A rather shameful and disturbing issue was raised again this week by the good people at the charity AgeUK about malnutrition in UK hospital, a problem that is more prevalent in older patients. Their report 'Still Hungry to be Heard' struck a chord with me for two reasons, firstly I spent many years working on a hospital ward where the majority of the patients were in the latter stages of dementia and organic mental illness, where I was struck at the number of issues that occurred during meal times, and secondly, when I had my stroke in 2009 I was hospitalised in a specialist stroke unit where the majority of patients were in their later years.
AgeUK tell us 185,446 of us left UK hospitals in 2008/2009 malnourished, in 2007 239 patients died due to malnutrition in 2007 (although more are suspected) and those aged 0ver 80 years of age are statistically more likely to become malnourished.
My experience of working on a hospital ward relevant for this age group pre-dates these statistics by some 10 years, however I had some major concerns at that time about suitable diets, volume of food consumption and the recording of food and fluid intake of the patients on the ward which I continually raised with my superiors, but as I was merely a young health care assistant at that time, my concerns mainly fell on deaf ears.
The meals that arrived were not chosen by the patients as their conditions meant that in most cases they were unable to exercise choice so a member of staff would contact the kitchen via the telephone and a trolley of enough food would be sent up to the ward to be distributed among the patients. Most of the contents were chosen by the staff and would be soft or puréed options, so we didn't actually know if the patients liked the food we were trying to give to them.
Not a huge amount of attention was given to nutritional values of the food the patients were given, the quantity or the provision for special diets.
As many as eight patients would require varying degrees of assistance to eat their meal with usually two members of staff available to provide that assistance, a number that didn't add up to an efficient and fulfilling meal time as the emphasis was very much on time, hence mealtimes were almost like a conveyor belt or patients appearing in front of the stressed staff member trying to feed them as quickly as possible.
There was also the contributory factor of the patients actual illness making meal times difficult, where some people would eat and forget they had, others had thought they had eaten but hadn't, some conditions would create an obsession with food to the extent that once they had eaten their meal they would wander around the other patients grabbing handfuls of their food. Others would refuse to eat as a protest at what was happening to them.
This made nutritional intake almost impossible and many of the patients on the ward would lose weight although this was extremely difficult to quantify as weighing patients with such advanced stages of dementia is extremely difficult as they often would become confused and distressed while you were trying to do so. As,many if not all of the patients would never be suitable to be discharged from hospital that became the norm.
Move onto 2009 when I was a hospital patient on a ward surrounded by older people and I could experience patient mealtimes from the other perspective and things didn't seem to have improved much, granted as I had relocated it was a different hospital to the one I had worked in and the ward I was admitted to had stroke survivors rather than patients with latter stage dementia but there are lots of parallels that maybe drawn with regard to assistance with food, puréed diets and the suitability of the food.
The only significant improvement I could detect was that a record was kept of what patients had eaten although the recording of quantity was a bit haphazard for instance 'ate half prtion of mash potato' when no mention was made of what a full portion would be, so the figures put forward by AgeUK are disappointing and shameful but to me, not surprising.
So what is the answer? Well AgeUK have proposed a seven step plan to help address this issue
Step 1 Hospital staff listening to patients, relatives and carers. We know what food we like or dislike, what food we can’t eat and whether we have small or large appetites. We need ward staff to ask us what our needs are at mealtimes and then act on what we say. If we, or our relatives and carers, are not consulted about our dietary needs we often end up with food that we simply cannot eat.
Step 2 All ward staff must become food aware. Missing a meal is just as important as a missed medication. Ward staff need to understand that every meal is important and it is not acceptable for us to miss even one meal. If we do it increases our chances of becoming malnourished.
Step 3 Hospital staff should follow their own professional codes and guidance from other bodies. The Department of Health’s core standards on food and help with eating state that we should get food suitable to our diet, as well as any help we require to enable us to eat our meals.
Step 4 We must be assessed for the first signs of malnourishment on admission and at regular stages during a hospital stay. Thirty per cent of us enter hospital already malnourished. It is essential hospitals detect any existing malnutrition, if they do not we will not get the help we need to get better. To detect whether or not we are malnourished, hospitals need to screen us all, upon arrival, for the signs of malnutrition.
Step 5 Hospitals should have 'protected mealtimes'. When we are eating our meals we do not want to be told that a doctor wants to talk to us or take a blood sample, or that we have to stop eating so we can go for a scan. We want the ward we are in to use protected mealtimes. This means that all non-urgent activity, such as ward rounds, tests etc., do not take place during mealtimes. This benefits us, as we get to eat our meals in peace, and the nurses benefit, as they have more time to help us at mealtimes.
Step 6 Hospitals should implement a 'red tray' system and ensure that it works in practice. Those of us who need help with eating should receive our food on a red tray (or some other colour) that allows ward staff to easily recognise that we need extra help at mealtimes.
Step 7 Hospitals should use trained volunteers where appropriate. Trained volunteers can provide us with the extra support we need at mealtimes, which could mean making sure our food is cut up and placed within our reach, or sitting with us so that we have company and
encouragement while we eat.
All of which are great ideas and I believe would work in assisting to reduce the number of cases of malnourishment in our hospitals, however I feel it needs to go a little further than that. The first step of feeding patients comes from the budget holders and the kitchen staff and the work needs to start long before the tray of food appears in front of a patient.
Also where there is the added component of wards with a high percentage of patients with dementia, I would ask that staff have nutritional training. I am aware that advice can be given by nutritionists on what should be eaten however this will in all likelihood bear no resemblance to the reality of a mealtime on such a ward. Members of staff with experience and the right training can help to ensure the right steps are taken to try and address this issue.
I will be watching carefully to see if any hospitals take up AgeUK's plan and what differences, if any, are made. I would also say that malnourishment in hospitals doesn't stop at older patients so if it has happened to you, no matter what your age, make your voice heard.