Chaffin Final CQI

Running head: CONTINUOUS QUALITY IMPROVEMENT 1CONTINUOUS QUALITY IMPROVEMENT 3

Continuous Quality Improvement of Pureed VegetablesMolly Chaffin The University of Southern MississippiIntroductionDysphagia, or any condition that results in difficulties chewing or swallowing, is frequently seen in hospital or long-term institutional facilities. This condition often contributes to decreased oral intake and therefore increases an individuals risk for malnutrition. According to Bhattacharyya (2014), approximately 4% of the United States population reported experiencing difficulties in chewing or swallowing; increased prevalence of dysphagia was also associated with increasing age and co-morbidities such as stroke, Alzheimers disease, Parkinsons disease, head and neck cancer, or other neurological causes. With new advancements in technology and medicine increasing the life span of the average American, dysphagia prevalence is only expected to increase in acute and long-term care facilities; therefore, proper treatment and interventions must be considered to accommodate these patients and prevent further health complications such as malnutrition or aspiration pneumonia. Adequate nutritional intake is often difficult for patients with dysphagia. A standard diet is often inappropriate due to the inability to properly chew or swallow foods, which in turn presents choking hazards. Diets must be properly adapted to meet the individuals chewing and swallowing abilities. Different levels of dysphagia diets are often employed at many healthcare facilities to provide the patient with the most palatable and appealing meal possible while still modifying the meal texture to the level that is required. For example, the Veterans Health Administration (VHA) of Biloxi utilizes three levels of the dysphagia diet. Dysphagia I diets include only full liquids, dysphagia II diets are composed of pureed foods, and dysphagia III diets include mechanical or chopped menu items. Each level also includes modifiable consistencies of liquids including thin, semi-thick, or thick liquids. While texture modified diets provide a solution for chewing and swallowing difficulties, individuals on these diets often experience decreased oral intake and nutritional inadequacy. This may be due to neurological complications affecting appetite, lack of appeal of texture modified foods, or decreased nutrient density due to increased water content of mechanical meals (Ilhamto, Keller, & Duizer, 2014). One study conducted by Pritchard, Davidson, Jones, and Bannerman and colleagues (2014) found that oral intake of the same meal significantly decreased when the texture was modified (66 g intake to 51 g intake). This study concluded that texture modifications resulted in decreased energy intake and decreased palatability ratings in healthy adults. Because texture-modified diets are essential for patients with dysphagia, proper preparation methods and plate presentation should be utilized to increase meal appeal, promote oral intake, and ensure adequate nutrition in these patients. One study conducted at Sainte Annes Hospital in Quebec attempted to determine if an experimental dysphagia diet would promote oral intake and weight gain in dysphagia patients (Germaine, Dufresne, & Gray-Donald, 2006). This diet provided minced or pureed menu items reshaped food molds to improve appearance; these items varied throughout a three-week cycle menu in which patients could note their preferences or aversions. Thickened beverages and nutritional supplements were also provided as needed. This study compared this experimental diet to those on a control diet, which met individual needs and preferences. The experimental group received one of three different texture modifications (minced-70, minced-3, or pureed) depending on patient need. This group was also provided thickened beverages and supplements as needed. The results of this study concluded that the experimental diet providing a more pleasing appearance and a greater variation of menu items. Germaine et. al (2006) also noted that supplemental beverages significantly increased energy intake. The average change from baseline to the end of the twelve-week intervention was an increase of 611 kcal/day in the intervention group compared to an 81 kcal/day increase in the control group. The intervention group also experienced an average weight gain of 3.90 kg whereas the control group lost an average of 0.79 kg from baseline to completion. From this study, it can be concluded that improving the appearance and variation texture modified diets and providing supplemental beverages to help meet needs can increase intake and nutritional adequacy of texture modified diets. While food molds and reshaping do contribute to the overall appearance of texture-modified meals, these methods are not always feasible in many hospitals or long-term care facilities. The VHA, for example, uses a cook-chill food preparation method where reshaped pureed items would be unlikely to hold form during rethermalization. Other methods, therefore, must be determined to provide visually appealing and palatable meals for individuals receiving a dysphagia diet. One factor of mechanical or pureed diets that tends to influence acceptability is the consistency. Many foods tend to appear soupy or watery following texture modification. Not only may this consistency cause food to appear less appealing, it may also alter the flavor or the nutrient content of the food. In cases where food molds are not an option, the consistency of texture-modified items must be properly controlled. Commercial thickeners are often used in food service facilities to assist in creating a proper consistency or thickness in beverages and foods in dysphagia diets. Commercial thickeners may be of a gel consistency or a powder form; these thickeners are added to the liquid or during pureeing to create a thicker form of the original product. Most commercial thickeners are advertised as unflavored; Matta and colleagues (2006), however, found that five out of five commercial thickeners tested created a slightly off-flavor. Different commercial thickeners also change the texture of the food or beverage in different ways. The results of this study reveal that the starch thickeners often produce a different flavor and more grainy texture than the gum thickeners. Gum thickeners resulted in a more slimy texture but produced more consistent results than the starch based thickeners. This study revealed that while commercial thickeners are useful in producing a more consistent and dense texture, thickeners may also produce altered flavors and textures.BackgroundAccording to observations by the nutrition and food service (NFS) administrative staff at the VHA, the vegetables in the pureed dysphagia diet experience the greatest variance in consistency and water content compared to the other meal items. This may be caused by a variety of contributing factors. First off, different vegetables contain very different water contents; for example, steamed squash has a much higher water content than carrots, and therefore may produce a more more soupy product upon blending. Due to the variation in water content, a standardized method for pureed vegetables does not exist; individuals preparing the items must use their own judgment to alter the recipe to produce the best end product. While most of the cooks who produce the pureed vegetables use a similar method and include the addition of a commercial gel thickener and extra water, each cooks method may vary slightly and produce different results. This preparation method also presents difficulties because the cooks do not see how the final product appears. Following preparation, the food is then chilled, portioned, and reheated individually for service. The consistency and appearance, therefore, may be different when the food is presented to the patient.

