Addressing Hospital-Acquired Hypoglycemia

BACKGROUND

Hospitalized patients who have diabetes often experience hospital-acquired hypoglycemia, a potentially serious adverse event; as a result, management of this condition has become an important quality of care indicator in the inpatient environment. A growing body of research and evidence-based clinical guidelines support proper timing of point of care (POC) blood glucose (BG) measurements, mealtime insulin administration, and meal delivery to reduce the incidence of both hypoglycemic and hyperglycemic events. Monitoring and improving the timing of these three patient care interventions are recognized as a crucial step in the safe and effective care of patients with diabetes.

PURPOSE

The objective of the QI project was to improve the timing of mealtime insulin administration related to bedside BG monitoring and meal delivery for patients with diabetes who receive mealtime insulin; a secondary goal was to decrease the number of episodes of recurrent hypoglycemia. The overall strategy was to change staff members' approach to mealtime insulin management from a series of individual tasks to a process-oriented collaborative approach.

METHODS

Nurses on the medical-surgical unit at one hospital within a large health system formed a QI team with staff members in information technology and food and nutrition services. The team implemented an eight-week QI pilot project (July 3 to August 26, 2017) using a multidisciplinary approach to coordinate between POC BG measurement, mealtime insulin administration, and meal delivery.

RESULTS

More than two years after the hospital-wide rollout of the practice change, follow-up analysis has shown that, on both noncritical and critical care units, recurrent hypoglycemia has decreased. For example, comparing data obtained in a six-month period before the pilot project (November 2016 through April 2017) with the same six-month period in 2018 and 2019, more than a year after the pilot project, the percentage of patient stays (admissions) on noncritical care units in which there was a recurrence of hypoglycemia fell from 41.8% (of 1,162 total hospital admissions) to 35.1% (of 792 total hospital admissions); similarly, the percentage of patient stays on critical care units in which recurrent hypoglycemia occurred decreased from 36.8% to 22.8%.

CONCLUSIONS

Findings suggest that ensuring a consistent 30-minute window between POC BG measurement and meal delivery enabled nursing staff to perform timely POC BG measurements and administer a more optimal mealtime insulin dose. Increasing interdisciplinary communication, collaboration, and awareness of best practice guidelines relating to proper mealtime insulin administration resulted in a sustained improvement in timing between POC BG measurements and mealtime insulin administration and between mealtime insulin administration and meal delivery.

Waste generation and carbon emissions of a hospital kitchen in the US: Potential for waste diversion and carbon reductions

This study measured the total quantity and composition of waste generated in a large, New York City (NYC) hospital kitchen over a one-day period to assess the impact of potential waste diversion strategies in potential weight of waste diverted from landfill and reduction in greenhouse gas (GHG) emissions. During the one-day audit, the hospital kitchen generated 1515.15 kg (1.7 US tons) of solid waste daily or 0.23 kg of total waste per meal served. Extrapolating to all meals served in 2019, the hospital kitchen generates over 442,067 kg (487 US tons) of waste and emits approximately 294,466 kg of CO2e annually from waste disposal. Most of this waste (85%, 376,247 kg or 415 US tons annually) is currently sent to landfill. With feasible changes, including increased recycling and moderate composting, this hospital could reduce landfilled waste by 205,245 kg (226 US tons, or 55% reduction) and reduce GHG emissions by 189,025 kg CO2e (64% reduction). Given NYC's ambitious waste and GHG emission reduction targets outlined in its OneNYC strategic plan, studies analyzing composition, emissions, and waste diversion potential of large institutions can be valuable in achieving city sustainability goals.

[Nutritional support strategies in pediatric cancer patients in Mexico]

BACKGROUND

Meeting the nutritional needs of pediatric patients on oncology services in low budget public hospitals of Mexico is a continuous challenge, due to its financial resources.

OBJECTIVE

To evaluate the effectiveness of a nutritional strategy for children and adolescents with cancer in a public hospital of Mexico, based on a complacency diet.

METHODS

Across-sectional study included 58 children and adolescents (1-18 years old). An assessment of nutritional status was applied and a dietary diary was elaborated for 24 hours with the double weight method.

