‘DIY’ breakfast program to improve rehab after brain injury

Michelle Quick, Jacqui Wheatcroft, Danielle Sansonetti, Natasha Lannin and Laura Jolliffe

Clinical practice guidelines recommend that people with an acquired brain injury (ABI) should engage in at least three hours of scheduled therapy a day, and opportunities for increased practice outside these times should be encouraged (Stroke Foundation, 2017).

However, it is often challenging to meet this target within inpatient rehabilitation, with only a fraction of the day spent actively completing rehabilitation in a structured therapy program (Janssen et. al., 2014). As occupational therapists, it is important to consider how to help patients increase intensity and duration of participation in functional activities within the ward environment to meet guideline recommendations and prepare for discharge.

Within the ABI rehabilitation unit, it was identified that opportunities for patients to initiate routine daily activities were limited. Additional opportunities for brain injury rehabilitation can be provided in groups, like upper limb, community mobility, fatigue management and meal preparation groups.

Activities may include applying cognitive strategies during functional tasks, using aids and equipment, grading tasks, and practising social skills such as taking turns and working with others. While breakfast groups have been extensively used, particularly in the general rehabilitation settings (Scaffa, 2013), there is limited evidence of meal groups to improve participation or function in the ABI population.

This project aimed to explore and evaluate an independent ‘do-it-yourself breakfast group program. Observational audits were completed before and after the unsupervised group was implemented to evaluate the program. In addition to patient participation, Functional Independence Measure (FIM™) and Functional Autonomy Measurement System (SMAF) scores, activity participation, frequency and time of use before and after the program was implemented were also recorded.

Patients in the 42-bed ABI rehabilitation ward were invited to attend the DIY breakfast program if they:

Had a rehabilitation goal of independent meal preparation; or

Their treating occupational therapist considered they were nearing independence with this goal.

Patients did not attend the DIY breakfast program if they:

Had behaviours of concern that affected the safety of others; Were on modified diets that could not be managed themselves Required assistance with walking; or Had significant cognitive issues that could pose a risk to self or others.

A review of the ward was completed, and a suitable room in an accessible, highly visible area – which could be locked if required for the safety of others (for example, if patients were exhibiting behaviors of concern) – was identified. Internal windows between the nurses’ station and the identified room further increased visibility.

This room contained equipment and furniture including: • Fridge/freezer (ingredients milk, yoghurt, bread etc); • shelving unit (with plates, cups, cutlery, cereals and spreads); • Kettle; • Table and chairs; • Tea towels; • Whiteboard; • Trolley to put dirty dishes; and • Hand hygiene station.

Due to fire alarm regulations a toaster could not be used in this setting.

A DIY program working party was established to develop work instructions and hygiene and food safety protocols, and troubleshoot any issues that arose. Patients were trained in “house rules” and how to use the area, and had a supervised breakfast preparation session with their occupational therapist. Once patients agreed to take part in the program, they were timetabled up to seven days a week and their ward breakfast delivery was cancelled for specified days. Patients were then responsible for initiating and making their own breakfast on these days.

Use of ward spaces: The pre-intervention observational audit determined that no patients had used the small dining room on the rehabilitation ward. Over the 315-minute post-intervention audit (between 5.45am and 11am), the DIY breakfast was used 16 times by patients. This equalled 135 minutes of activity engagement (mostly meal preparation), with a mean of 19 (SD 13) minutes per patient. Of the 315 minutes of post-intervention auditing, patients were seen using the space alone (totalling 127 minutes), with only eight minutes spent in shared company (two patients at once). The audit indicated that the DIY breakfast space served different purposes, with some patients choosing to prepare and eat their meal in the dining room, whilst others opted to eat in their own room and return their dishes to the kitchen afterwards.

Patient characteristics of those who used the DIY space: Of the 42 inpatients on the ward at the time of this study, 11 were involved in the DIY breakfast program. The average age of participants was 49 years (SD 10), 86 per cent were male, and the mean time since onset of injury was 175 days (SD 88.98). On the day of post-intervention auditing, four of the 11 patients did not use the DIY breakfast space due to appointment attendance (n=1), sleeping (n=2) or not wanting to socialise (n=1). In total, seven participants used the DIY space during post-intervention auditing. All patients with TBI had a PTA length greater than 25 days (thus, all were considered to have sustained a severe traumatic brain injury).

Photo: ©gettyimages /KucherAV

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Medical file audits of DIY breakfast program participants: Of the seven patients that used the DIY space in the post-intervention audit, medical file audits of their function indicated that the mean FIM total score was 109.1 (SD 8.6), mean FIM cognition/communication score was 26.6 (SD 4.7), and the mean FIM motor score was 82.6 (SD 9.9). The mean SMAF total (disability) score was -23.4 (SD 5.8) and mean SMAF total (handicap) score was -21.7 (SD 6.9). Therefore, the SMAF scores indicated that patients who had sustained moderate-severe brain injuries and required cognitive support (i.e. supervision, prompts, or aids) with daily tasks were more likely to benefit from this program.

Medical file audits for the number of breakfast sessions in which participants engaged (i.e. breakfast group, therapist facilitated sessions/self-initiated) increased from a mean of 2.4 to 9.7 (SD 5.4) sessions (over 15 days) before and after involvement in the DIY program. This equates to a mean difference of 7.3 (SD 3.9, CI 95% 3.7 to 10.9, p<.003).

Patients who took part in the DIY breakfast program reported that they enjoyed the independence and increased confidence of preparing their breakfast before they were due to return home. Restructuring the ward environment increased ward space use, increased delivery of meaningful semisupervised therapy, and was appropriate for patients who were not yet independent in higher risk kitchens (for example, those with a stove top, oven and microwave). Providing increased opportunity for practice provided patients and staff with additional information about how they managed their daily routines. The DIY breakfast program facilitated the following:

• The environment to be used to creatively promote patient activity and socialisation; • Patients more closely mirroring usual routines and preferences on how and where to spend their time; • Opportunities to gain independence in basic meal preparation and other domestic tasks e.g. washing dishes, cleaning bench tops; • Patients engaging in roles such as

“hosting” their visitors or making their own hot drink in the space to simulate a home environment and encourage socialisation; • Increased participation in routine activities without the need for significant additional costs or staff resources.

• Make small changes to the physical environment to increase opportunities for therapeutic intervention; • Evaluate kitchen equipment that is able to be used in designated area i.e. a toaster may not be able to be used due to fire restrictions; • Gather resources such as simple breakfast items, fridge, kettle, cutlery, etc; • Engage the whole team to support greater participation; • Encourage students, volunteers and family members to support patients to take part; • Develop tailored cognitive strategies such as alarms or visual cues to support a patient’s recall and initiation of breakfast preparation; • Consider all patients i.e. those who may not be able to use a full

kitchen due to stove tops and risks involved may be able to safely engage in a DIY breakfast program; • Evaluate risks for each patient i.e. those with allergies or swallowing requirements; and • Ward requirements for the DIY breakfast space may fluctuate over time due to the profile of patients. Be prepared to pause and recommence the group as appropriate. About the authors Michelle Quick is the senior occupational therapist for the Neuro Trauma stream at The Alfred hospital.

Jacqui Wheatcroft and Danielle Sansonetti are PhD candidates and grade four occupational therapists at Alfred Health.

Professor Natasha Lannin is Professor, Allied Health (Occupational Therapy), Alfred Health, Melbourne, Australia, and Professor, Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia.

Dr Laura Joliffe is a lecturer and academic in occupational therapy at Monash University.

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