ProcessUpon observation, it was noted that each cook prepares the pureed vegetables by different method. In general, the cook separates approximately one to two quarts of vegetables (unmeasured) during preparation, and places the vegetables into the blender. The cook then collects vegetable stock from the container in which the product was originally prepared and places the liquid into the blender with the vegetables. This liquid is also unmeasured, but appeared to be about a quarter of the content of vegetables. The cook then blends the vegetables with one 4 oz. container of the gel commercial thickener used at the facility. Upon one observation, the cook added dehydrated mashed potato mix to the pureed vegetables to increase thickness. These observations revealed that the method of preparation varies between cooks and between vegetables. None of the observations revealed the use of a standardized recipe or measurement tools in the pureed vegetable preparation. A method for testing the consistency was also not observed; the employees observed the blended product, poured the product into storage containers, and estimated consistency by appearance only.Comment by Roxanne Kingston: This shows that this is a perfect time for a CQI project! ObjectiveThe purpose of this study was to determine the best method for the production of pureed vegetables at the VHA in Biloxi. The study was designed to test three different preparation methods and conduct multiple sensory analysis evaluations to determine differences in appearance, texture, flavor, and overall acceptability. Following analysis of the results, the most favorable method would be converted into a standardized recipe and distributed to the cooks for future use.

