Eat, Drink, Move! Supporting people to keep well, in and out of hospital

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1 Eat, Drink, Move! Supporting people to keep well, in and out of hospital Helen Reilly, Therapy Lead and Professional Lead for Dietetics On behalf of HEFT Therapies Team

2 Eat, Drink Move! Simple and transferable HEFT is a large teaching NHS Trust 3 acute sites + community Simple principles apply to any setting A Therapy approach Innovative practice case study in AHPs into Action, NHS

3 Poor nutritional status, dehydration & immobility put patients AT RISK in hospital 2,3

4 Risk of poor nutrition and hydration Well recognised, multiple causes 3 million malnourished in UK, mostly in community ~ 1/3 of patients admitted to hospital & care homes show signs or risk of malnutrition Frail older people particularly at risk

5 Impact of poor nutrition and hydration High impact and risk Loss of muscle, increased pressure sores, Poor healing and recovery, confusion, UTIs, Low mood and lack of motivation Increased morbidity and mortality

6 Identify & support those at risk Nutritional Screening & treatment plans : active support to eat and drink High quality catering, in-house provision, part of the team Protected mealtimes with effective procedures to support good care 6 step check to prepare, feed and monitor mealtimes Red trays, food charts, red drinking utensils Promoting snacks and milky drinks Training practical flexible approach on the job promote good practice Collaborative approach - nursing catering and dietetics Robust monitoring of compliance & quality of care: metrics, audit, dashboard reporting ( Keeping nourished monitoring scorecard) BAPEN Gold award 2011

7 Impact of lack of mobility Recognition of Low physical activity in hospital In care homes In the frail elderly at home Immobility can reduce muscle strength by 2-5% per day! Estimated that 10 days in hospital leads to the equivalent of 10 years of ageing in the muscles of people over 80! 2 Rapid deconditioning & loss of functional capacity! Deconditioning syndrome awareness campaign (Academy of Fabulous Stuff) 4 #EndPJparalysis (Twitter)

8 Deconditioning Stiffness, loss of muscle strength Reduced blood flow Reduced bone mass Reduced lung function Pressure ulcers Blood clots Chest infection/pneumonia Reduced appetite and GI motility

9 Deconditioning Quickly results in: Reduced physical functional capacity Increased risk of falls Loss of confidence to mobilise Low social contact, reduced wellbeing & self confidence Reduced ability to independently manage activities of daily living

10 Deconditioning Keeping patients mobilising safely in hospital Reduces risks, morbidity, mortality 5 harm free care Reduces care package and support needed on discharge Significant benefits to LOS and cost of patient care Natural links between promotion of good nutrition, hydration, mobility Therapy approach Similar risks and barriers

11 How much do patients move in hospital? Activity measured using accelerometers (movement in any plane) How many minutes / hours in 24 hours?

12 How much do patients move in hospital? Pilot study (small sample) 8 minutes a day Control group (500+ patients) 40 minutes a day Not a lot!

13 Barriers to mobilisation Patient s ability some can t - but most can with help Time to support patients to mobilise safely Lack of equipment, in right place, at right time Expectation patients think they must stay in bed and think they are not allowed to wander round the ward / hospital Us are we more comfortable with the patient sitting safely in / by their bed? Managing falls risk (really?) We can find patients whenever we want them. Makes their care less demanding? (or more?) Patients confidence & giving them permission

14 Promoting Early Mobilisation Supports patients to be: The Mobility Bundle as mobile as possible as soon as possible safely Piloted on elderly care and respiratory wards

15 The Mobility Bundle Initial assessment of mobility, manual handling needs and falls risk as part of nursing assessment on admission and during hospital stay Mobility Chart used by Therapists to record how to mobilise safely as Therapy progresses Promotion of simple measures and opportunities to mobilise, independence with support where needed Promotes getting dressed, not staying in pyjamas #endpjparalysis A short information booklet for patients / carers

16 The Mobility Bundle Equipment Walking aids are stored on each ward Individual, labelled with patient s name Don t share walking aids - infection control Position in easy reach of patient in bed space Use equipment to maximise independence (e.g. toilet raises, bed levers, chair raises)

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18 The mobility bundle on trial 6 Formal trial over 6 months Led by therapy team and nursing teams 1179 patients, elderly care and medical respiratory wards Intervention group Control group 678 patients 501 patients Mobility bundle Standard therapy input Monitored activity level, impact on Hospital Acquired Pneumonia, pressure ulcers, falls and LOS

19 Promoting Early Mobilisation Trial results Intervention group Control Group HAP 25 (3.6) 50 (9.1) < Minutes active/day 83.1 (44.9) 40.5 (26.8) Step count/day 1103 (103.8) 388 (90.5) Patients on intervention wards showed: 50% reduction in hospital acquired pneumonia More likely to be in lowest quartile for length of stay No significant difference in pressure sores (but benefit of mobilisation to reduce pressure sore risk is well documented elsewhere) No significant difference in falls Increase in activity level (measured on a sample from each group) Increase in moderate activity (control group <5 mins/day, intervention group up to 10 mins/day Simple measures are highly effective and deliver positive clinical impact

