Knowledge Natter: inpatient feeding audit by Wildbore Vetstop

RCVS Knowledge

Welcome to this Knowledge Natter, by RCVS Knowledge. Here, we have friendly and informal discussions with our Knowledge Award champions, and those who are empowered by Quality Improvement in their work. Whether you are a veterinary surgeon, veterinary nurse, receptionist or member of management, Quality Improvement will and can positively impact your everyday life. Listen and be inspired.

Lou Northway

Hello everybody and welcome to this RCVS Knowledge Natter. My name is Lou Northway. I’m Quality Improvement Clinical Lead here at RCVS Knowledge and today I’m talking to Amy from Wild Boar Vets. Hi Amy.

Amy Wells

Hello.

Lou Northway

Thank you so much for taking time out of your busy working day to speak to me. But we are super excited to hear about your RCVS Knowledge Award. So before we get into it, learning more about your project, can you tell us a little bit about you and your team and your practice?

Amy Wells

Yeah, thank you for having me. So, we’re a small animal hospital. There’s about 50 of us in total. So there’s RVN’s, students, we’ve got a great PCA team, and front of house. So yeah, we’re a nice big team, and we’re in Worksop. I’ve been working at Wildbore for coming up to nine years now. I started off as a VCA and then progressed to do all my student training and then qualified coming up to about five years ago now, which has just flown. I don’t know where all the time’s gone.

Then so the project came by because I’d just done a certificate in medical nursing, and was looking for ways to improve patient care, which that’s what’s inspired me to look more into auditing and nutrition in particular.

Lou Northway

And it’s such a good project, Amy. And when I first read about it, thought, blimey, this is really a project which I’m sure every team in practice should have a closer look at. So you got inspired on your medical nursing certificate and you decided, I want to have a look at this. So what happened? How did it all start? How did you get your team on board? And how did things get underway?

Amy Wells

So we were just looking at – with me doing the certificate – if there’d be anything useful we could bring back to practice and it was all based on wanting to improve inpatient care on the wards. So that’s my particular passion area.

And I noticed looking through all the content in the certificate… and I ended up joining the Medical Nursing Academy that Laura Jones runs. So, I met her as well through doing the certificate… It was a really common theme about how nutrition can help with inpatient care. And I just felt it was really overlooked in practice. We focus on medication, fluids, and sort of the treatment plan. But then it’s a bit of an afterthought, giving them the food when it is actually, I’ve found through the study, it’s a really important part of recovery plan.

I just had a chat with my head nurse Claudine and our lead ward nurse Kim as well, which it was brilliant because they were really on board with looking at what we could do to improve patient care. And it was Claudine’s idea, actually. She wanted some evidence that we see if we do see inappetence, to see if it would be an actual worthwhile focus point and some evidence of what we’re doing at the moment if we are doing feeding plans or interventions and stuff and then getting that evidence then led on from that to looking at what we could do to change things.

Lou Northway

And how did you start sort of looking at your patient records and things? How did you sort of look at the data and collect that?

Amy Wells

So I just went back, at the time we had paper copies of the hospital sheets, which we have since gone on to scan in, so it’s a bit harder to look back now. Just looking at loads of different things, I got a bit carried away. I wanted to look at absolutely everything all at once.

Lou Northway

Yeah, I know that feeling. It is really easy to want to do that, and think, I’m going to change the world, but you have to keep it simple, don’t you? So yeah.

Amy Wells

I just looked at if they got feeding plans or resting energy requirements calculated as a starting point and then I wanted to look at if they was meeting their resting energy requirements so I had to look through their entire stay, add up all the different foods they’d had and the calories so it did actually take quite a lot of time to actually sort the maths and trolling back through, if they’ve been in for a few days to get all that data.

And then it was just while I was looking at the hospital sheets, it then went on from there. So I was looking at actually what food have we been offering them? Do we actually know what they normally eat? Then what have we been doing to make them try to eat? What kind of interventions have we done? And then…just collected all that data and then hoped that something useful had come out at the end of it really.

Lou Northway

Yeah, I think it’s really inspiring. When I was looking through your case report, you commented about, you know, getting to know really what the animal’s like. So we’re not just offering things that, you know, they don’t like normally, wet food, cat, and then we’re offering them biscuits and things like that. And one of the other things which stood out was not just offering chicken. And I thought, wow, how many nurses can resonate with that? So yeah, it really, really good. And then how did you go about sort of educating your team and opening them to sort of the concept of what you would be looking at.

