Nutrition Support Policy: Oral Nutrition and Enteral ... · Version 2.0 Approved 06/02/2017 Nutrition Support Policy: Oral Nutrition and Enteral Feeding (Adults Only) Current version

Version 2.0 Approved 06/02/2017

Nutrition Support Policy: Oral Nutrition and Enteral Feeding (Adults Only) Current version held on the Intranet

Check with Intranet that this printed copy is the latest issue

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Title:

Nutrition Support Policy: Oral Nutrition and Enteral Feeding (Adults Only)

Unique Identifier:

POL050

Document Type:

Policy

Version Number:

2.0

Status:

Approved

Responsible Director:

Director of Nursing

Author:

Anthony Twist, Dietitian

Scope:

Clinical Staff, Trust wide

Replaces:

To be Read in Conjunction with the Following Documents: (list related policies)

Mental Capacity Policy

Food Hygiene Policy

Keywords:

nutrition, refeeding, enteral, diet, dietitian

Considered By Executive Owner: Director of Nursing

Date Considered: 06/02/2017

Endorsed By:

Date Endorsed:

Approved By:

Director of Nursing

Date Approved:

06/02/2017

Issue Date:

06/02/2017

Review Date:

06/02/2019

Security Level:

Open Access Restricted Confidential




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Contents

1.Introduction……………………………………………………………………………………3 2.Definitions…………………………………………………………………………………….5 2.1 Malnutrition………………………………………………………………….……… 5 2.2 Nutrition Support……………………………………………………………. …. 5 2.3 Food First Approach……………………………………………………………… 5 2.4 Oral Nutrition Supplements……………………………………………………….6 2.5 Enteral Feeding…………………………………………………………………… 6 2.6 Refeeding Syndrome………………………………………………………………6 2.7 Body Mass Index………………………………………………………………… 6 2.8 Multi-Disciplinary Team…………………………………………………………... 6 3. Duties……………………………………………………………………………………. 6 3.1 Trust Board…………………………………………………………………………. 6 3.2 Director of Nursing………………………………………………………………. 7 3.3 Dietetic Team……………………………………………………………………… 7 3.4 Catering and Facilities Manager – refer to Trust ‘Food Hygiene & Code of practise’7

3.5 Speech and Language Therapists……………………………………………….7 3.6 Ward / Department managers…………………………………………………… 7 3.7 Healthcare Personnel…………………………………………………………… 7 3.8 Pharmacy……………………………………………………………………………7 3.9 Medical Staff……………………………………………………………………… 7 3.10 Infection Prevention and Control (IPCN)……………………………………… 7 4. Consent…………………………………………………………………………………… 8 5. Ethical and Legal considerations……………………………………………………... 8 6. Oral Nutrition Support…………………………………………………………………….8 7. Pathway for using ONS in the management of malnutrition…………………………8 8. Enteral Nutrition Support………………………………..…………………………… 8 9. Refeeding Syndrome…………………………………………………………………… 8 10. Record Keeping and Documentation………………………………………………… 9 11. Education and Training……………………………………………………………… 9 12. Review Process………………………………………………………………………… 9 13. Monitoring of this Document……………………………………………………………..9 14. Equality Impact Assessment (EQIA)…………………………………………………… 9 15. Implementation plan………………………………………………………………………10 16. Further Information / References………………………………………………………. 10 Appendix A: Nutrition Screening Tool (NST), NST Calculation and Care Plan

Implementation Appendix B : Pathway for using ONS in management of malnutrition. Appendix C: Enteral Nutrition Support Appendix D: NPSA Decision Tree for NG placement, NG Tube position confirmation and

bedside confirmation checklists

Appendix E: Refeeding Syndrome Guidelines Appendix F: Monitoring Programme for the Nutrition Support Policy




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1 Introduction: Purpose

Nutrition Support includes both the oral and enteral route of delivering nutrients including fluids to the gastrointestinal tract. Enteral feeding encompasses a range of different routes and systems for delivery of nutrition. Oral Nutritional Supplements (ONS) are a supplementary means of providing nutrition when there is difficulty or increased nutritional needs. ONS should not replace regular meals, snacks and drinks during the course of the day unless there is a medical reason to do so and the service user should be encouraged with oral dietary intake as best as possible.

The aim of this policy is to ensure that Healthcare workers are aware of the guidance for the care and management of patients who require Nutrition Support in either Oral Nutrition support and/or Enteral feeding. Parenteral Nutrition (PN) – the only indication for parenteral nutrition is failure of the gastrointestinal tract that is expected to last more than 7 days. The decision to request parenteral nutrition should be made by the patient’s supervising Consultant and documented in the medical notes. Any patient requiring parenteral nutrition will need to be transferred as soon as possible to an acute general hospital. The purpose of the policy is to:

Highlight those patients at risk of malnutrition through nutritional screening on admission and repeating this screening weekly or on change of condition.

Implement care plans for all patients with the view of improving nutritional outcomes and subsequent care.

Highlight the appropriate use of ONS and their prescription.

Minimise the risk of infection associated with enteral feeding.

Ensure compliance with National Guidelines for the management of enteral feeding.

Provide enteral feeding in patients who are malnourished or at risk of malnutrition.

