The Challenge of Hospital Nutrition Support

Richard C. Wilson BSc RD FBDA MTF Day 25 March 2014

Structure of this presentation

• The challenge and recent initiatives

• The current situation and how we try to rise to the challenge

• Future direction

www.malnutritiontaskforce.org.uk

King’s College Hospital NHS Foundation Trust

• Nature of King’s (pre – Oct 2013)

– Foundation trust– 1200 beds– 6,000 live births– ~70,000 admissions– 55% unplanned

• England 150,000 beds• England 10 million admissions

• 38 Dietitians– ~36,000 patient contacts per year

• Food service - PFI– Cook chill (Steamplicity)

• Plated cook chill• Microwave & steam regen.

• Initiatives in place– Protected Mealtimes– Red Trays– Ward housekeepers

Hospitality is key to care

• Hospitality is the foundation of all care

• The first hospitals were in monastery's

• Sanctuary for the sick, poor and destitute

• Providing shelter, security, nursing, nurture and nutrition

• 10,000 + staff need to be aware of this

• Hippocrates 400BC– “In all maladies those who are

well nourished do best. It is bad to be very thin and wasted.

• Approximately 1200 patients at King’s– ~120 on artificial nutrition

support– 1080 (90%) dependent on a

‘knife and fork’

Nutrition and human physiology

AWARENESS RAISING

• Entropy – 2nd Law of thermodynamics

• Matter has a tendency to become chaotic

• Human body made of very organised molecules

• Keeping them organised requires energy

Our collection of molecules

• Constantly being broken down and replaced

• Every seven years it is all replaced

• Replacement molecules are swallowed!

• All this requires energy• We measure energy in calories• 1kg of human = 7000kcal• 1 missed meal = -400kcal• = 60g (2oz) of tissue lost!!

Obese people can be undernourished too!

• These days Michelangelo would have needed considerably more marble!!

• Unintentional weight loss still has detrimental effects

Every performance review / feedback opportunity taken…

• What do the patients think of the food?

• ‘How Are We Doing?’ survey• Continuous performance

management• Virtuous circle of improvement

Monthly survey – response of 1236 patients following discharge

Sobering tales…

Nutrition can kill• We recently had a serious incident related to refeeding• Patient arrested and died

NICE ‘Nutrition Support in Adults’ CG032, 2006• High risk of developing refeeding problems if:

One or more of the following: Two or more of the following:

• BMI less than 16 kg/m2

• Unintentional weight loss >15% in last 3-6 months

• Little or no nutritional intake for more than 10 days

• Low levels of potassium, phosphate or magnesium prior to feeding

• BMI less thank 18.5 kg/m2

• Unintentional weight loss greater than 10% in last 3-6 months

• Little or no nutritional intake for more than 5 days

• A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

Strategic direction?

• Malnutrition is still a significant problem in hospitals including ours

• ICT systems offer ways to:– Raise awareness– Advise on need– Monitor progress against nutrition targets– Communicate plans between settings

• Based on research conducted by:– www.hospitalfoodie.com

The proposal

• Assessment on Wardware (MUST)

• Lookup target in DRV table

• Target provided by dietitian

• Data on nutritional inputs collected

• Intake visually mapped against targets

Benefits of this approach

• Includes all patients• Includes all feeding modalities• Visual analogue target engages all staff and

patients in meeting target• Holistic approach will improve communication

Between staff on site

Between care settings

Bringing the Hospitality back into Hospital!

• Delivering nurture, nourishment and sustenance is what care is all about

• The raw materials for recovery