Nutritional Care - The performance and assessment … Care The...Nutritional Care - The performance...
Transcript of Nutritional Care - The performance and assessment … Care The...Nutritional Care - The performance...
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