Reducing risk of development or exacerbation of nutritional deficits by optimizing patient access to mealtime assistance.

OBJECTIVE: Optimize patient access to mealtime assistance, decrease missed meal incidence, risk of malnutrition, reduce food waste and staff rework. DESIGN: Lean Six Sigma methodology informed a pre/post intervention design. SETTING: 31 bed ward including Specialist Geriatric services and Acute Stroke Unit within an Irish University teaching hospital. PARTICIPANTS: Clinical and non-clinical staff including catering, nursing, speech and language therapy, dietetics and nutrition; patients, relatives. INTERVENTIONS: An interdisciplinary team used the structured Define/Measure/Analyse/Improve/Control (DMAIC) framework to introduce visual aids and materials to improve the access of patients to assistance at mealtimes. MAIN OUTCOME MEASURES: Pre and post outcomes measures were taken for the number and cost of uneaten meals, rework for staff, staff and patient satisfaction, patient outcomes. RESULTS: Following a 1-month pilot of a co-designed process for ensuring access to assistance at mealtimes, average wasted meals due to staff not being available to assist patients requiring mealtime assistance went from 3 per day to 0 corresponding to an average reduction of 0.43 kg per participating patient in food waste per day. Patients receiving assistance did not require additional oral therapeutic nutritional supplements, evidenced no new incidences of aspiration pneumonia or swallowing difficulties and were discharged without requirement for ongoing Dietetics and Nutrition support. Following a 6 month Control period comprising repeated PDCA cycles, the initiative was incrementally introduced to a further 10 wards/units, with positive feedback from patients and staff alike. CONCLUSION: The co-designed new process highlights the importance of staff and patient collaboration, inclusion and participation in designing quality improvement projects.

A comparison of service organisation and guideline compliance between two adjacent European health services.

INTRODUCTION: Outcomes in stroke patients are improved by a co-ordinated organisation of stroke services and provision of evidence-based care. We studied the organisation of care and application of guidelines in two neighbouring health care systems with similar characteristics. METHODS: Organisational elements of the 2015 National Stroke Audit (NSA) from the Republic of Ireland (ROI) were compared with the Sentinel Stroke National Audit Programme (SSNAP) in Northern Ireland (NI) and the United Kingdom (UK). Compliance was compared with UK and European guidelines. RESULTS: Twenty-one of 28 ROI hospitals (78%) reported having a stroke unit (SU) compared with all 10 in NI. Average SU size was smaller in ROI (6 beds vs. 15 beds) and bed availability per head of population was lower (1:30,633 vs. 1:12,037 p < 0.0001 Chi Sq). Fifty-four percent of ROI patients were admitted to SU care compared with 96% of UK patients (p < 0.0001). Twenty-four-hour physiological monitoring was available in 54% of ROI SUs compared to 91% of UK units (p < 0.0001). There was no significant difference between ROI and NI in access to senior specialist physicians or nurses or in SU nurse staffing (3.9/10 beds weekday mornings) but there was a higher proportion of trained nurses in ROI units (2.9/10 beds vs. 2.3/10 beds (p = 0.02 Chi Sq). CONCLUSION: Whilst the majority of hospitals in both jurisdictions met key criteria for organised stroke care the small size and underdevelopment of the ROI units meant a substantial proportion of patients were unable to access this specialised care.