172.3 NUTRITION POLICY th - buckshealthcare.nhs.uk Policy.pdf · The consequences of malnutrition ... referred to the Speech and ... Patients who require food and/or fluid intake

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172.3 NUTRITION POLICY

Once printed off, this is an uncontrolled document. Please check the intranet for the most up to date copy.

Version: 3

Approved by:

Nursing , Midwifery and Therapy Professional Board 15th July 2013

Ratified by:

Risk Monitoring Group 4th September 2013

Name of originator/author: Liz Pryke, Nutrition and Dietetic Service Manager

Liz Evans, Nutrition Nurse Specialist.

Lead Director Lynne Swiatczak Chief Nurse and Director of Patient Care Standards

Name of responsible Nutrition Steering Committee

committee/individual:

Document reference: BHT Pol 112

Date issued: 4th July 2008

Review date: June 2013

New review date: June 2016

Target audience: All clinical staff

Uploaded to the Intranet: 23rd September 2013

See also: Guideline 65 Identifying Adult Patients at Risk of Under Nutrition and Dehydration Guideline 209 Adult Parenteral Nutrition Guideline 243 Protected Mealtimes Policy Guideline 276 Refeeding Syndrome Guideline 298 Adult Enteral Feeding Guideline 389 Weighing Neonates, Infants and Children Guideline 689 Adult Oral Nutritional Support

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Contents

1. Introduction ........................................................................................................................ 3

2. Organisational responsibilities ............................................................................................ 3

3. On admission ..................................................................................................................... 3

4. During hospital stay ............................................................................................................ 5

5. Catering service ................................................................................................................. 6

6. Education ........................................................................................................................... 6

7. Discharge process ............................................................................................................. 6

8. Monitoring the effectiveness of the policy ........................................................................... 7

9. Consultation and ratification ............................................................................................... 7

10. References ..................................................................................................................... 7

Appendix 1: Nutrition Steering Committee Terms of Reference ................................................ 9

Appendix 2: Malnutrition Universal Screening Tool (MUST) .................................................... 10

Appendix 4: Screening Tool for the Assessment of Paediatrics (STAMP) ............................... 12

Appendix 5: Ward Food and Drink Record Chart .................................................................... 13

For the Spinal Nutrition Screening Tool – SNST (electronic tool on Spinal IMS) click here.

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1. Introduction

Nutrition is an essential part of clinical care for all patients.

On admission to hospital up to 30% of all patients are at risk of malnutrition (BAPEN 2008, 2009, 2010) and many patients have increased nutritional requirements during their hospital stay.

The consequences of malnutrition include vulnerability to infection, delayed wound healing, impaired function of heart and lungs, decreased muscle strength, depression and, ultimately, premature death.

It is therefore important that those who are malnourished or at risk are identified early, as patients with malnutrition stay in hospital for much longer, are 3 times as likely to develop complications after surgery and have a higher mortality rate (BAPEN 2006/Age Concern 2006).

The BAPEN nutritional screening weeks have clearly demonstrated that malnutrition is a significant public health issue which must be addressed in the community – where it starts (BAPEN 2010).

“Consistent and integrated strategies to detect, prevent and treat malnutrition must be developed to effectively address malnutrition in the community and within and between all care settings to ensure that the health outcomes for all being admitted to hospital, care and mental health units are not compromised.

Our data show that particular attention should be paid to those being transferred from one care setting to another.” (BAPEN 2007)

Nutritional care is a multidisciplinary responsibility and the Trust supports the contribution of all staff groups.

This policy has been developed to try and ensure that all patients have their nutritional requirements recognised and met.

It is also important to promote healthy eating for some patients and staff and, for those who eat in staff restaurants, a variety of healthy eating choices should be available. 2. Organisational responsibilities

The Trust will have a Nutrition Steering Committee that reports to the Nursing, Midwifery and Therapy Professional Board (Appendix 1 – Nutrition Steering Committee Terms of Reference).

The Trust will have a Nutrition Support Team at both Stoke Mandeville Hospital and Wycombe Hospital. The team will comprise of a specialist pharmacist, specialist dietitian, nutrition nurse specialist and consultant.

All inpatient units will have a nutrition link nurse (RN) and there will be a nutritional lead for the community integrated team who will attend regular Nutrition Link Nurse Meetings (chaired by the nutrition nurse specialist) and be responsible for disseminating information back to their ward/work area.