Introduction: Scope This policy applies to all staff employed by the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, and also to all visiting staff including tutors, students, bank staff and agency/locum staff. Every member of staff has personal responsibility to ensure they comply with this policy.

Introduction: Background

Malnutrition is a state in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition), function or clinical outcome (NICE, 2006). Although the term ‘malnutrition’ can encompass both overnutrition/obesity and undernutrition, for the remainder of this document the term is only used to mean undernutrition.

Nutrition is a fundamental part of care. Malnutrition is common in all types of hospitals and care homes, all types of wards and diagnostic categories, and all ages. Malnutrition varies significantly according to the source of admission (own home, another hospital, another ward, care home), type of admission (i.e. emergency versus elective) and type of ward (i.e. care of the elderly, orthopaedic / trauma wards) (BAPEN 2012). The benefits of improving nutritional care and providing adequate hydration are immense, especially for those with long




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term conditions and problems such as stroke, pressure ulcers and falls (DOH, 2010). Age UK reports that patients over the age of 80 admitted to hospital have a five times higher prevalence of malnutrition than those under the age of 50 (BAPEN 2012). According to the BAPEN national nutrition screening survey April 2011, an average of 25% patients admitted to hospitals in England and Wales are malnourished (BAPEN, 2012). It is common and affects over 3 million people in the UK with associated health costs exceeding £13 billion annually. It is often unrecognised and untreated, yet it has a substantial impact on health and disease in all community care settings and hospitals (DOH, 2010). Malnutrition has detrimental effects on the individual, health, social services and society in general. Nutritional screening can identify those at risk and enable early intervention and avoid unnecessary problems from developing. When malnutrition is identified on admission to institutions it directs attention to the problems that led to its development before admission, such as disease, poverty, deprivation, geography, and attitudes towards nutrition, which can be influenced by education and training (BAPEN, 2012) Over recent years there has been an increase in the profile of Nutrition and its role in clinical care. ‘Nutrition and Patients: A Doctor’s Responsibility’ was published by the Royal College of Physicians in 2002 and gives clear direction on the doctor’s role while Essence of Care 2010 – Benchmark for food and drink highlights the role of Nurses (DOH, 2010). The National Patient Safety Agency (NPSA) has published a number of fact sheets highlighting the importance of nutrition care in the different settings within the hospital, while the Council of Europe published “10 Key characteristics of good nutritional care in hospitals. The National Institute for Health and Clinical Excellence (NICE) produced guidelines for ‘Nutrition Support in Adults’ in February 2006 and has written quality standards in association with NICE Guidelines for Nutrition Support(QS24, November 2012). Guidance from NICE identifies better nutritional care as the fourth largest potential source of cost savings to the NHS and nutrition and hydration are identified in the SHA Chief Nurses eight “high impact” clinical areas that could make huge cost savings for the NHS if Trusts and Care homes improved performance (BAPEN, 2010). Nutritional care is a multi-disciplinary responsibility, and the integration of workforce activities is absolutely essential. Without coordinated and complementary efforts of different healthcare workers, the result may be poor, even if individual disciplines excel (NPSA, 2008). Whilst nutritional screening in the April 2011 BAPEN national nutrition screening survey was found to be linked to care plans in most institutions, this was not routinely followed through into discharge planning. Continuity of nutritional care could therefore be hindered and at a vulnerable point in a patient’s journey, could be overlooked (BAPEN, 2010 and 2012). Improved nutritional care is dependant on effective management structures to ensure joined up multidisciplinary care pathways across acute and community settings. Clinical leadership, innovation and continual improvement are fundamental to the delivery of high quality nutritional care (NICE, 2006). Effective nutritional screening, nutritional care planning, high standards of food service delivery and appropriate nutritional support are therefore essential in all settings, and there is no doubt that a health service seeking to increase safety and clinical effectiveness must take nutritional care seriously (NICE, 2006). More recently the Department of Health has brought out The Hospital Food Standards Panel’s Report on Standards for Food and Drink in NHS Hospitals DoH and Age Uk August 2014. The panel recommends hospitals adhere to 5 required standards including the council




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of Europe key characteristics. RJAH has produced a Food and Drink Strategy as recommended by the panel.

2 Definitions The following definitions apply in this document: 2.1 Malnutrition Malnutrition is both a cause and consequence of ill health. Inadequate nutrition can lead to weight loss, nutritional deficiency, impaired immune function, decrease in cognitive function, depression and delayed rehabilitation. It is common and increases a patient’s vulnerability to disease. Malnutrition is a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function and clinical outcomes (NICE 2006) 2.2 Nutrition Support When a patient is unable to meet his/her nutritional requirements by oral feeding alone, nutritional support may be needed. These include

Oral nutrition support – for example, regular good quality meals, fortified food, additional snacks and/or ONS.

