Promoting Good Nutrition Steering Group
Progress Report
on work to support the implementation of the
Promoting Good Nutrition Strategy
MARCH 2016
Promoting Good Nutrition Steering Group Progress report
Objective / Organisation / RAG Status / Actions to Date / Planned Actions / Additional CommentsKEY CHARACTERISTIC 1. Everyone[1] using Health and Social Care Services is screened to identify those who are malnourished or at risk of becoming malnourished
Screening for malnutrition and the risk of malnutrition is carried out on people at specific points / BHSCT / G / All inpatients in Adult Acute Inpatient Wards are required to be screened for malnutrition using MUST on admission and then weekly.
Inpatients in Adult Mental Health Wards are required to be screened using MUST on admission and monthly, unless there is a clinical indication to repeat screening weekly.
In Community settings, people are required to be assessed using the Northern Ireland Single Assessment Tool (NISAT) documentation.
NHSCT / G / MUST scores are completed on admission and then reviewed weekly.
Monitoring of this is done by ward managers daily and weekly by Lead Nurses
Indications from monitoring show that not all patients would be assessed within 24 hrs of admission or reviewed as per nursing admission booklet. / To continue to monitor via Alamac system and Care Quality Audits / Current % (Dec 15) compliance within the acute settings = 91
SEHSCT / G / MUST is embedded in practice in all adult acute areas, including dementia and acute mental health wards. Overall compliance for the last quarter 90% on Qlikview dashboard as nursing KPI and commissioning target.
Also used in Chemotherapy Day Unit as part of toxicology screen.
Piloted in 2 Outpatient departments. Of the 67 patients screened 78% were low risk and 22% were medium risk with no high risk patients identified.
On first assessment in district nursing caseload. Results in district nursing demonstrate that of those screened, 13% are medium risk and 24% are high risk. / Continue to monitor MUST as KPI
Support offered on rolling basis for new staff
Follow up of medium risk patients identified in OPD to monitor nutritional status.
Audit district nursing case load to see if appropriate action taken for nutritional risk status
SHSCT / G / ACUTE
- MUST Screening is undertaken in all inpatient wards within SHSCT
- Training is provided to nursing and auxiliary staff on MUST by Dieticians, as required
- Nutrition screening now rolled out within Mandeville unit
- Scope/review training arrangements to assess current need for evolving workforce
- Audits will continue
- Review compliance within Mandeville unit
WHSCT / G / All patients have a MUST assessment done on admission and reviewed during their inpatient stay.
MUST is measured as a KPI for nursing and midwifery and reported to the Trust Governance Committee.
MUST assessment completed on admission for all patients. Regular review and update of MUST.
Compliance with MUST is monitored with the Trust KPI programme and currently the compliance sits at 90-95% for patients in the hospital setting. / Ward 43 cancer services in addition to using the MUST also record the patient’s daily calorie and protein intake in conjunction with the dietitian. Where appropriate a diet intake target is agreed. The ward have also instigated a diet supplement round twice a day between meals plus snacks i.e. high calorie high protein are readily availableward level for those patients who require little and often to stimulate their appetite. This patient often find standard meal times challenging in that they cannot tolerate the large meal at set time. The daily intake is recorded in all of the patients’ records i.e. nursing, dietitians and medical case notes.
Medicines Management, HSCB / 144 practices across the region have availed of the Management Dietetic Initiative (MMDI).
-3263 patients offered an appointment with dietitian
-2509 patients have been nutritionally assessed by the Medicines Management Dietitian (MMD).
-56.1% recommended to discontinue ONS
-27.4% amended to cost effective product
-Efficiencies of £2,015,836.09 have been realised to date. / Funding has been agreed to recruit MMD staff on a permanent basis. This process has started.
IHCP – Domestic Care / This is a vague statement that requires clarification.
