Prevention of dehydration

in hospital inpatients
Philippa Johnstone, Ratan Alexander and Nick Hickey

Key words: Hydration Drinking equipment Avoidable harm

Patient safety Quality improvement

ater is one of the six essential nutrients

but its importance can be easily overlooked.
Dehydrationthe loss or deficiency of
water in body tissuescan lead to multiple
morbidities and even mortality (Weinberg and Minaker, 1995).
The Francis report identified that in Mid-Staffordshire NHS
Foundation Trust:
Some patients were left with food and drink out
of reach and offered inadequate or no assistance in
consuming it. Even water or the means to drink it
could be hard to come by. (Francis, 2013: 1600)
As the Francis report also showed, older patients are
particularly at risk of dehydration (Francis, 2013). This may
Philippa Johnstone, Foundation Doctor (FY2), Queen Elizabeth
Hospital, Birmingham; Ratan Alexander, Consultant Anaesthetist and
Clinical Tutor; Nick Hickey, Consultant Vascular Surgeon and Clinical
Supervisor, Worcester Royal Hospital, Worcester
Accepted for publication: May 2015

568

Method
The study used a mixed methodology, with both quantitative
and qualitative data collected in an interview setting (Box1).
Interviews were conducted with patients who were taking
oral fluids on three surgical wards, on two separate occasions
(both were weekends). The questionnaire was talked through
with each individual patient and documented by the
interviewer, maintaining anonymity with just gender and
age being recorded for demographic data. Excluded from
interview were patients who were less than alert on the alert,
voice, pain, unresponsive (AVPU) level of consciousness scale

British Journal of Nursing, 2015, Vol 24, No 11

2015 MA Healthcare Ltd

Abstract

Background: The adverse effects of dehydration in hospital inpatients

can be severe, resulting in morbidity and even mortality. This study
examined the ability of surgical patients in a district general hospital
to undertake the seemingly minor but critically important task of
taking on oral fluids using the conventional, hospital-supplied, water
jug and glass. Methods: Surgical patients receiving oral fluids were
interviewed on two occasions. A questionnaire assessed the patients
capacity to use the water jug and recorded his or her experience.
The patients ability to use jugs with varying volumes of water was
then observed. Results: Some patients simply could not physically
lift the conventional jug of water and often went thirsty; 42% of
patients could not reach the jug of water at the time of interview;
31% of patients found the simple task of pouring a glass of water
difficult, very difficult or impossible. Conclusion: Patients need
their individual requirements to be assessed and their preferences
addressed on admission to hospital, by means of a fluid-assessment
chart. Alternative methods of hydration should also be considered.
Education and training on the importance of hydration remain
key. These small changes could improve patient hydration and
independence, thus preventing avoidable harm.

be for a number of reasonsfor example, owing to a decrease

in renal function and a decreased sense of thirst (Hodgkinson
et al, 2003). Hodgkinson et al (2003) specifically identified
a number of possible risk factors linked to a higher risk of
dehydration in the older adult:
Age
Functional ability
Gender
Visual impairment
Speaking ability
Incontinence
Ingestion difficulties.
With the average age of hospital patients being over 80,
this risk is of real relevance (Cornwell, 2012). In 2014,
a study found that of 103 patients (mean age 81 years)
admitted to hospital, 44% of those reviewed at 48hours were
dehydrated (El-Sharkawy et al, 2014). It is clear therefore
that dehydration remains a problem in hospital patients
and one that is frequently highlighted in the media (The
Telegraph, 2012). In their study of dehydration in hospitaladmitted stroke patients, Rowat et al (2012) found that 62%
of patients were dehydrated at some point during their
hospital stay, 36% on admission and 26% at least once during
their stay. It is an ever-increasing problem in hospitals and
one that in many cases is avoidable. Dehydration increases
a patients susceptibility to urinary tract infections, pressure
sores, constipation, pneumonia, confusion and disorientation
(Warren et al, 1994; Weinberg and Minaker, 1995; Stotts
and Hopf, 2003) while also increasing the risk of longterm conditions such as breast cancer (Stookey et al, 1997),
coronary heart disease (Chan et al, 2002), hypertension,
thrombosis and cerebral infarct (Manz and Wentz, 2005).
As part of a hospital quality-assurance investigation, the
authors wanted to investigate a group of factors that could
contribute to the patients ability simply to pour and drink a
glass of water.

