Nutrition and hydration collaborative – NHSI case study

About the collaborative

We ran a 180-day programme, with 25 volunteer trusts, to improve nutritional care by increasing the accuracy of nutritional screening and the appropriateness of nutritional interventions.

The overall aims of the collaborative were to support trusts to:

  • increase in the proportion of patients with an accurate nutritional screen
  • increase in the proportion of patients receiving appropriate nutritional interventions
  • introduce and increase the use quality improvement tools and techniques

In addition to the above aims organisations could identify their own quality improvement focus if appropriate.

25 trusts volunteered to be part of the programme to drive quality improvements, each shared their good practice, what they have learnt about quality improvement and helpful techniques with each other.

Our support offer

We supported the trusts taking part in the collaborative to adopt improvement methodologies and created a learning community for them to discuss the changes they implemented and share their findings.

Collaborative sessions were held which included presentations from external speakers to share good practice and opportunity for the trusts to share their improvement journey to date. Each session included an introduction to a quality improvement methodology including, process mapping, driver diagram development, using PDSA cycles to test theories of change, measurement for improvement and scaling, and sustaining change.

A range of trusts volunteered to take part from different care settings including acute, community, mental health and integrated trusts, and many of the trusts teams included representatives from nursing, dietetics, speech and language therapists, catering managers, doctors and quality improvement leads.

Link to article page here




    Showing the effectiveness of emergency physiotherapy practitioners – NHSI case study

    A case study from the University Hospitals of Derby and Burton NHS Foundation Trust, demonstrating the value of emergency physiotherapy practitioners in treating patients with musculoskeletal dysfunction in an emergency department.

    What was the aim?

    To show how musculoskeletal (MSK) emergency physiotherapy practitioners (EPPs) improved patient outcomes and patient flow while reducing costs in the emergency department (ED) at Queen’s Hospital, Burton-upon-Trent.

    EPPs work independently from doctors and nurses, undertaking expert management for patients with MSK dysfunction.

    What was the solution?

    One year’s data was collected to establish the mean number of ED attendances, the time to initial assessment, total time spent in ED and unplanned reattendance rates within seven days, for all patients seen by the EPPs. This data was compared to the national average published by NHS Digital.

    What were the results?

    Patients seeing the EPP in the ED:

    • were seen 10 minutes quicker than others in the region, and 20 minutes quicker than the national average
    • spent two hours less in the ED than patients nationally, and over half an hour less than others in the region
    • unplanned reattendances reduced by 50% to 60%

    Link to article page here

    Developing a therapy-led transitional unit to help discharge acute patients: NHSI case study

    A case study of a therapy-led unit in South Warwickshire NHS Foundation Trust aiding patients’ transition from hospital to home-based care.

    What was the aim?

    South Warwickshire NHS Foundation Trust found many medically fit patients were occupying acute beds because they were unable to manage at home, and were not yet safe to receive care or therapy there. Typically, they needed support at night or between care calls but no longer required 24-hour nursing.

    The trust therefore wanted to:

    • increase patients’ independence and daily living skills, avoiding the loss of confidence or ability associated with spending too long in hospital
    • reduce hospital delays and costly long-term health and social care, supporting people safely with less intervention
    • ensure people recover away from the acute hospital to accurately assess their health and social care needs
    • help patients return home if possible, for as long as possible
    • ensure decisions about long-term support are made outside hospital and people have access to therapeutic and reablement services

    What was the solution?

    The trust contracted with Warwickshire Care Services (WCS) to create a therapy-led transitional unit in Castle Brook, a modern and technologically advanced care home.

    Team makeup

    The 13-bed unit’s NHS therapy team consists of the therapy lead, who is an occupational therapist (OT), a rotational physiotherapist, a rotational OT, a part-time physiotherapy assistant, and part-time OT assistant. The unit has also recruited a Band 4 therapy assistant practitioner.

