SOUTH TEES HOSPITALS NHS TRUST - NICE
NICE Shared Learning Awards
Submission title: A Partnership approach to improving the nutritional care of our patients
Supporting information
1. NICE guidance clinical position statement – presented to Trust Clinical Effectiveness Committee and the Nursing and Midwifery Governance Committee
2. Terms of reference for Nutrition Steering Committee
3. NSC Reporting structure
4. Progress Update January 07
5. NSC Action Plan May 08
6. Minutes of June 08 NSC meeting
7. Examples of audit pre-NICE guidance
Parenteral Nutrition Audit
Essence of Care Food & Nutrition audit
8. Examples of audit post- NICE guidance
Catering Standards Audit 2007
MUST Audit
9. Examples of projects/actions
• Protected Mealtimes Policy May 08
• Positioning Leaflet for patients requiring assistance with feeding
• Re-feeding Syndrome Protocol
• Guidelines for Parenteral Nutrition
• Referral Form for Parenteral Nutrition
• TPN care Bundle
1. NICE Clinical Guideline 32 – Nutrition Support in Adults (Feb 06)
1. Introduction
The Trust Board ratified a Nutrition Strategy in 2004, the aim of which was to ensure:
… the patient receives the type of nutrition that he or she requires, at the right time, via the most appropriate route when they need it …”
The strategy sought to propose a 5 year action plan addressing:
■ Delivery of Nutritional Care
■ Clinical Risk
■ Resources
■ Innovations in Practice
As we enter Year 3 of the action plan, the recent publication of the NICE guidance;
the completion of the Food and Nutrition Essence of Care (EOC) audit and the results of the In-patient survey provide further impetus to continue to improve the delivery of nutritional care to our patients.
Nurses are key to the successful delivery of nutritional care. Nutrition is fundamental to good patient care and the needs of the patient are best addressed using a multi-disciplinary approach.
This paper aims to:
• Raise the Nutrition Steering Committee‘s awareness of the NICE guidance, drawing on relevant aspects of the EOC and the In-patient survey results.
• Consider the Trust’s current position in relation to the guidance
• Make recommendations for joint implementation across the organisation.
2. NICE guidance - Key priorities for implementation
The guideline offers best practice advice on the care of adults who are malnourished or at risk of malnutrition. The following recommendations are identified as priorities:
2.1 Key clinical priorities
• Screening for malnutrition or the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training.
• All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients
• Hospital departments who identify groups of patients with low risk of malnutrition may opt out of screening these groups. Opt-out decisions should follow an explicit process via the local clinical governance structure involving experts in nutrition support.
• Nutrition support should be considered in people who are malnourished, as defined by any of the following:
- a body mass index (BMI) of less than 18.5 kg/m2
- Unintentional weight loss greater than 10% within the last 3–6 months
- a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.
• Nutrition support should be considered in people at risk of malnutrition who, as defined by any of the following:
- have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer
- have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.
• Healthcare professionals should consider using oral, enteral or parenteral nutrition support, alone or in combination, for people who are either malnourished or at risk of malnutrition, as defined above. Potential swallowing problems should be taken into account.
2.2 Key organisational priorities
• 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.
• Healthcare professionals should ensure that all people who need nutrition support receive coordinated care from a multidisciplinary team.
• All acute hospital trusts should employ at least one specialist nutrition support nurse.
• All hospital trusts should have a nutrition steering committee working within the clinical governance framework.
3. Current Trust Position
Comments are based on evidence resulting from the EOC audit, audits carried out as part of the Nutrition Strategy and knowledge of service delivery.
3.1 Key clinical priorities
3.1.1 Nutritional screening
A nutritional screening tool is currently in use across the organisation recommending screening on admission and at weekly intervals. Results of the EOC audit indicate screening occurs in 50% or less clinical areas. The evidence-based MUST tool recommended by NICE has been piloted in the Trust over the past few months and will be introduced in June06. However we do not routinely screen out-patients with the exception of certain pre-assessment clinics.
3.1.2 Recognising malnutrition
Current practice is in line with NICE guidance where the screening tool is used effectively. The EOC audit results show that staff generally have good knowledge of how to refer appropriately to the dietitian but have poor written evidence of referral.
3.1.3 Treatment of Malnutrition: Oral
Again current practice is in line with NICE guidance if screening is carried out. The Essence of Care audit highlighted issues around barriers to successful assisted feeding practice at ward level. These included lack of staff available at mealtimes and difficulty in identifying patients requiring assisted feeding. A well-defined pathway of care exists for patients with swallowing difficulties/dysphagia including a comprehensive training package.
3.1.4 Treatment of malnutrition: Enteral
The organisation is compliant with recommendations for access, management, delivery and use of motility agents with the exception of continuous nasogastric feeding in ITU patients and the introduction of feed following PEG insertion. Care bundles are set up to look at nutrition in critical care and the management of PEG tubes.
Policies exist for placement and aspiration of naso-gastric tubes. A multi-disciplinary group have met to agree purchase of most suitable nasogastric tubes and pH paper.
3.1.5 Treatment of malnutrition: Parenteral
We are largely non-compliant with NICE guidance for access routes as an organisation.Cannula’s are used for peripheral feeding and Hickman or CVP lines for central access. TPN is not introduced at 50% estimated needs, nutritional requirements are not routinely assessed by appropriate healthcare professionals and we are not always adding vitamins and minerals to bags. TPN is not always discontinued using a step down approach.
3.1.6 Prescription
The organisation is compliant with recommendations for prescription of nutritional support. The Trust’s refeeding policy requires minor adjustments to adhere to NICE and will then be submitted to Pathfinder.
3.1.7 Monitoring
Current practice is in line with NICE guidance with the exception of re-screening on a regular basis. The EOC audit indicated this practice was generally poor particularly in terms of documentation.
