Dehydration: stopping a "sentinel event.".

Resident dehydration is one of those conditions that HCFA is really focusing on. Some practical steps for prevention

Dehydration is the most common fluid and electrolyte imbalance in the elderly. This is true for an elderly person whether living in the community or in a healthcare facility. In 1991, Medicare spent $1.2 billion on hospital treatment for the admission diagnosis of dehydration; i.e., according to the 1994 National Hospital Discharge Study, 189,000 such patients were discharged from a hospital stay, totaling 1,853,000 days of care. The average patient stayed an average of 9.8 days at $625 per day (1991 rates) for a total estimated cost of $1,158,125,000.1 The Health Care Financing Administration (HCFA) is concerned about dehydration in the elderly, in terms of both dollars and resident outcomes. This concern is expressed in documentation mandated for resident care for Medicare. In October of 1995, the Minimum Data Set (MDS) expanded the hydration emphasis of the resident assessment tool. Dehydration triggers are found in four sections of the MDS 2.0: Sections I, J, K and O. Hydration indicators are scattered throughout the MDS.

More recently, to be sure that facilities got the message about the importance of dehydration, HCFA "crowned" dehydration as a sentinel event in the recently released Quality Indicators (QIs). QI #15, Prevalence of Dehydration, includes all facility residents "who have been coded with a condition of dehydration, or with a diagnosis of dehydration (Section I3 on the MDS) with an ICD-9 CM code."[2]

To further solidify the message, HCFA made dehydration a priority for the survey process. In the July 1999 surveyor guidelines, dehydration was made a survey priority. If fecal impaction, pressure sores or dehydration is flagged, the resident must be preselected for the survey sample, even if only one resident is involved. If the facility has problems with weight loss, dehydration or pressure sores, the surveyors are instructed to take 50% of their preselected sample from this group.

The Investigative Protocol for Dehydration suggests that the surveyor also select the QIs that reflect on hydration, specifically: #11 - Prevalence of Fecal Impaction; #12 - Prevalence of Urinary Tract Infections; #13 - Prevalence of Weight Loss; #14 - Prevalence of Tube Feeding; #17 - Prevalence of Decline in Activities of Daily Living (ADLs); and #24 - Prevalence of Pressure Sores. The sample is to include residents with abnormal fluid losses associated with such conditions as vomiting, diarrhea, fever or infections.

Residents unable to get fluids on their own are targeted. The sample includes residents with fluid restrictions, dysphagia and a history of refusing fluids. Medications are also considered - especially diuretics, laxatives and cardiovascular agents. In short, before even entering a facility, the surveyors identify residents at risk for dehydration.

Dehydration issues are part of the reimbursement process for the Prospective Payment System (PPS). (An asterisk [*] after items listed below indicates which MDS indicators are triggers for dehydration.)

"Extensive Services" include IV feeding (K5a)(*), which is a trigger for dehydration on the MDS 2.0.

"Special Care" considers tube feeding with aphasia, and tube feeding (KSb)(*) as triggers for dehydration on the MDS 2.0. Also in Special Care is fever (J1h)(*), with any of the following conditions:

* Dehydration Diagnosis (I3)(*), Weight Fluctuations (J1a)(*), Dehydrated (J1c)(*), or insufficient fluid (J1d)(*);

* Pneumonia (I2e);

* Vomiting (J1o);

* Weight Loss (K3a) is a trigger for nutrition;

* Tube feeding (K5b)(*) is a trigger for weight loss and dehydration.

The "Clinically Complex" category for PPS includes infections (I2); dehydration (I3); and residents on dialysis (P1b), who might have their fluids restricted.[2]

Fluid Balance

Dehydration occurs more often in the elderly for a variety of reasons. One is the physiological changes in body composition that occur with aging. The body loses protein, which holds water, and gains fat, which holds no water. The elderly resident at 85 has only 60% total body water content, as opposed to a mature younger adult with a 70% total body water content. Women, in general, have a lower total body water content because of a higher body fat content. Thus, the elderly - particularly women - start with a fluid deficit.

