Improving nutritional care in our hospitals

4th May 2017 BAPEN Scotland

Denise Deas & Elisabeth Waterhouse Project Dietitians (Practice

Development)

• Nutritional care • Project over view • Study days • Facilitation • Sustained approach

https://uk.pinterest.com/pin/390687336400029939/

Good nutritional care?

https://www.youtube.com/watch?v=w1QaThLJi_0

Good nutritional care is dependent on a co-ordinated approach to the delivery of food and fluid by all healthcare professionals. This process takes into account the individuals requirements, preferences and cultural needs. Illness, disease and/or lifestyle can have a significant impact on nutritional status by altering nutritional requirements

(NHSGGC Nutrition Resource Manual)

Background • The provision of adequate nutrition and

hydration is a fundamental cornerstone of compassionate care and a basic nursing task which is frequently overlooked (Francis, 2013)

• Good nutritional care improves disease outcomes and patients quality of life (BAPEN, 2010).

• Maximising opportunities for individuals to eat and drink and maximising quality and choice of food and fluids offered are considered to be fundamental to improving intakes (Scottish Government, 2010)

• ‘This is the challenge, but one that can be met through clear communication and coordinated actions between all those involved in the food chain including input from the patients themselves. This will be central to the success of the wider nutritional care of patients’ (Scottish Government, 2010)

Overview of project • Money from Scottish Government in 2015 • 12 month secondment ending in May

2017 • Support good nutritional care within acute

ward areas • Support evidence for Care Assurance

Standards (CAS)

Project aim By May 2017, facilitated wards within NHSGGC will demonstrate 95% compliance with safe, effective and person centred nutritional care processes in relation to Care Assurance System (CAS) standard 8.

Project Objectives • Improve staff knowledge and

understanding in basic nutrition and hydration and its impact on adult acute patients whilst in hospital

• Support accurate and meaningful nutritional screening and assessment at ward level

• Improve care planning and evaluation in relation to nutrition

• Improve compliance with the meal time bundle

Study days

Aim To improve CAS Link Nurses (standard 8) and nominated HCSW knowledge and understanding of the impact of nutrition on patient care through education and training to support improvements in nutritional care at ward level.

Content • Basic principles of nutrition and hydration

including LBM and fluid balance monitoring

• Mealtime processes/bundle including TMD and tasting session of patient meals

• Signposting to specialist nutrition related services e.g. RD, NNS and SLT

• Scenario based nutritional screening with MUST and care planning

Nutrition • Major function of food is to provide the

body with energy • Imbalance = malnutrition • 25-34% hospital admissions are at risk

(BAPEN, 2016)

• Consequences of poor nutritional intake = lean body mass (LBM)

LBM Functions

Digestion

Skin integrity

and healing

mobility

Generation

of heat

Immune function

Organ function

Hydration • Water is essential for life and maintaining the

correct balance of fluid in the body is crucial to health (RCN 2007)

• Good hydration can assist to prevent or treat many conditions including constipation, cognitive impairment, pressure ulcers and UTI’s (RCN 2007)

• There must be provision to ensure patients are able to access a minimum of 1.5 litres of fluid per day (Food in Hospitals 2010)

Mealtimes and food provision • NHS GGC Mealtime bundle

- Mealtime coordinator - Meal choice sheet - Mealtime observation tool - Patient and staff questionnaires - Identifying assistance levels

Food first approach

• Communication • Ward provisions • Promote patient experience • need for supplements

Knowledge and understanding

60

65

70

75

80

85

90

Knowledge Understanding

PErc

enta

ge

Health Care Support Workers (HCSW) mean score of knowledge and understanding pre and post study day

Pre

Post

Knowledge and understanding

70

75

80

85

90

95

Knowledge Understanding

Perc

enta

ge

Link nurse (LN) mean score of knowledge and understanding pre and post study day

Pre

Post

Knowledge and understanding results

• 12% increase in knowledge of the link between malnutrition LBM was demonstrated by LN post study day.

• HCSW demonstrated an increased knowledge of the use of alternative measurements to obtain weights and heights pre (8%) and post study day (27%).

Confidence

0

1

2

3

4

5

6

7

8

9

10

Pre confidence in K and U Post confidence in K and U Pre confidence to championnutrition

Post confidence to championnutrition

Aver

age

con

fiden

ce le

vels

(0=

not c

nfid

ence

, 10=

ver

y co

nfid

ent)

Link nurse(LN) and health care support worker (HCSW) average confidence in nutritional knowledge and understanding and ability

to champion nutrition in practice, pre and post study day

HCSW

LN

Tasting

• Taster menu of patients food provided (produced by one of the two Central Food Production Units)

• Standardised meal choices • Choice of Soup, 3 main courses and a hot

pudding • 160 candidates who took part in the

survey

Tasting results

• >80% felt the quality of food provided was very good or excellent

• ~70% thought the quality was better than expected

• ~80% had positively changed there opinion of hospital food

Facilitation • Promoting hospital food and food first

approach • Promoting communication through

nutritional screening, care planning and catering staff

• Promoting compliance with mealtime bundle

• Promoting online training using learnpro and digital routes

Data collection results Q1 Has the patient been screened using MUST

within 24 hours of admission to hospital? • 44% (8 out of 18) of wards showed

improvement • 50% showed <10% improvement • 13% showed 10-20% improvement • 37% showed >20% improvement

Data collection results Q7 Has the patient been screened every 7

days from initial screen during hospital stay? • 33% (6 out of 18) of wards showed

improvement • 16% showed <10% improvement • 50% showed 10-20% improvement • 34% showed >20% improvement

Data collection results Q10 Is the MUST score accurate on the

current screen? • 61% (11 out of 18) of wards showed

improvement • 36% showed 10-20% improvement • 64% showed >20% improvement

Data collection results Q13 Does the patient has an appropriate

current documented nursing plan of care? • 50% (9 out of 18) of wards showed

improvement • 11% showed <10% improvement • 33% showed 10-20% improvement • 56% showed >20% improvement

Meal time observation results • 67% (12 out of 18) wards showed

mealtime improvements • Main areas of improvement - Patient hand washing - Choice of drinks with meal - Mealtime brief - Use of RAG system - Mealtime without interruptions

Meal time observation results

0

1

2

3

4

5

6

7

8

9

10

<10% 10-20% >20%

Num

ber o

f war

ds

% improvement

Number of facilitated wards showing improvements in compliance with the meal time observation tool

Sustainability • Patient centred care • Leadership • Culture change

• https://www.youtube.com/watch?v=V74AxCq

OTvg

Websites • http://www.rcgp.org.uk/policy/rcgp-policy-

areas/francis-report.aspx • http://www.bapen.org.uk/ • http://www.gov.scot/Resource/Doc/229423/0

062185.pdf • https://www.rcn.org.uk/

FFNPracticeDev@ggc.scot.nhs.uk Elaine Gordon, Denise Deas,

Elisabeth Waterhouse