Clinical challenge
To reduce the risk of poor nutrition in stroke patients through the use of the 'MUST' calculator. 

Historically some patients were not being screened prior to discharge by our clinicians, for a number of reasons, but often because of short admission stays. 

The SSNAP team were finding tools were being left blank in patient notes so they were therefore having to input that the MUST tool had not been completed prior to discharge on SSNAP, due to organisational reasons. 

This led to a lot of patients being included in the 'applicable to be seen by a dietitian' bracket, who not only weren't being seen by a dietitian prior to discharge, but actually might have been excluded from the denominator is a MUST score had been documented. 

This issue was reflected in our SSNAP scoring. 

Solution
Communication tools
The SSNAP team introduced a prompt sheet for clinicians in August 2017. The sheets are entered into the patient notes if the MUST tool has been left blank, asking the clinicians to complete it prior to discharge. 

Technological innovations
Following a successful bid to receive funding from NHS England in Safer Wards Technology Fund, County Durham & Darlington NHS Foundation Trust agreed an exciting partnership with Nervecentre Software to deliver an e-observation system to provide clinical staff with the ability to record and monitor patient observations via a mobile device. 

Following the introduction of this new technological innovation, the Stroke Unit and Nervecentre teams recognised an opportunity to improve MUST screening for stroke patients. The MUST tool was added to Nervecentre between February and March 2018. This means that when clinicians are carrying out patient observations they are prompted to also complete the MUST calculator. If the tool is not completed, clinicians are prompted by an 'overdue' message. 

Impact
Our SSNAP team have benefitted greatly from the initiative and the trust's audit compliance has been aided as locking patients to discharge is no longer held up by missing data. 

Our patient-centred SSNAP score for the 'if applicable, screened for nutrition and seen by a dietitian by discharge' component was only 32% in our Apr-Jul 2017 results. This improved to 48.7% in our Aug-Nov 2017 results and 50% in our Dec 2017 - Mar 2018 results, following the introduction of the prompt sheet from our SSNAP team. 

Once the MUST tool was added to Nervecentre our results for Apr-Jun 2018 increased to 92.3%. 

We are confident our patients are now being screened for nutritional risk, regardless of admission length, and being referred to our Dietetics Service when appropriate. 

Reflection
We can demonstrate a massive improvement in our approach to nutritional risk in stroke patients following the introduction of these Quality Improvement tools. 

Our ultimate aim is to score 100% for the 'if applicable, screened for nutrition and seen by a dietitian by discharge' component of our SSNAP results, which will evidence that every stroke patient we treat is screened for nutritional risk and referred to a dietitian if appropriate. 

This will benefit our patients significantly as they will be less susceptible to other health issues if their nutrition is managed effectively following a stroke. 

This case study was written by Kat Harding, Julie Southern & Alison Newman, County Durham & Darlington NHS Foundation Trust. 


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