THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

COUNCIL OF GOVERNORS

NUTRITION AND HYDRATION CARE EXECUTIVE SUMMARY

Ensuring the nutrition and hydration needs of patients are met is a key priority for the Trust. Expected standards are defined in a number of nutrition related policies whilst the broader context and ambition are described in the Trust Food and Drink Strategy 2017-2019. This paper provides an update and overview of assurance, patient feedback and practice development related to Nutrition and Hydration. The biggest risk facing the Trust in relation to nutrition and hydration is that the nutritional needs of an individual patient are not met, and a number of assurance measures are in place to minimise this, including elements within the Clinical Assurance Toolkit and mealtime audits. A risk based audit of food and nutrition was also carried out in 2017 by Internal Audit which provided a good level of assurance. A number of practice developments have been achieved in relation to nutritional care in the last year, including improving the safety needs of patients receiving enteral feeding through the transition to ENFit products and ensuring staff receive the training they require to deliver safe effective harm free nutritional care. Further work is in progress with a focus on hydration and guidance and in relation to those with the most complex needs for example those with cognitive impairment. The Trust has also pledged its commitment to reduce the total monthly volume of sugar-sweetened beverage sales, reaching a target of 10% or less of total volume of drinks sales for the month of March 2018 and continuing thereafter. Food is a very subjective issue, and feedback on the quality and acceptability of the food offered to patients is actively sought through a number of mechanisms and responded to. The Nutritional Steering Group leads the ongoing monitoring and assurance of nutritional care and has an active action plan to ensure progress. RECOMMENDATION To i) receive the briefing and note the actions taken to date.

Helen Lamont Nursing and Patient Services Director

Frances Blackburn

Deputy Director of Nursing and Patient Services, Freeman

Paula Coulson Associate Nurse Consultant

Agenda item 8(iv)

19th March 2018

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THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

NUTRITION AND HYDRATION CARE

1. INTRODUCTION / BACKGROUND Ensuring the nutrition and hydration needs of patients are met is a key priority for the Trust and is highlighted in both policy and the Trust Food and Drink Strategy 2017-2019. Malnutrition and dehydration are both causes and consequences of illness, have significant impacts on health outcomes and are integral to all care pathways. Surprisingly, these problems are still poorly recognised in community and health care settings despite numerous reports which have highlighted the fact that individuals in these settings often receive inadequate nutrition and hydration (Francis 2013) NHS England published Commissioning Excellent Nutrition and Hydration 2015-2018 to ensure that all people would receive safe and high quality nutrition and hydration support when required, through the commissioning of person-centred and clinically effective integrated services in community and health care commissioned settings

In 2015 NHS England was asked by Department of Health to review the Council of Europe ’10 key characteristics of good nutrition and hydration care’. The updated characteristics are:

1. Screen all patients and service-users to identify malnourishment or risk of malnourishment and ensure actions are progressed and monitored.

2. Together with each patient or service user, create a personal care/support plan enabling them to have choice and control over their own nutritional care and fluid needs.

3. Care providers should include specific guidance on food and beverage services and other nutritional & hydration care in their service delivery and accountability arrangements.

4. People using care services are involved in the planning and monitoring arrangements for food service and drinks provision.

5. Food and drinks should be provided alone or with assistance in an environment conducive to patients being able to consume their food (Protected Mealtimes).

6. All health care professionals and volunteers receive regular training to ensure they have the skills, qualifications and competencies needed to meet the nutritional and fluid requirements of people using their services.

7. Facilities and services providing nutrition and hydration are designed to be flexible and centred on the needs of the people using them, 24 hours a day, every day.

8. All care providers to have a nutrition and hydration policy centred on the needs of users, and is performance managed in line with local governance, national standards and regulatory frameworks.

9. Food, drinks and other nutritional care are delivered safely.

Agenda item 8(iv)

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10. Care providers should take a multi-disciplinary approach to nutrition and hydrational care, valuing the contribution of all staff, people using the service, carers and volunteers working in partnership.

The implementation of the ’10 key characteristics of good nutrition and hydration care’ is a requirement to meet the Hospital Food Standards SC19 in the NHS Contract for hospitals. There are significant financial benefits and opportunity cost savings for organisations who deliver good nutritional care. These are evidenced in the Department of Health Food Standards Panel Report (2014 updated 2017) (which makes it a requirement for Trusts to have a food and drink strategy), Healthier food and drink in a hospital setting (NICE 2016) Cost Saving calculations and the Health Economic Report (BAPEN 2015) The Care Quality Commission are retaining a focus on the delivery of good nutritional care as a core element of their routine inspections and Trusts will be required to demonstrate evidence of compliance to standards.

