Problems with suboptimal perioperative care despite widespread implementation of rapid response systems are well reported. In particular, management of perioperative fluid therapy continues to contribute to excess mortality and morbidity.^1,2 Recent NICE guidelines have attempted to find clinical equipoise on a controversial topic by endorsing a systematic approach to fluid management in hospitalised adults.³ However, improving fluid management at an individual and organisational level has proven to be very challenging.⁴ The aim of this project was to assess feasibility of “push messaging” to facilitate change in intravenous fluid prescribing practice on surgical wards.

Using a common application powered by social media technology WhatsApp, messages highlighting prescription practices following focused cycles of fluid chart review were sent to the junior doctors. Data from a small number of patients during the initial and follow up phase was used to assess the efficacy of the intervention. Informal interviews were also conducted to evaluate participant opinion of social media based educational interventions.

Initially, greater than 50% prescriptions did not have an indication recorded. In 35% of maintenance prescriptions recorded, the rate prescribed was 100 ml/min or higher. The recording of indication for each fluid prescription improved from 35% on the first cycle to 59% on the subsequent cycle. Opinions on the intervention and its efficacy as a supportive tool were largely favourable.

This work confirms a systemic tendency towards iatrogenic hypervolemia for maintenance fluid prescription and inadequate fluid resuscitation in patients with evolving or established shock. Improvement with the use of simple reminders using social media demonstrate proof of concept that prescribing practices may be improved in junior doctors by frequent targeted peer led electronic reminders Future work will focus on developing the current framework and exploring other ways to improve fluid management in perioperative care using social medical and eHealth technology.

References

1. Hogan H, Healey F, Neale G, Thomson R, Black N, Vincent C. Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. J R Soc Med. 2014;107:365–75

2. Walsh SR, et al. Perioperative fluid management: prospective audit. Int J Clin Pract. 2008;62:492–7

3. National Institute of Clinical Excellence. Intravenous fluid therapy in adults in hospital Clinical Guideline 174 London 2013

4. Powell AG, Paterson-Brown S. Safety through education. FY1 doctors still poor in prescribing intravenous fluids. BMJ. 2011;342:d2741