NICE Shared Learning Awards
Submission title: A Partnership approach to improving the nutritional care of our patients
Supporting information
1. NICE guidance clinical position statement – presented to Trust Clinical Effectiveness Committee and the Nursing and Midwifery Governance Committee
2. Terms of reference for Nutrition Steering Committee
3. NSC Reporting structure
4. Progress Update January 07
5. NSC Action Plan May 08
6. Minutes of June 08 NSC meeting
7. Examples of audit pre-NICE guidance
Parenteral Nutrition Audit
Essence of Care Food & Nutrition audit
8. Examples of audit post- NICE guidance
Catering Standards Audit 2007
MUST Audit
9. Examples of projects/actions
· Protected Mealtimes Policy May 08
· Positioning Leaflet for patients requiring assistance with feeding
· Re-feeding Syndrome Protocol
· Guidelines for Parenteral Nutrition
· Referral Form for Parenteral Nutrition
· TPN care Bundle
1. NICE Clinical Guideline 32 – Nutrition Support in Adults (Feb 06)
1. Introduction
The Trust Board ratified a Nutrition Strategy in 2004, the aim of which was to ensure:
… the patient receives the type of nutrition that he or she requires, at the right time, via the most appropriate route when they need it …”
The strategy sought to propose a 5 year action plan addressing:
n Delivery of Nutritional Care
n Clinical Risk
n Resources
n Innovations in Practice
As we enter Year 3 of the action plan, the recent publication of the NICE guidance;
the completion of the Food and Nutrition Essence of Care (EOC) audit and the results of the In-patient survey provide further impetus to continue to improve the delivery of nutritional care to our patients.
Nurses are key to the successful delivery of nutritional care. Nutrition is fundamental to good patient care and the needs of the patient are best addressed using a multi-disciplinary approach.
This paper aims to:
· Raise the Nutrition Steering Committee‘s awareness of the NICE guidance, drawing on relevant aspects of the EOC and the In-patient survey results.
· Consider the Trust’s current position in relation to the guidance
· Make recommendations for joint implementation across the organisation.
2. NICE guidance - Key priorities for implementation
The guideline offers best practice advice on the care of adults who are malnourished or at risk of malnutrition. The following recommendations are identified as priorities:
2.1 Key clinical priorities
• Screening for malnutrition or the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training.
• All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients
• Hospital departments who identify groups of patients with low risk of malnutrition may opt out of screening these groups. Opt-out decisions should follow an explicit process via the local clinical governance structure involving experts in nutrition support.
• Nutrition support should be considered in people who are malnourished, as defined by any of the following:
- a body mass index (BMI) of less than 18.5 kg/m2
- Unintentional weight loss greater than 10% within the last 3–6 months
- a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.
• Nutrition support should be considered in people at risk of malnutrition who, as defined by any of the following:
- have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer
- have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.
• Healthcare 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.
2.2 Key organisational priorities
• All healthcare professionals who are directly involved in patient care should receive education and training, relevant to their post, on the importance of providing adequate nutrition.
• Healthcare professionals should ensure that all people who need nutrition support receive coordinated care from a multidisciplinary team.
• All acute hospital trusts should employ at least one specialist nutrition support nurse.
• All hospital trusts should have a nutrition steering committee working within the clinical governance framework.
3. Current Trust Position
Comments are based on evidence resulting from the EOC audit, audits carried out as part of the Nutrition Strategy and knowledge of service delivery.
3.1 Key clinical priorities
3.1.1 Nutritional screening
A nutritional screening tool is currently in use across the organisation recommending screening on admission and at weekly intervals. Results of the EOC audit indicate screening occurs in 50% or less clinical areas. The evidence-based MUST tool recommended by NICE has been piloted in the Trust over the past few months and will be introduced in June06. However we do not routinely screen out-patients with the exception of certain pre-assessment clinics.
3.1.2 Recognising malnutrition
Current practice is in line with NICE guidance where the screening tool is used effectively. The EOC audit results show that staff generally have good knowledge of how to refer appropriately to the dietitian but have poor written evidence of referral.