RESEARCH

The Hydrant - Solving the problem

of reaching, lifting, or holding drinks:

One of the biggest reasons people in care get dehydrated is not lack of available fluids but lack of easy, independent access
to those fluids. If you cannot easily help yourself to drinks, or need to call for help, then it is likely that you will not be drinking enough.
The solution? The Multiple Award Winning Hydrant, a low-cost, easy to use, personal drinking system from Hydrate for Health
it solves the problem of reaching, lifting or holding drinks
Why is it so clever? The Hydrant closes the gap between the drinker and the drink.
The ingeniously simple clip/cap/handle enables the Hydrant to be attached to beds, chairs, wheelchairs, in fact almost anything,
so that the user has drinks available at all times without needing to call for help or struggling to reach across to a cup or glass.
Where does it work? Hospitals, care homes, special needs establishments, in maternity, and out in the community where
people are living with a condition that requires some sort of care from either relatives or social services.
Results? Hospitals are seeing substantial reductions in length of stay (20% +), use of drips and infections (up to 100%).
Care homes are seeing 80% reductions in falls, urinary infections and antibiotic use plus 70% reductions
in hospital admissions. Community users are reporting 80% reduction in urinary infections.
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2015 MA Healthcare Ltd

(Box2); those with cognitive impairment (Mini Mental State

test score of less than 7); and those who opted not to take
part in the study.
The focus of the interview was the equipment used by
patients to provide themselves with a drink of waternamely, a
water jug and glass. It is common practice to have these placed
on patients bedside tables to allow them to pour themselves a
glass of water as and when desired.This study looked at variables
around use of the water jug that could reduce the ease with
which patients pour themselves a glass of water, and attempted
to identify any improvements that could optimise the patients
ability to drink. Variables included whether the patient had a
physical impairment that limited their ability to perform the task;
whether the patient could reach the jug at the time of interview;
and whether they could lift it successfully.
The standard jug in the authors hospital contains just
over 1litre of water (weighing approximately 1.25kg). The
quantity in the jug at the time of interview was recorded.The
patients were then asked to try to pour a glass of water using
the same jug, but with three different levels of water: 500ml,
750ml and 1litre. They were then asked to rate the task on
a scale of difficulty.

Results
In all, 52 patients were interviewed, of whom 36 were male
and 16 female. The ages ranged from 38 to 98years, with
a median age of 72years. Demographic data are shown in
Figure1.

British Journal of Nursing, 2015, Vol 24, No 11

A total of 21% of interviewees reported that they could

not always lift the jug of water; 42% could not reach the jug
of water at the time of interview; and 31% reported that the
task of pouring themselves a glass of water was difficult, very
difficult or even impossible. Most jugs were filled close to
capacity and the mean weight of the jugs for patients (of
those measured) was 920 g. The majority of patients (48%)
preferred using a jug with the smallest quantity of water,
500ml, the average weight of which was 700g (taking into
account the weight of the plastic jug as well as the water
contained within).
The most common theme identified by far (by 14 people)
concerned the lids of the water jug. These were described,
for example, as tricky, terrible or that they always fall off .
Other problems identified concerned hygiene (the jugs dont
always look clean); the awkwardness of pouring the water
from the jugs (Figure2); and the tendency for the jugs to spill
in use. Unfortunately, the jugs were on occasion placed on
the most difficult side for the patient to usefor example, if
the patients movement on one side was limited, post stroke.
Perhaps the most worrying theme to be identified was that
patients repeatedly said that they did not want to bother the
nurses to ask for help. This was mentioned in 12 responses,
whether the patient simply could not reach the water jug, or
whether they needed physical assistance to drink.
During the interviews, the patients put forward some
suggestions for improvements, including:
Providing a measuring scale on the side of the jug to aid

569


Patients

age and gender

disability

Cognitive impairment score (Mini-Mental State Test)

Does the patient report being able to lift the jug of water?

