It seems obvious that when you’re not well, you will probably eat and drink less – after all you’re not doing much, and you may not have much of an appetite. In fact, it is important to eat and drink as much if not more that you would normally in order to recover in the quickest time possible. Under-nutrition can cause wounds to heal more slowly, increases the risk of complications and of infections and can lengthen the hospital stay. Adequate nutrition and hydration is particularly important for older people. In fact, food and drink are as important to getting well as medicine!
Even when the importance of nutrition is recognised, it doesn’t always mean a person will get an adequate amount. In fact, many older people will be malnourished when they are admitted to hospital or will become so during their stay. While loss of appetite and feeling unwell account for some of this, there are many other reasons that patients may miss meals or not finish them. They may be asleep when the meal is brought and not woken up, they may be unable to open the packaging, or they may not be able to cut up the food themselves. Others may be unable to feed themselves or sit themselves up in order to eat. All of these factors can contribute to patients being undernourished while in hospital.
Staff got a sense of what it's like to be unable to eat their meal through roleplaying scenarios like trying to eat while lying on a table.
Goulburn Valley Health recognised the importance of helping ensure patients were able to eat and drink at mealtimes and that not everyone who needed assistance was getting it. They also realised that the number of malnourished patients being admitted to the hospital was not being fully counted. So they embarked on a process to change this.
The approach was two pronged: ensuring every patient was screened on admission using the Malnutrition Screening Tool (MST), identifying those who were malnourished or at risk, and introducing red trays for patients who needed assistance to eat their meals. The MST also identified those needing meals assistance, and the level of assistance they needed.
In order to have an impact, they first needed to identify the scale of the problem. To do this an audit was conducted to see how many patients were sitting up for meals, could reach their tray, were given assistance if needed and were finishing their meal. The audit showed there was room for improvement on all the measures, and that around 20 per cent of those who needed assistance weren’t receiving it.
Having identified the need, the next challenge was to get everyone on board – not just the clinical staff, but also the catering staff, the patients, and their families and carers. For Lisa Pearson, Best Care for Older People (BCOP) Project Officer, and Wendy Swan, Manager Nutrition and Dietetics, this involved a lot of consultation to get it right. It was important that the trays would work with the existing catering equipment and systems – finding the right trays was “a project in itself” says Wendy.
One of the keys to the success of the initiative was involving the catering staff from a very early stage. Denise Maloney, Manager Hotel Services says that the fact that members of the catering staff had input in to the process of developing and implementing the system, as well as understanding why it was being done, made a big difference. “I think it’s imperative that you do [that], because at the end of the day they’re the people actually handing out the trays,” she says.
The next step was educating staff about the trays and the MST. Catering staff were educated about how to respond to patient queries about the new trays. A staff event was also held to launch the red tray system and the MST. Staff got a sense of what it’s like to be unable to eat their meal through roleplaying scenarios like trying to eat while lying on a table. A sense of fun and ownership helped the new system to gain acceptance. The system has also been designed so that any member of staff can flag that a patient requires a red tray.
Information brochures were developed for patients and their families and carers. These explained why red trays had been introduced and what they meant, as well as tips on how to maximise nutrition while in hospital. Each person who received their meal on a red tray was also given a flyer that briefly explained why their tray looked different and why it is important to eat and drink enough when in hospital. A video about nutrition and the red trays was also made for patients and families, and was provided in English, Arabic and Turkish.
The system has now become part of usual practice in the hospital, and is also being rolled out to the health service’s satellite campuses, as well as to local small rural health services. Patients and families are also accepting of the system, with many wondering why “no-one thought of it before”. Many have indicated they feel less anxious if they are unable to be at the hospital during meal times.
The mealtime audit was repeated several months after the trays were introduced and found improvements on almost all the measures. Significantly, the proportion of patients who needed help and didn’t receive it had dropped to just five per cent. The catering staff have also noticed a difference through their own waste monitoring, particularly a reduction to the number of meals returning to the kitchen untouched. “It was going unnoticed,” says Denise, “but now the red trays have certainly flagged it… it’s certainly increased the amount of patients eating their meals.”There is always room for further improvement, of course, and Wendy says that there is a continual need not to just make sure patients have assistance, but to make sure that it is timely and adequate also.
Reviewed 05 October 2015