SHSCT G ACUTE MUST Screening is undertaken in all inpatient wards within SHSCT Training is provided to nursing and auxiliary staff on MUST by Dieticians, as required Nutrition screening now rolled out within Mandeville unit ACUTE Scope/review training arrangements to assess current need for evolving workforce Audits will continue Review compliance within Mandeville unit WHSCT G All patients have a MUST assessment done on admission and reviewed during their inpatient stay. MUST is measured as a KPI for nursing and midwifery and reported to the Trust Governance Committee. MUST assessment completed on admission for all patients. Regular review and update of MUST. Compliance with MUST is monitored with the Trust KPI programme and currently the Ward 43 cancer services in addition to using the MUST also record the patient’s daily calorie and protein intake in conjunction with the dietitian. Where appropriate a diet intake target is agreed. The ward have also instigated a diet supplement round twice a day between meals plus snacks i.e. high calorie high protein are readily available ward level for those patients who require little and
-27.4% amended to cost effective product -Efficiencies of £2,015,836.09 have been realised to date. IHCP – Domestic Care This is a vague statement that requires clarification. The strategy refers to care settings including a person’s own home. People are not routinely screened for risk of malnutrition. NISAT is inadequate in our view in addressing the nutritional needs of persons in their own homes with potentially dementias or who live alone. People who need assistance with eating are clearly identified BHSCT G All inpatients that need assistance with eating are expected to be identified at nursing handover reports throughout the day and at mealtimes. Appendix 1
IHCP – Domestic Care Generally so especially in a residential setting. It is essential that sufficient time is allocated if a person requires assistance or encouragement to eat in a domiciliary setting. Organisations across NI are building on the implementation and learning from ‘Get your 10 a Day’ standards across all health and social care settings including people’s own home BHSCT G The Trust has a Nutrition Steering Group with representation from all key disciplines to deliver on the regional Promoting Good Nutrition (PGN) Strategy. This is implemented through 3 Sub Groups: The PGN Operational Group; The Clinical Nutrition Group; The Catering Group. NHSCT G Trust have accepted the standard for inpatient and day care however implementation is being reviewed as part of the review of the Trust Nutritional Strategy.
SEHSCT G The Ten a Day work stream in SET has now become the acute nutrition work stream of the Clinical Nutrition Learning from the acute work stream is replicated across other areas. Continue to build on previous work in line with regional strategy. SHSCT G ACUTE PGN has superseded ’10 A day WHSCT G Education sessions on Get your 10 a day have been delivered to nursing staff Ongoing awareness/ education to promote implementation IHCP – Domestic Care This is a requirement in regard to nursing and residential homes however there is no definition of an ‘organisation’ and there is no structure to ensure people in their own homes are benefitting
from the 10 A Day standard. People with swallowing difficulties are screened BHSCT G All people are screened and those with swallowing difficulties are referred to Speech and Language Therapy (SLT) colleagues for specialist assessment and intervention. Patients in the Integrated Stroke Unit are screened using the water swallow test. Patients who fail the test are referred to SLT colleagues. NHSCT A When there is an identified risk Referrals to SLT via solver if swallowing difficulties or potential for aspiration are detected. Review of capacity and demand to meet assessment timescales. SEHSCT A ACUTE: Previous attempts to offer screening training have resulted in poor uptake. Screening has now been revamped to take only 30 minutes. ACUTE: Initial ward based training will take place during February and March 2016 then monthly dates will be made available on HRPTS for staff to apply as appropriate.
