As the diet wheel turns, errors decrease
New program aids nutrition communication
In July 2008, a diabetic patient at Methodist LeBonheur Germantown (TN) Hospital looked down at his plate of concentrated sweets.
Danielle Sharp, RN, walked into the patient’s room and noticed him eating the wrong meal, which could cause his sugars to skyrocket. It had happened frequently, and Sharp was fed up.
“That was it—enough was enough. We had to do something about it,” she says.
The patient was admitted to Methodist with hyperglycemia, and because he was frequently served the wrong food, staff had trouble educating him about appropriate food choices for his diabetic condition.
Enter clinical directors Ptosha Jackson, RN, MSN, and Bea Allen, RN, MSN. The duo put their heads together and came up with an innovative solution to dietary errors like the one caught by Sharp: the diet wheel. The goal of the bright pink wheels—located on patients’ doors in four of the hospital’s units—is to ensure that physician orders are implemented and that patients receive the meals designed specifically for them and their current conditions.
“So far, it’s not 100% error free, but it has eliminated many errors,” says Allen. The Robert Wood Johnson Foundation, a philanthropic foundation devoted to improving health and healthcare, recognized the diet wheel as a “Promising Practice From the Field,” and extensive inventory of promising practices that have been implemented or developed across the country
Inventing the wheel
Even before the dietary error that Sharp noticed, diets were sometimes an issue for patients at Methodist. The problem lay in the process design for meals. After physicians made their early morning rounds assigning types of meals (e.g., low fat, nothing by mouth), dietary associates would receive the diet lists around 6 a.m. and start preparing. But while the meals were being arranged, physicians would make more rounds and sometimes change dietary orders.
“And physicians’ orders were not being carried out correctly because the unit is a very busy unit,” Allen notes.
The July 2008 dietary incident was caused in part by changed physician orders. That same month, Allen and Jackson developed a basic model for the wheel. Two paper wheels, which were later laminated, are layered on top of each other. The bottom circle is broken up into 16 slices, each one displaying a different dietary restriction. The top opaque circle has one slice cut out of it (similar in appearance to Pac-Man®), to reveal the correct dietary need.
Implementing the wheel
The hospital staff members looked at the top diets ordered by physicians and applied them to the wheel. If an additional dietary need was requested, a piece of paper would be attached to the wheel. Staff members can move the wheel to show a patient’s nutritional needs, such as clear liquids, low fat, or low sodium. Once a physician prescribes a proper diet to his or her patient, it can be applied to the diet wheel immediately, which is posted right outside a patient’s room.
“We started with a very elementary wheel, using bright-colored construction paper and magic markers,” Jackson says.
Implementation, however, was much more difficult than the initial construction—it took Allen and Jackson almost six months to get the diet wheel spinning. Not only did they have to figure out which diets should be shown on the wheel, but they had to train and educate physicians, nurses, and other staff. There was a learning curve before everyone fully understood it.
“It was actually really easy to train the staff once they knew what the diet wheel would be,” says Jackson. “They really grasped things quickly because they were in the mode of learning new innovations we had.”
Communication about the wheel was also an issue. At first, dietary associates who served the meals were not included in education and training because they were an outside company working within the hospital. The hospital wanted to perfect the process with the nurses and other staff first. Dietary associates were later brought on board through training with the hospital to ensure that the process would work.
“The diet wheel was one way that we could enhance communication between everyone,” Allen says. “It made for less confusion.”
Although dietary associates cannot see the list of previous meals given to patients, they do have a printed list of each patient’s diet to check against the wheel. If they see that the wheel has been changed, dietary associates will verify with nurses that the change is correct.
“Sometimes diets will be changed throughout the day by physicians based on patients’ current condition,” Allen says.
With multiple units using the diet wheel for their patients, monitoring its use is key. Weekly checks are conducted to ensure that all patients are receiving the correct meals. Patient charts are also reviewed for accuracy.
“Nurses are held responsible for keeping their patients’ diet charts updated,” Jackson says.
Sometimes patients are brought the wrong type of food, and according to Allen, whether they’ll eat the food anyway depends on the patient and whether nurses have provided dietary education.
“I’ve had patients who will obey and those who scarf it down,” Allen says. That’s an obvious problem, and it could pose a risk to patients’ health, something the wheel helps to avoid. “But I’ve also had some patients who question the dietary associates and ask to check with the nurse.”
Reinventing the wheel
Communication and training weren’t the only challenges with executing the diet wheel process. The simple design and structure needed to be tweaked. For example, the diet wheel was initially hung using tape.
“We had a new catering associate delivering the trays and saw a patient’s diet wheel that said NPO (nothing by mouth) and didn’t deliver a tray,” Jackson says. “But it turns out the patient’s family member knocked it on the floor by accident, hung it back up, and [that had] rotated the wheel by mistake.”
This prompted Jackson and Allen to add a magnetic clip that attaches to the metal door of the patient’s room. The wheel is also laminated on both sides for an easy wipe-down to avoid infection.
Spread of the diet wheel
The diet wheel is being used on four units of the hospital—cardiac, oncology, med-surg, and OB/GYN—after it was discovered by word of mouth that these floors were suffering dietary problems. Methodist LeBonheur Germantown is one hospital in a seven-hospital system, but as of now, it’s the only one using the diet wheel. However, Allen and Jackson will be working to expand the program to other facilities. “It’s been a slow process to spread to other units and facilities,” Jackson says. “We really want to teach people the principles behind the idea and not rush it.”
The concept of the wheel, the duo found, could be used for other purposes as well. After speaking at local conferences in the Memphis, TN, area, they found that St. Jude’s Children’s Hospital had adopted the diet wheel for use with pressure ulcers.
That spurred Methodist LeBonheur Germantown to come up with other ideas for future wheels that could help eliminate errors.
“Like St. Jude uses it for pressure ulcers, other hospitals can use it for fall risks,” Jackson says. “We have other ideas generating just from our diet wheel.”
Jackson and Allen believe a diet wheel can be successful in any hospital.
“Units in other hospitals need to make sure the diet wheel fits their units. It can be modified to fit different, unlisted diets,” Allen says. “It really does help eliminate errors because of its convenience.”
The aspect of patient safety is visible in the diet wheel process. Meals are an important part of patients’ days, and if a wrong meal is served, it could jeopardize their health. Allen gives an example of a patient who undergoes stomach surgery and receives a diet with solid foods. Because of this diet, he or she could have complications following the surgery, such as vomiting or sharp pain.
“It’s very important that diets are properly administered, just like a medication,” Allen says.
Before the wheel, dietary associates knew which foods to serve to which patient, but when they had to go back and change meals due to physicians chang-ing orders without notice, it was time-consuming. The diet wheel saves time and creates a more efficient process.
Thanks to the wheel, Sharp is much more confident that her patients are receiving the proper meals.