Older hospital patients — having their cake and eating it too!

A 10-year journey to improve nutrition at the Royal Brisbane and Women’s Hospital.

When thinking about hospital mealtimes, it is usual to think of poor quality food and impossible-to-open packaging. Or to think about eating while half-lying in bed, where the ability to feed yourself is restricted by drips, bandages and other medical paraphernalia. This scenario is far too common. Add in common problems of ageing such as poor appetite and difficulty swallowing, and it is not surprising that most older people eat poorly in hospital, delaying their recovery and return home.

But there is another way. The team at the Royal Brisbane and Women’s Hospital have shown that it is possible to increase the nutritional intake of older people by 20% by doing things a little differently at mealtimes.

Long-term program

Over the past 10 years, a series of foodservice and mealtime improvements have been progressively introduced on the acute medical wards. High-calorie and high-protein foods are now standard offerings on the menu for all older inpatients. This means that a hot breakfast, extra desserts, creamy sauces and high-protein nourishing soups are offered daily to help with recovery. Small frequent meals are also on the menu, because patient feedback indicated that three big meals a day was too hard to stomach. Nourishing snacks like cheese and biscuits, yoghurts, milk drinks and even cake are now offered twice daily for all patients. Other changes to the foodservice system have also been met with high patient satisfaction, such as ‘same day menus’, increased variety in the menu and a spoken menu system.

At the same time as improving the hospital food, a program was underway to provide better care for older patients. It is well known that “the older you are, the worse the hospital is for you”. To make sure that this wasn’t the case at the Royal Brisbane and Women’s Hospital, a doctor, physiotherapist and dietitian began working together to develop the Eat Walk Engage program.

Eat Walk Engage is based on the knowledge that good hospital care for older people starts with good nutrition, early and regular mobilisation, and meaningful activities to keep the mind active. This program has been shown to decrease the amount of time older people spend in hospital and the likelihood of developing a new health problem as a result of being in hospital (eg, pressure injury, delirium or decline in function).

A new approach to mealtimes

So, what does Eat Walk Engage look like for older patients and their families at mealtimes? Ward staff now highly value the mealtimes and have worked to rearrange their routines to maximise the number of staff available to help patients to eat their meal. This often involves changing staff meal breaks and shuffling around other tasks in their busy days to create extra time to spend with patients during meals. Sometimes patients are brought together to share their meal at a communal dining table that is set up with homely touches such as a tablecloth and small vase of flowers. Patients and their families come together a few times a week for a social morning tea or ‘happy hour’ in a patient lounge or garden outside of the ward environment.

When the team monitored the nutritional intake of older people in their hospital over the 10-year improvement period, they were delighted to see that patients were now eating an average of 20% more energy and protein each day (900 kJ (215 Cal), 9 g protein). The percentage of older people eating less than their minimum nutrition requirements has almost halved (60% to 35%). Importantly, feedback from patients and their families has been overwhelmingly positive.

According to the team at Royal Brisbane and Women’s Hospital, the patient was the most important part of this change. Keeping the patient and their story at the centre of every improvement helped to bring the team together and made sure that the work they did focused on something important to the patient. And finally, being patient is key. Change is not easy, nor does it happen quickly. Know that you are in this game for the long haul, and that your effort and perseverance will result in meaningful outcomes for your patients, even if it is 10 years later!

Factors for success Multidisciplinary implementation team: dietitians, nurses, doctors, occupational therapy, physiotherapy and foodservices bringing different perspectives to problems and solutions and allowed us to work together towards a common patient-centred goal. Making small, sequential changes: this allowed the team to build confidence and learn through the process, gain trust of ward staff and allowed time to embed processes and see the outcomes of the work. Using patient and carer stories to drive change: their stories allowed staff to see why improving nutrition was important and helped us to prioritise and focus on what patients told us was important to them. Measuring progress and sharing success: regularly auditing practice and outcomes allowed us to identify areas for improvement, measure success and generate evidence to convince organisational leaders to support and invest in the program. Using an implementation framework: provided us with a structure to guide our improvement program and helped us to avoid common mistakes in implementation (for example, using staff education as the implementation strategy, when change in systems and culture is what was needed). Be patient and persistent: it is not easy to make change, nor does it happen quickly. Know that you are in this for the long haul.

 

 

 

 

*Dr Adrienne Young is an Advanced Accredited Practicing Dietitian and is the Research Coordinator for Nutrition and Dietetics at the Royal Brisbane and Women’s Hospital. Her research and improvement work focuses on providing the best care for older people in hospital through implementing supportive systems of care.

 

 

Image credit: ©stock.adobe.com/au/aletia2011