Summer of Celebrations Part 1 by the SPSP Team

Reflections from Improvement Advisor, Paul Sammons

As an improvement advisor with no clinical background, I work closely with people who want to change things for the better, and who know their teams and roles well, but who don’t always have the skills to structure improvement work.  They may not have the capability to use the ‘model for improvement’ – a proven methodology that helps focus aims, identify change ideas and to measure what difference if any, a change actually makes.  Having completed the Scottish Improvement Leader programme (ScIL) in 2015/16 I do have that capability which, when brought together with practitioners who have a will and an urgency to change things for the better, can be very powerful.   I enjoy the privilege of working alongside, enabling, and learning from some fantastic individuals and teams who strive to improve services of their patients and service users.

Some of these moments will be with me forever – I recall working with Dr. Grecy Bell to motivate and enthuse a group of primary care staff about Medicines Reconciliation – not the most lively of topics, but Grecy created the ‘med rec fairy’ concept – a local champion in each GP practice who would carry the ‘wand’ to ensure their team saw med rec as a vital part of their work.

Another great memory for me was working alongside Dr. Mark Colwell – we teamed up to lead a local dental improvement collaborative, creating a structure around better decision making and treatment planning for patients on high risk medication.  Mark showed me how ceding power to his team enabled a flat hierarchy where all team members were able to critically observe each other’s practices, and contribute towards a more collaborative approach to patient care.   With the practices involved we improved much – starting even before patients arrived for their appointments – maximising the use of text messaging, moving through the patient’s journey. The work involved reception staff to engage with patients to obtain highest quality patient histories, and enabling dental nurses to observe and to prompt their bosses into even better patient conversations.

I have observed people in health and social care who once invigorated with a little QI magic, will stop at nothing to deliver better care, and who seem to have the energy to drive improvement forward in the most unlikely circumstances.  I spend time with Julia Hutchison in DG Smile dental practice, and I leave with a real spring in my step.  What is it about these people and all of the others that I get to support that is courageous, different and special?  I do reflect on a wee video that helps me answer that question.  You might like it too.  It is available on YouTube and can be viewed here.

I believe that attention to QI capability and capacity is key to improving services, and that we will see this develop through our local ever-expanding network of QI capable practitioners.  In the near future we will expand our practitioner level QI education and training – to ensure managers and leaders are well equipped to support, coach and supervise improvement projects.  In 2018/19 I plan to focus improvement efforts into the Women’s and Children’s teams as they settle into their new DGRI home.  I contribute to the improvement force field that is growing stronger across Dumfries and Galloway in health care and in social care.  I work as part of a small but wonderful team of hand-picked curious and quirky individuals – who quietly and tirelessly support each other, creating a synergy of support to our customers.  Perhaps you are close to that growing network of improvers – perhaps you feel the force like I do?  Well I do, and as I work with a widening spectrum of fabulous people I can honestly say that there is much joy in my work.  Long may it continue…

 

What Matters by Ken Donaldson & Alastair McAlpine

I recognise that it is a bit cheeky of me to put my name to this as I haven’t written any of it. A few months back I was scrolling through Twitter and came upon this thread that really moved me. The messages are simple yet immensely powerful. I have therefore simply taken some screenshots from Twitter and published them here. As you can see this is by a Doctor called Alastair McAlpine who is a Palliative Paediatrician in Cape Town, South Africa. Read on…..

Food is about so much more than just nutrition… by Claire Angus

Are you someone who craves the crunch of crisps? Enjoys a chicken and rice soup? A chocolate sundae where you delve through layers of whipped cream, ice-cream, chocolate brownie, chocolate pieces, and chocolate sauce?!

We could describe the foods above as containing lots of textures, or as having different consistencies… runny, crunchy, crispy, flaky, smooth, chewy, soft, thick, thin.

The consistency of your dinner is unlikely to be a high priority.. unless you’re a food critic or a chef! Most of us decide on food choices based on what sort of flavours we fancy, how ‘filling’ or for some folk ‘light’ a meal is. When we order in a restaurant, we often peruse the menu before picking a firm favourite dish, or maybe we pick something we know we could never make as well at home, or something expensive – if someone else is paying!!

For some people with ‘dysphagia’ (swallowing problems), choices about what to eat, and what they can safely eat, are more restricted.

