9 October 2020
Food for thought. Thoughts for food.

Jack Tabner

When you’re sick, what you eat and drink is so important to accelerating your recovery and making sure you don’t lose your muscle mass and functional mobility when spending lots of time in a hospital bed.

More than that, one of the things that can make for a positive or negative patient experience in hospital is invariably the food – choice, taste, quality of ingredients, nutritional content. I vividly remember spending time in hospital as a child and the toast was among the best food I have ever eaten…

At the end of August, I spent the morning with Amelia and Helen – our Lead Dietitians here at Medway – having a coffee and shadowing them at work. I wanted to know more about what they do, the challenges they face and the thoughts they have about the future of their service at Medway.

Here are some of my thoughts based on our discussions…

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Celebrations

Building the team – I was pleased to hear that a recent recruitment drive had got the internal team back to almost full complement after a difficult period with a growing caseload and a couple of key vacancies. Comparison to peer dietetics services on the Model Hospital had been useful when making the financial case for substantively recruiting to the service, recognising the wider benefits a high-performing service bring to the hospital e.g. length of stay reduction. Notwithstanding some Covid-19 related delays to on-boarding staff, the team will soon be the right size for the caseload and our patients will receive the right sort of input from Nutrition & Hydration experts.

MUST scoring – The team – and our ward teams – deserve plaudits for recent improvements to how we screen patients for enhanced input from the team via ‘MUST Scoring’. ‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines that can be used to develop a care plan. This time last year, MUST scoring was poor with less than 1/3 of patients having the correct score and only 18% being on correct care plan, after some good QI work led by the dietetic team, Jane Murkin, Katy White and Kerry O’Neill , this has now improved with some wards at around 90% for correct score and implementation of care plan, others have a little more work to do with compliance around 50% but we are working with those to try to improve patient outcomes. More to do but a marked improvement and really allows us to put our experts to work for our patients.

Catering improvements – Good joint working between our Retail Leads, our Catering leadership team and our Dietitians have delivered a recent overhaul of our menu, all focused on optimising nutritional care for our patients. I sampled some of the new menu – well done team.

Challenges

Paper vs. Extramed – I heard and observed in practice the difficulty the team has ensuring observations and assessments are recorded accurately. There tends to be a struggle with trusting the information that the Extramed system captures (e.g. changes in a patient’s weight), and so the natural human instinct to revert to paper is kicking in. I empathise with busy teams wrestling with IT systems that do not make it easy for staff to do the right thing and our Digital Strategy and pledge to deliver a single Electronic Patient Record will hopefully address much of the user frustration. However, recording information on a digital system is safer, more secure and more efficient for everyone than the paper notes ‘fail-safe’. I have therefore committed my teams to addressing some of the barriers to using the Extramed system effectively to ensure staff are not duplicating effort or missing essential documentation.

Getting the basics right – Like many of our specialist teams, our Dietitians play a key role not only in supplementing our Ward staff with the necessary expertise for patients with more complex needs, but also in embedding a training and coaching approach so that good practice is routine across our hospital. In amongst a very busy to do list and a much-pressured daily rhythm on our wards, collectively we are getting some of the basics wrong when it comes to patient nutrition and hydration:

  • x7 drinks per day – Between our Nurses and our Hostesses, we are required to ensure 7 drinks are administered every day per patient. From recent audits, we know that this doesn’t always happen. Undernourished and dehydrated patients are more likely to fall, they decondition at a faster rate, and it’s just plain wrong. Let’s not assume someone else is doing it…
  • Meal times – Meal times should be protected for our Nurses to spend time with our patients at the bedside ensuring our patients eat and drink sufficiently – but also taking the opportunity to speak to patients and pick up on the subtleties of how a patient is doing. The hustle and bustle on the ward and the growing demand upon our beds and services inevitably makes this a challenge – so much so that some patients are neglected during this time, anecdotally even some of our ‘red tray’ patients who require support to feed and require a specific diet.
  • Meal choice – the role of the hostess is critical, as is the relationship between the Nurses and CSWs on the ward and their hostesses. While there are some really lovely examples of staff going above and beyond to give patients a tasty meal or snack, there were some examples of patients being given the same meal every day for a week, or patients being offered a very limited choice because the time to re-heat the meals was a bore. We have a good and improving menu – let us make sure we offer our patients the best of what we can provide, allow them to make a choice by selecting from a menu, give them informed choices so they can meet their dietery preferences and deliver that food in the best way.

If one of your loved ones was with us in hospital, these are basic requirements of care that we should all be able to expect without much ceremony or fanfare. Yet due to lots of pressures, the fundamentals of care are being missed.

Our Dietitians cannot address all of this on their own. Improving these areas to ensure that we consistently get it right for all of our patients will take the time and efforts from a whole team: hostesses, volunteers, staff nurses, ward managers and matrons, therapists, doctors, CSWs, managers like me!

It may seem that some of this is less attractive to our teams than some of the more ‘clinical’ components of the care we provide (drugs, diagnostics, procedures) but this matters to our patients and it should really matter to us if we’re not getting this right consistently.

Changes

Nutrition strategy – I was pleased to hear about the ongoing work to develop a nutrition strategy for the hospital; something that not only sets out our long-term vision for nutritional care, but also something that prioritises and codifies two or three focus areas for us to work at here and now. This will likely include how we align our work to improve nutrition and hydration with other improvements going on at the Trust like the development of new ward environments. This will give us a good opportunity to ensure ward environments have dedicated areas for patients to get out of bed for meal times, stay mobile and enjoy their meal with as much interaction with others as is possible.

Nutrition Boards – Patients are not bed numbers. We have a duty in the care we provide to remember that in all that we do. One change I was particularly excited to hear about was the effort to roll out Nutrition Boards – whiteboards  with nutritional information on – so that patients can make known and visible their food and drink likes and dislikes. Not only is this essential to make sure we get it right for our patients with specific dietary requirements (vegetarian, vegan, halal) but also so we give our patients the fundamental right of choice!

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In my time here, it has struck me that nutrition is not something I’ve had lots of improvement-focused conversations about – something I’m keen to put right. That said, in spending time with Amelia and Helen and hearing about their team, I was assured that we have the passion and the skill internally to ensure nutrition and hydration is sufficiently prioritised amongst all the different priorities a busy hospital like ours has. Thank you to Amelia and Helen for putting up with me for a morning. I hope I wasn’t too much of a burden.

And if you’d like me to come and spend some time with you, please do let me know. As part of our Executive ‘back to the floor’ programme, I want to spend as much time as I can hearing from you your challenges, celebrations and changes!

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