NHS FORTH VALLEY. Fluid Management Policy

NHS FORTH VALLEY Fluid Management Policy Date of First Issue 19/01/2015 Approved Current Issue Date 01/8/2015 Review Date 01/8/2017 Version Version 2.1 EQIA Author / Contact Group Committee Final Approval Yes Marjory Gardiner (Lead ANP, Reliable Rescue) Nursing and Midwifery Policy Forum Version 2.1 July 2015 Page 1 of 19

Consultation and Change Record for ALL documents Contributing Authors: Consultation Process: Marjory Gardiner Lead ANP, Louise Boyle SCN ICU, Norma Pringle SCN CAU, Jackie Cappie SCN Cardiology, Lynne Paterson SCN Surgical Specialties, May Fallon Senior Nurse Practice Development, Janice Duffy SCN SCH, Margaret McLay SCN Day Surgery, Karen Paterson, Team Leader Recovery. Oonágh Cameron, Quality Improvement Manager Christine Christie, Senior Dietician, Dr Catherine MacLean, Acute Care Consultant Physician, Nursing & Midwifery Policy Forum Sara Dickie, Head Nurse Medicine Rita Ciccu Moore, Head Nurse, Surgery Senior Charge Nurse group Distribution: Change Record Date Author Change Version July 2015 Oonágh Cameron Multiple amendments in consultation with all SCN including community hospitals, ambulatory care, theatre recovery V2.1 Version 2.1 July 2015 Page 2 of 19

Contents Page 1. Introduction 4 2. Policy Statement 4 3. Duties within the organisation 5 4. Roles and responsibilities 5 5. Fluid balance monitoring 7 6 Theatre and Ambulatory care 11 7. Consent 11 8. Authorised professionals 11 9. Education and training 11 10. Monitoring and assurance 11 11. Discharge 11 Appendices 1. NHS Forth Valley Hydration Risk Factors Flowchart 2. NHS Forth Valley Daily Assessment Flowchart 3. NHS Forth Valley Hydration Care Plan 4. NHS Forth Valley Fluid Balance Monitoring 5. NHS Forth Valley Fluid Intake Monitoring 6. NHS Forth Valley Handy Measures 7. NHS Forth Valley Fluid Management Monitoring Tool Version 2 July 2015 Page 3 of 19 UNCONTROLLED WHEN PRINTED

1 Introduction Effective and consistent fluid management is recognised nationally as being an area of weak practice with poor fluid balance management and poor record keeping having been identified as contributing factors to the poor outcome of acutely unwell patients (National Confidential Enquiry into Peri-operative deaths (NCEPOD) 2009, National Institute for Health and Clinical Excellence (NICE) 2007 & National Patient Safety Agency (NPSA) 2007). Maintenance of adequate hydration is vital to health and preventing the deterioration of the acutely unwell patient. Basic nursing care, including fluid monitoring, is critical to good quality compassionate care (Vale of Leven Hospital Inquiry Report 2015). The NMC Code March 2015 identifies hydration as part of fundamental care and that nurses have a responsibility to provide help to those who are unable to drink fluids unaided. 2 Policy Statement The purpose of this policy is to outline the protocol for fluid management in all adult patients who require active fluid monitoring with the patient being the central focus of care, and due consideration should be given to their comfort at all times. The protocol will:- pro actively assess which patients need a fluid balance chart provide guidance for monitoring and review of patients who have been commenced on a fluid balance chart provide guidance on accurate completion of fluid balance charts Ensure that fluid balance is part of the nurses handover / safety brief Fluid balance is a term used to describe the balance of the input and output of fluids in the body to allow metabolic processes to function correctly (Welsh 2010). Timely and appropriate use of fluid balance observation and recording is an essential tool in determining adequate hydration. When patients are actually or potentially acutely ill they may show early warning signs which can be detected through accurate fluid balance. Successful fluid balance is dependant upon:- Timely/appropriate rationale for commencement/discontinuation Generic detailed & accurate measurement of Input/Output Consideration of insensible loss The policy excludes paediatrics/end of life care Version 2.1 July 2015 Page 4 of 19

