Quality improvement in record keeping using a tool fluid balance chart

Quality Improvement in Record Keeping Using the Tool Fluid Balance Chart
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Quality Improvement in Record Keeping Using the Tool Fluid Balance Chart
Introduction
Fluid Balance Chart (FBC) is practice-based nursing that refers to the existing balance between the quantity of water lost from the body and its quantity (McGloin, 2015). Evidence shows that the maintenance of the fluid balance charts has been poorly done over the years. The fluid balance charting process has been made difficult through a question and concept that various healthcare professionals inquire about (Jeyapala et al., 2015). Fluid balance charting remains practical in nursing practice with various external influences that affect the crucial role of fluid balance charting in patient care (McGloin, 2015).
The FBC document has been utilized within the healthcare system over several years. The tool is non-invasive and assesses the status of hydration within patients. The tool documents patient's water input as well as output within a 24-hour period. Such a process helps guide clinical decisions that entail medication administration alongside prescription and surgical interventions. However, fluid balance charting can easily turn unproductive and dangerous following inaccuracy or data inadequacy (Jeyapala et al., 2015).
Health practitioners require accuracy in fluid balance totals to plan appropriate care and reduce the risk of post-operative issues associated with dehydration, electrolyte imbalances alongside malnutrition (Liaw and Goh, 2018).). Medical professionals must identify the exact measure of urine or diarrhea output, oral intake, drainage of wound, and vomit. Nasogastric aspiration alongside drainage that helps assess hydration and electrolytes avoids overloading of fluids (Chung et al. 2012; McGloin, 2015).
The aspect of dehydration presents one of the prevalent issues in healthcare settings. However, the majority of the patients rely on the medical staff for the management of their fluid intake. Despite such reliance time constraints alongside inaccuracies, patients are at risk of failure (Litchfield, Magill & Flint, 2018). Therefore, there is a need for the fluid balance charts to be completed accurately to determine the patient's fluid input and output. It is equally important to identify any potential fluid loss or gain that could threaten human survival.
Fluid balance in the human body, also identified as fluid homeostasis, refers to balancing the body's fluid input alongside output levels. This helps in the prevention of various changes in fluid concentration (Payne, 2017). For an adult's body to maintain the required balance of nutrients, oxygen, and water, there is the requirement of an intake of approximately two to three liters daily.
The maintenance of balance occurs naturally through thirst to dilute the concentration of urine whenever the fluid is less concentrated. However, the occurrence of illness or injury can alter such natural mechanisms, therefore requiring monitoring and intervention (Payne, 2017). Studies conducted by Vincent and Mahendiran (2015) reveal that the nursing staff is very much aware of the importance of fluid balance. At times, it conducts unnecessary monitoring since a significant percentage of monitoring is done without a clinical indication. According to the study, the average completion rate of fluid balance charts was at 50%. A different study by Litchfield et al. (2018) discovered that despite nurses acknowledging the importance of fluid balance, the aspect of monitoring hydration levels on patients presented a competing priority that is inclined to time pressures. In this case, patients who were passive and independent were most vulnerable since they had the capacity to manage their own fluid intake but were too anxious to request fluids from staff.
Search Strategy
The search strategy focuses on finding both publish and unpublished studies, with a three-step search strategy being utilized in this study. The research will be conducted and data retrieved from the database such as Google Scholar and also MEDLINE. There will be a search of MEDLINE and CINAHL followed by the text words analysis as per the title and abstract alongside the index terms are undertaken across all the databases included. The terms that will be applicable in the search include a selection that indicates MeSH (Medical Subject Headings) terms and All Fields, including DeCS (Health Sciences Descriptors) as terms that point to descriptors as well as keywords. The appropriate Boolean operators AND and OR will also be applicable. Other search terms applicable in this study will include quality improvement, the tool fluid balance chart. The strategy also follows the selection of PDSA (Plan, Do, Study, Act) cycles that can easily be implemented within the wards.
Setting: The nursing staff of Albany Medical Center is our target audience
Outcome: the study investigates the quality improvement in record-keeping using the tool fluid balance chart
Factor: The study focuses on increasing the rate of appropriately completed fluid balance charts across the wards. This requires improvement within three specific areas: having the understanding of the importance of good fluid balance monitoring, appropriate identification of various patients who require monitoring, as well as simplicity through which the fluid balance charts could be completed. The target group are the nurses working in the hospital environment
Study Design: There is the identification and selection of appropriate studies that includes critical data assessment, data collection, data analysis, and presentation and ultimately result from interpretation. A questionnaire is applicable to highlight improvements as per the current charts that measure nurses' level of awareness before and after education.
