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Fluid Balance for Adult In-patients Clinical Guideline

V1.0

May 2019

Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 2 of 14

Summary

Fluid balance guide

Patient to commence fluid balance

Nursing team/Patient /Host informed

Fluid balance chart commenced

date + patient identity added

Input Intravenous

fluids/drugs NG/NJ/PEG

feed Oral Fluids

Output: Urine Stoma Vomiting N/G Aspirate

To be documented

Escalation: Acute patients with a urinary catheter output monitored hourly If patient produces <2mls/kg body weight/hr over 4hrs or <0.5mls/kg body

weight/hr exemption in CKD oliguria if agreed with medical team


1. Aim/Purpose of this Guideline

1.1. Fluid balance is an essential tool in determining hydration status. Recording intake and output tends to be one of the key activities undertaken at the bedside and is used in conjunction with the recording of vital signs and certain laboratory reports to set required fluid intake levels. Accuracy in recording fluid intake and output is vital to the overall management of certain patient groups and facilitates in the assessment and evaluating the patient’s condition. This will enable correct prescribing of intravenous and subcutaneous fluids. 1.2. The purpose of this policy is to raise staff awareness and provide clear standards in managing optimal hydration and maintaining effective fluid balance in the adult patient. The guidance aims to ensure that healthcare staff applies a safe and consistent approach to the assessment, recording and monitoring of an individual patient’s fluid intake and output which aims to:

Prevent or reduce adverse consequences associated with patient dehydration by establishing an effective standard and management for optimal hydration. Create one set method for recording detailed and accurate fluid input and output. Support staff to determine a timely and appropriate rationale for starting and stopping a fluid balance chart.

2. The Guidance

All inpatients within the Trust who meet the criteria for fluid balance measurement will have accurate and fully completed fluid balance charts as set out in this fluid balance policy. The following standards of practice will apply to all staff involved in patient monitoring and recording of vital signs and fluid balance charts.

Successful fluid balance is dependent upon: Timely/appropriate rationale for commencement/discontinuation One system for detailed & accurate measurement of input/output Consideration of sensible and insensible loss (sweating/vomiting/stoma output/diarrhoea)

2.1. Indications for commencing a Fluid balance chart

Fluid balance charts must be completed for the following patients unless a decision has been made otherwise by a medical practitioner or a senior registered nurse.

NEWS score >3 and/or risk of level 2 or 3 care Patients with sepsis


Patients discharged from Critical Care for a minimum of 48 hours post transfer or as indicated by outreach or medical/ surgical team. Temperature greater than 380 Centigrade. Excessive vomiting or nasogastric aspiration/drainage Diarrhoea and excessive output stoma/ ileostomy Post-operative patients. Excessive fluid loss from surgical drains/ cavity drains, wounds /VAC therapy Intravenous Fluids and drugs / or parenteral nutrition Enteral feeding i.e. PEG, NG, PEG-J, NJ Fluid restricted i.e. cardiac failure, liver failure, AKI, CKD Patients with urinary catheters, excluding patients with long term catheters in the absence of acute onset of illness. Sickle cell disease NBM > 12 hours When any doubt exists over fluid status. This is not an exhaustive list and other indications may be deemed necessary by the responsible healthcare professional

2.2 Completing a Fluid Balance Chart

See Appendix 3 Guide to documenting fluid balance See Appendix 4 Guide to Fluid Capacity of ward cups/beakers/jugs

2.3 Requirements over 24 hours

Clinicians are reliant on accurate 24 hour totals to inform clinical decisions in relation to fluid management including the prescription of intravenous fluids. This will prevent the serious complications associated with over or under hydration. Incorrect or poorly completed fluid balance charts and ineffective monitoring can result in detrimental effects on patient outcomes.

2.4 When to review and/or stop a Fluid Balance Chart

When patients are transferred to other wards / departments, a verbal and written handover must include whether the patient is on a fluid balance chart

Fluid Balance Charts must be reviewed in line with the patient’s clinical condition.

