Supporting safe swallowing of care home residents with dysphagia: How does the care delivered compare with guidance from speech and language therapists?

INTRODUCTION: Dysphagia affects up to 70% of care home residents, increasing morbidity and hospital admissions. Speech and language therapists make recommendations to support safe nutrition but have limited capacity to offer ongoing guidance. This study aimed to understand if recommendations made to support safe and effective care are implemented and how these relate to the actual care delivered. METHODS: Eleven mealtimes with residents with dysphagia were observed during 2020 using a tool capturing 12 elements of expected practice. Staff actions during mealtimes were compared with adherence to residents' care plans and speech and language therapist recommendations. RESULTS: Written recommendations predominantly focused on food and fluid modification. Observations (n = 66) revealed food texture, posture, and alertness were adhered to on 90% of occasions, but alternating food and drink, prompting and ensuring swallow completed adherence was less than 60%. Thickened fluids frequently did not align with required International Dysphagia Diet Standardisation Initiative levels. Nutrition care provided in the dining room was less safe due to a lack of designated supervision. CONCLUSION: Care homes need to be supported to establish a safe swallowing culture to improve residents' safety and care experience. WHAT THIS PAPER ADDS: What is already known on this subject? Dysphagia is associated with considerable morbidity and mortality and has been identified as an independent risk factor for mortality in nursing home residents. There is evidence that compensatory swallowing strategies, safe feeding advice and dietary modifications can reduce the risk of aspiration pneumonia. Care for nursing home residents at mealtimes is often task-centred and delegated to those with limited training and who lack knowledge of useful strategies to support the nutrition and hydration needs of residents with dysphagia. What this study adds? Written advice from speech and language therapists on safe nutrition and hydration for residents with dysphagia is focused mainly on food and fluid modification. Nurses and healthcare assistants have limited understanding of International Dysphagia Diet Standardisation Initiative levels or safe swallowing strategies and recommended practices to support safe nutrition care for residents with dysphagia are inconsistently applied especially when residents are eating in dining areas. Care homes are not aware of Royal College of Speech and Language Therapists guidance on how safe nutrition care of residents with dysphagia should be supported. What are the clinical implications of this work? Care homes need to prioritise a safe swallowing culture that ensures that residents with swallowing difficulties are assisted to eat and drink in a way that enhances their mealtime experience and minimises adverse events that may result in hospital admission. Speech and language therapists could play an important role in training and supporting care home staff to understand and use safe swallowing strategies with residents with dysphagia. The Royal College of Speech and Language Therapists could provide more assistance to care homes to support and guide them in how to implement safe feeding routines. Care home staff have limited knowledge about how to implement safe feeding routines and need more guidance from speech and language specialists on how they can support residents with dysphagia to eat safely. Creating a safe swallowing culture within care homes could help to improve nutrition care and enhance patient safety.

Realist synthesis protocol for understanding which strategies are effective to prevent urinary tract infection in older people in care homes.

AIM: To identify and characterize strategies, which contribute to the prevention of urinary tract infection (UTI) in older people living in care homes. DESIGN: The realist synthesis has four iterative stages to (1) develop initial programme theory; (2) search for evidence; (3) test and refine theory supported by relevant evidence and (4) formulate recommendations. Data from research articles and other sources will be used to explore the connection between interventions and the context in which they are applied in order to understand the mechanisms, which influence the outcomes to prevent UTI. METHODS: A scoping search of the literature and workshops with stakeholders will identify initial programme theories. These theories will be tested and refined through a systematic search for evidence relating to mechanisms that trigger prevention and recognition of UTI in older people in care homes. Interviews with key stakeholders will establish practical relevance of the theories and their potential for implementation. DISCUSSION: UTI is the most commonly diagnosed infection in care home residents. Evidence on the effectiveness of strategies to prevent UTI in long-term care facilities does not address the practicality of implementing these approaches in UK care homes. The realist synthesis is designed to examine this important gap in evidence. IMPACT: Our evidence-informed programme theory will help inform programmes to improve practice to reduce the incidence of UTI in older people living in care homes and related research. Patient and public involvement will be crucial to ensuring that our findings reach carers and the public. PATIENT AND PUBLIC CONTRIBUTION: Involvement of patient and public representatives is embedded throughout the study to ensure it is underpinned by multiple perspectives of importance to care home residents. Our co-investigator representing patient and public involvement is a lay member of the team and will chair the Project Advisory Group, which has two additional lay members. This will help to ensure that our findings and resources reach carers and the public and represent their voice in our publications and presentations to professional and lay audiences.

Using a multimodal strategy to improve patient hand hygiene.

OBJECTIVE: The role of health care worker hand hygiene in preventing health care associated infections (HCAI) is well-established. There is less emphasis on the hand hygiene (HH) of hospitalized patients; in the context of COVID-19 mechanisms to support it are particularly important. The purpose of this study was to establish if providing patient hand wipes, and a defined protocol for encouraging their use, was effective in improving the frequency of patient HH (PHH). DESIGN: Before and after study. SETTIN: General Hospital, United Kingdom. PARTICIPANTS: All adult patients admitted to 6 acute elderly care/rehabilitation hospital wards between July and October 2018. METHODS: Baseline audit of PHH opportunities conducted over 6 weeks. Focus group with staff and survey of the public informed the development of a PHH bundle. Effect of bundle on PHH monitored by structured observation of HH opportunities over 12 weeks. RESULTS: During baseline 303 opportunities for PHH were observed; compliance with PHH was 13.2% (40/303; 95% confidence interval 9.9-7.5). In the evaluation of PHH bundle, 526 PHH opportunities were observed with HH occurring in 58.9% (310/526); an increase of 45.7% versus baseline (95% confidence interval 39.7%-51.0%; P < .001). CONCLUSION: Providing patients with multiwipe packs of handwipes is a simple, cost-effective approach to increasing PHH and reducing the risk of HCAI in hospital. Health care workers play an essential role in encouraging PHH.