RESULTS

43 patients (74.4%) had an adequate nutritional status. The average energy intake was 72.8% and average protein intake 168.3% of the requirements. The hospital meals accounted for 67.5% of the energy intake, 28.5% resulted from snacks and 3.9% from oral nutritional supplements or polymeric smoothies.

CONCLUSION

The nutritional strategy based on offering a menu at the request supported by smoothies or oral nutritional supplements and the permission to introduce snacks to the hospital offers convenience and flexibility for meal times and favors the energy intake in hospitalized pediatric oncology patients.

Retail food reform: How to effectively bridge what we say and what we do in our hospital settings

Hospital leaders in Eastern Ontario, Canada, have acknowledged the critical role of food to health and the need for progressive change that goes beyond personal responsibility paradigms. The Healthy Foods in Champlain Hospitals program aims to create supportive, healthy nutrition environments in hospital retail food settings. Twenty independent hospital corporations have collectively initiated a plan to transition cafeteria, vending, franchise, and volunteer operations towards healthier offerings. Hospitals are actively implementing a set of progressively phased, evidence-based nutrition criteria, which cover food and beverage categories, preparation methods, product placement, and provision of nutrition information. Implementation strategies and successes, as well as challenges and limitations, are discussed.

Backcasting to identify food waste prevention and mitigation opportunities for infant feeding in maternity services

Food waste in hospitals is of major concern for two reasons: one, healthcare needs to move toward preventative and demand led models for sustainability and two, food system sustainability needs to seek preventative measures such as diet adaptation and waste prevention. The impact of breast-milk substitute use on health services are well established in literature in terms of healthcare implications, cost and resourcing, however as a food demand and waste management issue little has been published to date. This paper presents the use of a desk based backcasting method to analyse food waste prevention, mitigation and management options within the Irish Maternity Service. Best practice in healthcare provision and waste management regulations are used to frame solutions. Strategic problem orientation revealed that 61% of the volume of ready to use breast-milk substitutes purchased by maternity services remains unconsumed and ends up as waste. Thirteen viable strategies to prevent and manage this waste were identified. Significant opportunities exist to prevent waste and also decrease food demand leading to both positive health and environmental outcomes. Backcasting methods display great promise in delivering food waste management strategies in healthcare settings, especially where evidenced best practice policies exist to inform solution forming processes. In terms of food waste prevention and management, difficulties arise in distinguishing between demand reduction, waste prevention and waste reduction measures under the current Waste Management Hierarchy definitions. Ultimately demand reduction at source requires prioritisation, a strategy which is complimentary to health policy on infant feeding.

NHS should provide nurses with decent catering facilities

How about the NHS gives us access to decent catering facilities or even tables and chairs that aren't a 10 to 15-minute walk away from the ward or unit - which must be taken out of the already paltry half-hour meal break?

In the shadow of the asylum: the Stanley Royd Salmonella outbreak of 1984

In August 1984, an outbreak of Salmonella at Stanley Royd Psychiatric Hospital in Yorkshire led to the deaths of 19 elderly residents. It was an incident that attracted a good deal of comment in both the local and national press, and one that had enduring relevance for ideas about psychiatric care, food handling and catering provisions, hospital management and the official inspection of medical institutions. This article examines the impact that the 1984 outbreak had on official and popular perceptions of these issues. As well as bringing to public attention the fact that large numbers of vulnerable elderly patients were long-term residents in psychiatric hospitals, the Salmonella outbreak highlighted the inadequacies of Victorian hospital buildings in modern healthcare. Throughout the press reports and official investigations examined here, the provenance of Stanley Royd was repeatedly emphasised; its Victorian fabric persistently interfered with cleaning regimes, cold storage facilities and the conveyance of food to patients. Within institutions like Stanley Royd, 'new' and 'old' risks came together--the microscopic bacterium and the crumbling nineteenth-century building--to create a strong critique of existing psychiatric care. The episode also highlighted broader problems within the NHS, such as systems of management and the status of psychogeriatrics as a specialism.

