"A Well-nourished Hospital" The Donabedian Model approach to enhance patients' nutrition wellness in their hospital journeys

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Abstract Summary
Abstract ID :
Submission Type
Authors (including presenting author) :
Terry HY TING (1), WONG Chi Yan (1), Cindy CY CHEUNG (2), Sherry NG (3), Sammei TAM (4)
Affiliation :
Dietetics Department, North District Hospital Quality and Safety Department, North District Hospital Department of Surgery, North District Hospital Central Nursing Department, North District Hospital
Introduction :
An outcome review of 60 malnourished inpatients was carried out by the Dietetics Department of the North District Hospital (NDH) from 2016 to 2017 to evaluate the dietary intake adequacy. Only 10% of the patients had received adequate energy and protein intake (adequate intake implies > 75% of the estimated need). Another service evaluation of 41 randomly selected malnourished patients on June 2016 identified that only 62% of oral nutrition supplement (ONS) prescribed by the dietitians were consumed.
Objectives :
This study summarizes and reviews the overall effective of a series of quality measures implemented at NDH to enhance nutrition service quality since 2011 using the Donabedian Model approach (Structure, Process, and Outcome) as the main conceptual framework.
Methodology :
(1) Structure level enhancement: A cluster-based nutrition sub-committee led by the Cluster Quality & Safety Director and Cluster Dietetics Manager was formed as the governing body of nutrition care. A Nutrition Support Team (NST) was commenced in 2017 to further enhance nutrition service quality. (2) Process level enhancement: A cluster-level “Policy on Nutrition Care” was established to advise on the governance structure, management strategies and processes to optimise nutrition for well-being of the patients. Other clinical guidelines were also developed to enhance safety and risk management of our clinical practice. (3) Outcome level enhancement: Annual outcome reports to evaluate service effectiveness, to develop continuous quality improvement measures and performance measures in nutrition care (audit), consumption of oral nutrition supplement and effect of nutrition intervention. Intervention & Strategy for change: A systemic approach with multidisciplinary inputs is applied to ensure patients’ nutrition wellness. Activities focused on admission, during hospital stay, and to the post-discharge care: (1) Admission: All patients admitted to NDH will be screened by the nurse within 48 hours. Patients with malnutrition risk will be referred to the dietitian for further assessment (timely, safety and equitable). (2) Hospital-stay: All patients with malnutrition risk will be seen by the dietitian (timely and safety). Surgical patients with complicated nutrition problems will be referred to the Nutrition Support Team (patient-centred, effectiveness and safety). Nurses are responsible to ensure that nutrition care can be adequately and timely delivered to the patients (effectiveness, timely and safety). The Catering Department to prepare an “alert meal tray” to ensure patients are receiving attention during their meal time (effectiveness, timely and safety). Patient Care Assistants to ensure the accuracy and accessibility of the hospital diet and ONS (effectiveness, efficiency, timely and safety). (3) Post-discharge: Old-age home malnourished patients will be referred to our Community Outreach Service Team for follow-up (effectiveness, efficiency, timely, patient-centred and safety). Residential malnourished patients will be given an outpatient appointment for follow-up care (effectiveness, efficiency, timely, and patient-centred).
Result & Outcome :
(1) The energy and protein consumptions increased significantly from 53% to 83% and 50% to 85% respectively after the intervention. The baseline daily energy intake is 730±265kcal and increased significantly to 1131±311kcal with a p-value <0.01 (95% CI -506.0 to -296.9) after the intervention. (2) The baseline daily protein intake is 31±10.7g and increased significantly to 49±13.9g after intervention with a p-value <0.01 (95% CI -22.1 to -13.1). (3) The percentage of patient receiving adequate energy and protein intake increased significantly from 10% to 70% respectively after the malnutrition screening and the nutrition intervention (p-value <0.01). (4) The ONS consumption improved significantly from 62% to 95% after intervention (p value<0.01). (5) The 5-year average malnutrition compliance of the 2013-15 annual nutrition audit is 93.2%.

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