3. On admission

a) Nutritional screening

All adult inpatients will be nutritionally screened within 24 hours of admission and paediatric inpatients screened within 48 hours of admission, to try and identify those who are or are at risk of becoming malnourished (NICE 2006/Council for Europe 2007).

Screening tools used: - Adult patients - MUST (Malnutrition Universal Screening Tool), Appendix 2. - Adult patients with spinal injuries - SNST (Spinal Nutritional Screening Tool –

electronic tool on Spinal IMS). - Paediatric patients - STAMP (Screening Tool for the Assessment of Paediatrics),

Appendix 3.

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All community patients will be nutritionally screened using MUST and have a Waterlow Assessment completed at first assessment on admission to the caseload.

Palliative care patients will be individually assessed and individualised care plans will be developed.

The majority of maternity patients who are in hospital for a short length of time are not nutritionally at risk; therefore they will be nutritionally screened at the direction of the nursing staff.

All patients in critical care will be nutritionally assessed by a dietitian.

Details of nutritional screening will be documented in the individual patient’s medical notes or patient held documentation in the community.

All patients will be weighed on admission and have their height recorded. If this is not possible, the reason why should be documented in the patient notes.

A patient specific care plan will be written, implemented and monitored by nursing staff.

Community patients may require the assistance of carers or family for meal preparation and feeding, and individualised care plans should be negotiated with the patient and their carer or family.

Appropriately trained professionals will carry out nutritional screening. It is the responsibility of the ward manager or case manager to decide who has the responsibility for screening and ensure they are appropriately trained.

Suitable equipment for measuring height and weight will be available in all inpatient clinical areas. In a patient's home, MUST guidelines for alternative measurements are to be used if weight and height cannot be reliably measured.

If a patient is at risk of refeeding syndrome they should be discussed with the ward dietitian and Trust guidelines followed (Guideline 276).

Inpatients will be re-screened weekly or sooner if the patient’s condition changes. Community patients will be re-screened according to MUST guidelines or sooner if the patient's condition changes.

Children: All children will be weighed on admission and weekly thereafter. This will be interpreted by a doctor, nurse or dietitian (see Guideline 389 Weighing Neonates, Infants and Children).

Vulnerable adults: Any adult who is considered at risk from poor nutrition, for example those with learning, physical or sensory disability or those who suffer from depression or any type of dementia, should be screened on admission and, if necessary, be referred to the appropriate MDT member. An appropriate plan of care should be drawn up for them and consultation should be sought from the patient and carer. Meals should not be selected for these patients without their input – every effort should be made to find out their likes and dislikes and menus chosen by them accordingly.

Patients attending the Day Hospital will be nutritionally screened on their first visit and then if their condition changes.

Patients attending Chemotherapy Units will be nutritionally screened on their first visit and then if their condition changes.

All patients attending Outpatient Clinics will be weighed (specific clinics may be excluded from this, as agreed by Nutrition Committee). Children attending Outpatient Clinics will have their weight and height recorded.

b) Referral

All patients requiring parenteral nutrition should be referred to the Nutrition Support Team for initial assessment and advice (Guideline 209 Adult Parenteral Nutrition).

All patients requiring enteral nutrition should be referred to the dietitians on weekdays (starter nasogastric regimens are available in ward nutrition folders/intranet for out-of-hours) (Guideline 298 Adult Enteral Feeding). For community hospital and community patients established on enteral feeding, a community dietitian will be available to advise and support patients and carers.

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Patients with symptoms of neurological dysphagia or swallowing difficulties should be referred to the Speech and Language Therapy team. On the Stroke Unit where dysphagia trained nurses carry out swallow screening, they should ensure that the correct paperwork is completed and their recommendations should be documented in the patient’s medical records. The speech and language therapist should also be informed.

For all patients who are at risk of refeeding syndrome follow Trust guidelines (Guideline 276 Refeeding Syndrome) and discuss with ward dietitian.

Those patients requiring referral to a dietitian should be referred using the appropriate acute or community dietetic referral form and a nutritional screening tool score should be included on the referral (MUST, SNST or STAMP). Any member of the multidisciplinary team can make a referral.

For all inpatients who require a special therapeutic/ethnic diet, ward staff should contact their identified catering department (this will vary between sites, it may be the Helpdesk, catering department or catering staff at ward level). If the patient is following a complicated therapeutic diet or requires education please also refer for dietetic advice. Patients requiring education on weight reduction may be seen as an outpatient.

4. During hospital stay

Nursing staff will be responsible for ensuring that a meal has been ordered for every patient that is eating.

All staff should be aware of and adhere to the Protected Mealtimes Policy.

