Balanced fluid resuscitation in Sepsis, a Quality Improvement project
Michelle Ojard, P.A.-C1; Nikki Matos, APRN1; Hollie Saunders, M.D.2; Hassan Baig, M.D.1; Alexander Heckman, M.D.2; Jelena Halilovic, R.N.2,4; Kandise Crocket, R.N.1,4; Michelle Markum R.N., MPH, MBA4;  Pablo Moreno Franco, M.D.1; Ami Grek, APRN, D.N.P.1; Devang Sanghavi, M.D. MHA1
1Department of Critical Care Medicine, Mayo Clinic, Jacksonville, USA; 2Department of Internal Medicine, Mayo Clinic, Jacksonville, USA; 3Department of Emergency Medicine, Mayo Clinic, Jacksonville, USA; 4Department of Nursing, Mayo Clinic, Jacksonville, USA
Presenting Corresponding author email: meeder.michelle@mayo.edu 
Introduction/Background: The Surviving Sepsis Campaign bundle was developed with the goal of reducing mortality by 25% over 5 years by implementing a standardized 7-element bundle in hospitals across the country (1). The most recent 2016 guideline recommendations are a 4-element bundle which includes measuring serum lactate, obtaining blood cultures followed by antibiotic administration, starting fluid resuscitation for a recommended 30cc/kg for a systolic blood pressure <90mmHg or a lactate level >4.0mmol (1).  Frequently, the initial fluid choice for the 30cc/kg fluid bolus is normal saline 0.9% (NS); however, literature demonstrates that balanced crystalloids such as lactated ringer’s (LR) or Plasma-Lyte are safe and may even be preferable to normal saline (NS) (2,3). At our institution, 90% of the time providers were choosing normal saline instead of a balanced crystalloid. 
Aim/Objective: We embarked upon a quality improvement initiative to change the practice pattern of the resuscitation fluid from NS to balanced crystalloids.
Methods: We engaged the providers by conducting pre-intervention surveys to understand their preferences in terms of fluid choices and rationale for their choices. We followed this by conducting monthly PDSA cycles determining the intervention steps and assessing the impact of our interventions. We retroactively analyzed data from our institution’s sepsis data metrics to assess what percentage of patients received NS or LR from October 2018 – August 2019. Our intervention measures included but were not limited to giving Power Point lectures at other department’s monthly staff meetings, hanging educational posters in the hospital, and increasing the amount of LR available in the pyxis.  
Results: Post-intervention data from October 2019 – May 2020 was analyzed and revealed that the use of Lactated ringers increased from 9% to 26%, with a corresponding decrease in Normal Saline from 91% to 74%, without adversely affecting mortality. Figure 1 depicts the percentage of individuals who received normal saline vs. lactated ringers over a 20 month period, and the impacts of our various interventions. 
Discussion/Conclusion: We successfully changed our practice and utilized more balanced crystalloids as compared to NS as a part of our quality improvement project. The total change brought into effect was increase in use of LR from 9% to 26% as a fluid of choice for resuscitation in patient with severe sepsis or septic shock. This is an ongoing project with ultimate aim of improving this number further with more PDSA cycles. Changes in patient management across teams can be challenging, however we demonstrate how educational initiatives can drive change in fluid choices for sepsis resuscitation.
Acknowledgements:  The authors received no financial support for the research, authorship, and/or publication of this article.

References:
1.  Rhodes, A., et al., Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med, 2017. 43(3): p. 304-377.
2. Self, W.H., et al., Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med, 2018. 378(9): p. 819-828.
3. Semler, M.W., et al., Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med, 2018. 378(9): p. 829-839.

Balanced fluid resuscitation in Sepsis, a Quality Improvement project

2020 has been a challenging year for all. The COVID19 pandemic has provoked profound and probably long-lasting changes to healthcare systems but also the delivery of educational material to colleagues. 


Face-to-face conferences have had to be rescheduled and replaced with online meetings, given the continually evolving travel restrictions. 


The IFAD conference has not been spared these tribulations and we have decided to cancel the physical meeting to replace it by a virtual online meeting.


The 1st Virtual IFAD International Fluid Academy Days will again be a 3 day concise meeting on all aspects of fluid management and hemodynamic monitoring in the critically ill.