Implementation of NICE guidelines and the Research questions

1
Implementation of NICE guidelines and the
Research questions

• Susan Murray
• (National Collaborating Centre for Acute Care,
  Royal College of Surgeons)
• Centre for Public Health - NICE

2
Today.

• Implementing the nutrition support guideline
• Consider the key priorities for improvement
• The 5 key research questions
• Potential for a national approach to conducting
  research on nutrition support

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Nutrition support in adults
Launched February 2006
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Tools to assist implementation

• NICE short version summary of the
  recommendations
• Full version purchased via the NCC-AC
• Quick Reference guide
• Information for the public
• Implementation guidance
• Audit criteria
• Slide set
• Cost impact tool

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Implementation, Implementation

• NICE has only recently in the last year been
  involved in developing guidance for
  implementation
• Why it was not NICEs original remit
• Why awareness that guidance on implementation
  is needed

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Access the guideline online

• Quick reference guide a summary
  www.nice.org.uk/CG032quickrefguide
• NICE guideline all of the recommendations
  www.nice.org.uk/CG032niceguideline
• Full guideline all of the evidence and
  rationale www.nice.org.uk/CG032fullguideline
• Information for the public a plain English
  version www.nice.org.uk/CG032publicinfo

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Access tools online

• Costing tools
• costing report
• costing template
• Audit criteria
• Implementation advice
• Available from www.nice.org.uk/cg032

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Who is involved or considering ways to implement
the guideline?
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Understanding why this guideline was proposed can
assist implementation

• Topics proposed public, clinicians
• Where there are known problems, variation in
  practice
• Proposals via the Department of Health
• Why this guideline
• - because it is well recognised that many
  patients are malnourished
• - debate about the efficiency of oral sip feeds

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Why should the guideline be implemented?

• NICE guidelines are based on the best available
  evidence
• The Department of Health asks NHS organisations
  to work towards implementing guidelines
• Compliance will be monitored by the Healthcare
  Commission

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How was the guideline developed?

• 2 ½ years of development
• Multi disciplinary Guideline Development Group
  (15)
• Technical team (10)
• Stakeholders (100)
• Evidence searched screening, oral, enteral,
  parenteral, dysphagia, monitoring, nutrition
  support teams
• Evidence searched All populations

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Making sense of the evidence

• Searched for RCTs
• Studies in pockets Intensive Care, Surgery
• Difficult to make recommendations for specific
  populations e.g. orthopaedic, oncology
• Many problems with the studies
• Heterogeneity
• Indications for intervention differed between
  studies
• Controls
• Starting times
• Routes of support
• Duration of support
• Outcome measures

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Making Recommendations

• 77 recommendations
• Definite evidence for 17 recommendations
• In the absence of evidence
• - informal consensus
• - formal consensus - screening

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Issues in Nutrition Support
WHO ?
WHEN ?
WHAT ?
HOW ?
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Focus of recommendations is on Nutritional
Status not setting.

• Guideline useful for patients in Hospital and the
  Community

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Organisation of nutrition support
SCREEN
RECOGNISE
TREAT
ORAL
ENTERAL
PARENTERAL
MONITOR AND DOCUMENT
REVIEW
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Implementing the guideline

• 77 recommendations made but.
• 10 Key Priorities for Implementation

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The whole team makes it happen 4 of the Key
Priorities

• Healthcare professionals involved in patient care
  should receive education and training on
  nutrition support
• All people who need nutrition support should
  receive coordinated care from a multidisciplinary
  team
• Acute trusts should employ at least one
  specialist nutrition support nurse
• Hospital trusts should have a nutrition steering
  committee working within the clinical governance
  framework

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Screening
Where When
Hospital inpatients On admission and repeated weekly
Hospital outpatients First clinic appointment and when there is clinical concern
Care homes On admission and when there is clinical concern
General practice Initial registration, when there is clinical concern and opportunistically, e.g. flu jabs, long term condition clinics

• use a screening tool that includes BMI,
  percentage unintentional weight loss and
  consideration of the time over which nutrient
  intake has been reduced or likelihood of future
  impaired intake e.g. MUST

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Suggested actions

• Clearly identify who is responsible for screening
  in all care settings including care homes
• Ensure staff have access to and are using
  appropriate screening and assessment tools
• Ensure staff have access to appropriate equipment
  in the hospital and community setting, e.g.
  weighing scales that are regularly serviced

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Recognise who is malnourished

• Malnourished one or more of the following
• BMI of less than 18.5 kg/m²
• unintentional weight loss greater than 10
  within the last 3-6 months
• BMI of less than 20 kg/m² and unintentional
  weight loss greater than 5 within the last 3-6
  months

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Recognise who is at risk

• At risk of malnutrition one or more of the
  following
• eaten little or nothing for more than 5 days
  and/or likely to eat little or nothing for the
  next 5 days or longer
• poor absorptive capacity, are catabolic and/or
  have high nutrient losses and/or have increased
  nutritional needs

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When and what to give

• Health Care professionals should consider using
  oral, enteral or parenteral nutrition support
  alone or in combination, for people who are
  either malnourished or at risk of malnutrition,
  as defined above.
• Potential swallowing problems should be taken
  into account

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For patients with Dysphagia dont forget the
guidance

• Dysphagia- a key issue in the remit for the
  guideline
• No studies found on the benefits of modifying
  textures
• Working party of Speech therapists agreed
  recommendations
• Focus- obvious and less obvious indicators of
  dysphagia
• Caution on use of modifying textures of food and
  fluid

