Continuous Quality Improvement (CQI) Project

St. Francis Hospital, Hartford, CT

Identification of problem and study rationale:

Oral nutrition supplements are commonly provided to hospital patients to

optimize their nutritional intake during their stay. A study funded by Abbott Nutrition
in 2010 found that providing oral supplements to patients during hospital stays lead
to significant reductions in length of hospital stay, and 30-day readmission risk was
significantly decreased as well (News Media). Oral supplements may be ordered for
a variety of reasons, some being: general inadequate oral intake, increased nutrient
needs for wounds or pressure injuries, burn patients, oncology patients, or for
patients with swallowing difficulties or dysphagia. In all cases, oral nutrition
supplements are a resource to help patients meet their estimated nutrition needs.

This continuous quality improvement project focuses identifying whether or

not nutritional supplements are being appropriately ordered for patients. Each
nutritional supplement has its own specific function, and is meant to be consumed
by patients who will benefit from that supplements particular nutrient composition.
The goal of this project is to discover if supplements at St. Francis are being ordered
appropriately for patients who will benefit from the supplements specific usage.
The supplements being examined are Ensure Compact (4oz., 220 calories, 9 grams
protein per serving), Ensure Pudding (4oz., 170 calories, 4 grams protein per
serving) and Juven (1 packet, 80 calories, 14g AA). All supplements are ordered for
patients through EPIC charting system, and appear in that patients current diet
order. Through EPIC, users are able to view any patients diet order at any time.
Users are also able to look further into the chart to see the indication for ordering
that supplement, the patients current and past medical histories, and any further
patient information that may be related to the diet order. This system was used as a
tool during this CQI project to assess which patients were receiving these
supplements, and to find out if the order for the supplement was appropriate for the
specific patient.

Measurable Indicators:

These measurable indicators were provided by the St. Francis Clinical

Dietetics Manager (Amy Cote) and are agreed upon by Sodexo and all St. Francis
dietetics staff.

Supplement: Appropriate Usage:

Ensure Compact Low volume patients
Ensure Pudding Dysphagia/swallowing difficulty
patients
 Juven Wound healing patients

Ensure Compact would be chosen in comparison to other Ensure products

due to its low volume and nutrient dense composition. A diet order for Ensure
Compact was considered appropriate if the patient could not tolerate the full 8 oz.
Ensure due to age, multiple active hospital problems inhibiting ability to consume
typical volume, very poor appetite and oral intake, and/or patient refusal to
consume the 8 oz. version. Its also important to note that Ensure Compact
Chocolate is nectar thick at room temperature, and could therefore be used for
patients on nectar thick consistency diets (Ensure Compact).

Ensure pudding would be chosen over regular pudding as a nutritious

alternative to other sweets or snacks for patients with swallowing/chewing difficulty
or dysphagia. These patients would be on a consistency-modified diet such as soft,
pureed or full liquid (Ensure Pudding).

Juven has been clinically shown to support tissue building if used over the
course of two weeks, and lean body mass building if used over the course of four
weeks. This supplement comes in powder form in a packet and can be mixed into a
drink or provided via tube feed. The supplement contains glutamine and arginine to
support blood flow, collagen production and nitrogen metabolism. Therefore, this
supplement is ideal for wound patients (Juven).

Data Collection:

Each day for two weeks during my rotation, when I arrived and before leaving
for the day, I reviewed each patients diet order in Epic records. If a diet order was
shown to include one or more of the three oral nutrition supplements being
examined I would review the patients full chart including past medical history,
current hospital problems, diagnosis, previous diet orders, and current percentage
of oral intake. I would also look into speech language pathology notes, MD notes
and previous dietitian notes. From this information I could see what issues were
preventing the patient from meeting their estimated nutrition needs, current intake,
and why the MD or RD believed this particular supplement was appropriate for this
patient. I would then compare this to the standards for each supplement to
determine whether or not they were ordered appropriately. For example, if a patient
received Ensure Compact but did not have any volume issues and was not on a
nectar thick diet, then I would mark that as an inappropriate order for the patient,
because they could have tolerated the full Ensure Enlive (350 calories, 20 grams
protein), which provides more protein and calories than the Compact, and is more
beneficial if the patient is able to tolerate 8 oz. If the patient was elderly, had very
poor oral intake, and was refusing to drink full 8 oz. supplements, then Ensure
Compact would be marked as appropriate. Using this technique, I reviewed Epic
charts daily and recorded my findings in an excel document using patients initials
to keep track of those already accounted for. Initials were recorded under the
specific supplement, and a C or I was marked for incorrect or correct. At the end of
my study, I added up the number of Cs and Is for each supplement and related the
cells on the excel document to provide the percentage of correctly and incorrectly
ordered supplement.