3 Duties within the organisation Systems and resources are in place to facilitate implementation and compliance of the policy thus ensuring the requirements set out in this policy are fulfilled. Professional Lead Nurses have responsibility for distribution of this policy to staff within their area/directorate, ensuring that staff are aware of and have access to the Fluid Management Policy Senior Charge Nurses have a responsibility to ensure that this policy is implemented within their area and to ensure all staff groups are educated to the required level, whilst keeping up to date with current practice. Compliance will be monitored by undertaking regular audit. All clinical staff (nursing and medical) are responsible for their own compliance with the policy and delivery of accurate fluid balance contained within this policy. All clinicians must be made aware that the Fluid Management Policy is available on the intranet which can be accessed through Quality Improvement http://www.qifv.scot.nhs.uk/ 4 Roles & Responsibilities 4.1 Registered Nurses - assessment of patient needs Assessment of hydration has three main elements: clinical assessment review of fluid balance charts review of blood chemistry Scales & Pilsworth( 2008) The management of fluid balance in both maintaining an accurate record of intake and output and reconciling the totals after each entry is vital. This information is key to patients care delivery and is a record which enables other professionals involved in the patients care to make appropriate decisions (Vale of Leven Hospital Inquiry report (2015) The accurate recording and monitoring of fluid balance is regarded as being a nursing responsibility all registered nursing staff must ensure: Using NHS Forth Valley Hydration Risk Factors Flowchart (appendix1), all patients should be assessed within 4 hour of admission. Thereafter, using NHS Forth Valley Daily Assessment Flowchart (appendix 2), patients will be reviewed on a daily basis in acute care and weekly in a community setting for their fluid and hydration needs. This will inform the criteria for starting, continuing or stopping fluid monitoring All patients will commence NHS Forth Valley Hydration Careplan (appendix 3) and all individual hydration care needs and interventions assessed, documented and reviewed on an ongoing basis Version 2 July 2015 Page 5 of 19

Nursing assessment should include baseline vital signs, weight, thirst and physical appearance e.g. skin, mouth, and eyes whilst medical staff will assess baseline urea and electrolytes (NHS East of England 2010) All in-patients should be given a copy of the NHS Forth Valley, Staying Hydrated, Staying Healthy information sheet (order number ING1856) unless on a fluid restriction. A urine assessment should be undertaken on the first urine passed after admission, observing for colour and testing with a urinalysis strip. The full documentation of the result should be recorded and not just Negative or Positive Clear, timely and accurate completion of fluid charts, including input and output totals and positive or negative balances documented in patient unified notes every 24 hours, and action taken by the nurse to address these balances. Review of patient condition and early recognition with timely communication and escalation of patients deterioration through National Early Warning Score (NEWS) monitoring Patient safety issues/hydration status are communicated through bedside handover/safety brief if patient has an active fluid balance chart Patient s spiritual/religious beliefs should be documented to ensure that staff are informed of patients that are fasting. Consideration would be based on individuals needs and impact fasting may have on their continuing healthcare. 4.2 Non registered nursing staff (including student nurses) Some aspects of fluid balance recording may be delegated to non registered nursing staff if deemed competent by the Senior Charge Nurse/registered nurse. The non registered staff may:- Offer oral fluid as directed by the registered nurse or part of the Care & Comfort round checklist. Only record oral fluids taken by the patient Record fluid output including urine/bowels/stoma/vomit and drains All intake and output should be assessed continuously by the registered nurse caring for the patient. 4.3 Other non nursing staff-(ahp, housekeeper, volunteer etc) If a patient has been assisted to drink/ drink removed / toileted/ removed vomit bowls etc: then it is the staff member responsibility to inform the nursing team in order to ensure accurate fluid balance completion. 4.4 Medical Staff Medical staff are responsible for reviewing the patient on a continuing basis for their fluid and hydration needs including urea and electrolytes and this should be documented in the patients unified notes. Steps must be taken if the patient condition deteriorates to Version 2 July 2015 Page 6 of 19

undertake review of the patients condition, with timely communication and escalation to senior staff. 4.5 Role of carers/relatives Carers/relatives have a vital role in supporting more dependant individuals to drink and to assist in accurate fluid balance recording. Unless on a fluid restriction, carers should be made aware of the individuals need for fluid and encourage them to drink, and asked to inform nursing staff if fluids are given. 4.6 Role of the patient Supporting the patient to participate and take ownership of the management of their hydration status (where possible) is regarded as being beneficial and can improve compliance with monitoring of fluids input and output and therefore enhanced accuracy of fluid chart completion (Chung et al 2002, Reid 2004). If the patient is able then he/she should be fully supported to complete their own fluid charts. 5 Fluid Balance Monitoring 5.1 Indications and targets The indications for commencement of fluid balance monitoring should be assessed using the NHS Forth Valley Hydration Risk Factors Flowchart, (appendix1). The Registered Nurse with responsibility for the patient should assess and total the patient s fluid status entry by entry on an ongoing basis and report any abnormalities to the medical team. The total fluid intake /output are measured from12midnight 12midnight (mn). At this time the negative / positive fluid balance should be documented in the patient unified notes and assess whether it is in line for the target hydration for that patient and whether it is in line with the patients 24 hour hydration target. Patient eating Patient anorexic Target hydration: Female adults 1.6L per day 2.0L per day Male adults 2.0L per day 2.5L per day This is an average fluid target, however it is essential to consider other factors such as ambient temperature, patients losses and pyrexia and adjust accordingly. The need for fluid monitoring should be reassessed using the NHS Forth Valley Daily Assessment Flowchart (appendix 2). If the patient has any of the 6 risk factors, fluid balance monitoring must be continued. If no risk factors identified then following review by the registered nurse and / or clinical team, the fluid balance may be discontinued. The patient should continue to be reassessed on a daily basis in the acute setting and weekly in the community setting or if there is any change or deterioration in the patient s clinical condition. Version 2 July 2015 Page 7 of 19

