A teaching programme to improve compliance with guidelines about management of hypovolaemia in the emergency department

Abstract

Hypovolaemia is one of the most severe clinical conditions in patients admitted to the paediatric emergency department (PED). Both absolute hypovolaemia (e.g. severe dehydration) and relative hypovolaemia (distributive shock, due for instance to sepsis (1) can cause multiple organ failure. Faster correction of hypovolaemia is associated with better outcomes (2,3). International consensus guidelines about emergent fluid resuscitation of children with sepsis and hypovolaemia were issued recently (2,4,5). In 2005, the senior physicians at our PED noticed poor compliance with these recommendations in patients who had hypovolaemia diagnosed in the PED. Colloids were overused, and fluid infusion rates were usually lower than recommended. Optimal initial resuscitation for hypovolaemia in children may lead to a significant decrease in mortality (6). We therefore designed a teaching programme (TP) to improve compliance with the recommendations. To design and to evaluate the TP, we conducted a beforeafter study. We collected data on all fluid challenges given during a 6-week period in winter. We then developed a TP taking into account the main points of the international consensus guidelines. All 12 physicians working in the PED followed the TP. Data on fluid challenges were collected during the same 6-week winter period of the following year. We prospectively identified all patients who received fluid challenges during a 6-week period in the winter of 2006 encompassing the gastroenteritis seasonal peak in incidence. To this end, each of the 12 physicians working full-time or part-time at our PED was informed of the study aim and design. Each time they prescribed a fluid challenge during the study period, they completed a dedicated anonymous form to record the patient’s age, weight and main diagnosis; the fluid, volume and infusion duration; and the vascular access. According to standard practice in our PED, a senior physician reviewed all medical charts of PED patients daily. In addition, the main investigator checked once a week that all fluid challenges prescribed by the physicians were properly recorded. At the end of the period, we evaluated compliance with guidelines and we assessed the knowledge of the physicians by asking them how they would manage a patient described in a fictional scenario. Although their answers to the fictional scenario agreed closely with international consensus guidelines (data not shown), the review of fluid challenges showed excessive colloid use and insufficient infusion rates (Table 1). We used these data to build a 1-h TP on the emergent management of hypovolaemia in infants in accordance with recent international consensus guidelines (2,3). This 1-h TP was delivered each day during one week to ensure that all 12 physicians participated, regardless of their schedule. Key points in the TP were use of 20 mL/kg per fluid challenge in infants older than 1 month, use of the highest possible infusion rate and preferential use of saline (2,3). Three recent articles and a summary of the main recommendations were given to each physician. All physicians felt the TP was adapted to their medical practice, although three would have liked a longer programme. Finally, we prospectively recorded all fluid challenges given during the same 6-week period of the following winter (2007). Quantitative (medians [minimum–maximum]) and qualitative values were compared using the Mann–Whitney and Chi-square tests, respectively. Values of p < 0.05 were considered statistically significant. Changes in the main fluid challenge parameters between the two periods are reported in the Table. The physician in charge of the study excluded one fluid challenge