RESEARCH

SURVEY OF INTRAVENOUS FLUID THERAPIES AND ACCURACY OF GRAVITYFED INFUSIONS IN A TEACHING HOSPITAL
Bissett IPi, Brandt TPii, Windsor JAiii Department of Surgery, Faculty of Medicine and Health Sciences, University of Auckland, Auckland.i Manager, Surgical Research Network, Department of Surgery, Faculty of Medicine and Health Sciences, University of Auckland, Auckland.ii Professor and Head, Department of Surgery, Faculty of Medicine and Health Sciences, University of Auckland, Auckland.iii Abstract This study aimed to perform an audit of intravenous fluids to determine the accuracy of fluid administration at a single point in time. Forty medical students were trained in recording prescribed and actual infusion rates of intravenous fluids and sent to each ward of the hospital. The type of intravenous fluid, administration set and actual drip rates were recorded. These data were analysed to determine the accuracy of delivery of IV fluid therapies at the bedside. There were 734 patients in ward beds at the time, 181 of whom had a total of 203 IV sets at the bedside. Sixty-six percent of the IV sets were using a mechanical infusion pump and 34% were by gravity infusion. Only 4% of the fluids differed from that prescribed. At a single point in time the measured rate of the gravity sets varied from 0% to 160% of the prescribed rate with only 20% falling within 20% of this rate. Gravity infusion sets have poor minute to minute accuracy in our hospital setting. This represents an area of risk for patient safety and has important consequences on nursing workload as they are required to correct the inaccuracies in flow-rate. Introduction The administration of intravenous (IV) fluids is an

integral part of patient care in hospital allowing for the delivery of parenteral fluids and additives. Ensuring the accuracy of the infusion rate is an important goal in all settings, but there are some rate critical settings where the risks of both underand over-infusion must be avoided. These would include resuscitation, the delivery of toxic therapies and in the young and elderly. The control of the infusion rate is usually achieved with a roller-clamp or by a volumetric pump device. No published studies have audited the types and prevalence of fluid therapies in a hospital at a given time. Furthermore there have been few studies assessing the accuracy of IV fluid therapies1,2. It is therefore not possible to say whether the current use of rate control systems are appropriate. For instance there may be an over-reliance on the roller-clamp method or on the more expensive electronic volumetric pumps. This audit study is the first in a series to determine whether there is a case for the introduction of a more accurate rate control device. The aim of this study was to document the use of IV fluids in Auckland City Hospital at a single time point, to record the types delivery of IV fluids, to compare the charted IV fluids and the actual flow rate against the prescribed rate and to investigate the nature of any discrepancies recorded. Methods The proposed study was discussed with the chief medical officer, the head of nursing, members of the Quality Committee and the charge nurses on duty at the time that the audit was planned. Ethical approval to conduct the audit was obtained form both the Auckland District Health Board (ADHB) research committee, and the Northern Regional Ethics Committee. A team of 40 senior medical students were recruited to undertake the audit over a two hour period during the afternoon (May 7th 2007). An initial briefing session was held in the afternoon to explain consent and data collection procedures. Each student was supplied with a ward-specific clipboard of data sheets. Once on the ward the student checked with the charge nurse to ensure that they were aware of the audit. The student then visited each bedside and recorded data relating to the use of IV fluids for each patient present. The parameters that were recorded were: the gender and age of patient whether an IV set was present, and if so the type (gravity/volumetric pump/syringe) whether the volumetric pump was alarming; whether the IV set was connected to the patient, and if not, why not