Enteral tube feeding – the delivery of a nutritionally complete feed directly into the gut via a tube

2.3 Food First Approach The “Food First” approach aims to emphasise the importance of feeding people during their hospital stay to either improve or maintain their nutrition status and hence aid recovery 2.4 Oral Nutritional Supplements Oral Nutrition Supplements (ONS) e.g.Ensure Plus are classed as “border-line substances.” They can only be prescribed on an NHS prescription if the patient’s condition falls into a specific ACBS category:

Short bowel syndrome

Intractable malabsorption

Pre-operative preparation of malnourished patients

Inflammatory bowel disease

Following total gastrectomy

Dysphagia

Bowel fistula

Disease related malnutrition. 2.5 Enteral Feeding Enteral feeding is a process where nutrition is delivered into an individual’s gastrointestinal tract via a Nasogastric or Naso-Jejunal tube, a gastrostomy or a jejunostomy. It aims to provide nutrients to a person with a reduced/no swallow ability or in cases of severe or chronic illness. Enteral feeding should never be started without consideration of all related ethical issues and must be in the best interest of the patient. The access route should be decided on an individual basis according to the clinical indications, treatment plan and nutritional state of the patient. The indications for enteral feeding are as follows:

Nasogastric feeding: Short term feeding (less than 14 days) or longer when a patient is unsuitable for a gastrostomy.

Patients unable to tolerate any feeding orally due to swallowing problems.




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Inpatients with anorexia nervosa who are declining oral diet and/ or fluids

Gastrostomy feeding: Long-term feeding in the community (e.g. patients with dysphagia or long-term food refusal).

Post Pyloric Feeding (e.g. Naso-Jejunal tube or Jejunostomy): Post abdominal patients as advised by gastroenterology.

2.6 Refeeding Syndrome Refeeding Syndrome is not a singular condition but is a group of clinical symptoms and signs that can occur in the malnourished or starved individual upon the reintroduction of nutrition. In this patient group over-rapid and unbalanced provision of oral, enteral or parenteral nutrition can result in shifts in fluid and electrolytes. These biochemical abnormalities can result in a spectrum of presentations from fluid retention to cardiac arrhythmias, respiratory insufficiency and ultimately death. Refer to Appendix E: Refeeding Guidelines for Enteral Nutrition 2.7 Body mass Index Body Mass Index (BMI) is defined as the individual’s body mass divided by the square of his or her height: BMI = kg/m2 2.8 Multi-Disciplinary Team Multi-disciplinary Teams (MDT’s) are made up of a variety of expert health professionals who have specialised knowledge and training.

3 Roles and responsibilities 3.1 Trust Board The Trust Board has overall responsibility for provision of quality and safe care and are required to ensure there are effective systems in place to achieve the aims and objectives of this policy. 3.2 Director of Nursing The Director of Quality and Safety / Chief Nurse is responsible for ensuring there are robust systems in place to improve performance in relation to Nutrition support in particular, enteral feeding. 3.3 Dietetic Team It is the responsibility of the Dietetic team to ensure this policy is reviewed and amended at the review date or prior to this following new developments in asepsis. They will advise on the appropriateness for nutrition support and the route i.e. oral and/or enteral. The Dietitian will advise regarding appropriate ONS and/or suitable feeding regime to meet the patient’s nutritional and hydration requirements. They will also monitor the progress of a patient on nutrition support (oral, enteral) and advise any necessary changes to a patient’s ONS and/or feeding regime. 3.4 Catering and Facilities Manager – refer to Trust “Food Hygiene Policy” It is catering’s responsibility to ensure that the menus offer a wide and varied selection of food and beverages to meet the dietary, cultural, religious and nutritional requirements of patients. It is important to liaise with the relevant multi-disciplinary teams to ensure that the nutritional adequacy and suitability of foods are met. Food is tailored to meet an individuals needs as much as possible and food and beverages are available outside normal kitchen hours. To undertake regular self assessment of the food and beverage service to comply with PLACE assessment criteria and all aspects of the Protected Mealtimes Procedure.




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3.5 Speech and Language Therapists Speech and Language Therapists are responsible for the assessment of patients eating and drinking skills and any difficulties (dysphagia). They will provide advice on the appropriateness of ONS type and enteral feeding with regards to dysphagia and participate in multidisciplinary discussion as to the appropriateness of enteral feeding with regard to clinical dysphagia assessment and clinical experience in order to arrive at an evidence based person centred outcome. They will also monitor dysphagia while the patient is on an enteral feeding regime, where necessary providing information for the MDT with regard to reinstatement of oral feeding and assess/provide advice on oral intake/taste for pleasure for patients who are enterally fed long term. 3.6 Ward/Department Managers Ensure that staff are aware of this policy and have access to the appropriate resources in order to carry out the procedure appropriately. Ensure compliance with the policy within their team and that staff are competent in the practice and attend appropriate training. It is the responsibility of all ward staff to assess the dietary needs, preferences and highlight any mealtime assistance required of patients and that this is recorded and referred to by all ward staff. Where requested, food and fluid intake (including ONS) should be recorded daily on the food record and fluid balance charts. 3.7 Healthcare Personnel Ensure they have read and are familiar with this policy and adhere to the requirements. All Trust employees involved in the practice of enteral feeding are responsible for ensuring they are competent in the procedures used and deliver practice to the policy standards. 3.8 Pharmacy Pharmacy is responsible for providing a medicine information service for staff, patients and carers and advising on medicine administration in patients unable to take medicines orally. They play a key role in advising on Refeeding Syndrome. 3.9 Medical staff Medical staff are responsible for monitoring of bloods, urea and electrolytes and correcting any imbalances, treatment of micronutrient and biochemical deficiencies through supplements. They are also responsible for the insertion of naso gastric tubes. 3.10 Infection Prevention and Control (IPCN) There are potential hazards associated with enteral feeding which can make it a source for the growth of micro-organisms. Liquid nutrients provide an ideal medium for bacteria and can cause cross contamination to the feeding system during setting up and handling the equipment. The IPCN is responsible for monitoring practice and providing education in infection prevention and control through participation in audit/surveillance of practice.