3.2 Key organisational priorities
3.2.1 Education and training
All clinical areas have been offered the opportunity to access a Nutrition Link Nurse (NLN) training programme.EOC audit results indicate that not all clinical areas have access to a NLN. Dietetic assistants undertake nutritional training and will be able to access an NVQ Level 3 qualification in the near future. Nutrition training takes place for clinical teams. There is limited input into medical training. Training for housekeepers and catering staff is provided by the Trust’s Informed Client Dietitian.
3.2.2 Nutrition team including Specialist Nutrition Nurse
The need for a nutrition team was identified in the Trusts Nutrition Strategy however funding for a Specialist Nutrition Nurse and ring fenced medical time has not been identified.
3.2.3 Nutrition Steering Committee
Membership of the committee has been identified with the first meeting planned for May06. The group will report to the Clinical Effectiveness committee and link to the EOC steering group. The remit of the group will be to action findings of the EOC audit and implement NICE guidance.
4. Recommendations for implementation
• Introduction of screening into out-patient areas applying Opt-out criteria for those low risk specialities. Ensure the MUST tool is an integral part of assessments carried out on admission.
• Establish a Specialist Nutrition Nurse role to support colleagues to:
- minimise complications related to enteral tube feeding and parenteral nutrition
- ensure optimal ward-based training of nurses
- ensure adherence to nutrition support protocols
- support coordination of care between the hospital and the community.
• A business case be prepared to support the funded establishment of a Nutrition team with a responsibility for the management of patients requiring TPN
• Support the Nutrition Steering Group within the clinical governance framework i.e. through links with the Essence of Care group, Clinical Effectiveness Committee , NMGCB
• Ensure 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. Re-launch the Nutrition Link Nurse programme
• Education and training should cover:
• Nutritional needs and indications for nutrition support
• Options for nutrition support (oral, enteral and parenteral)
• Ethical and legal concepts
• Potential risks and benefits
• When and where to seek expert advice.
• Ensure patients and carers are adequately represented on the Nutrition Steering Group and in discussions around service developments. Consider carer/public involvement in addressing the problems of assisted feeding e.g. volunteer feeder programme.
5. Financial implications
The estimated costs of meeting the recommendations include:
• Establishing a Nutrition Team and employing a Specialist Nutrition Nurse
- Band 7 Extended Scope Practitioner (Artificial Nutrition) 0.5WTE
- Band 6 Specialist Nutrition Nurse 1.0 WTE £31686 (mid point)
- Ring fenced Consultant time 2 PA’s
- Additional pharmaceutical advisory time 0.1WTE Band 7
Costs will vary depending on the model of Nutrition team adopted
• Fully implementing the proposals around screening and training
Additional costs may arise if backfill is required for staff to attend appropriate training .Training could be delivered jointly by nursing and dietetic staff in the most cost-effective manner i.e. through Nutrition Link Nurses, ward-based training, cascaded training etc.
6. Conclusion
This paper should inform the terms of Reference for the Nutrition Steering Group and provide potential actions for the organisation to improve delivery of nutritional care to our patients.
Linda Irons Director of Nutrition & Dietetic Services May 2006
2. SOUTH TEES HOSPITALS NHS TRUST
NUTRITION STEERINGCOMMITTEE
TERMS OF REFERENCE
1. Report to:-
1. CLINICAL EFFECTIVENESS COMMITTEE
2. Purpose
2.1 The purpose of the committee is to oversee the implementation of NICE guidance NC32 – Adult Nutritional Support, action plans resulting from the Essence of Care Food and Nutrition audit and other relevant documents. Issues relating to national, regional and local policies will be debated and ratified. In addition the forum will scrutinise and review the systems in place to ensure, monitor and improve the quality of nutritional care delivered to patients and their carers.
3. Membership
Director of Nutrition and Dietetics
Assistant Director of Nursing
Lead Clinicians – Medical and Surgical
Pharmacy representatives
Patient representatives
Speech and Language Therapy representative
Dietetic representatives JCUH/FHN
Clinical Matron Representatives JCUH/FHN
Specialist Nutrition Nurse
Informed Client Dietitian
Assistant Director of Hotel Services
Deputy Hotel Services Manager
Hotel Services Manager, PFI Partners
Clinical Risk representative
Each member will have a nominated deputy. Membership will be jointly agreed by the Nutrition Steering Committee. There should be a commitment that each nominated member will attend the full meeting. If for whatever reason they are unable to attend, then they should negotiate with their nominated deputy to attend in their absence.
Members are responsible for cascading the information in a timely way from the meetings to colleagues who they are representing. If asked to seek views on issues, they are responsible for leading this within their own sphere of responsibility to ensure that comprehensive views are used to inform decision-making.
4. The Committee will review the membership of the Committee annually to ensure that it best reflects the requirements of the agenda within the Trust.
1. The chair of the group should be the Director of Nutrition and Dietetic Services
2. Individuals may be co-opted for specific projects.
5. A Quorum
A quorum will consist of not less than 60% of the members of the Committee present.
In instances where there are divided votes, the Chair or nominated deputy will make the final decision.
6. Procedures
1. The minutes will be approved by the whole Committee at the next
meeting.
2. Any member of staff may raise an issue with the Chair. The Chair will
decide whether or not the issue shall be included in the Committee’s business. The individual raising the matter may be invited to attend.
7. Frequency of Meetings
1. Meetings will be held no less than quarterly in each accounting year.
2. Extraordinary meetings may be called by the Chair or at the request of any member via the Chair.
8. Duties and Responsibilities
1. Each meeting will be structured with a pre-determined agenda.
Apologies will be required from those members who are unable to attend and minutes will be sent.
