Education, Research, and Quality Improvement: Education, Research, and Quality Improvement II |

Crystalloid Use in Resuscitation (CURE): A Quality Improvement Initiative FREE TO VIEW

Saraschandra Vallabhajosyula, MBBS; Heather Personett, PharmD; Mikhail Dziadzko, MD; Kenneth Sakata, MD; Alexander Kogan, MD; Kianoush Banaei Kashani, MD
Author and Funding Information

Mayo Clinic, Rochester, MN

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):628A. doi:10.1016/j.chest.2016.08.720
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SESSION TITLE: Education, Research, and Quality Improvement II

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM

PURPOSE: Excessive use of normal saline (NS) in comparison to balanced solutions in non-hypochloremic patients has been associated with adverse intensive care unit (ICU) and hospital outcomes, including metabolic acidosis, hyperkalemia and acute kidney injury (AKI). This quality improvement (QI) initiative was implemented to reduce the use of NS during intravenous fluid (IVF) resuscitation in non-hypochloremic patients.

METHODS: This QI study was conducted in a mixed medical-surgical ICU from July 2015 to March 2016. Define, Measure, Analyze, Improve and Control (DMAIC) cycles were used to design iterative plan-do-study-act (PDSA) cycles. Patients >18 years who required >500 ml of crystalloids for IVF resuscitation in the first 2 hours were included. Patients with cirrhosis or history of prior liver transplant and moribund patients were excluded. Baseline data were collected between July 2015 and September 2015 using electronic medical records. Pre-intervention care provider survey regarding resuscitation preferences was administered. Interventions included staff education, relocating to deprioritize NS use and increasing the availability of lactated ringers (LR) as representative of a balanced solution. Primary outcome included total and bolus NS use during ICU stay. Secondary outcomes included total and bolus NS use during initial 24-hours, percentage of IVF therapy with NS, ICU length of stay and AKI incidence. Non-parametric statistical analyses were used and P<.05 was considered statistically significant.

RESULTS: During the pre-intervention period, 54 patients [median age 61 (52-68) years, 35 (65%) males] met the inclusion criteria. Survey of physicians, physician extenders, nurses and pharmacists [110/152 (72%) respondents] revealed a lack of familiarity with alternatives (29%) and poor accessibility (16%) as common barriers to the use of LR vs. NS. High serum chloride (28%), high serum sodium (26%) and increasing serum creatinine (16%) were factors influencing fluid choices. PDSA cycles addressing education, availability and stocked solutions were designed. Following the intervention period, between January and March 2016, 22 patients were included [median age 59 (39-68) years, 18 (82%) males]. Baseline characteristics were comparable between groups. Primary outcome of NS use (2.4 (1.3-3.7) L vs. 1.5 (0.8-2.5) L, P=0.36) and bolus use (1.0 (0.5-2.0) L vs. 0.7 (0.3-1.0) L, P=0.31) was not different between groups. 24-hour bolus NS use was lesser in the post-intervention cohort (1.0 (0.6-1.8) L vs. 0.7 (0.3-1.0) L, P<0.001). Secondary outcomes of percentage NS total and bolus use, 24-hour use, AKI and ICU LOS were not different between groups. Counter balance measures of provider satisfaction, effective workflow and hyperkalemia were evaluated.

CONCLUSIONS: Using a combination of interventions including education, fluids relocation and increasing the LR availability was effective in decreasing the initial 24-hour bolus use of NS in the ICU. However this proof-of-concept study needs further validation in large-scale studies.

CLINICAL IMPLICATIONS: This pilot-QI initiative evaluated the feasibility of simple interventions to reduce NS use in the ICU.

DISCLOSURE: The following authors have nothing to disclose: Saraschandra Vallabhajosyula, Heather Personett, Mikhail Dziadzko, Kenneth Sakata, Alexander Kogan, Kianoush Banaei Kashani

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