    WCS’s team consists of a lead enabler and enablers with extra reablement training to continue rehabilitation while therapists are not on site.

    Daily handovers between the trust and WCS allow for effective communication and enhance team integration. A social worker and Age UK representative attend a weekly multidisciplinary team meeting. Three times a week, GPs visit patients who have been identified by the therapy team; district nurses visit as and when required.

    Admission and assessment

    Technology plays a major part in the speed of admission. The therapy lead screens the patient in the acute hospital, explains the service and gains written consent: it is important the patient understands the transfer is part of their ongoing treatment, and they remain the trust’s responsibility.

    A trusted assessment is then completed online with baseline information and care plans created for the patient. This is forwarded electronically to the unit for joint agreement that the patient is suitable. This prevents delay that would arise from the home visiting the patient on the ward.


    As the unit is based in a care home, it is less institutionalised and more therapy-enriched. Patients receive one-to-one and group therapy and are encouraged to recreate a routine like their own at home.

    The criteria require that patients are motivated and engaged with therapy and can return home within 21 days. Castle Brook is a short-stay, low-level rehabilitation unit that focuses on planning for safe discharge and reducing the amount of care or support required on discharge and in future.

    What were the challenges?

    Bed pressures in the hospital resulted in a room previously used for therapy being filled. Bed pressures also resulted in a need to adjust the criteria to help patient flow, which now allow one patient needing two people’s help to mobilise to be in the unit at any one time.

    Castle Book also now accepts patients awaiting support from community teams or social services.

    Differences between the trust’s and WCS’s policies and procedures required negotiation and problem-solving from both parties.

    What were the results?

    • 1,870 hospital bed stays saved between April and October 2017.
    • Average length of stay for the year to date is 14.3 days.
    • 89% of patients are discharged to their usual place of residence; 9% are re-admitted to hospital and 2% discharged to a care home.
    • 83% return home self-medicating.
    • 96% reduction in patients with night needs on discharge.
    • 100% of patients likely to recommend the service to family and friends (September 2017).
    • 100% of patients improving in at least one aspect of the Therapy Outcome Measure.
    • 93% of patients have improved in the Elderly Mobility Score.
    • The vast majority of patients are discharged with a reduction in predicted care packages on transferring to Castle Brook.
    • Some patients have returned home independently without care support on discharge.

    Link to article page here

    Developing a physiotherapy-led exercise group for older adults with frailty – NHS Improvement case study

    Exercise google 160204-F-GY014-011
    Image: google images, copyright free

    A case study from Newcastle-upon-Tyne Hospitals NHS Foundation Trust, examining the benefits of specialist exercise groups for older adults with frailty.

    What was the aim?

    Rising numbers of older adults living with frailty typically have impaired mobility, balance, strength and endurance. Specialist physiotherapy can identify and target such deficits through individually tailored exercise and health education.

    Group exercise may have advantages over individual care, such as peer support, shared experience and the formation of health relationships.

    The trust therefore wanted to develop an exercise group for older adults with frailty, to improve their functional performance.

    What was the solution?

    ‘Stay Strong’: a physiotherapy-led exercise group held at the Freeman Hospital’s Melville Day Unit. All patients were referred for day unit physiotherapy assessment and those who were suitable were offered a choice of individual or group exercise.

    Participants attended eight weekly groups of individualised and progressive exercise targeting flexibility, strength, balance and endurance, with supplementary home exercise. Health education topics included exercise recommendations and benefits.

    All 29 participants, with a mean age of 83, used walking aids and rarely went outdoors alone.

    What were the results?

    The Timed Up and Go test (TUG) and a patient experience questionnaire were used to evaluate the project. At the start, the mean TUG score was 31.7 seconds. The evaluation found:

    • 84% of those completing the eight sessions achieved an improved TUG score, with a mean gain of 6.6 seconds
    • of the 89% who completed the patient questionnaire, all ‘enjoyed’ the group and most felt it ‘made a difference’
    • 71% highlighted the group’s ‘social element’ as beneficial

    What were the learning points?

