From the 2024 HVPA National Conference
Ema Karakoleva B.S. (Penn State College of Medicine), Claudia Velasco B.S., Joshua Shoemaker M.S., Vladimir Khristov Ph.D., Ben Walters B.S., John Smith B.S., Yash Patel B.A., Noreen Masciello B.S., Katelyn Baggett B.S., Xiao Wei B.S., Brian McGillen M.D.
Background:
Accurate charting of fluid input and output (I/O) in acute care settings is essential for providing high-quality and effective patient care. High fluid balance in patients with heart failure and sepsis is correlated with higher in-hospital and 30-day mortality, highlighting the importance of strict tracking of net balance measurements. Completeness of fluid balance charts varies greatly from <25% to >75% based on different clinical settings, with up to 80% of calculation errors reported in general medicine wards and 33% in intensive care units (ICU). Barriers to accurate balance tracking, such as understaffing, lack of standardized processes, inefficient electronic medical record systems, and insufficient training, are multifactorial and systematic, affecting all members of the healthcare team and posing shared and unique challenges among different departments. Therefore, it is imperative to investigate and account for the perspectives of clinical staff to inform site-specific quality improvement strategies for optimizing patient care.
Objective:
The aim of this study was to explore healthcare workers’ perspectives and identify systemic barriers to workflow efficiency regarding input and output patient data charting in inpatient settings.
Methods:
This was a single-site, qualitative methods study including physicians and nursing staff at Penn State Health Milton S. Hershey Medical Center, a tertiary-care facility serving central Pennsylvania. Participants were blinded to study objectives, provided verbal consent, and answered verbal surveys comprised of open-ended questions and 10-point Likert scales. Rated responses were analyzed using SPSS V. 29.0.2.0 (20) statistical software with P < 0.05 signifying statistical significance. Open-ended responses were reviewed and categorized into overlapping themes.
Results:
A total of 13 healthcare workers (5 floor nurses, 5 ICU nurses, 3 physicians) completed the survey. On a 1-10 scale of increasing frustration from the process of I/O data reporting, physicians (M=4±1.3) scored similarly to nurses (M=3.9±2.4). The Mann-Whitney U test revealed a significant difference (U=25, p=0.008) in frustration levels between floor (M=1.8±0.44) and ICU (M=6±1.4) nurses. On a scale of 1-5 of increasing frequency, 50% (n=6) of all healthcare workers responded that I/O orders are appropriately placed “always,” and 75% (n=9) selected 3 or higher, while 58% (n=7) reported that workflow was impacted “often” and 17% (n=2) selected “always.” There were no statistical differences between the two nurse groups regarding appropriateness (U=6, p=0.222) and workflow impact (U=13, p=1.000) of I/O orders. Floor nurses tended to highlight challenges in team communication, particularly in cases involving uncertainty about patients needing specific care and a lack of consistency in adjusting input/output orders across the hospital stay. The same group also expressed worries about an insufficient nurse-to-patient ratio, leading to inefficiencies. Both floor and ICU nurses encountered similar challenges regarding the accuracy and reliability of input/output data collection, such as unaccounted food and drink brought in by family members.
Conclusions:
Our study demonstrated the impact of workflow variations in I/O data collection. Identified systemic barriers included accuracy and reliability of data collection, workflow efficiency, staff training, and interdisciplinary communication. Addressing these issues is crucial for enhancing efficiency of healthcare delivery and eliminating potentially wasteful practices, which align with the principles of high-value care.
Clinical Implications:
Targeted interventions and quality improvement strategies aimed at addressing systemic barriers in optimized I/O data collection would benefit the care of patients requiring strict fluid balance monitoring. These efforts can strengthen data-driven clinical practices, improving patient safety in acute care settings.