“Keeping it simple means it’s not only easy to implement, but also easy to sustain.”

Sundus Jawad, Prescribing and Care Homes Support Pharmacist, East Berkshire Clinical Commissioning Groups

Background

Oxford House ice lollies for residents - hydrationFewer residents are suffering urinary tract infections (UTIs) following the introduction of a hydration programme in care homes. UTIs are closely associated with dehydration. The project was designed to encourage residents to drink more fluids with the aim that this would lead to fewer UTIs requiring medication or hospital admission. This approach involved introducing structured drinks rounds seven times a day, designed and delivered by care home staff. The initial focus was in four care homes which had higher than average UTI admission to hospital rates. As a result the number of UTIs requiring hospital admission fell from 18 in 2015/16 to four in 2017/18. There were also fewer UTIs needing treatment with antibiotics within all four care homes.

The approach has now been extended to six more care homes in east Berkshire and three in Oxfordshire – making 13 in total – and there are plans to spread it further still. The care home hydration project has won a number of national prizes including three in the 2017 PrescQIPP awards and one in January 2018 from the Primary Care Pharmacy Association. It was also highlighted at Patient First in November 2017. A series of animated videos is being developed to spread the learning among care home staff.

Aims, objectives and scope

Dehydration is one of the most common causes of admission to hospital for care home residents. One in four nursing home patients admitted to hospital is dehydrated. Dehydration increases the risk of urinary tract infections (UTIs) which can lead to multiple complications including confusion, falls, acute kidney injury and hospital admission. The Oxford Patient Safety Collaborative identified addressing care home hydration as a key priority within its acute kidney injury programme. To address this it began building relationships initially with Windsor, Ascot and Maidenhead Clinical Commissioning Group and residential/nursing homes in their area. A pilot project was established in 2016 with four care homes in east Berkshire with a total of 150 residents. These homes had above average hospital admission rates for UTIs over the previous three years.

Method and approachOxford PSC Hydration - Halloween

Hydration training was delivered to more than 220 care home staff who then designed and delivered structured drinks rounds seven times every day. The trolleys were bright, inviting and offered multiple options of drinks, cups and glasses. Staff used their imagination to create attractive themed trolleys, e.g. Halloween.

Measurement plan

Oxford used a PDSA cycle:Oxford PSC PDSA cycle hydration

Find out more here.

Results and evaluation

The initial target was to reduce UTI-related hospital admissions year-on-year by 5%. In reality the results were far more impressive. Across the four care homes there was a 33% reduction (from 18 cases in 2015/16 to 12 in 2016/17). The downward trend has been maintained with just four UTI-related hospital admissions in the first nine months of 2017/18. The number of UTIs requiring antibiotics also fell – from an average of one every 13 days to one every 47 days. Skin integrity also improved and GP calls fell.

The four care homes also demonstrated sustained compliance of 98% with the commitment to provide seven structured drinks rounds each day. Qualitative data from a focus group of managers and staff indicated that residents were more alert and willing to participate in activities. One resident who had had recurrent UTIs every six weeks was UTI-free for eight months after getting actively involved in the project and recording their food and fluid intake in a diary. His mobility and social interaction improved as a result too.

The project has won a number of national prizes including three in the 2017 PrescQIPP awards and one in January 2018 from the Primary Care Pharmacy Association. It was also featured in the poster showcase at Patient First in November 2017.

“The training has given us understanding of why it’s important to ensure that residents have enough fluids – it’s looking at the whole system, not just a drink.”

Care Home Staff Member

Learning points

  • Always have a dedicated local authority or Clinical Commissioning Group link who knows the care home, works with them and who can support them, especially until this approach becomes routine practice.
  • Extra support is necessary in the first three months of the project.
  • It would be wise to include Healthwatch at the beginning of the project and also look at cross-boundary working including infection control, pharmacists etc.
  • Review guidance on UTI management locally in care home and GP services and implement good practice guidance.

Start and end dates

July 2016 to present.

Contact us for help and advice

Katie Lean, Patient Safety Manager, Oxford AHSN
E: katie.lean@oxfordahsn.org

More AHSN hydration projects

Kent, Surrey and Sussex AHSN has a hydration in care homes programme, for more details read the case study.