4. Consent Patients have a fundamental legal and ethical right to determine what happens to their own bodies. Valid consent to treatment is therefore absolutely central in all forms of healthcare. The decision to initiate enteral feeding will involve the patient, carer/family, and members of the multi-disciplinary team including Speech and Language Therapists and Dietitians. The clinical indications for enteral feeding must be reviewed regularly to prevent unnecessary device use. The Mental Capacity Act 2005 provides a statutory framework to empower and protect vulnerable people who may not have the capacity to make their own decisions about specific treatments and/or care.

5. Ethical and Legal considerations




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Nutritional support is not always appropriate. Decisions on withholding or withdrawing nutrition support require a consideration of both ethical and legal principles, both at common law and statute including the Human Rights Act 1998. When such decisions are being made guidance issued by the General Medical Council (GMC) and the Department of health should be followed. The decision making process and rationale must be fully documented in the clinical record.

6. Oral Nutrition Support The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (RJAH) is committed to nutrition screening all in-patients within 24-hours of admission. Re-screening is done weekly thereafter or when conditions change. The aim of nutritional screening is to seek, prevent and treat malnutrition during in-patient stay and consequently reduce the incidence of malnutrition out in the community. Ward action Plans The nutritional screening tool is completed and the actions box signed and dated. The ‘red/salmon pink tray/red mat’ and ‘Meritene, Milk, cake bar, cheese and biscuits’ actions must be ticked on the Diet Board. The weekly weight and food record chart actions passed on via nurses handover and on patient board. Refer to Appendix A for the Nutrition Screening Tool and an explanation of the 8 steps needed for the nutrition screening and the plan of care

7. Pathway for using ONS in the management of malnutrition. The pathway used by a dietitian to determine if ONS are needed is shown in Appendix B

8. Enteral Nutrition Support Feeding enterally is superior to the parenteral route in terms of physiology, immunology and cost, and has numerous clinical advantages such as helping to maintain normal intestinal function and structure (McClave et al 1999). There are now few patients who cannot receive some form of enteral nutrition through the various routes available. The route and level of enteral feeding is decided on an individual basis according to the clinical indications, treatment plan and nutritional state of the individual patient. In the first instance NG tubes for feeding purposes should be passed by experienced ward based doctors or nurses. It is the responsibility of the on call medical team to provide expert help as required. The procedures for this and administration of medicines enterally are shown in Appendix C

9. Refeeding Syndrome The pathophysiology of refeeding syndrome relates to the rapid rise in insulin production following a carbohydrate or protein shock, when protein-calories are administered at a rate above which the patient can tolerate. This can occur in those receiving even moderate dietary intake depending on their underlying nutritional, metabolic or physical condition and may arise with administration of glucose alone. This insulin release, associated with possible increased insulin sensitivity, leads to increased cellular uptake of glucose, fluid and electrolytes with associated altered plasma availability of electrolytes. Refeeding syndrome can manifest as either metabolic changes (hypokalaemia, hypophosphataemia, hypomagnesaemia, altered glucose metabolism and fluid balance abnormalities) or physiological changes (i.e. arrhythmias, altered level of consciousness, seizures, cardiac or respiratory depression) and potentially death. See appendix D for refeeding syndrome guideline.




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10. Record Keeping and Documentation A clear process should be established for documenting the outcomes of screening and the actions taken if the patient is recognised as malnourished or at risk of malnutrition. The insertion of enteral tubes and any further or subsequent information (e.g. tube changes, tube positions) must be documented in the clinical records. The decision to feed a patient following X-ray confirmation of Nasogastric tube must be documented in the patient’s medical notes, dated, timed and signed by that person. In accordance with national patient safety alert NPSA/2011/PSA002 Reducing the Harm Caused by Misplaced Nasogastric Feeding (NG) Tubes in Adults, Children and Infants, the position of a tube must be confirmed according to their decision tree (Appendix D). An NG Position Confirmation record (see appendix D) must be completed each time an ng tube is passed. An NG Tube Bedside Checklist (see appendix D) must be completed each time the position of the ng is checked e.g. each time the feed starts. Annual audit of completion to be carried out.

11. Education and Training 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. This should include those helping patients choose food, those serving meals, beverages and snacks, and those feeding patients. Managers of staff dealing with enteral feeds must ensure that their staff are competent and properly trained to do so. Ward staff should ensure that patients and carers are educated about hand decontamination and care of the feeding tube device, while enteral pump trainers should ensure that patients and carers are educated about enteral feeding system including how to recognise and respond to adverse changes when applicable to them.

12. Review process This policy will be reviewed two yearly unless there are significant changes at either national policy level, or locally. In order that this document remains current, any of the appendices to the (policy/ guideline / procedure) can be amended and approved during the lifetime of the document without the document strategy having to return to the ratifying committee.

13. Monitoring of this document The monitoring of compliance of this policy is an integral part of the trust governance and audit arrangements. The practice detailed in this policy will be monitored by audit and reviewed if serious incidents occur. It is the responsibility of all department heads/professional leads to ensure that the staff they manage adhere to this policy.