The strategy refers to care settings including a person’s own home. People are not routinely screened for risk of malnutrition. NISAT is inadequate in our view in addressing the nutritional needs of persons in their own homes with potentially dementias or who live alone.
People who need assistance with eating are clearly identified / BHSCT / G / All inpatients that need assistance with eating are expected to be identified at nursing handover reports throughout the day and at mealtimes.
In community settings people are clearly identified in a variety of ways. One example of good practice is in Learning Disability Day Care where each service user has their own individualised placemat with their name, photograph, dietary requirements and level of assistance clearly printed. / Appendix 1
NHSCT / G / Plate method of highlighting need for assistance is displayed above all patients beds.
SEHSCT / G / All acute inpatient wards have a method to identify patients who require assistance with eating.
Options for additional assistance at mealtimes explored and shared with ward sisters –include external and internal volunteers and reorganisation of ward routine.
Speech and Language Therapy have devised supervision levels for local application which identify individuals who require supervision/ assistance related to eating behaviours and dysphagia, SLTs are now including advice on these levels in individual care plans as appropriate. / Observational audit of mealtime to be carried out in March 2016
Continue to explore option of staff as internal mealtime volunteers
Supervision levels are being reviewed regionally by a panel of expert SLTs with a view to agreeing regional guidance and agreed protocols
SHSCT / G / ACUTE
- Part of nursing assessment
- Red tray / red mat in place for those who need assistance with eating
- Visi/white boards used to highlight those who require assistance with eating
Ongoing
WHSCT / G / Red tray system in place Staff use a red tray or red napkin to highlight the patients who require support with their meals
Medicines Management, HSCB / G / Those patients who availed of the MMD initiative and who were not already identified as needing assistance with eating were referred for further support as necessary in agreement with the patient’s GP.
IHCP – Domestic Care / Generally so especially in a residential setting. It is essential that sufficient time is allocated if a person requires assistance or encouragement to eat in a domiciliary setting.
Organisations across NI are building on the implementation and learning from ‘Get your 10 a Day’ standards across all health and social care settings including people’s own home / BHSCT / G / The Trust has a Nutrition Steering Group with representation from all key disciplines to deliver on the regional Promoting Good Nutrition (PGN) Strategy. This is implemented through 3 Sub Groups:
- The PGN Operational Group;
- The Clinical Nutrition Group;
- The Catering Group.
NHSCT / G / Trust have accepted the standard for inpatient and day care however implementation is being reviewed as part of the review of the Trust Nutritional Strategy.
SEHSCT / G / The Ten a Day work stream in SET has now become the acute nutrition work stream of the Clinical Nutrition Sub-Committee.
Learning from the acute work stream is replicated across other areas. / Continue to build on previous work in line with regional strategy.
SHSCT / G / ACUTE
PGN has superseded ’10 A day
WHSCT / G / Education sessions on Get your 10 a day have been delivered to nursing staff / Ongoing awareness/ education to promote implementation
IHCP – Domestic Care / This is a requirement in regard to nursing and residential homes however there is no definition of an ‘organisation’ and there is no structure to ensure people in their own homes are benefitting from the 10 A Day standard.
People with swallowing difficulties are screened / BHSCT / G / All people are screened and those with swallowing difficulties are referred to Speech and Language Therapy (SLT) colleagues for specialist assessment and intervention.
Patients in the Integrated Stroke Unit are screened using the water swallow test. Patients who fail the test are referred to SLT colleagues.
NHSCT / A / When there is an identified risk Referrals to SLT via solver if swallowing difficulties or potential for aspiration are detected. / Review of capacity and demand to meet assessment timescales.
SEHSCT / A / ACUTE: Previous attempts to offer screening training have resulted in poor uptake.
Screening has now been revamped to take only 30 minutes.
Information currently being collated from wards to facilitate ward based training to highest number of staff in the first instance. Training will be open to Nurses, medics and AHPs. / ACUTE: Initial ward based training will take place during February and March 2016 then monthly dates will be made available on HRPTS for staff to apply as appropriate.