Amy Wells

So once I got all the data together, I had another chat with Kim and Claudine and then we decided to have, as part of a practice meeting, for me and Kim to present the data, which I did as a bit of a quiz with them to see if they was expecting the results to be where we are to try and, well to get them all involved and then see if they got on board with where the numbers were then to try and get them more invested if that makes sense.

Lou Northway

Yeah. And what were the guesses like? Did they sort of guess roughly where they thought the team would be in regard to working that out? Or is it better or was it worse than sort of what you’d perceived as a team to start with?

Amy Wells

Surprisingly, we were quite pessimistic about it. I think the team knew it was an area that we would want to focus on and improve. But I’d say, yeah, they were quite realistic with their guesses for where we were currently at. So there was plenty of room for improvement for us.

Lou Northway

And it’s really interesting, isn’t it? Like the expectation sometimes versus reality, how you think you’re doing versus how you’re actually doing can be really different, which is why auditing like this is so, so important. And your first audit cycle you did retrospectively, didn’t you? So you looked at patient data from the year previous of the same month. Tell us more about that.

Amy Wells

Yeah, so I was looking back, so we wanted to know what the figures were like before we sort of started any of the changes we wanted to implement just to get a like an accurate representation and then see what a difference we could make with the changes that we were putting into place.

Lou Northway

And then you did that so that your team knew that you’d be looking at nutrition requirements, so you could really see a clear representation of a benchmark for yourselves. So you’ve used your nursing certificate and all your new knowledge, imparted your wisdom on your team, and then improved things. So how did it go, audit cycle to audit cycle? What improvements did you make?

Amy Wells

So I was really pleased with how it went. Like I was saying, I did look at an awful lot of things, so there’s quite a lot of numbers. But as a summary, to begin with, with feeding plans, we weren’t really doing them. It was at 3 % of inpatients for the month that I looked at. And then we got that up to 53%, which is from basically none to over half. So I was really pleased with that.

Lou Northway

Yeah, really good.

Amy Wells

And then we’re feeding chicken. So originally, we were feeding about a quarter of our inpatients just chicken and not even offering them sort of a balanced diet. It was just going straight to chicken. And then they were eating the chicken. So, there was no reason for us to really change it because there was there was eating and that was our main focus at the time. And I was really pleased with that. We got that down from 24 % to 5 % which with the number of inpatients that was just a single inpatient who actually had an allergy, so the owners had asked us to just feed them chicken.

Lou Northway

I mean, it’s super inspiring and those little changes, like really, really empowering for the team.

And how did you make it easier for the nursing teams to deliver the nutrition? Did you make any resources or anything like that that they had available to help them in practice speed things up a little bit?

Amy Wells

Yeah, so Kim changed the hospital sheets, so there was actually a dedicated section on feeding plans to kind of trigger when we’re looking through the hospital sheets that we need to make one. I think that made a good difference.

I made a calorie poster. So, it is really difficult if you’re busy and you don’t know how many calories are in the food. You’ve not really got time to do a full investigation. You just want to be able to work it out. So, we’ve got a calorie poster now with all the information on.

And then our consent forms were changed as well. So, we’ve got a special section now. It just asks what the normal food is.

And we’ve also got an impatient questionnaire as well, which we have a fill in at the time or if there isn’t time, we can send it to the owners or give them a phone call a bit later on and then ask them about what they’re feeding and as well if they’ve got like a special type of food bowl or any commands or anything and just make it a bit more of a personal experience for the patient.

Lou Northway

Yeah, that’s so lovely, Amy. It’s really important, isn’t it? And I can tell you a really funny story quickly about a very, very intelligent collie dog I looked after once who was in with a high temperature and not eating. And I had the dog in for a few days, and then on the Sunday, the owner came to visit and he said, love, you did say you could tell the dog to go eat.

And he said, because she won’t eat unless you say, go eat, because the dog had so much selfcontrol, she wouldn’t eat without this command. And I thought, oh my goodness, like I wish I’d known this on Friday. And as soon as that command came out of my mouth, the dog then ate. So yeah, just what you said, those questionnaires and like really taking the time to get to know the patient can just make such a massive difference. Yes. And I think that must have been really empowering for the team as well, for you all to make resources that really help support everybody in their roles.

Because we often find, don’t we, with processes, the more steps there are, the less often the steps are taken. So those little crib sheets make such a massive difference. So what does Wildbore look like now? So you’ve been well underway with this audit for quite a while now. So what are your current statistics looking like?