Methods

Ten vegetables were selected from the VHAs three-week cycle menu. Memos were distributed to the food service supervisors to save any leftovers from lunch and dinner production for a span of four days (February 16th through February 19th). These vegetables were labeled and placed in the refrigerator for collection by the dietetic intern on Tuesday February 17th and Thursday February 19th. During the first experimental process, the dietetic intern collected the first six vegetables for preparation using three different recipes. Sample number one included cup of strained vegetables blended with cup of water. Sample number two included cup strained vegetables, cup water, and 1 tablespoon of cornstarch. The third sample included cup strained vegetables, cup of water, and oz of commercial gel thickener. These three methods of preparation were conducted with each of the first vegetables, including asparagus, peas and carrots, carrots, cream style corn, collard greens, and an Italian blend. Each of the samples were labeled and portioned into the VHAs dishes used for patient service. All samples were then placed in the cooler until 9:00 a.m. the following morning, in which they were placed on a tray in the rethermalization unit along with the usual lunch meal. Following rethermalization, the trays were removed at 11:45 a.m. and transported to the NFS office. Nine volunteers were then asked to taste each of the three samples for all six vegetables and record the results on a sensory analysis form (displayed in appendix A). This process (including the collection of leftover vegetables, three preparation methods, rethermalization, and sensory analysis) was then repeated on February 19th and 20th. Four vegetables were tested on these days and included summer squash, zucchini, peas, and California blend (broccoli, cauliflower, and carrots). Data from the sensory analysis forms was then compiled into a spreadsheet for analysis. Results are displayed in figures 1-6.Evaluation results were categorized by appearance, texture, flavor, and overall acceptability. To condense the evaluation to one form, all characteristics were rated from none to extremely strong; for example, volunteers were to mark none, minimal, moderate, strong, or extremely strong pleasing appearances. These categories were given a score from 1 to 5, with 5 being extremely strong and 1 being none. Therefore, a higher score represented a stronger characteristic, but did not always represent preference. For example, a score of five might represent an extremely strong pleasing appearance, but a score of 5 in the texture category might represent an extremely strong gritty texture. ResultsAs predicted, scores and preferences between thickeners varied with different vegetables. Although all vegetables were prepared using a systematic method (two parts vegetable to one part water), the results varied in consistency, texture, taste and appearance. Not all vegetables were well accepted, specifically method #2 which used one tablespoon of cornstarch to thicken. Comments from method #2 included smoother texture, creamier, and best texture. A majority of the comments, however, were negative, including: thick, too thick, yuck! and pasty. The results of the sensory evaluations are discussed below.Method #1 included the most comments of good from ten different evaluation forms. This method, however, also had many comments including too lumpy, not well blended, and not smooth. Very few evaluators left comments on the evaluations for method #3. Four evaluators reported liked best! and six reported good for method number three.

AppearanceAs shown in table 1, the highest scores for pleasing appearance fell on average to method #1. As shown in the pictures, adding thickeners often altered the color of the vegetables. For the cream style corn (a more watery vegetable dish) the appearance scores were greater in method #3likely due to a more acceptable consistency.Table 1. Pleasing Appearance

#1#2#3

Italian Vegetable Blend2.92.23

Collard Greens3.222.113.22

Cream Style Corn3.2223.5

Carrots3.442.783.22

Peas and Carrots3.132.143.56

Asparagus2.781.883.22

California Blend3.122.753.13

Summer Squash3.252.863.38

Zucchini3.892.882.63

Peas3.382.133.38

Totals3.2332.3733.224

Figure 1. Pleasing appearance average scores.

TextureTexture scores also varied between vegetables. For example, method #2 most often produced the greatest slimy or slick scores. According to table 2, on average, vegetables prepared without any added thickener (method #1) scored the lowest in slimy/slick texture. With some vegetables such as summer squash and zucchini, however, method #1 scored higher (representing a greater slimy/slick texture) than method #3. Table 2. Slimy/Slick Texture

#1#2#3

Italian Vegetable Blend1.432.51.67

Collard Greens2.42.83


Carrots1.862.572


Asparagus222.67




Peas1.711.571.83

Totals1.8792.2842.141

Method #2 scored lower on average regarding a gritty texture. In this method, the cornstarch created a creamier consistency. Method #2 was also the least watery in all vegetables (as shown in table 4). Method #3, which utilized the commercial gel thickener, produced a less watery product than the vegetables prepared without any thickeners.Table 3. Gritty Texture

#1#2#3



Cream Style Corn1.81.41.4

Carrots22.142

Peas and Carrots21.81.5





Peas1.861.141.86

Totals1.8921.6111.763

Table 4. Watery/Soupy Texture

#1#2#3



Cream Style Corn3.51.292.33

Carrots2.671.21.75

Peas and Carrots2.612




Zucchini21.431.86

Peas1.7112

Totals2.3941.2122.075

Figure 2. Slimy/slick texture average scores.