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the reason for the IV the fluid prescribed and the fluid given (if different) the rate charted and the rate measured (for manual sets drops in 30 seconds were counted, for volumetric pumps, the rate set on the machine was recorded) the type of gravity set (standard 20 drops per minute or 60 drops per minute burette sets) any IV additives. The students were debriefed and the datasheets checked by the principal investigator, a senior consultant surgeon (I Bissett), to identify any initial anomalies that needed clarification. The data was then entered into a spreadsheet (Microsoft Excel) and checked for inaccurate data entry. The results were analysed according to the method of IV administration and presented as summary statistics. Results There were 840 inpatients, but only 792 patients were present on 44 wards at the time of the survey. Three wards were excluded because they did not give IV fluids (n = 2) and because of the request to be excluded (n = 1, Womans Assessment Unit). There were 239 patients who were receiving IV fluids. Fifty eight patients from adult, paediatric and neonatal intensive care units were excluded as it was not possible to record all details of their IV usage. Within the group of 181 ward patients there were 203 IV sets present by the bedside (Figure 1), 147 of which were connected in 117 patients at the time of the study. At the time of the study 16% (117/734) of ward patients in hospital had IV sets connected. Of the 147 connected IV sets there were 90 volumetric pumps (61%), 50 gravity sets (34%) and 7 syringe drivers (Figure 2). Of the 50 gravity sets there were 21 (42%) with a standard drip chamber and 26 (52%) with a burette set (150ml), and in 3 cases this information was not recorded. Of the 56 IV sets that were not connected, 68% were not required at the time, 19% were used for intermittent delivery of fluids dependent upon clinical protocol, and two patients were waiting for an intravenous luer to be inserted. The indications for intravenous fluid therapy are shown in Table 1. The prescribed fluid was different from that actually being administered in 6 (4%) of infusions. The differences included four cases where the fluid given was different from that
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Figure 1 The inpatients in Auckland City Hospital at the time of the study and those having intravenous fluid administration.

prescribed and 2 cases where the IV additive differed from that prescribed. In 3 cases the fluid being given was not prescribed on the intravenous chart. The accuracy of the IV fluid therapy was checked in the 50 patients with gravity sets. In 16 cases the flow rate was not calculated because the IV set was being used for the intermittent administration of medication. For the remaining 34 cases the prescribed and actual flow rates were compared (Figure 3). A rate of 100% indicates that the measured rate was the same as the prescribed rate and 0% indicates there was no flow at the time of the study. It was found that in only seven (20%) cases the flow-rate was within 20% of the prescribed rate. Discussion This pilot study has demonstrated that the majority (66%) of intravenous therapies are delivered by electronic devices (syringes and pumps), and that only 20% of those delivered by gravity sets had a flow-rate within 20% of the prescribed rate. The

actual fluid administered corresponded with that prescribed in almost all the patients (96%). These findings raise a number of questions, including to what extent do these findings reflect the actual delivery of fluid in the required time period? How many times does the rate need to be adjusted to achieve this? And what factors cause the inaccuracy in flow rate? The answers to these questions would require further studies performed over a longer period of time. Nursing factors, patient factors and factors relating to the intravenous giving set would need to be measured. Nursing factors would include inaccuracies in setting the flow-rate and inadequate monitoring of the flow-rate. Patient factors include limb position, the calibre of the vein and the venous pressure, and intravenous set factors including the height of the column of fluid and the phenomenon of cold flow creep. Cold flow creep occurs where the pressure exerted by the control device causes decreasing flow rates over time from increasing deformation of the intravenous tubing. This phenomenon was clearly demonstrated in the study by Flack and White3. They showed a decrease in flow rate from 30 drops per minute to 16 drops per minute over a 60 minute period in IV sets tested in the laboratory setting. They also showed, however, that the variations in vivo were much greater and related most strongly to the changes in the venous pressure of the patient. The present study does have limitations as it was performed only once during an evening in an attempt to acquire information on all patients at one point in time. There were 40 different data collectors and although some element of interobserver variation is likely this was minimised by a structured instruction period prior to the data collection. Inter-observer variation measurements were not attempted because in this snap-shot study the second measure of a rate at a different time may have represented flow variation over time rather than variation in measurement. Patients not in the ward at the time were not included and these patients might have had a different rate of IV fluid discrepancy although most would not have had an IV line connected. Variations in fluid rates seen at one point in time cannot be extrapolated as indicating that the patients did not receive the appropriate amount of fluid over a longer period as adjustments would have been made to the rate over time to correct any difference in rate from that charted. The accuracy of mechanical infusion pumps was not assessed in this study as the counting of drips in this setting is inappropriate. A mechanical pump that was running and not alarming was assumed

n Nil by mouth / unable to drink Post operative fluids IV drug administration Resuscitation Other 36 40 25 17 22