5.2 Fluid Balance Monitoring Where there are one or more risk factors NHS Forth Valley Fluid Balance Monitoring Chart (appendix 4) should be used. If only risk factor 5 requires assistance to eat drink or swallowing problems then NHS Forth Valley Fluid Intake Monitoring Chart (appendix 5) may be used in place of full intake and output measurement. Fluid Balance Monitoring should identify: Patients full name/addressograph Label Community Health Index (CHI) number Hospital Ward Date Patient weight: Patient s current weight should be recorded on admission and thereafter weekly if fluid balance or intake monitoring continues or daily if on fluid restriction. Subsequent weights should be at the same time of day with the same weighing scales, which should be calibrated regularly. (McMillan and Pitcher 2010). Fluid target: Fluid target should be identified and whether a positive, negative/ restricted or neutral balance Reason for monitoring: Risk factors present should be documented by ticking all those applicable Discontinuation: Where the patient has been assessed as no longer having any risk factors and fluid monitoring is no longer indicated, the person discontinuing the monitoring chart must sign and advise that clinical staff are aware of that decision. This should also be recorded in unified notes. Total balance Total balance is calculated taking into consideration: Total 24 hour intake Total 24hr urinary output Insensible loss ( approx 600-800mls/day) Version 2 July 2015 Page 8 of 19

5.3 Recording of input Oral Input All input should be measured in Millilitres (mls). It is not acceptable to record sips and should not be a matter of guess work. If medical staff instructs that a patient can have sips orally this must be measured and recorded as either 30-60 mls. Use a tumbler, cup or other vessel that have known or clearly marked volumes. NHS Forth Valley Handy Measures for Fluids (appendix 6) gives this guidance If possible/relevant, ask the patient/relative to document input and instruct clearly how to do so. Carers and relatives will also need to be made aware of the fluid volume of containers used in NHS Forth Valley Intravenous/Subcutaneous Input Once fluid is prescribed then this must be administered at the prescribed time or as soon as possible. All infusions of 125mls/hour or faster should be through a medical device and actual volume administered must be recorded hourly (e.g. 500mls over 4 hours would be 125mls/hr). This does not apply to theatres as more rapid boluses and large amount of fluids are required during surgery. If the fluid is not running through a medical device the total volume given is recorded at the end of the infusion Include each saline flush given between bolus of IV drugs on the fluid chart (If a patient is on multiple IV drugs it can add up to a substantial amount over a 24hour period). The cumulative total is the running total for the total amount of fluids given (oral/iv/naso Gastric (NG) etc) from the time the fluid chart commences and should be completed on each entry Nutrition Support The following must be included within fluid balance monitoring and documented on the fluid balance chart: Oral supplementary drinks Enteral nutrition (flushes and hourly rate) Parenteral nutrition (flushes and hourly rate) 5.4 Output All forms of fluid loss should be accounted for with as much accuracy as possible. Poor documentation can mean we miss early warning signs and the opportunity to detect poor output and intervention prior to harm. Running output totals must be completed throughout the day with a final output calculated every 24 hours. This balance whether positive or negative balance should be documented in the patient unified notes every 24hours. All output should be measured in millilitres (mls). Version 2 July 2015 Page 9 of 19

Urine output Staff have a duty to ensure fluid output is recorded as accurately as possible and to explain any ambiguity. If patients meet the criteria for fluid balance then it must be documented accurately. The cumulative running total of urine output should also be recorded and added to the total cumulative output. Patients must be given the appropriate receptacles for urine collection It is not acceptable only to write incontinent (++) Clinical staff should not estimate urine output in cases of incontinence. It should be recorded in the patient unified notes that the patient is incontinent and therefore unable to accurately document urine output on the fluid balance chart. Incontinent, patient must be checked every 2 hours as indicated by Care and Comfort rounds If urine output is less than 0.5mls/kg/hr or 2mls/kg over 4 hours medical staff should be informed immediately and documented in the patients unified notes, eg patient weight 65 kg = 32.5 mls per hour 130 mls per 4 hrs The exception is overnight when most patients will not pass urine overnight unless patient is catheterised Check patency of urinary catheters at a minimum every 2 hours as indicated by Care and Comfort rounds A full description of any abnormalities of the urine i.e. colour, consistency, should be documented in the patient unified notes and urinalysis taken if appropriate. Insensible loss In normal health and normal activity adults will loose 600-800mls/day insensible loss, therefore consider when assessing patients individual fluid balance and prescribing IV fluids. Drains Any drain output must be monitored and running totals calculated into the running total or if the drain is changed. If the patient has more that 2 drains a further chart can be utilised. Vomit / aspirate All vomit/aspirate must be measured as accurately as possible. A full description of the aspirate should be recorded i.e. colour, consistency, amount, and all relevant care documented in the patients unified notes. Version 2 July 2015 Page 10 of 19

