Evaluation of a Nurse-Driven Fluid Management Protocol to Improve Outcomes in Critically Ill Patients

Abstract

This article reports results of a nurse-driven fluid management protocol in a medical-surgical intensive care unit (ICU). Use of static measures such as central venous pressure monitoring, heart rate, blood pressure, and urine output is poor predictors of fluid responsiveness and can result in inappropriate fluid administration. Indiscriminate administration of fluid can result in prolonged mechanical ventilation time, increased vasopressor requirements, increased length of stay, and greater costs. Use of dynamic preload parameters such as stroke volume variation (SVV), pulse pressure variation, or changes in stroke volume with a passive leg raise has been shown to be more accurate predictors of fluid responsiveness. Improved patient outcomes including decreased length of hospital stay, reduction in kidney injury, decreased mechanical ventilation time and requirements, and reduced vasopressor requirements have been demonstrated by using dynamic preload parameters. ICU nurses were educated on cardiac output and dynamic preload parameters and a nurse-driven fluid replacement protocol was established. Knowledge scores, confidence scores, and patient outcomes were measured pre- and post-implementation. The results indicated that there was no change in knowledge scores between pre- and postimplementation groups (mean = 80%). There was a statistically significant increase in nurse confidence in using SVV (P = .003); however, this change is not clinically significant. There was no statistically significant difference in other confidence categories. The study indicated that ICU nurses were resistant to adoption of a nurse-driven fluid management protocol. While anesthesia clinicians are familiar with technologies to evaluate fluid responsiveness in the perioperative setting, the new technology posed challenges to ICU confidence. This project demonstrates that traditional methods of nursing education did not provide the support needed for implementation of a novel approach to fluid management, and that there is a need for further improvement in educational strategies.