Storyboard Entry Form 2014
Main author:Amelia Jukes on behalf of the Nutrition & Dietetic department and Adult Critical Care Unit at UniversityHospital of Wales
Email:
Telephone:029 20744294
Follow the detailed instructions in this template for writing your storyboard. Add your information in each section below and save this completed storyboard document. Please not amend this template.
Follow the instructions in the Information Guide for Authors to submit your storyboard.
The word limit is 1100 words including references. Your storyboard will not be accepted if you exceed the word limit.
1. Storyboard title:a clear concise title which describes the workOptimising the nutritional care of the critically ill patientin the Intensive Care Unit (ICU)
2. Brief outline of context:where this improvement work was done; what sort of unit/department; what staff/client groups were involved
The improvement work was undertaken in the Critical Care Unit at the University Hospital of Wales led by the Dietitians, with the Critical care unit nurses and medical team.
3. Brief outline of problem:statement of problem; how you set out to tackle it; how it affected patient/client care
Critically ill patients are usually reliant on artificial nutrition support to maintain their nutritional status. These vulnerable patients are unable to take food and fluid by mouth and frequently have higher nutritional requirements and losses, particularly in the acute phase of their illness. Patient’s nutritional intake and nutritional status is directly related to clinical outcomes, including patient morbidity and mortality. There is strong evidence that malnourished patients and those with inadequate intake have longer ICU stays and overall hospital length of stays when compare to those that are well nourished or have no period of inadequate nutrition. The Critical Care nutritional guidelines encompassing an enteral feeding protocol was devised and implemented by the Dietitian to reduce variability and risk and is used routinely by the clinical nursing team. The guidelines have been revised and updated on several occasionssince introduction in 1998 as a result of new evidence based practice and of practice based evidence within a continuous cycle of internal service evaluation audits.
4.Assessment of problem and analysis of its causes:quantified problem; staff involvement; assessment of the cause of problem; solutions/changes needed to make improvements
Regular service reviews of the adherence to and effectiveness of the critical care feeding guidelines are undertaken by the ICU Dietitians.
Key Measures:
- prompt commencement of nutrition
- adequacy of the nutrient provision
- appropriate use medication to aid delivery and absorption of the nutrition.
Service evaluationshave shown enteral feeding is interrupted frequently in the first 10 day period of critical care, for airway proceduressuch as intubation/extubation, and tracheostomy placement, theatre or radiological procedures, or loss offeeding tube. These interruptions are inevitable and often essential, and despite measures to standardise the period of interruption, the delivery of nutrition can be affected by up to 50% per day per interruption.
The ICU feeding protocol has subsequently been updated to minimise this loss by recommending feeding at an increased rate post the interruption. We are yet to identify another ICU that does this in the UK.
5. Strategy for change: how the proposed change was implemented; clear client or staff group described; explain how you disseminated the results of the analysis and plans for change to the groups involved with/affected by the planned change; include a timetable for change
The amended protocol proposalfor feeding interruptions waspresented and discussed in the regularCritical Care Quality and Safety meetingsattended by the Critical Care multidisciplinary team. The agreed changeshave been incorporated into the revised enteral feeding protocol and introduced to the unit via the Lead Clinical nurse and nurse teams.
The results of the change are monitored, discussed at Quality and Safety and necessary changes to protocols aremade in a cycle of continuous improvement.
6. Measurement of improvement:details of how the effects of the planned changes were measured
The impacts of the planned changes have been measured through local service evaluation within the ICU before and afterchanges were implemented. Our practice has subsequently been externally validated through participation inthe 2013 International audit, ‘Improving the Practice of Nutrition Therapy in the Critically Ill’where the results were compared with 205 hospitals worldwide. Data collected incorporated patient demographics, admission/diagnosis data, severity of illness and patient outcomes, and clinical nutrition information for the first 12 days of the patient’s ICU stay. Our ICU feeding guidelines in practice has placed the Health Board joint 4th in the world in delivering world class quality nutrition to critically ill patients.
7. Effects of changes:statement of the effects of the change; how far these changes resolve the problem that triggered the work; how this improved patient/client care; the problems encountered with the process of changes or with the changes
It is well documented that if you feed patients sooner they will leave ICU/hospital sooner. This international audit has confirmed more than 80% of patients in our unit that require artificial nutrition are commenced within 24 hr of admission as per local and standard practice guidelines, and almost 92% of the energy prescribed is received in our practice when compared to an average of 62% worldwide. In addition we have demonstrated that the use of parenteral nutrition and prokinetic agents are minimal, and where used are appropriate. This maximises efficiency and minimises costs. To make further gains in patient nutrition, further evaluations and revisions are required.
Critical to the success of the changes in nutritional care are the role of the medical and nursing team in implementing and maintainingthe nutritional guidelines. The Clinical Lead nurse is essential for reinforcing the revised protocol and adherence to it in practice.
Data collection is very time consuming and reliant upon manually gathering information from patient medical notes and test results.
8. Lessons learnt:statement of lessons learnt from the work; what would be done differently next time
The international benchmarking exercise will be repeated every two years.
The benefits of working with engaged clinical champions in the ICU are key determinants for the extent and speed of implementation. Throughout this iteration of the improvement cycle, these relationships have been built on. The impact of being recognised as a world class ITU nutrition care provider has given impetus to raising the profile of the work within the team and forms the springboard to greater engagement.
9. Message for others: statement of the main message you would like to convey to others, based on the experience described
True multidisciplinary approach to problem solving and repeated cycles of incremental change to practice with regular evaluation, delivers real improvement in care approaches. This approach can be replicated across the UK.
The NHS Wales Awards are organised by the 1000 Lives Improvement Service in Public Health Wales.