Nursing staff will be responsible for ensuring that the patient is ready for their meal (immediate area clear, hand wipes available, position of patient, etc.).

Hand wipes will be provided to assist patients with hand hygiene prior to eating.

Adequate numbers of appropriately trained staff must be available at mealtimes to ensure patients who require help with eating and drinking receive sufficient assistance.

Nursing staff should ensure that patients who require a special therapeutic diet are served with appropriate food/fluids.

Nursing staff should ensure that all ward and domestic staff involved in serving food/drinks to patients are aware of patients who require special therapeutic diets.

Patients should be helped whilst their meals are hot and appetising.

Patients who require support with eating and drinking should be clearly identified (e.g. red tray system – see Guideline 65 Identifying Adult Patients at Risk of Under Nutrition and Dehydration).

Patients who require food and/or fluid intake to be monitored must have informative, accurate and up-to-date food/fluid charts kept (Trust Food Record Chart - Appendix 4).

Ward staff should ensure that patients are provided with suitable aids to facilitate independent feeding (e.g. special cutlery, plates).

Patients should be offered a replacement meal if they miss their meal for any reason and can access snacks at ward level.

Every effort should be made to ensure that patients are able to enjoy their meal with dignity and privacy.

In the home: - Where patients are unable to self-manage their nutrition needs, case managers

should liaise with social care and/or families to ensure that the patient's nutritional needs are met in the home.

- Advice should be given regarding food fortification and the use of aids for eating and drinking, if necessary.

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5. Catering service

A 24 hour catering service is available and patients will have access to: - Hot/cold drinks and light refreshments (e.g. biscuits, cereal, etc.) - Snack boxes/light bites/hot meals are available to patients who have missed a meal

(this provision will vary between sites)

Daily menus for patient choice are available.

Daily meal programme will consist of:

Early morning drink Breakfast including drink Midmorning drink and snack* Hot lunch and drink Afternoon drink and snack* Supper and drink Evening drink (* Snacks will be provided at least twice daily.)

Meals/snacks/drinks will meet the estimated average requirement (EAR) for energy and reference nutrient intake (RNI) for protein, vitamins and minerals (DH 91).

Patients with cultural or religious dietary requirements will be catered for.

Patients who require a special therapeutic diet will be catered for.

Breastfeeding mothers who are staying with their children whilst inpatients will be supplied with sufficient food and drinks from the patient menu to support breastfeeding.

Facilities should be made available which encourage parents of young children to be resident during their stay. Parental separation anxiety in children inhibits nutritional and fluid intake. Parents are also very helpful in that they know what and when their child will eat. They usually want to feed and monitor intake and will assist staff if their child is not eating/drinking enough.

Patients should receive food presented in a way that is appealing and appetising.

Patients should be involved in planning/monitoring arrangements for food service provision.

Food and drinks should be served at the correct temperature for patient preference and meet the safety standards at all times.

Suitable crockery and utensils should be available at ward level.

All staff serving or handling food and drink will receive appropriate training to do so.

All patients will have access to a full colour menu in order that they can make an informed choice.

Staff

For those who work within the Trust and eat in the restaurants on the site (where available), a variety of healthy eating options should be available to enable staff to choose a well balanced diet.

6. Education

The nutrition nurse specialist/Nutrition and Dietetic Department will ensure that a robust training programme is maintained throughout the Trust. This will target all nurses, other health professionals and housekeepers. It will include liaison with patient experience groups, senior nursing groups and the university to ensure that nutritional care is given the highest priority. All nutrition programmes and study days will be audited and fed back to the Nutrition Steering Committee (NICE Guidelines 2006).

7. Discharge process

Any special dietary requirement or nutritional risk should be part of the nursing/medical discharge summary and clearly reported to any relevant healthcare professional in the community (and carer as appropriate).

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Community discharge process: If a nutritional risk remains on discharge from the caseload, self management advice or advice to carers or family should be provided.

When patients are discharged home on enteral nutrition (nasogastric/gastrostomy/ jejunostomy feeds) locally agreed guidelines should be followed to ensure transition from hospital to home is managed effectively. Adequate notice of discharge will allow effective training and equipment for home to be arranged (see Guideline 298 Adult Enteral Feeding).

Patients discharged home on enteral nutrition (nasogastric/gastrostomy/jejunostomy feeds) will be given training suited to their needs before discharge, to allow them to manage the feed safely at home.

Patients discharged home feeding via a nasogastric tube will require special arrangements to be made by the discharging ward for care of the tube and to manage tube feeding.

