Objectives
Having observed that fluid resuscitation was not systematically carried out with feedback loops in case of insufficient or too important fluid administration, the medical team proposed a new resuscitation strategy adapted to patients with 20-50% or to >50% BSA burns. The aim was to delegate a part of the protocol to the nurses. As written, the physicians’ algorithm was not understood by the nurses. The implementation process aimed to integrate the nurses.

Methods
Nurse meetings with the physicians to understand and analyse what is scary or problematic for nurses. Identification of types of goals that would be acceptable to the nurses mainly urine output and mean arterial pressure (MAP). Detailing the volume rate calculations and generating an XLS file with the equations providing guidance to increases or decreases of hourly fluid resuscitation volumes by +/- 25%: definition of cut-offs of urine output, MAP, SvO2, and Lactate that would generate calling the physician. Testing the procedure on simulated cases, and thereafter on 3 consecutive patients.

Results
The equation guided fluid handling was functional and efficient. Over resuscitation was avoided in 3 patients (mean: Age 46y, TBSA 36%), total volume remained < the theoretical Parkland volume. The number of fluid adaptations varied between 3 and 6 times in 24hrs.The new handling surprised the physicians; nurses and physicians felt a little unsecure about this new procedure. The volume to administer the next 24hrs was not clearly defined, but was 30-40% below the total of first 24hrs.

Conclusion

While the nurses felt empowered by the new protocol, they felt stressed by this new responsibility. But with the right tools and information, resuscitation was efficient reducing the number of additional fillings administered. And more adapted to the real needs of the patient, regardless of the initial estimate.

2 - How to best implement a new burn resuscitation strategy in the nurse team ?