Might be a dumb question but

[elijahvegas]

is ordering fluids in the er just a routine standard of care for docs or something? almost every patient we see docs order a liter of fluid right off the bat, regardless of any vitals that might indicate a need for it.

if an IVP med is ordered, theres a liter of fluid ordered with it.

sometimes pts will ask me why are they receiving fluids, and I end up having to give some vague answer like "in case we may think you're a bit dehydrated" or "it aids in circulating the medication we gave you into your system a bit easier" or if I'm giving a bp med i'll say "just in case you're sensitive to it and your pressure ends up bottoming out" but honestly I have no clue, and I don't get a straight answer when I ask the docs about it

anyone have any insight?

[Lisacar130]

That's what I'm talkin' about! Lol

[Neats, BSN]

I love this site where I can get some additional education (verified of course) I have always thought the reason for IV fluids: it is indicated for use in

conjunction with blood transfusions and for restoring the loss of body fluids. I just assume we place this IV (NS) for this very reason in case we need it for a patient presenting to the emergency room is there for an emergency. Now I understand people present to the emergency room for a wide variety of reason to include actual emergency to I want to get out of the cold weather.

The administrator in me is now questioning why do we place an IV on almost everyone who presents to the emergency room. The nurse in me thinks this is proactive for you do not know when a patient is going to turn south and you want that access. Humm.... I am interested in reading more responses.

[JKL33]

IV fluids are different beast than IV access - which can be reasonably justified in a lot more instances than some of our use of IV fluids can. No matter how skilled, no one really wants to be establishing a first IV when things have already headed south. I have no problem with all 1s, 2s and a number of solid 3s getting IV access.

Then you have the issue of unpleasant procedures - and minimizing them. Someone's getting labs; what're the chances there will be additional needs when the results come back?

And the issue of wasting precious nursing time or not wasting it....and someone's already getting venipuncture for labs....

These issues surrounding IV access are admittedly arguable, but it's not usually a random act of unnecessary intervention.

[Alex_RN, BSN]

Overuse of antibiotics

Please please please get a culture before turning on the ABX.

I LOVE my ED peeps. They do so much and take well-deserved pride in their work.

[Rocknurse, MSN, APRN, NP]

The fundamental cornerstone of emergency medicine is tissue perfusion. Without adequate tissue perfusion comes ineffective cell metabolism and without effective cell metabolism the patient dies. So, in a patient with whom you do not know what is wrong quite yet, a liter of fluid is an effective baseline treatment. It's difficult to know what the patient's preload is just by looking at them, and it's hard to know whether their SVR is low (thereby contributing to their inadequate tissue metabolism) so in these cases IVF won't harm them but it very well could help them. IVF can assist in a multitude of possible worst-case scenario differential diagnoses. Septic shock? IVF helps maintain vascular tone. Acute renal failure? IVF can only help kidney perfusion. Myocardial infarction? IVF can restore volume in cardiogenic shock. It has a good risk vs benefit ratio.

[elijahvegas, ASN, RN, EMT-P]

The fundamental cornerstone of emergency medicine is tissue perfusion. Without adequate tissue perfusion comes ineffective cell metabolism and without effective cell metabolism the patient dies. So, in a patient with whom you do not know what is wrong quite yet, a liter of fluid is an effective baseline treatment. It's difficult to know what the patient's preload is just by looking at them, and it's hard to know whether their SVR is low (thereby contributing to their inadequate tissue metabolism) so in these cases IVF won't harm them but it very well could help them. IVF can assist in a multitude of possible worst-case scenario differential diagnoses. Septic shock? IVF helps maintain vascular tone. Acute renal failure? IVF can only help kidney perfusion. Myocardial infarction? IVF can restore volume in cardiogenic shock. It has a good risk vs benefit ratio.

Makes the most sense but seems entirely too convenient.

[adventure_rn, MSN, NP]

During the national fluid shortages following Hurricane Maria, I noticed that my hospital started sending out memos asking that providers be very diligent about only ordering fluids when they were clinically indicated so that we wouldn't run out. Like others have said, they were usually being ordered routinely without a specific reason.

That said, I figure that most people could probably benefit from some IV fluid unless fluid restriction is indicated. The majority of people are chronically dehydrated (according to the article below, anyway). If you're sick, I'd imagine that your metabolic needs, and therefore fluid requirements, would increase; in addition, if you're just laying around in a hospital bed all day not feeling well (plus your nurse with 4 other patients doesn't have time to bring you water every half hour), you may well become even more dehydrated. I think of it like the mobile 'Hangover Buses' that drive around Vegas hanging banana bags (also below); if you're dehydrated and not feeling well, fluid is a small, easy step to help you feel better. It probably isn't worth starting an IV, but if you've already got IV access then it seems potentially helpful and relatively benign.

75% of Americans May Suffer From Chronic Dehydration, According to Doctors

Got $225? These guys say they can cure your hangover

[JKL33]

Assuming this conversation is more about those very soft 3s, and the 4s inappropriately up-triaged to 3s than patients who might be headed towards septic shock...

The problem has decreased in places where accelerated throughput has become Objective #1 (a separate issue in itself). It used to be that anyone with a few beers on board bought themselves a banana bag and anyone who vomited x1 or who had a headache or any one of numerous other mild/moderate ailments got a liter or two of IV fluids. Not so much any more.

