JCPSLP
Volume 16, Number 3 2014
153
groups were conducted with stakeholders to inform the
areas for intervention. Seven speech pathologists, four
nurse unit managers and the food services coordinator
analysed qualitative data regarding barriers to acheiving
higher accuracy across auditing parameters and identified
areas for intervention. Following this process a three-fold
intervention was implemented: 1) targeting safe swallowing
bed-signs; 2) improving the level of supervision on the
plating line; and 3) improving the level of supervision in the
re-therm trolley room in the kitchen.
Results
First audit
The first audit results (see Table 1) identified some
inaccurate diet/fluid code matching across the EMOS,
patient’s medical file and bed-sign. Poor use of the safe
swallowing bed-sign was evident. These results prompted
analysis and intervention to increase the presence of the
safe swallowing bed-signs, increase accuracy of diet/fluid
code matching across the parameters, and reduce the
number of patients receiving incorrect meals.
Intervention based results of the audit
Safe swallowing bed-signs
The safe swallowing bed-sign acts as a key communication
tool between the speech pathologist, nurse and food
services staff in identifying diet/fluid requirements at the
point of diet/fluid delivery at the bedside. It is the
responsibility of the speech pathologist to place a safe
swallowing bed-sign above the bed of patients with
dysphagia. The food services staff use this sign to
cross-check the patient’s name and meal requirements
against the plated meal before delivery. This is the final
cross-checking point in the complex meal delivery system
(see Figure 1) and is essential to minimise incorrect meal
delivery. Poor compliance with the presence of safe
swallowing bed-signage prevents this cross-checking to
occur and was at least one of the causes of incorrect meal
provision during the audit.
Speech pathologists identified several barriers during the
focus group:
1. Lack of bed-signs available in the department
2. Lack of bed-signs available while on the ward
3. Forgetting to place a bed-sign
4. Bed-signs falling down and not being replaced at bed-
side by nursing staff
5. Bed-signs being placed initially but not moved with
patient who is transferred to another bed or ward.
instances where there is no risk for the patient to receive
the older meal order, the new diet/fluid change will take
effect from the next mealtime. Staff from seven disciplines
– nurses, ward clerks, speech pathologists, dietitians,
menu monitors, fluid preparation staff and personal service
assistants (PSA) – are involved in meal provision.
Of the average 15,400 meals produced per week, the
food services department estimates 10% (~1,540 meals) of
these to be texture modified meals and/or fluids (TMD/F).
Given the complexity of the meal provision system and
the potential for error and adverse events, the aim of this
project was to reduce the number of incorrect texture
modified diet/fluids delivered to patients with dysphagia at
the Austin Hospital.
Method
The existing TMD/F provision process map (see Figure 1)
was revised following consultation with multiple
stakeholders including nurse unit managers (n = 10), deputy
manager of dietetics and food services coordinator. This
review enabled documentation of current procedures within
each relevant department at the ward and kitchen levels.
The parameters in the process map informed the
generation of an auditing tool developed for the purposes
of this study.
The auditing parameters were:
1. Presence of a safe swallowing bed-sign.
2. Presence of a meal tray slip.
3. Matched safe swallowing bed-sign to meal tray slip.
4. Matched meal tray slip to diet/fluid code on electronic
meal ordering system (EMOS).
5. Matched meal tray slip to plated meal.
6. Matched plated meal to diet/fluid code on EMOS.
7. Matched plated meal to documented diet/fluid code in
patient’s medical file.
8. Matched diet/fluid code documented in patient’s
medical file to diet/fluid code on EMOS.
9. Presence of correct meal delivered.
An initial audit was conducted across eleven acute adult
wards in the Austin Hospital over three breakfast, lunch
and dinner meals over four non-consecutive days. Over the
auditing period 82 patients were on texture modified diet/
fluids recommended by speech pathology; however, 6 (7%)
of these were not delivered resulting in a sample size of
76 meals. Reasons for meals not being delivered included
patients fasting for procedures or being too drowsy for oral
intake.
Following the initial audit and analysis of the results,
a review of the process map was undertaken and focus
Table 1. Summary of audit results
Audit 1
Audit 2
Number of TMD/F meals delivered
76
35
Presence of safe swallowing bed-sign
61%
74%
Presence of meal tray slip
99%
100%
Matched bed-sign to meal tray slip
89%
85%
Matched meal tray slip to diet/fluid code on EMOS
93%
94%
Matched meal tray slip to plated meal
97%
94%
Matched plated meal to diet/fluid code on EMOS
92%
94%
Matched plated meal to documented diet/fluid code in patient’s medical file
95%
94%
Matched diet/fluid code documented in patient’s medical file to diet/fluid code on EMOS
95%
97%
Presence of incorrect meal delivered
3%
0%
