Kingston Hospital

Team Leaders

  • Cathy Forbes, Food First Project Lead
  • Leanne Fishwick, Dietetic Team Lead

SEPT community Health Services,
Bedfordshire Nutrition and Dietetic Department, Dunstable Health Centre, Dunstable, LU6 3SJ.
01582 707400

Team Members

  • Helen Glyn-Davies – Clinical Service Manager, Nutrition and Dietetics
  • Kalpana Mepani – Dietitian
  • Vittoria Romano – Dietitian
  • Clare Morris – Dietitian
  • Lorna Faid – Dietitian
  • Natasha Farleigh – Assistant Project Manager
  • Lucy Gough – Assistant Dietetic Practitioner

What was the problem you were trying to address?

The project was initiated in September 2009 with the aim of improving the identification and management of malnutrition in local care homes.  Data from BAPEN’s nutrition screening weeks in 2007 and 2008 had found that 30-42% of residents admitted to a care home in the last 3 months were at risk of malnutrition.  However it is also widely recognised that malnutrition is under-recognised and under-treated and locally we found that although most care homes used a malnutrition screening tool, various tools were in use, errors were common and that screening did not always lead to implementation of an appropriate management plan.  This is similar to results found by Bailey (2006) in an acute hospital trust.  Identified barriers to following nutritional policy include poor understanding  of the importance and relevance of nutritional screening and a lack of expertise in using screening tools (Rasmussen et al, 1999, Porter et al, 2009).

Therefore the project intended to create a robust system of training, audit and support to enable a culture change within social care that would make malnutrition a priority and more than a paperwork exercise.  To support this, the work has linked to the harmfree care agenda since its launch in October 2011.

Objectives:

  • Care home staff working at all levels (including management, care assistants and catering team members) aware of the consequences of malnutrition and the benefits of managing nutritional risk appropriately
  • Care home staff able to complete MUST screening tool accurately and in a timely manner for all new admissions and existing residents
  • Care home staff aware of how to take a Food First approach to managing malnutrition in order to promote the creation of individualised and person centred care plans
  • Programme of on-going reviews of practice to ensure high standards of nutritional care achieved and maintained
  • Promote a “whole home” approach to managing malnutrition

How did you create your project plan?

Initial meetings with nursing and catering representatives from a local care home to identified barriers to good nutritional care including poor communication between catering and nursing teams, lack of understanding regarding MUST screening tool despite in-house training and a need to generate interest in changing practice.

Discussions with other dietetic teams undertaking similar work raised common themes and problems.

Scoping audits at care homes revealed that not all care homes had a screening protocol in place and many did not follow the BAPEN guidance on how frequently to undertake screening. These also revealed that care homes were often unaware of errors in MUST documentation and of best practice.

Project plan has continued to be developed and refined after receiving feedback on training from key stakeholders, including council social care team, GPs, care home staff and other dietitians working locally.

Key Actions

  • Development of Food First in Bedfordshire Care Home Scheme
    • Requires care homes to undertake self-reported audit of practice, attend training sessions and be audited against Food First standards
    • To achieve status and receive certificate to display management must agree to Food First expectations
    • Re-audits carried out 6 monthly – certificates removed if fail to meet standards
  • Development of Food First training
    • Practical training on how to carry out MUST screening
    • Introduction to local MUST management guidelines – including identifying underlying causes for poor oral intake and creating a personalised action plan
    • Sharing of good practice
  • Development of suite of Food First supporting resources
    • Evidence-based and peer reviewed information sheets on how to tackle common reasons for poor oral intake, e.g. constipation, dementia, mouth problems
    • Simple and practical advice sheets on how to increase oral intake through fortified diet, nourishing drinks and snacks

Main Outcomes

  • 60% of local care homes achieving Food First status
  • Over a 1000 care home staff trained (total)
  • Over 90% of those trained by the team have rated the quality of the training highly and 80% expect the training to have a significant impact on their future work
  • Reduction in reliance on ONS, 63% patients reviewed stopped ONS as it was deemed unnecessary once an individualised care plan had been initiated. This has meant a reduction in the prescribing costs of ONS of 25-50% (depending on locality) providing the PCT’s with savings.
  • Closer working relationship between nutrition and dietetics and social care
  • Raised awareness of the importance of malnutrition at the highest trust levels
  • Winners of trust Effective Team Award and Advancing Healthcare Leadership Award
  • Short listed for Patient Safety awards

How are you going to maintain the improvement?

Cultural and organisational change being achieved will help to ensure that the work is not a “quick fix” but a sustainable approach.

The project is constantly adapting and changing to ensure that standards are maintained and further improvements are made e.g. new resource development, re-design of the way training is delivered to ensure greater engagement.

Posts currently funded to end March 2013 via savings made on ONS spend. Going forwards, funding will aim to be sought via commissioners due to improvements in nutritional care and anticipated reduction in sequelae of malnutrition and therefore improvement in patient outcomes. The project has a huge role to play in improving patient safety and helping to promote harmfree care in the community setting.

Tips for others planning similar projects

Creation of award scheme ensured consistency of approach and incentivises care homes and staff to engage in the process of training and audit. This also rewarded positive behaviour – rather than focussing on negatives in an area where bad publicity is common.

Clear focus is essential and necessary to ensure that project does not stray off course.  Also required when trying to change embedded practices and opinions.

Important to get enough staff funded on the project (especially at the start) to ensure that changes can be achieved and maintained. Also, strategic and high level support essential – achieved in this case by sharing work, promoting positives whenever possible and linking to national healthcare agenda.