14. Equality Impact Assessment (EQIA) This document has been subject to an Equality Impact Assessment and is not anticipated to have an adverse impact on any group.




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15. Implementation Plan

This nutrition policy largely describes current practice. Implementation Plan. Once approved copies of this policy will be sent to appropriate clinical and non clinical staff including ward managers, STAR nutrition link nurses and catering managers. In addition to current delivery methods Nutrition training will be offered to clinical staff via e learning.

16. Further Information/References ‘Essence of Care – Benchmark for Food & Nutrition’ Department of Health (2010) ‘Nutrition Screening Survey in the UK and Republic of Ireland in 2011 – A Report by BAPEN’ (2012) Nutrition and patients: a doctor’s responsibility. Royal College of Physicians. 2002. Vol 2, No 5, pp.391-394. National Institute for Health and Clinical Excellence (2006) Nutrition Support in adults, oral nutrition support, enteral tube feeding and Parenteral nutrition, CLINCAL Guideline 32 ISBN 1-84629-150-X. Quality standard for nutrition support in adults (QS24). November 2012

Supporting a multi-disciplinary approach to nutritional care and valuing the contribution of all staff groups working in partnership with patients and users. NPSA, April 2008. Accessed online www.malnutritionpathway.co.uk Date accessed 17 January 2014. National Patient Safety Agency. Fact sheet 03. Accessed by following the link: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59865&q=0%c2%acnutrition%c2%ac 17-01-2014. Council of Europe Resolution Food and Nutrition Care in Hospitals. 10 Key Characteristics of good nutritional care in hospitals. 12-11-2003. The Hospital Food Standards Panel’s Report on Standards for Food and Drink in NHS Hospitals DoH and Age Uk August 2014

http://www.malnutritionpathway.co.uk/

http://www.nrls.npsa.nhs.uk/resources/?entryid45=59865&q=0%c2%acnutrition%c2%ac




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Nutrition Support Tool: Appendix A

The 8 Steps to Calculating Nutrition Risk: Appendix A

To calculate the patient’s nutrition risk score involves 8 steps. The following information needs to be measured and documented on the Nutrition Screening Tool:

Document the date the Nutrition Screening Risk Assessment is being completed

Document an accurate weight for the patient

Document an accurate height for the patient

Use the Body Mass Index (BMI) chart to document BMI (Kg/m2) Step 1: Unintentional weight change over the last 6 months

Unplanned weight loss over 3-6 months is a more accurate risk factor for malnutrition than BMI

To establish the patient’s weight loss score, ask if there has been any unintentional weight loss in the last 3-6 months, and if so how much (or look in available patient notes, if patient is unsure or unreliable)

If the patient has not lost weight, score 1.

Score Unintentional weight change over the last 6 months

Significance

1 None Within “normal” intra-individual variation

2 0-3kg (1-7lb) Within “normal” intra-individual variation

3 3-6kg (8lb-1 stone) More than “normal” intra-individual variation – early indicator of increased risk of malnutrition

4 > 6kg (1 stone) (unintentional) Clinically significant

Circle the score and continue to Step 2

Step 2: Visual Appearance / Body Mass Index (BMI) (kg/m2)

BMI gives a rapid interpretation of chronic protein-energy status based on an individual’s weight and height.

Take the subject’s height and weight to calculate BMI or refer to BMI chart on the ward to establish the patient’s visual appearance / BMI.

Score Unintentional weight change over the last 6 months

Weight category Significance

1 Well Nourished (BMI 18.5-24.9)

Desirable weight Poor protein – energy status unlikely

2 Thin (BMI 16-18.5)

Underweight Poor protein – energy status possible

3 Very thin / emaciated (BMI<16)

Underweight Poor protein – energy status probable

Appendix A




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Step 3: Appetite and Interest in Foods and Drinks

To establish the patient’s score, gauge appetite and intake through the use of either a Food Record Chart, or through what the patient has reported.

Score Appetite and interest in food and drinks

Significance

1 Good–eats most of 3 meals and has regular drinks. Tolerates most prescribed supplements

Within “normal” intra-individual variation

2 Poor – leaves > half of meals/drinks Clinically significant

3 Very poor – leaves most of meals/drinks

Clinically significant

4 Nil intake, virtually nil or NBM Clinically significant


Step 4: Ability to eat and drink.

Gauge a patient’s ability to eat based on the use of a Food Record chart, left over meals or speaking with the patient. It might be that the patient requires a red tray to highlight patient needs assistance with feeding.

The scoring in this section highlights potential cognitive problems associated with eating and drinking e.g. mental health problems e.g. Dementia, eating disorders

Indicate which option is chosen in order to establish the scoring e.g. poor fitting dentures OR malabsorption.

Score Ability to eat and drink – please circle appropriate option

Significance

1 No difficulties eating and drinking Within “normal” intra-individual variation

2 Needs special utensils OR frequent regurgitation OR mild D+V

More than “normal” intra-individual variation – early indicator of increased risk of malnutrition

3 Difficulties swallowing, Requires Modified Consistency, Slow (or needs help) to feed/drink, Poor fitting dentures, moderate D+V


4 Unable or unwilling to eat/drink, cognitive difficulty, malabsorption e.g. excessive wound losses, severe D+V


Indicate which option is chosen from the various options provided e.g. cognitive difficulty or difficulties swallowing etc





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Step 5: Increased Nutritional Needs.

