The role of nutrition in both wound healing and pressure ulcer (PU) prevention is well documented (Saghaleini et al, 2018). However, what is less well known is the link between hydration, wound healing and PU prevention due to the effect of dehydration on blood volume and skin turgor. Fluids are responsible for providing transport of vitamins and nutrients to, and waste products away from, cells as well as allowing oxygen perfusion and hydration to wounds (Posthauer, 2012).

      Classification of dehydration is as follows (Posthauer, 2012):

Isotonic dehydration — an equal loss of both water and sodium caused by diarrhoea and vomiting

Hypertonic dehydration — the loss of total body weight due to reduced water intake, pathologic fluid loss or both

Hypotonic dehydration — a predominant loss of sodium over water loss, resulting in extracellular fluid loss. This can occur due to renal disease, diuretic usage or reduced intake of both water and sodium.

Dehydration facts

      Nearly two thirds of hospital admissions are of people over the age of 65 years old, 37% of these admissions are dehydrated on arrival to hospital, with 62% remaining so 48 hours after admission. (ElSharkawy et al, 2014). Dehydration can lead to an increased risk of mortality in patients who are acutely unwell and an increase in the risk of further illnesses including urinary tract infections (UTIs), seizures, acute kidney injury (AKI) and hypovolemic shock, as well as increasing the risk of PU and falls.

      This all suggests that there needs to be more emphasis on prevention of dehydration and a proactive rather than a reactive approach is required.

      In 2020, an acute gastroenterology (GI) ward at the Leicester Royal Infirmary was chosen to participate in the Trust's Pressure Ulcer Collaborative as part of a ‘Pathway to Excellence’ journey. Representatives from seven wards in the Trust came together to discuss their ward's achievements, and areas in which they needed development to improve the pressure area care they were providing.

      Noting that many patients on a GI ward are dehydrated due to their illnesses and conditions, the acute GI ward chose to concentrate on the problem of dehydration. It was identified that, within the Trust, patients are not formally assessed for dehydration on admission or throughout their stay unless blood tests are taken, which causes discomfort to the patient and incurs a financial cost. As part of the collaborative a review was undertaken to determine if there was an existing risk assessment tool that could be piloted in the acute area.

WHAT IS GULP?

      A review of available literature identified that a risk assessment exists and is used in community settings in some areas of the country; this is called the GULP dehydration risk screening tool and was developed by the Food First Nutrition and Dietetics Team (2012).

      The original tool was developed for use in community settings and assesses three factors to gain an overall risk score of low, medium or high. This risk score is then used to implement the correct suggested plan of care based on the level of harm that continued dehydration poses:

G Gauge 24-hour fluid intake and measure against an identified requirement

U Urine colour

L Look for signs, symptoms and risk factors for dehydration

P Plan

      It was determined that, with some modification, the assessment was suitable for use with inpatients in an acute hospital setting and written permission was obtained to adapt the tool accordingly from the Food First Team.

The adapted tool

      G:The 24-hour fluid requirement was made more specific to an individual’s needs by using a person’s age and weight to identify their fluid requirement based on a formula of 30ml/kg of weight for patients 60 and over (Hodgkinson et al, 2003) and 35ml/kg for patients under 60 years old (Zeman, 1991) and adding an estimated guide of how many cups of drink are required to meet this, based on the cup size and a fluid estimation tool already in use within the Trust.

      U: As many GI patients have dark urine due to jaundice, which may be unrelated to their dehydration status, this was highlighted on the urine colour assessment to reduce the incidences of false high scores in this category. Incontinence was also addressed, with the addition of monitoring of wet incontinence products and consideration of how strong the urine smells. A urine colour guide was also added.

      L: The signs and symptoms of dehydration were reviewed and additions were made to account for patients who struggle to get to the toilet as fluid intake may be deliberately reduced by these patients. The use of thickened fluids was also added, as this can be a predisposing factor to poor oral intake as a result of patients' dissatisfaction with thickened fluids (McCurtin et al, 2018) due to the texture, taste and sensation as well as an increased feeling of satiety and thirst felt with their use (Cichero, 2013).

      P: The low, medium and high-risk care plans were altered to make them more relevant to acute hospital settings.

      Formal validation of the amended tool may need to be considered in the future.

Exceptions when using the tool

      If a patient is started on IV fluids, only oral fluid intake is to be counted when assessing GULP scores (this includes intake via enteral feeding methods) If the patient is started on an oral fluid restriction for any reason, the assessments should be discontinued until the restriction is lifted

      If a patient is nil by mouth (NBM) the assessment is put on hold until oral fluids are restarted (unless the patient is receiving enteral feed/fluid, in which case this should be counted as oral fluid intake).

      The adapted tool was then peer reviewed by a Consultant Gastroenterologist, an Intestinal Failure Specialist Nurse and a Senior Dietician, who all gave constructive positive feedback.

How to complete the tool

1. Assess the patient’s oral intake for the previous 24 hours based on the provided minimal requirements – is it:

      > their minimal requirement (Score 0)

      < their minimal requirement but > 1000ml (Score 1)

      < 1000ml (Score 2).

2. Assess the patient’s urine colour based on attached guide:

      Colour 1–3, no smell, several wet pads a day (Score 0)

      Unable to assess due to non-adherence/jaundice, smells at times, only 1–2 wet pads a day (Score 1)

      Colour 4–8, very strong smell, pads only slightly wet (Score 2).

