Improving Isotonic Maintenance Intravenous Fluid Use in The Emergency Department - Pediatrics - American Academy of Pediatrics

5/21/23, 5:06 PM Improving Isotonic Maintenance Intravenous Fluid Use in the Emergency Department | Pediatrics | American Academy of Pediatrics
QUALITY REPORTS | JULY 01 2021
Improving Isotonic Maintenance

Intravenous Fluid Use in the Emergency
Department 
Bolanle Akinsola, MD  ; John Cheng, MD ; Srikant B. Iyer, MD, MPH ;
Shabnam Jain, MD, MPH
Address correspondence to Bolanle Akinsola, MD, Department of Pediatric Emergency

Medicine, School of Medicine, Emory University, 1547 Clifton Rd, Atlanta, GA, 30322. E-
mail: bakinso@emory.edu
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no
potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial

relationships relevant to this article to disclose.
Pediatrics (2021) 148 (1): e2020022947.

https://doi.org/10.1542/peds.2020-022947 Article history 
BACKGROUND
Maintenance intravenous fluids (IVFs) are commonly used in the
hospital setting. Hypotonic IVFs are commonly used in pediatrics
despite concerns about high incidence of hyponatremia. We
aimed to increase isotonic maintenance IVF use in children
admitted from the emergency department (ED) from a baseline
of 20% in 2018 to >80% by December 2019.
METHODS
We included patients aged 28 days to 18 years receiving
maintenance IVFs (rate >10 mL/hour) at the time of admission.
Patients with active chronic medical problems were excluded.
Interventions included institutional discussions on isotonic IVF
based on literature review, education on isotonic IVF use per the
American Academy of Pediatrics guideline (isotonic IVF use with
appropriate potassium chloride and dextrose), electronic
medical record changes to encourage isotonic IVF use, and
group practice review with individual physician audit and
feedback. Balancing measures were the frequency of serum
electrolyte checks within 24 hours of ED admission and
occurrence of hypernatremia. Data were analyzed by using
statistical process control charts.
https://publications.aap.org/pediatrics/article/148/1/e2020022947/179977/Improving-Isotonic-Maintenance-Intravenous-Fluid?autologincheck=redirect… 1/20
RESULTS
Isotonic maintenance IVF use improved, with special cause
observed twice; the 80% goal was met and sustained. No
difference was noted in serum electrolyte checks within 24 hours
of admission (P > .05). There was no increase in occurrence of
hypernatremia among patients who received isotonic IVF
compared with those who received hypotonic IVF (P > .05).
CONCLUSIONS
The application of improvement methods resulted in improved
isotonic IVF use in ED patients admitted to the inpatient setting.
Institutional readiness for change at the time of the American
Academy of Pediatrics guideline release and hardwiring of
preferred fluids via electronic medical record changes were
critical to success.
Subjects: Emergency Medicine, Quality Improvement
Topics: body fluid, electronic medical records, emergency

service, hospital, fertilization in vitro, hypotonicity, intravenous
fluid, electrolytes, hyponatremia, maintenance or restoration of
fluid or electrolyte balance, inpatients
Maintenance intravenous fluids (IVFs) are commonly used in

children in the hospital setting and are administered to achieve a
homeostatic balance between fluid needs and any ongoing
losses.1,2 The basic principles for prescribing maintenance IVFs
in children were established in the 1940s and 1950s. Holliday
and Segar3 in 1957 described a simple formula for determining
the maintenance need for water in children and recommended
the use of a hypotonic saline solution, equivalent to 0.2% normal
saline (NS) in 5% dextrose (D) in water. Since that time,
recommendations for prescribing maintenance IVFs have
remained unchanged4 until recently, and historically hypotonic
IVFs have been used commonly in the pediatric population.
Older editions of pediatric textbooks in the United States have
hypotonic IVFs as the recommendation for maintenance IVF

