The I-Hydrate project Optimising the hydration of older residents in care homes Why are older adults vulnerable to dehydration?

Changes as the body ages: Potential consequences of dehydration: • Kidneys concentrate urine less effectively • Urinary tract infections (UTI) meaning more fluid is lost • Chest infections • Less muscle = less stored water • Kidney failure • Loss of thirst reflex • Constipation Physical and/or cognitive factors: • Delirium • Difficulty swallowing (dysphagia) • Falls • Dementia • Stroke • Fear of incontinence • Difficulty holding Dehydration in care home residents

It can be difficult to make sure care home residents are adequately hydrated • 12% of older adults admitted to hospital from care homes were dehydrated, compared to 1.3% of older adults admitted from their own homes (Wolff et al., 2015).

Research has shown that a high proportion of care home residents do not drink the recommended minimum daily intake of 1500ml

Often care home residents require additional support to eat and drink, and are dependent on others to provide them with sufficient fluids I-Hydrate – what was the project about?

Aim: To optimise the hydration of older residents in nursing homes

Key objectives: • Increase the number of residents consuming recommended minimum of 1500ml per day • Reduce variation in fluid intake between residents • Reduce morbidity associated with dehydration • Improve experience and quality of life of residents

Improvement science methods: • Collaboration with staff and residents/families to explore the barriers and facilitators to optimal hydration care • Co-design, and trial, new ways of working using Plan-Do-Study-Act (PDSA) cycles - a structured approach for achieving change Understanding hydration practice in two care homes

The following approaches were used to explore current hydration practice:

1. Care delivery patterns: how and when fluid is delivered (6am-9pm) • Patterns of fluid delivery and types of fluid available/served (including fluid rich foods) • Explore potential variation between resident location (own room, dining room/lounge)

2. Fluid consumption by individual residents: fluid served and consumed (6am-9pm) • Followed eight individuals to determine average fluid intake (including fluid rich foods) • Stratified into three resident hydration groups: independent, needs prompting, needs assistance • Excluded residents receiving end of life care or those supported by PEG feed

3. Perspectives of staff, residents and relatives • Conversations with staff about how care is organised to serve drinks and support residents to drink Patterns of care observed

Only 7 opportunities where drinks are served • Refills were rarely offered

Most cups held 150ml • This means if a resident received one drink at each opportunity they would only receive 1050ml a day

Limited choice of drinks (, squash or water) • Preferences assumed – residents not asked what they would like

Hydration low priority for staff

Lack of accurate systems for monitoring intake Timing of fluid delivery

Residents were more likely to receive a drink at mealtimes and the mid-afternoon drinks round

Drinking opportunity Number (%) of residents receiving a drink Early morning (6-8am) 10/39 (26%)

Breakfast (8-10.30am) 33/35 (94%)

Mid-morning (10.30-12pm) 11/50 (22%)

Lunch (12-3pm) 31/38 (82%)

Mid-afternoon (3-5pm) 30/47 (64%)

Dinner (5-7pm) 25/40 (63%)

Evening (7-10pm) 21/45 (47%)

Data from care delivery patterns at Home A & Home B, 6am-9pm Baseline results: Hydration support need & mean fluid intake

Independent Needs prompting Needs assistance

Fluid intake: 1071ml Fluid intake: 1040ml Fluid intake: 946ml Fluid served: 1574ml Fluid served: 1938ml Fluid served: 1175ml = 68% consumed = 54% consumed = 81% consumed

Data from fluid consumption by individual residents at Home A & Home B, 6am-9pm What can we do to improve? Proposed interventions Key components of care Staff training on hydration

Identifying & responding when hydration Mealtime guides for each resident needs are not met Drinks Menu Providing residents with the drinks and fluids to meet their needs, preferences and Evaluate drinks preferences; extend choice abilities Evaluate preferences; extend choice Increased opportunities for fluid consumption included in daily care Protected Drinks Time

Drinks & fluid rich foods with meals Understanding each residents drinking needs, preferences and abilities Documenting fluids & monitoring at risk residents Hydration training for care home staff

Two hour training session • Interactive activities: emotional mapping, case studies, quiz • Practical skills: preparing and tasting fluid thickeners

Training evaluation (161 staff): • Knowledge before = ‘good’, knowledge after = ‘very good/excellent’ • Learning was not necessarily translated into practice • There is a need for care staff to develop reflective practice skills

Developed ‘huddle’ training • 10-15min training with all staff on shift • Role modelling of key skills by senior staff Plan-Do-Study-Act (PDSA) cycles

PDSA cycles were used to trial proposed changes to care, this would begin on a small scale so any issues which arose could be taken into consideration for the next trial. Repeated cycles were carried out until changes to care were ready to become routine practice.

