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Nutrition support in adults
February 2006
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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
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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
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Prevalence
Estimates vary depending upon the screening tool used
Using body mass index (BMI <20 kg/m² ):
• 10-40% of adults in hospitals and care homes are underweight
• <5% underweight in the general population at home
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The need for this guideline
Malnutrition is common
It increases a patient’s 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
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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
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Organisation of nutrition support
SCREEN
RECOGNISE
TREAT
ORAL ENTERAL PARENTERAL
MONITOR AND DOCUMENT
REVIEW
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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?
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St. Bartholomew’s Hospital/Science Photo Library
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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
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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
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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’
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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
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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
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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
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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
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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
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Consider oral nutrition support
and
stop when the patient is established on adequateoral intake from normal food
surgical patients may have different needs
if patient malnourished/at risk of malnutrition
can swallow safely and gastrointestinal tract is working
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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
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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
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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
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Consider enteral tube feeding
and
use the most appropriate route of access and mode of delivery
stop when the patient is established on adequateoral intake from normal food
surgical patients may have different needs
has a functional and accessible gastrointestinal tract
if patient malnourished/at risk of malnutritiondespite the use of oral interventions
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Consider parenteral nutrition
use the most appropriate route of access and mode of delivery
stop when the patient is established on adequateoral intake from normal food or enteral tube feeding
surgical patients may have different needs
and has either
introduce progressively and monitor closely
if patient malnourished/at risk of malnutrition
a non-functional, inaccessible or perforated
gastrointestinal tract
inadequate or unsafe oral or enteral nutritional intake
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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
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Support in the communitySupported 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
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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
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Access tools online
Costing tools
•costing report•costing template
Audit criteria
Implementation advice
Available from: www.nice.org.uk/cg032
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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