Nutritional Care - The performance and assessment challenge

The Institute for Hospitality in Healthcare Conference, Hobart, 2011Brian Johnston

Let’s consider the following

� Why have this standard� What is its intent� Practical implementation issues� The experience so far� Some issues to consider

Some history (1)

McWhirter 1994Clinical implications� High incidence of protein energy malnutrition in hospital patients was

first shown more than 15 years ago� Poor nutritional status adversely affects health and recovery from

illness or injury� In this study 40% of patients were undernourished on admission to

hospital and two thirds of all patients lost weight during hospital stay� Only a few patients were given nutritional support, but most of these

showed improved nutritional status� Continued lack of awareness of importance of clinical nutrition

suggests need for education on this subject

BMJ 1994;308:945-8

Some history (2)

Malnutrition in hospitals

‘The number of malnourished people leaving NHS hospitals in England has risen by 85% over the past 10 years.

Malnutrition affects the function and recovery of every organ system, increases the risk of infection, extends hospital stay, and makes readmission more likely.

Nutritional support is an important part of medical treatment …..is treated in law as equal to drugs.’

Editorial (Lean and Wiseman), BMJ 2008; 336 : 290 (Published 7 February 2008)

Background Evidence (1)� Malnutrition in adults in hospitals

– reported in international & Australian studies � Deterioration in nutritional status

– over course of hospitalisation � Cause of malnutrition in developed countries

– diseases associated with poor appetite, dysphagia, malabsorption & increased nutrient requirements

� Inadequate intake – due to the provision of inadequate quantities of

suitable food or alternate nutrition sources / difficulties with eating / lack of assistance

Background Evidence (2)

� Implications for health & recovery from illness / surgery – Impact on skeletal, muscle, gastrointestinal, immune

function & wound healing

� Prevalence of Malnutrition– High in all healthcare settings 30 – 50%– Under recognised under diagnosed– Leading to decline in nutritional status– Associated with adverse clinical outcome

& costs

Malnutrition is defined as:

“state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size composition), function & clinical outcome”

Dietitians Association of Australia

Emphasis on malnutrition

Another definition ….. UNICEF

� Malnutrition

… “under nutrition but technically it also refers to over nutrition. People are malnourished if their diet does not provide adequate calories and protein for growth and maintenance or they are unable to fully utilize the food they eat due to illness (under nutrition). They are also malnourished if they consume too many calories (over nutrition)”.

Malnutrition Consequences

THE INDIVIDUAL� Muscle wasting / weakness

� Delayed wound healing

� Risk pressure areas

� Infection

� Dehydration

� Impaired mobility

� Constipation / diarrhoea

� Impaired metabolic profiles

� Apathy & depression

Nutrition Standards for Adult Inpatients in NSW Hospitals

THE HEALTH SYSTEM

� Increased:– LOS– Readmissions– Costs– Clinical intervention– Antibiotic use– Staff time per patient

Why have a standard

� Standards– Broad statements of principle or intent– Can provide an integrated and structured

framework for managing an organisation’s performance and its quality program.

� Criteria – a specific subset of requirements for observable behaviour/performance within a standard

Why have a standard (2)

Standards: �Address a recognised need�Evidence based (as far as practicable)�Developed through a transparent and

consultative process�Outcome focused�Achievable�Measurable

Why have a standard (3)

Strategic use:� Guide behaviour� Build team work� Policy Implementation� Data Collection� Performance monitoring

– Policy effectiveness– Skill levels

� Resource allocation decision making

Was it developed by the ‘right people’

Nutrition

EQuIP 4Referenced in the guidelines

EQuIP5Standard 1.5

The organisation provides safe care and services

Criterion 1.5.7

The organisation ensures that the nutritional needs of consumers/patients are met

Risk Management 2.1.2 Incident Reporting 2.1.3

Culturally appropriate

1.6.3

Appropriateness 1.3.1Effectiveness 1.4.1

Infection Control 1.5.2Skin Integrity 1.5.3

Assessment 1.1.1 Care Planning 1.1.2

Nutrition1.5.7

1.5.7 Relationships to other criteria

Contracts 3.1.4

Intent of the criterion (1)

Original wording and intent:“The incidence and impact of malnutrition is minimised through a prevention and management strategy.”

