Evidence–Based Practice: A sustainable hydration workflow for acute stroke patients in ASU

Abstract Description

Authors (including presenting author) :

Karin Chow(1), YM Chu(2), Julie Kwong(3), WC Shum(4), Madeleine Leung(5)

Affiliation :

(1) ASU of Tuen Mun hospital (2) ASU of Tseung Kwan O hospital, (3) ASU of Kowloon West Cluster hosptials, (4) ASU of Prince of Wales hospital, (5) Neurosurgery of Queen Mary hospital.

Introduction :

Stroke patients are high risk to develop dehydration due to swallowing difficulty or functional disability. Evidence of meta-analysis showed that dehydration using blood BUN/Creatine ratio (BUN/Cr) <15 were found in stroke patients. Studies on targeting BUN/Cr ratio hydration management were able to reduce rate of stroke-in-evolution (RR 0.8) and had better outcome (RR 0.77) in 3 months. After reviewing current practice in stroke units, a systemic clinical workflow for hydration management has been developed. The workflow includes hydration screening with BUN/Cr, interventions for extra fluid fed round, supplementation by prescribed intra-venous fluid and encouraging patient and caregiver involvement.

Objectives :

To adopt a sustainable hydration practices to acute stroke patients at ASU.

Methodology :

The workflow is developed using John Hopkin Nursing Evidence Based Practice Model. The workflow has been applied in participating 3 acute stroke units. Before implementation, workshops were conducted to nursing staff to reinforce the need and compliance. As there are different infrastructure in participating hospitals, some modifications providing not breaching the principles, would be allowed. Data of recruitment criteria, blood tests, signs and symptoms of dehydration, stroke severity were collected and evaluated.

Result & Outcome :

 In TMH, retrospective data retrieved from 1st July to 31st August 2018 for control group, while 1st October to 30th November 2018 for intervention group. 154 out of 217 patients met inclusion criteria. Patients with intervention, BUN/cr ratio > 15 is decreased from 69.6% to 60.9%. Before program, the mean BUN/cr ratio is increased from “day 1” of 17.05 to “day 4-7” of 19.07 (p-value < 0.02). After program, the mean BUN/cr ratio is decreased from 16.21 to 14.57 (p-value < 0.03). Patients with BUN/cr ratio > 15 is decreased from 69.6% to 60.9% as compared.  In CMC, YCH and PMH, data retrieved from 1st Oct to 31st Oct 2018. A total of 147 stroke patients admitted with 11 patients (7.48%) met the criteria and recruited. The averages BUN/Cr ratio were decreased from 23.94 to 21.80.
 In TKOH, data captured in November 2018, 41 out of 45 patients recruited, encourage self-fluid intake and extra fluid fed provided. 10 patients documented as condition improved after intervention provided by nurses. Conclusion: This evidence-based practice provides a foundation for a system improvement in targeting extra fluid fed round to IVF administration as well as the development of a fluid management algorithm for stroke patients.