Barriers and opportunities to improve fluid balance recognition and reduction: a qualitative study

Introduction – Excess cumulative fluid balance is a common complication impacting critically ill pediatric patients that is associated with worse clinical outcomes. Nevertheless, there are inconsistent practices in recognizing and reducing excess fluid balance. Purpose – Assess contextual factors that inform fluid-based practices across four pediatric intensive care units. Methods – We conducted semi-structured interviews across 4 PICUs from August to October 2025. Through an iterative process informed by prior survey data, we followed the established implementation science Reach, Effectiveness, Adoption, Implementation, Maintenance/Practical Robust Implementation and Sustainability Model framework to develop an interview guide. Questions explored fluid balance recognition and reduction. Participants were recruited using purposive sampling via email recruitment. We used Rapid Assessment Procedures with two independent coders. Thematic saturation was reached within the first round of interviews. Results – We performed thirty-eight interviews comprised of nurses (n = 19), physicians (n = 12), advanced practice providers (n = 4), and trainees (n = 3). Institutions had balanced numbers of interviews. Theme 1 centered on the limitations of data used for fluid balance recognition, namely that these data are affected by patient variability, rely on subjective exam findings, and depend on inaccurate tools. Theme 2 highlighted insufficient emphasis on limiting unnecessary fluid administration. Theme 3 addressed cultural barriers including educational gaps, lack of standardization, entrenched unit practices, and insufficient communication. Discussion – These themes highlight the need for accurate data reporting, shifts in emphasis of fluid management, and cultural/systemic changes. We theorize that these suboptimal approaches to fluid balance management could inform clinical decision support tools, research priorities, and quality improvement initiatives.