- Dorothy Loane, Senior Community Dietitian, Community Nutrition and Dietetic Service, HSE Dublin Mid- Leinster, Marlinstown Office Park, Mullingar, Co. Westmeath, Republic of Ireland.
- Ms. Andrea Walsh, Clinical Nurse Manager (CNM) 2
- Ms. Frances Hughes Byrne and Ms. Margaret Harte, Healthcare Assistants (HCAs), The Lodge Ward
- Ms. Shirley Quinn, CNM 2
- Ms. Allison Donnelly and Ms. Mary Frances Farrell, HCAs, St. Therese’s Ward
- Ms. Karen Johnston, CNM 2
- Mr. Ian Redmond and Ms. Caroline Gerarty, HCAs, Padre Pio Ward (all of St. Josephs Care Centre, Longford).
- Ms. Dorothy Loane, Senior Community Dietitian.
Involved at strategic level:
- Ms. Pauline Lee, Acting Director of Nursing
- Ms. Emer McTiernan, Clinical Placement Co-ordinator/Practice Development
- Ms. Anna-Marie McKeon, CNM 1, Padre Pio Ward
- Mr. Eunan Gallagher, chef (all of St. Josephs Care Centre, Longford)
- Ms. Petrina Barden, Domestic Supervisor and Ms. Orla Brady, Community Dietitian
Involved at implementation level:
- Ms. Orla Brady, Community Dietitian, St. Vincent’s Care Centre, Athlone, Co. Westmeath
- Ms. Grainne Flanagan, Clinical Specialist Dietitian for Older Persons, St. Vincent’s Community Nursing Unit, Mountmellick, Co. Laois.
- Ms. Carola Diettrich, Community Dietitian, Abbeyleix District Hospital, Abbeyleix, Co. Laois.
- Ms. Pauline Dunne, Senior Community Dietitian, St. Mary’s Care Centre, Mullingar, Co. Westmeath. Ms. Laura McNamara, Ofalia House, Edenderry, Co. Offaly.
- Ms. Olivia Kelly, Senior Community Dietitian, Riada House, Tullamore, Co. Offaly.
- Ms. Mary McKeon, Community Dietitian, Birr Community Nursing Unit, Birr, Co. Offaly.
- Ms. Sharon Kennelly, A/Senior Community Dietitian, St. Brigid’s Hospital, Shaen, Co. Laois.
What was the problem you were trying to address?
What prompted you to do the project?
To investigate compliance and consistency of practice with regard to Dietitian and Speech and Language Therapist (SLT) recommendations, an audit of safe feeding and nutrition practices was carried out by Dorothy Loane, Senior Community Dietitian and 2 SLTs working in St. Josephs Care Centre (Public Long term residential care facility), in December 2010. Audit findings revealed that Community Dietitian recommendations regarding fortifying residents’ meals and drinks were not fully implemented. This finding was identified as a risk management issue, as without implementation of these dietetic recommendations, residents were at increased risk of malnutrition, ultimately affecting their morbidity and mortality.
Discussions within the Community Nutrition and Dietetic service revealed that all dietitians were having similar issues regarding inconsistencies in adherence to food fortification recommendations across all public long term residential care centres in the region (x 9 care centres).
It was agreed to pilot a ‘Food Fortification Project’ in St. Josephs Care Centre, Longford, and to amend the regional policy based on the outcome. Healthcare assistants are involved in both food delivery and assisting residents at mealtimes where necessary. However, up to this point, HCAs did not have a defined role in food fortification, and due to variations in documentation and reporting practices across the region, there was no measureable way of knowing if food fortification was consistently carried out as per community dietitians’ recommendations.
Community dietitians were keen to support HCAs and CNMs role in ensuring a consistent, logical and measurable approach to food fortification as an outcome of nutritional screening.
Project Objectives set:
- To develop a standardised Food Fortification process for use in conjunction with nutritional screening.
- To support CNMs and HCAs in implementing a food fortification plan prior to dietetic intervention. To facilitate a ‘person centred’ approach to food fortification.
