Background: Maintenance intravenous fluids (IVFs) are a critical treatment utilized frequently in pediatric medicine to support children with impaired enteral intake suffering from a wide variety of illnesses. Traditional pediatric practice of utilizing hypotonic fluids is thought to derive from Holiday and Seger’s mathematical calculations on IVFs that concluded that the use of hypotonic fluids would adequately provide maintenance water and sodium requirements. Hypotonic fluids have been linked to development of iatrogenic hyponatremia that carries risk of hyponatremic encephalopathy and cerebral edema. New clinical practice guidelines were published in Pediatrics in December 2018 that strongly support the use of isotonic fluids instead of hypotonic fluids in children older than 28 days. Initial baseline data collected from resident physicians in an urban pediatric residency program indicated a significant knowledge gap in this area. A resident-led quality improvement (QI) initiative was formed with the goal of decreasing use of hypotonic IVFs by at least 50 %.

Methods: Children studied were aged greater than 28 days old and admitted to the pediatric hospital medicine service with a diagnosis of dehydration. Retrospective chart review of the electronic medical record was performed to assess baseline data including isotonic fluid ordering rates in children, associated electrolytes and potential adverse outcomes. A series of plan-do-study-act (PDSA) cycles were then implemented. Initial PDSA cycle consisted of educational sessions targeted at faculty in the Hospital Medicine and Emergency Medicine Divisions as well as pediatric residents. A subsequent PDSA cycle created an order set within the electronic medical record (EMR) for IVF ordering with prompts to encourage isotonic fluids when appropriate.

Results: Initial analysis of the study population prior to interventions found median percentage of hypotonic fluid use to be 85 %. Following implementation of interventions, the median percentage of hypotonic fluids ordered significantly decreased to less than 20 %.

Conclusions: This resident-led QI initiative developed focused interventions to change the prescribing practices in an academic pediatric hospitalist division through education, retrospective chart review and changes to the EMR. We demonstrated a marked decrease in hypotonic fluid prescribing following two PDSA cycles, far exceeding our initial goal. Additionally, our success in dramatically changing this outdated practice indicates that a resident-run QI team can successfully implement meaningful changes within their institutions. This suggests significant potential for future QI projects developed in a similar model. Further areas of study planned include detailed analysis of adverse complications such as hypernatremia, development of institutional guidelines and post-intervention analysis of how well improvements were sustained over time.

IMAGE 1: Percent Hypotonic Fluids Utilized