JCPSLP Vol 16 no 3 2014_FINAL_WEB

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%

153

JCPSLP Volume 16, Number 3 2014

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