Importantly, the search process will include studies that answer the identified research question. The studies will relate to the topic; the quality improvement in record-keeping using the tool fluid balance chart.
In this case, the inclusion criteria consider different original research studies published between 2015 and 2021 and written in English. The inclusion also considers adult patients and nurses as well as titles that consider the subject of study. Further, the exclusion criteria consider articles that address the pediatric population. Notably, the articles that do not originate from the research, with shallow information on fluid balance chart and quality improvement, are excluded.
From the results of the methodology, the search strategy generated 1000 references, out of which 100 were duplicates, therefore, excluded from the study. In this case, there were a total of 1,200 studies selected; however, 1,100 were excluded after their titles and abstracts failed to match the study's objective. In this case, the remaining were only 100 articles. The scrutiny of the full texts of the 100 articles identified the content applicable. In this case, 70 studies were excluded for not attaining the inclusion criteria standards; therefore, only 30 studies were found legible for this review. The implementation of each intervention measure to a period of one week followed by surveys on a daily basis and monitoring compliance for four days (Fida et al, 2018).
Critical analysis of the background and drivers for the quality improvement proposal
The inclusion of fluid therapy plays a crucial role when it comes to the management of patients who are critically ill. The process of resuscitating patients alongside the restoration of their organ's perfusion demands giving out a large volume of fluid. The research reveals that the effect of fluid overload can delay and decrease the level of patient survival. In this process, the act of monitoring a patient's input and output requires a routine recording on the chart for the reasons for estimating the patient's status of fluid balance (Asfour, 2016).
The hospital nursing metrics across the different hospitals highlight that representation of the fluid balance chart documentation appears to be sub-optimal on all wards outside of ICU (Fida et al., 2018). The reports reveal that the level of quality of fluid balance recording varies across the hospitals. One of the major reasons for the FBC's poor completion was a shortage of staff and lack of time alongside inadequate training (Reid, 2004).
Notably, the aspect of fluid overload occurs in the event that the fluid applicable in the expansion of the intravascular fluid compartment results in the depression of ventricular function. This may be due to the aspect of overfilling, alongside the impaired capillary permeability that allows fluid access out of the circulation and redistribution back to the extravascular space (Phillips et al., 2018). Such a scenario occurs whenever the response to the subsequent episodes of hypotension produces an impaired kidney function that reduces the level of excretion of sodium as well as water. This occurs in the process of administering more fluid to the body. Some situations require that the patient be provided with invasive hemodynamic monitoring to estimate adequate circulatory volume. Notably, the estimation of the level of body fluids in a patient is made possible through a non-invasive physical examination methodology, frequent fluid balancing alongside measuring changes in body weight. The implementation of the appropriate resuscitation measures is a requirement in the quest to maintain adequate circulatory volume as well as prevention of fluid overload, therefore, help in achieving homeostasis (Jeyapala et al., 2015).
The routine nursing activity entails charting fluid input as well as output on an hourly basis. Further, the nursing activity involves the overall calculation and totalling of the daily fluid balance recordings. This represents one of the non-invasive methodologies commonly applied within the intensive care units (ICU) that helps estimate body fluids' status (Abd Elalem & Fouad, 2018). The mathematical procedure applicable in identifying the fluid output from the patient's input is recorded in a simple process. However, the aspect of managing a critically ill patient seems complex. The process of charting daily fluid balances demands a lot; therefore, it seems cumbersome and time-consuming. This also entails recording various infusions of fluid that include liquid nutrition, blood elements, and intravenous medications. A higher aspect of keenness and diligence is also a requirement in the process of recording urinary output alongside the loss of other body fluids. These also include the loss of various body fluids from the surgical process. However, the nurses are prone to error in charting and calculating fluid balance totals, especially whenever they are dealing with large numbers of calculations. Such errors can easily be reduced upon the implementation of a computer-based spreadsheet within the clinical information system. Despite such accuracy as provided by computers, it is not easy to eliminate errors resulting from missed or double entries entered on the bedside monitor (Phillips et al., 2018).
The level of inaccuracies compounds in the case where there is a lack of correction on water loss from the body through insensible fluid losses such as through fever and breathing. The various obvious losses of fluid from the body, such as through urine and surgical drains, can be placed through measurement; however, the insensible loss of fluids depends on such variables that an unpredictable that entails fluid loss within expired air. Such issues that relate to the recording of inputs and outputs within the patients in the ICU combine to create less accurate charting fluid balances. This leads to an increase in the magnitude of clinical significance whenever there is a repeat of errors over several days (Jeyapala et al., 2015).