administration5,6 ; however, more recent editions highlight the
potential risks of acquired hyponatremia with continued use of
hypotonic maintenance IVFs.7 Physicians, including those in
training, continue to use hypotonic fluids as maintenance
fluids.8,9 In contrast, published evidence-based guidelines for IVF
use in children younger than 16 years of age from international
institutions favor the use of isotonic solutions.10
There have been concerns raised about a high incidence of

potentially life-threatening hyponatremia with the use of
hypotonic solutions, especially in hospitalized children.11–14
Moritz and Ayus11 introduced the idea of using an isotonic
saline solution as a maintenance IVF, and there are several other
studies that have since supported the use of isotonic solutions
as a safer choice for maintenance IVFs.15–17 Despite these
studies, maintenance IVF therapy in children has primarily been
opinion based, and national guidelines have been lacking.18 This
has resulted in high variability in maintenance IVF prescribing
practices among physicians.8,19
The American Academy of Pediatrics (AAP) released a clinical

practice guideline (CPG) regarding the use of maintenance IVFs
in December 2018. The AAP CPG states that “patients 28 days to
18 years of age requiring maintenance IVFs should receive
isotonic solutions with appropriate potassium chloride (KCl) and
dextrose (D) because they significantly decrease the risk of
developing hyponatremia (evidence quality: A; recommendation
strength: strong).”18 Our institution had a low rate of isotonic
fluid use (at 20%), and we wanted to improve our adherence to
the latest guidelines and evidence-based review of the literature.
Our SMART (specific, measurable, achievable, realistic/relevant,

timely) aim was to improve the use of isotonic IVFs in emergency
department (ED) patients aged 28 days to 18 years being
admitted to the inpatient unit with maintenance IVFs from a

baseline of 20% in January 2018 to 80% by December 2019.
Methods
Context
The setting of our quality improvement (QI) initiative consists of
3 pediatric EDs in a large tertiary care pediatric health care
system with an annual volume of >245c000 visits in 2019.
Historically, our institution had a low rate of isotonic
maintenance IVF use (20%), and there was variation in
maintenance IVF prescribing practices among the ED physicians.
Even before the AAP guideline recommending use of isotonic

maintenance IVFs was released, we were actively discussing a
switch to isotonic maintenance IVFs at our institution in
accordance with a review of current evidence. Despite these
ongoing discussions about potential harmful effects of
hyponatremia due to hypotonic fluids, including reports of
serious injury and child death,20–22 the use of hypotonic fluids
persisted. Several years before, our institution had moved from
D5%–0.2% NS to D5%–0.45% NS. In December 2018, our
institution modified our ED CPG for management of bronchiolitis
to avoid the use of hypotonic IVFs because of the risk of
syndrome of inappropriate antidiuretic hormone–induced
hyponatremia and recommended isotonic IVFs as the preferred
fluids. However, the overall use of isotonic fluids for patients
requiring maintenance IVFs, but without a diagnosis of
bronchiolitis, remained unacceptably low in our institution.
Additionally, our institution’s hospitalist group was participating

in a Value in Inpatient Pediatrics Network (a quality network of
the AAP) national project on Standardization of Fluids in
Inpatient settings. Our aim for this project was to describe and
standardize the use and monitoring of IVFs in inpatient pediatric
settings across the United States. Although this project was

focused on the inpatient setting, it coincided with the ED
initiative to improve the use of isotonic maintenance IVFs in
patients being admitted from the ED to the inpatient setting.
Planning the Intervention
Maintenance Fluids Selection

Maintenance IVFs were classified as either isotonic or hypotonic.
Commonly used maintenance IVFs at our institution included
D5%–0.2% NS, D5%–0.45% NS, D5%–0.9% NS, D5-lactated
Ringer’s solution (LR), each with or without KCl. Isotonic IVFs
included D5%–0.9% NS and D5-LR, whereas hypotonic IVFs
included D5%–0.45% NS and D5%–0.2% NS solutions, each with
or without KCl. NS and LR without dextrose were not considered
maintenance fluids. Maintenance fluids were defined as the
fluids above at a rate of >10 mL/hour.
Target Population
Patients 28 days to 18 years of age at the time of admission from
the ED to the inpatient setting who were receiving maintenance
IVFs were included. Our exclusion criteria included patients who
we determined to require fluid therapy individualized to their
specific needs, which may not always be isotonic fluids
(Supplemental Table 1). Our exclusion criteria were selected on
the basis of International Classification of Diseases, 10th Revision
(ICD-10) diagnostic codes, and they were consistent with the
exclusion criteria in the AAP CPG (Supplemental Table 2).
Members of our pediatric emergency medicine clinical quality