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Indicators of Dysphagia

• Obvious indicators
• Difficult, painful chewing/swallowing
• Regurgitation of undigested food
• Difficulty controlling food/fluid in mouth
• Drooling
• Hoarse voice
• Coughing or choking before, during or after
  swallowing
• Feeling of obstruction

• Less obvious indicators
• Change in respiration pattern
• Unexplained temperature spikes
• Wet voice quality
• Tongue fasciculation
• Heart burn
• Throat clearing
• Recurrent chest infections
• Atypical chest pain

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If the person has dysphagia

• Recognise co-morbidities that increase the risk
  of dysphagia
• People who present with any obvious or less
  obvious indicators of dysphagia should be
  referred to healthcare professionals with
  relevant skills and training in the diagnosis,
  assessment and management of swallowing disorders
• People with dysphagia should be given a drug
  review to ascertain if the current drug
  formulation, route and timing of administration
  remains appropriate and without contraindications

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• Dont be overwhelmed by the guideline?

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Why guidelines are not implemented?

• Dont know or forget about the guideline
• Dont agree with the recommendations
• Isolation professionals disagree with the
  recommendations
• Psychological the patients wont like it
• Limited resources time, money, skills
• Organisational issues barriers to change
• Some recommendations easy to implement and
  require one person compared to others requiring a
  team approach to bring about change

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Solutions

• Dont know or forget about the guideline
• Dont agree with the recommendations
• Isolation professionals disagree with the
  recommendations
• Psychological the patients wont like it
• Limited resources time, money, skills
• Organisational issues barriers to change
• Some recommendations easy to implement and
  require one person compared to others requiring a
  team approach to bring about change

• Promote raise awareness posters, talks
• Team approach steering group to decide on
  strategies to improve clinician and patient
  confidence and adherence

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What can dietitians do to assist implementation?
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Dietitians are some of the key people who could
assist implementation of the guideline?

• Awareness and understanding about the potential
  number of patients who are malnourished or at
  risk?
• Concerned that variation in practice is not
  effective
• The guideline is a useful tool that can influence
  practice and improve the delivery of nutrition
  support
• Dietitians have the knowledge and experience to
  have a vital impact on education and developing
  systems to improve the delivery of nutrition
  support

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Suggested actions

• Identify an implementation group strategy
• Raise awareness of the guideline recommendations
  and why it is needed among all staff directly
  involved in patient care
• Include nutrition support within induction
  programmes
• Identify staff training needs and provide
  training using externally commissioned and
  in-house programmes
• Review service protocols and care pathways
• Audit current practice

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Research Recommendations

• Several research recommendations were proposed
• 5 were identified key research questions
• these were areas where the GDG had the greatest
  difficulty to propose a recommendation due to the
  paucity of evidence in that clinical area
• and if research is conducted in these areas this
  would potentially improve NICE guidance and
  ultimately patient care in the future

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The 5 key research recommendations

• Education
• Screening
• Oral nutritional supplements
• Monitoring
• Enteral tube feeding

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The research recommendations

• Formal educational intervention for all health
  care professionals v no formal education
• Nutritional screening programme v no screening
  programme
• - in primary care,
• - care homes (dementia),
• - inpatients,
• - outpatients
• Which components of nutritional monitoring are
  clinical and cost effective?

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The research recommendations

• Oral nutritional supplements
• v dietary modification/food fortificatn
• v dietary modification/food fortification /-
  dietary counselling
• Enteral tube feeding v no enteral tube feeding
• in people with dementia and dysphagia

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Which ones would you be interested in being
involved with?

• Education
• Screening
• Oral nutritional supplements
• Monitoring
• Enteral tube feeding

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What would the study be like?

• Scenario Screening has never been done in an
  outpatient setting
• Outpatient Aim to screen patients attending out
  patients on Mon, Tues and Thurs
• What to do trained nurse or researcher
• Weight, height, history of food intake patient
  reports reduction or improvement in appetite
• Clearly define (measures)

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Outcomes for the research questions

• change in nutritional status
• hospital admissions, hospital duration
• GP visits
• complications
• survival
• quality of life
• cost effectiveness

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NICE and the key research questions

• NICE will consider the 5 key research questions
• Propose and lobby potential funders via the NHS
  RD
• NICE will also support and back
  proposals/protocols for the research
  recommendations and emphasise their importance
  and the potential need to improve the evidence in
  a guideline

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Research, money resources proving the case

• While considering a protocol for a research
  question
• Conduct an audit of the area of interest
  (example to be inserted)
• this will help raise the profile that the problem
  probably continues and add to the case that
  research is needed
• Dont run off in enthusiasm and try to conduct a
  study on your own
• Do become involved in setting the agenda for
  research there is a fundamental problem out
  there. Poor infrastructure for delivering
  nutrition support

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Proposals for setting up research

• national approach to study design several
  centres agree on a well developed protocol for
  study (BAPEN, PENG, BDA)
• number of centres carry out studies increase
  patient number
• potentially quicker to produce evidence and
  influence the update of the guideline
• national coordinator
• focus on useful and meaningful outcomes

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How many will benefit from this guideline?
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Everyone has a part to play

• This guideline should
• help healthcare professionals recognise
  malnourished patients and those at risk
• guide healthcare professionals to choose the best
  method of nutrition support
• reduce the number of people with malnutrition
• Set the agenda for further research in nutrition
  support