The adult Speech and Language Therapy team work closely with many adults who have acquired ‘dysphagia’ as a result of a health condition i.e. stroke, brain injury. Our main roles are in assessment of an individual’s swallow (how strong is it? How quick is it?), giving handy hints and tips about how to make swallowing easier depending on the particular difficulty (sitting upright whilst eating, tucking chin to chest), and advising on how food and drinks can be modified so that they’re easier to manage (and prevent unpleasant coughing/choking, and pesky chest infections!!)

So that you look less like Theresa May coughing on water at this conference…

And more like this happy lady.. happy whilst eating her chips from the canteen…

We used to use ‘stages’ to describe the consistency of drinks, and ‘textures’ to describe the consistency of foods. As is often the case with healthcare which develops and evolves, there is to be change! This change comes in the form of introducing a new way to talk about food and drink consistencies. The plan is for these to be used internationally, as pretty colourful triangles and numbers can be understood in any language. Here’s a diagram of the new International Dysphagia Diet Standardisation Initiative (IDDSI) triangles.

Essentially, starting from the very bottom at level 0 is the ‘thinnest’ liquid available – think plain old water. As you work your way up the levels, the consistency gradually thickens – think of yoghurt drinks and smoothies. At level 3, there is an overlap where the consistency can be provided as a moderately thick drink, or a liquidised food (e.g. McDonald’s chocolate milkshake/custard) and as you work your way up to level 7, the food becomes more challenging – requiring more mouth control in biting, chewing with your teeth, mashing with your tongue, co-ordinating a mix of different textures (think of that chicken and rice soup/chocolate sundae I mentioned right at the start!) and controlling a strong timely swallow.

Our adult Speech and Language Therapy team embraced a food challenge to try and understand the new descriptor ‘levels’ and to experience what it might be like to be recommended a specific consistency ‘level’ and to prepare meals accordingly. It was much harder than we anticipated!

Here are some of our reflections:

Level 3 – Liquidised Food

Laura’s first stumbling block was when she realised she doesn’t own a blender! She therefore changed the task to see if she could buy a day’s worth of convenient food and drinks at level 3 consistency.

Whilst it’s maybe not as healthy as making a meal from scratch, and probably more expensive, she felt it was more realistic for people like her who prefer meals that are more easily prepared. She was required to think ‘out of the box’ – buying fruit and veg puree from the baby aisle, although she highlighted that this might feel slightly demeaning to an older adult. She reflected on the challenge, saying “If I had to have my food and drinks modified to this level on a long term basis then I don’t think I would manage with the hunger! I would probably ask for the support of a registered dietitian to offer suggestions on improving oral intake and maintaining nutrition and hydration.”

Level 4 – Pureed food

Becky cooked a mushroom risotto, before putting it through the food processor!

Becky reflected on the experience, saying that she would feel frustrated if she was having to prepare food to level 4 consistency out of necessity, as she struggled to ensure that the consistency was correct. Claire who also prepared food to level 4 consistency felt that it took longer than usual to prepare dinner as she was having to blend and sieve everything. This can be a real pain if you only have one of each and are required to keep washing everything as you go! Jan who also completed the challenge felt that she would miss the different textures of foods if she was required to prepare all meals to level 4 consistency.

 

Level 5 – Minced & moist food

Amy cooked bhurjee, an Indian take on scrambled egg.

She felt that the challenge helped her think about how complicated it can be for patients/family/carers of people with dysphagia to prepare food to the correct consistency level. Whilst Helen was completing the challenge, she reflected on the fact that food is about so much more than nutrition.  It is often used for social occasions, and gifts, and she thinks that she would struggle going out to eat in cafes/restaurants with friends and family if she was only able to eat food which was minced and moist. Another valuable insight offered by Helen was the added layer of difficulty there may be whilst preparing food of modified consistencies, if an individual’s cause of dysphagia is post-stroke, and they are required to do food preparation (i.e. small chopping, dicing, blending, sieving) with their non-dominant hand.

 

Level 6 – Soft & bite-sized food

Kirsty cooked a Balmoral chicken with peppercorn sauce, level 6 style!

She felt uncomfortable as an adult having her dinner presented cut up into 1.5cm bite-sized pieces almost as if for a child, but still managed to present it beautifully!! Helen prepared macaroni cheese, assuming that this would be an easy way round a level 6 meal. Turns out that pasta which measures up as 1.5cm when dry, expands to 2cm when cooked, and therefore each and every piece of pasta had to be trimmed by 0.5cm to meet the IDDSI descriptor of 1.5cm!! Talk about time consuming! IDDSI’s 1.5cm thumb nail sized pieces have been proposed as this is smaller than the adult trachea (wind-pipe), and therefore minimises the potential of a choking risk. Helen felt as though the challenge made IDDSI’s strict descriptors more practical, and personal, and removed them from just being on paper. 