The patient’s clinical condition adds to the nutritional requirements and therefore can contribute significantly to the overall nutritional risk.

All pressure sores are automatically scored higher in order for Dietetic input and assessment to be carried out.

Score Increased Nutritional Needs Significance

1 No condition causing increased needs Within “normal” intra-individual variation

2 Mild /minor surgery, infection, neuro condition (eg MND, Dementia)

More than “normal” intra-individual variation – early indicator of increased risk of malnutrition

3 Moderate/chronic disease e.g. COPD, major surgery, infections, CVA, gut disease (eg Crohn’s Disease)


4 Severe Injury, disease or sepsis Any form of pressure sores


Indicate which option is chosen from the various options provided e.g. CVA or sepsis etc


Step 6: Overall risk of malnutrition

Add scores together to calculate the overall risk of malnutrition Tick the required action boxes, take the actions and sign the risk

assessment Score 5 – 7 Low Risk Score 8 – 10 Medium Risk Score 11 – 19 High Risk Step 7: Management guidelines All patients require a nutrition action plan. The calculated nutrition risk will determine what nutrition action needs to be carried out. In all circumstances a food first approach needs to be used prior to the use of ONS.

Score Risk Action to take

5 – 7 Low Risk Check weight and BMI

Repeat the Screening Tool if any deterioration

Encourage eating and drinking and provide healthy snacks between meals.

See next page for continuation of the table.




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Step 7: Management guidelines table continued.

Score Risk Action to take

8 – 10 Medium Risk (patient needs monitoring to prevent becoming high risk) 1 and 2 actions record behind patient bed or on patient board 3-6 actions record on special diet board

1. Monitor accurate weight and BMI weekly 2. Commence food record chart 3. Encourage eating and drinking and provide

snacks between meals. 4. Offer full fat milk as a nourishing drink [NOT

renal patients] 5. Utilise a red tray if patient needs help to

eat/open meal packaging 6. Offer nourishing drinks (eg Build-

up/Complan) [NOT renal patients]

Handover to ward staff e.g. HCA, Housekeeper

Repeat score after 1 week, if no improvement refer to dietitian

11 – 19 High Risk Follow recommendations for action as per ‘medium

risk’ and refer to Dietitian




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Plan of care

Eating well (a full meal is eaten): Discontinue Food Record Chart if consistently eating well for 3-4 days. Inform the

Dietitian if patient is known to Dietitian.

If intake appears to reduce rescreen using the Nutrition Screening Tool. If the score changes, follow appropriate action plan.

Approximately three quarters of a meal is eaten Provide a snack between meals

Provide milky drink between meals (Not Renal Patients)

Monitor intake for the remainder of the day

Meal is declined or less than half is eaten Establish why meal is declined / half is eaten.

Refer to Nutrition Screening Tool Action Plan.

Communicate problems and actions with patients, and if they wish, their relatives or carers.

If appropriate:

Offer assistance at mealtimes.

Offer appropriate utensils if problems handling food e.g. arthritis (Discuss with Occupational Therapists).

Problems with chewing food (e.g. poor dentures) – consider referral to dental service.

Offer an alternative meal e.g. toast with butter/margarine and preserve, sandwich, snack box.

Offer a Build-up soup or milk shake / Complan soup or milk shake (Not Renal patients).

Provide a snack.

Provide a milky drink between meals e.g. full fat milk (Not Renal patients).

Inform nurse in charge of action taken and outcome and document in nursing records.




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Pathway for using ONS in the Management of Malnutrition: Appendix B

Individual identified as high risk according to Nutrition Screening Tool

Record details of malnutrition risk (screening result or clinical judgment) Agree goals of intervention

Consider underlying symptoms and cause of malnutrition e.g. nausea, infections and treat as appropriate

Consider social requirements e.g. ability to prepare meals, shopping, prescription collection Reinforce advice to optimise food intake, confirm individual is able to eat and drink and

address any physical issues e.g. dysphagia, dentures

Short-term nutritional support

Confirm need for ONS – is individual able to manage nutritional intake from food alone?

If yes Discontinue ONS and provide Build-up advice including non-prescription energy drinks e.g. Build-up/Complan soups and shakes. If no And intake remains inadequate, ONS prescription for <4 weeks: 1-3 ONS/day (consider ACBS indications) in addition to oral intake and advice.

Longer term nutritional support when food approaches alone are insufficient

Confirm need for ONS through gathering information from a diet history / Food Record Chart

1-3 ONS/day in addition to oral intake (Build-up advice) and dependant on patient’s nutritional requirements

Consider ACBS indications Request GP input to review the need for

ongoing ONS prescription.

(Managing Adult Malnutrition in the Community)




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Enteral Nutritional Support: Appendix C Procedure Hands must be decontaminated thoroughly using soap and water or alcohol hand gel before and after handling equipment and the preparation process. Disposable aprons must be worn when preparing equipment and opening of feed. Preparation and opening of feeds must be carried out in a clean environment. A no-touch technique should be adopted when preparing the feed during priming and connecting to the administration set/feeding tube. Commercially produced, pre-filled ready to hang feeds must be used wherever possible as these are least likely to become contaminated in preparation and use.

