Title: Nutrition support in adults
1Nutrition support in adults
February 2006
2Changing clinical practice
- 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
3Malnutrition
- Malnutrition is a state in which a deficiency of
nutrients - such as energy, protein, vitamins and minerals
causes - measurable adverse effects on tissue composition,
- function or clinical outcome
4Prevalence
- Estimates vary depending upon the screening tool
used - Using body mass index (BMI lt20 kg/m² )
- 10-40 of adults in hospitals and care homes
are underweight - lt5 underweight in the general population at
home
5The need for this guideline
- Malnutrition is common
- It increases a patients vulnerability to ill
health - Nutrition in the home or in hospital may not be
adequate - Decisions on providing nutrition support are
complex - There is a wide variation in nutritional care
standards
6Nutrition support
- Methods to improve or maintain nutritional
intake - oral nutrition support e.g. food, fortified
food, sip feeds - enteral tube feeding delivery of a
nutritionally complete feed directly into the gut
via a tube - parenteral nutrition delivery of complete
nutrition intravenously
7Organisation of nutrition support
SCREEN
RECOGNISE
TREAT
ORAL
ENTERAL
PARENTERAL
MONITOR AND DOCUMENT
REVIEW
8What needs to happen
- Screen
- Recognise who is malnourished and who is at risk
- Treat oral, enteral, parenteral
- Monitor and review
- needs a multidisciplinary team
- where do you fit in?
9St. Bartholomews Hospital/Science Photo Library
10The whole team makes it happen
- 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
11Suggested actions
- Identify an implementation group
- Raise awareness of the guideline recommendations
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
12Screening
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
13Suggested 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
14Recognise 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
15Recognise 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
16Normal provision
- When unwell, normal food and drink with physical
help to eat if required, will often suffice - If this fails, is impractical or unsafe, measures
to provide nutrition support may be indicated - This nutrition support may be alone or in
combination - Oral
- Enteral
- Parenteral
17What to give
- The total nutrient intake of people prescribed
nutrition support should account for - energy, protein, fluid, electrolyte, mineral,
micronutrients and fibre needs - activity levels and the underlying clinical
condition - gastrointestinal tolerance, potential metabolic
instability and risk of refeeding problems - the likely duration of nutrition support
18Consider oral nutrition support
if patient malnourished/at risk of malnutrition
and
can swallow safely and gastrointestinal tract is
working
stop when the patient is established on
adequate oral intake from normal food
surgical patients may have different needs
19If 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
20High risk of refeeding problems
- One or more of the following
- BMI less than 16 kg/m
- unintentional weight loss greater than 15
within the last 3-6 months - little or no nutritional intake for more than
10 days - low levels of potassium, phosphate or magnesium
prior to feeding
- Two or more of the following
- BMI less than 18.5 kg/m
- unintentional weight loss greater than 10
within the last 3-6 months - little or no nutritional intake for more than 5
days - a history of alcohol abuse or drugs including
insulin, chemotherapy, antacids or diuretics
21High risk of refeeding problems
- Consider
- starting nutrition support at 10 kcal/kg/day max
- increasing levels slowly
- restoring circulatory volume and monitoring
fluid balance and clinical status - providing thiamin and multivitamin/trace element
supplement - providing extra potassium, phosphate and
magnesium
22Consider enteral tube feeding
if patient malnourished/at risk of
malnutrition despite the use of oral interventions
and
has a functional and accessible gastrointestinal
tract
use the most appropriate route of access and mode
of delivery
stop when the patient is established on
adequate oral intake from normal food
surgical patients may have different needs
23Consider parenteral nutrition
if patient malnourished/at risk of malnutrition
and has either
a non-functional, inaccessible or
perforated gastrointestinal tract
inadequate or unsafe oral or enteral nutritional
intake
introduce progressively and monitor closely
use the most appropriate route of access and mode
of delivery
surgical patients may have different needs
stop when the patient is established on
adequate oral intake from normal food or enteral
tube feeding
24Monitoring
- Review indications, route, risks, benefits and
goals of nutrition support at regular intervals - Frequency is dependent upon the patient, mode of
feeding, care setting and duration of nutrition
support - Review and update monitoring protocols in
hospital setting, e.g. nutritional,
anthropometric, clinical and laboratory
25Support in the community
- Supported by a co-ordinated multidisciplinary
team and receive an individualised care plan - Given training and information on
- management of delivery systems and the
regimen and how to troubleshoot common
problems - delivery of equipment, ancillaries and feed
- Given routine and emergency telephone contact
numbers for appropriate healthcare professionals - Given contact details for relevant support
groups, charities and voluntary organisations
26Everyone has a part to play
- This guideline should
- help healthcare professionals recognise
malnourished patients and those at risk - guide healthcare professionals to chose the best
method of nutrition support - reduce the number of people with malnutrition
27Access tools online
- Costing tools
- costing report
- costing template
- Audit criteria
- Implementation advice
- Available from www.nice.org.uk/cg032
28Access 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