Top Quotes

Care home managers from training evaluation “the programme has helped us to feel confident that we are addressing malnutrition…[working with the Food First team] gave staff a sense of self pride at doing [their] job properly”.

SEPT Chief Executive Professor Patrick Geoghegan “[the Food First team] have a passion for their work and for delivering the best patient improvement outcomes. Whilst this programme is in its infancy its impact is already demonstrating a measurable change in practice”

Team Leaders

  • Dr Nicola Simmonds, Consultant Gastroenterologist
    Luton and Dunstable Hospital. E-mail: nicola.simmonds.ldh.nhs.uk

Team Members

  • Nicola Simmonds, Consultant Gastroenterologist
  • Hazel Rollins, Nutrition Nurse Specialist
  • April Smith, Chief Dietitian
  • Sue Batty, Catering Services Manager
  • Jacqui Arnold, Nutrition Research Nurse
  • Alison Balman, Senior Dietitian

The team could not have done this without the great support from the Trust Chief Executive, Stephen Ramsden and the Trust Chariman, Eric Fountain.

What was the problem you were trying to address?

Our Trust had taken the decision in 1996 to introduce a soup and sandwich evening meal. There was concern from the dietitians and nutrition nurse specialist that this would have a detrimental effect on patients’ food intake. This led to a weighed food intake demonstrating that no patient met their recommended daily energy and only 2/20 patients met their protein requirements. A patient satisfaction survey had shown that 21% of patients did not enjoy the evening meal and there had been a 27% increase in dietetic referrals over a year and a 19% increase in the monthly expenditure on oral nutritional supplements.

In 1998 we received charitable funds for our “Eating Matters” project. This was a broad ranging project attempting to address every stage of nutritional care from nutritional screening, food availability and service, staffing and monitoring.

How did you create your project plan?

We started by identifying all the stakeholders in the delivery of nutritional care to patients and by creating a process map of all the various steps involved. Meetings were help to ensure all the following staff groups were included in the consultation exercise:

Senior nurses, ward sisters and nutrition link nurses

  • Dietitians
  • Caterers
  • Therapists
  • Fire Officer
  • Nutrition Steering Committee members
  • Medical staff

The members of the project team met on a weekly basis to discuss progress and drive further actions. The project would not have been possible without the nutrition research nurse who was responsible for the day to day data collection and coordination with the other stakeholders to purchase the new equipment, appoint and train the additional staff and liaise with the dietitians and catering department over the improvements in food provision.

Contributors to Eating Matters

Eating Matters

Key Actions

  • Provide additional equipment (scales, stadiometers, toasters, microwave ovens on the wards, specialist crockery and cutlery)
  • Provide additional food (diabetic snacks, snacks for small appetites, cakes with afternoon tea, sandwiches for the Day Hospital, ward provisions)
  • Review the patient menu (Improved range and supply of ward provisions, re-introduction of a cooked evening meal, improved ethnic meals, changed sandwich supplier, porridge made with milk not water, improved choices on menu, patient feedback encouraged)
  • Employ new staff (nutrition research nurse, 2 ward hostesses)
  • Monitor outcomes (nutrition risk screening audit, weight change study, patient satisfaction survey, weighed food intake study, food wastage, dietetic contact episodes, oral nutritional supplement use, observational audit, length of hospital stay, toaster fires)

Main Outcomes

  • Improved patient screening (recording of weight increased from 57% to 91%, height from 6% to 61% and BMI from 11% to 33%)
  • Reduced plate waste
  • Reduced tray waste on wards with ward hostesses (by 3-8%). Other wards showed an increase in tray waste over the same period, particularly in surgery where levels ranged from 24-33% wasted).
  • Greater food availability on wards with ward hostesses
  • Specialist feeding equipment makes one quarter of those using it independent in feeding
  • Far fewer toaster fires (from 29 to 2 per year) – ensuring toast is readily available on all the wards
  • Patient satisfaction improved, with the numbers rating their meals as good or very good increasing from 47% to 63% and those rating their meals as poor or very poor decreasing from 19% to 6%
  • Increased numbers of patients meeting >95% of their energy (from7% to 47%) and protein requirements (from 11% to 52%)
  • Patients lose less weight (in Medicine the percentage of patients losing weight during their hospital stay reduced from 22% to 15%)
  • Reduced supplement use (from a peak of 3500 units per month to 1500 units per month)
  • Increased dietetic referrals (the number of dietetic contacts increased from 6521 to 8801)
  • Reduced average length of stay in Medicine from 4.8 days in 1998 to 4.3 days in 2000

How are you going to maintain the improvement?

This proved to be the greatest challenge. We were able to translate much of the work we had already done into implementing the Better Hospital Food programme. However, catering yet again became the target for savings and we struggled to maintain the crucial working relationship with the catering department that is essential to ensuring adequate food availability on the ward. We were also unable to extend the ward hostess programme, despite the evidence of cost savings in terms of reduced waste.

We concluded that in the days of competing priorities for finance, the priority was to ensure that nutrition was mandated as part of commissioning, with financial penalties for failure to achieve targets. We ensured that our Trust was one of the first wave Trusts taking part in the Patient Safety Express programme and that this was supported at a senior level. Nutritional care on the Care of the Elderly wards is now also a CQUIN and we are pleased to report that the staff on the ground remain passionate about good nutritional care.

Tips for others planning similar projects

  • Identify all your stakeholders
  • Engage senior management
  • Be realistic about the amount of time it will take
  • Lobby hard for sufficient resources
  • Ensure that you foster a great relationship between the catering department and the wards
  • Develop a robust communications plan

Top Quotes

Top Quotes

Loyd Grossman visit 2004 - quote

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