Case Study – May 2017
Nottingham University Hospitals – Think Drink Project
About the Project
Think Drink initiative was established in 2015 at NUH. The cause and extent of the problem
was identified through audit data of fasting times for patients waiting for surgery and valuable Patient Public Involvement feedback from patients about their experiences. The audit data indicated excessive fasting times for patients across the trust, an average of nine hours; this coupled with some negative feedback from patient, saying they were very thirsty and kept without fluid for long periods prior to their surgery. The overall aim of the initiative is to minimising fasting times for patients across the trust thus improving patient outcomes and experience, reducing dehydration and morbidity.
Think Drink is a very special project, it is not a difficult concept it is about a change in culture that has been longstanding across not only Nottingham University Hospitals but lots of hospitals across the NHS. Such a simple idea has had such a positive and wide spread impact on improving our patients’ experience; the project has encompassed all wards and departments and really is Trust Wide. Changing the longstanding culture of ‘nil by mouth from midnight’ has had minimal cost implications for us as a Trust and makes such an immense difference to our patients experience and outcomes.
In terms of contributing to the project’s success, it would not have been made possible without increasing awareness of the benefits of shorter periods of fasting to both staff and patients. Improving communication between theatres and ward staff with the development of specific guidelines and algorithms to simplify the process of fasting.
The project is a simple but innovative project which aims to minimise fasting times for our patients to improve patient experience and outcomes. Complications of excessive fasting are a patient safety issue; minimising fasting times reduces dehydration, hypoglycaemia and potentially reduces the incidence of electrolyte imbalance and acute kidney injury.
Implementation has been made possible by the inclusivity of all staff, students and patients through education and training. This has been achieved by developing and adopting specific eating and drinking guidelines and an approved drinks list and incorporating ‘Think Drink’ moments in theatre briefings in order to enhance decision making and communication.
Education and training of staff, students and patients has been undertaken across the whole of the organisation by credible and enthusiastic champions to promote engagement. The success has been measured by improved feedback and audit data; fasting times have reduced from 9 hrs to 3.5 hrs.
More importantly for sustainability, there appears to have been a cultural shift. Wards are more aware of prolonged fasting, and theatres are more comfortable with shorter periods of fasting.
Other organisations across the NHS have shown interest in the project, challenging long held perceptions is not easy and requires persistence and credible champions.
How Did We Achieve It?
A Project Group was formed which was made up of various members of the multi-disciplinary team including nurses, dieticians, anaesthetists who analysed the feedback from patients and the audit data which was then disseminated to theatre and ward staff at team meetings along with an action plan. The reasons for excessive fasting were explored from both process (theatre list planning, clarity of information given to patients), cultural (the ritual of ‘nil by mouth from midnight’) and educational (what are the recommended fasting times) paradigms.
Innovative solutions were generated by on the ground staff aiming to improve both patient outcomes and experience. The interventions targeted staff and patient understanding of the rationale for limited fasting, and ways to facilitate safe fasting times within changing theatre schedules. Small scale rapid pilots were used to refine the guidelines before wider roll out.
Theatre briefings now include a ‘Think Drink’ moment where a named member of the team clarifies with the anaesthetist and surgeon which patients can drink and until what time, based on the expected duration of cases. This is done for all patients on the theatre list and repeated during the day, this is communicated to the ward and admission areas. Ward and admission areas are then able to offer patients drinks up to two hours prior to their procedure. Patients are able to choose from a specially formulated drinks list to further improve their experience this includes: tea and coffee with no more than one fifth of skimmed, semi or soya milk, dilute squash, still energy drinks or drinks part of the enhanced recovery after surgery. The project guidelines incorporate adult and paediatric patients and include elective and emergency patients.
In terms of delivering and embedding the project, a Project Lead was employed to work closely with theatre and ward areas throughout the hospital, disseminating the guidelines and providing education and training to all staff and patients in order to promote understanding and engagement.
What Have We Achieved?