Partnerships with Patients and Family Caregivers

This paper discusses six areas of hospital experience that can be improved: parking, hospital gowns, visiting hours, emergency room triage, hospital food, and care plans and discharge summaries. The areas were identified by a group of patients and family caregivers who reviewed large numbers of patient experiences and identified simple and easy to measure changes. Their recommended changes are called "Key Performance Targets."

Healthy eating is on the table as employers sign up to campaign

Employers are pledging to provide healthy food for nurses and other staff by signing up to Nursing Standard's Eat Well, Nurse Well campaign.

Uninterrupted service on the hospital menu

Lee Vines, sales and marketing director at PKL Group, a leading supplier of temporary and permanent catering infrastructure, considers the challenges facing hospital caterers and estates managers in ensuring that catering equipment is kept up-to-date and fit-for-purpose. He also discusses the options available to make sure kitchen services are able to run without interruption during planned or unplanned periods of kitchen 'downtime'.

Mystery meals no more

Nearly one-third of patients admitted to U.S. hospitals are malnourished. Nutrition in- and outside the hospital is a patient care priority.

Extending the food chain

A Toledo, Ohio, hospital used to throw away the meals it didn't serve. Now it helps to feed its hungry neighbors.

A hospital nutrition improvement programme

Healthcare Improvement Scotland (formerly NHS Quality Improvement Scotland) led an 18-month national programme that aimed to achieve reliable improvements in nutritional care by focusing on three priority areas: mealtimes; long-term conditions; and transition to care homes.

Home-cooked care

Hospital patients undoubtedly benefit when visitors bring in home-cooked meals. Patients are more likely to be well-nourished if they can eat food they enjoy. But it can present practical difficulties. Banning such food can prevent visitors from showing they care and present nurses with a dilemma.

Hospitalfoodie: an interprofessional case study of the redesign of the nutritional management and monitoring system for vulnerable older hospital patients

BACKGROUND

To date, a solution to the problem of hospital malnutrition in older patients in the UK has not been found through previous approaches using isolated interventions.

AIMS

To identify opportunities for, and to develop and prototype a new food and nutritional management system able to meet individual patients' daily requirements.

METHODS

Using an interprofessional team approach, design researchers worked alongside food scientists, dieticians, medical sociologists, ergonomists, computer scientists, technologists, key stakeholders and a 'food family' (those concerned with nutrition management, and food supply and delivery in hospital, i.e. food producers, caterers, ward staff, nurses dieticians, physicians, speech and occupational therapists), as well as with older people representatives. Through ethnography and workshop-based methods, major opportunities for service improvement were identified. An iterative design and development process was deployed using mixed methods including ethnography, mapping, personas, storyboarding, role-playing, enactment and narratives. Prototypes of interactive interfaces were developed to test the workability of an electronic nutritional management and monitoring system linked to a nutrition composition database. In parallel, new food products were developed, led by food scientists, and a catering supply and delivery system for ward-based food provision was also developed. The methods used to facilitate interprofessional collaboration, the engagement of the food family, and to develop the food and nutrition service concept are described.

RESULTS

A demonstration prototype was displayed in exhibition format at a series of conferences to gather further feedback.

CONCLUSION

Early responses to the 'hospitalfoodie' demonstration prototype were favourable and indicate that, with further development, the prototype may offer the means for improving nutritional care standards in hospitals and be adaptable for use across other patient groups.

Transforming care at the bedside: Patient-controlled liberalized diet

A 2003 partnership between the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation created an initiative to redesign medical-surgical inpatient care - Transforming Care at the Bedside (TCAB). TCAB is intended to transform the elements that affect care on medical/surgical units by rapidly creating, testing, and measuring new ideas. TCAB began as a pilot with three hospitals nationwide, including the University of Pittsburgh Medical Center (UPMC) Shadyside in Pittsburgh, Pennsylvania. UPMC Shadyside initiated its TCAB efforts with an interdisciplinary initiative, involving registered nurses (RNs), nursing assistants, registered dietitians (RDs), and medical doctors (MDs), to transform nutritional services for medical-surgical inpatients. The Patient Controlled Liberalized Diet Program, piloted in late 2003 and rolled-out house-wide in August, 2004, puts the patient in control. The goal is to improve nutritional status and satisfaction among inpatients by empowering them to make menu selections and providing individualized nutrition education. Positive quantitative and qualitative outcomes have resulted, leading to plans for system-wide (19-hospital) spread and further programmatic evolution.