Dates will be publicised to all wards/ AHP managers and through medical channels as appropriate.
RQIA has stated that swallow awareness training should be essential for nursing staff in hospital care- SLT will therefore continuously monitor uptake of training and work with nursing teams to ensure ease of access,
COMMUNITY: Ongoing promotion of swallow awareness training.
SHSCT / A / ACUTE
- SHSCT guidance developed: Procedure for Trust Staff to support Adult Service Users who have Eating, Drinking and Swallowing Difficulties
- Nurse champions have been identified to do swallow screens
- All stroke patients are screened using the water swallow test- patients who fail are referred to SLT.There is a rolling programme for training nurses in water swallow screening carried out across 2 acute sites by SLT
- Ongoing
A
WHSCT / G / Patients are referred for SALT assessment when identified as having swallowing difficulties
Medicines Management, HSCB / G / Those patients who availed of the MMD initiative and who were not already identified as having swallowing difficulties were referred for screening as necessary in agreement with the patient’s GP.
IHCP – Domestic Care / Providers report some delays in screening in certain areas.
Systems and guidance are in place for appropriate and timely decisions in relation to the need for enteral or parenteral nutrition / BHSCT / G / The Trust’s Nutrition Support Team (NST) deals with parenteral referrals on the Royal and City Hospital sites. The NST accept requests for advice and referrals via bleep at any time during the working day. Ward based Dieticians work as part of the Multidisciplinary Team and advise when nutritional support via other routes are not meeting individual patients nutritional needs and advise on support required via other routes.
At induction, Dieticians are trained on allprocesses/policies relating to this aspect of nutrition support.
During out of hours, Trust wide requests for parenteral nutrition are logged on a register and reviewed. Requests are followed up and education sessions delivered, when required. / A business case in the Mater is being worked up to attain the necessary funding for a Dietician to help facilitate the provision and management of PN on this site
NHSCT / A / As there is no comprehensive MDT nutritional support team in place within either of the acute sites, decisions may not be made in as timely a manner as could be possible and there have been no recent audits carried our regarding appropriateness of enteral/ parenteral feeding decisions. / A draft proposal paper has been written to highlight need for a dedicated MDT nutritional support team. This needs to be finalised internally, prior to sharing with commissioners. / Trust policy in place for enteral and parenteral feeding in line with NICE guidelines.
SEHSCT / G / Enteral – we have drafted new guidelines for enteral feeding which are currently out for consultation in the Trust
Central line audit carried out – 100% compliance achieved for reason for insertion and removal and care planning.
Managed the process for the implementation of NFIT enteral feeding giving set connections in line with National Safety Alert. / Audit to be repeated in other clinical settings.
SHSCT / A / ACUTE
- SHSCT Enteral Tube feeding guidelines for Adults available
- Dietitians are involved in all acute patients on enteral nutrition
- Stop gap feeding regimen in place for out of hours commencement of feeding
- Feeding algorithm available in ICU to facilitate early enteral feeding
- Dietitians involved in patients receiving TPN
- DHH / CAH across site MDT working for TPN patients
- Home Enteral feeding coordinator service
- SHSCT Enteral Tube feeding guidelines for adults are in the process of being updated
No acute nutrition support team
WHSCT / A / Reviews completed by ward based clinical pharmacists for on most wards. PN pharmacist reviews those patients commenced on PN.
IHCP – Domestic Care / G / Yes
People on multiple medications (polypharmacy) will have regular medication reviews / BHSCT / G / Inpatients are assessed regularly, and medication reviews are undertaken.
Some Wards across the Trust have a ward based Pharmacist whose role is to provide medication review and reconciliation.
NHSCT / G / Pharmacy staff are ward based and community patients are reviewed by GPs.