Data Analysis:

Please see attached excel document for collected data and data analysis. For
each of the three supplements examined, the first column contains the initials of
the patients receiving that supplement at some point during the 2-week data
collection period. The second column for each supplement shows whether the
supplement was correctly or incorrectly (C or I) indicated for that patient. The next
column gives the rationale for the indication based on the standards for that
supplement. The boxes directly underneath the data collected for each supplement
shows the total number of correct supplements, incorrect supplements and total
supplements ordered. For example, column D24 shows the amount of Ensure
Compact that was ordered correctly for patients, D25 shows the amount of Ensure
Compact incorrectly ordered, and D26 shows the total number of that supplement
ordered. Columns B34 and D34 relate these numbers to show the percentage of
correctly and incorrectly ordered Ensure Compact. The same format was followed
for the data collection of Ensure Pudding (columns G-J ) and Juven (columns K-N),
with final percentages listed in B35 and D35, and B36 and D36 respectively. Column
D38 shows the total number of patients used for data collection. Column D39 shows
the total number of patients correctly ordered nutritional supplement, with
percentage correct in column E39. Column D40 shows the total number of patients
with supplement incorrectly ordered, and percentage incorrect in column E40.

Figure 1: Depiction of percentages of correctly and incorrectly ordered nutritional

supplements over 2-week data collection period
Percentages of Correctly and Incorrectly Ordered Ensure Compact, Ensure Pudding and Juven
120%

100%

80%

60%

40%

20%

0%
Ensure Compact Ensure Pudding Juven

Correct Incorrect

Figure 2: Depiction of total nutritional supplements correctly and incorrectly

ordered during 2-week data collection period
 Total Correct vs. Incorrect Nutritional Supplement Ordered

Correct Incorrect

As shown in Figure 1, and on the excel document, 55% of Ensure Compact

was ordered correctly, and 45% of Ensure Compact was incorrectly ordered during
the 2-week data collection period. Thirty-three percent of Ensure pudding was
ordered correctly, and 67% was ordered incorrectly. Lastly, Figure 1 shows that
100% of Juven was ordered correctly, and 0% was ordered incorrectly.

Figure 2 shows that in total, more than half of all 3 nutritional supplements
examined were ordered correctly during the data collection period (59.26%), and
the remaining 41% were ordered incorrectly.

Discussion:

The results show that out of the 3 nutritional supplements examined, Juven
was the only one that was correctly ordered 100% of the time. Each patient that
received Juven had wounds, which fits the standard for that nutritional supplement.
However, over the 2-week data collection period, only 4 patients were ordered
Juven. This could be a limiting factor to these results since the dataset was so small.
To further investigate whether Juven is correctly ordered at St. Francis, this study
should be continued for several months to a year to increase the sample size and
gather more data.

The results also showed that Ensure Pudding was ordered incorrectly at a
higher percentage than the other 2 nutritional supplements (incorrectly ordered
67% of the time). Two of the patients that were ordered Ensure Pudding did not
have dysphagia, chewing or swallowing difficulty, and were not on a modified
consistency diet, therefore, ordering this nutritional supplement for these patients
was not justified based on the standard. Only 1 of the patients was correctly ordered
Ensure Pudding, as they were on a pureed, national dysphagia diet 1. However,
similar to Juven, the sample size for Ensure Pudding was very small, with only 3
patients ordered this nutritional supplement during the 2-week data collection
period. Again, the data for this supplement should be collected for several months
to a year in order to have a larger sample size and increase the accuracy of the
data.

