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Quality Improvement Process: Collecting I/O DataAngela SokolowskiFerris State University AbstractMeasuring a patients input and output can be very complicated, though it may seem like a simple task. These measurements are vital data that can change the patients care plan and outcome of response to treatment. It is necessary to incorporate several members of the patient’s team to ensure accurate measurements. Team members involved in this process include nurse aides, registered nurses, the dietary department, the physician, and lastly, the patient and family. The process must be made simple and clear, and be consistent. Training for the staff, patient, and family is imperative to insure compliance and accuracy with measurement of the input/output process. The final shift analysis and documentation should be completed by the nurse. Daily weights have importance in that they can assist in determining if the measurements are accurate and if the patient has a negative fluid imbalance. Charts for keeping track must be placed where everyone has access to them, including patient and family. After much investigation, it has been determined that measuring input and output (I/O) for patients in a hospital setting needs work to improve the accuracy of the data that is being collected. For many units within the hospital this is a standard of care, whether on a cardiac, post surgical, or orthopedic and neurologic unit. This standard of care is used to, not only measure the patient’s progress, but to determine the course of care given. Without accurate I/O data, patients are given unnecessary drugs, issues such as sepsis or dehydration are missed, and the quality of care drops. The value of collecting team members from multiple disciplines to work together on a solution is priceless. Reasons for I/O MeasurementsMany of the units need I/O measurements to be accurate. Patients on a post surgical unit have drains that collect blood and other fluids, such as chest tubes and Jackson-Pratt Drains. These drains allow the surgeon to determine if the patient is bleeding. Cardiac and Renal units need accurate I/O to determine if the patient has proper function of the heart and kidneys, and if they are developing life threatening illness that could come from electrolyte imbalances. Daily weights can also indicate a patient's fluid status. The weight will increase if a patient is getting into a fluid overloaded state and will decrease if dehydration begins to occur. Patients with congestive heart failure and renal failure can become in a fluid overloaded state and it is important to weigh these patients on a daily basis (Scales, 2008). These daily weights can become part of the I/O process. The Neurological units have many patients with Peg tubes that require good calculation of I/O to determine if the patient is absorbing nutrients. These are just a few of the many reasons that I/O would be measured and used for the care of patients. Problems with Current PracticeFluid balance recording is notorious for being inadequate and inaccurately completed (Bennett, 2010). Examples of bodily fluids to be included in I/O collection data are urine, emesis, blood, stool, stomach contents, and anything in a drain from an incision or wound. There are many problems with our current practices of data collection. First, nurse aides (NA’s) are not properly trained on the purpose of this data collection. They are very familiar with the importance of vital sign data and should be equally trained and equipped to monitor this I/O data. They are not always trained on exactly what this data means for the patient’s care. If they understood the real importance of this information, they may be more careful when documenting these numbers. The NA’s should be given real life scenarios about the dangers of improper data collection with I/O measurements, such as death from dehydration, bladder retention and the horrible facts of what can happen if they continue to retain urine, perhaps how a patient may bleed to death before anyone realizes what is happening, and even how volume overload can cause respiratory distress and death. Second, a problem that we currently experience is the lack of ease when documenting this data. The documentation should be done immediately. This prevents errors and omissions. There are several ways that they can currently document this data. They can write it on a small 4x4 template that we have been using at the bedside for many years (which is often missing and have been replaced with paper towels at times), they can enter it into the computer which may seem time consuming, or they can use a marker and write it on the fluid restriction chart. This creates a problem at the end of the shift. There are just too many places to find data to document it in the chart. There needs to be one simple place to document data to be saved until the end of the shift. Since the electronic health record (EHR) came, there has been a lot of confusion about the storage of data for I/O. There have been no new policies regarding this issue written as of yet. Lastly, there are several people involved in handling fluids for consumption with our patients. At times family members bring in things for the patient to make them feel better. They don’t understand the importance of either limiting fluids or documenting the amount consumed. Our patients and their family members need to be educated from the start of data collection so that they can help to assist in this collection. Also, the dietary department brings fluids with meals for our patients. They need to be educated on the importance of this data collection, the proper places to store data, and how important it is that patients on fluid restrictions do not receive additional fluids. Collaboration of Team Members to Make a ChangeA team of individuals that can make a difference include