Amy Wells

So I have done another cycle since submitted this to our CVS Knowledge and it was quite a few months after because I wanted to see…did the original, me and Kim did the presentation July and then audited August and we didn’t really give anyone much time to actually get the new habits on board. I just looked at the results straight away without really giving the team much time.

So it was good to see in a new cycle, which I was also worried maybe the momentum would drop and would maybe go back into old habits. And the results were, I’d say maybe a little bit more of an improvement. I can’t remember the actual figures off the top of my head, but we’d certainly not dropped in any of the areas that we had improved and we’d maybe gone upwards a little bit more. So that was quite encouraging.

Lou Northway

Yeah, fantastic. Really good. I any improvement is an improvement, right? Whether it’s half percent, one percent or 10 percent, you know, we’re happy with that. And it’s sustained change over time, isn’t it? And, you know, you guys have really made a huge improvement from where you began. yeah, hats off to you. Fantastic. What tips would you have for teams in practice listening now if they were going to be starting this audit in their practice? What would you say to them?

Amy Wells

I mean, I guess I’d just say to give it a go. I that sounds a bit vague, I didn’t think that we’d see improvement in every single area I looked at. So that was amazing to actually get the evidence that we’d improved. Like you say, no matter how big an improvement, any improvement’s brilliant.

I’d say maybe get a bit of evidence behind you to then share with the rest of the team, especially the vets as well if it’s something like wanting to place more feeding tubes, which is another area. I’ve not really mentioned, but we are pushing.

Lou Northway

Yeah, let’s talk about that. Let’s talk about that because that’s a really good one, isn’t it? Because, Scott, I’m taking over. I’m really bad at doing this because tell us all about the feeding tubes and how you massively improved the utilization in your practice.

Amy Wells

So with the feeding tubes, it was quite a challenge because it’s just something as a practice. We would place them if we got a really poorly patient who’s not eaten for a long time and was sort of waiting until they were really, really poorly. And then there was a point where they needed the feeding tube because they just not getting any nutrition at all, which looking through all the studies, in the certificate and in the Academy as well there’s quite a lot of evidence out there that that early intervention even if it’s just a little bit of nutrition versus them not eating or just getting them to eat a bit more than they were doing. It’s been shown in some of the studies that it does make a big difference in their recovery and making them feel better.

I showed… when me and Kim did the presentation initially, I did link a few studies as well just to try and back up what I was saying rather than it being me just having like an opinion, tried to back it up with some actual science. then we’ve had a speaker in which I was really excited about. She came in just a few weeks ago and demonstrated how to place nasoesophageal tubes, which again is something that the nurses can do as well. It doesn’t have to just be vets doing it. So I’m really hoping now we’ve got that extra person. She was a nurse from a referral centre and really knew what she was talking about, they placed them all the time there. I’m really hoping that will inspire the team to keep pushing for them and keep getting a few more tubes placed.

Lou Northway

And that’s amazing, isn’t it? Really amazing to hear that you’ve increased your team’s confidence and their ability to place tubes in patients that may need it earlier on perhaps than maybe what happened in the past. So that’s amazing to hear. So, nutrition has been the focus up until now. Are there any other sort of audits in the pipeline or underway that you’d like to tell us about?

Amy Wells

With us being such a big team, there is quite a lot of auditing going on with other members of the team. So I’m trying to think of some that they’ve done recently. Perioperative temperatures, so coming in and out of theatre, that’s quite a big focus that we don’t let the temperatures drop while we’ve got them through there.

We also look at getting our antibiotic usage down. I’d really like; we’re talking at the moment about doing some pain scoring auditing. So, anything to do with comfort of our inpatients. It’s an area that I particularly love looking into. And then I’d say we do quite a lot of nurse utilization as well. The lead nurses, they’ve been looking into nurse consults and nurse procedures as well. So, seeing how many stage one dental’s we’re doing as nurses versus the vets and trying to get our delegation up as high as we can.

Lou Northway

Brilliant, sounds amazing. I want to come and hang out for a week, I think. Well, it’s been really lovely speaking to you, Amy, and the work that you and your team have achieved is really fantastic. And I’m sure those listening will feel really inspired and empowered. And if you are listening right now, Amy’s case report is going to be available on the RCVS Knowledge website. So you can see step by step the steps they took to undertake their audit and all of their outcomes in their lovely glory. So thank you so much Amy and I hope to speak to you again in the future when you are hopefully going to become a Knowledge Award winner again for another audit.

Amy Wells

Thank you very much, it’s been lovely to talk to you.

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