This assignment will be uploaded automatically to Turnitin upon submission to verify this is your original work and no parts were copied from another student.Turnitin is now more closely integrated wi

O b je c tiv e . To id e n tify and describ e c u rre n t c lin ica l nu rsin g pra ctice in flu id bala nce m o n ito r in g and m ea sure m ent accuracy in ICUs, c o n d u c te d as p a rt o f a bro a d e r s tu d y in p a rtia l fu lfilm e n t o f a M aster o f N ursing degree.

M e th o d s . A q u a n tita tiv e a p p ro a c h u tilis in g a d e s c rip tiv e , e x p lo r a to r y s tu d y d e sig n was a p p lie d . An a u d it o f 103 ICU reco rds was c o n d u c te d t o e sta b lis h th e c u r r e n t p ra ctice s and accu racy in re c o rd in g o f f lu i d b a la nce m o n ito r in g . Data w e re c o lle c te d u sing a p u rp o s e -d e s ig n e d to o l based on releva nt lite ra tu re and pra ctice experience.

Results. O f th e o rig in a l recorded flu id balance calcula tion s, 79% de via te d by m ore th a n 50 mL fro m th e a u d ite d calcula tion s. F u rth e r­ more, a s ig n ific a n t re la tio n s h ip was s ho w n be tw e e n in accu rate flu id balance c a lc u la tio n and a d m in is tra tio n o f d iu re tic s (p=0.01).

Conclusion. The m a jo rity o f flu id balance records w ere in c o rre c tly calcula ted.

S AfrJC rit Care 2014;30(2):55-57. DOI:10.7196/SAJCC.193 M a in t a in in g a b a la n c e b e tw e e n f l u i d in ta k e and o u t p u t plays an im p o r ta n t role in th e m a n a g e m e n t o f a c r it ic a lly ill p a tie n t. The a c c u ra te assessm ent o f t h e f lu i d bala nce da ta c o lle c te d d u r in g physical assessment as w e ll as d u r in g m o n ito r in g a c tiv itie s and re co rd -ke e p in g fo rm s an essential p a rt o f th e baseline p a tie n t in f o r m a t io n t h a t g u id e s m e d ic a l an d n u r s in g in te r v e n tio n s t o achieve ph ysio log ica l s ta b ility in a p a tie n t. Changes in a c ritic a lly ill p a tien t's flu id balance can c o m p lic a te th e p a tien t's clinica l c o n d itio n .

It is, th e re fo re , necessary th a t f lu i d ba la nce pa ra m e te rs are accu­ ra te ly m o n ito re d and recorded fo r all p a tie n ts in in te nsive care units (ICUs).111 A daily ob serva tion sheet is used to record all vital signs, nursing interventions, medical procedures and th e flu id balance fo r each 24-h pe rio d o f a day. The flu id balance record comprises records o f th e intake and o u tp u t o f fluids by a p a tie n t over a 24-h period. The difference betw een th e volumes is calculated to pro vid e th e 24-h flu id balance.121 The m o n ito rin g o f a patient's f lu id balance is o f great im p o rta n ce in u n de rsta nd ing and m anaging a patient's clinical status and, as such, accurate m o n ito rin g and recordin g o f flu id balance data plays an essential role in p a tie n t care m an agem ent.131 Several stu d ie s have c o n s id e re d th e re la tio n s h ip b e tw e e n flu id im balances and p a tie n t outcom es in c ritica l care. The Sepsis Occurrence in A cu te ly III Patients (SOAP) stu d y by V in cen t et al.,m c o n d u c te d across 198 ICUs in Europe in 2002, d e te rm in e d th a t a p o sitive f lu id balance is a strong p ro g n o s tic f a c to r f o r death in c r iti­ cally ill patients. Sim ilarly, research by Alsous et a/.,151 Boyd et al.m and Payen et o/.I7] c o n clu d e d th a t a m ore p o sitive flu id balanceis associated w ith an increased risk o f m o r ta lity in p a tie n ts w ith se p tic shock or acute renal failure. Furtherm ore, Rosenberg et a/ . 181 d e te rm in e d th a t a cu m u la tiv e ne g a tive flu id balance in pa tien ts w ith acute lu ng in ju r y is associated w ith lo w e r m o rta lity . The conclu sions o ffere d by these studies req uire th a t m o n ito rin g and reco rd in g o f flu id balance data m u st be c o m p le te and accurate, w ith assessment o f a p a tien t's flu id balance b e in g recognised as an im p o r ta n t c o m p o n e n t o f n u rsin g any c ritic a lly ill pa tie n t.