Preparation and storage of feeds Feeds must be stored according to manufacturers instructions and where applicable food hygiene legislation. Unopened feed should be stored in a clean, cool, dry place away from a

heat source. Feed expiry dates must be checked before use. Stock rotation procedures must be followed to avoid feeds exceeding their expiry dates. Additions to sterile feeding containers are made only when there is no alternative and following an initial risk assessment.

Check that the correct prescribed feed is being given to the patient.

Feeds must not be decanted unless absolutely necessary. If the feed requires decanting, reconstituting or diluting, a clean work area should be prepared and equipment dedicated for enteral feed use only should be used.

Before opening, the outside surface of bottles, cans or cartons should be wiped clean.

Ready to hang feeds must be stored in a refrigerator once opened and must be used or discarded within 24 hours.

Water, medication or other substances must not be added directly into the feed container.

Check the position of all nasogastric tubes before each use, using aspiration and pH indicator paper.

Administration of feeds

Minimal handling and an aseptic technique should be used to connect administration system (giving set) to the enteral feeding tube.

Once the giving set is attached do not open again.

All feeds and administration sets must be labelled with the start date and time.

Once opened, the ready to hang feed must be used or discarded within 24 hours

To minimise infection risk, reconstituted feeds must be decanted into a sterile container and labelled with the date and time of reconstitution. This feed has to be used within 4 hours. Only mix 4 hours volume of feed at the one time.

Administration sets (giving sets) and feed reservoirs e.g. Flocare containers, are for single use only and must be disposed of within 24 hours.

Appropriate documentation must be completed in patient records e.g. date and time of feed, pH, type of feed given and volume.




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Flushing the feeding tube

The tube must be flushed with sterile water, before and after feeding and before, between and after administration of medication.

Only oral/enteral syringes (purple syringes) that cannot be connected to intravenous cannulas are to be used for administering sterile water or medications.

Oral/enteral syringes are deemed as single use items and they must be discarded after each use.

Sterile water bottles are dated when opened and discarded within 24hours.

Hand hygiene must be observed both before and after the procedure.

Care of equipment

The pump must be cleaned daily with a detergent wipe and allowed to air dry.

If enteral feed dries on the equipment itself and becomes too hard to be removed by a detergent wipe, to use warm soapy water and a clean cloth to remove the dried enteral feed, followed by wiping down with a detergent wipe and allowing the equipment to air dry.

Medication Administration via Enteral route It is recommended that all patients receiving medicines via the enteral route have a care plan detailing the medicine formulation and procedure for administration. Wherever possible a licensed liquid formulation or soluble/dispersible formulation of the medicine should be used. Opening a capsule or crushing a tablet before administration will constitute an unlicensed use of medicine. Not all oral liquid medicines are suitable for PEG/NG tube administration. If a licensed liquid preparation or soluble/dispersible formulation is not available contact a Pharmacist for advice. A pharmacist must always be consulted if there is any doubt about administering a medicine via the enteral route. Some medicines are known to interact with enteral feeds and/or gastric acid and a pharmacist should be consulted to advice on any drug-nutrient interactions that might occur. Breaks required from enteral feeding can vary between medication types.

Administration procedure

Only oral, enteral or catheter-tip syringes (purple syringes) that are not compatible with IV devices must be used to administer oral/enteral medicines, feeds and flushes.

Stop the enteral feed

Flush tube with at least 30ml sterile water before and after administering medicine, and with at least 10ml between medicines. If client is on restricted fluids this amount may need to be modified; the quantity of fluid administered must be recorded on the fluid balance chart.

Administer each medicine separately,

Restart the feed if required allowing a break if needed following the administration of medicines.




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Nasogastric Tube Position Confirmation Record: Appendix D This bedside checklist should be completed by person passing ng tube, for all patients requiring ng tube placement, on insertion and on all subsequent insertions.

Patients Name:

NHS Number / Hospital Number: Use Label If Available

DOB:

Ward:

Nasogastric tube insertion / reinsertion

Date and time of insertion / reinsertion

Clinical decision to pass ng tube documented in notes / EPR

NEX Measurement

External length once secured

Nostril used on insertion / reinsertion – L / R

Aspirate obtain – Y / N

Ph of aspirate (if obtained)

X-ray required – Y/ N

Inserted by:

X-ray interpretation (if applicable)

Date and time of x-ray interpretation

Is this the most current x-ray? Y / N

Is the x-ray for the correct patient? Y/ N

x-ray results Eg “NG has passed down midline past level of diaphragm and deviates to left. It is safe to feed via the NGT”.

X-ray interpreted by:




Page 21 of 24

Decision Tree for Nasogastric Tube Placement Checks in ADULTS

Example NEX measurement (Place exit port of tube at tip of nose. Extend tube to earlobe, and then to xiphisternum).

Insert fully radio-opaque nasogastric tube for feeding (follow manufacturer’s instructions for insertion) and use water as lubricant.

Confirm and document secured NEX measurement.

Aspirate with a syringe using gentle suction.

Aspirate obtained?

