Lau MY, Wan MF, Wong PH, Cheng YC, Mok LC Department of Orthopaedics & Traumatology Pamela Youde Nethersole Eastern Hospital

Lau MY, Wan MF, Wong PH, Cheng YC, Mok LC Department of Orthopaedics & Traumatology Pamela Youde Nethersole Eastern Hospital

Older people are vulnerable to dehydration (Ylinenvaara et al., 2014) Unable to self-feed Pain Fasting Minimized fluid input intentionally to decrease voiding frequency Consequence is: high in mortality and morbidity (Sansevero, 1997) Aging Disease 2/22

Clinical Research on Dehydration in PYNEH O&T Dept (collaboration with Nethersole School of Nursing, CUHK in early 2013) Screening showed that more than 20% of patients were identified as dehydration Dehydration is significantly associated with the occurrence of postoperative complications related to respiratory, gastrointestinal and hematological aspects (Chan, et al., 2018) 3/22

Lack of standardized and scientific method for assessing the hydration status of older people during peri-operative phase (Begum & Johnson, 2010) Management protocol in placed couldn t fully tackle the problems of dehydration in elderly group 4/22

Objectives To reduce patients who dehydration rate among elderly undergoing orthopaedics operation To facilitate nurses for early identification of dehydrated patients peri-operatively To prevent postoperative complications associated with dehydration 5/22

Patient aged 65 or above Admit to In-patient Orthopaedic wards for operation 6/22

Admission Age 65 and Plan for operation Screen BUN / Cr ratio 25 or Clinical features of dehydration Implement Dehydration preventive measures 7/22

1. Calculation of Blood Urea Nitrogen(BUN)/Creatinine(Cr) ratio Definition of Dehydration BUN / Cr ratio 25 (Hodgkinson, Evans & Wood, 2003) BUN/Cr ratio= [Serum urea (mmol/l) / Cr (umol/l)] X 247.62 2. Clinical signs and symptoms of dehydration e.g. - dry skin/lip/oral mucosa - furrowed tongue Example: Urea 8.5 mmol/l Creatinine 76 umol/l BUN/Cr ratio = (8.5 76 ) X 247.62= 27.69 (dehydrated) Lab. Results of Renal Function Test 8/22

BUN/Cr Ratio 25 OR Clinical features of dehydration Dehydrated patient Use of signage at bedside to alert healthcare staff The progress of hydration status was recorded and monitored continuously in the Hydration Status Chart 9/22

1. Encourage fluid intake Fluid round with at least 300ml per AM/PM shift if not contraindicated 10/22

2. Closely monitor intake and output - I/O Chart - Measure the weight of napkin after napkin change and match with the corresponding volume of urine by using 小便量度對照表 11/22

3. Seek medical advice for considering IV fluid supplement if oral intake not indicated 12/22

4. Mark the result of BUN/Cr ratio in the Hydration Status Chart till signs and symptoms of dehydration resolved 13

2413 patients were recruited (Sep 2015 to Dec 2017) 681 patients (28.2%) were identified as dehydrated Euhydrated 71.8% Dehydrated 28.2% 14/22

ALL identified dehydrated patients had improvement in the hydration status (BUN/Cr ratio & clinical signs) Nearly 50% of dehydrated patients were significantly corrected from dehydrated to euhydrated status upon transfer out or discharge (BUN/Cr ratio < 25) Hydration Status Upon Transfer Out or Discharge 49% Corrected 51% In the progress of improvement 15/22

Prospective audit on staff compliance was conducted in Sept 2017 Overall compliance rate was high (97.5%) Audit Report Standard Criterion Yes No N/A Compliance % 1. Assess patient for risk of dehydration before operation by checking the BUN/Cr or clinical signs & symptoms and monitor by Hydration Status Chart. 34 0 3 100.00 2. Accurate calculation in BUN/ Cr ratio. 37 0 0 100.00 3. Identify the risk factor(s). 37 0 0 100.00 4. Implement appropriate dehydration preventive measures 21 0 16 100.00 to patient at risk. 5. Inform ward staff for patient's risk of dehydration. 16 0 21 100.00 6. Educate patient and /or significant others to increase fluid intake if no contraindication. 7. Reassess patients for dehydration risk regularly and when required by checking BUN/Cr or clinical signs & symptoms. 8. Review preventive measure(s) regularly and when required. 18 0 19 100.00 35 2 0 94.59 21 2 14 91.30 9 Document the preventive measures applied. 19 2 16 90.48 Equal Weighted Compliance % 238 6 89 97.54 15/22

Conclusion High prevalence of dehydration among elderly patients User friendly tool can facilitate early detection of dehydration Prompt rehydration interventions improved patients hydration status hence associated postoperative complications were minimized Staff compliance is the key element for success 16/22

Enhance patients recovery after operations Shorten length of stay in hospital and reduced medical costing 17/22

18/22

References Begum, M.N. & Johnson, C.S. (2010). A review of the literature on dehydration in the institutionalized elderly. European e-journal of Clinical Nutrition and Metabolism, 5(1), e- 47-e53. Chan, H. Y. L., Cheng, A., Cheung, S., Pang, W. W., Ma, W. Y., Mok, L. C., Wong, W. K. & Lee, T. F. D. (2018). Association between dehydration and postoperative complications in older persons undergoing orthopaedic surgery. Journal of Clinical Nursing Hodgkinson, B., Evans, D. & Wood, J. (2003). Maintaining oral hydration in older adults: A systematic review. International Journal of Nursing Practice, 9(3), S19-S28. Sansevero, A.C., (1997). Dehydration in the elderly: strategies for prevention and management. The Nurse Practitioner. Volume 22(4), 41-42, 51-57, 63-66. Ylinenvaara, S.I., El, O., Berg, K., Zdolsek, J.H., Krook, H. & Hahn, R.G. (2014). Preoperative urine-specific gravity and the incidence of complications after hip fracture surgery. European Journal of Anesthesiology, 31(2), 85-90. 19/22

Acknowledgement Dr. TSANG Wai Leuk (CONS O&T PYNEH) Mr. MOK Long Chau(DOM O&T PYNEH) Mr. CHENG Ying Cheung (NC O&T PYNEH) Ms. LAI Siu Wing Vicky (WM O&T PYNEH) Ms. MA Wai Yiu (WM O&T PYNEH) Ms. NG Wai Shan (WM O&T PYNEH) Mr. PANG Wai Wah (WM O&T PYNEH) Ms. WONG Pui Han (APN O&T PYNEH) Ms. WAN Man Fong (RN O&T PYNEH) ALL PYNEH O&T Nurses 20/22

21/22

Questions & Answers 22/22