It really frustrates me when I have to do something that isn't really indicated. I work hard to gain trust, and patients believe I am doing what is right for them, even when I am not.

Yes/agree. But what bothers me every bit as much (possibly more) is the risk/benefit thing. About the time someone doesn't need something that apple cart is upset by definition. I never loved "headache cocktail for all" mentality, for example - - it's at those points that you get to find out who has dystonic reactions from the handful of IV pushes they got, who gets significant chest pain from unnecessary IV caffeine, and all sorts of other things we might have wanted to avoid if we had the choice. So these situations are at the top of my list of "things."

**

Anyway, back to the OP. Why does this happen? [These are not meant to excuse and are only for the purposes of contemplation]

- No one wants to hear back "They didn't do anything!" or worse, "They didn't even care and they didn't do anything!" - the "not caring" being evidenced solely by the fact that nothing was done that couldn't be done at home. People don't like criticism, and this kind of criticism is not without ramifications anyway.

- HPIs are interesting. If you take enough and observe enough you will see that it's difficult to put some of them down on paper and then do "nothing." If you are in the ED, you know what I mean. Right or wrong, some of what we do is according to what people say and the whole thing is a delicate issue. It's hard to do nothing medical because it can easily not "look good" retrospectively.

- Efficiency. It's awful hard to take the risk of trying gatorade/water only to be told that people still feel as if they're on their deathbed. Now it's back to square one an hour later and time's still ticking and patients are stacking up. Prudence and efficiency are at odds in the current environment.

- Too many people triage according to individual provider practices, which was never correct. Those ESI levels are to be applied in any ED type/situation all across the country. If you make a patient an ESI 3 because you think your provider might order (what you believe are) unnecessary IVs and a bunch of junk - guess what just became even more likely?

- There are many other little things that come into play but these are the main ones that came to mind right now.

What can we do about it?

- Number one thing is to establish collaborative and collegial relationships through which the patients' best interests can be advocated, rather than signing on to the "us vs. them" mentality with regard to providers. If you have good relationships and excellent communication, it's not at all difficult to say, "You know, s/he's able to keep fluids down - can we try some gatorade/water and PO zofran?"

- We can triage correctly. ED nurses should be able to tell who doesn't feel well vs. who is sick or poses significant risk of being sick. Stop up-triaging.

- We can advocate and encourage increased provider-patient communications. We can do cheesy things like saying, "That patient was really relieved after you talked to her and explained everything..." I'm 100% convinced that a 5-minute sit-down provider-patient discussion where "caring" is displayed and rationales are discussed has the ability to significantly decrease unnecessary tests and treatments. I've been watching and doing little experiments for a long time and it makes a difference. People need to be able to trust and when they are given good reason and opportunity to do so, it's much more likely that they will.

- We can advocate the idea (with those above us, not providers) that nurses have a legitimate professional place in helping educate about reasonable expectations. This has nothing to do with ever telling a patient that they "don't need to be here" or in any way chastising them or putting our customer service goals at risk. Instead, it's about saying things like, "That sounds miserable - - we can take a look and see if you need antibiotics or if this might be a viral illness where you kind of have to wait it out. If that's the case, we can ask if there's anything to help with some of the symptoms you've been having." (Or whatever). And for goodness' sake, look like we care. It's not that difficult.

- We can acknowledge providers' various verbalized concerns about all of this. They have their rationales, and whether those are well-founded/realistic or not, they deserve to be heard and considered.

- We, nurses, can stop huffing around and acting like these things happen because providers are lazy, stupid, greedy, evil or have some other major character deficit. Unnecessary treatments don't arise in a vacuum, the fault-finding flows all too freely when you're not the ultimate one on the hook.

[CBlover, BSN, RN]

I couldn't agree more. I feel like we MAJORLY over-treat and people know it and they just keep coming back like the neighborhood cats. I feel like if there were more "treat & street" Docs the waiting room wouldn't back up with 20 people simply because we could get folks in and out. You know, I have had HORRIFIC stomach viruses, my young son of 2 has, and we are still alive without going to ER for fluids. I just wish people understood what the word "emergency" means in emergency room. I feel like if a gal in her 20s comes in with N/V/D for 6 hours we should send her home with a script for Zofran and call it a day.

And I do the same thing you do when people ask "Oh am I dehydrated" when I hang fluids. I literally don't know what to say most of the time. I think we probably all stay dehydrated a good bit of the time. None of us drink enough so I just tell them that it helps rejuvenate the body under times of physical stress.

[maybug, ADN, BSN, RN]

I get what you are saying. I've always thought to myself that if I were a patient in the hospital and a nurse tried to give me protonix I would refuse.

[djh123]

I do think it's kind of automatic, and as another commenter says, are sometimes overused. It wasn't the ER, but when I had a cholecystectomy, the next day I noticed a little of BLE edema, and I thought oh yeah, I remember hearing that they gave me a lot (too much) of fluids when I was in surgery.

The 'automatic' fluid thing reminds me of a doctor I've worked with who - yes, I'm exaggerating, but not entirely - orders a CBC/CMP for almost anything and everything. But I do kind of get it...

[charlottegirl]

Lol don't forget BID heparin sq and the colace!