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nutrition and
hydration in the
elderly
Caroline Lecko
Frequency
The scale of avoidable harm associated with 200
the provision of nutrition and hydration across 100 81
healthcare is unknown. This is despite work by 15
0
the National Patient Safety Agency and many Acute Community Mental health
other professional associations and lobbying
Type of harm
groups to raise awareness among frontline
healthcare staff, service providers, and policy Figure 2 Care setting in which the dehydration
makers of the affects and costs associated with incident was reported
malnutrition and dehydration.
and hydration. Figure 1 demonstrates themes
Nutrition and hydration related patient safety identified among the remaining 55 cases and
issues continue to be under-reported to the the associated degree of harm following the
National Reporting and Learning System review. The review is not extensive but is
(NRLS), and the plethora of guidance, toolkits, consistent with previous reviews in relation to
and campaigns have not achieved sustainable the types of incidents reported.
and reliable improvements in the delivery and
provision of nutrition and hydration to some of
the most vulnerable people in care. Hydration
A wider review of the NRLS in 2012 (in
Should we be concerned? Lets consider some of press) looked specifically at dehydration and
the facts. overhydration as a patient safety issue. It
A 2011 review (unpublished) of nutrition considered all reported patient safety incidents
and hydration related patient safety incidents from the inception of the NRLS on 1 January
reported to the NRLS provided an opportunity 2004 to 31 March 2012 (note that reporting to
to identify the specific patient safety risks the NRLS began in 2001). Using the keywords
associated with nutrition and hydration. The dehydration and overhydration in the free text,
review considered all incidents reported over a total of 7,856 incidents were identified. Because
a one-year period (1 September 2010 to 31 it was not possible to review all these incidents,
August 2011) using a free text search. From all reported deaths (142), incidents of severe
the 60,397 incidents identified, all reported harm (257), and a sample of 50 each of moderate,
deaths and a sample of 50 incidents from all low, and no harm incidents were reviewed.
other reported degrees of harm were analysed. From the 549 incidents reviewed, 173 were
A total of 330 incidents were reviewed, of excluded because they did not met the search
which 275 were excluded because they were criteria (eg they were not related to dehydration
not relevant to or associated with nutrition or overhydration) and a further eight were
excluded because they were duplicated reports.
Lack of assesment The remaining 368 were identified as relevant
Equipment to the search criteria and were included in the
Nil by Mouth (patient led) review. Although the search terms used included
Out of hours availability
the term overhydration, all the 368 incidents
Nil by Mouth (porlonged period)
reviewed were associated with dehydration.
Pressure ulcer
Medication Due to the complexity of establishing
Failure to assess dehydration as a cause of death, this review
Dehydration focused on identifying common themes in the
Clinical Nutrition No incident reports. The first theme considered
Low
Dysphagia the care setting in which the incident occurred
Moderate
Misplaced NG Tube (Figure 2).
Severe
Choking Death
0 2 4 6 8 10 Each of the reported incidents was then
Figure 1 Themes and degree of harm associated with nutrition and analysed to identify subthemes in the free text
hydration (Figure 3).
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Conclusion
There is increasing evidence that malnutrition
and dehydration contribute to avoidable harm
to people in our care. The people most at risk
are often the most vulnerable: the elderly, those
with long-term conditions, and the acutely
unwell. Too often healthcare professionals
overlook this aspect of care.
Reliable and sustainable improvements in the
provision of nutrition and hydration will help
reduce avoidable harm and will improve patient
outcomes and their experience of our healthcare
services. Some of these improvements require a
service redesign at a local level and others (such
as solutions for naso-gastric tube placement or
redesign of packaging) require innovations and
technologies that need to be driven at a national
level.