Systems and guidance are in place for appropriate and timely decisions in relation to the need for enteral or parenteral nutrition BHSCT G The Trust’s Nutrition Support Team (NST) deals with parenteral referrals on the Royal and City Hospital sites. The NST accept requests for advice and referrals via bleep at any time during the working day. Ward based Dieticians work as part of the Multidisciplinary Team and advise when nutritional support via other routes are not meeting individual patients nutritional needs and advise on support required via other routes. At induction, Dieticians are trained on all processes/policies relating to this aspect of nutrition support. During out of hours, Trust wide requests for parenteral nutrition are logged on a register and reviewed. Requests are followed up and education sessions delivered, when required. A business case in the Mater is being worked up to attain the necessary funding for a Dietician to help facilitate the provision and management of PN on this site
People on multiple medications (polypharmacy) will have regular medication reviews BHSCT G Inpatients are assessed regularly, and medication reviews are undertaken. Some Wards across the Trust have a ward based Pharmacist whose role is to provide medication review and reconciliation. NHSCT G Pharmacy staff are ward based and community patients are reviewed by GPs. SEHSCT A Clinical pharmacists prioritise patients in the following way: Medicines reconciliation on discharge Medicines reconciliation on admission Review patients especially those on Polypharmacy & high risk meds SOP for prioritisation Patient turnaround is such that the review of kardexes is often Roll out of e-whiteboards Increase the use of to help identify & prioritise patients Medicines optimisation supported through the use of evidence based medicine Seek funding for clinical pharmacists in areas not covered by clinical pharmacy E-whiteboards timescale – all acute areas by May 2016 The majority of patients on multiple meds are in the older age group “A Guide to Support Medication Review in Older People” developed by NI network of pharmacists
SHSCT G ACUTE Where MUST undertaken, patients/clients with nutritional needs have an individualised care plan Adult Fluid Balance Charts in place Resources available to support MUST for various settings Formal dietetic access criteria which includes MUST available on Trust intranet Nutrition Ward File for non- acute hospitals developed, training provided and in use. ACUTE Work ongoing – to incorporate nutrition screening and individualised action plans reflective of menu provisions in case notes WHSCT A This plan may be documented by more than one discipline/profession. Example good practice includes Ward 43 (cancer ward) in addition to using the MUST also record the patient’s daily calorie and protein intake in conjunction with the dietitian. Where appropriate a diet intake target is agreed. The
SHSCT A ACUTE Where team members are available, nutrition needs are consulted upon. COMMUNITY Where possible, nutrition needs are consulted upon. ACUTE Ongoing COMMUNITY Continue to promote involvement via nutrition training WHSCT A Efforts are made to ensure this is adequate involvement with the patient family members and health professionals. Multidisciplinary involvement in nutrition care plans. Medicines Management, HSCB All relatives/carers of patients’ seen by a MMD were given the opportunity to attend clinic appointments to develop the patients’ care plan. IHCP – Domestic Care This can vary from setting to setting. In a nursing or residential setting this is the case, however not usually in a domiciliary setting.
Time frames are not always maintained when referrals span a normal weekend. SHSCT G Patients are referred to SLT via GP/Consultant Criteria for referral to SLT is in place and nursing/ medical staff are aware of procedure for referring to SLT service. Ongoing Capacity issues for SLT WHSCT G Answer as at point 1 Medicines Management, HSCB Swallowing difficulties as before. IHCP – Domestic Care See above. KEY CHARACTERISTIC 3. The care provider must include specific guidance on food and beverage services and nutritional care in its service delivery and accountability arrangements Menus are planned to achieve optimum nutrition and hydration BHSCT G Meals are planned with Dietician colleagues to ensure that all patient meals, including special diets, are nutritionally balanced and coded. Standard recipes are used. Menus are coded using a A Group which includes catering and dietetics colleagues are putting in place a standardised menu across Belfast Trust, changing twice per annum. This will be completed by April 2016. Appendix 3