Improving hydration of care home residents by increasing choice and opportunity to drink: A quality improvement study.

BACKGROUND & AIMS: Dehydration is recognised as an important problem among care home residents and can be associated with severe consequences. Insufficient provision of fluids to meet resident preferences and lack of assistance to drink have been identified as key factors driving under-hydration of care home residents. Using targeted interventions, this study aimed to optimise hydration care for frail older people in a care home setting. METHODS: The study used quality improvement methods to develop and test interventions to extend drinking opportunities and choice in two care homes. Changes were made and evaluated using Plan-Do-Study-Act (PDSA) cycles. Data were captured on the amount of fluids served and consumed, and staff and resident feedback. The long-term impact of the interventions was assessed by measuring daily laxative and antibiotic consumption, weekly incidence of adverse health events, and average fluid intake of a random sample of six residents captured monthly. RESULTS: The interventions were associated with an increase in the amount and range of fluids consumed, in one home mean fluid intakes exceeded 1500 ml for three consecutive months. Laxative use decreased significantly in both homes. A number of practical and organisational barriers affected the sustainability of interventions. CONCLUSIONS: Interventions to optimise the hydration of care home residents can be effective. Plan-Do-Study-Act cycles provide an effective methodology to implement new interventions into existing practice in care homes. Sustainable change requires strong leadership, organisational support and teamwork.

I-Hydrate training intervention for staff working in a care home setting: An observational study.

BACKGROUND: Dehydration is a complex and well-recognised problem for older people residing in care homes. Within the social care sector support staff provide the majority of direct care for residents, and yet receive minimal training. OBJECTIVES: To design, deliver and evaluate a hydration specific training session for care home staff to develop their knowledge and skills in supporting the hydration of care home residents. DESIGN: An observational study comprising a pre-test post-test survey of staff knowledge following a training intervention. PARTICIPANTS AND SETTINGS: Training of care home staff took place in two care homes in North West London. METHODS: An interactive training session was developed and delivered, with content informed by observations of hydration care within the two homes and evaluated using CIRO model. Participant self-evaluation forms were used to collect data after the session regarding satisfaction and usefulness of the session, and pre and post levels of self-reported knowledge across six facets of hydration care. Training facilitators captured qualitative data in the form of field notes. Observations of hydration care explored the impact of training on practice. RESULTS: Eighteen training sessions were delivered. A total of 161 participant evaluation forms were returned. There was a significant increase in self-reported knowledge across all six facets of hydration care (p = 0.000). The majority of participants found the training enjoyable and useful, and expressed an expected change in their practice. Participants enjoyed the interactive components of the training. A lack of reflective practice skills meant participants were unable to reflect realistically about the hydration care provided in the home. CONCLUSION: Focused training on hydration in the care home environment benefits from being interactive and experiential. Although such training can be effective in increasing staff knowledge, inclusion of skills in reflective practice is required if this knowledge is to be translated into practice.

Implementing holistic practices in mental health nursing: a national consultation.

BACKGROUND: A national consultation exercise was held as part of a review of mental health nursing in England. OBJECTIVES: To gather views as to how best to develop mental health nursing to support a holistic approach to care, taking into account psychological, physical social and spiritual needs. DESIGN: National open consultation by email over a 3-month period. PARTICIPANTS: 326 written replies were received. The largest group of responses was from National Health Service (NHS) organisations (n=92, 28.2%); 69.9% of responses were from groups or organisations (n=225). METHODS: A consultation document was devised by a national reference group, including four questions relating to the development of practice in the four domains of: psychological, physical, social and spiritual care. RESULTS: The majority of responses supported mental health nurses (MHNs) providing psychological therapies (n=271, 95.1%). To support this happening, responders most frequently described a need for appropriate specialist training post-registration (n=114). To improve physical well-being of service users, the most frequent suggestion was that MHNs should promote healthy lifestyles, e.g. by encouraging physical activity and advising on ways to reduce illicit drug, alcohol and tobacco use (n=152). Responders most frequently cited the need for MHNs to understand resources to support social inclusion (n=110), e.g. knowing how to access local resources, benefits, housing and employment advice. MHNs were most frequently seen as requiring appropriate training to help them support spiritual/religious needs (n=96). CONCLUSIONS: The consultation was successful in obtaining views, in particular, of organisations and groups. These subsequently influenced national recommendations made by the Chief Nursing Officer's Review of Mental Health Nursing.

Mental health nurses: changing practice?

Project 2000 envisaged that the nurse practitioner of the future should act as an "agent for change", using research evidence to address those aspects of practice deemed detrimental to patient care. A Department of Health funded study investigating the careers of nurse diplomates provides information on the extent to which newly qualified nurses were able to change aspects of practice, what factors inhibited changes and which personnel played a key role in facilitating change. Key factors which inhibited newly qualified nurses acting as change agents were lack of experience and confidence, as well as attitudes of other members of staff. Staff of a higher grade, immediate line managers and healthcare assistants all played a key role in facilitating change.