Adherence to Daily Weights and Total Fluid Orders in the Pediatric Intensive Care Unit

BACKGROUND: Fluid is central to the resuscitation of critically ill children. However, many pay limited attention to continued fluid accumulation. Fluid overload (FO) is associated with significant morbidity and mortality. The Volume Status Awareness Program (VSAP) is a multi-phase quality improvement initiative aimed at reducing iatrogenic FO. For baseline data, the authors examined a retrospective cohort of patients admitted to the pediatric intensive care unit. METHODS: Cohort included diuretic-naive patients admitted to the pediatric intensive care unit at a tertiary care children’s hospital in 2014. Furosemide-exposure was used to indicate provider-perceived FO. Variables included daily weight and total fluid (TF) orders, and their timing, frequency, and adherence. Implementation of VSAP phase 1 (bundle of interventions to promote consistent use of patient weights) occurred in June 2017. RESULTS: Forty-nine patients met criteria. Five (10%) had daily weight orders, and 41 (84%) had TF orders—although 7 of these orders followed furosemide administration. Adherence to TF orders was good with 32 (78%) patients exceeding TF limits by < 10%. Thirty (63%) had > 5% FO by day 1, and 22 (51%) had > 10% cumulative FO by day 3. Following phase 1 of the VSAP, the frequency of daily weight orders increased from 6% to 88%. CONCLUSIONS: In our institution, use of fluid monitoring tools is both inconsistent and infrequent. Early data from the VSAP project suggests simple interventions can modify ordering and monitoring practice, but future improvement cycles are necessary to determine if these changes are successful in reducing iatrogenic FO