Can the patient reach the current jug of water?

Volume in current jug

Is the patient able to pour a jug of water from the following

jugs? 0.5litre, 0.75litre, 1litre

Difficulty rating: 15

Additional comments from patient

Physical

Box 2. Alert, voice, pain, unresponsive (AVPU) scale

Alert:

spontaneous eye-opening, speaking and intact motor

functions, e.g. moving limbs

Voice: responds when spoken to, e.g. grunt or actual

speech

Pain: responds to pain, e.g. sternal rub

Unresponsive: no response to pain, i.e. no eye, voice or

motor movement
Table 1. Ability to lift and patient preference by jug volume
Volume of jug (litres)

Percentage of patients
able to lift jugs

Preferred jug*

0.5

98.1

48

0.75

90.4

27

84.6

18

*7% of patients preferred either 0.5 or 0.75 litre jugs

Male
Female

91-100

Age range

81-90
71-80
61-70
51-60
41-50
<40
10

10

Number of patients
Figure 1. Demographic data of participants

accurate fluid intake

jugs for those needing to tip rather than pour
(such as those with tremor)
Disposable liners
A two-handled jug.
Weighted

Discussion
Although the causes of dehydration are multifactorial,
as shown by Stewart et al (2009), it is the duty of health

570

practitioners to encourage oral fluid intake in order to

maintain a healthy fluid balance (Francis, 2013). The
National Institute for Health and Care Excellence (NICE)
guidelines on nutrition support in adults (written in 2006
and most recently reviewed in 2014) specifically state:
Healthcare professionals should ensure that care
provides [] food and fluid of adequate quantity.
(NICE, 2014: 1.1.2)
Because water is provided at the bedside, there is a mistaken
assumption that the patient remains hydrated.Yet, in practice,
many patients do not in fact hydrate satisfactorily for a variety
of reasons, such as insufficient physical strength to lift the jug;
insufficient dexterity to pour water successfully from the jug
into a glass; inability to reach the jug; or a general decline in
health that decreases the patients awareness of thirst and the
need to drink.

Is the water jug and glass suitable for

every patient?
For many patients, this conventional jug and glass are
perfectly adequate, provided the patient is monitored to
ensure that they are physically capable of managing the
simple pouring operation required. However, this is not the
case for all patients.
It is clearly not just in this study that the poor design of the
hospital jug has been noted. In 2010, Matron Sharon Brierley
of Stockport NHS Foundation Trust noted similar issues with
water jugs and beakers, and set about changing the design in
the trust (Brierley, 2010). More recently, in April 2014, on
a national scale, a new jug was developed and introduced
into the NHS supply chain (Lecko and Jones, 2015), which
featured highly during Nutrition and Hydration Week in
March 2015. This new jug addressed many of the design
issues raised by the authors studynamely, by adding
graduations for volume measurements on the handle, having
well-fitting lids, and making the jug smaller.
Although these were excellent improvements in jug
design, there remain several issues surrounding hydration,
which the present study highlights. For instance, however
good the jug is, if the patient is still unable to reach the
jug, or unable to lift it, there is potential for that patient
to become dehydrated. Furthermore, if neither the patient
nor the health professional is educated sufficiently on the
importance of drinking while in hospital, it will not be seen
as a priority, as it should be. Not only is drinking essential
for health, but it also makes economic sense for hospitals to
provide drinking water and prevent dehydration to reduce
incidences of pathology and thereby reduce the need for
medication; reduce professional time required to nurse
the patient; and, at a cost of about one-tenth of 1p for
each litre of water, it is a cost-effective way of maintaining
patients health (Royal College of Nursing (RCN) and
NPSA, 2007).
As the RCN and National Patient Safety Agency (NPSA)
state: the importance of water often gets overlooked
(RCN and NPSA, 2007: 37). A review by the National
Reporting and Learning System (NRLS) specifically
looked at dehydration and identified 142 related deaths