 

Completion of this challenge highlighted for many of the team just how important food is.. for socialising, for comfort, for enjoyment! Most of us will celebrate good news by popping open a bottle of bubbly, or heading out for dinner in a favourite restaurant! Whilst these new descriptors have rigid descriptions – they have been created and tested so that everyone can enjoy food and drink as safely as possible!  

 

Claire Angus is a Speech & Language Therapist for NHS Dumfries and Galloway

  

(The International Dysphagia Diet Standardisation Initiative (IDDSI) is being implemented throughout Dumfries & Galloway over 2018 in all hospital, care and home settings. From 21st May, the fluid thickener Nutilis Clear changes to follow the new levels of drink, and anyone using Nutilis Clear will need to mix their drinks slightly differently.)

 

• For more information on IDDSI, look for links on the Beacon flash adverts or visit:

http://iddsi.org/Documents/IDDSIFramework-CompleteFramework.pdf

• Follow the adult SLT team on social media using:

@SLT_DG on twitter

@SpeechandLanguageTherapyadultService:NHSD&G on facebook.

Realistic Medicine—is it achieveable? by Heather Currie

A few months ago I was fortunate enough to be able to attend the Realistic Medicine conference held at Easterbrook hall. Hearing personal stories was, as always, moving and thought provoking. Little did I know that I would be having my own Realistic Medicine experience within a week.

My dad was a legend. Cantankerous, stubborn, opinionated, yet determined, resourceful, creative, inventive and mischievous! He has had many encounters with the NHS over recent years, mostly good but not all, from which I have learnt much. His outpatient journey, which I described in a previous blog, inspired me to look into how our outpatients run in the hope that we could do better.

He was always a farmer and continued to be involved, always knowing best (!)  until he was no longer physically able. At the age of 89, despite cardiac failure, chronic kidney disease, gout, peripheral vascular disease and osteoarthritis he managed to stay at home in the country, looking out onto hills and fields of sheep and cows, with help from family and carers until June 2017. Then, with decreasing mobility and some cognitive decline, he agreed to move into a care home. A care home on a working farm with a room looking out onto a field of cows was perfect. The staff were wonderful and he settled well, enjoying the company, feeling safe and good cooking! But he was inevitably becoming frailer.

One Sunday morning in October when I was visiting, he was quite drowsy. On discussing with the staff they mentioned that he had had blood tests showing worsening renal function and this was being monitored. My response was that perhaps blood tests were not needed and that most important was that he was comfortable. 

The following night around 11.00pm I was phoned from the care home to let me know that he was going into hospital and that the ambulance was about to leave.  Further blood tests had been taken. The results had been seen by an out of hours doctor somewhere in the north of England, who recommended hospital admission and ordered the ambulance. When I asked “What are we hoping to achieve?” the response was that while the care home staff and paramedics agreed that keeping him comfortable was the correct path for him, they could not go against the recommendation of the out of hours doctor.  I knew that he would not want to be taken to a hospital many miles away, for what? Phone calls to family members confirmed that they felt the same. Dying in the ambulance or on a hospital trolley was a distinct possibility, instead of comfortably with family with him, in the room looking onto a field of cows.

Several phone calls later enabled me to speak to the out of hours doctor. After explaining dad’s history, he agreed to cancel the ambulance and send a colleague out so that the care home had whatever was needed to keep him comfortable.  Having only blood results to go on, he could not make the fully informed recommendation. But why were blood tests taken in the first place? 

Dad died the following evening. Several family members had been able to visit during the day, he showed no signs of distress and at the end my daughter and I were with him, in the room looking onto a field of cows.

 If a death can be good, this was one, but could so easily have been very different. As my nephew later said, “Heather, none of us could have had that conversation. To move him would have been a disaster.” But why, when the family, the care home staff and the paramedics all believed that the right course of action was for him to stay, were all of us initially over ruled by a doctor who had never met my dad and had limited access to his medical history, albeit he was acting in good faith? 

So we achieved a realistic outcome this time, but is Realistic Medicine universally achievable? 

Possibly, but a major change in mind set from ourselves and from the public is desperately needed.

First and foremost we need to be kind,

But we also need to be brave

And we need to be realistic!

Heather Currie is an Obstetrician and Gynaecologist and Associate Medical Director for Women’s, Children’s and Sexual Health and NHS Dumfries and Galloway