council (consisting of pediatric emergency medicine attending
physicians and ED nurses at our institution) started meeting in
mid to late 2018 to identify key drivers that would potentially
improve isotonic maintenance IVF use (Fig 1). The key drivers
included increasing awareness of the evidence around
superiority of isotonic IVFs, improving ordering of isotonic IVF by

making hypotonic IVFs more difficult to order, and encouraging
provider engagement and awareness of individual practice
patterns. Implementation of component changes began in
January 2019.
FIGURE 1
Key driver diagram revealing primary drivers and interventions

for the project SMART aim. SMART, specific, measurable,
achievable, realistic/relevant, timely.
Key Interventions
Institutional Discussions Between Nephrology, the ED,

and Hospital Medicine on Use of Isotonic Maintenance
IVFs Based on a Literature Review
Although discussions had been initiated by nephrology leaders,
consensus from ED and hospital medicine physicians was
achieved after a thorough review of the literature. We
emphasized not only the benefits of isotonic fluids but also their
safety with both these groups of physicians. This acceptance of
isotonic fluids by the hospital medicine service was obtained
before project initiation. The timing of the release of the AAP
CPG only a few months later helped boost these discussions.
Education of Providers on Isotonic Maintenance IVFs in

Accordance With the AAP CPG
Specifically, education of providers included a presentation of
the literature review during ED provider meetings with
opportunities for dialogue and questions. In addition, the AAP
CPG was distributed to all ED providers via e-mail.
Electronic Medical Record Changes to Encourage Use of

Isotonic Maintenance IVFs
We identified that making isotonic fluids more visible and easier
to order in our electronic medical record (EMR) could potentially
increase their rate of use. Therefore, we added isotonic IVFs into
a quick order set in our EMR, making them easily visible to the
ED physicians to encourage its use. We also moved all hypotonic
fluids to a separate order set in our EMR, thus making them less
easily accessible, and added a best practice advisory pop-up
(which is a highlighted reminder in our EMR) to inform
physicians about the risk of hyponatremia with hypotonic IVF
use (Figs 2 and 3). We anticipated that although our education
campaign would result in improvement in the use of isotonic
maintenance IVFs, an EMR change would yield a high level of
reliability.
FIGURE 2
A, Screenshot of quick order set in the Epic EMR. B, Screenshot

of quick fluids order set in the Epic EMR.
FIGURE 3
Screenshot of hypotonic fluid panel in the Epic EMR.
Group Practice Review and Individual Feedback to Outlier

Providers on Their Isotonic IVF Use
Group practice review occurred monthly at division meetings
and via e-mail. Individual feedback was provided via e-mail to
outlier providers every 3 months to improve compliance. Review
and feedback were performed by designated attending
members of the clinical quality council in charge of the QI

initiative. Data for the feedback was procured by using a
physician-level report from the EMR. After individual
performance data were distributed, members of the clinical
quality council were available to discuss any concerns. We
defined outlier providers as ED physicians who had a rate of
isotonic maintenance IVF use of <50%. As the rate of isotonic
maintenance IVF use increased gradually, ED physicians who had
a rate of isotonic IVF use of <75% were also given individual
feedback via e-mail to encourage continued compliance.
Study of the Intervention