The Projects efficacy has been measured by improved patient feedback; this has been collated in a number of ways. One of the ways in which this has been collated is in the form of PPI feedback, the feedback received thus far has been exceptionally positive. Another measure used to assess the impact of the project is audit data of fasting times for patients across the Trust. This has reduced from 9 hours to just 3.5 hours which is a huge improvement especially given the size of NUH and the enormous culture change required.
We continue to gather feedback and have seen a reduction in negative comments regarding excessive waits; however on-going comments have enabled us to focus on continuous improvement. As a Trust we have made huge inroads in changing the culture and ritualistic practice of ‘nil by mouth from midnight’. This has only been made possible by improving knowledge and communication and cohesion between staff and different specialities.
Moving forwards in order to sustain the fantastic success of the project, we aim to continue to carry out regular teaching sessions for staff by developing a video; this can be shown to students and staff at Trust induction days and mandatory training.
With the implementation of specific eating and drinking guidelines, think drink moments and algorithms we have made a sustained change in culture. New staff coming into the Trust perhaps unaware of the Project and guidelines will see it being championed and learn from the example set by other staff.
Nutrition link professionals continue to champion the project in individual ward areas. Furthermore, patient information will be made available on the intranet to reinforce the importance of remaining hydrated prior to surgery, not only in terms of patient experience but examining and explaining some of the complications which are attributable to dehydration and pre-operative fasting.
The initiative is extremely relevant to other trusts in the Country, the project has enabled us to greatly increase patient experience whilst at the same time improve patient outcomes. Using the most up to date evidence for fasting showing that long periods of fasting are no longer beneficial and that shorter period of fasting have better outcomes for patients. NUH have recently been shortlisted for a Nursing Times Award for the Project and the Project has received positive recognition in NUH’s recent CQC report.
- Challenging the long-held dogma (‘nil by mouth from midnight’) is not easy and requires persistence and credible champions.
- When there are competing pressures (reducing starvation versus perceived risk of list delays/cancellations) these need to be discussed openly.
- Focussing the project on the patient rather than the process allows staff to speak up as the patients’ advocate.
- Small things, such as clarifying what fluids are allowed until what time can make a huge difference to our patients.
Beads of Courage: Making a Difference for Each Child
The Beads of Courage programme was introduced to the UK, from America, through the paediatric oncology units. The beads are a concrete visual representation of each intervention a child has undergone during their treatment, helping them talk about their condition, fears and hopes. As a Community Children’s Nursing team, the children and young people (CYP) we support with cancer started to receive the beads supplied to us by the Regional centre.
Mags Hirst, our play specialist, recognised the benefits of this scheme and was passionate about extending it locally to the many children we care for complex and life-limiting illnesses, but who do not have cancer. As the beads are not funded by the NHS, as a team we identified funding streams to ensure sustainability and to ensure local CYP could continue to benefit from these. The Beads provide them with a unique approach to personalising care by working in partnership with CYP and their families, enabling them to understand and talk about the impact of their condition and treatment on their daily lives.
The beads and the story they tell are unique to each child, their siblings and their families. The beads build a picture and a memory for each family that they can keep and reflect on. It gives credibility to their journey in a concrete and understandable way that can be used to explain to a child, when they are older, what had happened to them, or as memory for the family if their child is no longer with them.
We were the first team in the UK to introduce the beads for children and young people with a non- oncology diagnosis, and the celebration annually of the children and their beads is a spectacular, happy, exciting event. With the positive attitude and leadership demonstrated by Mags, a willingness to identify unique elements of each child’s journey, and our ability to share a joint, team vision, keeping children and families at the centre of what we all do, we have been able to work together to truly benefit children. These benefits are achieved at the most challenging time in a family’s life and through the most painful journeys they will ever have to face, providing a platform for them to express their own, unique stories and paths
As a service we aim to provide individualised, compassionate care and believe that the Beads of Courage, in a small way, can give credibility to the child and their family of the challenges they face on an almost daily basis for, what is often, a lifetime.
