The Aged Care Quality and Safety Commission has issued a clinical alert following the preventable death of an older person from severe dehydration. Here’s what aged care providers should know and do to prevent, identify and respond to dehydration.
Dehydration is a serious clinical risk for older people receiving aged care services. The Aged Care Quality and Safety Commission (Commission) has issued a clinical alert on preventing and responding to dehydration in older people receiving aged care services following a South Australian coronial inquest into the death of an older person living in residential aged care who died from acute renal failure caused by severe dehydration. The coroner found the death was preventable and identified a lack of systems to monitor fluid intake and recognise the potential for dehydration.
The alert is an important reminder that preventing dehydration is not simply a matter of offering residents and older people something to drink. Providers need effective systems to identify people at risk, monitor and manage fluid intake, recognise when concerns need to be escalated and review their processes when things go wrong.
Here’s what aged care providers need to know.
Older people can be particularly vulnerable to dehydration because of age-related physiological changes, medical conditions, medications and difficulties accessing or consuming fluids. The Commission identifies a number of risk factors, including:
Cognitive changes can also mean that an older person is unable to recognise or effectively communicate that they are thirsty. Providers therefore need to consider dehydration risk holistically as part of the person's individual assessment and care planning, rather than relying on the person to request fluids or just giving fluids at mealtimes.
The Commission expects providers to proactively identify and assess dehydration risks, monitor and manage fluid intake and respond to changes in an older person's condition.
Providers must have policies and processes to identify older people who are at higher risk of dehydration when they enter their service.
Assessment should not stop at admission. The Commission expects providers to reassess an older person's hydration needs when there is a change in clinical status, a dehydration risk is identified or symptoms are present.
Providers should consider factors such as:
For each older person, the Commission says providers should discuss and agree on the strategies they will use to monitor and manage fluid intake, document those strategies in the person’s care plan and regularly review and maintain both the plan and the strategies.
This is the gap the Coroner identified. A general commitment to hydration is not a strategy. An individualised, documented and reviewed plan is.
Fluids should be available and within easy reach across the day, and older people should get the support they need to receive and consume them. That may mean physical assistance, prompting the person, or consulting health professionals such as occupational therapists about assistive equipment.
Food and fluids offered must also meet the person’s individual requirements and preferences, including texture-modified food, thickened fluids and any fluid restriction – while respecting their right to make informed decisions about where, when and what they eat and drink.
Monitoring matters most for those already identified as being at increased risk, and during times when fluid losses spike – acute illness, increased urination, vomiting, diarrhoea or hot weather. The Commission expects early referral for medical assessment in those circumstances.
The alert makes one very practical point about documentation: workers need to know the typical volume of fluid held in the standard glassware, mugs and bowls used at the service, as well as which foods have a high fluid content. Fluid intake records are only as good as the estimates behind them.
Dehydration is a serious clinical concern and requires prompt action.
The Commission states that if dehydration is suspected, the older person should be encouraged to increase their fluid intake, where appropriate, and referred promptly to a general practitioner (GP) or other medical practitioner for assessment, diagnosis and a treatment plan.
Late signs of dehydration can include:
If dehydration is strongly suspected or diagnosed, providers should ensure that:
Importantly, the response should not end once the immediate clinical concern has been addressed. Providers should consider why the dehydration occurred and whether changes are needed to prevent it happening again.
The Commission's alert highlights the importance of having systems that support the prevention and management of dehydration.
Aged care providers should consider whether their current systems can answer the following questions:
If the answer to any of these questions is no, providers should consider whether their policies, procedures, training and monitoring systems need to be reviewed.
The Commission's alert makes clear that dehydration is not only an individual clinical issue. It can also indicate a problem with the systems used to assess, monitor and respond to risk.
Where harm or repeated concerns occur, providers should investigate contributing systemic factors and consider whether their processes need to change. The Commission specifically highlights the importance of effective clinical governance to ensure policies and processes reflect current evidence-based practice.
This may include reviewing:
The aim should not simply be to demonstrate that a hydration policy exists. Providers should be able to demonstrate that the policy is implemented effectively and that workers understand their responsibilities.
The Commission's dehydration alert is an important reminder that dehydration can cause serious harm and that relying on visible signs or symptoms may not be enough to identify the problem early. Providers need proactive systems for identifying risk, monitoring fluid intake, responding to concerns and escalating issues for clinical assessment.
Aged care providers should review their current hydration policies, care planning, monitoring, staff education and escalation processes to ensure they reflect current evidence and the Commission's expectations.
More broadly, the alert demonstrates why effective clinical governance matters. Good governance systems help providers identify risks, respond when something goes wrong and make improvements that reduce the likelihood of the same problem occurring again.
Nicole Chen
Nick Edwards