Dehydration: stopping a "sentinel event." - steps taken by the Health Care Financing Administration to prevent dehydration among elderly patients of health care facilities

Nursing Homes, Oct, 1999 by Annette M. Kobriger

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]