However, the measurement of the various changes in body weight provides an alternative non-invasive methodology that helps estimate body fluids' status. Such a process helps in reducing errors associated with the calculation of fluid balance totals. The level of accuracy over the fluid balance totals assumes a one-kilogram change in the level of bodyweight that is basically equal to one liter gain or loss as per the body fluid volume (Phillips et al., 2018). The process of measuring the body weight helps in the identification of fluid overload in the case of evaluating the gains alongside losses occurring daily in relation to fluid present in the body. The various body weight changes present almost entirely the result that alters the fluid body volume in less time. However, such a method proves unreliable on critically ill-patients who overstay more than seven days since the bodyweight at such a point is more likely to be influenced through muscle alongside fat loss and bone demineralization (Jeyapala et al., 2015).
The aspect of weighing the incapacitated adult ICU provides room for challenges regarding measuring body weight changes compared to the accurate recording of the fluid balance totals. The aspect of obtaining appropriate body weight measurement requires putting in place various practice guidelines alongside compliance by medical professionals in following the set procedures for the purposes of ensuring accuracy. Before any of the procedures are undertaken, the patient's bed is emptied after the bodyweight measurements are recorded. The process of lifting critically ill patients by the use of slings and hoists requires the manpower of several nursing staff. However, beds having built-in scales ensure the reduction of the excess workload involved in weighing patients. The process can also prove reliable in case the nurses forget to remove unattached in fastening the bed. According to the studies by (Litchfield et al., 2018), there was no achievement in approximately a third of the patients interviewed following a series of consecutive successful bodyweight measurements through the use of weight enabled beds.
The aspect of providing guidance to fluid therapy in ICU involves such methods as recording body weight changes and daily fluid balances. However, the process works under the assumption that fluid overload is identified over several days in critically ill patients. Considering the potential for errors alongside the issues surrounding accountability for insensible fluid losses, the application of the weight-based methodology in monitoring body fluid status is deemed more accurate in identifying fluid overload. Despite the preference, several studies reveal a poor correlation between changes in the measured body weight reflected on the fluid balance chart (Litchfield et al., 2018).
Drivers for the quality improvement proposal
There has not been any form of consistency in nursing practice, therefore, the aspect of keeping an accurate fluid balance chart presents a balancing act in itself. The ability to enforce different changes calls for the act of empowering other individuals towards grasping the vision. Such a move helps in ensuring that various obstacles hindering change are all resolved. It is always challenging the activity of enlisting all staff for the empowerment program due to different backgrounds alongside the environment's culture. The most crucial thing that necessitates identifying the recurring issues that concern inadequate alongside inaccurate fluid balance charting entails identifying the hindrances to the practice of maintaining accurate fluid balance charting. This also entails the various ways applicable to improving the practice capable of sustaining and ensuring accurate completion of the fluid balance charting within nay practice environment (McGloin, 2015).
Time pressures and inadequate training influences the quality of nursing practice and activity within the hospital environment. Time pressures are an emerging trend in nurses' work environs (Abdollahzadeh et al., 2017).). This section will, therefore, ensure that all the findings have been applied in the hospital environment.
The aspect of time pressures can have adverse effects on both patient care and the workplace. Studies have shown that there has been a report on the nurses' side that time pressures could easily result in mistakes related to emotional upset and poor recordings. Such mistakes can be extreme to the point of putting a patient at risk. There is a relationship between poor training and the inability to manage time (Davies et al., 2017). Another study was conducted, and it revealed that poor time management increased the chances of one making errors when it comes to the care of patients. Importantly, motivation for work is very important in any work environment.
The Proposal and summary of key evidence
The PDSA cycle 1: there will be the implementation of a new chart across the medical wards at the chosen hospital. The researcher will seek to speak to all staff at different shifts in order to explain the project. This will require a lot of workforce to rotate across the wards in all shifts (McGloin, 2015).
The PDSA cycle 2: there will be a need to raise awareness through posters around nursing wards. This will call for the need to attend nursing handover sessions for the publicity of the project regularly.
The PDSA cycle 3: the process will require the ward Sisters' engagement to launch the e-learning system. This calls for the designing of an appropriate certificate that nurses could include within their training portfolios.
The PDSA cycle 4: this will include the nature of review on the fluid balance charts from the ward doctors. This requires various adjustments on the monitoring time to ensure the ward doctors' presence at the time of chart changeover.
The PDSA cycle 5: the continuance in applying the final version of the fluid balance chart includes the post-intervention measurement chart.
The strategy applied in this case entailed the inclusion of a small group of education for the medical staff, creating board magnets capable of helping the multidisciplinary teams in identifying patients who require mon...