Shared learning database

The Royal Berkshire NHS Foundation Trust
Published date:
February 2011

The Royal Berkshire NHS Foundation Trust has developed a comprehensive, multidisciplinary strategy to improve the nutritional care of our patients. This approach functions at grass-roots level, encouraging cross-boundary working between wards and professional groups, and enabling staff to recognise the critical role that nutritional support plays in patients' recovery. Trust wide evidence based policy is implemented through the Nutrition Steering committee and the network of Nutrition Champions, a model that creates its own momentum, shares best practice and encourages improvements in care.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The key aim of our strategic multidisciplinary approach was to improve the nutritional care of our patients by ensuring effective screening and treatment of patients at risk of malnutrition. To be able to introduce good nutrition and hydration practices it is necessary to know the patients at risk. There is grade A evidence that identifying and treating patients at risk of malnutrition will improve the quality of care that patients experience and will lead to highly significant reduction in their complication rates and length of stay. Yet NICE (2006) found that only about 1/3 of patients were screened on admission to hospital. Subsequently, patients at risk of malnutrition are not recognised and referred for treatment (Elia et al, 2005). Our approach was to engage all disciplines in our organisation to meet the NICE guidance on screening and nutrition support that should be considered in people who are malnourished or at risk of malnutrition. This approach provided clear leadership and guidance through the Trust Nutrition Steering Committee in the co-ordination of a range of activities, which established the evidence on the prevalence of malnutrition and screening rates in our Trust and also enabled us to respond effectively to its findings. Key activities involved launching a multidisciplinary Nutrition Champion network and local Divisional Nutrition Quality Forums. 1. Identify malnutrition through screening using Malnutrition Universal Screening Tool (MUST) for all in- patients within 24 hours of admission to our Trust. Set target that a minimum of 75% of our patients to be screened in this time frame by March 2011. 2. Implement Nutrition Care Bundle and Nutrition Care plan for all patients identified or at risk of malnutrition (all patients with a MUST score of 1 or more). Target set that minimum 75% completion of care bundles by March 2011. 3. Promote interdisciplinary model to support best nutritional practice/involvement of staff. This included establishing a Trust - wide Nutrition Champion network and multi-professional Nutrition Quality forums within each Clinical Division. With the support and lead from the Nutrition Steering Committee these activities would provide the way for us to: · Act on our evidence by increasing awareness of our baseline audit of screening and malnutrition prevalence at local as well as trust wide level. · Support the implementation of our standards/policies with the effective use of MUST/ Nutrition Care Bundle. · Facilitate adoption of the changes. · Regularly monitor practice to assess whether change has been made and is effective. Implementing these requirements would result in a drive for all in -patients being screened for malnutrition at the appropriate time and the appropriate care plan /actions instigated when malnutrition identified.

Reasons for implementing your project

Our Trust is committed to promoting excellence in nutritional care, ensuring that such care is safe, effective and personalised. Multi-professional Nutrition Steering Committee (NSC) established in Trust in 2000, with new Clinical lead for Nutrition and Chair of Committee in post in June 2009. Steering Group meets 3x a year and a smaller group the Nutrition Business Committee meets monthly to implement strategy as directed by NSC. Our Nutrition and Hydration Policy / Protected Mealtime Policy demonstrates how the 10 key characteristics of good nutritional care have been adopted across the Trust. Malnutrition Universal Screening Tool implemented June 1st 2009. The Committee's focus has been on the implementation of NICE Guidance on Nutrition Support (2006) .Two major trust wide audits have been conducted to assess prevalence of malnutrition within the Trust and use of the Malnutrition Universal Screening Tool (MUST). Results in April 2010 showed that the Trust prevalence of malnutrition to be around 30% of all in patients. It also showed that only 24% of all in patients have a MUST carried out within 24 hours of admission to the trust, 2 out of 3 at risk patients not identified as being at risk. A comprehensive action plan to address these issues specifically was developed by the NSC to respond to the findings in a collaborative and effective way. The action plan aimed to roll out the Elderly Care multi -professional model across the Trust. Elderly Care wards who met regularly to review their practice in a multi-professional quality forum and who had an established Nutrition Champion network scored above average in all nutrition audit indicators. A Trust wide multi-professional Nutrition Champion network was established in July 2010 together with local Divisional Nutrition Quality Forums. With guidance from Nutrition Steering Committee these networks and forums have been working at many levels to facilitate change in practice to meet our standards.