3.1.3 Treatment of Malnutrition: Oral
Again current practice is in line with NICE guidance if screening is carried out. The Essence of Care audit highlighted issues around barriers to successful assisted feeding practice at ward level. These included lack of staff available at mealtimes and difficulty in identifying patients requiring assisted feeding. A well-defined pathway of care exists for patients with swallowing difficulties/dysphagia including a comprehensive training package.
3.1.4 Treatment of malnutrition: Enteral
The organisation is compliant with recommendations for access, management, delivery and use of motility agents with the exception of continuous nasogastric feeding in ITU patients and the introduction of feed following PEG insertion. Care bundles are set up to look at nutrition in critical care and the management of PEG tubes.
Policies exist for placement and aspiration of naso-gastric tubes. A multi-disciplinary group have met to agree purchase of most suitable nasogastric tubes and pH paper.
3.1.5 Treatment of malnutrition: Parenteral
We are largely non-compliant with NICE guidance for access routes as an organisation.Cannula’s are used for peripheral feeding and Hickman or CVP lines for central access. TPN is not introduced at 50% estimated needs, nutritional requirements are not routinely assessed by appropriate healthcare professionals and we are not always adding vitamins and minerals to bags. TPN is not always discontinued using a step down approach.
3.1.6 Prescription
The organisation is compliant with recommendations for prescription of nutritional support. The Trust’s refeeding policy requires minor adjustments to adhere to NICE and will then be submitted to Pathfinder.
3.1.7 Monitoring
Current practice is in line with NICE guidance with the exception of re-screening on a regular basis. The EOC audit indicated this practice was generally poor particularly in terms of documentation.
3.2 Key organisational priorities
3.2.1 Education and training
All clinical areas have been offered the opportunity to access a Nutrition Link Nurse (NLN) training programme.EOC audit results indicate that not all clinical areas have access to a NLN. Dietetic assistants undertake nutritional training and will be able to access an NVQ Level 3 qualification in the near future. Nutrition training takes place for clinical teams. There is limited input into medical training. Training for housekeepers and catering staff is provided by the Trust’s Informed Client Dietitian.
3.2.2 Nutrition team including Specialist Nutrition Nurse
The need for a nutrition team was identified in the Trusts Nutrition Strategy however funding for a Specialist Nutrition Nurse and ring fenced medical time has not been identified.
3.2.3 Nutrition Steering Committee
Membership of the committee has been identified with the first meeting planned for May06. The group will report to the Clinical Effectiveness committee and link to the EOC steering group. The remit of the group will be to action findings of the EOC audit and implement NICE guidance.
4. Recommendations for implementation
· Introduction of screening into out-patient areas applying Opt-out criteria for those low risk specialities. Ensure the MUST tool is an integral part of assessments carried out on admission.
· Establish a Specialist Nutrition Nurse role to support colleagues to:
- minimise complications related to enteral tube feeding and parenteral nutrition
- ensure optimal ward-based training of nurses
- ensure adherence to nutrition support protocols
- support coordination of care between the hospital and the community.
· A business case be prepared to support the funded establishment of a Nutrition team with a responsibility for the management of patients requiring TPN
· Support the Nutrition Steering Group within the clinical governance framework i.e. through links with the Essence of Care group, Clinical Effectiveness Committee , NMGCB
· Ensure all healthcare professionals who are directly involved in patient care should receive education and training, relevant to their post, on the importance of providing adequate nutrition. Re-launch the Nutrition Link Nurse programme
· Education and training should cover:
• Nutritional needs and indications for nutrition support
• Options for nutrition support (oral, enteral and parenteral)
• Ethical and legal concepts
• Potential risks and benefits
• When and where to seek expert advice.
· Ensure patients and carers are adequately represented on the Nutrition Steering Group and in discussions around service developments. Consider carer/public involvement in addressing the problems of assisted feeding e.g. volunteer feeder programme.