Frequency must be determined and recorded by the registered healthcare professional to ensure that fluid requirements are met and balance is maintained.

Stopping fluid balance is the decision of the responsible clinician or registered nurse. Patients must be assessed thoroughly before making such a decision


3. Monitoring compliance and effectiveness

Element to be monitored

Ward areas to be compliant 100% with completion of accurate fluid balance documentation Including input, output , totals and balance

Lead Fluid balance working group / Critical Care Outreach Team / Ward managers/matrons

Tool Audit carried out by critical care outreach/ Fluid balance working group Datix incident reporting – review of related incidents

Frequency Fluid Balance documentation audits yearly for those areas complying with standard those below standard will be monitored quarterly.

Reporting arrangements

Nutrition steering group

Acting on recommendations and Lead(s)

Nutrition Steering Group monthly meetings. Fluid balance working group.

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned through Matron/ Sister meetings

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 4.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/OurOrganisation/EqualityAndDiversity/HumanRightsEqualityAndInclusion.aspx


Appendix 1. Governance Information

Document Title Fluid Balance for Adult In-patients Clinical Guideline V1.0

Date Issued/Approved: 1st March 2019

Date Valid From: May 2019

Date Valid To: May 2022

Directorate / Department responsible (author/owner):

Susan C. Kennedy Clinical Lead Renal Dietitian

Contact details: 01872 252424

Brief summary of contents

This document provides the framework for clinical staff in the management of patient hydration and monitoring of fluid balance. The document ensures that staff are guided by the expected standard set by the organization.

Suggested Keywords: Fluid Balance Adults In-patients

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: November 2018

This document replaces (exact title of previous version):

New document

Approval route (names of committees)/consultation:

Nutritional Steering Group Feb 2019 Therapies Clinical Governance Forum Feb 2019

Care Group General Manager confirming approval processes

Robin Jones

Name and Post Title of additional signatories

Not Required

Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings

{Original Copy Signed}

Name: Kevin Wright Clinical Support Care Group

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and

Internet & Intranet Intranet Only


Ratification):

Document Library Folder/Sub Folder Clinical/Dietetic

Links to key external standards

NICE Nutrition Support for adults cg32 (updated 2017) NICE Intravenous fluid therapy in adults in hospital cg174 (updated 2017) NICE Acutely Ill patients in hospital: Recognition of and response to acute illness in adults in hospital. cg50

Related Documents: BMJ Quality Improvement Reports 2015: Improving fluid balance monitoring on the wards Milton Keynes S.Jeyapala et al

Training Need Identified? Yes - Learning and Development Department to be informed

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

November 2018

V1.0 Initial issue Susan Kennedy Lead Renal Dietitian

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.


Appendix 2. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed

Fluid Balance for Adult In-patients Clinical Guideline V1.0

Directorate and service area: Nutrition Support Team

New or existing document: New

Name of individual completing assessment: Susan C. Kennedy Clinical Lead Renal dietitian

Telephone: 01872 252409

1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?

To provide the framework for clinical staff in the overall management of maintaining patient hydration and accurate monitoring of fluid balance. The document ensures that staff will be guided by the expected standard set by the organisation

2. Policy Objectives*

Create one set method for recording detailed and accurate fluid input and output.

Support staff to determine a timely and appropriate rationale for starting and stopping a fluid balance chart.

Support person centred planning

3. Policy – intended Outcomes*

Prevent or reduce adverse consequences associated with patient dehydration or fluid overload by establishing an effective standard and management.

4. *How will you measure the outcome?