PLAN What exactly are we going to do? How will we measure improvement? DO Carry out the plan and capture data STUDY What were the results? What went well? What did not go well? ACT Are we going to make any changes based on our findings? Do we implement the change or repeat Langley GL, et al. The Improvement Guide the cycle? PDSA: Protected Drinks Time

Aim: To focus Healthcare Assistants (HCA) on hydration during a routine care activity (mid-afternoon drinks round)

Intervention • Staff to offer all residents two drinks • Provide assistance to those who need help to drink • Staff allocated to specific roles • Takes around 45mins Outcomes of Protected Drinks Time

Results Critical to success

• Increased % of residents getting drinks Leadership • Increased number of drinks per resident • Clear allocation of roles & responsibilities • Increased amount of fluid consumed • Ensuring hydration is the priority • Embedding as a routine activity • Positive staff and resident feedback

Equipment “Allocating roles means • Trolley/s needed in time for activity everyone is contributing to • Adequate stock of drinks the drinks round” (HCA) • Clean and appropriate cups/

Skills • Training in assisting & positioning residents to drink PDSA: Drinks before/after meals

Aim (Home A) Aim (Home B) Drinks given to residents brought Drinks offered to residents in to dining room before breakfast lounge/dining room after lunch and dinner

Intervention • Tea/ dispensers set up in dining room (juice and squash available) • Encourage choice by using the Drinks Menu

Results • Fluid consumption increased • Fluid intake was not reduced at the next drinking opportunity • Independent drinkers drank more than those who needed assistance • Mostly benefited residents in lounge/dining room with residents in their rooms or who need full assistance less likely to get a drink Identifying cold drinks preferences

Percentage of positive answers given by residents (n=47) pineapple juice 95 apple juice 83 mango juice 81 strawbery milk 76 cranberry juice 74 • 47 residents tested 28 orange juice 72 chocolate milk 72 different cold drinks almond milk 71 grape juice 67 carrot juice (with fruit) 61 • Residents preferred tomato juice 60 coke 60 fruit juices to squash dandelion and burdock 60 lychee juice 58 tizer 57 • Water was not popular raspberry and cranberry juice 54 milk 52 pineapple and coconut juice 52 lemon barley water 50 • The most frequently lemonade 50 orange squash 50 served cold drinks in lucozade 48 red squash 40 the homes were squash non-alcohlic wine 31 and water sparkling water 25 not available in the home water 24 available, commonly offered non-alcoholic beer 11 available, rarely offered cold filtered water 0 0 10 20 30 40 50 60 70 80 90 100 PDSA: Drinks Menu

Aim: To enable residents to choose their preferred drink and encourage consumption of more than one drink

Intervention • Drinks Menu created with large, bright images • Available in communal areas, on drinks trolley and in resident rooms • Staff used the menu during Protected Drinks Time • Pureed fruit was made available as an alternative to biscuits and cake for resident with swallowing difficulties Outcome of the Drinks Menu

Results

• Increased the types of fluids available to residents • Increased the consumption of fruit juices • Many residents chose to have both a hot and a cold drink at one opportunity • Staff were sometimes surprised by the choices residents made • Combining Protected Drinks Time with the Drinks Menu gave the best results Identifying cup preferences Preferences were tested with 10 residents based on: • Ease of handling, volume, pleasantness to drink, appearance

“It’s not too heavy so Standard teacup Test the residents can hold them easy and drink by “The handle on themselves” (HCA) the teacup burns my fingers” (Resident)

“It’s great! It works, he’s drinking so much more now” (Family member) • Holds 150ml (Home A), 200ml (Home B) • Holds more fluid (250-280ml) • Very small handle, difficult to hold • Large wide handle, easy to hold • Thick china • Lightweight bone china (<250g) PDSA: Introducing new mugs

Intervention “The tea is much more • New mugs trialled with residents at breakfast satisfying” (Resident) • Mug was lightweight with a large wide handle

Results • Increased amount of fluid consumed • Positive staff and resident feedback