Figure 3. Gritty texture average scores.

Figure 4. Watery/soupy texture average scores.

TasteAccording to table 5, the addition of cornstarch to pureed vegetables altered the taste greater than the commercial gel thickener. The gel thickener altered the taste very little compared to method #1 in which no thickeners were added (1.78 compared to 1.74). According to the evaluations, altered taste scores were highest using preparation method #2. This means that the cornstarch altered the flavor of the vegetables more significantly than the other two methods. It is unclear, however, whether or not all evaluators fully understood this section. Scores varied significantly for each vegetable and each method within this section. Evaluators were also left blinded to the preparation methods; method #1 was not necessarily used as a control, and therefore taste alterations were not compared to a control sample.Table 5. Altered Taste

#1#2#3




Carrots1.862.141.71

Peas and Carrots1.52.752




Zucchini1.51.881.75

Peas221.38

Totals1.7412.3381.777

Figure 5. Altered taste average scores.

Overall AcceptabilityAverage scores regarding overall acceptability proved to be the greatest tell in the preferred method of preparation. While certain methods may have scored more favorable in appearance or texture, the overall acceptability summarized all of the factors to determine which vegetable preparation was favored overall. According to table 6, preparation method #3 produced the greatest acceptability, with an average score of 3.31. Method #1 followed with an average score of 3.15. Method #2 scored the lowest average acceptability, with a score of 2.3. Individual vegetables did not always this pattern. The zucchini preparation method #1, for example, scored much higher than preparation method #3 (3.5 compared to 2.71). This is likely due to the appearance of method #3, which scored much lower than method #1 in this vegetable. Table 6 also reveals that methods #1 and #3 tied in acceptability for peas and summer squash. This could be due to the fact that squash and peas are somewhat starchy vegetables, which tended to puree more smoothly and easily than other vegetables. Therefore, thickener may not be as necessary in these vegetables as it would be in others. Table 6. Overall Acceptability

#1#2#3


Collard Greens2.752.333.57


Carrots3.252.863.29


Asparagus32.293.29


Summer Squash32.573

Zucchini3.52.432.71

Peas31.713

Totals3.1472.33.305

Comment by Roxanne Kingston: Graphs really help to show the results visually!Figure 6. Overall acceptability average scores.