In South Africa (SA), th e practice o f a registered nurse is regulated by th e Scope o f Practice draw n up b y th e SA Nursing Council.191 Chapter 2, section 2(i) o f these regulations identifies th a t flu id balance m o n ito rin g is pa rt o f th e scope o f practice o f a registered nurse.

Therefore, a registered nurse w o rking in a critical care en viro nm en t is responsible and a cco un ta ble fo r th e accurate reco rd in g and calcula tion o f flu id balance w h en caring f o r and m anaging a critica lly ill patient. Managing a patient's flu id balance is as equally im p o rta n t as carrying o u t any o th e r p a tie n t care a c tiv ity fo r th e critica lly ill, such as a d m in isterin g a m edica tion pre scriptio n or p ro v id in g n u tritio n .121 Fluid balance m an ag em en t in ICU patients is com plex. M o n ito rin g and m easurem ent o f flu id balance requires close a tte n tio n to ensure th a t c urre nt m ethods are ap plied accurately and con sisten tly to provid e th e m ost c om p le te data, up on w h ic h p a tie n t m anagem ent decisions can be based.

Based on practice experience and u n d e rpin ne d by an in form al a u d it o f 24-h flu id balance charts in a local ICU, where seven o u t o f ten calculated totals were incorrect, th e research question posed was:

W hat are th e curre nt practices o f registered nurses in ICUs w ith regard to flu id balance m on ito rin g ?

SAJCC November 2 0 1 4 , Vol. 3 0 , No. 2 55 ARTICLE A q u a n t i t a t iv e a p p ro a c h u t i l is i n g an exploratory, descriptive study design was applied. The study was conducted in ICUs across three purposively selected hospitals o f one private sector hospital group. The ICUs o f these hospitals were similar in terms o f th e ir patient admission profiles, w ith the same nursing docum entation and policies applied at all three hospitals.

An a udit to o l was developed from relevant literature and clinical experience to assess particular aspects o f the sampled fluid balance records. Two critical care nurse experts evaluated the content and face validity o f the audit tool; no changes were required. A pretest o f the audit tool was conducted at one additional ICU o f the same hospital group to determine the accuracy and relevance o f the measurements; no changes were required. The pretest data were not included in the study data.

A statistician determined the tool to be appropriate and adequate for data collection and analysis purposes.

Ethical approval for the study was obtained from the Human Research Ethics Committee at the Faculty o f Medicine and Health Sciences, Stellenbosch University, as well as the relevant committee o f the hospital group.

The population for this study was critical care patient records. The study sample was drawn from fluid balance records according to the following inclusion criteria:

• Nursing records o f admissions to ICUs for th e firs t 48 h o f th e patient's stay, from 1 July to 31 December 2011 • Patients over the age o f 18 years as per the definition o f an adult in the Children's Act No. 38 o f 20051' 01 • P atients classified as 'in te n s iv e care':

a ctivity 1 or 2 on the patient classification system o f th is h o s p ita l g ro u p . This cla ssifica tio n was used by th e d o c to rto d e te rm in e fin a n cial charges to th e p a tie n t. No w r it t e n p o lic y re g a rd in g this classification was available from the hospitals.

A simple random sampling technique was im plem ented to select patient records for th e a u d it: all th e adm ission num bers o f patients meeting the inclusion criteria were id e n tifie d th r o u g h th e hospital in fo rm a ­ tio n system and admission record book o f th e ICU. The p a tie n t record file th a t was connected w ith every th ird p a tie n t adm ission n u m b e r was draw n u n til th e required sample was achieved. The sample size was calculated to ensure adequate precision in population estimates, using 95% confidence intervals (CIs). A sample size o f 80 fluid balance records would have resulted in 6% precision in the 95% Cl w idth, assuming a 10% error rate in the calculation o fth e flu id balance. This was well w ith in the accepted precision o f between 5% and 10%. A sample size o f N= 103 was selected and divid e d specifically among the various units under th e guidance o f th e statistician (Table 1).

D escriptive statistics were recorded and the Mann-Whitney U-test was used to test associations betw een recorded variables and fluid balance calculation accuracy.

Data were recorded on the study audit tool by the researcher and a field worker together in the three hospitals. The fluid balance calculation recorded in eachpatient record for a 24-h period during the first 48 h o f a patient's stay was noted on the audit tool. A control calculation of each recorded fluid balance total was done by the researcher and verified by the field worker. These audited calculations were recorded in the audit tool. The deviation between the original calculations and the audited calculations was determined and recorded.

In a d d itio n to th e flu id balance calculation, baseline vital sign data, modes o f fluid o u tp u t (e.g. diarrhoea), specific data regarding the adm inistration o f blood products, and the number o f continuous intravenous infusions were recorded on th e a udit tool.