How did you implement the project

To achieve our objectives the key principle was to promote collaborative working with ownership of good practice in screening and treatment of our patients with malnutrition. The heart of this has been to build on the Elderly Care model across the Trust. A Trust- wide multi professional Nutrition Champion network was established together with Nutrition Quality Forums in each Division. The matrons identified enthusiastic healthcare staff that had a genuine interest in promoting nutritional care in each ward. Clear role / accountabilities for the champions were agreed. A series of workshops were set up to enable the champions to meet on a regular basis to share best practice and review progress in achieving the nutritional standards. Their role focuses on promoting safe, effective and personalised nutritional care. It encompasses the following: - Act as a good role model - Complete monthly audits on the use of MUST and Nutrition Care bundle - Promote protected mealtimes, right meal, right time, right help - Put nutrition on ward/department agenda - Work with team to take forward any required actions from audit findings. The Nutrition Care Bundle was implemented on August 1st 2010. This was through the Champion network. Monthly monitoring of the use of MUST / Care Bundle have been conducted by the Champions in their wards so that their teams take ownership and responsibility of the findings. The Nutrition Champion network has promoted collaborative working, providing not just a trust-wide but local focus on meeting our nutritional standards. To also support our changes Nutrition Quality forums were established. Facilitated by a Practice Development Nurse these forums enable health care teams to keep focused on the objectives/ promote effective participation in meeting them/increase team synergy/role clarity. All of the above activities are co-ordinated through the Nutrition Steering Committee, supported within the Clinical Governance framework.

Key findings

50 Nutrition Champions established throughout the Trust in July 2010 and three Divisional Quality Forums. Progress on meeting our key nutritional standards is monitored by our Nutrition Champions through a programme of audit and feedback reports to the Trust Nutritional Steering Committee and local Divisional Quality Forums. The Nutrition Champion Network and Quality Forums set up and facilitated by a Practice Development Nurse/Assistant Chief Nurse. Champion workshops x4/year. Quality forums are bi-monthly. Trust baseline audit findings in April 2010 identified that only 24% of all in patients had a MUST screen completed within 24 hours of admission. Trust average for December 2010 is now 62% patients screened within 24 hours (75% within 48 hours) The Nutrition Care Bundle/Care plan was implemented on August 1st 2010 with standard all patients with a MUST of 1 or more to be commenced on bundle. (in Dec 2010 78% of patients identified as needing a Nutrition Care bundle were commenced on one with 81% of those patients having a completed care bundle). Plans to further improve the % of patients having a MUST screen within 24 hours of admission to the Trust are in place. These include ensuring all clinical areas have access to weighing scales for bariatric patients; to ensure that MUST scores/actions are communicated at handover/ward rounds, display charts showing progress at ward level of monthly auditing findings, effective role modelling, celebrate success. An ongoing programme of audit is in place- include MUST screening/care bundle/red tray and Essence of Care audit that reviews direct patient feedback on care.

Key learning points

· Leadership and co-ordination of effort is key to success. A Trust wide Nutrition Committee with a committed chair and executive support from the organisation is essential to teams leading innovative changes to enhance patient care. · Clarity of our nutritional standards /targets and strengthening the monitoring of these are a priority. · Ownership and responsibility at local level of monitoring standards and responding to findings. · The opportunity to set up multi-professional groups of health care workers through the Nutrition Champion Network/Quality forums to come together/ learn together/work together with the objective of implementing sustainable change at both local/trust level to improve nutritional care. Meet regularly to maintain motivation, enthusiasm and impetus. Effective facilitation of such networks/ forums is essential. · Setting clear goals, identifying who?s doing what and when is essential and clear plans of action. · Review impact of changes at regular intervals and adapt plans where appropriate. · Patient involvement-representation at committee level and feedback through Essence of Care nutrition audits essential to make sure changes are patient focused. · Celebrate success. Overall an integrated, strategic approach with clear leadership that promotes interdisciplinary working, effective facilitation and support for a range of activities to create a mass action effect has had an effective result in bringing about sustainable change to improve nutritional care.

Contact details

Carol Thatcher/Dr Aminda De Silva/Joan Potterton
Practice Development Nurse/ Consultant Gastroenterologist and Clinical Lead for Nutrition
The Royal Berkshire NHS Foundation Trust

Secondary care
Is the example industry-sponsored in any way?