Engaging the patient: Improving oncology patient meal experience through bedside terminal meal ordering. Vicki Barrington, APD PeterMacCallum Cancer Centre Email:v.barrington@latrobe.edu.au This Session is supported by: J Hum Nutr Diet. 2018 Jul 2. doi: 10.1111/jhn.12573 1
Peter Mac- a new oncology hospital in 2016 Opportunities with the move o Improve patients meal experience o Improve patients nutritional intake Photo Credit:Peter MacCallum Cancer Center. www.petermac.org Photo Credit: Peter MacCallum Cancer Center. www.petermac.org What’s new in the kitchen v Better designed kitchen (1/3 size) Ø Work flow Ø Under bench fridges Ø Temperature controlled area v New equipment that works! Ø Cooking Ø Plating Ø Dishwasher v New Food and Nutrition Meal Management system Ø Purchasing Ø Menu ordering Ø Patient nutrition 2
Challenges § No increase in staff § No increase in budget- although some re-location spend § Smaller kitchen but bigger hospital footprint § No change to the menu § Limited input to type of food service and design Ø layout, heat boost trolleys, equipment Food Service Model Changes East Melbourne Parkville On site Cook fresh/cook chill hybrid o On site Cook fresh/cook chill hybrid o o No change 4 week cycle menu o o 4 week cycle menu o No change to menu Paper menus- 3 meals o Bed side meal ordering ( CBORD) o o Lag time of a full day between ordering Meal ordering up to 1 meal in advance and receiving a meal o o Order meals 24/7 o Ability to order fewer meals at 1 time Inefficient collection process o Ability to order up to 1 hr minutes before a o meal o Nutrition information for each item No nutrition information on menu o o Daily nutrition intake summary Limited mid meal service at point of o service Mid meal ordering and increased mid meal o o Poor diet safety options o Lack of ONS What has not changed: Malnutrition Prevalence § The oncology population is one of the highest risk groups for malnutrition § Oncology patients are 1.7 x more likely to be malnourished compared with other acute hospital admissions. 1 § Barriers to adequate nutrition are multi-factorial Ø Barriers in the ward Ø Barriers in the kitchen SGA-C 7% Overall Nutritional MST<2 38% Status(Inpatients): Well nourished 49% SGA-B 44% Malnourished 51% SGA-A 11% Source: Loeliger J, Kiss N. Phase II Malnutrition in Victorian Cancer Services: summary report. Department of Health and Human Services, State Government of Victoria, Melbourne. 1. 2009 DAA Practice guidelines for the nutritional management of malnutrition in Adult patients 3
Patients remember their food….. Patients remember their food. .......Ask the patient Photo Credit:PeterMacCallum Cancer Center. www.petermac.org Bedside Meal Ordering Project - Consumer engagement throughout the project o Consumers involved in the design of the Bedside Terminals screen look and language o Consumer testing and feedback throughout project o Patient data gathered from previous surveys & feedback o 2015 Honors Student thesis “ Oncology inpatients’ experiences with meal ordering and intake " o Interviews addressed patients’ understanding of their nutritional needs and experiences with access and provision of food in hospital. Patient Themes Menu Communication Nutritional Appetite Factors PATIENT Service & Food quality Delivery times 4
Bedside Meal Ordering Service and Delivery times • Can order meals up to 1 hour prior to meal • Enable patients to order fewer meals in service advance • Can order 1 meal ahead up to next day’s • Can order meals 24/7 meals Menu Communication • Diet Code displayed • Photos and descriptions of meals • Assist CALD patients 5
Menu Communication Menu Communication § Patients and staff can ring menu coordinators directly to address menu issues and concerns Nutritional factors • Enable patient to have easy access to nutritional information • Nutrient composition for every food item 6
Nutritional factors • Summary of meal order and nutrition Nutritional Factors Recipe ingredients on FS staff iPads Mid Meal options • No mid meal defaults • Improved mid meal safety and food options • Included ONS 7