2. The Nutrition Steering Committee will consider any matters relating to nutritional care which will include:
a) The implementation, development and ongoing management of nutritional care related to the Trust.
b) The establishment and maintenance of procedures and systems to underpin the safe and effective delivery of nutritional care in the Trust.
3. Monitor the work of other groups, Committees, Forums, etc relating to nutritional care.
4. Review trends and/or issues arising from other internal and external groups.
5. Recommendations arising from the work of any nutritional care groups will be considered at the Governance Committee for debate and approval.
9. Review
The Clinical Effectiveness Committee will review the Terms of Reference of the Nutrition Steering Committee annually to ensure that it remains fit for purpose and is best facilitated to discharge its duties.
3.
GOVERNANCE STRUCTURE
[pic]
Membership of Nutrition Groups
|Nutrition Steering Committee |Linda Irons, Sallyanne Mckinney, Clare Alexander,| |
| |Grace Atkinson, Liz Audsley | |
| |Anne Sutcliffe, Alison Smith, Audrey Kirby, Ann | |
| |Powell, Jan Richards, Barbara Gilbank | |
| |John Greenway, Sam Dresna | |
| |Paul Birch, Carol Tarren, Mark Larking | |
| |Ann Raw , Philip Halton | |
| |Fiona Rawlings, Catherine Pentland | |
|Parenteral Nutrition |Sallyanne Mckinney, Fiona Rawlings, John | |
| |greenway, Sam Dresna, Jo Mckenna, Rachel Edson, | |
| |Laura Chapman, ?John Hancock | |
|Catering |Linda Irons, Grace Atkinson, Karen Wiles, | |
| |Jennifer Ellis, Paul Birch, Carol Tarren, Mark | |
| |Larking, Alison Smith, Audrey Kirby, Ann Raw, | |
| |Philip Halton | |
|Oral and Enteral Feeding |Georgia Payne, Clare Alexander, Liz Audsley, Kate| |
| |Lamballe, John Greenway/Registrar, S<, | |
| |Pharmacist, Barbara Gilbank, Nurse | |
|PEG Group |Clare Alexander, Sallyanne Mckinney, Maxine | |
| |Easby, Liz Audsley, Karen Wiles, Paula Hynd, Ann | |
| |Powell, Barbara Gilbank, John Silcock, Sharon | |
| |Brewster | |
|Home Enteral Feeding Group |Georgia Payne, Ruth Weatherall, Maxine Easby, Viv| |
| |Matthews, Philippa Rosenbrier, Sharon Brewster, | |
| |Tracy Allston, Paula Hynd | |
|Naso-gastric feeding group |Anne Sutcliffe, Judith Connor, Sallyanne | |
| |Mckinney, Alison Smith, Audrey Kirby, Gill Hunt, | |
| |Julie Pagan | |
|Assisted feeding group |Judith Connor, Linda Irons, Liz Audsley,Gill | |
| |Everson, Halina Baker,Melanie Crofts, Alison | |
| |Smith,Emma Cox,Angela Kelly | |
|Nutrition Screening |Adult – Kate Lamballe, Linda Irons, Paula Hynd, | |
| |Savitha Shyam Sundar | |
| |Paediatric – Ruth Weatherall, Alison Smith | |
|Infection Control Issues |Rachel Edson, Hue Hoang, Kate Lamballe, Mel | |
| |Gannon, Control of Infection Nurse | |
3. REPORT FOR CLINICAL EFFECTIVENESS SUB COMMITTEE
January 2007
Trust Nutrition Steering Committee (NSC)
Progress Update
The NSC is meeting regularly i.e. 6-8 weeks and is well attended with representation from nursing, dietetics, patient representatives, medics, S<, Pharmacy and catering.
The agenda has focused around the NICE guidance CG32 Nutritional Support in Adults incorporating actions from the Essence of Care audit, Inpatient survey and audit of nutritional standards for catering
NICE guidance CG32
A. Key clinical priorities
Nutritional screening
A nutritional screening tool is currently in use across the organisation recommending screening on admission and at weekly intervals. Results of the EOC audit indicate screening occurs in 50% or less clinical areas. The evidence-based MUST tool recommended by NICE has been piloted in the Trust over the past few months and will be introduced by March 07. However we do not routinely screen out-patients with the exception of certain pre-assessment clinics.
Action:
• Funding obtained to produce necessary training tools, BMI charts to support the introduction of the MUST screening tool
• Programme of training to begin Jan 07 on JCUH site, Feb 07 FHN.
• Agreed Opt-out areas
• Group set up to link into Primary care to set up pathway of care for patients identified at risk by out-patient screening.
Treatment of malnutrition: Enteral
The organisation is compliant with recommendations for access, management, delivery and use of motility agents with the exception of continuous nasogastric feeding in ITU patients and the introduction of feed following PEG insertion. Care bundles are set up to look at nutrition in critical care and the management of PEG tubes.
Policies exist for placement and aspiration of Naso-gastric tubes however these need to be reviewed.
Action:
• Introduced Refeeding policy – agreed by CESC Nov06
• Naso-gastric feeding – group established to review existing policies. Placement of naso-gastric tubes to be produced as a care bundle. New pH paper introduced.
• Audit completed looking at nutritional supplements prescribing practice and arrangements for discharge at JCUH and FHN. Results indicate 33-35% patients are prescribed supplements without nutritional assessment.
• Discharge communication for GPs has been adapted to improve information available for monitoring patients in the community. Work carried out in conjunction with the PCTs.
• PEG feeding – multidisciplinary team meeting set up to discuss all referrals for PEG placement on a weekly basis. Ann Powell to produce paper for Tricia Hart making recommendations for the use of syringes.