� The wording of the first draft identified as too negatively focused and based on an anti-harm, rather than a positive, model

� It should not be a developmental criterion?

� It should aim to raise the bar

Intent of the criterion (2)

� Nutritional needs met during healthcare journey� Optimise nutrition to support well being & recovery� Prevent / manage malnutrition as per guidelines� Applicable to all organisations

– Diversity of settings– LOS > 7days across all inpatient areas– Emergency Department– Paediatrics– Community

Themes within the guidelines

Policy/Guidelines� governance� risk screening, assessment, care planning,

monitoring and discharge planning� planning and provision of food, fluids, and nutritional

supplements� mealtime environment and assistance to eat and

drink� patient information and communication� education and training for staff.

Themes within the guidelines (2)

Management strategy� nutrition risk screening on admission and at agreed

intervals during stay

� meal/menu planning to suit health service population and individual patient’s needs

� provision of timely assistance to eat

� implementation of artificial nutrition support therapy when oral intake is inadequate as per agreed procedures

� nutritional care planning at discharge/transfer of care

Themes within the guidelines (3)

Individual screening, assessment and care

�Nutrition risk screening

�Provision of nutritional care

�Evaluation of nutritional care

�Patient/carer education

�Monitoring of consumption by ‘at risk’ patients

Themes within the guidelines (4)

Staff education

� the benefits of good nutrition care for recovery

� the organisations nutrition care processes, including how the food / meal service system operates

� malnutrition and its adverse effects on patient outcomes

Prompt PointsUnder the subheading Nutrition management strategy:

� Which potential problems may place customers / patients ‘at risk’ within your facility? How are these consumers / patients identified? What changes are made to better manage these identified risks? What evidence is there of a multidisciplinary nutrition management strategy?

� Are incidences related to nutrition reported, analysed, trended and used to improve quality procedures?

� Are there identified roles and responsibilities for staff related to nutrition care?

Performance Measures

� Suggestions ONLY

� A range of indicators for each criterion

� Assist in the measurement and evaluation of

performance

� Not all suitable for all organisations

� Useful to a range of health services

� May be modified to suit organisational needs

Practical implementation issues

� At risk patients – identification and reassessment� Hospital policy on responsibilities� The role of volunteers� (Metropolitan monthly) meal service questionnaire

– Taste– Nutritional quality– Temperature– Appearance

“Celebrating the contribution the Improving Nutritional Care Programme is making towards improving nutritional care in NHSScotland, 09 June 2011”

Queensland Health

Nutrition Education Materials Online (NEMO)

Surveyors

1. EQuIP5 e-learning tool, including examples of what to look for.

2. A compulsory question for surveyors on the e-learning tool.

3. Surveyor development program item – 2011.

Organisations and Surveys (1)

Education program� 14 courses

• 9 calendar (170 attendees)• 5 on-sites

� Positive feedback� Context variation discussed

Organisations and Surveys (2)

Survey results so far� ~ 90% successful

� Recommendations:– nutritional assessment– multidisciplinary approach– access to dietitian

� Comments:– Access to dietitians– Near miss reporting?– Actioning of changes in ‘base line’ measurements

What about the patients!

Final Report of the Special Commission of Inquiry into Acute Care Services in NSW Public HospitalsCommissioner Peter Garling SC, November 2008

� I received a lot of submissions about hospital food. It can be and has been the butt of many uncomplimentary jokes and remarks. But I have to say that NSW Health seems to me to be putting a lot of effort into improving the food in hospitals.

To sum up

� This is not a new issue and its clinical significance is recognised

� EQuIP5 provides:– a national focus; – a framework for performance and assessment;

and – data collection.

� Does your organisation have a plan?

� For patients it is an issue broader than nutritional content