The kidneys of the elderly have less urine-concentrating ability. This means their bodies cannot hold water as effectively as a younger person's. As a result, they urinate more often. Toileting programs in LTC facilities compensate for this by toileting residents every two hours.

The thirst response - a normal protective mechanism to prevent dehydration - is lost with aging. Simply put, the elderly do not get thirsty as often as younger adults. Residents who cannot get their own fluids must depend on staff to provide them.

Cognitive and physical changes make the resident totally dependent upon staff to get an adequate fluid intake. These changes decrease the opportunity to get fluids or to go to the toilet, and fear of having an accident discourages many elderly persons from taking fluids.[3]

Residents like to go to bed early - sometimes right after supper at about 5:30 to 6:30 p.m. and then normally stay in bed until 5:30 to 6:30 a.m. When this is the case, the elderly are in bed 12 hours a day, with no access to fluids.

Table 1. Fluid intake and loss involved in maintaining fluid
balance.

In (Oral Intake)              Out (Loss from):

Food              700 cc      Skin & lungs      920-1,000 cc
Fluids          1,500 cc      Urine             500-1,400 cc
Water of                      Feces                80-100 cc
Metabolism        200 cc

Total           2,400 cc                      1,500-2,500 cc

Maintaining Fluid Balance

Fluids enter the body via eating or drinking. As food is used by the body, additional fluid, called the water of metabolism, is created.

Intravenous and tube feedings provide both food and fluids. The 1 calorie/cc tube feeding provides approximately 80% of the feeding as free water. For example, 1,500 cc of Ensure or another product (1 calorie/cc) provides 1,200 cc of free water. Ira resident requires 1,500 cc of fluid, an additional 300 cc of fluid is required, as a flush to provide the additional free water. Having inadequate fluids in the tube feeding or intravenous therapy leads to dehydration.

Table 2. Examples of fluids found in a typical diet that includes
two to three 8-oz. (240 cc) glasses of milk.

                  2 glasses milk      3 glasses milk

Milk                  480 cc              720 cc

Coffee or tea(*):
3 6-oz cups           540 cc              540 cc

Fruit juice:
14-oz. glass          120 cc              120 cc

Soup:
6-oz cup              180 cc              180 cc

Total Intake        1,320 cc            1,560 cc

* Sometimes not counted as fluids because they contain caffeine and
can trigger dehydration

Fluid is usually lost from the skin and lungs. This is often called "insensible water loss," because we are unaware of it. Fluid is also lost through urine and feces.

Since the loss of body fluids is about 1,500 cc per day, the golden rule is to maintain at least 1,500 cc input per day. Specifics regarding fluid balance can be found in Table 1.

Fluid intake usually includes mealtime. Fluid components of a typical daily diet are shown in Table 2.

What happens if a resident does not drink milk? Or, what happens with a resident who will only take milk at breakfast? What about the resident who will only drink milk at meals, and does not want coffee or tea? Or consider the resident who might only consume 25% of the total meal - what happens to his/her fluid balance?

The following is an example of what can happen if a resident refuses his/her milk, and the fluids are not replaced: Mrs. Smith does not drink the 780 cc of milk provided with her meals. After three days, this amounts to 2,300 cc, or about 2.3 liters. If this 2.3 liters of fluid from milk were translated into pounds (2.2 pounds per liter), it would be: 2.3 liters fluid (the fluid deficit) x 2.2 = a fluid loss of 5.06 pounds. This five-pound fluid loss in three days would be considered a trigger in (J1a): "weight gain or loss of more than three pounds in seven days."

"Insufficient fluids" - "did not consume all or most fluids in the past three days" (J1d) might also be triggered, as might "dehydrated" - "output exceeds input" (J1c). If weight loss of greater than 5% of body weight has occurred within a month, (K3a) might also be triggered. J1d, J1c, J1a and K3 are all triggers for dehydration.