Treatment of malnutrition: Parenteral
We are largely non-compliant with NICE guidance for access routes as an organisation.Cannula’s are used for peripheral feeding and Hickman or CVP lines for central access. TPN is not introduced at 50% estimated needs, nutritional requirements are not routinely assessed by appropriate healthcare professionals and we are not always adding vitamins and minerals to bags. TPN is not always discontinued using a step down approach.
Action:
• Multidisciplinary PN group has been set up. The membership is as follows:
J.Greenaway (Gastroenterologist), S.Dresna (Surgeon), S.Mckinney (Dietitian), F.Rawlings (Pharmacist), Janice McKenna (ITU Nurse)
An anesthetist from FHN is to be invited onto the group.
• Agreed actions for the PN group include producing:
- Guidelines for PN use
- Standard referral form for Parenteral Nutrition
- Guidelines for appropriate lines and line care
B.Key organisational priorities
Education and training
The guidance recommends that 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.
All clinical areas have been offered the opportunity to access a Nutrition Link Nurse training programme. Dietetic assistants undertake nutritional training and will be able to access an NVQ Level 3 qualification in the near future. Nutrition training takes place for clinical teams. There is limited input into medical training.
Action:
• Attended N&M Clinical Governance Board to discuss options for training
• Regional programme for NVQ Dietetic Assistants
• To approach Academic Division re: medical training opportunities
• Launch event planned for May/June 07
• Input into doctors induction. JG to investigate
• Accessing specialty lunchtime meetings
• Contact Nurse reader at Teesside Uni. LI to progress
Nutrition Team
NICE recommends that healthcare professionals should ensure that all people who need nutrition support receive coordinated care from a multidisciplinary team. All acute hospital trusts should employ at least one specialist nutrition support nurse.
The need for a nutrition team was identified in the Trusts Nutrition Strategy 2002 however funding for a Specialist Nutrition Nurse and ring fenced medical time has not been identified.
Action:
• Setting up meetings with appropriate drug/feed companies to look at funding opportunities, working with John Greenaway, supported by Nursing Director
• Identified key individuals with interest - medic,dietitian,pharmacist
• Anne Sutcliffe & Linda Irons jointly producing business case for Nutrition Nurse Specialist. Long term funding opportunities may arise out of new Enteral Feeding Contract 2008.
• Established TPN working group with remit as above.
Nutrition Steering Committee
All hospital trusts should have a nutrition steering committee working within the clinical governance framework.
The NSC was established and has met regularly since May 06. The terms of reference have been ratified by the CESC.The group will report to the Clinical Effectiveness committee and link to the EOC steering group. The remit of the group will be to action findings of the EOC audit and implement NICE guidance.
Action:
• NSC will report regularly to the CESC
• Membership includes Dep. Nursing Director, Clinical Matrons, medics, patient rep, PFI rep, catering, pharmacy, dietetics,
• All relevant groups within the organisation have been mapped out and there is at least one representative (usually the Chair) sitting on the NSC to ensure coordinated activity. (see attachment)
Essence of Care/in-patient survey/Nutritional Standards for Hospital Catering audit
These aspects of nutritional care will be dealt with by the Catering sub-group.
The purpose of the group is to:
• Discuss issues relating to national catering documents and local policies.
• Ensure that action is taken on the implementation of NICE guidance and Standards for Better Health relating to food provision
• To advise on the issues highlighted in the Essence of Care and Nutritional Standards Audit.
• To be aware of all National and European proposals for the improvement of patient nutritional care
The Catering Group will consider any matters relating to the provision of nutritional care which includes:
• The implementation, development and ongoing management of catering and food service in the Trust.
• The establishment, maintenance and review of procedures and systems to underpin the safe and effective delivery of catering and food service in the Trust to ensure patients receive adequate nutrition.
In audits, the Trust does not perform well in relation to assisting patients who have difficulty feeding themselves. An Assisted Feeding Group has met and agreed an action plan as follows:
• To undertake a mapping exercise identifying areas of high demand for assisted feeding
• To produce guidelines re: positioning of patients for feeding,
• Wd12 are to audit use of red napkins to indicate the need for assisted feeding along with a protected mealtime pilot.
• To investigate introducing a volunteer system for assisted feeding
• To meet with NTees to discuss their nationally acclaimed scheme
Report produced by: Linda Irons, Chair Nutritional Support Committee/Director of Nutrition & Dietetics
5
NICE GUIDANCE CG32 - PROGRESS REPORT MAY 08
|Key priorities |Update |Action |
|Nutritional Screening | | |
|Introduce MUST screening tool into all in-patient areas|As from 1st November all nutrition |Continue to roll-out programme|
| |support referrals required MUST score |of audit |
| |First audit of MUST tool completed on |Act on results of audit and |
| |1/3rd wards |target poorly performing areas|
| | |with further training |
| |MUST session included in monthly nurse | |
| |update training targeting junior |Present audit results to NMGC |
| |nursing staff and HCAs. | |
| | | |
| | |Need to introduce into |
|Group set up to link into Primary care to set up | |out-patient areas – agree |
|pathway of care for patients identified at risk by |Continue discussions with primary care |appropriate areas |
|out-patient screening. | | |
|Enteral Feeding | | |
|Introduced Refeeding policy – agreed by CESC Nov06 |Placed on Pathfinder Sept 07 |Audit compliance Sept 08 |
| | | |
| | | |
| | |To be progressed by NNS |
|Naso-gastric feeding – group established to review |Revised adult and paediatric | |
