Results in a SNAP

A MUST for effective compliance monitoring?

Emily Walters, Chief Dietitian

A brief history...

Launch of policy for Malnutrition in Adults (2006)

– Information on intranet– Hard copies of MUST paperwork for wards– Senior nurse briefings – Ward-based teaching– Nutrition Link Nurse training days– MUST score for inpatient referrals to Dietitian

Audit 2007 Southampton General Hospital

• Most nurses felt that “MUST” was important• Three quarters believed that ‘all or most’ patients on their ward were routinely screened

BUT…– 14 % screened within 24 hours of admission– 31 % screened within 7 days– 81 % of patients at risk of malnutrition had been missed

Steps to support change included...• Trust prioritisation of nutrition

- nutrition is 1 of 7 key patient safety areas

• External interest e.g. CQC

• A Trust champion with power to change practice e.g. Associate Director of Nursing

• Individuals required to take ownership and responsibility e.g. Matrons, Ward Managers

• Links with other initiatives e.g. infection control team, catering red trays

Compliance remained variable – why?

• Competing pressures• No central reporting or consequences of non-

compliance unlike other areas e.g. hand hygiene

• A need for formal monitoring within the Trust if the policy is to compete with other agendas?

• MUST within 24 hours admission and evidence of care plans for ‘at risk’ patients became a KPI with central monitoring

Monitoring compliance

• How to monitor compliance?– Large organisation - time consuming to audit– Small ‘snapshot’ audits across the trust did not

provide trustwide assurance – The ‘hawthorne effect’ was experienced with

planned audits

• How were others monitoring compliance?

Introducing SNAP!

Developing the audit using SNAP• SNAP software was used to create an

online audit questionnaire and reporting system

• Who was involved?– Associate Director Nursing– Clinical Effectiveness Manager– Chief Dietitian

• What did we need to know?• What would be useful to know?

SNAP audit questions• Baseline data – month, area auditing, auditor• MUST within 24 hours admission?• MUST category?• MUST score correct?• Nutrition care plan for those ‘at risk’?• Repeat score?

Monthly Inpatient MUST Audit 2011 TARGET: ANTS TO AUDIT AT LEAST 10 SETS OF NOTES (Including KARDEX) PER WARD EACH MONTH

- sample from 2 bays (results will be reported at ward level via the dashboard) - TO BE INPUTTED BY 28TH OF EVERY MONTH

Q1 Auditor's name: Q2 Month of the year audited: January 2011 May 2011 September 2011 January 2012 February 2011 June 2011 October 2011 February 2012 March 2011 July 2011 November 2011 March 2012 April 2011 August 2011 December 2011 Q3 Patient's hospital number Q4 Current Ward: AMU C Neuro E3 F5 GICU A Bramshaw D Neuro E4 F6 Emerg

Admit GICU B

Clinical Decisions U D2 E5 Colorectal F7 C5 Isolation

Ward CCU D3 E7 Urology F8 Stroke Unit MHDU CHDU D4 E8 F9 closed NICU CICU D5 Eye Unit G5 SHDU CSSU D6 F1 G6 Stanley

Graveson C4 D7 F2 G7 Respiratory

centre C6 D8 F3 G8 C7 E2 F4 G9

SNAP audit process• Each ward submits a monthly audit of 10

patients• Data entered by nursing staff directly into the on-

line questionnaire– minimising data transfer work – reducing errors

• A monthly summary report provides compliance data at both ward and trust level.

• Validation of results is possible as patient hospital numbers are included in the audit data.

Did wards participate?

0 100 200 300 400 500

Number patients

2009

2010

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Number patients audited for compliance with malnutrition risk policy

Example of data report

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

AMU (131)Bramshaw (10)

Clinical Decisions U (-)CCU (16)

CHDU (10)CICU (1)

CSSU (11)C4 (-)

C6 (10)C7 (3)

C Neuro (6)D Neuro (14)

D2 (11)D3 (8)D4 (5)D5 (-)D6 (-)D7 (-)

D8 (3)E2 (-)

E3 (11)E4 (1)

E5 Colorectal (6)E7 Urology (4)

E8 (-)Eye Unit (4)

