Go Decaf!: implementing 'decaf by default' as a quality improvement intervention to reduce toileting-related falls...

Caffeinated hot drinks are routinely offered as the default in hospitals despite guidance recommending caffeine reduction for urinary urgency. Caffeine may increase urinary frequency, disrupt sleep and contribute to toileting-related falls, particularly among older adults living with frailty.

Routinely collected incident reporting data at an National Health Service (NHS) Foundation Trust identified that around one quarter of inpatient falls were toileting-related. Staff recognised caffeine as a potential contributor but reported limited ability to influence drink provision within existing ward routines.

A registered quality improvement initiative used two sequential Plan-Do-Study-Act cycles to implement a 'decaf by default' approach across acute and community wards, an emergency department and a care home, followed by evaluation after organisation-wide rollout. Routine incident reporting monitored toileting-related falls, while staff and manager experience was assessed using structured questionnaires.

Decaffeinated hot drinks were offered as the default, with caffeinated drinks available on request. Implementation was supported by staff education, shared decision-making materials, face-to-face clinical support and a patient-facing 'Taste the Difference' activity.

Across pilot sites, toileting-related falls as a proportion of all inpatient falls reduced from 19%-21% to 11%-15%. Toileting-related falls reduced by approximately 11% in Cycle 1 and 20% in Cycle 2, with seven wards achieving reductions greater than 50%. Following organisation-wide rollout, the proportion of inpatient falls that were toileting-related reduced from 33.2% to 25.9%. Managers reported calmer ward environments, improved sleep, reduced agitation and fewer urgency-driven toileting attempts. Patient and relative feedback was predominantly positive or neutral.

Changing default drink provision to decaffeinated options is a feasible, low-cost intervention associated with fewer toileting-related falls and improved ward environments while preserving patient choice. Sustained improvements following organisation-wide rollout suggest the approach is scalable using existing clinical infrastructure.