SEHSCT / A / Clinical pharmacists prioritise patients in the following way:
- Medicines reconciliation on discharge
- Medicines reconciliation on admission
- Review patients especially those on Polypharmacy & high risk meds
Patient turnaround is such that the review of kardexes is often not possible with current staffing levels
Not all areas have a clinical pharmacy service. /
- Roll out of e-whiteboards
- Increase the use of e-whiteboards to help identify & prioritise patients
- Medicines optimisation supported through the use of evidence based medicine
- Seek funding for clinical pharmacists in areas not covered by clinical pharmacy
- Rehab ward LVH (elderly care)
- Trauma & Orthopaedic wards 18 & 19 Ulster
- Use KPIs regarding med rec stats (sent monthly to the HSCB) to support bids for clinical pharmacy staffing.
The majority of patients on multiple meds are in the older age group
“A Guide to Support Medication Review in Older People” developed by NI network of pharmacists with a special interest in older people. Dec 2015 v1.5
SHSCT / G / ACUTE
Inpatients are assessed regularly, and medication reviews are undertaken.
Some Wards across the Trust have a ward based Pharmacist whose role is to provide medication review and reconciliation. /
- Ongoing
WHSCT / A / Not all wards have a ward based pharmacist but this is currently being addressed.
Medicines Management, HSCB / 5-year investment, £2.55million invested in 2016/17, rising to £14million per annum in 2020/21, to support pharmacists in GP practices. This investment is an important component to deliver Medicines Optimisation which is an approach that seeks to maximise the beneficial clinical outcomes for patients from medicines with an emphasis on safety, governance, professional collaboration and patient engagement.
IHCP – Domestic Care / This is not necessarily the case, however we understand that the HSC Board is making investment in Pharmacy provision in General Practice.
KEY CHARACTERISTIC 2. Everyone using care services has a personal care support plan and where possible has had personal input, to identify their nutritional care and fluid needs and how they are to be met
All adults at risk of malnutrition have a personal nutritional care plan / BHSCT / G / All adults at risk of malnutrition are required to have a nursing care plan. These individuals are referred to Dietetic colleagues for specialist assessment and intervention. At this stage a personal nutritional care plan is developed.
One example of good practice is in Care of the Elderly Wards where cartons of cream are supplied at breakfast to be used on patient’s porridge to increase the calorific content of the meal. Detail on this requirement is included in the patient’s care plan.
NHSCT / G / Revision of Careplans to ensure person centredness has commenced. / Spread plan and timescales agreed.
SEHSCT / G / In place for all acute wards and district nursing caseloads
Audit carried out in 2015 showed that patients identified as medium risk more likely to have an updated care plan than those at high risk who had been referred to Dietician
Nursing homes have this in place for some patients but there are gaps here and in other areas of Primary Care. / Guidance regarding care after MUST screening now includes that all medium risk interventions should continue in partnership with nursing and dietetics
Training sessions delivered in Care homes regarding nutrition awareness.
SHSCT / G / ACUTE
- Where MUST undertaken, patients/clients with nutritional needs have an individualised care plan
- Adult Fluid Balance Charts in place
- Resources available to support MUST for various settings
- Formal dietetic access criteria which includes MUST available on Trust intranet
- Nutrition Ward File for non- acute hospitals developed, training provided and in use.
- Work ongoing – to incorporate nutrition screening and individualised action plans reflective of menu provisions in multi-disciplinary case notes
WHSCT / A / This plan may be documented by more than one discipline/profession.
Must assessment and nursing care plans are developed post admission documented / Example good practice includes Ward 43 (cancer ward) in addition to using the MUST also record the patient’s daily calorie and protein intake in conjunction with the dietitian. Where appropriate a diet intake target is agreed. The ward have also instigated a diet supplement round twice a day between meals plus snacks i.e. high calorie high protein are readily available at ward level for those who require this service. This patient often find standard meal times challenging in that they cannot tolerate the large meal at set time. The daily intake is recorded in all of the patients’ records i.e. nursing, dietitians and medical case notes.