CLINICAL AUDIT: EQUINE INTRAVENOUS FLUID THERAPY
client confidence, professional development, reduce stress and im- prove job satisfaction. Intravenous fluid therapy (IVFT) is administered to the equine pa-
tient to restore circulating volume, and when ongoing fluid require- ments cannot be matched by oral intake. An initial bolus is commonly given to restore the fluid deficit and an ongoing fluid therapy plan is produced based on the maintenance requirements and ongoing losses. This follows the assessment of multiple factors including heart rate, jugular refill time, mucous membrane colour, capillary refill time, skin turgor, urine output and clinical illness (Menzies- Gow, 2017 ). Critical to the effectiveness of IVFT is the ability to deliver fluids to the patient at the prescribed rate. There are many factors which may interfere with this, such as partial or complete occlusion of the in- travenous catheter as the horse changes its head and neck position, periods spent off fluids when patients are taken out of the stable (e.g. for walking exercise or veterinary intervention), lack of recognition of inadequate or excessive fluid flow rates, to name a few. For this audit, our standard was to ensure each patient receives
the volume of fluid prescribed to treat the condition they were ad- mitted for. It had been observed at Newmarket Equine Hospital that fluid
therapy was not being administered at the rate prescribed. The ob- jectives of this clinical audit were therefore to quantify the extent of this problem, investigate potential contributory factors, and develop an action plan to resolve these matters.
MATERIALS AND METHODS
Data for the original audit were collected retrospectively during the period of 1 January 2020 to 30 June 2020 and the re- audit prospec- tively from 1 January 2021 to 30 June 2021 after the implementa- tion of changes. Data were collected using the intensive care unit (ICU) record
sheets for each patient. The following information was intended to be recorded by clinicians but if data were incomplete, estimated or excluded, it was noted in the data collection. Data extrapolated from the intensive care sheets included the prescribed fluid plan (including rate and type of fluids), the weight of the horse, the clin- ical reason for receiving intravenous fluids, the catheter type, com- plications that may have affected intravenous fluid administration and the start and end times of IVFT for each patient. The volume of fluid received was recorded for each day- time
(08:00– 18:00) and night- time (18:00– 08:00) period, as these periods mirrored the change in shifts from routine staffing to out- of- hours staffing at the hospital. If the data collected for the fluid volume ad- ministered during each day- and night- time period was not recorded within 1 h of the start or end of the time period, an estimate was made based on the rate of administration between recorded time points on either side. If there were more than 6 h between record- ings, the time period was excluded from the study as the margin of error to estimate was considered too great. Originally, the volume of fluid received was calculated by using the final column in the original
Collected data were entered into an Excel (Microsoft) spreadsheet. Formulas were constructed in the spreadsheet, which calculated the prescribed volume of fluids each patient should have received from the start of the IVFT to the end of the IVFT, during each day- time and night- time period. Data were then analysed through a series of pivot tables and graphs. The difference between the intravenous fluid vol- ume prescribed and the volume received for each patient was then calculated for each day- time and night- time period. Periods, where a bolus of fluid was administered, were excluded from analysis, as no specific rate was prescribed (i.e. the bolus rate of fluid administra- tion was as fast as possible). Fluid volume was statistically analysed using XLSTAT (Microsoft)
software. For each horse, the difference in fluid volume prescribed and received in 2020 was compared with that of 2021 using a Mann– Whitney U test. Significance level α = 0.05. To determine the difference in volume of fluid received by a
horse, the prescribed amount is subtracted from the actual amount received. A negative value indicates that the horse received less than the prescribed amount, whereas a positive value indicates that the horse received more than the prescribed amount. The distribu- tion of these volumes in both years is compared in Figure 3 . To calculate the median, the original values of the data set were
used as this captures the central tendency of the data. This included positive, negative and zero values to ensure an accurate representa- tion of the data.
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ICU sheet (Figure 1 ). The volume received was noted by looking at the hanging bag and estimating the volume remaining in the bag. This number was then written in the ‘Due’ column. In the re- audit, the fluid graph was used (Figure 2 ). A fluid plan was created and after the bolus has been administered, the line of best fit (LOBF) is drawn according to the fluid plan. Commonly occurring events considered to have affected intra- venous fluid administration included:
• Intravenous catheter and extension set complications, for ex- ample swelling, poorly positioned catheter placement and/or suturing.
• Low head/neck position due to foraging or eating from the ground, resulting in kinking of the catheter and partial or com- plete occlusion.
• Disconnection of IVFT to walk the horse or for veterinary intervention.
For every case, each of these events was recorded once as either
having occurred (1) or not (0), irrespective of the number of times the event occurred throughout the duration of fluid therapy. A total score of 0 (none of the events occurred) to 3 (all these events oc- curred at least once during the period of fluid therapy) was then as- cribed to each case.
Data and analysis
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