3. Look for current signs of dehydration and

3. medical conditions or medications which predispose the patient to dehydration:

      Score 0, 1 or 2 based on the guidance information on the risk assessment.

4. Scores are totalled to give an overall risk of Low, Medium or High.

5. Appropriate care plan can then be initiated based on patient score.

                                                     Figure 1. Adapted GULP dehydration risk assessment, by Deputy Sister Karen Green

THE PILOT

      For the pilot, 6 patients in one bay were selected and had their GULP score reviewed on Tuesdays and Saturdays for the duration of their stay (Figure  2). There were 6 patients chosen. This allowed for a variety of GI conditions to be observed within the selected bay, on a randomised basis, while still allowing concise monitoring conditions to ensure high levels of compliance with the tool and associated identified care plan. A pilot study is defined by Porta (2008) as:

     "A small scale test of the methods and procedures to be used on a larger scale.”

      Informed consent was obtained from all patients in this pilot study for non-patient identifiable data to be collected, recorded, and compared and for the appropriate care plan to be implemented. As this data was collected on tools and assessments already recognised and in use within the Trust such as fluid balance charts (FBC) and the Waterlow risk assessment tool it was not necessary to gain ethical approval to add this data to the GULP tool. The tool did not replace routine blood tests during the trial.

RESULTS

      It was noted that 5 of the 6 patients in the pilot study were dehydrated on admission to hospital as indicated by their GULP risk assessment score. On discharge 3 of these 5 patients had a lower GULP risk score than on admission suggesting an improved hydration level. There were 2 patients who remained at the same risk level. Throughout the study, no patients had a decline in their dehydration status or developed AKI.

      Although the pilot was only conducted on 6 patients, it indicated that it is possible to identify patients who are dehydrated or at risk of dehydration earlier on in their admission and monitor them easily throughout their stay. Furthermore, through the early implementation of a basic hydration-specific care plan, none of those at risk of dehydration within the pilot group developed AKI during their admission.

      In 50% of the sample group, as the patient’s GULP score went down so did their Waterlow (Figure  3). This limited pilot was therefore considered successful, as a positive correlation was shown in half the sample group. Pilot studies when designed and conducted well may give an indication of the likely outcome of a larger trial (van Teijlingen and Hundley, 2002).

Next steps

      On the basis of the successful pilot, the initiative is moving forward to an extended although still limited patient group to ascertain whether the tentative results from the pilot are replicated in a larger patient group over an extended period.

      The tool was to be used on all suitable admissions to the GI ward over a 6-month period between 1  July 2021 and 31 December 2021. This data will then be collated to identify whether the reduced Waterlow scores seen in the initial pilot are replicated on a larger scale. The incidence of PUs on the ward during this 6-month period will also be compared with the incidence of PU during the same 6-month period for the previous three years (2020, 2019 and 2018), as well as to those of a control ward, also GI in speciality for the 6-month trial period. Following this, the tool will potentially be used in other specialities to extend the pilot further.

Limitations

      The initial pilot was incredibly limited and was carried out as such to test the efficiency and usability of the tool before a larger pilot took place over an extended period. The tool has only been used in GI medicine and so it is not clear whether the same results will be obtained in different acute specialities throughout the Trust. The tool was initially met with some resistance from ward staff and, due to the Trust operating a paperless system, the tool was occasionally missed during regular patient assessment.

Declaration of interest

There are no conflicts of interest.

REFERENCES

1. Cichero JA (2013) Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutr J 12: 54. https://doi.org/10.1186/1475-2891-12-54.

2. El-Sharkawy AM, Watson P, Neal KR et al (2015) Hydration and outcome in older patients admitted to hospital (The HOOP prospective cohort study). Age Ageing 44(6):943-7. https://doi.org/10.1093/ageing/afv119

3. Food First Nutrition and Dietetics Team, South Essex Partnership University NHS Foundation Trust (2012) GULP Dehydration Risk Screening Tool. https://tinyurl.com/mds2db2u (accessed 3 September 2022)

4. Hodgkinson B, Evans D, Wood J (2003) Maintaining oral hydration in older adults: a systematic review. Int J Nurs Pract 9(3):S19–S28. https:// doi.org/10.1046/j.1440-172x.2003.00425.x

5. McCurtin A, Healy C, Kelly L et al (2018)Plugging the patient evidence gap: what patients with swallowing disorders post-stroke say about thickened liquids. IJLCD 53(1):30–39. https://doi.org/10.1111/1460- 6984.12324

6. Porta M. A Dictionary of Epidemiology (5th edn). Oxford University Press, 2008

7. Posthauer ME (2012) Dehydration and wound healing: know the facts. [Weblog] Wound Source. https://tinyurl.com/2s3a3epj (accessed 3 September 2022)

8. Saghaleini SH, Dehghan K, Shadvar K et al (2018) Pressure ulcer and nutrition. Indian J Crit Care Med 22(4):283–9. https://doi. org/10.4103%2Fijccm.IJCCM_277_17

9. van Teijlingen E, Hundley V (2002) The importance of pilot studies. Nurs Stand 16(40):33–6. https://doi.org/10.7748/ns2002.06.16.40.33.c3214

10. Zeman FJ . Clinical Nutrition and Dietetics. 2nd edn. Macmillan Publishing Company: NewYork

This article is excerpted from the Wounds UK | Vol 18 | No 3 | 2022 by Wound World.