    • Frailty management and inactivity in older adults are gaining priority in NHS care.
    • Specialist physiotherapists have the skills to delay deterioration and improve frailty through exercise and health education.
    • The ‘Stay Strong’ group showed psychosocial and physical gains in older adults with frailty.
    • Implementing ‘Stay Strong’ in the day unit was an innovative service improvement that supports active ageing.
    • Investment is needed to develop community-based opportunities to support older adults to achieve better health, and prevent the morbidity associated with frailty.

    Link to article page here

    Cardiovascular screening of patients with serious mental illness – NHSE case study

    Leading change

    A mental health nurse at Bradford District Care NHS Foundation Trust (BDCFT) led a project to improve physical health for people with a serious mental illness (SMI). The project introduced the a screening tool, aligned to the ‘Lester tool’, which was designed to increase the identification of cardiovascular illness, delivering service improvement in the physical health of SMI patients and removing unwarranted variation between physical and mental health, within both primary and secondary care services.

    Where to look

    Improving life expectancy of people living with SMI is a national priority in the Five Year Forward View for Mental Health. Evidence indicates that people with SMI have significantly shorter life spans than the general population, with cardiovascular disease (CVD) being a particular risk factor (Improving the physical health of people with serious mental illness: a practical toolkit, NHS England 2016Improving physical healthcare for people living with severe mental illness (SMI) in primary care: Guidance for CCGs, NHS England 2018). A BDCFT nurse recognised this unwarranted variation among the SMI patients seen by the Community Mental Health team, recognising that routine screening for cardiovascular illness was less common with SMI patients than for other risk factors, such as suicide risk, especially in secondary care.

    What to change

    The nurse led on an audit to review SMI patient experience and medical practice across Community services. Results from an initial audit conducted across primary care highlighted potential missed opportunities for patients with SMI to receive a Cardiovascular Risk Score and an effective review of their physical health.

    This led the team to start to develop and implement service improvement for these patients with SMI. The nurse and a multidisciplinary team introduced the Lester tool, which helps frontline staff make assessments of cardiac and metabolic health, helping to cut mortality for people with mental illnesses.

    The team designed, developed and implemented a digital template for the primary care information system with the aim of seeing if SMI patients offered the template-based screening received better or worse quality care than patients who were not offered the template-based screening in a side by side comparison.

    The BDCFT nurse worked with a Psychiatrist GP Lead and Data Quality Specialist to develop and implement a computer based template for the primary care information system to carry out a high quality annual physical health check using the standards recommended by the Lester Tool. The nurse focused on the cardiovascular risk assessment element of the computerised physical health check template. It was piloted in six GP practices and then rolled out across Bradford and Airedale.

    The initial findings suggested that by making a computerised health screening tool available, teams could carry out higher quality physical health reviews and detect more patients at risk of significant cardiovascular illness. Where the template was not used, there was identified unwarranted variation in the uptake of cardiovascular screening for SMI patients. Identified within the pilot, three quarters of patients with a template-based medical review received effective cardiovascular screening and subsequent referral to further specialist support as needed.

    The use of an electronic template more than doubled the rate of uptake of recommended Lester Tool standards and the detection of significant cardiovascular risk in line with the Five Year Forward View for Mental Health. The nurse’s evaluation identified clear opportunities to improve health screening for people with SMI. Alongside the effective roll out of the Lester Tool within general practice, the nurse lead encouraged partners within secondary care to utilise the Lester Tool. This ensured a reduction in the duplication of screening and provided more effective patient focused care, supporting healthier and longer lives for SMI patients.

    How to change

    The computer based template is now a core tool across all GP practices in Bradford and Airedale. All patients commencing on a prescription of antipsychotics are referred for appropriate baseline physical health checks and ongoing monitoring, until stable enough to return to the care of their GP. Care staff undertake the screening tests, having been supported to also perform phlebotomy and ECGs in line with the Lester Tool, and to give lifestyle advice (including referrals to further services where needed). Care staff work with a Mental Health Nurse specialising in physical health to support the development across inpatient and community services.