|existing policies. Placement of naso-gastric tubes to |naso-gastric feeding policies to go to | |
|be produced as a care bundle. |N&MGC |Supplement audit to be |
| | |repeated following |
|Audit completed looking at nutritional supplements | |introduction of MUST |
|prescribing practice and arrangements for discharge at |Introduction of MUST tool should reduce|Summer 08 |
|JCUH and FHN. Results indicate 33-35% patients are |need for supplement prescription by | |
|prescribed supplements without nutritional assessment. |medics | |
| | |Replace syringe with suitable |
| | |single use alternative by |
|NPSA Patient Safety Alert 19: promoting safer | |March 08 |
|measurement and administration of liquid medicines via |Task group met, agreed on replacement |Delay because of manufacturing|
|oral and other enteral routes |syringes to ensure compliance |problem. Risk alert to go out |
| |Arranging event for staff to bring |when supply date given |
| |along tubes in use in Trust to test | |
| |compatibility with new syringes |Complete pack and pilot on Wds|
| | |21/23/neuro/ community |
|To be compliant with NICE guidance Trust requires a | |hospital in SUMMER 08 |
|comprehensive package for patients discharged home on | |To go to NMGC following |
|enteral feeds |Draft competency package produced |completion of pilot. |
| |Containing a training checklist based | |
| |on tracheostomy pathway. | |
| |Updating patient information for | |
| |discharge dealing with troubleshooting |For Clinical Effectiveness |
| |and monitoring entral feeding at home. |Committee approval |
| |Adult and paediatric version | |
|PEG feeding | | |
| | | |
| |Producing PEG care guidelines for use | |
| |at ward level. Out for comment within |Re-audit Oct 08 |
| |PEG group | |
| |PEG displacement guidelines produced | |
| |for A&E and MAU | |
| | | |
| |Pre-assessment form introduced to | |
| |ensure all patients requiring PEG | |
| |placement are referred to dietetic | |
| |service | |
|Parenteral Feeding | | |
| | | |
|Agreed actions for the PN group include producing: |Guidelines for indications for use of |To go on Pathfinder. Request |
|- Guidelines for PN use |PN |guidance from CESC on |
|- Standard referral form for Parenteral Nutrition |completed. Agreed by NSC. For |disseminating guidance |
|- Guidelines for appropriate lines and line care |ratification by CESC | |
| | |To introduce once formal |
| | |Nutrition team in place |
| |Referral form for PN agreed by NSC | |
| | | |
| | | |
|Education & Training | | |
| | | |
|Input into doctors induction. JG to investigate |Production of Nutrition Handbook for F1|On-going part of F1 and F2 |
|Accessing specialty lunchtime meetings |and F2 doctors by Pharmacy and |training |
|Contact Nurse reader at Teesside Uni. LI to progress |Dietetics | |
|To approach Academic Division re: medical training | |Setting regional objectives |
|opportunities | |for nutrition training for all|
| | |levels of medical staff to fit|
| | |in with national review |
| | | |
|Nutrition Team | | |
|Setting up meetings with appropriate drug/feed |Unsuccessful beyond training monies. |Agreed contract which includes|
|companies to look at funding opportunities, working | |‘added value’ sponsorship for |
|with John Greenaway, supported by Nursing Director | |up to 5 years. Now need to |
| | |agree costings and membership |
| | | |
| | |Finally agreed funding, going |
| | |out to advert |
|Anne Sutcliffe & Linda Irons jointly producing business|Business case for Nutrition Nurse | |
|case for Nutrition Nurse Specialist. Long term funding |Specialist provisionally approved at | |
|opportunities may arise out of new Enteral Feeding |FMG | |
|Contract 2008. | | |
| | | |
| | | |
|Established TPN working group with remit as above. |Group meeting regularly, not | |
| |functioning as Nutrition team | |
|Audits | | |
|The establishment, maintenance and review of procedures|Protected mealtimes policy approved |Monitoring of pilot wards by |
|and systems to underpin the safe and effective delivery| |Trust staff |
|of catering and food service in the Trust to ensure |Introduction of new bulk meal service |Training programme for nursing|
|patients receive adequate nutrition. |across JCUH |staff and Sovereign staff |
| | |Programme of audit to ensure |
| |Need processes in place to ensure |nutritional adequacy |
| |patients receive nutritionally adequate| |
| |meals, are assisted with feeding where | |
| |required and optimize the mealtime |Audit protected mealtimes |
| |experience. |policy Autumn 08 |
| | | |
| | | |
6
Nutrition Steering Committee.
Minutes of meeting held on 23rd June 2008
Present:
Linda Irons, Director of Nutrition and Dietetic Services (Chair)
Sallyanne McKinney, Extended Scope Practitioner, Dietetics
Rachel Askew, Sovereign Catering Services, JCUH
Georgia Payne, Operational Manager/Specialist Dietitian
Fiona Rawlings, Pharmacy
Clare Lord-Hatton Operational manager/Specialist Dietitian
Anne Sutcliffe, Deputy Director of Nursing
Carol Tarren, Hotel Services Manager, FHN
Judith Connor, Clinical Matron, Cardiology
Liz Audsley, Operational Manager/Senior Dietitian, FHN
Anne Powell, Specialist Nurse Endoscopy
Apologies:
John Carr, Sovereign Catering Services, JCUH
John Greenaway, Consultant Gastroenterologist, JCUH
Audrey Kirby, Clinical Matron, Neurosciences
1) Notes of last meeting
Accepted as a true record.
2) Matters Arising.
All to be covered as agenda items
3) Progress with sub-groups.
a) Catering.
. Protected mealtimes policy –was implemented on all wards at JCUH from 2nd June 08 to coincide with the introduction of the new meal service. JC reported that the introduction had gone well to date with only a few issues raised by AAU, A&E and SOU where there had been a misunderstanding of the policy. JC had been interviewed by the Nursing Times re: the policy.
CT reported she had submitted the ‘place mat’ system to the HCA as an example of good practice and that Protected Mealtimes were in place on all wards at FHN.
It was agreed that the red napkin pilot should be rolled out to all wards by 1st July 08. RA agreed to follow this up with Carillion. AS/LI/JC are due to meet to discuss a standard diet sheet for all wards and a process for the ordering of special diets. This will also address assisted feeding.