Results 24-h calculated fluid balance totals The o rig in a l recorded 24-h flu id balance total was compared w ith the audited fluid balance total performed by the researcher and field worker. The difference in calcula­ tio n was referred to as the deviation in fluid balance ca lcu la tio n , and is presented in Table 2 for descriptive reasons.

In the a u dit o f 103 flu id balance documents, a total o f 71 (68.9%) recorded calculated fluid balance totals were w ithin a 500 mL deviation from the fluid balance calculated by the researcher. Fourteen recorded calculations (13.5%) were found T a b l e 1.S a m p l i n g f r a m e w o r k H o sp italIn te n s iv e -c a r e beds, nAdmissions:

July - D e c e m b e r 2 0 1 1, nRecords s a m p le d , n A 261 02034 B281 02734 C381 02235 D12300Pilot study Table 2. Deviation in fluid balance (A/=103) C a lc u la te d d e v ia tio nO v e ra ll 0 - 3 7 0 60 - 5051 - 5 0 0501 - 1 0 0 01 001 - 2 0 0 0> 2 0 0 1No record n982249 14765 Percentage95.121 4813.56.85.84.9 Median deviation (mL)167 201467541 2493 310 - Mean deviation (mL)493 21184 7541 3713 116 - Range (mL)0 - 3 7060-4661 -463 501 - 9841 008- 1 9282 260 - 3 706 - 5 6 SAJCC November 2 0 14, Vol. 30, No. 2 ARTIC LE DiacRon,iJ i B ReeloR'C RJk nJReeloR'C BIlnk eRIelIR'niJ In a c c u ra te f lu id c a lc u la tio n , m e d ia n (IQR) V a r i a b l e Yes N o p - v a l u e Received blood products 180.5 (60- 1 312) 167 (61 -530) 0.95 CVP measured 202.5 (90 - 764) 119 (41 -320) 0.09 Matched doctor's prescription 155 (60 - 530) 201 (63 - 708) 0.61 Diuretic administered 279(102-996) 106 (46 - 350) 0.01 Received >2 intravenous drugs 257 (75 -708) 138 (60-435) 0.16 IQR = in t e r q u a r t il e r a n g e ; CVP = c e n tra l v e n o u s p ressure.

to deviate between 500 mL and 1 000 mL, w hile seven recorded calculations (6.8%) were found to deviate between 1 000 mL and 2 000 mL. Six recorded calculations (5.8%) were found to have a deviation o f >2 000 mL.

There was a significant association between the adm inistration o f diuretics and inaccurate flu id balance calculation (p=0.01), b u t there was no association between other variables and the outcome o f interest (Table 3).

Discussion The definition o f a net positive fluid balance as a volume >500 mL used in the study by Alsous e ta /.151 was applied in this study. Of great concern were the 27/103 documents, m ore th a n 25% o f th e sam ple, w it h a deviation o f >500 mL between the recorded ca lc u la tio n and th e c o n tro l ca lcu la tio n .

Equally o f concern were th e five p a tie n t records where no fluid balance calculation was available at all. These findings repres­ ent a risk fo r the critically ill patient when one considers th e fin d in g s o f previous studies related to positive fluid balance and p a tie n t m o rta lity .14'81 The fin d in g s o f this study showed that fluid balance calculation is n o t treated as a p rio rity in the nursing m a n a g e m e n t o f a c r itic a lly ill p a tie n t.

The incorrect calculation o f flu id balance means t h a t every p a tie n t m anagem ent decision utilising these flu id balance data was influenced by inaccurate inform ation.

Perren et al.1" 1 performed a similar study in Switzerland and expressed th e ir concern a b o u t th e accuracy o f flu id balances in critically ill patients.1111 Additionally, the significant association between inaccurate fluid balance calcula­ tio n and diuretic administration (p=0.01) suggests that when diuretics are adminis­ tered, there is a higher chance o f thecalculated fluid balance being incorrect.This finding supports the researcher's concern th a t a careful and accurate approach to fluid balance does not enjoy high priority in managing critically ill patients in this context. Diuretic therapy is a commonly prescribed therapeutic modality; in this study, 38.8% (40/103) of critically ill patients had diuretics recorded as being adminis­ tered during the first 48 h o f their admission.

Inaccurate fluid balance data may result in inappropriate application o f diuretic therapy, resulting in fluid imbalances that affect the haemodynamic stability o f patients.

The findings of this study are limited by the focus on one hospital group and may be regarded as a pilot study for further development.

