Mind the Hunger Gap Case Studies Team Alpha Queen Elizabeth Hospital, London As part of London s Queen Elizabeth Hospital s long-standing battle against malnutrition in the acute setting, they put together a working party of dynamic, forward thinking, optimistic and innovative dietitians and dietetic assistants. They are known within their department a Team Alpha. Their working ethos is to actively improve nutrition and hydration for patients and ensure an excellent continuity of care. A summary of recent projects/work includes: Nutrition Risk Score (NRS) Complete overview of the MUST screening tool and development of a new improved user friendly nutritional screening tool. NRS is soon to be in the validation process with the support of senior management and medical colleagues. Currently, NRS is used on one acute site within the trust, Queen Elizabeth Hospital, Woolwich. Trust-wide audit They recently completed a trust-wide audit encompassing three acute sites, assessing the percentage of patients screened within 24 hrs of admission and the accuracy of nutritional screening on each patient. This audit allowed them to also compare NRS accuracy and uptake versus MUST. Nutrition Link Folder/Nurses They completely revisited and revised the nutrition link programme. This involved designing and formulating a new folder for each ward. The folders were centred on clear, concise and practical information relevant to all staff working at ward level. Policies were removed and replaced with concise practical guidelines. As part of this process, they developed a chapter on First Line Dietary Information sheets, to empower ward staff to offer and support patients/family/carers with simple practical dietary information for those patients not under the care of a dietitian. Nutrition link nurses and health care assistants were recruited from each ward to support the programme. Teaching/Training To support the introduction and use of NRS on the wards, there is continual focus on teaching and training. As part of this, they continually offer and support micro-teaching on the ward training of 1-4 RGN/HCA on the ward to avoid ward managers needing to release large numbers of staff for PowerPoint facilitated training. This has been very well received on the wards at the Queen Elizabeth Hospital. Other training projects included student nurses and link nurses/hca study. FEAST Re-launch of the local food focus group encompassing a new logo FEAST (Food Essential As Treatment). This is a multidisciplinary group of interested people including nursing representatives. They look at ways of improving the service of nutrition to patients within their hospital. Within the group, they branch into smaller working parties to carry out specific tasks e.g. monitoring red tray system and protected meal times through regular lunch time visits to the wards. Nutrition Road Shows A New Year plan of action is already in development for Team Alpha. To support the introduction of the NRS tool on the acute site at Queen Mary s Hospital Sidcup, they plan to run a road show in the conference centre/canteen. They plan to have three workshops running all day for ward staff to drop in and be trained on the new screening tool and food first policy. Again, the ethos behind the day is to avoid ward managers releasing staff for long periods and for it to be a practical and dynamic session for staff. 0
Care at Home - Newcastle City Council in Collaboration with The Newcastle upon Tyne Hospitals NHS Foundation Trust Care at Home is a city wide service supported by 280 carers and a multi-disciplinary team. Adults requiring a care package are referred to this service for 6 weeks reablement or palliative care. The service aims to facilitate improved wellbeing, independence and ensure care packages are tailored to individual needs. Everyone entering the service is nutritionally screened (using the MUST screening tool). Initial data from this process (6 months) suggests the service is detecting people at risk of malnutrition in the community: Of 841 service users nutritionally screened, 27% were identified as being at risk of malnutrition; 16% high risk and 11% medium risk. 170 service users (20%) went on to be referred to the dietitian. Importantly the screening process is underpinned by the following: Referral forms into the service require the social worker to detail any nutritional concerns, including hospital admission and discharge weights (informs the screening process making it more reliable). All workers carrying out nutrition screening have their own set of portable weighing scales and have been trained on the screening process, first line advice and monitoring. To date nearly 200 of the carers have completed a training programme which includes a session on nutrition awareness. It emphasises their role in encouraging balanced eating, effects on health and wellbeing, spotting, managing and monitoring those at risk of malnutrition. They are actively encouraged to initiate food records and report concerns. Staff from local private care agencies, are also invited to attend. The presence of a dietitian and a dietitian assistant to develop and support the screening process, care pathway and training. Malnutrition largely originates in the community (BAPEN, 2010). Our experience at Care at Home suggests that a management pathway within adult social care is feasible and helps to detect and manage malnourished adults living at home. Without this, the negative effects of malnutrition would remain undetected and potentially undermine the reablement process which aims to facilitate the recovery of skills, function, wellbeing and confidence so people can continue to live at home. 1
