Authors (including presenting author) :
Karin Chow, M M Wong, Pak Hong Chan, W S WOng, Elsa Ng, K F Chan, Michael Fu
Affiliation :
Acute Stroke Unit, Department of Medicine & Geriatrics, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority.
Introduction :
Dehydration among stroke patients has been cited in various research studies as it potentially affect the ischemic penumbra and influence strok4e evolution in their acute phase of stroke.
Objectives :
A project named “Hydration alert education scheme” implemented in Tuen Mun Hospital (TMH) Acute stroke unit (ASU) since July 2018 till present, aims to:
Evaluate the barriers encountered by staff in improving oral hydration
Formulate and implement a simple and cost-effective interventions
Methodology :
Total 30 patients recruited as case study in July 2018, and revealed that only less than 10% of patients having their hydration needs addressed. Of which, more than 65% were noted to be dehydrated (BUN/creatinine ratio > 15) on admission. Although physician’s primary response to patients with “encourage fluid intake”. Staff mentioned busy of ward environment, no effective and simple assessment tools for stratification of dehydration and unclear task responsibility as the major barriers.
A mixed methodology approach, in which two ‘Plan Do Study Act’ (PDSA) cycles were undertaken in October 2018 and December 2019, adopted to achieve our aims.
PDSA cycle 1 (1st October to 30th November 2018): assessment twice daily by calculating the balance of intake and output (I&O) chart and BUN/creatinine ratio of patients. Patients enrolled if either one assessment results indicated as risk of dehydration. Proactive discussion with case’s doctor should be perform, then followed by an extra fluid fed round and delivery of education pamphlet with explanation provided.
Blood test of BUN/creatinine ratio retrieved as data analysis, compared to data retrieved from 1st July to 31st August 2018. Total 154 patients recruited, of which, the mean BUN/cr ratio is increased from 17.05 (on admission) to 19.07 (day 4 to day7) (p-value < 0.02) before program. After program, the mean BUN/cr ratio is decreased from 16.21 (on admission) to 14.57 (day 4 to day 7) (p-value < 0.03). Patients with BUN/cr ratio > 15 was decreased from 69.6% to 60.9% after program launched. But unfortunately, the consistency of this program is failed after 3 months due to time pressure and manpower constraint.
PDSA cycle 2 (implemented in November 2019): a simplified workflow by just tracing patients with deficit balance in I&O, then calculate the BUN/creatinine ratio as step two, followed by hoisting a modified “Hydration alert” signage after case discussion with doctor during their ward round. Two responsible nursing staffs specifically appointed for program monitoring. “Hydration alert” signage placed and supporting staffs were instructed to provide extra fluid fed round automatically.
Result & Outcome :
This revised “Hydration Alert scheme” resulted in a 6.5-fold increase in patients’ hydration needs being assessed and addressed. More than 70% of admitted stroke patients were under hydration monitoring with modified interventions provided. Patient with BUN/cr ratio > 15 is 58% shown in day 4 -day 7.
Conclusion: This project provides a foundation for a system improvement in proactive assessment of hydration status and targeting extra fluid fed round in a busy clinical setting. By collecting qualitative feedback from staffs regarding the sustainability, coupled with the low implementation cost and ease of use. These simplified assessment tools and “Hydration Alert” may be a simple, effective, transferable and sustainable solution to the problem of dehydration among post stroke inpatients.
