1. Nutrition support in adults February 2006

2. 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

3. 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

4. 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

5. The need for this guideline Malnutrition is common It increases a patients 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

6. 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

7. Organisation of nutrition support SCREEN RECOGNISE TREAT ORALENTERALPARENTERAL MONITOR AND DOCUMENT REVIEW

8. 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?

9. St. Bartholomews Hospital/Science Photo Library

10. 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

11. 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

12. Screening WhereWhen Hospital inpatientsOn admission and repeated weekly Hospital outpatients First clinic appointment and when there is clinical concern Care homesOn admission and when there is clinical concern General practiceInitial 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Consider oral nutrition support and stop when the patient is established on adequate oral 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

19. 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

20. 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

21. 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

22. Consider enteral tube feeding and use the most appropriate route of access and mode of delivery stop when the patient is established on adequate oral intake from normal food surgical patients may have different needs has a functional and accessible gastrointestinal tract if patient malnourished/at risk of malnutrition despite the use of oral interventions

23. Consider parenteral nutrition use the most appropriate route of access and mode of delivery stop when the patient is established on adequate oral 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

24. 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

25. Support in the community Supported 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

26. 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

27. Access tools online Costing tools costing report costing template Audit criteria Implementation advice Available from: www.nice.org.uk/cg032

28. 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