Leading Better Care
Sharing Good Practice
NHS Board: NHS Ayrshire & Arran
Ward: Medical Receiving Unit – Ayr Hospital
Details of Improvement:
What was the particular problem that this case study is about?
Meeting the nutritional needs of patients:
Due to the consistently high level of patient flow and the demands put on clinical practice, the Charge Nurse was aware that not all patients’ nutritional needs were being met on every occasion.
The feeling was that patients who required full assistance at mealtimes due to identified deficits in their own ability were being supported. Concern existed where patients who were ‘in-between’ the fully able and totally dependant patient groups patient’s that required “a little help” were not consistently supported at mealtimes.
How was this identified?
Introduction of the Clinical Quality Indicator for Food Fluid and Nutrition brought a focus on this topic and prompted the Charge Nurse to increase observation and measurement of the performance of staff, ward routine in relation to meeting nutritional requirements for patients and highlighted the need to improve the structures and processes currently in place.
The local Protected Meal Times guideline was also implemented around the same time as the CQI, providing CNs and staff with robust guidance to support improvement in practice.
What were the implemented improvements (what tools/techniques did you use)?
Introduction of the CQI allowed the Charge Nurse to measure performance related to protecting mealtimes and provided a baseline of information and the tool to continuously measure performance on a weekly basis. Other approaches included:
· Visual aids to highlight the times for meals and provide information for patients and visitors
· Education of staff to reinforce nutrition as a core priority in the patient’s daily care needs
· Developed approaches to improving the routine in the ward at mealtimes. This involved testing different approaches to protect and support meal times ensured that a robust process was implemented where by the ward could continue to function as a busy admitting unit, meeting the needs of patient flow, while dedicating staff to supporting meal times.
· Improved documentation to identify individual needs of patients and record interventions.
What is the situation now?
The Charge Nurse feels reassured that patients in the ward have their nutritional needs met, regardless of what level of support is required. Staff are engaged in the processes implemented ensuring that nutrition is given priority as part of the daily ward routine.
How is the change sustainable?
Observation of practice at meal times ensuring that the processes are reliable as part of the ward routine.
Daily identification of staff dedicated responsibilities related to patient flow and meal times
CQI performance measurement weekly
Continued education and awareness raising for staff through continuous feedback from the Charge Nurse
Measurable outcomes
What are the patient benefits?
· Patients are consistently receiving the support required to enjoy meals, reducing disturbance and ensuring that assistance is provided by staff.
· Reducing risks associated with nutrition and tissue viability as nutritional needs are met consistently.
What are the staff benefits?
· Nutrition and mealtimes are given more priority as part of the ward routine.
· Staff are more aware of patient needs and the importance of identifying the patients who need‘a little help’ at meal times.
· There is an organised approach to ensuring that patient’s nutritional needs are met despite the demands and complexities of a busy receiving unit.
What are the organisational benefits?
· Improved patient experience of meal times and care delivery
· Organised ward routine to meet the demands of the service
· Contributing to improving the TV outcomes for patients
How did staff feel before the improvement/during the improvement and after the improvement?
Staff were not completely bought into the changes for improvement and the feeling was that initially they didn’t all acknowledge the importance of this development.
As the improved processes became part of the ward routine there was a shift from the initial doubt that it would not be possible to bring about this change. Staff became empowered to take the lead at meal times, protecting and supporting their patient’s needs in a consistent and reliable manner.
What are the lessons learnt and what would you do differently next time?
It is not possible to put patient flow on hold, A&E have to be supported to ensure that patients are admitted to the ward in a timely manner. This allows the potential risks and needs of patients to be identified quickly and also supports the priority of meeting nutritional needs.
Meal times do not always have to be disrupted by patient flow demands, the ward processes can be organised to ensure that both meal times and patient flow can function together and be patient centred. The key to success is in identifying the processes that best meets the patient needs, ward demands and staff workload. In this case, not all staff on duty need to be dedicated to meal times, but a clear structure of who and how this is supported on a daily basis allows the ward to function effectively without putting patient’s nutritional requirements at risk.
What plans are there to spread the improvement?
The CQI and PMT guideline is in place across all in-patient areas and improvement support is provided to individual wards where issues are identified, enabling the development of processes to meet the demands of individual specialist areas with varying routines and patient flow demands.
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Contact information for case study
Charge Nurse Leona Murdoch, Station 7, Ayr Hospital
Susan Hannah, Clinical Improvement lead, Lister St, Crosshouse Hospital