Action: RA/LI/AS/JC
There has been a request by Julie Suckling for additional special diet training for the housekeepers working in Elderly care. It was agreed this will be valuable for all housekeepers. RA agreed to progress this
Action: RA
AS requested that all patient feedback received regarding the new bulk system be sent to her. Paul Birch is provided with a monthly report from Carilion containing this information.
Action: AS to contact PB
AS asked if the problem with speed of food service on Wd 29 had been resolved. JC explained they had been given a second housekeeper and more food was supplied on the trolley. The problem was now resolved.
b) Supplemented oral feeding.
MUST screening –. The first of the quarterly audits to look at MUST compliance was carried out in April 08 looking at 12 wards scattered across the Trust ensuring all divisions were represented. Initial results indicate that there is a significant improvement in the number of patients being nutritionally screened however the audit did not look at the quality of completion of these forms. The next audit will pick up this issue.
AS asked where this information had been fed back – LI had taken it to CESC. AS requested the information is cascaded to Clinical Matrons and the Essence of Care group. It was also suggested the dietitians contact Jeanette Power-Jepson regarding the Quality of Care reviews in Medicine. It was agreed this work should not be duplicated.
LA to carry out MUST tool audit on FHN site picking up on quality issues.
Action: GP/LA/LI
The dietitians are continuing to provide MUST training as part of Nursing Preceptorship and Fundamental Aspects of Nursing care.
c) Enteral tube feeding.
NPSA: We are now compliant with NPSA guidance in all areas except Neonatology where there are issues regarding the use of syringe drivers. AS will contact Chris Renshaw.
Single use Medicina syringes are now available across the Trust for oral and enteral use. We are aiming to use Medicina ‘24hr use’ syringes for discharge supplies once approved by the MDA. The PCT’s wil be recharged for these supplies. All giving sets are NPSA compliant.
Action: AS/GP
Nutricia Contract – The changeover from Abbott to Nutricia for oral and enteral feeds is now complete on the JCUH and FHN sites. Nutricia have commented on the exceptional good turnout of nursing staff at pump training sessions. The wards have however requested further training as only 10% of total nursing workforce has received training. It was agreed the most effective training was ward based and ward staff should directly contact Nutricia for further sessions. CLH to liaise with ward staff.
120 pumps from the JCUH and 25 pumps from the FHN site had been uplifted by Abbott.
There has been an issue with HCA pump training regarding signing off competency. Nutricia has only been signing off qualified nursing staff. Group agreed HCA’s should also be deemed competent if training passed.CLH to contact Nutricia. GP to investigate the possibility of this training being included as part of mandatory equipment training programme
Action:CLH/GP
Home enteral feeding group will need to update much of their information to reflect the new contract and change in products and processes. Current work includes
• Revision of current discharge policy and procedures
• Review patient information/training checklists
• Review guidance on type of water used for flushing tubes. To involve David Charlesworth.
The group plan 2 future audits of discharge procedures and patient satisfaction.
PEG group – CLH reported the group are considering producing a care bundle for PEG’s. The post PEG placement care information is due to be presented to N&MGC by Ann Powell. AS suggested the care bundle should include aspects of infection control to prevent bactereamias.
Nutricia nurses will come into hospitals to train patients for home but require 48 hours notice.
LI asked if AP had planed any further training to include NG tube placement and aspiration techniques. None is currently planned however Sallyanne will include in next years Nutrition Study day
AS explained that the new Corporate Practice development Team could pick up this training along with the Patient Educators.
Action: CLH/AP/SAM/AS
d) Parenteral nutrition.
LI and SAM had taken the PN referral form and guidelines for indication of PN to the CESC. These had been ratified by the group with a recommendation that a duplicate copy of the referral form should be filed in the medical notes. SAM to seek advice from Dr Paterson, Health Records Committee.
A concern was expressed by a number of consultants with regard to the unavailability of PN over weekends and Bank Holidays. It was agrees SAM would set up a meeting with interested parties to discuss the possibility of PN with additions being available for weekend use.
Action:SAM
Dr Greenaway has indicated that he would be willing to provide one session per week to support the Nutrition team if funding were made available. LI is meeting to agree the allocation of ‘Added value’ monies associated with the Nutricia contract next week when the amount of money available will be clearer. The advert for the Nutrition Nurse Specialist is due to go out this month.
4) Education and Training
The next Nutrition Study day is planned for 19th May 09
Action: SAM
5) Any other business
Nurse representation – LA was concerned there was no FHN nursing rep on the group following the change in role of Janice Partlett. LA/CT agreed to discuss representation with FHN matrons to ensure one was always present.
It was suggested Mike Stevenson, the new Matron for Paediatrics and Julie Suckling, the new Elderly care Matron, be invited to join the group
Action: LA/CT/LI
6) Date and Time of next meeting.
22nd September 08 1.00 -2.30pm in Rehab Seminar room.
7
‘To evaluate the useage, appropriateness and wastage of Parenteral Nutrition in adult patients at The James Cook University Hospital’
Sallyanne Wilson
Extended Scope Practitioner
Dietetics Department
JCUH
Background and Aims.
Parenteral Nutrition is a method of providing nutritional support, where nutrients are delivered directly in to the circulatory system through a venous catheter. It is required when the intestine is unavailable/inaccessible or unable to absorb or digest an adequate supply of nutrients, on a permanent or temporary basis (BAPEN,1996).