Data were obtained from the EMR for all eligible patients who
were admitted to the inpatient unit on maintenance IVFs
between January 2018 and December 2019. January 2018 to
November 2018 (before the AAP CPG release) was considered
the baseline period. For our data reports, we use Clarity, a
structured query language server database within our institution
enterprise data warehouse connected to our EMR system (Epic;
Epic Systems Corporation, Madison, WI) that allows for querying
via Microsoft’s Structured Query Language Server Management
Studio software. Data reports included admission diagnosis, type
of maintenance IVFs (isotonic versus hypotonic), and results of
electrolyte studies (specifically a comprehensive or basic
metabolic panel, if performed) within 24 hours of admission.
Measures
The main outcome measure was the rate of use of isotonic
maintenance IVFs, defined as the number of eligible patients
who received isotonic maintenance IVFs out of the total number
of eligible patients who received any maintenance IVFs.
Balancing measures included (1) change in frequency of serum

electrolyte levels checked within 24 hours of admission from the
ED and (2) monitoring for occurrence of hypernatremia (defined
as a serum sodium level >145 mEq/L) with the use of isotonic

maintenance IVFs (compared with hypotonic maintenance IVFs)
after the initiation of the QI intervention in January 2019.
Analysis
Shewhart p-charts23 were used to continuously evaluate the
main outcome measure (use of isotonic fluids), plotted on the
vertical axis against time on the horizontal axis. Each data point
represents 1 month of data. Three σ limits were used to set the
upper and lower control limits, and standard rules were used to
determine special cause variation, including 8 or more values
above the baseline centerline. Balancing measures are described
as frequencies and percentages and are compared by using the
χ2 test. The level of statistical significance was set at P < .05.
Ethical Consideration
Our institutional review board determined the project to be
non–human subjects’ research; thus, it was exempt from
institutional review board review.
Results
A total of 10 040 patients, with an average of 418 ± 65 patients
per month, met inclusion criteria and had maintenance IVFs
ordered between January 2018 and December 2019.
Isotonic maintenance IVF use increased rapidly after the

initiation of our interventions. Special cause variation was
observed twice after implementation of changes, with the 80%
goal being met and sustained for 8 months (Fig 4).
https://publications.aap.org/pediatrics/article/148/1/e2020022947/179977/Improving-Isotonic-Maintenance-Intravenous-Fluid?autologincheck=redire… 10/20
FIGURE 4
A p-chart showing the proportion of isotonic maintenance IVF

use (January 2018 to April 2020), with key interventions
annotated. LCL, lower control limits; UCL, upper control limits;
1s, 1 standard deviation; 2s, 2 standard deviation.
Of 4858 admitted patients, 647 (13.3%) had serum electrolyte

levels checked within 24 hours of admission from the ED before
the initiation of our interventions, compared with 655 of 5182
(12.6%) admitted patients after implementation of changes (P >
.05).
Occurrence of hypernatremia was 7.4% (31 of 418) in patients

who received maintenance isotonic fluids, not significantly
different when compared with those who received maintenance
hypotonic fluids 6.7% (16 of 237) (P > .05). The median
(interquartile range) sodium value in patients who received
isotonic maintenance fluids was 147 (146–170) mEq/L.
Occurrence of hyponatremia in patients receiving hypotonic

maintenance IVFs before the QI intervention was 22 of 464
(4.7%) compared with 8 of 237 (3.3%) after the QI intervention (P
> .05).
Discussion
Our improvement initiative increased the use of isotonic
maintenance IVFs in ED patients (aged 28 days to 18 years) being
admitted to the inpatient setting from a baseline of 20% to 80%,
which was subsequently sustained for 8 months. Our findings
are similar to those in a study done by Rooholamini et al,24 who
were able to show sustained improvements in the use of isotonic
maintenance IVFs after the creation of an evidence-based clinical
pathway to standardize IVF use. Also, because our project was in
the ED, we had the additional advantage of not having to change
fluids after the patient was admitted, thus avoiding waste.
The support of nephrologists in our institution and agreement

from hospital medicine (the service that receives the largest
number of admissions from the ED) helped to make this project
feasible and the practice change more palatable for ED
physicians. This was an important proactive step because the
choice of maintenance IVFs impacts inpatient services more than
the ED. Furthermore, our hospital medicine service was already
planning to participate in the Value in Inpatient Pediatrics
Network Standardization of Fluids in Inpatient settings project
and was primed for the change to isotonic fluids for
maintenance needs; this worked in our favor.
The timing of the publication of the AAP guideline helped

