Audit of the appropriateness and accuracy of fluid intake and output monitoring: experience in a tertiary hospital
The current practice of fluid intake and output monitoring for hospitalised patients in one local acute care tertiary hospital was unclear and inconsistent. Inaccurate fluid balance monitoring and poor documentation can result in poor clinical outcomes.
To provide an overview of the current practice of ordering, monitoring and documentation of patient fluid intake and output during hospitalisation.
Electronic charts of 2199 adults were reviewed for appropriateness and accuracy of monitoring and documentation of the fluid balance records. Data retrieved for each patient included: (1) Was daily fluid balance monitoring clinically indicated? (2) Was daily fluid balance monitoring prescribed by the doctors or initiated by the nurses? (3) Was the daily fluid balance documentation accurate for the entire admission?
Of the reviewed patients, 68% were on fluid balance monitoring, of whom 31% were prescribed by medical teams and 69% were nurse-initiated. Among patients who were receiving fluid balance monitoring, 78% were clinically indicated (35% prescribed by doctors), and 22% had no clinical indications (18% prescribed by doctors). Overall, documentation accuracy of the intake and output charts was 77%, with 100% accuracy in the oral and intravenous fluid intake, and 21% accuracy in the output documentation. Among the inaccurate documentation of monitoring with no quantifiable amount, ‘void in toilet’ was the most inaccurately documented (93.3%).
It is vital to address the current disparities in hospital practice, which include prescribing fluid balance monitoring for patients without a clinical indication and documenting incomplete or poor quality information in patients' intake and output charts. Future quality improvement and research work is needed to improve patient safety and outcomes.
Monitoring fluid balance through accurate documentation of patients' intake and output charts is vital during hospitalisation and is a critical component in the care of acutely ill hospitalised patients, as well as part of providing safe patient care (Georgiades, 2016; National Institute for Health and Care Excellence (NICE), 2017). Fluid balance monitoring has been reported to be a challenging task, especially when patients are confused, uncommunicative and incontinent (Vincent and Mahendiran, 2015). As a result, inaccurate fluid balance monitoring and poor documentation can lead to poor clinical outcomes in the acutely ill hospitalised patient, including missed recognition of warning signs of dehydration, affected cardiac and renal function, prolonged hospitalisation and increased mortality (Grams et al, 2011; NICE, 2017; Healthcare Quality Improvement Partnership, 2018). Fluid balance and monitoring has been recognised by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) as one of the critical factors relevant to quality patient care during hospitalisation (Healthcare Quality Improvement Partnership, 2018). It is well documented that the current practices of fluid intake and output monitoring for inpatients is inconsistent, incomplete and lacks accuracy (Shepherd, 2011; Eastwood et al, 2012; Nazli et al, 2016;).
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