Discussion and ConclusionAccording to the results, the most preferred method of preparation for pureed vegetables is preparation method #3 (2 parts vegetable, 1 part water, oz. commercial gel thickener). This method is similar to the current preparation method most commonly used by the cooks. The results of this study, however, help to create a more standardized recipe for the cooks to follow by determining the proper measurements to be used. These results should be easily translated to produce the correct quantities of vegetables, typically about one quart of each pureed vegetable. This will allow the cooks to use the larger 4 oz. packet of gel thickener per quart of vegetables prepared. An inservice was conducted for the cooks who typically prepare pureed vegetables following this study. Specific instructions were given for preparation of the vegetables, which included the following four steps:1. Obtain one quart of cooked vegetables prepared for the regular meal.2. Drain excess water from vegetables. When possible, strain vegetables to remove water (may not be possible with veggies such as stewed tomatoes or creamed corn).3. Gather quart of water from sink or from water used to cook vegetables; set aside.4. Place vegetables in blender with one half of the water and 4 oz. of gel thickener. Blend until smooth, adding water as needed.If followed, this recipe should produce the most preferred method of preparation for the pureed vegetable dishes. During this inservice, the idea was also discussed that when the appropriate ratio of water to vegetable is utilized, a gel thickener is not always necessary. Therefore, the cooks are to determine if alterations to the recipe are necessary depending on the vegetable. During this lesson, the cooks discussed some of their tips to blending to the correct consistency. Other challenges were discussed including the type of commercial thickener that the facility uses. The cooks provided suggestions that a powder form of thickener provides a better consistency for certain vegetables. RecommendationsThis continuous quality improvement study determined the most preferred method of preparation of vegetables for the pureed diet. Following the inservice lesson for the cooks, one major recommendation determined from this study is the utilization of the new standardized recipe. To ensure that the vegetables are a proper pureed consistency, the cooks should follow this recipe closely by measuring the vegetables and the water. This recipe does suggest that cooks use their best judgment in the amount of water to add to the blender, and to add water gradually and as needed to create what the individual cook views as the proper consistency. The preparation of pureed vegetables requires knowledge of the patient need and subjective reasoning to determine the proper consistency. This standardized recipe may not perfect the method, but give the cooks greater guidance for preparation. It also should make the cook more aware of the amount of water per vegetables, and hopefully create a better product by increasing the cooks awareness of the consistency of the product. Another recommendation with follows along the lines of using the new standardized recipes involves the straining of appropriate vegetables. According to observation, straining the vegetables before blending did not occur. Even though the water will be added back in during the blending process, straining the vegetables allows the cooks to control the amount of water that is put into the blender. Cooks are therefore more aware of the amount of ingredients. Ensuring that cooks strain the vegetables prior to blending should help prevent excess water that leads to soupy pureed vegetables. The last recommendation developed from this study involves the continuous quality improvement of the pureed vegetables. Test trays are currently conducted at the VHA every day. These test trays rotate through the various diets that are offered at the facility; therefore, the pureed diet is tested quarterly. During the pureed test week, it would be beneficial to use the sensory analysis form for the vegetables for each day of sampling. For best results, multiple people should sample the vegetables each day and complete an evaluation form such as the one in appendix A. Multiple evaluation forms would provide a wider range of data, and conducting these evaluations each day of the test week would allow sampling of vegetables from different cooks. This continuation of the study would also provide feedback to management staff for when an inservice on preparation of pureed foods may be needed. Collecting follow-up data after the completion of this study would provide insight for management staff and promote quality products at this facility in the future. Comment by Roxanne Kingston: Good! You really though through this process and provided some good recommendations for the future.

ReferencesBhattacharyya, N. (2014). The prevalence of dysphagia among adults in the United States. Otolaryngology-Head Neck Surgery, 1(5). Doi: 10.1177/0194599814549156.Ilhamto, N., Keller, H. H., and Duizer, L. M. (2014). The effect of varying ingredient composition on the sensory and nutritional properties of a pureed meat and vegetable. Journal of Nutrition in Gerontology and Geriatrics, 33(3), 229-248. Doi: 10.1080/21551197.2014.927307.Pritchard, S. J., Davidson, I., Jones, J., and Bannerman, E. (2014). A randomised trial of the impact of energy density and texture of a meal on food and energy intake, satiation, satiety, appetite and palatability responses in healthy adults. Clinical Nutrition, 33. 768-775.Germaine, I., Dufresne, T., Gray-Donald, K. (2006). A novel dysphagia diet improves the nutrient intake of institutionalized elders. Journal of the American Dietetic Association, 106(10). 1614-23. Matta, Z., Chambers, E., Gracia, J. M., Helverson, J. M. (2006). Sensory characteristics of beverages prepared with commercial thickeners used for dysphagia diets. Journal of the American Dietetic Association, 106(7). 1049-54. Doi: 0002-8223/06/10607-0003$32.00/0 doi: 10.1016/j.jada.2006.04.022.

Appendices

Appendix A: Data Collection ToolComment by Roxanne Kingston: The extra work you did on this data collection tool is nice! It more appropriately grasps the characteristics than the original one.

Appendix B: Flowchart

Appendix C: Fishbone Diagram

Documents

Chaffin Final CQI