% 26 29 18 12 16

Table 1 The indication(s) for intravenous fluid therapy. More than one indication per patient was permitted.

to be performing according to specifications. The testing of this was outside the scope of this snapshot study. Although it may have been preferable to perform this study without prior warning of the charge nurses this was not permitted by hospital management. One might expect, however, that the fore-warning would have led to drip rates being more closely monitored than at other times thereby rendering our results an underestimation of the usual inaccuracy of drip rates. A study by Bivins et al1 compared electronic flow control with a roller clamp control mechanism in 448 patients with 700 infusion sites. This showed that gravity IV sets required more checks per hour and more frequent adjustment of the rate of flow than the electronic flow control sets. Interestingly, the gravity fed IV sites also required more frequent reinsertion of the drip and were more often associated with extravasation of the fluid into the tissues. Crass and Vance2 performed a similar study in a University Hospital monitoring 86 patients on gravity-fed intravenous fluids over a 4 day period. Using measures performed at about 2 hourly

Figure 3 The accuracy of IV flow rates, with the actual flow rates expressed as a percentage of the charted rate for gravity sets (n = 50). When charted and actual flow rates are the same it is 100%.

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intervals, they showed that less than 15% of IV infusions fell within 10% of the charted rate and 21% within 20% of that charted, results remarkably similar to the present study. They also showed that despite this discrepancy the overall infusion rates were closer to that charted because of regular intervention by the nursing staff to adjust the giving rate. A further study to assess a different device for gravity fed fluid infusion, Dial-A-Flo (Sorenson Research Company, Salt Lake City, USA), did not show any advantage over a standard infusion set alone4. This device, like the roller-clamp it was compared with, relied on compression of a short length of IV tubing to adjust the rate. The alteration of infusion rate over time seen with these devices may be due to the phenomenon of cold flow creep. There are clinical settings in which inaccuracies in flow rate can result in severe adverse events, such as over-infusion of fluids to the elderly leading to heart failure and too rapid infusion of medication resulting in toxicity. Although mechanical infusion pumps would normally be used in these situations in New Zealand there are many international settings where mechanical pumps are unavailable and all intravenous infusions are given by roller-clamp infusion set. This study shows that there is significant room to improve the minute to minute accuracy of the flowrate of gravity fed IV fluids. Whether one of the newer control systems would improve this accuracy and also reduce the dependency on the more expensive electronic pumps, needs to be tested. There is scope for a trial using a more accurate flow rate control device for use with gravity fed IV fluid therapies to determine whether this would lead to less nurse intervention and ensure a more accurate and cost-effective delivery of intravenous fluids. Acknowledgements The authors wish to acknowledge the assistance of fourth and fifth year medical students from the University of Auckland in performing the data collections and especially Hannah Giles for helping organise the students and Marina Krikanova for data entry. Appreciation is also expressed to Medicine Mondiale for sponsoring the study. References 1. Bivins BA, Rapp RP, Powers P, et al. Electronic flow control and roller clamp control in intravenous therapy: a clinical comparison. Arch Surg. 1980;115 (1):70-2. Crass RE, Vance JR. In vivo accuracy of

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gravity-flow i.v. infusion systems. Am J Hosp Pharm. 1985 Feb;42:328-31 Flack FC, Whyte TD. Behaviour of standard gravity-fed administration sets used for intravenous infusion. Br Med J. 1974;3:43943. Rithalia SV, Rozkovec A. Evaluation of a simple device for regulating intravenous infusions. Intensive Care Med. 1979;5:41-3.

Address for Correspondence Ian P Bissett, Associate Professor, Department of Surgery, Faculty of Medicine and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand. Fax: +64 9 3779656 Phone: +64 9 3737999 Email: i.bissett@auckland.ac.nz

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