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DODD and SMITH
FIGURE 5 Analogue scales were modified by writing intervals in marker pen and adding a red sticker over 5 L intervals to assist interpretation from the ground. (a) Modified analogue scales. (b) Horse attached to fluid giving set with 2 × 5 L fluid bags suspended from the modified analogue scales.
the requirements for that patient and compare progress at different times. The IC (intensive care) sheet for each patient is kept outside each individual intensive care box, making it a convenient way to record values for each horse. The improvements to the IC sheet con- sisted of a table structure so essential parameters were most ap- parent and easy to compare through different hours of the day and night. A column for the intravenous catheter was used as a prompt for primary caregivers to ensure the catheter was checked regularly. Prior to the implementation of improvements, the assessment
of the volume of fluid remaining in hanging bags was made by vi- sual estimation. Caregivers considered this difficult and consistency was lacking between individuals. Informal discussion highlighted in- stances where estimates varied by up to 7 L between individuals. To improve estimates, scales were used to provide a real- time measure of the weight of the fluid bags, from which volume could be extrap- olated. An industrial analogue scale was zero- offset at the start of fluid therapy for each patient. Small stickers were applied to the industrial scales in 5 L increments to allow them to be read from a height (Figure 5 ). When trialling methods to quantify the volume of fluid remaining
in hanging bags, digital scales were tested but were rejected as they would turn off automatically to save power, and the scales automati- cally performed zero- offsets which could not be disabled. A Newton Force Meter (NFM) was also considered. This required a static closed system and so the force vectors add up to 0 so the volume hanging should be equal to the NFM. Horse movement would not allow this system to be reliable due to acceleration forces. In addition, costs were significantly greater.
The most common event contributing to deviation in fluid vol-
ume received was low head and neck position when foraging. When foraging or eating, the lower head and neck position can result in kinking of the intravenous catheter, impeding flow. This may be exacerbated by suboptimal catheter placement. The incidence and these complicating events were highlighted during the first part of the audit. During the second part of the audit, while numerically the catheter complications may not have improved, detection of such catheters and intervention was more frequent. Feeding from a height or use of a muzzle to discourage foraging behaviour was employed. Increased effort was also made to place catheters parallel to the jugular furrow, and extension sets were sutured to avoid kink- ing or malposition of the catheter. The horse ' s head and neck were positioned in their normal head carriage when inserting and securing the catheter (sedate horses hold their head lower therefore sutures will pull on the skin when awake). In addition, the catheter and/or extension set were re- sutured or replaced if significant positional changes or swelling resulted in a reduced flow rate. Disconnecting patients from fluids to provide walking exer-
cise was another common cause of reduced fluid administration. In some cases, this was made up as part of the therapeutic plan. Disconnection of fluid therapy was always expected to be recorded in patient records but was often not documented in the original audit as its importance was not fully appreciated. In the period of re- audit, there was a higher percentage of horses recorded as being discon- nected from fluid therapy. The raised awareness of the effect of walking exercise on rates of fluid administration, and the recording of the duration of walking exercise in the patient ICU record sheets
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