‘Better Care Through Building
Teams’
Implementation of a Nutritional
Care Bundle on the Stroke Unit at
Royal Bournemouth Hospital
Stroke Therapy Team
RBH
October 2016
Nutritional Care and Stroke
• Strong link between nutritional intake,
hydration and mortality rates, rehab outcomes
and dependency post-stroke (FOOD trial, 2003; Nip et
al 2011)
• National guidance (NICE 2008)
– All patients screened with MUST on admission
– All stroke patients to undergo a water swallow
screen assessment within 4 hours of admission
– Screening should trigger referral to dietitian and
SLT for full assessment
Nutritional Care on the RBH Stroke
Unit
• Inconsistent- no defined patient pathway
• High rate of PEG referral and insertions
– 2015- 40 referrals, 26 insertions
• High rate of PEG mortality
– 2015- 5 RIP on ward = 19.2 %
Opportunities for Improvement
• 3 new consultants
– Strong, collaborative leadership
• Dedicated and motivated team
• Open to innovative ways of working
– Breakfast and lunch group
– Smoothies on the ward
• Continual service improvement
– National audit results
‘The Team’
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3 consultants
2 ward nurses
Dietitian
2 Speech and Language
Consultant therapist
Nutrition Support Team
‘The Team’
What We Did…
• Process mapping
• PDSA cycles
• Myers Briggs
• Implementation of the ‘Nutritional Care
Booklet’
What we found…
• Audit of Nutritional Care Booklet
– Identification of ‘gold standards’ for good
nutritional care
– Development of Nutritional Care Bundle…
Nutritional Care Bundle
Stroke Nutritional Care Bundle
Within 1
month
Week 2-3
Acute Phase
Time
Activity
IV fluids commenced within 24 hours
Completed
Yes / No / NA
NGT inserted and feeding commenced
within 48 hours
Yes / No / NA
Seen by dietitian within 2 working days
Yes / No / NA
RBH Dysphagia Outcome scale
documented within 72 hours
Yes / No / NA
Documented MDT discussion, involving
Consultant, regarding long term feeding
plan
Yes / No / NA
Documented patient +/- family
discussion, involving the MDT, regarding
long term feeding plan
Yes / No / NA
Capacity assessment regarding decision
for long term feeding documented
(date: ____________)
Yes / No / NA
Comments
After week 2-3, the nutritional care plan should be reviewed by the MDT weekly; document in Nutritional Care Booklet.
For patients who may be appropriate for a PEG, a Nutrition Team referral should be considered within 1 month post stroke.
What we found…
• Audit of Nutritional Care Booklet
– Identification of ‘gold standards’ for good
nutritional care
– Development of Nutritional Care Bundle
• At baseline:
– 15 % of audited patients met all elements
– 20 % of food charts incomplete
– 65 % MUST assessments incomplete
Challenges…
• Time
• Difficulty arranging meetings with different
specialities
• Differing priorities of some within the team
• Maintaining enthusiasm for long-term project
• Difficulty embedding new practice
– Filling in booklet
Outcomes on the Stroke Unit
Clinical
• Full results from re-audit pending
– Reduced numbers of PEG referrals, insertions and mortality
– PEG referrals more appropriate and timely
• Improved perceived patient/family satisfaction
– Better communication
– More consistency
Team
• Appreciation of specialities within team
• Collaborative team working
The Future…
• Continue to work on and refine the Nutritional Care
Booklet
– PDSA
• Maintain ‘gold standard’ of care
• Patient/family feedback
• Further work on improving nutritional care as part of a
team
– Development of smoothie club
– Improving practice with MUST screening/nursing documentation
– Organising information sessions for patients/carers on texture
modified diets
– Creating a nutrition information board for patients and carers
– Increase engagement of the wider ward team with nutritional care