212 Chapter 7 remain, particularly regarding nil-by-mouth policies and the composition of commonly used intravenous fluids. These deficits, combined with insufficient documentation of the indications for intravenous fluids, reflect a blind spot among participants about the importance of sufficient knowledge and awareness of the risks associated with intravenous fluid therapy. Although nurses from general hospital wards are not responsible for prescribing intravenous fluids, we found that the majority of nurses will independently start, stop or change intravenous fluid therapy. Eastwood et al. [25] described that nurses from Intensive Care wards actively propose adjustments to intravenous fluid therapy decisions during daily rounds or in non-urgent situations. Most nurses in our study emphasized that it is not common to intervene independently, but that it occurs in acute situations or while awaiting a physician’s assessment of the patient’s situation. The difference might be caused by the fact that in most intensive care units prescribers are available nearby, whereas on general wards it could take some time for a physician to be available at the ward during the evenings, nights and weekends. The introduction of nurse-led protocols in specialized care wards has been shown to reduce unnecessary intravenous fluid therapy [26, 27]. These protocols ensure that the evaluation and adjustments of intravenous therapy do not solely depend on daily rounds with prescribers. Makaryus et al. [28] published a visual general guideline for emergency room patients, focusing on minimizing preoperative nil-by-mouth time and discontinuation of intravenous fluids immediately postoperatively [28]. Such guidelines should be tailored and combined with water and electrolyte balance [4], blood pressure [4, 29], and other relevant factors before being applied in general hospital wards. Despite formal regulations in the Netherlands, there is a perceived shared responsibility for fluid therapy. We found that prescribers expect nurses to independently start, change, or stop intravenous fluids. This shared responsibility suggest a need to revise current regulations, recognizing intravenous fluid therapy as a shared responsibility between prescribers and nurses. This could be the foundation for developing a collaborative protocol to guide both nurses and prescribers to more targeted infusion therapy. Targeted intravenous fluid therapy As with all treatments, intravenous fluid therapy should only be given when indicated. The three essential indications for intravenous fluid therapy are resuscitation, replacement, and maintenance [30, 31]. Van Regenmortel et al. reported that 25% of the doctors did not check the electrolytes in the lab, and that 85% of the doctors did not check the patient’s weight before prescribing intravenous fluid therapy, this negligence carries the risk of
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