Calls to improve hydration practice

Data presented by the British Association for Parenteral and Enteral Nutrition (BAPEN) and the Parenteral and Enteral Nutrition Group of the British Dietetic Association (PENG) has indentified a serious shortfall in policies to ensure the provision of adequate fluids for vulnerable patients. The data, taken from an online survey of 429 healthcare professionals, demonstrated an alarmingly low availability of hydration guidelines. Only 31% of the respondents’ Trusts had general hydration guidelines, while for patients on enteral tube feeding, only 20% reported having specific hydration guidelines. According to ‘Malnutrition Matters Meeting Quality Standards in Nutritional Care’, a BAPEN commissioning toolkit1, the benefits of improving nutritional care and providing adequate and appropriate hydration are huge, especially for patients with long-term conditions and problems such as stroke, pressure ulcers or falls. Evidence shows that if nutritional needs are ignored health outcomes are worse and meta-analyses of trials suggest that provision of nutritional supplements to malnourished patients reduces complications such as infections and wound breakdown by 70% and mortality by 40%.2 “The provision of adequate fluid and nutrition is considered a core fundamental element of patient care, yet the results of our online survey demonstrate that improvements in hydration policies are required,” said Ailsa Brotherton, honorary secretary to BAPEN. “Our data suggests a need for cross-disciplinary education and empowerment to encourage consideration of the enteral route as part of normal hydration practice where there is an over reliance on IV fluids. “The NHS costs of poor management of nutrition and fluids are significant. The malnourished cost approximately £2,000 per patient per year and BAPEN estimates that total malnutrition associated costs amounts to over £13 bn annually,” she said. The findings of the online survey suggest a lack of confidence, or a reluctance to share knowledge around the daily amount of fluid that should be given to patients receiving enteral tube feeding, as only 32% of respondents actually answered this question. Interestingly, of those who answered, the majority stated the amount of fluid to be 30-35 mL/kg per day, as outlined by the PENG guide to clinical nutrition. Ailsa Brotherton explained more about the survey: “Initially, we undertook the survey due to concerns about patient hydration. Nutrition has been given a higher profile recently, although it is still an issue of concern. However, hydration has not been given the focus it deserves. We believe that the issues of hydration and nutrition, need to be looked at together. “Patients who become dehydrated are more likely to become confused, their blood pressure usually drops, they have a low urine output and are at a higher risk of falling. Over hydration can also pose problems, so patient hydration does need to be properly managed,” she said. Healthcare professionals should be aware of the dangers of dehydration, however the findings of the BAPEN/PENG survey indicate that the provision of adequate fluid does not always translate into routine clinical practice. The Francis Report, for example, highlighted multiple examples of patients who had very poor nutritional care and had suffered from dehydration. It said that: ‘At Stafford some patients were left food and drink and offered inadequate or no assistance in consuming it. Even water or the means to drink it could be hard to come by.’ Dehydration also has an enormous impact on avoidable harms. For example, pressure ulcers, falls and urinary tract infections in patients with catheters, and mortality. Therefore attention to improving the provision of fluid by the most acceptable method and looking for signs of dehydration are urgently required. BAPEN has introduced its virtual Quality Improvement (QI) programme, which addresses the challenges facing nutrition and hydration teams in hospitals and care settings today. The QI programme provides a forum to bring together members of nutrition and hydration teams to share successes and best practice with the aim of improving levels of nutrition and hydration care in the UK. “Nutrition and hydration teams face huge issues and challenges and the key will be to find workable strategies to make real change happen,” said Dr Tim Bowling, BAPEN chair and consultant in Gastroenterology and Clinical Nutrition. “We believe that this QI programme will provide teams with a valuable way of working together that will be hugely beneficial to all those involved in nutrition and hydration.” Ailsa Brotherton went on to highlight some good practices that are occurring around the country. “BAPEN has introduced some e-learning nutritional modules, developed to promote awareness and educate frontline staff,” she said. “We have also linked with NHS Midlands and East, where Lyn McIntyre and her team, have been doing some great work around the issues of hydration. “The work that has been done at Midlands and East is exemplary – they have created a great toolkit that encourages active management, recording fluid intake and output, it is a really practical and useful resource. It integrates hydration and nutrition and they are working right across the health economy – they have introduced a nutrition steering group which is working with hospitals and community teams across the region.”

Active management toolkit

Lyn McIntyre, deputy director – patient experience, National Commissioning Board (Midlands and East region), explained more about the toolkit being used at NHS Midlands and East, and why it was introduced. She said: “Effective and consistent fluid management has been recognised by National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2009) as an area of suboptimal practice and has also been highlighted as an area of clinical practice that clinicians in the east of England wanted to improve. Managing fluid balance was reported as an area of considerable weakness following a regional audit undertaken in 2010 and therefore a regional risk to patient safety. In 2011 a Steering Group developed the ‘Intelligent Fluid Management’ process which clearly demonstrated the flows between the key areas for successful fluid management underpinned by education and communication at every stage (Fig. 1). Nine core principles for successful fluid management were also developed as highlighted in Figure 2. “The aim was to provide a consistent approach, be user friendly and readily accessible to practitioners at all levels,” continued Lyn McIntyre. “Many clinicians and experts reviewed the bundle during its development phases and improvements were made following each stage of the feedback.” Once the format was agreed the bundle was circulated to all organisations across the region for dissemination and implementation as part of the QIPP Safe Care programme. The bundle was further developed into a national e-learning package as part of the national ‘harm-free care’ resource library (http://www.e-lfh.org.uk/projects/ harm-free-care/). “It was also adopted across the Midlands and East Strategic Health Authority (SHA) in 2011 as part of a wider ambition to eliminate avoidable grade 2, 3 and 4 pressure ulcers,” she said. As well as dehydration, poor nutritional status is associated with a high risk of pressure ulcers and therefore a key priority for any strategy to eliminate them. “The aim was to use the elimination of pressure ulcers as an outcome measure for nursing care. Pressure ulcers are more likely to occur in patients who are malnourished, dehydrated, elderly and obese and it is therefore important that all fundamental aspects of high quality nursing care are in place,” said Lyn McIntyre. “BAPEN suggests that by providing better quality care, even a 10% saving of the annual health care costs for malnutrition could save £130,000 million. “To support the SHA Pressure Ulcer Ambition, ten work streams were set up. This included a cluster wide Nutrition and Hydration Steering Group, led by me and supported by Andrea Cartwright, nutrition nurse consultant from a local Foundation Trust, with the aim of identifying the key areas for improvement by April 2013,” she said. The areas identified were: