Improving the Assessment and Quality of Referrals for Hyponatraemia in a Geriatric Department: A Quality Improvement Project

Introduction
Hyponatraemia is a prevalent laboratory abnormality in older patients associated with falls, delirium, and prolonged hospital admissions. Despite established guidance, initial assessment is frequently incomplete, with premature endocrinology referrals made before adequate evaluation. This project aimed to improve the quality of hyponatraemia assessments, initial management, and referrals within our geriatric department.

Methodology
A two-cycle quality improvement project was conducted using a Plan–Do–Study–Act (PDSA) framework. Baseline audit data (Cycle 1, n=50) identified inconsistent documentation of fluid status, incomplete or poorly timed investigations, and premature specialist referrals. A multidisciplinary intervention bundle was implemented, including an acronym-based assessment prompt embedded within the hospital electronic system, enabling clinicians to apply a standardised approach, targeted teaching for doctors, and nursing huddles emphasising accurate fluid assessment and paired urine sampling. Post-intervention re-audit (Cycle 2, n=14) assessed the same metrics.

Results
Following intervention, documentation of fluid status improved from 28% to 78.6%, and medication review increased from 68% to 100%. Premature endocrinology referrals reduced from 36% to 0%. Although fewer patients underwent serum and urine sodium and osmolality testing in Cycle 2 (21.4% compared to 66% in Cycle 1), investigations were performed appropriately: samples were paired, timely, and targeted to clearly documented euvolaemic patients. This represented a qualitative improvement compared to Cycle 1, where unpaired or delayed samples limited diagnostic utility. Thyroid function tests were performed in 57.1% of cases, reflecting inclusion in routine frailty panels. Mean length of stay reduced from 9.9 to 8.6 days; a positive trend, though multifactorial. No patients had a 9am cortisol sent in Cycle 2, highlighting an ongoing area for improvement.

Conclusion
A low-cost, multidisciplinary team-led intervention improved the quality of hyponatraemia assessment, eliminated premature specialist referral, and promoted appropriate use of investigations. Future work will enhance collaboration between geriatric and endocrinology services to optimise hyponatraemia management in older adults.