1. The NICE experience Christine Baldwin
Division of Medicine, Imperial College London
& The Royal Marsden Hospitals, London
PEN Group Annual Conference,
London, August 2006

2. Structure
Process
Type of evidence
Implications for dietitians

3. The need for this guideline
Malnutrition is common
Nutritional provision in hospital and community may be inadequate
Provision of nutritional support requires complex decisions
Wide variation in nutritional care standards

4. Topic nomination
“to develop a guideline on appropriate methods of feeding patients who:
are still capable of deriving some of their nutritional requirements by conventional feeding and/or
have difficulty swallowing
including the use of nutritional supplements and enteral and parenteral feeding methods”
DoH and Welsh Assembly

5. The process (1) Proposal
National Collaborating Centre for Acute Care (NCCAC)
Scope
stakeholders

6. The process (2) Guideline Development Group: Clinicians GP
Dietitians (2)
Speech & Language Therapist
Nurses
Patient Groups
pharmacists

7. Development of clinical questions
The process (3)
Development of clinical questions

8. Clinical questions P atients I ntervention C omparison O utcomes
Malnourished patients
I ntervention
More food or nutritional supplement
C omparison
No intervention
O utcomes
mortality

9. Process (4) Literature search Review of papers
Extraction of data on identified outcomes

10. Process (5) Development of guidelines from evidence base
1st consultation
2nd consultation
Final guideline produced
Stakeholder comments
Stakeholder comments

11. The guideline www.nice.org.uk Quick reference guide (a summary)
NICE guideline (all of the recommendations)
Full guideline (all of the evidence and rationale)
Information for the public (a plain English version)
NOTES FOR PRESENTERS
The guideline is available in a number of formats. You can download them from the NICE website or order hard copies of the quick reference guide or information for the public by calling the NHS Response Line on
Please refer to the accompanying implementation advice for the policy context and useful links.

12. Changing clinical practice
Department of Health has asked NHS organisations to work towards implementing the guidelines
Compliance will be monitored by the Healthcare Commission
NICE guidelines are based on the best available evidence

13. Aims of the guideline
Authoritative evidence-based guidelines on nutritional support :
‘Who?
When?
What?
How ?’
excluding children and immunonutrition

14. Valid evidence
Systematic review of multiple randomised controlled trials (RCTs)
Large RCTs
Non-randomised, case-control studies
Non-experimental studies from more than one centre
Opinions based on clinical evidence

15. Problems of evidence (1)
Study design
Which studies are included
Heterogeneity
Study quality
Definition of malnutrition
Interventions

16. Problems of evidence (2)
Wanted: volunteers for randomized, placebo controlled trial

17. No evidence available
NICE found no RCTs with the introduction of screening as the intervention that then looked at either change in process or clinical measures as outcomes.

18. NICE argument:
Even if evidence proves that nutrition support is effective, it does not necessarily follow that screening for malnourishment is of benefit

19. Potential Solutions Formal Consensus Techniques (but lack of time)
Potential benefits of nutrition support may be better addressed by non-RCT techniques (but NICE lack the resources)
Formal Consensus Techniques
(but lack of time)
NICE recognized our problems and allowed some Guidance based on first principles

20. Nutritional screening
Inpatients
Outpatients
Residents of care homes
Attendees of GP surgeries
should all be screened for risk of malnutrition (D (GPP))

21. Grading of evidence A B C D D (GPP) meta-analysis or good quality RCT
extrapolated evidence from good quality RCTs or meta-analysis of cohort studies C D
D (GPP)
good practice point

22. Recommendations 77 recommendations 10 priorities for implementation
5 research recommendations
Grade A = 8
Grade B = 9
Grade D (GPP) = 60

23. Key priorities for implementation
10 recommendations:
Screening (3)
Identification (2)
Nutritional support (1)
Education (4)

24. Nutritional screening
Inpatients
Outpatients
Residents of care homes
Attendees of GP surgeries
should all be screened for risk of malnutrition (D (GPP))

25. Screening Two most important features:
linked to effective treatment pathway
leads to beneficial outcome

26. Implications (1) Numbers of: hospital inpatients (n=11,157)
hospital outpatients (n=10,823)
community

27. Implications (2) Who will carry out screening?
Need adequate numbers of dietitians
Who will raise awareness?
 referrals
available to see patients
provide training

28. Implications (3) Research recommendation:
Would a screening programme for all patients impact on clinical outcomes (LOS, QOL, complications), compared with no screening?

29. Education
“Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training” to enable accurate data collection (D (GPP))

30. Implications (1) Staff training: Clear procedures medical staff
nursing staff
management

31. Implications (2) Research recommendation:
“Further research is needed to ascertain whether an educational intervention … for all healthcare professionals … would have an affect on patient care [LOS, QOL, complications], compared to no formal education.”

32. Oral nutritional intervention
“Healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition.” (A)

34. Nutritional supplements Dietary advice + nutritional supplements
The debate
Dietary advice vs
Nutritional supplements vs
Dietary advice + nutritional supplements

35. Implications (1)
Can dietitians see all the patients that need intervention?
Which intervention?
develop policies
training to ensure consistency

36. Implications (2) Research recommendation:
Benefits to patients at nutritional risk offered sip feeds vs dietary counselling:
survival
complication rate
LOS
QOL
cost

37. Consider enteral tube feeding (ETF):
if patient malnourished/at risk of malnutrition
despite the use of oral interventions
and
has a functional and accessible gastrointestinal tract
use the most appropriate route of access
and mode of delivery
NOTES FOR PRESENTERS
For the purposes of this guideline, enteral tube feeding refers to the delivery of a nutritionally complete feed (containing protein or amino acids, carbohydrate with or without fibre, fat, water, minerals and vitamins) directly into the gut via a tube. The tube is usually placed into the stomach, duodenum or jejunum via either the nose, mouth or the direct percutaneous route. Enteral tube feeding is not exclusive and can be used in combination with oral and/or parenteral nutrition. Patients receiving enteral tube feeding should be reviewed regularly to enable re-instigation of oral nutrition when appropriate. Most enteral feeding tubes are introduced at the bedside but some are placed surgically, at endoscopy or using radiological techniques, and some are inserted in the community.
Enteral tube feeding should be considered for patients who are malnourished or at risk of malnourishment, who can’t be fed orally and who have a working and accessible gut.
Whenever possible the patient should be aware of why this form of nutrition support is necessary, how it will be given, for how long, and the potential risks involved. There may be considerable ethical difficulties in deciding if it is in a patient’s best interests to start a tube feed.
stop when the patient is established on adequate
oral intake from normal food
surgical patients may have different needs

38. Enteral feeding
“Healthcare professionals should consider enteral tube feeding in people who are malnourished or at risk of malnutrition, respectively, and have:
(D (GPP))
inadequate or unsafe oral intake, and
a functional, accessible gastrointestinal tract ”

39. Elective enteral feeding
No evidence of clinical benefits
“Enteral tube feeding should not be given to people unless they are malnourished or at risk of malnutrition and have; inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract, or they are taking part in a clinical trial.” (A)

40. Surgical patients: early post-op ETF
ETF vs nil by mouth
“General surgical patients should not have [ETF] within 48 hours post-surgery ...” (A)
23 RCTs: combined results do not support the use of early ETF

41. Are they NICE guidelines?
Not perfect BUT they do raise the profile of nutritional care and oblige organizations to take it seriously.

42. Challenge and opportunity for dietitians
Summary
Challenge and opportunity for dietitians

43. Acknowledgements Joanna Prickett Dietitian,
All members of the Guideline Development Group
North Bristol NHS Trust