The Beads of Courage embrace and celebrate each child’s unique experience and personal journey with regards to their complex or life limiting condition.
The beads are a physical reminder of each child’s personal story; their treatments, every hospital attendance, every visit by a community nurse, every intervention they have to have, and gives CYP the opportunity to build a visual representation of their personal journey, supporting their emotional, social and spiritual needs. The beads also provide a way to open and improve dialogue not only within families but with those around them, such as friends at school and other professionals who may not have the broad understanding of the challenges and achievements each CYP has on their journey
We also provide beads for siblings. These recognise the challenges siblings face with having a brother or sister who is unwell and who is often away from home. They also provide a way to celebrate and acknowledge the support siblings provide as carers and recognise the impact having a child with a life-limiting illness in the family can have on siblings, for example when parents are away from home with the poorly child or miss family and school activities.
Mags Hirst provided the leadership for introducing this innovation for children with life-limiting illnesses. She contacted the programme lead, and explored the use of the beads in a wider context. We were informed that the licence was available for CYP with life-limiting, non-oncological conditions and complex health issues. We then sourced initial funding and became the 1st team in the UK to provide the beads outside the oncology world.
We identified a pilot group of CYP already known to the team, and in partnership with the children and their parents, discussed if this was an innovation they would welcome. The feedback was incredibly positive with universal agreement that this was something to be rolled out and which would benefit their child, as well as the wider family and friends.
Our pilot consisted of 8 CYP and we provided families with ‘Bead diaries’ to help us understand and evaluate the benefits of the beads in terms of family memories and recall, as well as the costs involved in providing the beads retrospectively to the point of diagnosis. Without exception, each family enrolled on to the pilot programme was able to comprehensively complete their child’s diary, one family being able to recall 9 years of complex care.
Through our initial investment, Mags was able to purchase the beads required to commence the pilot and complete these CYP bead collections. Each family has reported back the positive benefits and the therapeutic value of threading the beads alongside their children. The therapeutic value reported included enabling families to remember and talk together about the detail of the treatments received, including the pain experienced and courage shown by the children and the great pride parents had in their child’s ability to face these challenges.
Our electronic records incorporate a care plan which highlights the beads programme as an intervention in itself, so that we can ensure all children and their siblings, who are eligible for the beads, are considered for the programme and the beads offered
The positive impact of the beads cannot be emphasised enough. Children and young people now have a voice that they may not have had previously. They are able to discuss and articulate their own, individual, stories in words and language they understand. The children, and their families, are able to take their unique combination of beads to hospital and clinic appointments and express what has happened to them since they were previously seen.
The impact on professionals has been astounding, most have never contextualised what it means to be a child or young person with a complex or life limiting condition. To see the beads, threaded together, is a very humbling experience for both clinicians and non-clinicians and is a reminder of why we all work in the roles we do and that all of us are working together to ensure positive experiences of health care for our patients or client group
We wanted to give the CYP a voice, a way of talking through their experiences, fears and successes. We have evidence of a young girl who was selectively mute, as a result of her fears and worries due to her ill health. Using her beads as a platform to speak, she was able to explain to people what scared her and what she has endured and earlier this year she was supported by Mags to stand up in school assembly and talk about her journey
We are measuring the beads in terms of cost and report 1/4ly on this to our financial team and donors, to ensure effective and appropriate use and ongoing sustainability of the beads
The greatest measurement we have is qualitative from the feedback and engagement from the children and their families both in terms of engagement with the initiative, a positive expectation that the children will receive their beads from the nurses who visit them, the accumulation of retrospective beads for interventions by professionals outside of the team and increasing attendance at our annual tea party for children and families where we celebrate the immense courage and bravery the show each day.
Key Learning Points
- Be open and honest when discussing the purpose of the beads with families and children before they start on the initiative
- The reflection needed can be painful for families and this needs to be supported
- The ongoing funding needs to be considered as this needs to be sustainable, families and children will discuss and compare, so there needs to be equal access
- Storage….you will needs lots of storage!