British Journal of Nursing, 2015, Vol 24, No 11

2015 MA Healthcare Ltd

Box 1. Questionnaire information collected at interview

1=Easy

Percentage of patients (%)

2=Little difficulty
3=Difficult

80

4=Very difficult
5=Impossible

60

40

20

3
4
Difficulty rating 15

Figure 2. Rating the difficulty of pouring a glass of water

and 257 incidents of severe harm between 2003 and 2012

(Lecko and Best, 2013). Lecko and Best further note:
Good hydration is a core element of clinical
care, yet our review of incident reports from the
NRLS suggests that this aspect of care is all too
frequently overlooked or poorly addressed.(Lecko
and Best, 2013:14)
Fortunately, however, good training and effective supervision,
following the advice of the Hospital Hydration Best Practice
Toolkit produced in conjunction with the NPSA (RCN and
NPSA, 2007), should help to avoid such oversights.

Conclusion
On the basis of the results of this study, the following
measures would be beneficial. First, an individual assessment
of the patients needs on admission to hospital. This could be
achieved by the addition of a fluid-assessment chart to the
initial nursing paperwork, to be completed when a patient is
admitted. The health professional would be able to offer the
choice of water jug volume (500ml, 750ml or 1litre) and
then the patient could decide, with assistance, which they
would most easily be able to manage. The preference of jug
volume would then be recorded in the oral nutrition plan
and the jug colour coded for the specific volume required.

KEY POINTS
n
Dehydration

is a prevalent healthcare issue

n
Raising

awareness of the importance of hydration can reduce avoidable harm

for patients

n
Health

professionals have a duty to ensure patients are well-hydrated

n
Innovative
n
There

drinking aids can improve hydration

should be an aim to secure better patient safety through promotion of

quality-improvement projects

572

Second, thought should be given to devising a system that

records those who have difficulty drinking and alerts those
who look after the patients nutrition to this difficulty.
Third, alternative apparatus to the water jug and glass to
enable the patient to drink more easily, such as water reservoir
bags with a hose and mouthpiece, should be investigated. One
such example of this is the Hydrant (marketed by Hydrate for
Health). There have now been multiple studies assessing the
use of the Hydrant in NHS hospitals (Patient Safety Federation
and South Central NHS, 2011; Evans, 2014). The Hydrant is
an independent hands-free drink system, similar to the familiar
sports bottle, which is clipped on to the side of the bed with
an attached flexible hose that the patient bites to open the valve
and enable the flow of water. Studies have reported various
improvements with the Hydrant, such as easier fluid-balance
monitoring and increased fluid intake, reducing the need for
intravenous fluids (Sutton and Stroud, 2013). One report even
suggested a 20% reduction in length of stay (Braid and Smith,
2012). Although there is potential for more extended use of the
Hydrant in certain settings, there have been reports suggesting
that older patients find the bite-and-suck technique difficult,
and appear to prefer more traditional methods of drinking
(Sutton and Stroud, 2013).
Finally, hydration should be a primary staffing priority. It is
clear that the majority of healthcare staff are under pressure at
work, not least nurses. A study by the RCN found that 46%
of the 2500 nurses surveyed said that there were generally
not enough staff to ensure patients get the help they need
to eat and drink (RCN, 2007). For this reason, it is essential
to instil methods to make it easier for the staff to improve
patient hydration.
These four simple measures could be implemented easily
and all have the potential greatly to improve patient hydration
and thus their wellbeing.
In summary, there is a need for continuing improvement
with regard to patient hydration. While there is optimism
about the current methods of providing oral fluid intake
that are under evaluation and potential improvements they
could bring, training and education are the key factors
for achieving sustainable best practice for patients. The
hydration of patients is, and must remain, the duty of every
BJN
health professional.
Conflict of interest: none
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