toolkit produced nationally by the BDA, Catering association and RCN. A Manual for use at ward level as an education tool to ensure all staff are aware of the foods allowed on special diets is in draft form. This will be completed by April 2016. NHSCT G Menu reviews are completed biannually to ensure the menu plan/offer is suitable for all patient/client groups. Catering and Dietetic services work in conjunction and menus are nutritionally assessed by Dietitians/ through Dietetic involvement externally if purchased. All menus for acute and community catering will continue to be reviewed biannually. Catering and Dietetic colleagues will continue to work in conjunction Menus are altered each year to facilitate the introduction of seasonal fayre e.g. summer, Halloween and Christmas. Menus are also altered during the annual national nutrition and hydration week and for catering services excellence day promotion. SEHSCT G Menus have been nutritionally analysed and where high protein is recommended, a snack menu supplements the standard menu All acute menus are planned by catering with dietetic and Speech and Language (SLT) input. Collaboration regarding On review, menus will continue to be developed in line with patient requirements
textures in line with National Descriptors Guidance SHSCT G ACUTE SHSCT Good Nutrition Policy Sept 2012 SHSCT Framework for implementation of Good Nutrition Policy May 2013 Menu planning group established within the Trust to review patient menus. Ongoing work of Menu planning multidisciplinary group to formalise menus and the menu planning process - to ensure a consistent process across the Trust in terms of quality assuring nutritional content/meeting the nutritional needs of the patients/clients. New dysphagia menu to be introduced in DHH in 2016 to include textures B,C and D Significant capacity issue for Dietitians as this is an extensive exercise requiring full nutritional analysis of recipes and menus not resourced WHSCT G All patient menus meet the nutritional standards outlined within the British Dietetic Association Digest Document (2012): Improving outcomes through food and beverage Service. Audit of food fortification of puddings at kitchen level completed July 14 and July 15. Completed
between catering, dieticians and nursing colleagues. Dieticians work closely with the catering teams to ensure this is the case. There is a standard menu which is coded to allow patients to make an informed choice. There are also a number of special diet menus which ensure the needs of all patients are met. and ensure there is sufficient choice for patients. NHSCT G Menu reviews are completed biannually and are nutritionally assessed by Dietetic staff Dietetic colleagues will continue to work in conjunction In 2015 the menu design for both acute and community facilities was altered to accommodate the allergen regulations and dysphagia recommendations. SEHSCT G Menus have been designed to ensure they are suitable for a variety of dietary requirements e.g. there is always choice for gluten free, texture modified diets. These have been approved by a Dietitian. Content of menus in Trust facilities currently under review Development of a menu which can be appropriately modified
to ensure access to appropriate consistencies for those with dysphagia in all instances to cater for national dysphagia Diet texture C, D and E SHSCT G ACUTE As above – menu analysis CAH and DHH with Action plan. SHSCT Good Nutrition Policy Sept 2012 SHSCT Framework for implementation of Good Nutrition Policy May 2013 Menu planning group established within the Trust to review patient menus. • As above Ongoing work of Menu planning multidisciplinary group to formalise menus and the menu planning process - to ensure a consistent process across the Trust in terms of quality assuring nutritional content/meeting the nutritional needs of the patients/clients. New dysphagia menu to be introduced in DHH in 2016 to include textures B,C and D Capacity issue for dietetics to continually review and update menu changes. Lack of dietetic support for regional contracting for catering products. WHSCT All patient menus meet the variety of client special diets as outlined within the British Dietetic Association Digest Document (2012): Improving outcomes through food and beverage Service SAFFRON project ongoing. Post SAFFRON project additional dietetic resources to support and review changes in the system is problematic.
WHSCT G Feedback is sought from relatives if they are present at mealtimes or are assisting with feeding relatives Medicines Management, HSCB Feedback captured by the MMDI demonstrates 92% of patients reported comparable or improved wellbeing following their appointment with the MMD. GP feedback has been overwhelmingly positive, with 100% of GPs reported their knowledge of ‘Food First’ and nutritional screening using the 'Malnutrition Universal Screening Tool' (‘MUST’) had improved. IHCP – Domestic Care Yes in Residential and Nursing home setting, not in domiciliary setting unless persons are in receipt of commissioned community meals There is a nutrition coalition established BHSCT The Trust has a Nutrition Steering Group with representation from all key disciplines and Directorates. The Group reports to the Trust Appendix 5
