Managing Malnutrition for those with swallowing difficulties is difficult and complex for the patient and every member of their care team. It’s a problem which a team at Salford Royal Hospital, here in the UK, has been working to resolve with an e-Learning Package.

It seems incredibly useful and so we invited Laura O’Shea, the AHP Lead for Speech Therapy to tell us about the work she and joint project lead Tony Ward, Community Dietetics did…

…After years trying to manage the impossible task of delivering training to care staff and a shortage of resources to deliver this, Salford SLT and Dietetic teams decided to try something different. A training needs assessment had previously been conducted in nursing homes which revealed that only 27% of nursing home staff and no catering staff had received training in dysphagia and malnutrition, despite this being a central role in their daily duties. All care home managers had requested additional training sessions with 75% of these stating a preference for e-learning training. Demand for training had further increased following CQC inspections.

We know that dysphagia is associated with increased morbidity, mortality and reduced quality of life. Pneumonia is a common sequelae of dysphagia and is associated with higher costs of care (Katzan et al 2007). The incidence of dysphagia in acute care has been reported to be 33%, and studies have shown that 30–40% of patients in nursing homes have swallowing disturbances (World Gastroenterology Guidelines, 2007).

At Salford Royal an analysis of incidents reported from 2015 revealed that 47 incidents were reported regarding unsafe feeding practice or nutrition. Most of the incidents are reported as ‘near misses’, however the consequence of inappropriate feeding can be catastrophic and we are becoming more familiar with cases in the media whereby patients are given incorrect textures and choke.

According to the NICE guidance (2006), it is possible to reduce length of stay by 1 day by addressing nutrition. Hospital Acquired Infections cost the NHS 7.3billion pounds a year, whereas malnutrition costs 13 billion pounds a year and currently ranks as one of the top 3 expenditure for NHS. At any given point in time more than three million people in the UK are either malnourished or at risk of malnutrition. The vast majority of these are living in the community. However a hospital admission provides a vital opportunity to identify malnutrition and initiate treatment, it is therefore crucial that staff are properly trained to recognise and treat malnutrition and dysphagia as an integral part of patient care.

Raising awareness of malnutrition and dysphagia is challenging and currently relies on didactic teaching sessions. This restricts the amount of staff that can be released at any one time and sessions can be poorly attended. An audit of current ‘MUST’ training session provided by Dietetics revealed that despite monthly training sessions to care home staff only 44% of patients are screened for malnutrition correctly. Only 17% of referrers to dietetics had ‘MUST’ training despite the monthly sessions. We therefore concluded that an e-learning package would be an efficient and cost effective training method. In addition we believed this would also be beneficial for high staff turnover, accessibility to all staff and reduction in the time and cost of releasing staff for training.

When Salford was selected nationally to be a pilot site for the Age UK malnutrition pathway along with the ongoing developments with the Salford Integrated Care Pathway collaboration, we felt it was a timely point to progress with the eLearning

An initial scoping exercise revealed that no training was available that dovetailed malnutrition and swallowing difficulties that appealed to a general audience and staff in a variety of care settings. Current staff training by the council is focussed on healthy eating as opposed to malnutrition and dysphagia. Questionnaires were completed by staff working in care homes pre and post training to assess the need for training. These showed that following training staff had increased knowledge and confidence. Specifically this showed that:

• Only 27% of nursing home staff, and 0% catering staff had received training in malnutrition and dysphagia despite this playing a central role in their daily duties.
• All nursing home managers requested additional training sessions to maximise their staff uptake following the pilot study.

Further to this, the majority of nursing home managers stated a preference for nutrition e-learning training thereby reducing the need to release groups of staff at any one time for training.

What did we do?
We were successful in applying for an innovation grant to secure funding to develop the module and used an external company to fulfil this.

We wanted the content to appeal to acute and community staff and based the modules around a patient story. Other videos from medical and nursing staff were from Salford Royal employees.

The module is split into to 2 sections namely for swallowing difficulties and malnutrition. Broadly the modules cover: What is dysphagia?, Management of dysphagia including Positioning and Modified textures of diet and fluids, Safe feeding, Safeguarding issues, consequences of Malnutrition, Nutritional screening and Management of malnutrition

The aim of the training is to enable staff working with patients at risk of dysphagia and malnutrition to have a better understanding of dysphagia and malnutrition, in order for them to identify and manage their difficulties appropriately.

The module is hosted on the Salford Royal Foundation Trust learning platform. It was also initially hosted on Salford City Council’s learning platform to allow care home staff to access the training, however due to problems with resources and administration it has not been possible to continue with the council hosting the elearning. A decision was made for the training to be recommended not mandatory, however it is held up as good practice for staff to complete in acute and community. Staff are also signposted to the training if they have been involved in an adverse incident related to dysphagia or malnutrition.

The system allows managers to monitor how many of their staff have completed it and this information is used within nursing accreditation assessments to ensure safe and reliable care. To date 751 members of staff at Salford Royal hospital have completed the module and passed the skills assessment. Staff include a variety of grades of nurses, housekeepers and trust volunteers. We feel this is a significant achievement as it with challenges in staffing levels, it would not have been possible to have delivered face to face training to so many staff members.

Evaluation

Many AHP service will share the challenges of providing data which demonstrates patient outcomes. In theory, improved awareness and identification of dysphagia and malnutrition should reduce hospital admissions, however in reality patients are often admitted with a multitude of health issues rather than a single diagnosis of malnutrition or aspiration.

SLTs are usually the main reporters of adverse incidents related to dysphagia e.g., patients being given inappropriate textures or amounts of food / fluids. In comparison to data in the first 8 months of 2015/2016, there has been a 27% decrease in adverse incidents related to dysphagia at Salford Royal Hospital.

Due to difficulties with the council continuing to host the elearning module, community evaluation has been more difficult. It is anticipated that as part of the Integrated Care Programme, that this will be available for other staff who work in the community who are not employed by Salford Royal Hospitals.

Implementation of the eLearning should also improve efficiency of resources within Dietetics and SLT due to an increase in appropriate referrals being made to both services. Analysis of referrals shows an overall increase in referrals to the SLT service but a slight drop in inappropriate referrals from 28% to 24%. It would be expected that referrals should increase due to increased awareness of the need for SLT and dietetics. This again reflects the difficulty in making claims on data as many factors can contribute.
Due to the generic content of the module, we are looking to see if the module could be marketed beyond Salford staff.

Article written by Laura O’Shea SLT laura.oshea@srft.nhs.uk and Tony Ward, Dietitian tony.ward@srft.nhs.uk

For enquiries please contact Laura O’Shea, AHP Lead for Adult SLT on laura.oshea@srft.nhs.uk or Debbie Lawford, Operational manager for Dietetics debbie.lawford@srft.nhs.uk