registered nurses (RN’s) from several units, NA’s, a physician, a member from the dietary department, and the patients and their families. RN’s from several units will help to insure that the different types of data collection are represented. Allowing NA’s to add input about the process will make them feel as though their opinion matters, and may make them more likely to adhere to the plan. It is also important to understand their perspective about how they will actually collect the data, and what will and won’t work. Generally they spend the most time collecting I/O information from our patients. The physicians need to be involved and understand the importance of consistency with their order writing for fluid restriction patents and daily weights for certain diagnosis. They will also need to monitor the data and report any unusual findings as soon as possible so that the nurses can follow up to find any potential problems. Their input about any other necessary policies and potential reasons for I/O data collection will be needed. The dietary department will need to assist with providing portion sizes for measurement purposes and will need to add input on difficulties with documentation. They remove a high number of trays from the rooms with potential data on them. The patients and their families will not be on the team to make the policies directly but their daily input will help on an individual basis. It will be of ut most importance to educate them about how we collect this data, and ask for their assistance in this matter. We can also get their input on the difficulties they face and use this information to work toward better data collection in the future. The Policy for Measurement and DocumentationWith policy changes comes the need for education. The staff, patients, and family will all need to be educated. Every patient (and their families) on I/O measurement and fluid restriction will need to be educated about how to collect and measure fluids consumed and excreted. They will need to be taught which containers to use for measurement and where to document these values. They will need to be made understand the importance of this data collection as well. The team will begin with a meeting to put together a comprehensive educational piece for the staff and the patients/family members. The educational piece will include how and where to document the data from the measurements of I/O (see Appendix A). It will also include where in the room the chart will be stored. To be effective the chart must be displayed where it is visible to all staff, and preferably to patients and their relatives (Bennett, 2010). We want consistency, so they will all be stored in the same place, on the closet door below the clock. This will need to be changed every day by the third shift for the following day. It is important to conduct return demonstrations with staff, patient, and family to assess their ability to measure and document accurately (Elkin, Perry, Potter, 2004).The chart consists of a place to store data for each shift. The left side of the chart has an area for the input, while the right side has an area for output, and type of output (urine, drain, or emesis for example). Below each section is an area to tally up the numbers for each shift. This also makes it more obvious to the next shift if there has been a lack of output or excessive input. Next, near the bottom right corner, there is a square to write in how much of a fluid restriction the patient has in a 24 hour period. The bottom left corner contains a square to store the daily weight. The far right has a colon the full length of the page that has values for the measuring fluid restrictions. The nurse from the morning shift should break this up into sections to show the patient how much they can have on each shift. Most patients do not use milliliters (ml) to measure so there are values ranging from one to eleven. These numbers represent cups and they help patients and their families to see how far into the restriction they are for the shift and day. Each time a cup of 180 ml is completely consumed, a number is marked off from the bottom, along with the left side that contains numbers for the staff. These numbers are in milliliters and are what should be documented in the final chart for the input and output. Next we need to discuss who will be responsible for the final documentation in the chart. It has become apparent that the numbers being documented are not accurate. As the famous quote goes, “If you do what you've always done, you'll get what you've always gotten (Anthony Robbins).” We need drastic change to make this new policy work. We will now be expecting the RN’s to review the measurements for the shift and do the final documentation. At this time they will be able to recognize any problems that need to be reported to the physician or any discrepancies that need to be fixed. ConclusionIn conclusion, it has been known for some time that accurate I/O collection in the hospital setting is rare. The time has come to firm up the policies on collection and documentation. A simple and consistent procedure will ensure that everyone understands where and how the collection data is to be stored. It is important to include many members of the patients care team, and the patient and family as well. Everyone will need to be educated on the proper process and follow up from the RN and doctor is absolutely mandatory. As a team we can remain strong and provide the best possible care for our patients. ReferencesBennett,?C.?E. (2010). Fluid Balance- Check at a Glance- A New Way of Displaying Cumulative Totals. ., Perry,?A.?G., & Potter,?P.?A. (2004). Nursing interventions & clinical skills. St. Louis, Mo: Mosby.Scales, K. (2008). The importance of fluid balance in clinical practice. Nursing Standard, 22(47), 50+. Retrieved from ................
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