Conclusions in this study, the m ajority o f audited 24-h flu id balance calculations were shown to be incorrect; 79% (81/103) o f the original recorded fluid balance calculations deviated by >50 mL from the audited calculation. The accuracy o f th e 24-h balance calculated is questionable, w ith only 21% o f the original flu id balance to ta ls d e v ia tin g by <50 mL from the audit calculations. This is o f great concern. Several s tu d ie s 14'81 have noted a re la tio n s h ip betw een flu id im balance and m o rta lity in c ritica lly ill patients. The findings indicate th a t treatm ent decisions are often based on inaccurate fluid balance in fo rm a tio n, w hich may lead to negative consequences for the patient.

A significant association was shown between the administration of diuretics and inaccurate 24-h fluid balance calculations.

With diuretics prescribed specifically to manage fluid imbalance, this finding indicates that the accuracy o f the calculated fluid balance must be confirmed prior to diuretics being prescribed or administered.Within the context o f lim ited resources, any clinical recommendations must be realistic and p ra c tic a l. One suggested exam ple is in s titu tin g a system o f checking flu id balance calculations at specific intervals, such as du rin g p a tie n t handover at sh ift change, d u rin g th e p a tie n t assessment process or d u rin g p a tie n t m anagem ent discussions. Awareness around th e poten­ tial consequences o f calculation errors must be reinforced du rin g p a tie n t discussions and continuing education sessions.

The requirement to provide accurate, correct fluid balance m onitoring and recording as part of the patient's vital sign data must be established as a fundamental standard o f practice fo r every nurse practising in an ICU. Regular outcome- driven audits w ill assist in identifying where and when errors occur, allowing for specific interventions to be designed and implemented.

Further studies may assist in refining the particular challenges o f accurate fluid balance recording, for instance cumulative fluid balance over more than 24 h.

References 1. Culleiton AL, Simko LC. Keeping electrolytes and fluids in balance. Nursing2013 Critical Care 2011;6(2):30-35. [h ttp :// dx.doi.org/10.1097/01 :CCN.0000394395.67904.4d] 2. Scales K, Pilsworth J. The im portance o f fluid balance in clinical practice. Nursing Standard 2009;22(47):50-57.

[http://dx.doi.org/10.7748/ns2008.07.22.47.50.c6634] 3. Elliot D, Aitken L, Chaboyer W. ACCCN's Critical Care Nursing, 1st ed. Marrickville, Australia: Mosby Elsevier, 2007:440,445-446.

4. Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European intensive care units: Results o f the SOAP study. Crit Care Med 2006;34(2):344-353.

5. Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Negative flu id balance predicts survival in patients w ith septic shock: A retrospective study. Chest 2000;117(6):1749-1754.

6. Boyd JH, Forbes J, Nakada T, Walley K, Russell JA. Fluid resuscitation in septic shock: A positive flu id balance and elevated central venous pressure are associated w ith increased mortality. Crit Care Med 2011;39(2):259-265.

[http://dx.doi.Org/10.1097/CCM.0b013e3181 fe e b l 5] 7. Payen D, de Pont AC, Sakr Y, e t al. A positive flu id balance is associated w ith a worse outcome in patients w ith acute renal failure. Crit Care 2008;12(3):R74. h ttp://c cforum .com / content/1 2/3/R74 (accessed 27 October 2014). [h ttp :// dx.doi.org/10.1186/cc6916] 8. Rosenberg AL, Dechert RE, Park PK, Bartlett RH, National Institutes o f Health-National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network. A review o f a large clinical series: Association o f cumulative flu id balance on o utcom e in acute lung in ju ry: A retrospective review o f the ARDSnet tidal volume study cohort. J Intensive Care Med 2009;24(1):35-46. [h ttp :// dx.doi.org/10.1177/0885066608329850] 9. South African Nursing Council. R2598, Regulations relating to th e scope o f practice o f persons w h o are registered or enrolled under th e Nursing Act, 1978. Regulation o f the Nursing Act, 2005 (Act No. 33 o f 2005). Pretoria:

Government Gazette, 491,2006:34.

10. South African Government. Children's Act 38 o f 2005.

h ttp ://w w w .ju stice.g ov.za/le gis lation/acts/2 00 5-0 38% 20 childrensact.pdf (accessed 27 Octobe r 2014).

11. Perren A, Markmann M, Merlani G, Marone C, Merlani P.

Fluid balance in critically ill patients. Should we really rely on it? Minerva Anestesiol 2011;77(8):802-811.

SAJCC November 2 0 1 4 , Vol. 3 0 , No. 2 57 Copyright ofSouthern AfricanJournalofCritical Careisthe property ofHealth &Medical Publishing Groupanditscontent maynotbecopied oremailed tomultiple sitesorposted toa listserv without thecopyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.