Adverse events associated with clinical care are captured through Mortality Review and Serious Incidence. Any issues relating to hydration and fluid balance will be identified through these processes

5. Who is intended to benefit from the policy?

All adult in patients and clinical staff

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

Yes Yes

Please record specific names of groups RCHT Strategic Nutrition group Senior matrons Ward managers Critical care outreach steering Fluid balance working group


Are there concerns that the policy could have differential impact on:

Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Age X

Sex (male,

female, trans-gender / gender reassignment)

X

Race / Ethnic communities /groups

X

Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.

X

Religion / other beliefs

X

Marriage and Civil partnership

X

Pregnancy and maternity

X

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

X

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No X

What was the outcome of the consultation?

Approved.

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


9. If you are not recommending a Full Impact assessment please explain why.

Not indicated

Date of completion and submission

November 2018.

Members approving screening assessment

Policy Review Group (PRG) APPROVED

This EIA will not be uploaded to the Trust website without the approval of the Policy Review Group. A summary of the results will be published on the Trust’s web site.


Appendix 3. Guide to documenting fluid balance

If patients meet the criteria for fluid balance then they meet the criteria for accuracy!

All members of the nursing team should be alerted to commencement of a fluid balance chart.

The Trust fluid balance chart should be used All fluid balance charts to be completed with the patients name,

date, and ward and hospital number. Oral input:

Ensure ward team is aware of patient risk of dehydration. Fluid must only be recorded as input once it has been consumed. The patient should be informed why he/she has commenced a fluid

balance chart. The patient and/or visitors should be encouraged to chart fluid input where applicable and mental capacity has been established.

Ensure ward team nurses /Heath Care Assistants/hosts/medics are aware of fluid capacity of cups and jugs used on the ward (see appendix 3)

Alert ward hosts when a patient has commenced a Fluid balance chart on ”Patient Nutrition & Hydration Prompt / hand-over sheet” (see appendix 4). This will enable assistance in documenting fluid intake. The Host team should alert the nursing team to concerns regarding a patient’s poor fluid intake. The hosts will note fluid consumed when replenishing water jugs and tea/coffee consumption.

Do not document in ‘sips’ - document in mls.

Intravenous Input:

Whenever possible IV fluids to be administered via a volumetric pump and rate charted hourly

Intravenous fluids not administered through a volumetric pump should be documented at the commencement of infusion with type of fluid

include IV drug volume and 0.9% Normal Saline flushes are recorded as input as this can accumulate to a large volume in some patients

Detailed & Accurate Output:

All team members must be aware to document fluid loss. All forms of sensible fluid loss must be accounted for with as much accuracy as is reasonably possible


Patients must be informed of the importance of documenting urine output and provided with receptacles for urine collection and measurement.

It is unacceptable to write ambiguous comments for urine output. However if the patient has gone out to the toilet this should be documented and patient encouraged to use urinary receptacles provided.

Document all stoma, nasogastric aspirate/drainage or drain output. Acute staff must be able to estimate urine output in cases of

incontinence The amount of each vomit If there have been multiple episodes of diarrhoea or vomiting

attempt to arrive at an estimated volume

Estimation of fluid balance:

As much as possible oral fluids should not be estimated, recognised measuring containers must be used (see Appendix 3) and actual volume documented.

Insensible loss should be considered when assessing the fluid balance

Urine output should be estimated in cases of incontinence. i.e. weighing of pads

Care must be taken in the case of vomiting, diarrhoea and blood loss that attempts are made to arrive at an estimate of volume.

Escalation:

Acute patients’ with a urinary catheter in situ must have their output monitored and measured hourly until the patient’s clinical condition has improved

If adult patient’s produce <2mls/kg body weight over 4hrs or < 0.5mls/kg body weight/hr then this is an automatic trigger for referral requiring primary medical and nurse responder review (exemption in chronic renal failure patients where the medical team is aware of oliguria – this would need to be confirmed by the medical team). (ex 70kg man <2mls/hr over 4hrs = <140mls or <0.5mls = <35mls/hr)

Running totals must be completed during the day as per fluid chart.



Appendix 4. Patient Nutrition & Hydration Prompt Sheet