Supplements as Medicine (SAM) refers to a small dose of high energy, high protein supplement administered at regular intervals, this is a method of nutrition provision for patients who are having difficulty meeting their requirements. In 2018 a number of audits along with patient and nursing surveys were completed in the 30-bed Geriatric Evaluation and Management Unit of the Prince Charles Hospital to evaluate the SAM process. The results indicated only 23% of patients were consuming SAM and there were a number of barriers identified by nursing staff when it came to delivering SAM. These results guided the development and implementation of strategies with the aim to improve SAM provision and consumption. Hopeful outcomes will include; improved patient care, staff satisfaction, wastage and potential for health-care cost savings.
Evaluation of the effectiveness of "Supplements as Medicine" in a geriatric population
The use of a “Supplements As Medicine” (SAM) or Medication Pass Nutrition Supplement Program (MEDPASS) program can be impactful if implemented effectively and tailored to the local context. A gap between evidence and practice was clearly identified as a local audit found that only 23% of patients with charted SAM were consuming the prescribed dose. Assessing the barriers to patient intake of SAM and addressing the identified problems has the potential to not only improve the nutritional status of our vulnerable patient population but also reduce cost to the HHS through a reduction in wastage.
Outcome evaluation will be conducted by completing medication audits (similar to the audit to assess the problem). This will include patient consumption, nursing provision, medication chart signing and escalation if not consumed.
Patients with disease-related malnutrition may have nutrition impact symptoms including poor appetite and early satiety. A literature review found that nutritional supplements contribute towards beneficial clinical outcomes for malnourished patients. Evidence is stronger to support the use of oral nutrition supplements in specific patient groups including the acutely ill elderly and hip fracture patients. Literature surrounding the use of SAM or MEDPASS indicate this method of nutrition provision can be utilised effectively. This is supported by the malnutrition chapter of Queensland Health's Framework for Effective and Efficient Dietetic Services (FEEDS). SAM is used frequently for patients within Geriatric Evaluation and Management (GEM) as there is a high prevalence of geriatric patients who have an extended length of stay in hospital and require increased nutritional requirements for a variety of comorbidities.
The project incorporates two main frameworks; the Knowledge To Action (KTA) framework and the Theoretical Domains Framework (TDF). The KTA Framework was used as follows:
1. Identify problem – Audits completed found that SAM consumption was poor with only 23% of patients consuming the charted dose.
2. Adapt knowledge to local context - It was determined SAM was important to continue in GEM given high rates of malnutrition and cognitive impairment.
3. Assess barriers to knowledge use – Nursing surveys found that nurses believed nutrition was important; however there were barriers to providing SAM including time constraints, equipment and lack of knowledge.
4. Select, tailor and implement interventions – Focus groups were held with MDT to develop strategies to address the identified barriers.
5. Monitor knowledge use and evaluate outcomes – Audits of supplement provision by nursing staff and consumption by patients will be completed.
The TDF was used in developing the nursing surveys to help analyse and target areas of behaviour change. With this framework, the survey results could be compared with the COM-b model and mapped to areas of the Behaviour Change Wheel.
The areas that were targeted included:
• Environmental restructuring - Suitable equipment (addition of cups/measurement tools)
• Enablement - Addition of SAM to nursing orientation and escalation procedure (with patient refusal)
• Education - Nursing education sessions
The strategies are currently being implemented and post-implementation data is due to be collected in 2020. This will involve medication audits like those conducted pre-implementation.
The biggest learning was not assuming the problem and planning solutions before investigating the evidence. It was not hypothesised that issues such as lack of suitable cups/measuring tools would be barriers. These identified barriers can be addressed with simple strategies.