. Monthly data was collected. Outcome measures included tonicity of maintenance IVF, number of serum WBC levels (proxy for routine labs), and duration of maintenance IVF. Process measures were daily weight measurements while on IVF. Balancing measures included floor-to-PICU transfers, serum Na levels, adverse events, and length of stay. The model for improvement and serial PDCA cycles were utilized to test changes throughout the study.
There were 314 patients (baseline: cycles 1-20, n=242; action period: cycles 21-25, n=72). There was improved exclusive isotonic fluid use over time, and 98% compliance during the action period. There was an 18% decrease in the number of routine labs per hospital day. There was no significant change in adverse events, floor to PICU transfers and hospital length of stay.
Participation in a national QI collaborative and interdepartmental collaboration were associated with improved health care value in the inpatient pediatric setting, as demonstrated by sustained use of maintenance fluid that is safer for the patient (isotonic vs hypotonic) and reduced number of “routine” blood draws.