Clinician attitudes and concordance with self-assessed and actual intravenous fluid prescribing patterns: A single-institution evaluation of survey and electronic prescribing data

Recent studies suggest that balanced fluids improve inpatient outcomes compared to normal saline. The objective of this study was to obtain insights into clinicians’ knowledge, attitudes and perceived prescribing practices concerning IV isotonic fluids and to analyze perceived prescribing in the context of actual prescribing. This study, conducted at a single center (Medical University of South Carolina), included 1) a cross-sectional survey of physicians and advanced practice providers (APPs) (7/2019-8/2019) and 2) review electronic health record (EHR) claims data (2/2018-1/2019) to quantify the prescribing patterns of isotonic fluids. Clinicians perceived ordering equivalent amounts of normal saline and balanced fluids although normal saline ordering predominated (59.7%). There was significant variation in perceived and actual ordering across specialties, with internal medicine/subspecialty and emergency medicine clinicians reporting preferential use of normal saline and surgical/subspecialty and anesthesia clinicians reporting preferential use of balanced fluids (p < 0.0001). Clinicians who self-reported providing care in an intensive care unit (ICU) reported more frequent use of balanced fluids than non-ICU clinicians (p = 0.03). Actual prescribing data mirrored these differences. Clinicians’ self-reported use of continuous infusions (p = 0.0006) and beliefs regarding the volume of fluid required to cause harm (p = 0.003) were also associated with self-reported differences in fluid prescribing. Clinician experience, most clinical considerations (e.g., indications, contraindications, barriers to using a specific fluid), and fluid cost were not associated with differential prescribing. Persistent normal saline utilization is associated with certain specialties, care locations, and the rate and volume of fluid administered, but not with other clinical considerations or cost. These findings can guide interventions to improve evidence-based fluid prescribing.