20 Eat Drink Move! Existing good practice to promote nutrition & hydration Plus simple measures to increase mobility Therapy-focused approach Supports health, wellbeing and recovery from illness Maintains physical functional capacity as far as possible in hospital Easily transferrable to other settings Promotes benefits of keeping nourished, hydrated and mobile to maintain health in older people in any setting

21 Current HEFT Eat Drink Move activity Promote mobility bundle, small increase = significant impact 1000 steps? #900steps 7 Promote snacks and milky drinks Go the extra 500 (2 milky drinks and 2 snacks a day = extra 500 kcals and 20g protein) Protected mealtimes to support good nutritional care and give time to walk with patients to choose meals, wash hands or get to the day room Social eating and use of day rooms (where they exist) Enhance the mealtime environment, ward becomes a restaurant Make a meal of afternoon tea china cups, extra snacks, music, reminiscence materials, company, volunteers, themed afternoon teas and events All healthcare staff to leave patients with a drink in reach and encourage a drink

22 Special afternoon tea events High level of social engagement & participation Lots of mobility! Impressive intake of snacks and drinks Fantastic feedback from patients and staff

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24 Ward Coffee Morning th June 2016 Are you doing this again tomorrow? How much do I owe you? Its nice to chat When is the next one? This would be good to come to when I go home Its been fabulous, bet you ve been up all night cooking Information pack very interesting, can I keep it to show my family later? Is this open everyday?, its only 1 minute away from my bed. I would like to come back every other day. So nice to drink tea from a china cup The cakes are lovely I like this café, I feel much better away from my bed

25 Coffee morning 8 th June 2016 Fluid / nutrition intake Patient Fluid intake overall 07/06/2016 (24 hours) Fluid intake coffee morning Fluid intake overall 08/06/2016 (24 hours) Cake Yoghurt Biscuits Mrs S 3 cups 3 cups 9 cups 2 Mr M No chart 2 cups No chart 2 3 Mr B 6 cups 2 cups 8 cups Mr R No chart 3 teas No chart 2 1 Mr M 3 cups 3 cups 12 cups 3 1 Mrs C No chart 1 cup No chart 1 Mr P 6 cups 2 cups 9 cups 1 3 Mrs B No chart 1 cup No chart 3

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27 Shake into Summer Can you Gorgeous come back everyday Whose birthday is it These are lovely Lovely surprise I ve got a cup of tea, can I have a milkshake as well I m really enjoying this

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30 COMMENTS I have enjoyed this so much and afternoon tea and cake you cannot beat it. Best ever can we do this again It s been a lovely experience I can t believe just how competitive they all were, they all wanted to win Staff member I m shattered Staff member Exercising while having so much fun Staff member Coffee really nice in a china cup

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33 What next? Additional Therapy Support Workers Volunteers

34 Critical success factors Demonstrating clinical benefit of increased mobilisation Aligning to other successful initiatives already on place as Eat, Drink, Move! Joint approach Therapies, Nursing, Catering Taking training to ward level - deliver and promote repeatedly on the job Don t depend on release of staff for one off training Promoting at every opportunity to maintain engagement, interest and profile Aligning to Trust priorities, falls risk, tissue viability, length of stay, safe discharge Linking to local and national events N&H week, Falls Prevention Week, National Older Peoples Day, Occupational Therapy Week, Dietitians Week Building in robust monitoring to secure compliance and sustained high profile

35 Contacts and links Academy of fabulous stuff, #eatdrinkmove #endpjparalysis #AHPsintoaction HEFT Eat Drink Move resources, see HEFT Therapies website:

36 References 1. Allied Health Professionals into Action, NHS England 2017, Case study 4 #AHPsintoaction 2. Korterbein P, Symons TB, Ferrando A et al. Functional impact of 10 days bed rest in healthy older adults. J Gerentol A Biol Sci Med Sci. 2008;63: Whitlock J. SSKIN bundle: preventing pressure damage across the health-care community... Surface, Skin inspection, Keep moving, Increased moisture management, Nutrition. Br J Community Nursing, 2013 Sep: Supplement: S Deconditioning syndrome awareness campaign Dr Amit Arora, The Academy of Fabulous Stuff 20/1/ Nolan J, Thomas S. Targeted individual exercise programmes for older medical patients are feasible, and may change hospital and patient outcomes: a service improvement project. BMC Health Serv Res. 2008;8:250. Epub 2008/12/ M Stolbrink, L McGowan, H Saman, T Nguyen, H Reilly, S Jones & AM Turner. The Early Mobility Bundle: a simple enhancement of therapy which may reduce incidence of hospital acquired pneumonia and length of hospital stay. J Hosp Infect 2014 Sep:vol 88;issue1;p Agmon A, Zisberg A, Efrat G et al JAMA Intern Med. 2017;177(2): Association between 900 steps a day and functional decline in older hospitalized patients.

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