Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
This project employed a targeted Plan-Do-Study-Act (PDSA) driven education strategy to build nurses' capability in fluid assessment. Its purpose was to strengthen clinical decision making and prevent avoidable haemodialysis admissions.
Implementation sites: Royal Brisbane and Women's Hospital, Metro North HHS
Dates: October 2024 - June 2025
Aim
The goal of this project was to reduce acute hospital admissions due to fluid overload amongst haemodialysis patients.
Outcomes
- 30% reduction in acute hospital admissions due to fluid overload amongst haemodialysis patients as per admissions data
- increased capability and confidence in nurses performing fluid assessments
- increase in number of fluid assessments being performed and documented
- observed more consistent and concise documentation of fluid assessment
- development of a fluid assessment digital clinical learning resource for nurses
- development of an adult renal specific fluid assessment band in interactive view ieMR
- development and leading a statewide working party to standardise fluid assessment practices amongst renal nurses in Queensland
Background
Within Metro North Kidney Health a growing trend in acute hospital admissions related to fluid overload among haemodialysis patients was identified. Admission data revealed a consistent upward pattern, with noticeable spikes during holiday periods, signalling gaps in early detection and management of fluid imbalance. This prompted us to explore the root causes and consider whether workforce capability, system processes, or documentation issues were contributing to avoidable deterioration.
Initial investigation revealed two major contributing factors.
First, medical staffing shortages reduced access to timely clinical review, increasing reliance on nursing staff to recognise early signs of fluid overload.
Second, a staff survey showed low confidence and inconsistent capability among nurses in performing comprehensive fluid assessments, interpreting clinical cues, and documenting findings accurately.
Nurses reported uncertainty about how to structure assessments, limited hands-on training opportunities, and challenges using the electronic medical record (ieMR) for fluid-related documentation. A literature search confirmed that these barriers were common in dialysis settings, where nurse-led fluid assessment is recognised as essential but often underdeveloped. These findings shaped the central problem statement: How can we strengthen nursing confidence, competence, and documentation practices in fluid assessment to reduce preventable fluid-overload admissions?
Methods
To address this, the education team working collaboratively with Nurse Unit Managers (NUMs) adopted the Plan'Do'Study'Act (PDSA) framework as a structured and iterative improvement model. In the Plan phase, we analysed admission data, synthesised evidence from the literature, and reviewed staff feedback. This triangulated evidence confirmed increasing admissions linked to fluid overload and highlighted clear knowledge and skill gaps in the workforce.
In the Do phase, the nurse education team implemented a targeted and multifaceted educational strategy. This included fluid-assessment focus months, laminated prompts in the clinical spaces, local and service wide education via power point presentations, chair-side hands-on training and, mentoring by the Clinical Nurse Clinical Facilitator, and structured guidance on completing fluid-related documentation in ieMR. The goal was to build staff capability, embed consistent fluid-assessment practices, and strengthen clinical communication across the haemodialysis service.
The Study phase involves assessing the impact of these interventions through post-implementation data collection, including staff confidence measures and hospital admission rates. Early findings demonstrated a positive clinical impact, with a 30% reduction in fluid-overload hospital admissions, indicating meaningful improvement in early recognition and management. Staff feedback also suggested growing confidence, though documentation in ieMR remains a significant barrier due to its complexity and time demands.
During the Act stage, the team has initiated further system improvements based on emerging insights. An application has been submitted for development of a dedicated adult renal fluid-assessment tab in ieMR to improve usability and streamline documentation. Concurrently, a self-paced digital Clinical Learning Resource is being developed to provide ongoing support, reinforce learning, and ensure sustainability of practice improvements.
Overall, the PDSA cycle has provided a robust structure for both understanding the problem and implementing a responsive, data-driven educational strategy. The early reduction in admissions demonstrates the impact of nursing capability on patient outcomes, and ongoing refinement will continue to strengthen safe, proactive haemodialysis care.
Discussion
The success of this project relied heavily on a supportive clinical environment, strong leadership engagement, and a culture open to quality improvement. Haemodialysis units are busy, high-acuity settings, and creating space for staff to learn, practise and embed new skills required significant coordination and flexibility. The presence of educators familiar with renal workflows, along with nurses' willingness to participate in hands-on teaching, created a foundation that enabled early adoption of the fluid-assessment education strategy. Collaboration across the MN kidney service also ensured consistency in messaging and alignment of practice standards.
However, several challenges emerged that shaped the lessons learned. Securing protected time for education in fast-paced dialysis units proved difficult, as competing clinical demands often limited staff availability for teaching sessions. Additionally, navigating the tape associated with requesting changes to electronic systems, such as ieMR enhancements, slowed progress. Because renal services are not fully digital, the application for a dedicated fluid-assessment tab had to be submitted through The Prince Charles Hospital-based digital governance pathways, adding layers of administrative delay. Developing a digital learning package posed similar obstacles; the project received no specific funding, and e-learning development was not considered a high organisational priority. Educators also lacked direct access to e-learning authoring platforms, requiring laborious approvals and multiple gatekeepers, which limited agility and innovation.
Despite these constraints, the project demonstrated several strengths. The PDSA framework enabled a disciplined, iterative approach that helped the team respond quickly to emerging issues. Nursing engagement was strong, with staff expressing a desire to improve their fluid-assessment skills and clinical confidence. The early 30% reduction in fluid-overload admissions highlighted the value of targeted education and reinforced the impact of well-supported nurses on patient outcomes. The project also strengthened collegial relationships between educators, CNCs, and frontline nurses, improving shared understanding of fluid management priorities.
Opportunities identified through this work extend beyond the local service. There is a clear need for streamlined access for nurse educators to develop digital learning resources without excessive administrative barriers. Improved digital pathways would support timely creation of high-quality educational materials and promote consistency across services. There is also substantial opportunity for statewide alignment. Through the Queensland Nephrology Nursing Network (QNNN), the team is already leading statewide efforts to standardise fluid-assessment education. Nationally, contributions to the Renal Society of Australasia (RSA) education resource development broaden the project's reach and help ensure parity in nursing capability across Australia.
If undertaken again, earlier stakeholder mapping, clearer digital governance navigation, and building a small project budget for e-learning development would be prioritised. Having an established mechanism for educators to access digital authoring tools would also significantly reduce delays.
Given the universal challenge of fluid overload in haemodialysis, this initiative is well-suited for scale across Queensland Health, particularly in regional and satellite units where timely medical review may be limited. The next steps include ongoing data monitoring, progressing ieMR improvements, finalising the digital Clinical Learning Resource, and expanding statewide
References
Alexiadis, G., et al 2017 ' Comparison of multiple fluid status assessment methods in patients on chronic haemodialysis ' International Urol Nephrol (49) 525-532
Douglas, C., et al (2014) What factors influence nurses assessment practices? Development of the Barriers to Nurses use of Physical Assessment scale ' Journal of Advanced Nursing 70 (11) 2683-2694
Nagalingam, K., Whiting, L., Farrington, K., Migliozzi, J., & Pattison, N. (2024). Clinical assessment of fluid status in adults with acute kidney injury: A scoping review. Journal of Renal Care
Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan'do'study'act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298
Wehrle, Chase,. et al (2021) - Barriers to Accurate Fluid Measurement in Perioperative Patients: A Mixed Methods Approach. Journal of Surgical Research, (260), 95 - 103
Key contact
Nicki Parker
Clinical Nurse Clinical Facilitator
Metro North Kidney Health Services
Metro North Hospital and Health Service