provide the impetus needed to change physician practice toward
using isotonic maintenance IVFs. We leveraged the AAP
recommendations to launch an educational campaign
(presentation of the AAP guidelines during monthly division
meetings as well as e-mail communications to all physician
providers) on the robust literature that supported the use of
isotonic maintenance IVFs.
A key intervention that helped the success of this initiative was

an EMR change that made it easier for providers to order
isotonic fluids rather than hypotonic fluids, thus encouraging the

use of isotonic maintenance IVFs. This EMR change was
discussed during quality committee meetings and was
supported by ED leadership, which allowed for it to be quickly
operationalized in all of the EDs. Studies reveal that EMR-based
clinical decision support at the point of care can be an effective
tool for changing professional behavior and increasing
adherence to evidence-based recommendations.25,26 Although
we anticipated some improvement with our education
campaign, we believe that our EMR change was useful in
achieving a higher level of reliability. We also believe that this
EMR change helped ED physicians sustain their use of isotonic
fluids and thus implement the AAP recommendations after
active interventions were discontinued.
Quarterly feedback to individual physicians on their isotonic

maintenance IVF use and comparison to group practice also
helped to improve compliance, especially with outlier
physicians.27,28 It is also possible that ED physicians readily
adopted isotonic maintenance fluids because there was minimal
perceived risk to their use in this population of patients who was
getting admitted and could be monitored for any complications
during the admission.
Despite evidence suggesting a low risk of hypernatremia

associated with isotonic fluid administration, some concerns
remain that, in children, its use could lead to complications such
as hypernatremia, fluid overload with edema and hypertension,
and hyperchloremic acidosis.29–31 Therefore, one of our
balancing measures included monitoring for increased
occurrence of hypernatremia with isotonic maintenance IVF use.
We also wanted to monitor if physicians were checking
electrolyte levels more often to look for hypernatremia. In our
institution, there are no protocols in place regarding the
frequency of electrolyte checks, and electrolyte checks are
usually based solely on physician discretion. We noted that there

was no change in serum electrolyte checks within 24 hours of
admission in patients, and there was no increase in the
occurrence of hypernatremia among patients who received
isotonic maintenance IVFs when compared with those who
received hypotonic fluids. This is consistent with studies
published in the literature.32 Friedman et al33 concluded that
isotonic fluid administration is safe in the general pediatric
patient population, and there was no increase in the occurrence
of hypernatremia with isotonic fluids.
Limitations
Although the AAP CPG did not make any recommendations
regarding the safety of LRs, in our initiative, we included LRs as
isotonic maintenance IVFs because they have a fluid and
electrolyte composition similar to that of human plasma.
However, LRs were used extremely infrequently in our institution
(<1% both before and after the QI intervention). Additionally, this
is a single-center study. We had the ability to change our EMR
and apply decision support (best practice advisory), and we had
the benefit of a quality infrastructure in our facility in the form of
a quality council committee. However, we believe that our
implementation strategies can be successfully replicated at
other institutions.
Conclusions
Our initiative resulted in sustained improvement in the use of
isotonic IVFs as maintenance IVFs in patients admitted from the
ED to the inpatient setting. There was no change in the
frequency of electrolyte checks or the occurrence of
hypernatremia after implementation of changes. Rapid
implementation of AAP recommendations may have been
successful, in part, because of institutional readiness for change
at the time the AAP guidelines were released. Additionally,
hardwiring the preferred fluids via EMR changes was a key

intervention to success.
Dr Akinsola conceptualized and designed the study,

contributed to educational content and dispersion of
education to physicians, provided group and individual
practice feedback to physicians, coordinated, collected, and
supervised data collection, drafted the initial manuscript,
and reviewed and revised the manuscript; Dr Cheng
contributed to the education and dispersion of education to
the physician group, gave group practice review and
individual feedback to providers on their isotonic
maintenance intravenous fluids, and reviewed the
manuscript; Dr Iyer assisted with the data analysis and
critically reviewed the manuscript for important intellectual
content; Dr Jain conceptualized and designed the study,
contributed to educational content for physicians,
coordinated, collected, and supervised data collection,
critically reviewed the manuscript for important intellectual
content, and revised the manuscript; and all authors
approved the final manuscript as submitted and agree to be
accountable for all aspects of the work.
FUNDING: No external funding.
AAP American Academy of Pediatrics
CPG clinical practice guideline
D Dextrose
ED emergency department
EMR electronic medical record
ICD-10 International Classification of Diseases, 10th