If the resident is getting all of his/her fluids though an intravenous line or a tube feeding, weight loss will result if adequate fluids are not provided through those routes. On the MDS 2.0 (K6b), have the caregiver check how many cc of fluid are provided by the feeding. HCFA usually recommends 30 cc of fluid per kilogram of weight per day. The exceptions to this might include residents with cardiac or renal problems. If Mrs. Smith weighs 130 pounds, or 59 kilograms, multiply her weight in kg by 30 (cc of fluid per kg requirement) to come to her total daily fluid need: 1,770 cc.

Residents who cannot drink on their own require staff intervention to be sure they receive adequate fluid intake. The care plan defines how the staff will accomplish this goal.(4)

Fluids Out

Fluid losses from the skin and lungs are increased in a hot environmental temperature and with increased respiratory effort. For instance, residents with chronic obstructive pulmonary disease, because of increased respiratory effort, will require more fluids to maintain fluid balance.

Another major source of fluid loss is fever. Fluid needs increase 6% with every degree (Fahrenheit) of temperature rise over baseline. If Mrs. Smith has a 3 [degrees] temperature rise above her normal baseline temperature, her fluid needs are increased 18% and are now 2,088 cc. What if she also experiences vomiting and diarrhea, which increase her fluid loss, and has had very poor food and fluid intake because she has felt so sick? What if she is on diuretic therapy?

How many long-term care residents return from the hospital with a diagnosis of dehydration accompanying the diagnosis of pneumonia or a urinary tract infection? Fever (I1h) is a trigger for dehydration, as is diuretic therapy (O4e).

If there are inadequate fluids in the body, the body has a difficult time getting rid of body wastes, resulting in constipation or fecal impaction. An inadequate amount of fluid consumed also results in production of a very small amount of odorous, dark-colored urine. A specific amount of fluid is required to cause a "flush response" of the bladder.

Also in the bladder are bacteria that can easily grow in the body's warm, moist environment, and the waste products accumulating in the bladder provide nutrients for these bacteria. The result is often a UTI (I2j), and is a trigger for dehydration.

When the body has inadequate fluids, less oxygen and glucose are circulated to the brain, resulting in confusion, falls, decreased ability with ADLs and a decrease in cognitive status.

Blood is a body fluid, so any internal bleeding is a loss of fluid. Internalbleeding (J1j) also triggers dehydration.

Getting Fluids In

Here are the five best tips for increasing fluid intake, shared by facilities across the nation based on their experiences[3]:

1. Give residents a drink first thing in the morning. Remember, they have been without fluids for (up to) 12 hours and are very thirsty. Make giving a drink part of the morning care.

2. Give more fluids with medications - about 160 cc. The resident will need the fluid to take the meds and can be persuaded to take a few more sips to make the medicine go down.

3. For nursing assistants, direct attention to the resident needing special assistance with fluids by using a special colored napkin on the feeding tray.

4. Include a drink as part of "one-on-one" conversations with nursing, social work, activities personnel and family members.

5. Make fluids fun! Try offering mock or real cocktails, root beer floats, hot fudge sundaes, party-flavored punches, etc. Be creative!

Think of it this way: The elderly live in a desert - unless someone brings them fluid.

References

1. Weinberg AD, et al. Dehydration: Evaluation and Management in Older Adults. JAMA 1995; 274:1552-6.

2. Kobriger AM. Nutrition in Long-Term Care 2002. Chilton, Wisconsin: Kobriger Presents, Inc., 1999:54.

3. Kobriger AM. Planning and Evaluating Hydration Needs in the Elderly. Chilton, Wisconsin: Kobriger Presents, Inc., 1997:22, 117-34.

4. Kobriger AM. Care Planning for Nutrition Professionals in Long-Term Care, Chilton, Wisconsin: Kobriger Presents, Inc., 1998:1.

Annette M. Kobriger, RD, CD, MPH, MPA, is president of Kobriger Presents, Inc., which provides seminars, publications and consultation nationally for the long-term care industry. She may be contacted at [phone]; e-mail: [e-mail]; or visit the Kobriger Presents, Inc., Web site at www.kobriger.com.