PLACE: making national assessment criteria applicable to mental health Helen Barrett

Transcription

1 PLACE: making national assessment criteria applicable to mental health Helen Barrett Senior Specialist Dietitian DHUFT Teaching Fellow University of Surrey

2 Problem Many of the existing recommendations for inpatient healthcare are focused towards meeting physical health needs. The needs of mental health units are different.

3 Characteristics Physical Health Stress factors for acute and chronic inflammation. Some patients non-ambulatory. Some patients receiving ++physiotherapy. Reduced access to sunlight. Potentially reduced appetite due to physical condition. Mental Health Stress factors absent. Patients undersection with variable leave. Reduced access to sunlight. Potentially increased appetite due to boredom/medications. Sedating medications. Medications that potentially reduce BMR.

4 Solutions? Stimulus control. Activity programme. Ensure lowest effective dose. Applicable catering provision.

5 Solutions? Stimulus control. Remove snacking/food prompts. Water fountains or kitchenettes where appropriate. Activity programme. Working with gym instructor. Hospital wide programme of activity. Ensure lowest effective dose. Reducing caffeine/nicotine consumption via education. Applicable catering provision. ROADBLOCK

6 Roadblock why? Pride. Hit their targets set by the Hospital Caterers Association. PLACE (Patient Led Assessment of the Care Environment).

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8 Results

9 Questions 2015 Hot meals encouraged. 5+ options at each meal encouraged. 3 course meal encouraged. Use of full-fat milk encouraged. Offer snacks between meals. Hot, milk based drink offered in the evening.

10 Problems with PLACE Promotes obesogenic environment. Overwhelming choice for some patients. Promotes abnormal eating habits (all-inclusive holiday resort). Difficult to follow nutritional care plans.

11 Initial proposal: Physical health and mental health are inextricably linked. Action is needed to improve the physical health of people with mental health problems (The Mental Health Foundation, 2011). Poor mental health is associated with an increased risk of diseases such as cardiovascular disease, cancer and diabetes. Poor physical health can exacerbate already existing mental health problems. Healthy balanced inpatient menus within the scope of patients taste preferences is a chance to role model healthy eating practices and demonstrate choices that can address these increased risks. Thomas Inman stated in 1860, first, do no harm which is carried forward to modern health care. It advises physicians to be cautious against overmedication of patients. PLACE is designed with the physical health setting in mind, where patients energy requirements are substantially higher due to physical stressors on the body for example a patient undergoing surgery their requirements can increase by up to 40% (Barak 2002, Cortes 1989, Swinamer 1988) and every opportunity to enable these additional calories needs to be taken. Cooked food is well known for having a higher nutritional content than cold items and thus recommending two cooked meals a day is appropriate in general hospitals. By measuring mental health settings against criteria set for physical health settings, we are encouraging the creation of an inappropriate and obseogenic environment for our service users we are overmedicating them. All service users should be treated holistically. We should not be following policies which are inappropriate to our patients. We cannot create an unnatural style of eating that harms our patients; modern eating behaviours do not include 3 courses at meal times and a cooked meal twice a day. Additionally the ability of some service users to sustain this way of eating is low, due to cost, time and skill restraints. With this in mind, role modelling inappropriate eating habits can complicate discharge, and I have seen this happen twice. Weight gain is a well observed side effect of commonly used anti-psychotic medication via the mechanism of artificially increased hunger (Lester Tool, 2014). The argument that patients do not have to eat all the opportunities offered is unrealistic. Additionally the inpatient setting does not provide the same number of distractions as the community which increases the focus on mealtimes. We need a new approach that empowers individuals to make healthy choices (Healthy Lives, Healthy People: Our strategy for public health in England, Secretary of State for Health). This is especially important for mental health services with their known increased risk of morbidity. Helen Barrett Senior Specialist Dietitian St Ann s Hospital Dorset Healthcare University Foundation NHS Trust

12 Initial response: Thanks for copying me in, Graham I think this is a really hard one and I look forward to discussing it tomorrow. I absolutely get the problem of modelling appropriate eating behaviour and I think that would be a great aim for us to consider. Where I think I move away from Helen and Chris (slightly) is in how that is enacted. I also think we might have different interpretations of what constitutes an unnatural style of eating that harms our patients. We have to balance the need for choice with the need for food that promotes health. I recognise that the two are uneasy bedfellows, but it s not impossible to do both together. One of the problems we have in both acute and MH is that in some areas there isn t any real choice and we have to work to change this. For instance, if you look at a typical vending machine, the only choice you have is between a sugary drink and a sugary drink or a chocolate bar and another chocolate bar. Not a real choice at all. I think the question I would ask is what would an ideal menu look like? In my mind, this is one that provides a wide range of options on timing and content, but makes it easy for me to choose healthily at any time. So ideally I would like a breakfast that offers me healthier options (low sugar cereal with skimmed milk, or a boiled egg, or toast with low fat spread), then two main meals that also offer me healthier options (a baked spud, or a well-constituted sandwich, or a healthy hot option). In acute care, we look for ways to increase calorie content in our menus, but in MH we could equally look for ways to reduce it. Neither of those requires us to reduce choice. I d also push back slightly on the idea that a hot option is inherently less healthy than a cold one. I ve seen many people choosing from salad bars that are heaving with mayonnaise and dressing, and that consist largely of starch salads (potato/pasta/rice) because they think this is healthier than the grilled chicken with veg that is on the hot counter. In the staff canteen here, for instance, the daily salad choice is usually three starch salads (all with sauce/dressing), one or two bean salads (ditto), coleslaw in mayonnaise, plus tomatoes, cucumber and lettuce as the only plain options. You d be hard pressed to get a healthy calorie count in that, especially once you ve added a protein portion. By contrast, the hot counter usually contains no more than two starch options (one always plain), with no more than one of the protein options in sauce, and all veg cooked simply. Most days, it s easier to construct a healthy hot meal than it is a healthy salad. All this said, I do sympathise with your situation. Modelling healthy eating is hard and a part of that has to be working with individuals on their food choices. So just as in acute we would help underweight patients choose more nourishing options, so in MHS we ought to help them choose something less calorie dense. Of course, we should also be helping them be more active, in order to equalise their intake and output, but maybe that is a topic for another day! Thanks for your thoughtful input. I hope that at the very least you are reassured that we do read and consider the suggestions that come our way. We ll feed back after Graham and I meet tomorrow. Liz

13 Colleague support

14 The penny drops

15 Questions 2017 Portion-size as directed by the dietitian. Full-fat milk available in response to clinical need. in Adult Mental Health services it is not necessary to routinely offer snacks to all patients where dietitian advice is that this is inappropriate In some circumstances and subject to dietitian advice it may be appropriate to offer only decaffeinated versions of tea and/or coffee in Adult Mental Health services it is not necessary to routinely offer a hot milk-based drink to all patients where dietitian advice is that this is inappropriate

16 What does this mean? Changes made with the support of catering. (ED separate). Afternoon cake removed as standard. Special requests approved by dietitian and head of catering. Decrease in double meals. Food For Life Bronze Award currently in process. Seasonal menu. Chefs have personal input into the recipes. Dishes chosen on patient consultation Audit on patients weights before and after changes in process. Self-efficacy audit in process. Patient food satisfaction the food is making me fat improved.

17 Action points Do challenge legislation Lengthy process. Make sure you have the evidence and reference any correspondance. Maintain patient centred care Should be there to protect your patients If it doesn t then the legislation needs to change. Get the backing of additional specialist dietitians/mhg if you feel you are being ignored.