Within the community setting, patient/client mealtimes are protected without unnecessary interruption. A Policy entitled ‘Prioritising the Mealtime Experience (Protected Mealtimes) has been drafted and has been submitted to Standards and Guidelines Committee for approval. NHSCT A Protected Mealtimes Policy in place but not always adhered to. Policy being revised and to promote awareness of the importance of Protected Mealtimes for patients. Policy to be fully endorsed by the Chief Executive. SEHSCT A In acute areas staff mealtimes and ward routines have been adapted to ensure that the maximum assistances with patient meals is available Work has been done with Catering to ensure that meals replacement and snacks are available for patients who have missed a meal because of e.g. On-going work with staff to reduce unnecessary interruptions at mealtimes so that each patient’s individual mealtime is protected as far as possible On-going work to increase number of mealtime volunteers
going of the ward for an investigation SHSCT G Protected mealtimes implemented in all inpatient settings There is a need to continue to actively promote and reinforce ‘Protected Meal Times’ and to minimise interruptions WHSCT A Protected mealtimes are in place and policy updated and approved Dec 2015. Protected meals are challenging to achieve. Patients are frequently attending different departments for diagnostics treatments. IHCP Domestic Care Yes Ensure the environment encourages eating e.g. by removing distractions BHSCT G All staff are required to ensure that the environment encourages eating. Some Adult Inpatient Wards have space to provide designated dining areas. Examples of good practice are evident in Musgrave Park Hospital and the Mental Health Inpatient Wards in the Mater Hospital. Also, in the Physical Disability Day Care Centre,
been carried out – including obesity awareness and health checks how to spot signs of malnutrition SHSCT G Nursing and auxiliary staff receive nutrition/MUST training by Dieticians Medical students receive training by Dieticians on nutritional screening Meal support volunteers receive training from dietetics and nursing (runs 3 times per year for new volunteers) Competency of staff once trained is assured via the monthly NQI audits Need to review the frequency of training E-Learning tools required to be sourced, agreed regionally and purchased Nutrition awareness training required for all staff re the causes and consequences of malnutrition but contingent on capacity of Nutrition and Dietetic service WHSCT G Staff attend MUST training during induction and outside of this if required Medicines Management, HSCB The Northern Ireland Centre for Pharmacy Learning and Development (NICPLD) have offered a range of learning opportunities to support those who may be required to screen for malnutrition in adults and to raise awareness of the causes
malnutrition/appropriate prescribing of ONS. IHCP Domestic Care Yes All health and social care staff will have raised awareness of the causes and consequences of malnutrition BHSCT G Nursing staff have raised awareness of the causes and consequences of malnutrition through pre- and training. A series of training sessions have been commissioned with CEC for Registered Nurses specifically tailored to cover PGN, MUST and the consequences of malnutrition. The training sessions for Registered Nurses are to be delivered and subsequently evaluated. NHSCT G Information on malnutrition and consequences shared on NHSCT intranet. Nutrition training sessions incorporate awareness of malnutrition (however not always well attended). Intention to become involved in the National Nutrition and Hydration week (w/c 14th March)
SEHSCT G Training delivered regularly for nurses in acute setting – both at ward level and at induction. District Nurses and Community Psychiatric nurses have also been trained Nutrition awareness has also been included in nursing auxiliary Proqual training Safe and Effective Care Department included MUST screening and nutritional awareness as part of Commissioning Priority days In Learning Disability nutrition awareness sessions have been carried out – including obesity awareness and health checks Further MUST training and nutritional awareness planned for Safe and Effective care Commissioning priority days Awareness training for Social Care Staff in planning stage Meetings with domiciliary care provider to discuss training for staff Contact made with local coordinators of sheltered housing for Older People Trigger card to target friends and families of older people developed – linked to leaflet on how to spot signs of malnutrition SHSCT ACUTE G Swallowing difficulties and Nutrition awareness video developed for Trust Domiciliary care staff and in use. Plan to be used with other staff groups Continue to monitor awareness WHSCT G Within cancer services the treatments, side effects, disease progression and fatigue all have a major impact
IHCP – Domestic Care This is not met in a domiciliary setting Flexibility and anticipatory management is evident in the transition of children to adult services BHSCT G The transition of children to adult services is required to be individualised. NHSCT A During the transition from Children’s to Adult services, each child’s nutritional plan of care is transferred to the relevant adult service. SEHSCT G During the transition from children’s to adult services the individual care plan is transferred to relevant professionals including any nutritional care needs. SHSCT A Holistic transitional plan for children to adult services which includes an assessment of nutrition needs. Ongoing WHSCT G Transition from children to adults services is an on-going programme of work
