Author: Duncan Stevenson (Graphic Designer)

To improve the correct level of support
provided with feeding for patients
following stroke
Stacey Jones — Senior Occupational Therapist / Chief Nurse Fellow

1. Background
Project took place on the Acute Stroke Unit (32 beds) at Cheltenham General
Hospital, Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT). Project team consisted of Stroke Therapy staff and other members of the stroke
Multidisciplinary team (MDT).
Criteria for project was; patients who required support with feeding after stroke due to a physical, cognitive or visual impairment.
Concerns raised by the stroke therapy team was that not all patients were receiving the correct level of support for feeding. Were being over or under supported, or patients who required use of aids to be independent did not have access to them.
MDT questionnaire was completed using open and closed questions; to share
concerns, views on reasons why patients were not having correct support and
suggestions on how this could be changed.
MDT questionnaire results:
Concerns:
No formal training on how to support a person with feeding.
No formal feeding assessment.
Red plate and assistance/support signs do not provide adequate information.
Reasons why patients were not receiving the correct level of support:
Habitual
Time constraints
Staffing levels
Lack of knowledge on what support is required e.g. prompting, adaptive cutlery.
Poor awareness of how to promote independence, appreciation of deficits and use compensatory strategies.

2. Reviewing the Literature
Literature review concluded that it is common for patients to have difficulties with
feeding after stroke and that malnutrition is associated with poor clinical outcomes in hospital, increases length of stay and clinical complications. Supporting with feeding is essential to enable or maintain functional independence, improve quality of life,
psychological wellbeing and to aid nutritional intake.
3. Guidelines etc.
No guidelines for feeding after stroke from National Institute for Health and Care
Excellence (NICE, CG162) or Royal Collage of Physicians (RCP, 2016). GHNHSFT
has no policy or guidelines for supporting a person with feeding after stroke. No formal
therapy feeding assessment or competency for staff to assess a person in the activity
of feeding.
4. Method
A fishbone and diver diagram were completed to consider multiple ways to achieve the end goal, analyse the complex problem, look at causes and casual relationships
between drivers, view whole potential impact of change and stakeholder engagement.
PDSA cycles were completed for feeding assessment version 1 and 2, then used
version 3 as a pilot in QI project. Therapy Staff Competency written and agreed for staff to complete prior to using feeding assessment.
Referral criteria for feeding assessment; was any patient who had a cognitive, physical or visual impairment following stroke. Data was collect for 12 weeks, 6 weeks prior to implementation of feeding assessment and 6 weeks after. Run chart was used to
display data with median and percentage aim.
5. Results
Analysis of the data for the 12 weeks of the project found that the median for the 6 weeks prior to the assessment being implement was 53%, the median for the 6 weeks after as 45%. Week 9 and 10 were exceptionally low percentages (33% and 24%),
consequently this made the median percentage for the last 6 weeks lower than
expected. Discussion with the MDT has concluded that across GHNHSFT services are understaffed with nursing staff due to vacancies, sickness and staff requiring annual leave. There has also been changes to therapy staff in regards to vacancies, sickness and annual leave. Both of these factors have impacted on staff’s ability to support
patients correctly during meal times.

5. Results Continued
A process measure identified was equipment available on the stroke ward to enable
independence. Over the 12 weeks only 1.6% of patients required equipment to enable independence, however 0% received it. Equipment was available on the ward but was not provided by staff. Due to this patients were either over or under supported with feeding. Reviewing the data collected the most people record to require equipment to enable independence in one week was 2 patients. All of the other weeks was either 1 or 0 patients that required equipment.
6. Summary
Implementation of the therapy staff competency, feeding assessment and
recommendations have not significantly made changes to the percentage of patients receiving correct support for feeding: indicating that patients after stroke have a high dependency for feeding. Staffing levels contribute to patients having the correct level of support required for feeding.
Competency and feeding assessment will be continue to be used by Occupational Therapists in the stroke team. Benefits of using the feeding assessment was that
patients had their needs formally assessed with an in-depth analysis of function and deficits. This enhanced therapists clinical decision making for treatment plans, feeding techniques and meaningful goals.
Useful for staff and families to have guidance on supporting patients correctly to
maximise nutritional intake, psychological wellbeing and functional independence.

7. Future
Staff training on how to assist a person with feeding after stroke.
Ward purchasing adaptive aids.
Lunch group / social dining on wards.
Task analysis / Activity Breakdown Sheet.
8. Opportunities for improvement in other areas of the Trust.
Use feeding assessment and competency across the therapy service.
Nutrition and Hydration Champions.
Induction / formal training for all staff on how to appropriately support feeding for individuals with physical/cognitive/visual deficits.