5. Financial implications
The estimated costs of meeting the recommendations include:
· Establishing a Nutrition Team and employing a Specialist Nutrition Nurse
- Band 7 Extended Scope Practitioner (Artificial Nutrition)0.5WTE
- Band 6 Specialist Nutrition Nurse1.0 WTE £31686 (mid point)
- Ring fenced Consultant time 2 PA’s
- Additional pharmaceutical advisory time 0.1WTE Band 7
Costs will vary depending on the model of Nutrition team adopted
· Fully implementing the proposals around screening and training
Additional costs may arise if backfill is required for staff to attend appropriate training .Training could be delivered jointly by nursing and dietetic staff in the most cost-effective manner i.e. through Nutrition Link Nurses, ward-based training, cascaded training etc.
6. Conclusion
This paper should inform the terms of Reference for the Nutrition Steering Group and provide potential actions for the organisation to improve delivery of nutritional care to our patients.
Linda Irons Director of Nutrition & Dietetic Services May 2006
2. SOUTH TEES HOSPITALS NHS TRUST
NUTRITION STEERINGCOMMITTEE
TERMS OF REFERENCE
1. Report to:-
1.1 CLINICAL EFFECTIVENESS COMMITTEE
2. Purpose
2.1 The purpose of the committee is to oversee the implementation of NICE guidance NC32 – Adult Nutritional Support, action plans resulting from the Essence of Care Food and Nutrition audit and other relevant documents. Issues relating to national, regional and local policies will be debated and ratified. In addition the forum will scrutinise and review the systems in place to ensure, monitor and improve the quality of nutritional care delivered to patients and their carers.
3. Membership
Director of Nutrition and Dietetics
Assistant Director of Nursing
Lead Clinicians – Medical and Surgical
Pharmacy representatives
Patient representatives
Speech and Language Therapy representative
Dietetic representatives JCUH/FHN
Clinical Matron Representatives JCUH/FHN
Specialist Nutrition Nurse
Informed Client Dietitian
Assistant Director of Hotel Services
Deputy Hotel Services Manager
Hotel Services Manager, PFI Partners
Clinical Risk representative
Each member will have a nominated deputy. Membership will be jointly agreed by the Nutrition Steering Committee. There should be a commitment that each nominated member will attend the full meeting. If for whatever reason they are unable to attend, then they should negotiate with their nominated deputy to attend in their absence.
Members are responsible for cascading the information in a timely way from the meetings to colleagues who they are representing. If asked to seek views on issues, they are responsible for leading this within their own sphere of responsibility to ensure that comprehensive views are used to inform decision-making.
4. The Committee will review the membership of the Committee annually to ensure that it best reflects the requirements of the agenda within the Trust.
4.1 The chair of the group should be the Director of Nutrition and Dietetic Services
4.2 Individuals may be co-opted for specific projects.
5. A Quorum
A quorum will consist of not less than 60% of the members of the Committee present.
In instances where there are divided votes, the Chair or nominated deputy will make the final decision.
6. Procedures
6.1 The minutes will be approved by the whole Committee at the next
meeting.
6.2 Any member of staff may raise an issue with the Chair. The Chair will
decide whether or not the issue shall be included in the Committee’s business. The individual raising the matter may be invited to attend.
7. Frequency of Meetings
7.1 Meetings will be held no less than quarterly in each accounting year.
7.2 Extraordinary meetings may be called by the Chair or at the request of any member via the Chair.
8. Duties and Responsibilities
8.1 Each meeting will be structured with a pre-determined agenda.
Apologies will be required from those members who are unable to attend and minutes will be sent.
8.2 The Nutrition Steering Committee will consider any matters relating to nutritional care which will include:
a) The implementation, development and ongoing management of nutritional care related to the Trust.
b) The establishment and maintenance of procedures and systems to underpin the safe and effective delivery of nutritional care in the Trust.
8.3 Monitor the work of other groups, Committees, Forums, etc relating to nutritional care.
8.4 Review trends and/or issues arising from other internal and external groups.
8.5 Recommendations arising from the work of any nutritional care groups will be considered at the Governance Committee for debate and approval.
9. Review
The Clinical Effectiveness Committee will review the Terms of Reference of the Nutrition Steering Committee annually to ensure that it remains fit for purpose and is best facilitated to discharge its duties.