IHCP – Domestic Care N/A Services and staffing to support the aims of this strategy are realigned or developed and those which do not are scaled down or stopped BHSCT G Services and staffing are reviewed in order to support the aims of the Strategy and ensure resources are appropriately employed. NHSCT G As necessary, within commissioning of services. SEHSCT G Dietetic hours have been reduced to introduce Dietetics assistants in primary care service to support review of patients and on-going demand on dietitians caseload Ward staff mealtimes have been changed to support patients’ mealtimes Developed skills of nurses in nutritional screening and monitoring of nutritional care plans Additional dietetic assistants are being recruited to deliver the PAAT model to support a sustainable model in nursing homes We want to progress the submission of the business case for the Nutrition support nurse in the Trust Develop intermediate care teams to screen and monitor
activity. One member of the sub-committee represents the Trust at the regional meetings. The sub-committee has four work streams which cover acute, community, patient experience (catering) and enteral and parenteral nutrition. Each of these work streams has a plan of work updated yearly and the work streams feedback progress at each meeting SHSCT G Acute implementation group established with working subgroups. Multi-disciplinary representation. Review of Terms of reference and frequency of acute nutrition meetings WHSCT G Medicines Management, HSCB A panel has been convened as part of the NI Formulary process to consider the development of a formulary for ONS as well as vitamins and minerals.
This will include a ‘7 Steps to Appropriate Prescribing of Adult Oral Nutritional Supplements (ONS) in Primary Care’ to support PGN implementation across primary care. This will be accessible via the NI formulary internet site as well as links from the Gp intranet. IHCP – Domestic Care Each setting will have developed their own performance management arrangements in regard to Residential and Nursing homes in line with RQIA requirements Regional and structured approaches to the management of long term enteral and parenteral nutrition are in place BHSCT G The Regional Intestinal Failure Centre is funded. There is a Regional Dietetic care pathway in use for the management of patients requiring enteral nutrition. Clinics/Meetings BCH Site – weekly MDT clinic, with a post clinic meeting the following day. There is an
SEHSCT G MUST is a KPI and commissioning target – compliance in the last year has ranged from 90 – 96% Pilot of MUST screening in Outpatients completed. Standards set for Care Homes – regulated by RQIA Consider benefit of piloting in outpatient settings Audit compliance with accuracy of monthly screening in care homes SHSCT G ACUTE MUST is audited as a CNO KPI and SHSCT NQI ACUTE Ongoing WHSCT A MUST is part of the nursing KPI programme The work plan and improvement project described at point 4 is a continuous programme. IHCP – Domestic Care Not in a domiciliary setting Nutritional care is in line with evidence based guidelines on the safe management and administration of BHSCT G Nutritional care is line with evidence based guidelines. A Multidisciplinary Group has been established to manage the implementation of ‘enfit’ across the Trust. Giving set
enteral and parenteral nutrition. Health and safety legislation is an integral part of delivering safe nutritional care. transition is now complete and successfully implemented. Work is currently underway on a gant chart for successful implementation of ‘enfit’ syringes and giving sets. This Group reports on progress to the Food & Nutrition Steering Group. A Service level agreement for manufacture and provision of parenteral nutrition to home cohort of patients is in place. NHSCT G Policies in place reflect NICE guidance. The Trust promotes use of best practice guidelines and evidence for the safe management and administration of enteral and parenteral nutrition. SEHSCT G Trust and Royal Marsden guidelines for enteral feeding are in place Audit of confirming position of NG tubes is informing the development of practice Enteral feeding guidelines being reviewed and updated and training delivered NG tube guidance updated and being implement4ed with training Business case for the Nutrition Support Nurse for the trust needs funding to meet NICE guidance
work together as outlined above SHSCT A No Nutritional Support Team, however relevant disciplines work together. WHSCT G While we don’t have a defined nutritional team there is excellent collaborative working between dietetic, support service and nursing staff Business case for MDT Nutrition Team developed Progressing through Acute Directorate IHCP Domestic Care Not in domiciliary settings unless there is District Nurse involvement and even then it is sporadic.