6 Theatre and Ambulatory Care Tracking volumes in and out during surgery would be hard to continuously record and insensible losses almost impossible to estimate therefore, only cumulative totals of fluids infused and outputs at the end of theatre will be recorded on the anaesthetic record For all elective patients, on arrival to ward, the nurse in charge of the patient will be responsible for commencing Fluid Balance Monitoring Chart and transferring the cumulative theatre totals to this. Any inpatient going to theatre, if Fluid Balance Monitoring Chart is in place it should accompany patient. This is to enable theatre staff to accurately assess current fluid balance status On return to ward, the nurse in charge of the patient will be responsible transferring the cumulative theatre totals and to continue monitoring the patient 7 Consent Fluid balance monitoring does not require patients (or carers) consent. 8 Authorised Professionals All professional staff within NHS Forth Valley that are involved in the preparation, provision and monitoring of hydration status must at all times act in accordance with their Professional Code of Practice. 9 Education and Training All staff should receive training on fluid management and the importance of how this relates to patient safety and care. Highlight to healthcare staff the importance of health benefits of correct hydration and avoiding over or under hydration by attending appropriate study days and on the job training. 10 Monitoring and Assurance Using NHS Forth Valley Fluid Management Monitoring Tool (appendix 7) Senior Charge Nurses will be responsible for undertaking a random sample of 5 sets of patient documentation weekly to assess compliance with the policy. 11 Discharge On patients discharge from hospital all fluid balance charts should be filed in the patient case notes for a period of two years. Version 2 July 2015 Page 11 of 19

Appendix 1 NHS Forth Valley Hydration Risk Factors Flowchart Version 2.1 July 2015 Page 12 of 19

Appendix 2 NHS Forth Valley Daily Assessment Flowchart Version 2 July 2015 Page 13 of 19

Appendix 3 NHS Forth Valley Hydration Care Plan Version 2 July 2015 Page 14 of 19

Appendix 4 - NHS Forth Valley Fluid Balance Monitoring Version 2.1 July 2015 Page 15 of 19

Appendix 5 - NHS Forth Valley Fluid Intake Monitoring Version 2 July 2015 Page 16 of 19

Appendix 6 - NHS Forth Valley Handy measures Food Measure Food Measure Clear Plastic tumbler 200 ml Bowl of milk pudding 150ml Crockery mug 180 ml Custard with cake 100ml Disposable plastic cup 150ml Jelly 85ml Drinking beaker with spout 200ml Ice cream tub 85ml Jug 1000ml Yoghurt 125ml Bowl of soup 150ml Gravy 70ml Version 2.1 July 2015 Page 17 of 19

Appendix 7 NHS Forth Valley Fluid Management Monitoring Tool Version 2.1 July 2015 Page 18 of 19

References Chung LH, Chong S. and French P. (2002) The efficiency of fluid balance charting: an evidence based management project. Journal of Nursing Management Vol 10, 103-113. McMillen R, Pitcher B (2010) The balancing act: Body fluids and protecting patient health. British Journal of Healthcare Assistants; 5: 3, 117-121. NCEPOD (2009) Adding insult to injury. www.ncepod.org.uk National Institute for Health and Clinical Excellence. (2007) 50 Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. NHS East of England (2010) Intelligent Fluid Management Bundle Nursing and Midwifery Council (NMC) (2012) Record keeping Guidance for nurses and midwives. Reid J (2004) Improving the monitoring and assessment of fluid balance. Nursing Times. Vol 100, No 20, p36. Scales K, Pilsworth J (2008) The importance of fluid balance in Clinical practice. Nursing Standard. 22, 47, 50-57. The Right Honourable Lord McLean (2015) Vale of Leven Hospital Inquiry Report, 12, 216 Welch K (2010) Fluid balance. Learning Disability Practice; 13: 6, 33-38 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact 01786 434784. For other formats contact 01324 590886, text 07990 690605, fax 01324 590867 or e-mail - fv-uhb.nhsfv-alternativeformats@nhs.net Version 2.1 July 2015 Page 19 of 19