Additionally, the results showed that Ensure Compact was ordered correctly
more than half of the time. However, it was still ordered incorrectly 45% of the time
during the data collection period. Ensure Compact had the largest sample size, with
20 different patients ordered this nutritional supplement during the 2-week period,
11 correctly ordered and 9 incorrectly ordered. Although this had the largest sample
size, I would still recommend continuing data collection for this nutritional
supplement to increase accuracy of the data.

Overall, out of the 3 nutritional supplements examined, more than half were
correctly ordered, but 41% were incorrectly ordered. This data suggests that, aside
from Juven, the other 2 nutritional supplements were ordered incorrectly a
significant amount the time during this 2-week data collection period. Ideally,
nutritional supplements should be correctly ordered 100% of the time based on the
standards for each supplement. However, Ensure Pudding was ordered correctly less
than half of the time, and Ensure Compact was ordered correctly just slightly more
than half of the time. The data suggests that an intervention is needed to increase
accuracy of ordering nutritional supplements.

Suggested Interventions:

There could be a few different reasons contributing to the inaccuracy of

nutritional supplement ordering. For example, it could be human error the ordering
form on Epic lists Ensure Compact as the first Ensure option to choose, because it is
in alphabetical order. Ensure Enlive used to be the first Ensure option listed, but
once Ensure Compact was added to the list, this order changed. This may be
causing accidental ordering of this nutritional supplement as a result of human
error. People may think they have ordered Ensure Enlive when they actually clicked
Compact instead. Some of the charts I viewed showed that dietitians had
recommended that patients receive Ensure Enlive, but then were actually ordered
Compact. This leads me to believe it was human error in these cases. An
intervention would be to either change the order so that Ensure Enlive is listed as
first, then Ensure Compact, or Ensure Compact could be written in bold to further
emphasis the difference between the supplements.

Another cause for error couldve been a lack of education about the
nutritional supplements. The dietitians are well-educated about the nutritional
supplements available, but other hospital staff are not. Many of the patients that
were incorrectly ordered supplements were those that had not been seen by a
dietitian yet, and the supplements were ordered by the nurse or doctor. Some of
these employees may not have fully understood the standards of usage for Ensure
Compact or Ensure Pudding, and therefore ordered them incorrectly. An intervention
would be to complete education sessions with the hospital staff to inform them of
the nutritional supplements available, what their uses are, when they should be
ordered, and where they are on the supplement ordering form. For example, staff
should be taught that Ensure Pudding is used for dysphagia patients and modified
consistency diets. Also, the hospital staff may not have known that Ensure Compact
is only 4 oz. with less calories and protein than Ensure Enlive. They could be
educated on this, and on the ordering form it could clearly state 4 oz. next to
Compact so that other employees will be reminded of the difference between the
supplements.

One last intervention could be having a form on the Epic system that lists
each supplement and the standard for usage so each employee can be reminded
before ordering it. This would be most helpful if it popped up on the nutritional
supplement ordering form as an employee was about to order the supplement. This
way, they could see all of the supplements, what theyre used for, and could double
check if the supplement theyre ordering is appropriate for the patient.

With these interventions, it would be possible for supplements to be ordered

more accurately, and would help patients get the proper nutrition during their stay
at St. Francis Hospital!

References:

Ensure Compact | Abbotts nutrition business. (2017). Nutrition.abbott. Retrieved 21

March 2017, from https://nutrition.abbott/uk/product/ensure-compact

Ensure Enlive Advanced Therapeutic Nutrition Shake. (2017).

Abbottnutrition.com. Retrieved 21 March 2017, from
https://abbottnutrition.com/ensure-enlive-advanced-therapeutic-nutrition-
shake

Ensure Pudding | Abbott Nutrition. (2017). Nutrition.abbott. Retrieved 21 March

2017, from https://nutrition.abbott/au/product/ensure-pudding

Juven(R) for a Faster Recovery from Surgery | Abbott. (2017). Abbottnutrition.com.

Retrieved 21 March 2017, from https://abbottnutrition.com/juven

News Media | Abbott U.S. | Benefits of Nutrition Intervention. (2017). Abbott.com.

Retrieved 21 March 2017, from
http://www.abbott.com/newsroom/news/benefits-nutrition-intervention.html