Clinical Service Improvement Project
The clinical nutrition manager at the North Central Bronx Hospital (NCBH) and I decided that my Service Improvement Project (SIP) would be to address the quantity of unused oral nutritional supplements that were being returned to the kitchen from patient floors. The foodservice staff at NCBH started collecting data on unused supplements returned from patient floors in early August of 2013 due to the excessive number of cans being returned each day. Entries consisting of the date, medical record number, patient initials, room number, formula, and the number of cans returned were completed daily in logbook. This information was collected for the purpose of finding out why the number of unused supplements being returned was so high. In mid-November of 2013 I began my SIP utilizing the information collected from the previous three months.
Working from the information contained in the unused supplement logbook I was able to locate the patient’s electronic medical record (EMR) in an attempt to ascertain the reason or reasons why their supplement on a particular day was returned unused. Areas of the EMR that I searched for information included: input/output logs, diet orders, nurses daily notes, med/surg notes, and nutrition notes. Information was also obtained through patient interviews. I chose 11 patients representing a range of variables including short- and long-term stays, oral and tube feeding supplement use, and the floor to which they were assigned to look into further.
The average length of stay was 12 days ranging from the shortest stay of two days to a maximum of 39. Six of the patients were receiving their supplements orally and five were receiving enteral nutrition. Based on the 11 patients there were 61 total days on which unused supplements were returned totaling 181 individual cans. This is an average of 16.5 cans per patient per stay or an average of 1.4 cans per patient per day. At an average of 370 kcal per can patients were not consuming an average of 507 kcal a day that were prescribed in their diet order.
Thirteen different reasons were identified as possible explanations for the return of these unused supplements. Nine of the 13 reasons for returns were legitimate reasons why a patient may not have consumed their supplement. They included: NPO orders, changed orders, patient at a test, residuals, patient dislike, tube feed rate changed or stopped, discharged patients, GI intolerance, and patient in surgery. These nine reasons accounted for 42.6% of all returned supplements. The other four reasons identified accounted for 13.1% of returned supplements. They included: duplicate orders, patient transfer, no order for supplement given, and late orders which are all issues of the hospital’s procedures. Another 44.3% of returned supplements could not be linked to any information as to why they had been returned. While these instances could not be used in my project they were shared with NCBH staff in an effort to improve the consistency of charting on supplements.
I chose two aspects of this issue to develop solutions for. The first area for improvement identified was the menu room staff and their process of preparing orders of supplements. The practice was to prepare all supplements for the following day based on orders entered into the EMR by 3:00 PM. The staff from the menu room and I decided that supplement orders would be prepared in conjunction with each meal service based on current orders in the EMR at those times throughout the day. The issues addressed by this solution include: NPO orders, changed orders, discharged patients, patient transfer, and late orders. Another solution I developed was a decision flowchart titled, ‘Discontinue Oral Nutrition Supplementation’ for use by the dietitians, nurses, and doctors at NCBH. This flowchart was created to address the following issues: patient dislike and GI intolerance. It was observed that patients who had expressed a dislike of their supplement due to either GI intolerance or taste would continue to receive the supplement for the length of their stay. The flowchart helps to make decisions on whether or not a supplement should be discontinued and if an alternate formula should be provided. It also describes the process of addressing flavor preferences of patients. This solution addressed the issues of patient dislike and GI intolerance towards a current supplement.
The changes to the menu room’s procedures and the decision flowchart were implemented on December 23rd about a month after the initial data collection period beginning on November 18th. Both the day and evening shift menu room employees were informed that December 23rd was the start date to begin the procedures discussed and agreed upon. Throughout the month leading up to the implementation of the decision flowchart I attended a Nursing-Nutrition meeting and a providers meeting with the clinical nutrition manager to discuss the proposed changes to the monitoring of supplement orders. I also had the opportunity to present the finalized decision flowchart to the medical residents to explain its purpose in an effort to increase the usage of the tool.
On January 13th I collected data using the unused supplement logbook from December 23rd to compare the number of cans returned on average prior to the start date and after. I found that 818 cans had been returned over the 120 days preceding the start of my service improvement project for an average of 6.8 cans per day. In the 23 days that followed the start of the project there were 134 cans returned for an average of 5.8 cans per day. During the course of the project the number of cans of supplements being returned was decreased by one can per day or 14.7%. This was an encouraging result which indicated that the new procedures put in place had a positive effect. The project did not eliminate the return of all unused supplements, and neither was that its intended purpose, however it did decrease the percentage of supplements being returned by a similar amount of the four reasons identified earlier as hospital procedural issues accounting for 13.1% of returned supplements. Although, it is unclear whether the decrease in returned supplements as a result of the project were in this category. I spoke with the dietitians, dietitian technicians, nurses, and residents concerning the usage of the flowchart and the changes in the menu room during the following three and a half weeks from their implementation. This process should be continued by the clinical nutrition manager. By involving all appropriate departments on a continual basis in this improvement effort greater change can be realized. Input from these personnel regarding any shortcomings of the project will make it possible for improvements to be made resulting in better patient care.