2. MEETING THE NUTRITIONAL NEEDS OF PATIENTS To ensure the Trust meet the nutritional needs of patients we continue to ensure that nutritional screening is undertaken for all inpatients and that as a minimum all out-patients attending for a new appointment receive screening in the form of height, weight and calculation of their body mass index (BMI). Following this nutritional screening patients are supported in terms of their nutritional requirements on an individual basis. This is achieved through a multi-disciplinary approach implementing the findings of the nutrition screening in the form of a care plan. Some patients may require additional expert support from Dietetic and Speech and Language Therapy staff, and may require nutrition in the form of enteral or parental nutrition. All patients require ongoing monitoring based on their individual needs and staff must take into account the reason for their hospital admission which may impact on their ability to consume sufficient nutrients and therefore increase their risk of malnutrition. “Protected mealtimes” which restrict all non-essential ward activity during mealtimes aim to remind all disciplines of staff of the importance of effective nutrition and the support required by many patients to achieve this. New technology has enabled specific nutritional needs to be highlighted on the eRescue Patient Whiteboard, and staff can utilise local visual indicators such as over bed warning triangles and red tumblers and jug lids to highlight the requirement to monitor and support hydration. i) Food and Drink Strategy The Trust Food and Drink Strategy was developed and approved by Trust Board in 2016. This documents the Trust’s commitment and ambition in relation to providing effective nutrition and hydration for patients, staff and visitors. Underpinning the strategy delivery is an Action Plan to ensure that all identified objectives are achieved and maintained. The Action Plan is monitored through the Nutrition Steering Group.

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Staff Healthy Eating guidelines have been developed to promote to staff the concept of healthy eating and to be supportive towards an ‘eating well’ culture in the workplace in order to meet the recommendations of the Hospital Food Panel Report and the requirements of the Better Health at Work Award. The Trust responded to a letter from Sir Bruce Keogh, (Appendix Three) pledging its commitment to reduce the total monthly volume of sugar-sweetened beverage sales, reaching a target of 10% or less of total volume of drinks sales for the month of March 2018 and continuing thereafter. Nationally all PFI companies have been asked to commit to the reduction. Charitable outlets within the Trust are progressing the switch to reduced sugar options and the Trust is currently working with them to achieve this. The Trust is required to upload data on volumes of drinks and sugar content to the Department of Health on a quarterly basis commencing on 1st April 2018. This commitment links effectively into the Trust initiative of Making Every Contact Count (MECC) in relation to public health and wellbeing. ii) Hydration Best Practice Standards Maintaining good hydration and avoiding dehydration can be challenging within inpatient settings and is associated with poorer clinical outcomes. Dehydration is generally caused by not drinking enough fluid or by losing too much fluid and not replacing it. This can occur through vomiting, diarrhoea, sweating or increased urinary frequency in for example patients with diabetes or additional fluid loss from drains or surgical interventions. Good hydration helps to prevent and treat:

Pressure damage

Constipation

Urinary tract infections

Kidney and gall stones

Low blood pressure

Heart disease The Trust Food and Drink Strategy includes an objective to develop hydration best practice standards in line with NICE guideline CG174. Work has been undertaken to audit a new hydration chart to monitor patients who do not require the full monitoring of a fluid balance chart but still require monitoring of their fluid intake. Two audits have been completed in medicine, surgery and oncology. These indicate that further work needs to be done to develop a tool that is of value and beneficial in busy care environments. There has also been a pilot of a revised fluid balance chart in the Emergency Assessment Suite to improve fluid prescribing and recording, evaluation and retesting is ongoing. Future work will include a task and finish group to develop and establish clear clinical guidance bringing these pieces of work together through the development of hydration best practice standards.

