Rational fluid therapy, pharmacy practice in 2020, patient safety and human factors in healthcare were the main themes at the joint national conference of the UK Clinical Pharmacy Association and the Guild of Healthcare Pharmacists held in April 2014
Christine Clark PhD FRPharmS FCPP(Hon)
Studies have shown that poor fluid management contributed to more than 50% of post-surgical deaths and 20% of deaths were actually caused by errors in fluid administration, said Marcia McDougall (Consultant in Anaesthetics and Intensive Care and Fluid Lead,
NHS Fife). Up to one-fifth of patients suffer morbidity due to problems with fluids according to the National Institute for Health and Care Excellence (NICE) report in 2014, she added.
Fluid prescribing is usually left to the most junior doctors but teaching of this topic is inconsistent and many of these doctors lack knowledge and confidence.
The catabolic response to illness or injury, including surgery, involves sodium and water retention, loss of potassium and decreased urine output partly as a result of reduced ability to excrete a sodium load by the kidneys. Failure to understand this issue often results in administration of fluids that actually make the situation worse, said Dr McDougall. Chloride causes renal vasoconstriction, acidosis and poor urine output. Fluid retention and oedema follow together with gastrointestinal stasis and weight gain. Inadequate potassium supplementation further reduces the ability to excrete sodium and lack of calories reduces cellular homeostatic functions.
The aim of fluid treatment is to give the right amount to maintain normovolaemia, creating neither salt and water overload nor salt and water depletion, explained Dr McDougall.
Having too much salt in the body creates a situation akin to drinking seawater. The kidneys require additional water to dilute the salt in order to excrete it. A sodium dose of 1mg/kg/day would require 4.6G sodium chloride for an 80kg man – but a litre of normal saline contains 9G. Sodium chloride is poorly excreted, can cause fluid retention, renal dysfunction and hyperchloraemic acidosis. In general, it is better to restrict sodium input and use balanced solutions, said Dr McDougall. Sodium chloride should not be given as the default option just because it is cheap, she added. Sodium chloride overdose can also occur when it is used as the diluent for multiple injections, she noted. One large observational study including more than 30,000 surgical patients had shown that mortality and major complications were significantly lower in patients who received a balanced crystalloid solution compared with those who received normal saline.
In December 2013, NICE published a guideline on fluid therapy in adults. This built on the earlier Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP). One key provision is that balanced salt solutions should replace 0.9% sodium chloride for crystalloid resuscitation or replacement except in hypochloraemia. The standard fluid for maintenance should be 4% dextrose with 0.18% sodium chloride with added potassium if required. Fluid requirements should be monitored guided by history, clinical assessment, weight, blood results and previous charts. Recommended daily requirements are shown in Box 1.
The NICE quality indicators in this area call for each hospital to have a named individual who takes the lead on intravenous (IV) fluids. They also
specify that all adult patients should be treated by individuals who have been trained and assessed as competent in managing IV fluids.
Pharmacy practice in 2020
By 2020, pharmacists will be recognised as clinicians and will be the first point of call for medicine matters. Bill Scott (Chief Pharmaceutical Officer, Scotland) and Alpana Mair (Deputy Chief Pharmaceutical Officer, Scotland) described how the vision and action plan for pharmacy in Scotland, Prescription for Excellence, is built on the pillars of the person-centred approach, safety and effectiveness. Pharmacists, known as ‘general practice pharmacists’, will not work in isolation but will work in group practices taking responsibility for patients with multiple morbidities. Others will undertake regular rounds in care homes and hospital-based colleagues will work in communities to follow up patients at home. Pharmacists will also work with social care services to support patients at home.
Pharmacists’ time will be released by making full use of pharmacy technicians and robotics. One role of pharmacists in the future will be to deal with common problems to help to reduce the number of visits to Accident and Emergency departments.
Some of these things are already happening in Scotland, noted Ms Mair.
Pharmacists will have close relationships with patients and support person-centred care and self-management. This could include helping patients to decide which medicines to take and which not to take, said Ms Mair. Multiple morbidities tend to start after the age of 50, sooner in deprived areas. Pharmacists could take on prescribing for many long-term conditions once a diagnosis has been established. In future, pharmacists could be allocated a caseload of patients to manage – and this would release medical prescribers to deal with more complex cases.
Safety and effectiveness
Preventing injury and harm from medicines and evidence-based practice will remain central to pharmacy work. Furthermore, the Scottish patient-safety programme, which has been mainly hospital-focused so far, is now extending into primary care. Checking that prescribing is appropriate at the outset and undertaking reviews of medicines will be important in ensuring that medicines are used effectively. Measures, such as driving down inappropriate use of cephalosporins, can have immediate benefits, for example, reducing the incidence of Clostridium difficile infections, she noted.
Prescribing pharmacists had started by providing specialised, single-disease services but in future they will move away from this approach.
In order to bring the plans to fruition, electronic sharing of medical records will be essential, said Ms Mair. Patients will also have full access to their medical records. “Patients must be involved as partners not as victims,” said Professor Scott.
As part of the implementation process there has been extensive consultation with other professions in both primary and secondary care. There is widespread recognition of the need to improve the patient’s journey and considerable support from hospital doctors and GPs for the further development of the pharmacist’s role.
Learning from errors
“You never think that you will go into hospital and get an incorrect dose of a drug”, Lisa Richards-Everton told the audience. Mrs Richards-Everton became a committed campaigner for patient safety after her husband Paul died as a result of a medication error involving an overdose of amphotericin. She described how her husband, who was undergoing treatment for non-Hodgkin’s lymphoma, became ill during the course of chemotherapy and was prescribed amphotericin by a junior doctor. The product that he chose from the eBNF was different from the one held on the ward but the nurses were unaware of the differences. Mr Richards received a dose of 325mg instead of 65mg and deteriorated rapidly.