Older people's care experience in community and general hospitals: a comparative study

Community hospitals are an important component of the post-acute care pathway for older people. The objective of this study was to describe and contrast patients' and carers' experiences of community and general hospitals. Interviews with patients and carers revealed similarities in the perceptions of care between the two settings. These included appreciation of staff sensitivity, a sense of security, encouragement of independence and lack of activity. The community hospital was appreciated for its location, atmosphere, accommodation, greater sense of freedom, quality of food and staff attitudes. UK health policy promotes the development of community hospitals. This should be progressed in a way that retains key strengths of the specific service they offer.

Safety of patient meals in 2 hospitals in Alexandria, Egypt before and after training of food handlers

We assessed the food safety knowledge and food handling practices of 23 food handlers in 2 hospitals in Alexandria, Egypt [Gamal Abdel Nasser (GAN) and Medical Research Institute (MRI)] before and after a food safety training programme, and also the bacteriological quality of patient meals and kitchen equipment. There was a significant improvement in all knowledge-associated parameters except for personal hygiene in GAN. There was an improvement in the food safety practices in both hospitals. The bacteriological quality of most patient meals and food preparation surfaces and utensils improved after training. The bacteriological quality of patients' meals served in GAN was generally better than that in MRI.

[The role of the public health personnel in the Prevention Department (in the Hygiene Services and Public Health Care and Hygiene of Food and Nutrition): proposal for the future of public health care]

A global and local discussion on Public Health relevance is taking place, including the future role and organization of its services. Noteworthy becomes the role played by Public Health Specialists. This work presents the results of a workshop, carried out following the Guilbert methodology, whose aim was to define Public Health Doctors functions and their related activities. The programme involved 30 professionals from Triveneto area (North Eastern Italy), working in Prevention Departments at National Health Service and Universities. The key-functions identified were: 1) Health status assessment and identification of community risk factors, 2) Health Promotion, 3) Prevention, 4) Protection, 5) Planning, 6) Communication, 7) Professional Training, 8) Alliances and resources for complex Public Health programs, 9) Crisis management in Public Health, 10) Research. For each function activities were identified, meaning concerning areas and contents that must be warranted by professionals. This experience allowed to share existing attitudes and experiences present in Triveneto area, and it can stand as a feasible instrument for different settings. Nevertheless, it appears mandatory explaining at each level in the society role and functions of Prevention Departments.

Nutrition now. Ripe for reform

Levels of nutritional care for patients in the community are difficult to gauge, but community nurses can make a difference to those at risk.

Something for everyone

Providing food in hospital that complies with patients' religious and cultural sensitivities can improve wellbeing and reduce time in hospital.

Keeping food local

Procuring NHS food from local producers can be cost effective and increase patient satisfaction by offering patients more choice and better food.

Time to share. Interview by Adele Waters

The RCN's Nutrition now campaign, supported by Nursing Standard, is giving nurses the resources to stop patients becoming dehydrated and malnourished.

Developing the role of a ward housekeeper within a multidisciplinary team

The implementation of a housekeeper induction competency programme demonstrates the innovative way that the clinical standards facilitator has led the development of the housekeeping service at one NHS Trust. This service has been developed to ensure that there is sufficient training, support and opportunity to share best practice for the housekeepers. A Trust-wide approach using the multidisciplinary team (including dieticians, catering and facilities managers) has contributed to the raising of standards in meeting the patients' nutritional needs, as well as improving the ward environment. NHS Estates guidance (DH, 2001b) relating to the housekeeping service and the Essence of Care benchmarks for nutrition (DH, 2001a) were used to provide this framework for continuous quality improvement.