Revision
IVF intravenous fluid

KCl potassium chloride
LR Lactated Ringer’s solution
NS normal saline
QI quality improvement
Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have
indicated they have no potential conflicts of interest to
disclose.
FINANCIAL DISCLOSURE: The authors have indicated they
have no financial relationships relevant to this article to
disclose.
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Copyright © 2021 by the American Academy of Pediatrics
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5/21/23, 5:06 PM Improving Isotonic Maintenance Intravenous Fluid Use in the Emergency Department | Pediatrics | American Academy of Pediatrics

QUALITY REPORTS | JULY 01 2021

Improving Isotonic Maintenance

Address correspondence to Bolanle Akinsola, MD, Department of Pediatric Emergency

FINANCIAL DISCLOSURE: The authors have indicated they have no financial

Pediatrics (2021) 148 (1): e2020022947.

Subjects: Emergency Medicine, Quality Improvement

Topics: body fluid, electronic medical records, emergency

Maintenance intravenous fluids (IVFs) are commonly used in

hypotonic IVFs as the recommendation for maintenance IVF

There have been concerns raised about a high incidence of

The American Academy of Pediatrics (AAP) released a clinical

Our SMART (specific, measurable, achievable, realistic/relevant,

admitted to the inpatient unit with maintenance IVFs from a

Even before the AAP guideline recommending use of isotonic

Additionally, our institution’s hospitalist group was participating

settings across the United States. Although this project was

Planning the Intervention

Maintenance Fluids Selection

Members of our pediatric emergency medicine clinical quality

superiority of isotonic IVFs, improving ordering of isotonic IVF by

Key driver diagram revealing primary drivers and interventions

Institutional Discussions Between Nephrology, the ED,

Education of Providers on Isotonic Maintenance IVFs in

Electronic Medical Record Changes to Encourage Use of

A, Screenshot of quick order set in the Epic EMR. B, Screenshot

Screenshot of hypotonic fluid panel in the Epic EMR.

Group Practice Review and Individual Feedback to Outlier

members of the clinical quality council in charge of the QI

Study of the Intervention

Balancing measures included (1) change in frequency of serum

as a serum sodium level >145 mEq/L) with the use of isotonic

Isotonic maintenance IVF use increased rapidly after the

A p-chart showing the proportion of isotonic maintenance IVF

Of 4858 admitted patients, 647 (13.3%) had serum electrolyte

Occurrence of hypernatremia was 7.4% (31 of 418) in patients

Occurrence of hyponatremia in patients receiving hypotonic

The support of nephrologists in our institution and agreement

The timing of the publication of the AAP guideline helped

A key intervention that helped the success of this initiative was

isotonic fluids rather than hypotonic fluids, thus encouraging the

Quarterly feedback to individual physicians on their isotonic

Despite evidence suggesting a low risk of hypernatremia

usually based solely on physician discretion. We noted that there

hardwiring the preferred fluids via EMR changes was a key

Dr Akinsola conceptualized and designed the study,

FUNDING: No external funding.

AAP American Academy of Pediatrics

CPG clinical practice guideline

EMR electronic medical record

ICD-10 International Classification of Diseases, 10th

IVF intravenous fluid

KCl potassium chloride

LR Lactated Ringer’s solution

6 Greenbaum LA. Pathophysiology of body fluids and fluid

14 Foster BA, Tom D, Hill V. Hypotonic versus isotonic fluids

22 Friedman JN; Canadian Paediatric Society, Acute Care

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