Amphotericin injection (Fungizone®) had been identified as a high-risk product in 2005 because of the complex dose calculation and preparation procedure. In 2007, after two fatal incidents, the National Patient Safety Agency issued a Rapid Response Report warning of the potential for confusion with amphotericin products and recommending risk-reduction measures. By 2010 there were still trusts that had not implemented the risk-reduction measures. “It is crucial to comply with patient safety alerts to protect patients; if hospitals had taken heed of previous alerts and taken amphotericin back into pharmacies, then Paul would still be alive today,” said Mrs Richards-Everton.
Human factors in healthcare
In aviation, the build quality of aircraft has progressively improved to the point where very few accidents are due to engineering or design failure, but human beings are still the ‘mark 1 version’ – and they make mistakes. In fact, the root cause of 80% of errors lies in human factors, explained Chris Seal (Squadron Leader, RAF [retired], healthcare and aviation human factors and safety consultant). Human factors, defined as all the factors that can influence people and their behaviour, affect everyone and everything, he added.
Personality and behaviour are important factors. The ideal team member is neither passive (‘a doormat’) nor aggressive (domineering and disrespectful), but an assertive individual who behaves in a balanced, professional respectful way, said Captain Seal. Such people are prepared to speak up, communicate openly and directly but show respect for others’ views.
Errors often occur when there is a high workload combined with stress and fatigue. The ‘Swiss cheese’ model of errors postulates that organisations have layers of barriers, defences and safeguards to prevent errors. If an error slips through one barrier the next safeguard often stops it but occasionally a mistake will slip through all the impediments and reach the patient. Training in human factors helps to make people aware of the weaknesses in the safety procedures and better able to deal with them.
Communication is a critical skill and it is important to realise that body language and tone convey 95% of a message. When speaking on the telephone or in an operating theatre much of this is lost. What is said needs to be accurate, brief and clear. It is useful to have a standardised format for handover situations such as situation, background, assessment and recommendations (SBAR). Closed-loop communication can be useful when critical information has to be conveyed, such as checking the dose of a drug for IV administration. This involves the sequence, query, read back, confirm.
Briefings and checklists are also important ways of ensuring that everyone has the necessary information to perform well and safely.
Situation awareness is a critical concept in safety training. It describes the circumstance where the individual’s perception matches reality. Studies in simulation training of pilots have shown that pilots with better situation awareness perform better than those with poor situation awareness. Captain Seal suggested that good situational awareness involves watching for a number of things including the use of non-standard or improper procedures, fixation on a single factor (and ignoring other developments), ambiguity or mismatches in data and situations where no one seems to be in charge. “Don’t ignore gut feeling – if you think something is stupid then it probably is,” he advised.
By 2030, one-fifth of the population will be over the age of 65 years and this poses unprecedented challenges for the healthcare system, according to Bernadette Ashcroft, (CEO, Age Concern, Tameside, UK). A 50-year-old can expect to live until the age of 86 but only until the age of 57 in good health, she added.
Age UK represents the interests of 14 million elderly people; that is, those over the age of 50, she explained. Surveys show that youth ends between the ages of 26 and 62 years, depending on the age of the respondent. Similarly, old age starts between the ages of 53 and 75 years. Later retirement might increase the age at which perceived ‘old age’ starts in future.
Age discrimination is a real and serious concern. In general, the country fails to make use of the skills of the elderly. However, British Airways has an ‘older’ team because older workers are usually loyal, have a strong work ethic, a wealth of experience and empathy with elderly people.
Five key steps can help to promote wellbeing throughout life and, especially, in later life. Connecting with other people by socialising and meeting with friends and being physically active are two important measures. Taking notice of the world, by, for example reading, newspapers and keeping up to date, is helpful and so is learning new things. Finally, giving is beneficial. “Be kind to others and give of yourself,” recommended Ms Ashcroft.
Research shows that older people in care are often unable to express their needs and do not like to ‘rock the boat’. They should be able to rely on provision of care that meets their needs. Clinical pharmacy services can help, not only by adjusting doses for elderly patients, but also by talking to patients and finding out what they can manage when it comes to handling medicines, said Ms Ashcroft.
Demand for health services is growing at the rate of 4% per year but funding is not keeping pace with this, Roy Lilley (Independent Health Policy Analyst, writer, broadcaster and commentator) told the audience. After 2015, the financing of the National Health Service looks uncertain and health service staff will need to be open to new ways of delivering services, he continued.
Mr Lilley had a number of suggestions to improve the efficiency and effectiveness of services. Safety could be improved by mandating the required nurse:patient ratio similar to the way in which the cabin crew:passenger ratio is mandated for air travel. This is already carried out in California and Australia, he said. Commissioners could drive up the standard of services by specifying the standards that they require when commissioning.
Another useful measure would be to establish a proper geriatric service. Geriatric patients who develop problems should not be sent to accident and emergency departments, which are primarily geared to deal with injuries and urgent care. The majority of problems with elderly patients are predictable deterioration rather than accidents or emergencies.
Everyone should allow their health information to be collected in the national database (‘Care.data’) because this will provide valuable information about patterns of disease and treatment outcomes that could help to improve services. People should not be afraid of this, after all, people happily give a wealth of personal information to supermarket loyalty programmes, said Mr Lilley.
He also said that the health service should not rely on inspections to deliver quality but focus on sharing of best practice instead.
Daily requirements for maintenance fluid therapy
(based on NICE and GIFTASUP guidelines)
Sodium Approximately 1mmol/kg
Potassium Approximately 1mmol/kg
Calories Minimum 400 calories (that is, 100g dextrose)