- To develop appropriate standardised tools i.e. ‘50kcal food fortification exchange list’ and 600kcal
- ‘Food Fortification Action Plan’.
- To support CNMs and HCAs to pilot the initiative.
- To review the current regional screening policy to include the standardised Food Fortification Process.
- To roll out the standardised Food Fortification process in all care centres for older persons in the region.
- July 2011: Identify and assign CNMs and HCAs to work on project.
- August 2011: Initial local pilot carried out in St. Josephs care centre.
- September-October 2011: Evaluation of pilot.
- November 2011: Review of regional screening policy to include the standardised Food Fortification Process.
- January-March 2012: Staff education sessions, roll out of regional policy and implementation of food fortification process within all 9 sites in the region.
How did you create your project plan?
- Quarterly Multidisciplinary Nutrition Team Meetings are held in St. Josephs Care Centre.
- Discussions took place at this forum as to how to improve consistency of adherence to recommendations re food fortification, made by community dietitian.
- The project plan was devised and agreed with each appropriate discipline.
- 50kcal exchange list and 200kcal snack list (developed following evaluation of pilot) developed.
- 'Food Fortification Action Plan’ devised.
- Healthcare Assistants piloted ‘50kcal exchange list’ as method of adding 600kcal extra to residents’ diet/day.
- Food Fortification Flowchart devised.
- All community dietitians in Co. Laois, Offaly, Longford and Westmeath with a service to an Older Persons Care Centre were consulted. Edits were made to above mentioned documents based on this consultation process.
- Regional Older Person’s Care Centre Screening MNA® (Mini Nutrition Assessment) policy updated and re-circulated to all Care Centres.
- Community Dietitians held update sessions for all relevant staff in each of the Care Centres for older persons across the 4 counties.
- All care centres for older persons in Co. Laois, Offaly, Longford and Westmeath are now following the Food Fortification process as incorporated into the screening (MNA®) policy.
- There is now a standardised method of recording food fortification practices.
- Healthcare Assistants/nursing staff must sign/date each time food fortification/extra snack is given to a resident, or must document reason if same not given to/taken by a resident.
- Greater ‘person centred’ approach evident - HCAs adapting food fortification/snacks provided based on personal preferences of each individual resident.
How are you going to maintain the improvement?
- The regional screening (MNA®) policy states that it is the responsibility of the registered nurse carrying out MNA® screening to identify residents requiring food fortification and to direct HCAs to implement and follow the food fortification action plan.
- Healthcare assistants will liaise with CNMs if they have any queries/problems regarding implementation of food fortification action plan for particular residents.
- Community dietitian will liaise with CNMs and HCAs when reviewing residents on their caseload with a Food Fortification Action Plan in place. Community dietitian highlights issues, if any, related to completion of Food Fortification Action Plans to CNM as appropriate.
- Re-audit of safe feeding and nutrition practices will be conducted in St. Josephs Care Centre, Summer 2012. Food Fortification Action Plans will be reviewed as part of this audit.
- Feedback at Nutrition Team Meetings.
- Annual Audit of regional policy (MNA®) by care centre staff.
- Health Information & Quality Authority (HIQA) inspections of practice.
Tips for others planning similar projects
- Involvement of staff at project planning stage gave greater ownership to the project.
- Need to have ‘buy-in’ from both management and staff ‘on the ground’ in order for development and implementation to be successful.
- Recommend management have clear, transparent, and consistent plan in place before implementation to deal with members of staff who do not follow Food Fortification Action Plan as per policy.
- The screening tool used in this case was the MNA® (Mini Nutrition Assessment). However, the results of this project i.e. the ‘Food Fortification Action Plan’ Flowchart model could easily be adapted for use with any validated nutritional screening tool e.g. ‘Malnutrition Universal Screening Tool’ (‘MUST’).
‘Very user friendly approach. A lot more evidence based’.
‘ We can stand over this and quantify our practice much better’.
‘easy to get 600kcals’.