Critical to success • Residents provided with more fluid just by changing the type of mug used “They are given bigger • Need to establish a consistent, sustainable volumes and drink supply of suitable mugs more” (HCA) PDSA: Mealtime Guides

Aim: Produce a simple communication tool containing information about each resident’s needs & preferences

Intervention • Colour coded to show level of support needed • HCA helped develop information for the guides • Located in bedrooms, dining room & on drinks trolley

Results “They look good but I know • Positive staff feedback during development stage these things as I know the residents. They may be • Guides not utilised by staff once implemented more useful for new staff or • Responsibility, time and mechanisms needed for updating guides agency” (HCA) • Staff tend to rely on verbal communication Staff and resident/family involvement

Staff • Newsletters – providing updates on successes • Posters – promoting hydration • Training huddles – around key hydration issues and care activities

Residents/family • Providing updates at residents and family meetings • Liaising with family members ‘on the go’ Measurement – how do we know change is an improvement?

In order to find out whether the interventions made a difference to residents various measures were collected at each home:

1. Laxative consumption • Laxatives data shown as average dose per resident per day • Daily data (collected monthly)

2. Monthly observations of fluid delivery and intake (one day between 6am-9pm) • Six residents observed, selected randomly each month • Observations of fluid served and consumed (including fluid rich food) • Provided mean fluid intake for each month Laxative consumption

Both homes demonstrated a significant decrease in laxative use towards the end of the project

1.2

per 1.0 0.8

laxative 0.6 0.4 resident/week 0.2 doses of 0.0 23/11/2015 23/12/2015 23/01/2016 23/02/2016 23/03/2016 23/04/2016 23/05/2016 23/06/2016 23/07/2016 23/08/2016 23/09/2016 23/10/2016 23/11/2016 23/12/2016 23/01/2017 23/02/2017 Home A weekly doses/resident mean lower natural process limit upper natural process limit

1.2 1.0 0.8 0.6 0.4 0.2 resident/week 0.0 06/12/2015 06/01/2016 06/02/2016 06/03/2016 06/04/2016 06/05/2016 06/06/2016 06/07/2016 06/08/2016 06/09/2016 06/10/2016 06/11/2016 06/12/2016 06/01/2017 06/02/2017 06/03/2017 averagelaxative dose per Home B average doses/resident/week mean line (from baseline) lower natural process limit upper natural process limit Impact on mean fluid intake at Home B This graph shows that after some time for embedding of interventions, particularly PDT, the final three months of the project saw mean fluid intake rise to over 1500ml

1800

1600

1400

1200 Drinks menu + allocating HCA to After meal drink 1000 Staff training assist in lounge trial Mealtime Guides introduced 800 Drinks menu PDT + staff allocation sheet Fluid Fluid intake (ml) 600

400

200

0 05/04/2016 03/05/2016 31/05/2016 28/06/2016 26/07/2016 01/09/2016 04/10/2016 08/11/2016 06/12/2016 10/01/2017 Date of observation mean fluid intake median recommended minimum intake Success criteria for improvement

1. Leadership & Culture • Strong senior management support • Allocation of roles and responsibilities • Mentoring and role modeling of good practice • Embedding hydration care as a routine activity

2. Training & Skills • Competence in assisting & positioning residents to drink •Confident in communicating with residents to support and enable choice (Mental Capacity Act) • ‘Huddle’ training to reinforce learning & practice • Accuracy of recording fluid intakes and taking appropriate action

3. Equipment & Resources • Ensuring adequate stock of drinks, appropriate cups/mugs available • Trolleys equipped and available to distribute drinks Final thoughts

Strategies to optimize the hydration of care home residents can be effective

However… The care home environment is challenging: • Residents may have significant care needs • There is often high staff turnover

Sustainability requires: • Consistent leadership • Changes embedded into routines of care • Ongoing staff training – both in the classroom setting and on-the-job Funding Funded by NIHR North West London Collaboration for Leadership in Applied Health Research & Care (NWL CLAHRC). This presentation presents independent research partially commissioned by the National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme North West London. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

References Wolff A, Stuckler D, McKee M. Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality. J R Soc Med 2015;0(0):1-7. Langley GL, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed. San Francisco: Jossey-Bass, 2009.

Contact Please see https://www.uwl.ac.uk/i-hydrate for more information and resources If you have any comments or questions please contact Professor Jennie Wilson: [email protected]