67% of the inpatients in acute medicine at Imperial are over 70 and 49% have cognitive impairment. The Francis Report (2013), the CQC and Alzheimer’s Disease International (2014) have identified that this group are vulnerable to dehydration and malnutrition in hospital. Recent reports have also shown that people with dementia in hospital have poorer outcomes; we believe that poor intake contributes to this. Our aim was to implement a person centred pathway to support nutrition and hydration for these patients with our FM providers, Sodexo.
For 12 months prior to implementation, we used PDSA cycles on aspects of the proposed pathway, including use of music, coloured crockery, activity before eating, social eating and bento boxes (snack boxes ) We also received feedback using interviews from patients, families, staff and dietetics. Using the results, we developed a three tier pathway and secured funding to implement it. The pathway includes:
Core Support. Basic level of support to be provided to all patients with dementia on wards.These patients were not referred to the team but had:
-Fruit Juice or squash instead of water.
Enhanced Support: Referred when there are concerns about intake. These patients were seen by the team, this includes all the core elements and :
-Different food delivery
-Five small meals a day, finger food menus and Vive Petite meal range.
-Music during meals
Intensive Support: Referred when a patient had stopped eating. It included the core & enhanced options as well as:
-Physical activity if able.
We employed two healthcare support workers to implement the pathway. The project is now in place on 29 wards, predominantly medicine, but also in surgery. 450 patients have received enhanced support during this time. We found that the most important element of the service was identifying the needs of the patients and responding; often the reasons why a person was not eating was not related to food, but rather depression, pain, fear or isolation.
The role of the HCSWs changed as the project progressed and became about championing the well -being of the patients. They have now become valued members of the Multi-disciplinary team: -‘This project has allowed us to support the frail and vulnerable in a way we have not previously done. The patients nutritional needs can often be overlooked during an emergency visit and the team were able to respond to this when the need arose.’ (Deputy Director of Nursing,)- ‘It has completely changed the way I practice’ (Dietitian)-‘This is so creative’ (Carer). The project ran for 15/12 and funding was secured for £137K. This included £89K from the Charity, £26K from Sodexo and £22K from Medicine. The combined sources meant that we had wider support as they all had a vested interest in the success of the project. It remained in budget.
The project has improved patient experience and dramatically impacted on patient outcomes. We audited 120 patients (40 pre, 40 Core, 40 Enhanced):
Results showed post implementation:
•Shorter length of stay (average 5 days)
•Lower readmission rates
Core (those on the participating wards who were not seen by the team).
•lost average 2.1kg less weight
•17% reduction dehydration
•12% reduction Hospital Acquired Pneumonia
•5% Reduction Delirium
•27% reduction Challenging Behaviour
•10% reduction 1:1 care
Enhanced (case managed).
•41% less lost weight
•30% reduction dehydration
•15% reduction acquired UTIs
•17% reduction Hospital Acquired Pneumonia
•20% reduction Delirium
•45% reduction Challenging behaviour
•15% reduction 1:1 Care
Internally, the project has been well received and it has been agreed to continue funding it permanently. It has received external interest and has been presented at:
•32nd International Conference of Alzheimer’s Disease International in Budapest in 2016. (presented by the Healthcare Support Workers)
•National Dementia Action Alliance Hospitals Meeting in 2016.
•Two National Acute Frailty Network meetings.
•Poster at BGS Meeting 2016
•Nursing Standard Article 2016
•Journal of Dementia Care Feature 2017
•Seven other NHS Trusts have approached us and met to discuss how they can use the model in their trusts.