Appendix A Detail on criteria for audit of the use of pre-hospital initiation of fluid replacement therapy in trauma | Pre-hospital initiation of fluid replacement therapy in trauma | Guidance

Possible objectives for an audit

An audit on pre-hospital initiation of fluid replacement therapy in people experiencing trauma could be carried out to ensure the following.

Fluid replacement is used appropriately.
Training programmes for people providing pre-hospital care for people experiencing trauma are consistent with the guidance.

Possible patients to be included in the audit

An audit on the first objective above could be carried out on the prehospital management of adults and older children who have physical injuries as a result of trauma (excluding those with an isolated head injury), over a reasonable time period for audit, for example, 3 months. The audit could exclude individuals who are trapped or, alternatively, individuals who are trapped could be added as an exception to relevant audit criteria. An audit on the second objective above could be carried out on training programmes currently being attended by ambulance staff or by other healthcare professionals who provide pre-hospital care to people experiencing trauma.

Measures that could be used as a basis for audit

The measures that could be used in an audit of the use of pre-hospital initiation of fluid replacement therapy in trauma are given in table 1.

**Table 1 Measures that could be used as a basis for audit of the use of pre-hospital initiation of fluid replacement therapy in trauma**
Criterion	Standard	Exception	Definition of terms
1. Intravenous (IV) fluid is not administered if a radial pulse (or for a penetrating torso injury, a central pulse) can be felt	100% of adults and older children for whom a radial or central pulse can be felt	None	–
2. The woman and the clinician responsible for treatment decide jointly on the choice of treatment for HMB after an informed discussion of a. the woman's desired outcome of the treatment and b. the relative benefits of all the treatment options and the adverse events associated with them and c. the clinical condition, anatomical suitability and preferences of the woman	100% of adults and older children who are given IV fluid in a pre-hospital setting	None	Paramedics and other healthcare professionals trained in advanced life support (ALS) will need to agree locally on when solutions other than crystalloids are to be used (any exceptions to criterion 2b)
3. IV fluid is initiated en route to hospital	100% of adults and older children who are given IV fluid in a pre-hospital setting	If it is not considered appropriate to move the patient	Paramedics and other healthcare professionals trained in ALS will need to agree locally the circumstances in which it is not considered appropriate to move the patient (with documentation for audit purposes)
4. The individual who is given IV fluid is: a. reassessed following administration of each bolus of fluid and b. given boluses only until a radial pulse (or for an individual with a penetrating torso injury, a central pulse) is felt	100% of adults and older children who are given IV fluid in a pre-hospital setting	None	Paramedics and other healthcare professionals trained in ALS will need to agree locally on what constitutes reassessment, and how reassessment is documented, for audit purposes
5. IV fluid is administered only by a healthcare professional who has been appropriately trained in advanced life support and pre-hospital care	100% of adults and older children who are given IV fluid in a pre-hospital setting	None	Ambulance trusts will need to agree locally on what constitutes appropriate training, for audit purposes

The measure that could be used in an audit of the training programmes for people providing pre-hospital care for individuals experiencing trauma is given in table 2.

**Table 2 Measure that could be used in an audit of the training programmes for people providing pre-hospital care for individuals experiencing trauma**
Criterion	Standard	Exception	Definition of terms
1. The training programme for healthcare professionals is consistent with measures 1 to 4 above	100% of training programmes attended by staff employed by an ambulance or hospital trust	None	Trusts will need to agree to include basic training as well as continuous professional development sessions, for audit purposes

Calculation of compliance

Compliance (%) with the measures for audit of pre-hospital initiation of fluid replacement therapy described above is calculated as follows:

Number of adults and older children whose care is consistent with the criterion plus number of adults and older children who meet any exception listed, divided by number of adults and older children for which the measure applies, multiplied by 100.

Compliance (%) with the measure for audit of training programmes described in above is calculated as follows:

Number of training programmes whose content is consistent with the guidance, divided by number of training programmes to which the measure applies, multiplied by 100.

Ambulance and other relevant staff should review the findings of measurement, and use their judgement to review cases in which fluids have been administered. For example, if a radial pulse is barely palpable in an individual with severe tachycardia, pallor, reduced capillary return and clouded consciousness, the team may decide that it would be appropriate to administer a small aliquot of fluid and review carefully. The team should identify if practice can be improved, agree on a plan to achieve any desired improvement and repeat the measurement of actual practice to confirm that the desired improvement is being achieved.

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