Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

Data Element
Total Output
Description
The total volume that the patient put out during a calendar day, from all sources, including urine, stool, and drains like chest tubes, surgical drains, intrathecal catheters, external ventricular drains, peritoneal catheters.
Submitted By: Ali Abbas MD / UCSF
Data Element Information
Use Case Description(s)
Use Case Description This data element could be used in several ways, both for clinical care and research. In clinical care, this information is extremely important during transitions of care (e.g. transfer), because clinicians need to understand the current fluid status of the patient, and past intake/output is one of the most important data points to inform this. It is difficult to care for a patient with uncertain volume status if this information is missing.

This data element is particularly important in critical illness, and should therefore be an essential part of the pandemic preparedness toolkit. Pulmonary edema is one of the earliest manifestations of volume overload, which limits oxygenation. Therefore, in the care of the critically ill patient with hypoxia, careful management of hypoxia is extremely important. Additionally, inadequate management of volume status can lead to renal failure, which is a serious complication of critical illness and associated with poor outcomes.

For these reasons, this data element is needed no just in clinical care, but also in critical care trials, especially those in sepsis, where there is long-standing and unresolved controversy about the optimal approach to VI fluid administration, and in Acute Respiratory Distress Syndrome (ARDS), including ARDs caused by COVID-19 due to fluid sensitivity of the lungs. Inclusion of this data element would improve our ability to implement clinical trials in critical illness. [1]

[1] https://www.nature.com/articles/s41746-022-00580-2#MOESM1
Estimate the breadth of applicability of the use case(s) for this data element This data element is one of the most commonly reported data elements in daily care of patients. It is reviewed daily on rounds for the vast majority of hospitalized patients, because fluid balance can affect several organ systems including the cardiovascular, pulmonary, and renal systems. It is also one of the most common data points that are reviewed in order to plan interventions including IV fluid boluses, diuretics, or placement of drains.
ONC Priority
  • Address public health interoperability needs of reporting, investigation, and emergency response
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC 9097-7 Fluid balance 24hrs
SNOMED CT 251856003 Fluid balance
https://loinc.org/9097-7/
Additional Specifications N/A
Current Use (Level 2) Captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer
Extent of exchange N/A
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) The main concerns with this data element is that this data is collected at the point of care and often messy. For example, urine output is frequently not assessed by volume, but by the number of voids, so output may be recorded as 500ml + 5x void. Additionally, output is often estimated, rather than measured precisely. There is no uniform way of describing what counts. Additionally, there is no uniform definition of what counts as intake and output, e.g. dialysate fluid is often recored both in the intake and output column.
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns None beyond usual health data elements.
Estimate of Overall Burden Given this element is already represented in the vast majority of EHRs used for inpatient care, there should be minimal burden to implementing. The main burden will be on EHR vendors to operationalize the definition in the EHR given the challenges above.
ASTP Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 0 - Use cases apply to a limited number of care settings or specialties, or data element represents a specialization of other, more general data elements.
Evaluation Comment This data element represents a specific type of clinical observation or finding.

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