Henderson Court Age UK Age UK's Henderson Court Resource Centre for the elderly, Eve Nutrition (a private nutrition clinic in Hampstead) and The Rotary Club of Hampstead have joined the British Dietetic Association (BDA) Mind the Hunger Gap national campaign by running regular nutrition clinics at Henderson Court. According to the British Dietetic Association (BDA) more than 3 million people in the UK are at risk of malnutrition. Malnutrition makes people more prone to infections and slower to recover among many other problems. Rotarian Dr Val Eve a Public Health Nutritionist says "Malnutrition in the UK does not discriminate between social classes and sometimes results from elderly people's isolated life style feeling unmotivated to prepare food and therefore are eating less. Our sense of thirst and hunger also decreases with aging which means that we need a proactive approach to solve the problem and ensure regular and adequate meals. Community resource centres like Henderson Court are key players in the provision of meals to the local elderly - ensuring at least one meal a day is easily accessible. Our aim is to raise awareness of the BDA Mind The Hunger Gap campaign in our community and the work of Henderson Court Resource Centre which is threatened with closure due to cuts in social care budgets. The centre has over 200 registered users and provides over 150 meals a week. Together we hope to raise funds and look to other collaborative solutions to keep this service open and available to the local community. 2
Team Alpha Walsall Community Health Malnutrition is common among older people in nursing and care homes. It is frequently unrecognised and is often under-treated in the UK(2). Malnutrition costs an estimated 13 billion in the UK(3). It is recommended that all patients admitted to a nursing or care home, be screened for malnutrition(2). Despite this, there remains little information on the prevalence of malnutrition in this population. Malnutrition has a negative impact on a patient s health, and in turn this has cost implications for the NHS. Therefore identifying and appropriately treating malnutrition can avoid knock-on healthcare complications and inflated costs. The aim of this study was to establish the prevalence of malnutrition in older people in nursing and care homes using the Malnutrition Universal Screening Tool (MUST)(1), (2), (3). The study also aimed to determine how many residents were appropriately prescribed oral nutritional supplements (ONS), and by whom. 249 residents (mean age 84; 73% female) from 6 nursing and care homes (5 nursing and 1 care home) were screened for malnutrition using MUST from January 2010 to May 2010. The screening was carried out by the community dietitian and Nutricia Nurse, as well as staff trained on the use of MUST. 58% (144 residents) were screened as being low risk, 19% (46 residents) were screened as medium risk and 23% (58 residents) were screened as high risk. This mean BMI for each risk group was as follows; low risk (26.0kg/m2). (Please note: 1 resident was admitted to hospital and no previous data available as she was a new resident). Low risk Medium High risk risk Hospital 2 (0.8%) 0 (0%) 5 (2%) GP 8 (3.2%) 8 (3.25) 6 (2.45) Dietitian 7 (2.8%) 7 (2.8%) 18 (7.3%) From the table, only 13% (including ~7% at high risk of malnutrition) of residents in the care homes taking supplements were monitored and reviewed by a dietitian. 10 low risk and 8 medium risk residents has been prescribed ONS either when discharged from hospital and from a GP. These residents were not monitored. After the MUST screening, these 18 residents who were on ONS were able to stop. Appropriate dietary advice was given to the staff on management of these residents, and also to re-screen according to care plans. Malnutrition is common in the nursing and care homes studied: 18% of residents were at risk of malnutrition according to MUST (6.0% medium risk, 12% high risk). Most of the residents with malnutrition did not receive ONS or dietetic input for oral nutritional support. Residents in the nursing and care homes studied were inappropriately prescribed ONS without further review (Table): 4.0% of low risk residents on ONS prescribed by either the hospital of GP, 3.0% of medium risk residents on ONS prescribed by the GP. This study shows that malnutrition is common (18%) across nursing and care home settings. Without continued staff training and resident screening using MUST, malnutrition would have been unrecognised and untreated. The study also showed that identifying and appropriately treating malnutrition could potentially reduce health care costs. 1. Elia M (2003) The MUST report. Nutritional screening for adults: a multidisciplinary responsibility. Redditch, UK, BAPEN. 2. NICE Guideline (2006). Nutrition support in adults. Clinical guideline 32. 3. www.bapen.org.uk 3
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