Kidney Week

Abstract: SA-OR53

Identifying Opportunities to Reduce Fluid Overload: A Multicenter Quality Improvement Partnership

Session Information

• Fluid, Electrolyte, and Acid-Base Disorders: Clinical Advances
  October 26, 2024 | Location: Room 4, Convention Center
  Abstract Time: 05:40 PM - 05:50 PM

Category: Fluid, Electrolytes, and Acid-Base Disorders

• 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

• Dziorny, Adam, University of Rochester Medical Center, Rochester, New York, United States

Adam Dziorny, MD, PhD

• Kothari, Ulka, New York University Grossman School of Medicine, New York, New York, United States

Ulka Kothari, MD

• Drury, Stephen C., University of Rochester Medical Center, Rochester, New York, United States

Stephen C. Drury, MS

• Dapul, Heda R., New York University Grossman School of Medicine, New York, New York, United States

Heda R. Dapul, MD

• Shah, Ami, New York University Grossman School of Medicine, New York, New York, United States

Ami Shah, MD

• Fitzgerald, Julie C., The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States

Julie C. Fitzgerald, MD, MS, PhD

• Braun, Chloe Grace, The University of Alabama at Birmingham, Birmingham, Alabama, United States

Chloe Grace Braun, MD

• Barbera, Andrew Jason, The University of Alabama at Birmingham, Birmingham, Alabama, United States

Andrew Jason Barbera, MD

• Odum, James D., The University of Alabama at Birmingham, Birmingham, Alabama, United States

James D. Odum, MD, MEd

• Martin, Susan Duddy, University of Rochester Medical Center, Rochester, New York, United States

Susan Duddy Martin, MD

• Hasson, Denise Claire, New York University Grossman School of Medicine, New York, New York, United States

Denise Claire Hasson, MD

Background

Fluid overload (FO), characterized by a pathological percentage cumulative fluid balance (%CFB), is prevalent among critically ill children and is linked to extended length of stay (LOS), morbidity, and mortality. The objective of this project is to reduce FO and associated %CFB in Pediatric Intensive Care Units (PICUs). We automated data collection across this multisite quality improvement collaborative through a federated data collection framework, local analysis, and central result aggregation. By applying this paradigm alongside sampled observations and nursing surveys, we aimed to identify strategies to reduce %CFB and ultimately enhance patient outcomes.

Methods

We identified key drivers of ICU positive %CFB, developed SMART Aims, and chose key metrics including demographics, %CFB, urine occurrence counts, relationship to Holliday-Segar (H-S) maintenance fluid rates, and associations with mechanical ventilation (MV) and ICU LOS. Individual sites extracted data, ran analysis scripts, then collected rounds’ discussions of FO and nursing surveys.

Results

Over a 6-month period we included 2336 ICU encounters encompassing 1984 children. Mean number (%) of patients with day 2 CFB >5% significantly differed by site (A: 153 (54.4%), B: 157 (37.6%), C: 489 (46.4%); p<0.001). Mean number of patients with urine occurrences and number of patients receiving >100% of H-S fluids on day 1 differed by site (p<0.001 for each). MV orders were significantly associated with receiving >100% of H-S fluids on day 2 at each site (A: 25.0% vs 15.4%; B: 34.0% vs 23.4%; C: 43.0% vs 15.8%). Days 1 and 2 CFB >5% was significantly associated with increased ICU LOS at each site (p<0.001). Rounds discussions (N=76 days, 791 patients) demonstrated 64.3% discussed fluid balance and 22.9% set fluid balance goal. Nurse survey results (N=117 nurses) were remarkably similar across sites, identifying barriers to accurate fluid balance capture, achievable opportunities for improvement, and desired educational opportunities.

Conclusion

Positive %CFB is a common but variable issue across multiple ICUs. Our findings pinpoint specific areas for improvement at each site, guiding the development of Plan-Do-Study-Act cycles for better fluid management.

Funding

• NIDDK Support