‘Water water everywhere and not a drop to drink’ – I sometimes wonder if that’s how some patients and service users feel.
Over the last five or six years I have become increasingly aware that dehydration is a common problem in many of our healthcare settings – hospitals and care homes – and yet the fact that patients and residents are becoming, or are already dehydrated, often appears of little concern to many health and care professionals.
This strikes me as really very strange when the risks associated with dehydration are known and well-documented. Although, since the publication of the NCEPOD report ‘Adding insult to injury’ which highlighted that hydration is an important consideration in keeping kidneys healthy and the prevention of AKI , there has been an increasing interest in this aspect of clinical care.
We have a couple of key challenges to tackle if we want to have an impact and prevent dehydration. Firstly, we need to have standardisation or agreement on the definition of dehydration and secondly, whilst it is possible to identify dehydration using biochemistry, with serum osmolality of >300mOsm/kg as current dehydration being the gold standard, we do not currently have a simple, practical and cost effective method of identifying dehydration across the range of healthcare settings. It is both inappropriate and costly to undertake biochemistry routinely in large numbers of care home residents.
However, we also have other challenges and myths to tackle. Here are just a couple.
The first myth relates to the assumption that it’s easy to get people to drink – I can assure you that it is not and this is especially true for some of the most vulnerable people in our care. Older people are often fearful of drinking as they believe they will need to use the toilet more or even worse become incontinent. People requiring thickened drinks due to swallowing problems are often reluctant to take these drinks; some reports suggest that 75% of people with swallowing problems are dehydrated.
The second myth relates to what we should be drinking. There are many that suggest it just has to be water – this is not true. All fluids contribute to our daily intake and we need to be able to offer choice and variety to encourage people to drink. We also need to be creative – I recently heard about one care home that started to provide wonderful jellies to their residents in an attempt to increase their fluid intake. We must remember that approximately 20% of our fluid comes from the food we eat.
I often hear that we need to provide education and training to health and care staff around the importance of hydration and I do agree, but we must ensure that this is targeted (and accessible) to where we will do most good. Having recently learnt about two unpublished studies reporting that between 45% and 63% of patients are dehydrated on admission to hospital, I believe this would be achieved by working better and more closely with our local care home providers.
Caroline Lecko
Caroline has led on nutrition and patient safety since joining the National Patient Safety Agency (NPSA) in 2006 and has subsequently transferred to the patient safety domain team within the NHS England. She has worked on a range of national and international projects to raise awareness of the importance of good nutritional care to prevent avoidable harm to patients and service users.
Caroline was a lead for the development of the commissioning guidance for Nutrition and Hydration which was published in the autumn of 2015.