Try each of these techniques to help gain aspirate:

If possible, turn adult onto left side

Inject 10-20ml air into the tube using a 50ml syringe

Wait for 15-30 minutes before aspirating again

Advance or withdraw tube by 10-20cm

Give mouth care to patients who are nil by mouth (stimulates gastric secretion of acid)

Do no use water to flush

NO

Test aspirate on CE marked pH indicator paper for use on human gastric aspirate

YES

Aspirate obtained?

Proceed to x-ray: ensure reason for x-ray documented on request form

Competent clinician (with evidence of training) to document confirmation of nasogastric tube position in stomach

DO NOT FEED or USE TUBE Consider re-siting tube or call for senior advice

PROCEED TO FEED or USE TUBE Record results in notes and subsequently on bedside documentation before each feed / medication / flush

A pH between 1 and 5.5 is reliable confirmation that the tube is not in the lung, however it does not confirm gastric placement as there is a small chance the tube tip may sit in the oesophagus where it carries a higher risk of aspiration. If there is any concern, the patient should proceed to x-ray in order to confirm tube position. Where pH readings fall between 5 and 6 it is recommended that a second competent person checks the reading or retests.

Where pH readings fall beteen 5 and 6 it is recommended that a second competent person checks the reading or retests.

NO

pH between 1 and 5.5

pH NOT between 1 and 5.5

YES

YES

NO

National Patient Safety Agency




Page 22 of 24

Nasogastric Tube Bedside Check List

Patients Name:

NHS Number / Hospital Number: Use Label If Available

DOB:

Ward:

The position of the nasogastric tube should be checked:

Following initial insertion (please use placement checklist to record this).

Before administering each feed.

Before giving medications, unless given when feed already in progress.

Any new or unexplained respiratory symptoms or if oxygen saturations decrease.

At least once daily during continuous feeds.

Following episodes of vomiting, retching or coughing spasms.

When there is suggestion of tube displacement.

If you are not able to confirm that the tube is in the stomach it should be removed and reinserted. This should be documented on the nasogastric tube placement beside checklist.

Date

Time

pH

External tube length

Checked by:

Date

Time

pH

External tube length

Checked by:

If any new or unexplained respiratory symptoms, contact medical team immediately and stop feed.




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REFEEDING SYNDROME GUIDELINES FOR ENTERAL FEEDING: Appendix E Refeeding syndrome: Severe fluid and electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding. Refeeding can result in falls in electrolyte levels which, in itself can cause cardiac problems. Reference: Nutrition Support in Adults. Oral nutrition support enteral tube feeding and parenteral nutrition. 2006 NICE.

Identify ‘At Risk’ Patients High risk of developing refeeding problems if:

Patient has one or more from this list:

BMI less than 16kg/m2

unintentional weight loss greater than 15% within the last 3-6months

little or no nutritional intake for more than 10 days

low levels of potassium, phosphate or magnesium prior to feeding

OR

Two or more from this list:

BMI less than 18.5kg/m2

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

Routinely carry out: U&Es, LFTs and FBC Check: Potassium (K

+), Phosphate (PO

3-4), Magnesium (Mg

2+)

Potassium. If K

+ < 3mMol/l give IV KCl –

40mmol in 1 litre over 12 hours. If K

+ 3-3.5mMol/l give

oral/enteral Kay-cee-l liquid 20ml tds(1mmol/ml) / Sando-K tablets 1-2tds (12mmol each) Discontinue once K

+ is >4.0

mMol/l and recheck every day in case of a rapid fall in levels

Phosphate. If PO

3-4 <0.4mMol/l give IV eg

Phosphate Polyfusor 25mmol over 12-24 hours depending on weight. If PO

3-4 0.4-0.8mMol/l give

oral/enteral Phosphate Sandoz 2 tablets tds (16.1mmol each) Discontinue once PO4 is >1.0 and recheck every day in case of rapid fall in levels

Magnesium. If Mg

2+ < 0.55mMol/l give IV

Magnesium Sulphate 50% (2mmol/ml – give up to 24mmol in 24hours) If Mg

2+ 0.55-0.7mMol/l give

oral/enteral Magnesium Glycerophosphate liquid 10ml bd (1mmol/ml) Discontinue once Mg

2+ is >0.8

mMol/l and recheck every day in case of rapid fall in levels

At least 30 minutes before feed starts:- Give Thiamine and Vitamin B complex at the same time

Oral/tube route: Thiamine: Oral/enteral dose 200mg daily for 10 days and Vitamin B complex: 1 tablet tds or Vigranon liquid 5ml tds for 10 days

No oral route possible: IV: 1 Pair Pabrinex ampoules once daily for 2 days

Commence feeding - As dietitian’s regimen or emergency regimen. Re-check electrolytes K+, Phosphate and Mg2+ DAILY for 5 days or until stable




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Monitoring Programme for Nutrition Support Policy: Appendix F

Element to be monitored

Lead Tool Frequency Reporting arrangements

Acting on recommendations and Lead(s)

Change in practice and lessons to be shared

Oral Nutrition Support Use of Placement and Bedside Checklists for NG tube feeding

Audit Dept Quality Matron Link Nurses Ward Managers Nursing or Medical staff or dietitian

Ward Audits EPR Audit

At least Twice Yearly 1/year

Nutrition and Hydration Steering Group Nutrition And Hydration Steering Group

Ward managers to alter practice. Ward Managers

Recommendations implemented on wards by nursing staff. Patients representatives involved in audits. -