The Atlas of Shared Learning

Case study

Development and implementation of a holistic hydration care assessment tool (RoC)

Leading change

A hydration specialist nurse in Cornwall led on the development and implementation of a hydration risk assessment tool to help carers and staff assess patient need and risk.

Where to look

The hydration specialist nurse first noticed unwarranted variation in hydration support for patients through visits to a care of the elderly ward. When reviewing tools available to reduce this variation, she identified that there wasn’t a consistent approach in use to identify the level and type of support a patient needed to maintain their hydration or identify their associated risk of dehydration.

What to change

The specialist nurse identified that the absence of an assessment tool for support with drinking represented a fundamental gap in evidence based practice for hydration care; highlighting this as a patient safety issue she developed a tool to address this. She also identified in current practice that although some measure were in place such as the red jug and tray scheme that highlighted to staff which patients needed help with drinking, this wasn’t underpinned by an evidence-based assessment tool.

It also became apparent that patients and / or their family members needed to be routinely involved in assessing and agreeing hydration needs and this wasn’t consistently happening in practice also.

The tool designed aimed to reduce these unwarranted variations and also supported a better understanding of hydration by staff of the importance of encouraging elderly people to drink, and need for oversight of this to avoid dehydration in the frail.

How to change

The specialist nurse consulted with a wide range of healthcare professionals and other care staff including patients’ relatives and the public at public forums for elderly people before developing the tool. The tool is a one-page dehydration risk assessment tool called ‘RoC (reliance on a carer) to Drink’, with a supporting care plan guide written on the back of it. The aim of the tool is to help ‘all concerned’ to understand and recognise the ‘invaluable role of carers’ and fundamental basic care to support frail and vulnerable people to drink as best they can.

RoC provides a systematic approach in identifying what support an individual needs for safe swallowing, holding a cup, and encouragement to maintain and where needed increase their daily fluid intake.

Each area is divided into red (high risk), amber (medium) or green (low), to show where the risk of dehydration is greatest. An appropriate visual reminder (e.g. red, amber or green drinks coasters) is used to show at a glance for staff and visitors the level of support needed. A coloured care plan summary of the assessment is added to their individual care plan

Adding value

Two reviews of RoC to Drink have been undertaken, the first as an informal evaluation in a Cornwall community hospital elderly care ward. The second was as a much larger independent evaluation as part of the ‘Hydrate in Care Homes’ project held over six months by Kent Surrey Sussex Academic Health Science Network (KSS AHSN). Eighty-nine care homes took part, including thirty-eight randomly allocated to the ROC care home group. As part of this two hundred and six ‘Hydrate Champions’ were identified, half of whom were given an hour of additional training to support RoC implementation and roll out.

  • Better outcomes – From the available data, the latest study has showed significant differences in hospital admission rates from the previous year between ROC allocated homes compared with those that weren’t:
    • An 85% greater reduction in urinary tract infection (UTI) admissions;
    • A 22% greater reduction in fall-related admissions, in particular a 9% greater reduction in fractured neck of femur related admissions;
    • The standardisation of assessment for dehydration contributes to better assessment of a patients needs whilst providing a timely staff prompt to ensure patients at risk of dehydration were adequately supported.
  • Better experience – Patients and their families reported feeling reassured when staff used the tool. Anecdotally it was reported communication improved across the ward, including with domestic and catering staff as well as visitors. The evaluation study found that 100% of RoC hydration champions involved in the review would opt to continue to use the tool and summary plan after the end of the project – with 94% confident in its use. All RoC hydration champions in care home sites said they enjoyed the role. 72% of residents felt they were drinking more than in the previous 3-6 months, with more staff encouragement the key factor.
  • Better use of resources – RoC supports the efficient deployment of staff to meet patient need. Admissions avoidance has major resources benefits for the NHS. Evaluation of the tool shows the project overall indicated a saving of more than £200,000 in acute admissions costs.

Challenges and lessons learnt for implementation

  • At first nursing staff were resistant to the idea of another risk assessment tool and additional paperwork however, when they saw how simple RoC was, they became supportive.
  • As a direct result of staff and family feedback, the ROC tool has been further developed and now includes support needed for eating; highlighting that food also supports daily fluid intake. A ‘holistic’ section identifies support needed for communication, mouth care, safe positioning and continence. This combined ROC tool has been well received by all concerned, including the Care Quality Commission.

Find out more

For more information contact:

Naomi Campbell,

Hydration Specialist Nurse,