Patients who are being considered for home parenteral nutrition should be referred to the Nutrition Support Team for arrangements to be made.

8. Monitoring the effectiveness of the policy

Essence of Care – patient focused benchmark food and nutrition

PLACE inspections

PET/patient satisfaction surveys

Formal catering monitoring

Audits of nutritional screening/appropriate equipment/red tray/protected mealtimes/ discharge process

Feedback from patient experience groups

Breaches to be reported via incident reporting system

9. Consultation and ratification

The consultation for this policy will include:

Members of the Nutrition Steering Committee

Members of Nursing, Midwifery and Therapy Professionals Board

Matrons

Managers (including departmental managers which may be affected, such as Speech and Language Therapy/Nutrition and Dietetics/Infection Control)

Property services/catering

Patient Experience Group

Risk Monitoring Group

10. References

Council of Europe Resolution on Food and Nutritional Care in Hospitals (November 2003).

Improving Nutritional Care: A joint action plan from the Department of Health and Nutrition Summit Stakeholders [2007].

Organisation of Food and Nutritional Support in Hospital (2007), BAPEN.

Death by Indifference, Mencap 2007.

Dietary Reference Values (1991). Department of Health.

Hungry to be Heard (2006). Age Concern England.

Russell C A , Elia M (2008). Nutrition screening survey in the UK in 2007, Redditch, BAPEN.

Russell C A , Elia M (2009). Nutrition screening survey in the UK in 2008, Redditch, BAPEN.

National Institute for Health and Clinical Excellence (NICE) 2006. Nutritional Support in Adults, CG32.

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BAPEN (2011). Nutrition screening survey in the UK and Republic of Ireland in 2010.

British Dietetic Association (BDA) 2012. The Nutrition and Hydration Digest: Improving Outcomes through Food and Beverage Services.

Care Quality Commission (CQC) 2010. Essential Standards of Quality and Care, Outcome 5.

NICE (2006) Clinical Guideline 32 Nutrition support in adults

Spinal Nutrition Screening Tool http://swanlive/sites/default/files/nutrition_care_plans_how_to.pdf

Appendices Appendix 1 Nutrition Steering Committee Terms of Reference Appendix 2 Malnutrition Universal Screening Tool (MUST) Appendix 3 Screening Tool for the Assessment of Paediatrics (STAMP) Appendix 4 Ward Food and Drink Record Chart (WZZ 1570) For the Spinal Nutrition Screening Tool (electronic tool on Spinal IMS) click here.

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Appendix 1

Nutrition Steering Committee Terms of Reference

1. Name of Group The Nutrition Steering Committee is a sub committee of the Nursing, Midwifery and Therapy Professional Board.

2. Purpose of Committee The Nutrition Steering Committee provides professional guidance on nutritional issues which are relevant to the Trust.

3. Key Tasks 3.1 To develop the Trust’s Nutrition Strategy and Action Plan. 3.2 To monitor and support the implementation of the Nutrition Strategy. 3.3 To provide a forum for raising the profile of nutrition within the Trust. 3.4 To discuss and, where appropriate, implement national nutritional priorities and

guidelines. 3.5 To provide educational and continued professional development in nutrition to all grades

of staff. 3.6 To investigate any incident reports related to provision of nutrition in the Trust. 3.7 To facilitate and monitor the nutritional content and quality of meals supplied to the

Trust.

4. Membership Membership is open to representatives from the following areas: Consultant Gastroenterologist (Chair) Consultant Surgeon Dietetics – acute and community Facilities and Estates – representing Trust catering Medicine management Nursing – Matron from each of three divisions. Nutrition Specialist Nurse Nursing - community PALS Pharmacy Speech and Language Therapy

5. Frequency of Meetings The Nutrition Steering Committee shall meet bi-monthly, alternating between Stoke Mandeville and Wycombe Hospital sites.

6. Quorum A quorum shall be 5 members from 3 professional groups. If members are unable to attend they should send an appropriate deputy to attend on their behalf if possible.

7. Reporting Arrangements Minutes of the meeting to be reported to Nursing, Midwifery and Therapy Professionals Board. Agenda and any supporting papers to be sent out to each member of the committee one week before the date of the meeting.

8. Links to other committees Nutrition Link Nurse Meeting Catering Quality Review Group at Wycombe Domestic Service Review Group at Stoke Mandeville Housekeeper Group Spinal Nutrition Group

January 2013

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Appendix 2

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Appendix 3

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Appendix 4

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