JCPSLP Vol 16 no 3 2014_FINAL_WEB

Clinical insight

Reducing error in a complex system Texture modified diet and fluid provision Charissa Zaga and Joanne Sweeney

This paper describes how a complex meal provision system in an acute hospital setting supports clinical decision-making in dysphagia management at the ward level. The aim was to reduce the number of incorrect texture modified diet and/or fluids delivered to patients with dysphagia. A process map of the meal provision system at The Austin Hospital was revised and an auditing tool created for the purposes of this study. This auditing tool comprised nine key parameters in the meal provision process for texture modified diet/fluids. An audit was conducted across eleven acute wards over three breakfast, lunch and dinner meals over four non-consecutive days. Following analysis of the audit, focus groups were held with seven speech pathologists, four nurse unit managers and the food services coordinators. Audit results, barriers to achieving higher accuracy across auditing parameters and areas for intervention were discussed in these groups. Intervention was three-fold: targeting safe swallowing bed- signs, and supervision of the plating line and in the re-therm trolley room. Three and a half months after the first audit and implementation of the interventions, a subsequent audit was conducted on six acute wards over two breakfast and lunch meals on two consecutive days. Overall reductions in the number of delivered meals of incorrect texture were noted between the initial audit and the subsequent audit results. D ysphagia is associated with many different etiologies across the lifespan, including but not limited to neurological conditions, trauma, respiratory disorders, psychiatric conditions and effects from polypharmacy (Cichero, 2006). The estimated prevalence of dysphagia varies depending on the classification of the medical condition. Consequences of unmanaged cases

of dysphagia can lead to significant poor health outcomes including aspiration, pneumonia, malnutrition, asphyxiation and death (Langmore et al, 1998; Cichero, 2006). A common method of management for dysphagia by speech pathologists is the provision of texture modified diet and fluids (Garcia, Chambers & Molander, 2005). Cichero (2006) reports that thickened fluids or altered texture provide additional cohesion to the bolus, slow oral and pharyngeal transit and provide greater oropharyngeal control of the bolus. Austin Health is a major provider of tertiary health services and health professional education and research in the northeast of Melbourne comprising 980 beds across three sites. At Austin Health, the meal provision system is complex. Meals are transported across the three sites, multiple disciplines are involved from the prescription of diet and fluids to delivery at the patient’s bedside. All meals are prepared at the Heidelberg Repatriation Hospital (HRH) in a large food production kitchen. Meals for the Austin Hospital and HRH are transported to the Austin Hospital for plating and heating in re-therm trolleys. Meals for Royal Talbot Rehabilitation Centre (RTRC) are transported directly to RTRC for heating and serving. Meals for patients at the Austin Hospital are taken to the ward in the re-therm trolley and delivered. Meals for HRH are placed in the re-therm trolley at the Austin Hospital, then loaded onto a truck and transported back to HRH where the re-therm trolley is unloaded, taken to the ward and the meals are delivered. There are two electronic meal-ordering systems: TrakCare and ChefMax. All ward staff including nurses, dietitians and speech pathologists order meals via TrakCare. Following this, menu monitors enter the TrakCare diet code into ChefMax with the patient’s relevant menu preferences. ChefMax generates a meal tray slip that is printed for each patient and placed on the tray where the meal is plated. There are set meal ordering cut-off times on TrakCare whereby any diet/fluid changes entered after the cut-off time will not come into effect. This reflects the timeframe of the process from when the meal reports and meal tray slips are printed, plating begins and all plated meals are placed in the re-therm trolley. At the Austin Hospital, this timeframe is approximately two hours; however, at HRH this timeframe is between 5 and 11 hours. Speech pathologists must communicate all diet/fluid changes verbally to the menu monitors in cases where delivery of the new diet/fluid would result in risk to the patient (e.g., patient with worsened dysphagia requires a more modified diet). This process aims to ensure the meal that is plated and delivered is safe as the meal report for plating has already been printed. In

THIS ARTICLE HAS BEEN PEER- REVIEWED MEAL PROVISION PATIENT SAFETY TEXTURE MODIFIED DIET KEYWORDS ADVERSE EVENT AUDIT

Charissa Zaga (top) and Joanne Sweeney

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JCPSLP Volume 16, Number 3 2014

Journal of Clinical Practice in Speech-Language Pathology