Parenteral Nutrition is an expensive method of nutrient delivery and is associated with mechanical, septic and metabolic complications (Trager et al, 1986; Oakes et al, 1991). It is also suggested that Parenteral Nutrition is of no clinical benefit to patients if provided for 4 days or less (BAPEN, 1996). However, it should be used in all individuals exposed to 7 or more days of inadequate nutrition once all enteral routes have been explored and excluded (BAPEN, 1996). There are a number of papers that demonstrate the reduction of complications, inappropriate useage and improved quality of nutrient delivery in hospitals with a dedicated nutrition team using standard protocols and delivering regular training to ward staff.
A smaller audit carried out during 1998 highlighted the lack of awareness and inappropriate use of Parenteral Nutrition at JCUH. However, data collection was limited for those patients not referred to the Dietitian (predominantly critical care).
At the JCUH there are no uniform guidelines or protocols for the useage and delivery of Parenteral Nutrition to adult patients. In addition, there is no dedicated nutrition team, hence no regular or controlled delivery of training to ward staff. In view of this the aim of this audit is:
‘To evaluate the useage, appropriateness and wastage of Parenteral Nutrition in adult patients in order to highlight cost savings and support the need for a multi-disciplinary nutrition team within South Tees Hospitals NHS Trust.’
Standards/Objectives to be measured.
● Number of patients receiving Parenteral Nutrition during the audit period.
● Where Parenteral Nutrition is being used.
● Rationale for use – Parenteral Nutrition should only be used when the gastro-intestinal tract is non-functioning and/or inaccessible.
● Whether Enteral Nutrition is tried before Parenteral Nutrition.
● Proportion of patients referred to the Dietitian for Parenteral Nutrition, hence receiving improved quality of nutrient delivery and assessment/review of nutritional status and nutritional requirements.
● Route used for Parenteral Nutrition – can affect composition of nutrient delivery.
● Complications of Parenteral Nutrition.
● Use of standard and specially made bags compared to individual nutritional requirements.
● Number of days of Parenteral Nutrition use – little or no clinical benefit if administered for 4 days or less.
● How patients are weaned off Parenteral Nutrition and whether adequate nutritional requirements (at least 50%) are met before Parenteral Nutrition is discontinued.
● Number of Parenteral bags discarded/not used, hence money wasted.
● Inappropriate use of Parenteral Nutrition.
Method.
Having applied and secured a part-time secondment to the clinical audit department, a prospective audit was carried out over a 3 month period from 11/06/04 until 11/09/04. This involved the completion of an audit questionnaire (see appendix 1) by the Dietitian for all adult patients receiving Parenteral Nutrition during this period. Data was obtained from the manufacturing department (pharmacy), dietetic colleagues, medical/nursing staff and patient case notes (medical and nursing).
Results.
Details of all the audit results can be found in appendix 2. However, the main results obtained are highlighted in this section.
54 adult patients at JCUH received Parenteral Nutrition over the 3 month audit period from 11/06/04 until 11/09/04.
[pic]
Which speciality areas are the highest users of PN?
The highest users of PN were General Surgery with 20 patients/37% (primarily Upper GI with 10 patients/18% and colorectal with 7 patients/13%), followed by Urology (12 patients/22%) and critical care (11 patients/20%).
[pic]
What was the rationale for PN use?
Bowel rest accounted for 16 patients (30%) receiving PN followed by lack of bowel sounds (8 patients/15%). Large gastric aspirates, vomiting, ?obstruction and abdominal distension were other reasons documented for PN use. It was unknown why PN was being used in 9 patients (17%).
Whether Enteral Nutrition is tried prior to PN.
Only 18 patients (34%) were tried with enteral nutrition prior to starting PN. Of these, 7 patients (13%) were only tried with oral feeding rather than artificial enteral nutrition and as few as 4 patients (7%) were tried with jejunal feeding.
Proportion of patients referred to the Dietitian/assessment of nutritional requirements.
11 patients (20%) were not referred to a Dietitian for nutritional assessment prior to commencing PN – these patients were primarily under critical care Consultants. 22 patients (41%) did not have a detailed nutritional assessment (including assessment of nutritional requirements) prior to commencing PN – this includes all those under critical care. It is estimated that almost 40% displayed evidence of malnutrition on initial dietetic consultation.
Route used for PN.
During the audit period, 37 patients (70%) received Central PN and 16 patients (30%) received Peripheral PN through a cannula. However, 4 of the Peripheral PN patients had central lines inserted for administration of PN due to poor venous access and 1 of the Central PN patients was transferred on to Peripheral PN due to line infection.
[pic]
Complications of PN.
During the audit period, 29 patients (54%) did not appear to display PN complications. However, complications were apparent in 25 patients (46%). The most commonly reported problems were thrombophlebitis and/or poor venous access in 50% of the 16 patients who received Peripheral PN. Metabolic complications (including electrolyte imbalances, fluid balance problems and hypo/hyperglycaemia) accounted for 15 to 20% of all PN patients. Of the 37 patients who received Central PN, 5 patients (14%) had a line infection confirmed.
Use of standard and specially made bags compared to requirements.
[pic]
Standard 9g or 14g bags were used in 44 (81%) of PN patients – the compositions of which can be seen in appendix 3. 20 patients (37%) had the regime changed during PN use, primarily the electrolyte content and/or addition or exclusion of vitamins and trace elements.
Only 19 patients (54%) met both their nitrogen and energy requirements through the PN regime. 8 patients (15%) received above their estimated energy requirements in order to achieve their full nitrogen requirements. 20 patients (37%) did not receive their full nitrogen requirements through the PN regime and 5 patients (9%) were below both nitrogen and energy requirements, primarily due to the limitations in the composition of peripheral PN regimes.
[pic]
Duration of PN use.
During the audit period, 24 patients (45%) received PN for 4 days or less. Only 29 patients (54%) received PN for a more appropriate minimum of 5 days. 1 patient did not proceed with PN after the bags were ordered. The inappropriate number of days useage for PN was most evident in critical care (HDU, ITU 2 and ITU 3) and Urology, accounting for 18 out of the 24 patients in total (75%).