RESULTS Project Aims 1. Determine if the new bedside menu ordering system enhances overall meal experience and improves nutrient intake 2. Compare data to previous baseline meal service audits conducted in 2014 and 2015 o Patient meal experience o Ordering patterns o Plate waste o Energy and Nutrients consumed Results Meal Experience Survey Demographics 2015 2016 No Pts 59 50 Gender Female 44% Female 54% Male 55% Male 46% LOS Mean = 10d Range = 2-52d Mean = 6d Range = 2-33d Age Mean = 59y Range =19-90 y Mean= 65y Range = 23-90y CALD 29% CALD 33% CALD 8
Patient Ordering Patterns • 60% patients use Bedside meal ordering terminals independently o 33% CALD, o 49% > 65years Photo. Credit:CBORD www.cbord.org. • 25% patients have assistance by menu co-ordinators/staff o Unwell patients still have individual assistance o Allocate time to patients who need assistance Patient Ordering Patterns Decrease of 10% in Default Meals patients receiving default 30 25 meals 25 Perrcent Patient o More likely to eat what 20 15 15 you choose 10 o Less wastage 5 0 2015 2016 Mid Meal Orders Increase of 100% in 66 patients ordering mid meals 70 60 o Availability of nutrient Percent Patients 50 dense snack and fluids 40 33 30 o Less wastage as no 20 10 defaults 0 2015 2016 Meal Experience Survey results Effects of Meal Ordering 2015 2016 P value I understand how to fill in the menu 38(65%) 33(66%) Not sig Choosing the right food is difficult, 35(61%) 16(32%) P=0.002* there isn’t enough nutrition information When the food arrives I always want 32(55%) 43(87%) P=0.0005* what I’ve ordered I did not receive the food I ordered 26(45%) 6(13%) P=0.0002* *P<0.05 9
AVERAGE ENERGY INTAKE 2014 2016 P = 0.004 P = 0.00001 10000 9500 9500 8940 9000 8000 6997 7000 6517 6000 Kilojoule 5000 4663 4000 3000 2000 1000 0 Ordered Consumed EER Average Protein Intake 120 2014 2016 P = 0.02 98 100 82 P = 0.0017 80 70 70 68 Grams 60 55 40 20 0 Ordered Consumed EPR Average Plate Waste P=0.47 41 P=0.82 P=0.3 37.5 36.3 35.2 35.3 34.3 32.2 A% Plate Waste 28.1 BREAKFAST LUNCH DINNER DAILY TOTAL 2015 (n=96) 2016 (n=85) 10
Summary Bedside meal ordering is a success 1. Improving access to ordering and meal timing can improve oral intake for both meals and mid meals independent of food service cooking/preparation model. 2. Patients of all ages are ready to adopt technology and have embraced Bedside meal ordering. 3. Patients’ want to actively participate in their healthcare at all stages. 4. Bedside meal ordering empowers patients’ to feel engaged about their nutritional care and meal experience whilst in hospital. Thankyou! Peter Mac Patients and Consumers o Latrobe University and Monash University students o Update from Jacq Black Current situation at o PeterMac, 2 years on Where to from here o Photo Credit:Peter MacCallum Cancer Center. www.petermac.org Where is Peter Mac now? 11
Background • 2.5 years post move to new facilities and implementation of CBORD food service system • Understand CBORD system better but still a lot more we can do with it Patient ordered on the bedside terminal Patient ordered via menu coordinators Patient is nil by mouth • It’s time for change and improvements Menu review No change to menu in >7 years Day therapy chairs increased Kitchen is ⅓ four-fold! size! Menu review Existing Plus short 28-day order and menu mid meals cycle Food wastage / patient consumption data • Not currently being used at Peter Mac • Brings many benefits Mobile intake • No more student projects taking photos and watching plating lines! Calculated food wastage • Potential improvement to food charts Calculated protein and energy intake 12
Mobile intake Food allergy management • Increase in food allergies and range • CBORD is a better system for managing food allergies • Implemented specific food allergy diet codes, previously already had gluten free Food allergy management • Increasing difficulty in providing safe meals to patients with an unusual reported food allergy 13
Food allergen management Policies and Communication Food preparation procedures • What is the process • Is it safe enough? for communicating • Do food services staff •What is currently in food allergies? understand the place? • How do food services importance of this? •What do we need to know a patient has an develop? allergy? •Dissemination of these Thank you Jacq Black Jacqueline.black@petermac.org 14
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