1. The Challenge of Hospital Nutrition Support Richard C. Wilson BSc RD FBDA MTF Day 25 March 2014

2. Structure of this presentation The challenge and recent initiatives The current situation and how we try to rise to the challenge Future direction www.malnutritiontaskforce.org.uk

3. King’s College Hospital NHS Foundation Trust Nature of King’s (pre – Oct 2013) –Foundation trust –1200 beds –6,000 live births –~70,000 admissions –55% unplanned England 150,000 beds England 10 million admissions 38 Dietitians –~36,000 patient contacts per year Food service - PFI –Cook chill (Steamplicity) Plated cook chill Microwave & steam regen. Initiatives in place –Protected Mealtimes –Red Trays –Ward housekeepers

4. Hospitality is key to care Hospitality is the foundation of all care The first hospitals were in monastery's Sanctuary for the sick, poor and destitute Providing shelter, security, nursing, nurture and nutrition 10,000 + staff need to be aware of this Hippocrates 400BC –“In all maladies those who are well nourished do best. It is bad to be very thin and wasted. Approximately 1200 patients at King’s –~120 on artificial nutrition support –1080 (90%) dependent on a ‘knife and fork’

5. Nutrition and human physiology AWARENESS RAISING Entropy – 2 nd Law of thermodynamics Matter has a tendency to become chaotic Human body made of very organised molecules Keeping them organised requires energy

6. Our collection of molecules Constantly being broken down and replaced Every seven years it is all replaced Replacement molecules are swallowed! All this requires energy We measure energy in calories 1kg of human = 7000kcal 1 missed meal = -400kcal = 60g (2oz) of tissue lost!!

7. Obese people can be undernourished too! These days Michelangelo would have needed considerably more marble!! Unintentional weight loss still has detrimental effects

8. Every performance review / feedback opportunity taken… What do the patients think of the food? ‘How Are We Doing?’ survey Continuous performance management Virtuous circle of improvement Monthly survey – response of 1236 patients following discharge

9. Sobering tales… Nutrition can kill We recently had a serious incident related to refeeding Patient arrested and died NICE ‘Nutrition Support in Adults’ CG032, 2006 High risk of developing refeeding problems if: One or more of the following:Two or more of the following: BMI less than 16 kg/m 2 Unintentional weight loss >15% in last 3-6 months Little or no nutritional intake for more than 10 days Low levels of potassium, phosphate or magnesium prior to feeding BMI less thank 18.5 kg/m 2 Unintentional weight loss greater than 10% in last 3-6 months Little or no nutritional intake for more than 5 days A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

10. Strategic direction? Malnutrition is still a significant problem in hospitals including ours ICT systems offer ways to: –Raise awareness –Advise on need –Monitor progress against nutrition targets –Communicate plans between settings Based on research conducted by: –www.hospitalfoodie.com

11. The proposal Assessment on Wardware (MUST) Lookup target in DRV table Target provided by dietitian Data on nutritional inputs collected Intake visually mapped against targets

12. Benefits of this approach Includes all patients Includes all feeding modalities Visual analogue target engages all staff and patients in meeting target Holistic approach will improve communication Between staff on site Between care settings

13. Bringing the Hospitality back into Hospital! Delivering nurture, nourishment and sustenance is what care is all about The raw materials for recovery