National Institute for Health and Clinical Excellence (NICE)
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Poor drip care putting patients' lives at risk

Hospitals should provide better training to staff in how to use IV drips to avoid putting patient safety at risk, according to draft guidelines from NICE.

Many adult patients in hospital require intravenous (IV) fluid therapy, or fluid given through a drip, for reasons such as severe dehydration or a major loss of fluids. Deciding the right amount, composition and rate of IV fluids to be administered can be difficult, with evidence showing that too many hospital patients are dying as a result of receiving incorrect amounts of IV fluids.

A report from the National Confidential Enquiry in Patient Outcome and Death found that around a fifth of hospital patients who received too little fluid management before surgery, and a third who received too much IV fluids, died within 30 days of having their procedure.

One reason for this is that many NHS staff are insufficiently trained in IV fluid management, with healthcare professionals receiving limited training even before they are fully qualified. Another reason is that experts rarely agree on which IV fluids are best, which leads to a wide variation in practice.

To help tackle this, NICE has published draft clinical guidelines on intravenous fluid therapy in adults in hospital.

The draft guideline includes a number of recommendations to help improve training and education. These include that hospitals should establish systems to ensure that all healthcare professionals involved in prescribing and delivering IV fluid therapy are trained on the principles covered in the guideline.

These should then be formally assessed and reassessed at regular intervals to determine competence in a range of areas including assessing the risks benefits and harms of IV fluids, prescribing and administering IV fluids, and monitoring patient response.

NICE also recommends that healthcare professionals should follow certain protocols when prescribing IV fluid therapy. These include remembering the 5 Rs, namely: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment.

IV Fluid therapy should be offered as part of a protocol described by a set of algorithms provided in the guideline. These cover the pathway of care from assessment, to replacement and redistribution.

The type of fluid to be administered, and the rate and volume to be administered, should be included in IV fluid prescriptions. The IV fluid management plan should detail the fluid and electrolyte prescription over the next 24 hours.

The draft guideline also recommends that healthcare professionals do not use a type of colloid known as tetrastarches - a starch-based IV fluid. This echoes the findings of a review published earlier this year by the Cochrane Collaboration which claimed that the use of hydroxyethyl starch might increase a patient's chance of dying.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "Making sure someone has the right level of fluid in their body is fundamental to good, basic care but this isn't always happening.

"There can be serious consequences if the wrong amount or composition of IV fluids is prescribed. If a person receives too much or too little fluid this can lead to problems like fluid in the lungs, dangerously raised or lowered potassium or sodium levels or nutrients such as glucose; and in some cases, heart failure.

"There is a lack of training in IV fluid management before the healthcare professional is fully qualified; professionals may be overworked and not able to give patients the attention they need; and experts often don't always agree on which IV fluids are best, leading to wide variation in practice. All these things compound the problem."

He added: "The NICE guideline, when published, will represent best practice for the NHS.

"It will support healthcare professionals to provide a quality of care for adult patients that helps to hasten recovery and reduce the likelihood of potentially devastating accidents occurring in the administering and monitoring of intravenous fluid therapy.

"After all, the NHS is in the business of getting people better, not making them worse."

A draft version of the guidelines is now available, as is a form for providing comments on the proposed recommendations.


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