    The Mental Health Physical Review Template (aligned to the Lester Tool) has now been adapted for primary and secondary care, community and inpatient settings. It guides clinicians through completing a comprehensive check, to ensure effective interventions and decisions are made.

    The template is supported by guidance on the specific responsibilities of both primary and secondary care staff when carrying out physical health checks. The Yorkshire and Humber Academic Health Science Network (YHAHSN) has enabled further development and is promoting a national roll out.

    Link to article page here

    Falls Prevention Nurses lead collaborative falls service improvement with West Yorkshire Fire and Rescue Service – NHSE case study


    Leading change

    The Falls Prevention Nurses at Bradford District Care NHS Foundation Trust (BDCFT) have led change by working in partnership and collaboratively on falls prevention with the West Yorkshire Fire and Rescue Service (WYFRS).

    Where to look

    The Falls Prevention Team at BDCFT provides advice and support to other services and organisations across Bradford and Airedale. The team identified unwarranted variation and missed opportunities to enhance their falls prevention work. This led them to begin offering falls awareness training for WYFRS, supporting them to start providing falls prevention advice and information to their service users as part of their day to day work and linking with their ‘Safe and Well’ strategy. This is a safer community’s strategy launched nationally by the fire service looking at key areas for preventative work in the community. WYFRS chose falls prevention as one of their focus topics and with support from nursing leadership.

    The BDCFT nurses recognised that the fire service is well-placed to support prevention practice and population health, notably in the reduction of fire incidence and associated deaths. They are routinely working with ‘vulnerable’ people that may be at risk of falls and who are not receiving any support or intervention to minimise this. The team identified that through collaborative working, the fire fighters could develop an additional skill set that could improve local people’s outcome in relation to falls.

    What to change

    Before the change, referral pathways from WYFRS into falls services were not in place, and home fire safety assessments were predominantly focused around fire prevention. A pilot was initiated and it was agreed that following training a falls screening tool would be incorporated within the home fire safety assessment form to identify individuals at risk of falling. If indicated, fire fighters would then be able to refer onto appropriate nursing service for a multifactorial falls assessment.

    How to change

    Fire crews involved in the pilot received training from the Falls Prevention Team Leader for BDCFT. The falls screening tool was developed as part of a task and finish group involving health and social care professionals across different organisations within the area, also including from WYFRS. A feedback workshop was held and received positive responses from both fire fighters and community nurses who were involved.

    As a result of this and other successful pilots across West Yorkshire, the training has now been launched and delivered across Bradford and Airedale with members of the falls prevention team involved in the development of the regional training programme. The training has been delivered to all fire fighters across the district by the Falls Prevention Nurse for BDCFT and a training officer for WYFRS. The training has given fire fighters the skills to assess individuals who may be at risk of falling, give basic advice and relate this to their fire prevention work.

    Link to article page here

    Limiting patient harm due to Acute Kidney Injury – AHSN network case study


    A team at South Tees Hospitals NHS Foundation Trust in Middlesbrough developed a programme to raise awareness of Acute Kidney Injury (AKI) and to recognise and treat the condition promptly. Since the programme started there has been a sustained reduction (36%) in AKI cases within the surgical wards at Middlesbrough. This successful programme and pathway has been shared with seven other trusts in the North East of England.  As a result of the AKI project and its links to CRAB Clinical Informatics Limited (C-Ci), other NHS Trusts; Imperial, Frimley Park, Wexham Park, North Devon, St Helen’s, Lincoln, Yeovil, Bartholomew’s, The Royal London and Southend, have now also been consulted, meaning this project has the potential for much wider spread.

    The South Tees Hospitals NHS Foundation Trust team was also highly commended in July 2017 at the national Patient Safety Awards.

    Link to article page here