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Nutrition and Hydration week is 12th to16th March and a number of activities are planned which will focus on the importance of effective hydration for patients and staff. iii) Enteral Nutrition Enteral feeding refers to the delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach, duodenum or jejunum. The Trust implemented an NHS England patient safety alert March 2015 reference number: NHS/PSA/W/2015/004, which was part of a global standardisation programme for enteral feeding connectors (implementation by the International Organisation for Standardisation (ISO). It was identified that different types of medical devices could easily be connected using Luer connectors. For example, an enteral feed administration set could be connected to a tracheostomy tube. In the UK and worldwide, such wrong route errors have resulted in patient injury and death. To reduce the risk of misconnections, the International Organisation for Standardisation (ISO) developed a series of new International Standards for small bore connectors in a range of medical devices (ISO 80369). These products are known as ENFit and globally the first devices to be fitted with the new ISO connectors were enteral feeding tubes. The transition to full utilisation of ENFit products for all enteral connections is now fully completed within the Trust. This means no entral feeding equipment can be attached to different types of equipment such as Intravenous Cannula. iv) Staff Training To support effective patient screening for malnutrition within the Trust, a staff training video has been developed to assist staff to complete the Malnutrition Universal Screening Tool ‘MUST’ for all adult inpatients. This follows a revision of the assessment documentation to ensure patients are screened for signs of malnutrition within 24 hours of admission. A trust wide multidisciplinary survey has been undertaken as part of developing a wider training needs analysis which will meet expressed needs of staff over and above mandated training. Future work will include establishing a training video for the (Screening Tool for the Assessment of Malnutrition in Paediatrics) STAMP and establishing and implementing a training offer in partnership with colleagues from education and training to ensure we have a range of educational interventions available. v) Nasogastric feeding tube practice Displacement of nasogastric (NG) tubes can cause serious harm or death if inserted or misplaced into the lungs and undetected before use. Introducing fluids or medication into the respiratory tract or pleura via a misplaced nasogastric tube is a Never Event.

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To mitigate against such events the Trust have implemented the recommendations of an NHS Improvement Patient Safety Alert reference number: NHS/PSA/RE/2016/006. As part of this work the Nasogastric tube policy has been updated and the insertion and ongoing care charts have been revised in 2017 and implemented to support safe effective care. Staff training continues for medical and nursing staff with clear direction that staff should receive training and be assessed as competent before undertaking insertion, assessment and ongoing care of nasogastric tubes. A rolling Trust-wide audit and review of practice continues to provide assurance of safe effective care.

vi) Dementia/Delirium/Cognitive impairment and Nutrition Meeting the needs of patients with cognitive impairment is a recognised challenge. Patients with cognitive impairment may present with significant problems which impact on nutrition and fluid intake such as swallowing difficulties and a decline in behavioural and functional ability. Such problems can be challenging to manage in the acute setting. Supporting the nutritional care of patients with cognitive impairment, forms part of the Trust Dementia Care Strategy. All wards have guidance sheets which assist staff to support patients. Care should be person centered and aim to support patients to retain their independence as much as possible. Ongoing work that is being progressed includes:

Reinforcing the use of the ‘Forget me Not’ card to reinforce patients’ food and drink likes and dislikes.

Revision of the guidance for clinical management of complex feeding problems in adults with cognitive impairment.

A multi-disciplinary approach to screening and assessment including consideration of mental capacity and best interest decisions and involving the patient, family and carers in decision making.

Supporting carers through “John’s Campaign” (A national campaign to ensure that family and carers of patients with dementia remain involved in the patients care following admission to hospital or care setting) to facilitate them to continue their caring role and ensuring that their nutrition and hydration needs are met.

A nutrition support menu designed to meet the needs of those with a cognitive impairment including the availability of finger foods and additional snacks and robust monitoring of nutritional intake.

Continue to support the use of colour contrast crockery and cups to aid recognition.

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Effective multi-disciplinary communication via nutrition care plans to highlight individual needs such as assistance support, adapted cutlery and crockery, thickened fluids and pureed food if swallowing is compromised.

vii) Nutrition Link Nurse Group Nutrition Link Nurses are identified within each inpatient setting and they, and nutrition champions such as housekeepers, are supported through a Link Nurse Group and continue to work to support best practice in their individual areas and disseminate key nutrition and hydration information. viii) Policy and Governance Context There is a robust policy framework which underpins nutritional care including the Trust Nutrition and Hydration Policy, Protected Mealtime Policy and Trust Food Hygiene Policy. All have recently been reviewed and updated in line with standard review process to ensure they reflect current evidence and guidance and are fit for purpose. The Nutritional Steering Group which includes Governor and Community Advisory Panel representation has oversight of all developments and provides leadership, challenge and support. The group has just revised its terms of reference to ensure they are fit for purpose and encompass all Trust nutrition and hydration care in both acute and community settings. ix) Quality Assurance

The Matrons undertake an audit of observed practice on an annual basis, reviewing each other’s areas. This takes place in the spring and results are discussed at Matrons and Sisters Forums with individual area’s results reviewed at Ward / Directorate level.

Food tasting is carried out via a multi-disciplinary approach with the support of CAP and Public Governors and periodically SALT Team and Dietetics. The food tasting proforma is aligned to NHS Estates, PLACE and CQC Outcome 5 recommendations / requirements.

