Nutrition support in adults

1
Nutrition support in adults
February 2006
2
Changing 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

3
Malnutrition

• 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

4
Prevalence

• 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

5
The 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

6
Nutrition 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

7
Organisation of nutrition support
SCREEN
RECOGNISE
TREAT
ORAL
ENTERAL
PARENTERAL
MONITOR AND DOCUMENT
REVIEW
8
What 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?

9
St. Bartholomews Hospital/Science Photo Library
10
The 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

11
Suggested 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

12
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

13
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

14
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

15
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

16
Normal 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

17
What 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

18
Consider 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
19
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

20
High 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

21
High 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

22
Consider 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
23
Consider 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
24
Monitoring

• 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

25
Support 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

26
Everyone 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

27
Access tools online

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

28
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