Challenge
To reduce rates of dehydration and malnutrition after stroke.

Solution
Process Changes

• Patients are weighed on admission and then weekly thereafter with members of the nursing and therapy team actively involved with this.
• Patients who are unable to obtain adequate nutrition and hydration by mouth are quickly considered for tube feeding with the dietitian trained to support the nursing staff with timing the insertions.
• Mealtimes revised to give the best possible support with eating and drinking – patients receive traffic light coloured trays to help identify feeding requirements and adapted cutlery to maximise independence.
• A mealtime coordinator ensures that patients safely receive their meals and document special requirements centrally on the ward.
• Nasal bridles (an effective and safe way to secure a patient’s nasal tube) are used as routine for patients who are unable to tolerate tube feeding and experience frequent tube dislodgement.

Team working and Organisational changes

• Ensure a specialist dietitian is available to advise staff at ward meeting about individual patients;
• Ensure a specialist dietitian educates the wider MDT team on risk of malnutrition as outlined in the 2016 RCP guideline for stroke, troubleshooting and joined up multidisciplinary working;
• Maintain strong links with dietitians working in the community to ensure that those patients discharged from hospital who require nutritional support continue to receive the care they need in a home environment.

Education to embed good practice​

• Maintain regular education and training opportunities for staff;
• Embed into nursing culture the importance of completing nutrition screening tool on admission and then weekly thereafter with timely dietitian referral and input for those at risk. Nutrition and hydration is everyone’s business

Impact
The risk of malnutrition after stroke has been minimised by changing practice, structure and education across the multidisciplinary team (MDT) caring for patients. Changes to our service have enabled the unit to consistently identify and provide support for people at risk of malnutrition. This has been demonstrated by achieving the SSNAP standard of 100% of patients being screened for risk of malnutrition and 100% of those identified at risk being referred to and seen by a dietitian prior to discharge.

This case study was written by Alex Lang, Stroke and Elderly Care Dietitian at Guy’s and St Thomas’ NHS Foundation Trust. The team that lead this QI hospital included Marion Kagka, Angela Roots, Dr Jonathan Birns, Nicky Green, Daniela Torcoli, and Dr Ajay Bhalla.


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