A full dietetic review of all menus offered remains outstanding due to the need for additional dietetic resource. A business case to address this has been submitted as this is a recommendation of Hospital Food Standards of the CQC that the Trust do not currently meet. x) Patient Feedback Patient feedback is received through the annual National Inpatient Survey, through the PALS survey Friends and Family, PALS issues, Complaints and Take 2 Minutes feedback forms. A summary of this feedback is attached in Appendix One. Over the last Financial Year there have been a total of 858 comments received by the Trust on the subject of Food / Nutrition (a decrease of 227 on the previous period). The majority of these have been from the Friends and Family Test with 702 items of feedback. Feedback for Food and Nutrition is mostly positive at 73%,

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23% is negative and 4% is either neutral, mixed or an information request. All feedback is reviewed individually at departmental level and then collectively at the Nutrition Steering group. In the National Inpatient Survey 2017:

Of the 493 patients (519 completed the survey) who had food in hospital - 306 (62%) rated the food as ‘Very good’ or ‘Good’ - 416 (82.2%) said ‘Yes, always’ when asked if they were offered a choice

of food - 95 patients said they needed help to eat meals and of these 74 (77.9%)

always received help, 16 (16.8%) sometimes got enough help and 5 (5.3%) said No.

Of 514 responses to the question ‘During your time in hospital, did you get enough to drink?’, 483 (94%) said Yes, 3(0.6%) said ‘No, because I did not get enough help to drink’ and 18 (3.5%) said ‘No, because I was not offered enough drinks’. 10 (1.9%) gave another reason

The only food / drink related question that scored significantly better than the ‘Picker Average’ (81 Trusts who used Picker to run the survey), was

‘Did not always get enough help from staff to eat meals’ (22% reported a problem compared to the Picker average of 37%)

No food / drink related results had significantly improved or worsened compared to the 2016 survey.

xi) Audit and Assurance Processes Assurance in relation to completion of nutritional screening and mealtime service is undertaken as part of the Clinical Assurance Toolkit (CAT) and a Mealtime audit undertaken by Matrons peer review as mentioned above. The next audit will take place in March 2018.

Within the Trust Clinical Assurance Toolkit (CAT) assurance is sought regarding completion of malnutrition screening and that care plans and mealtime assistance is in place. This continues to demonstrate consistent high standards (Appendix Two).

Internal Audit completed a risk based audit of food in nutrition between June and September 2017. This concluded that governance, risk management and control arrangements provide a good level of assurance that risks identified are managed effectively. Minor remedial actions identified related to completion of the ‘MUST’ Training Video, which was in progress, and ensuring food hygiene and safety competence was completed at Ward level. Matrons are ensuring this is completed.

3. RISKS AND RISK MITIGATION Failing to meet the nutritional needs of individual patients and the management of patients with complex nutritional needs are the most significant clinical risks and

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this paper illustrates the clinical work and assurance that is in place to mitigate these risks. Food is a very subjective but also very important quality indicator which contributes to the patient experience. Patient led food tastings and scrutiny of patient feedback are proactively undertaken to ensure the Trust offer is acceptable and valued by patients and ensure the reputation and benchmarked position of the Trust is maintained Full dietetic menu review is required as part of overall assurance that all meals have been nutritionally assessed for their content.

4. SUMMARY Work continues to progress to ensure the Trust meets its responsibilities with regard to nutritional care. A Trust Food and Drink Strategy is in place to demonstrate the Trust commitment to nutrition and hydration and support staff to deliver effective care. Audit work has commenced in relation to hydration and fluid balance monitoring and prescribing and ongoing work includes the formation of Trust-wide hydration best practice standards. Work has progressed in relation to ENFit to ensure that enteral feeding is safe and in line with global practice as outlined by ISO. In relation to nasogastric feeding, work continues to ensure safe and effective care through robust staff training, guidance through policy and supportive documentation that is fit for purpose. Training and documentation have been reviewed in relation to nutritional screening, to ensure patients are assessed and monitored for malnutrition. A training needs analysis is currently being undertaken to review and shape future training for all staff groups. Protected mealtimes appropriate care planning and assistance are all in place, this is subject to ongoing assurance measures. The Trust continues to review and act upon patient feedback, informing patients through mechanisms such as ‘You said we did’. The Trust continues to participate in external benchmarking through PLACE processes.

5. RECOMMENDATION(S) To i) receive the report and ii) note the actions taken..

Helen Lamont Nursing and Patient Services Director

Frances Blackburn

Deputy Director of Nursing and Patient Services, Freeman

Paula Coulson Associate Nurse Consultant

19th March 2018

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Nutrition Feedback

Appendix One

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Trust Clinical Assurance Toolkit (CAT) Nutrition Trend

Appendix Two

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Appendix Three

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