F1 (-)F2 (9)F3 (9)

F4 (10)F5 (5)

F6 Emerg Admit (24)F7 (1)

F8 Stroke unit (1)F9 closed (-)

G5 (1)G6 (-)G7 (-)G8 (-)G9 (-)

GICU A (4)GICU B (1)

IC5 Isolation Ward (7)MHDU (5)

NICU (8)SHDU (3)

Stanley Grav eson (7)Respiratory centre (2)

C3 (2)

89% 11%100%

100%100%100%

100%100%

100%

100%100%100%

100%

100%

100%

100%

100%100%100%100%

92% 8%100%

25% 75%100%100%100%100%100%

86% 14%50% 50%

100%

100%

100%100%100%

93% 1%100%

Yes No

MUST score documented within 24 hours of first admission? by Ward or department that originally admitted the patient to hospital

Did a KPI & monthly trustwide auditing make

a difference to policy compliance?

2011 Trust wide MUST nutrition screening % compliance, all wards

81%79%

83%

90%88% 87%

89%86%

90% 92% 91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

YesNoTarget

Improved use of nutrition care plans for ‘at risk’ patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Month of the year audited

2947%

1227%

1433%

924%

2036%

917%

1730%

1725%

1628%

1020%

23%

No

3353%

3273%

2967%

2976%

3664%

4583%

4070%

5275%

4272%

4180%

6397%

Yes

Q13 X Q2 Nutrition plan in place for medium and high risk patients

Repeat screening improved from 83% to 89% (Feb–Dec 2011)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Month of the year audited

3217% 26

15%

2217%

3221%

85%

116%

2012%

2415%

1912%

117%

1611%

No

15583%

15185% 111

83%

11879%

14195%

17394%

15388%

13185%

13688%

14993%

12689%

Yes

Q14 X Q2 Repeat screening for for patients in hospital for longer than 7 days

What other information?

Divisional data example

Div A Div B Div C Div D Total Number audited with MUST within 24 hours

48 163 10 119 340

Number with category 47 161 10 118 336 % with category 98% 99% 100% 99% 99%

MUST score components

Percentage with score

Number patients with score

BMI score correct 97% 355/365 patients

Weight loss score 90% 328/365 patients

Acute disease score 93% 341/365patients

Data analysis to identify trends• Acute medical unit (AMU) admitted approximately 30% of all cases in the audit.• Other wards contributed a maximum of 3% each of the overall admissions.

2011 Trust wide MUST nutrition screening % compliance, all wards

81%79%

83%

90%88% 87%

89%86%

90% 92% 91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

YesNoTarget

2011 Trust wide MUST nutrition screening % compliance, all wards (excluding N/A and ourlier: AMU)

85% 85%88%

93% 91% 89%93% 92%

95% 97%94%

0%

20%

40%

60%

80%

100%

120%

Yes (%)NoTarget

Compliance on AMU increased from 73% to 82%

(Feb – Dec 2011)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Month of the year audited

3427%

3636%

2630%

1720%

2119%

2220% 22

18%

2627%

2721% 19

19% 2017%

No

9173%

6464%

6270%

6980%

8781%

8980%

9982%

7273%

9979%

7981%

9983%

Yes

Line Chart showing AMU's trend for documenting MUST scores within the first 24 hours of admission to hospital(based on ward patient was first admitted to - excluding N/A cases)

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Trustwide Trust excluding AMU AMU

Percentage of patients with a documented MUST score within 24 hours admission

Feb-11

Mar-12

Impact of SNAP audit on MUST score within 24 hours admission

• 13% improvement Trust wide• 81% Feb 2011 to 94% March 2012

• 12% increase Trust wide without AMU• 85% Feb 2011 to 97% March 2012

• 16% increase on AMU • 73% Feb 2011 to 89% March 2012

Summary of key findings• A ‘trustwide’ approach needed• Key leaders identified and available for support• KPI set with central monitoring

• SNAP made monthly trustwide audits possible• SNAP provides data for clinical quality dashboard • SNAP e-results viewer (free to all areas) enables

everyone to see results at their desk top• SNAP data helps identify training needs

Identification and treatment of malnutrition risk has improved as a result of using SNAP