[pic]
How patients are weaned/discontinued from PN.
30 patients (56%) had PN discontinued due to commencing oral diet and/or fluids. Only 15 patients (28%) were weaned on to artificial enteral nutrition. 8 patients (15%) passed away during the PN audit due to deterioration in their clinical condition (not PN related).
Only 16 patients (30%) were receiving adequate or 50% of nutritional requirements orally or via artificial enteral feeding prior to PN being discontinued. Nearly two thirds of patients were inadequately weaned off PN on to oral/enteral nutrition. Parenteral Nutrition is primarily discontinued at the medics request before the patient is achieving an adequate enteral intake.
Number of PN bags discarded/not used.
During the 3 month audit period, 36 PN bags were discarded/wasted – these bags were a combination of specially made bags and standard bags with additions, hence they only have a 6 day expiry from date of manufacture/additions added. (This includes 5 days refridgeration and 1 day/24 hours for administration). In terms of cost, each bag costs an average of £100, hence 36 bags is a minimum wastage of £3,600 – this would equate to £14,000 annually. 22 of the returned/unused bags were from ITU 2 and ITU 3 (61%) who did not request dietetic input. The remaining unused bags were from General Surgery (12 bags/33%), including surgical HDU.
[pic]
Inappropriate use of PN.
During the audit period, only 15 patients (28%) received PN appropriately. 27 patients (50%) received inappropriate PN – this was due to receiving PN for 4 days or less and/or because the GI tract was accessible and functioning, hence enteral nutrition would have been more appropriate. In addition, 8 of these patients were very poorly when PN was commenced, of which 7 passed away within 1 to 2 days. Inappropriate PN occurred across all specialities but was most predominant in Urology (11 patients) and surgical HDU (7 patients). It accounted for 88 bags in total during the 3 month audit, at an approximate cost of £65 per bag, therefore a total cost of £5,720.
For 12 patients (22%), PN was neither appropriate nor inappropriate - they generally received a minimum of 5 days of PN. However, some of these examples were:
● 2 patients temporarily received PN in place of their NG feeds in view of abdominal distension, however, this resolved within a few days.
● 1 pancreatitis patient had already been receiving PN at another hospital, hence this was initially continued at JCUH, then NJ feeds were started.
● Another patient had ?bowel obstruction which was later diagnosed as bowel cancer with widespread peritoneal disease.
● Another 4 patients would have required jejunal feeding, e.g: following gastrojejunostomy, pancreatic pseudocyst and duodenal perforation, however, this was not tried prior to starting PN.
Discussion.
This PN audit only covered a 3 month time period, hence it can not be assumed that there would be the same number of PN patients had the audit been conducted over another 3 month period. However, in adult patients receiving PN at JCUH, the audit has identified many important issues which need to be addressed. The main issues can be summarised into the following, which will then be discussed in further detail:
● Inappropriate use/wastage of PN bags
● Patients not having a detailed nutritional assessment/not receiving their nutritional requirements through the PN regime/limited number of standard bags available
● Lack of multi-disciplinary working and varying levels of expertise around PN
● Inconsistencies with the use of PN within specialities
Inappropriate use/wastage of PN bags.
At least 50% of patients received inappropriate PN during this audit period – this was equivalent to a ‘waste’ of 88 PN bags at a cost of approximately £65 per bag, hence £5,720 in total. 36 bags were returned to Pharmacy over the 3 month audit period and discarded. This resulted in an additional wastage figure of £3,600. If these figures remained static over a 12 month period, this would result in an annual ‘wastage’ figure of approximately £37,280!! It could be argued that a proportion of these patients should have received enteral nutrition as a more appropriate alternative, which would then account for the use of some of this money. However, enteral nutrition is a far cheaper method of feeding than PN (BAPEN, 1996). In addition, the cost of treating the 25 patients (46%) who displayed complications of PN could also be added on to the previous ‘wastage’ figure – particularly the 8 patients on peripheral PN who had thrombophlebitis and the 5 central PN patients who had treatment for a line infection. The availability of the jejunal route should mean a reduction in the number of patients receiving PN. However, as this audit showed, only 4 patients (7%) were tried with jejunal feeding prior to PN. It is difficult to assess whether this small number is related to a lack of awareness of jejunal feeding and/or accessibility to the relevant health professionals/equipment needed to insert NJ and/or surgical jejunostomy tubes.
Patients not having a detailed nutritional assessment/not receiving their nutritional requirements through the PN regime/limited number of standard bags available.
As previously identified, 11 patients (20%) were not referred to the Dietitian for nutritional assessment (all under critical care Consultants). In addition to these, a further 11 patients (hence 41% in total) did not have a nutritional assessment (including assessment of nutritional requirements) prior to commencing PN. This could go part way to explain why only 19 patients (54%) met both their nitrogen and energy requirements through the PN regime. However, this could be further explained by the fact that at JCUH there are currently only 2 standard bags available, of which only 1 of these is for peripheral PN use. It is possible to order special bags from manufacturing, however, due to the number of inappropriate PN referrals and the fact that PN is frequently discontinued by medics unexpectedly, dietitians involved in ordering PN are most likely to order a standard bag nearest to the patient’s requirements. A standard bag without additions can be returned to manufacturing if unused and the ward will be re-imbursed. Otherwise, the wastage cost would be much higher than the above figure.
Lack of MDT working and varying levels of expertise around PN.
The audit highlighted that in 100% of cases PN was initiated by medical/surgical/critical care doctors and that the majority of these also decided when PN was discontinued. PN is often used because the patient already has a central line in place, hence this is felt to be an appropriate reason why PN should be used. In addition, PN may be started over a weekend without a dietetian, hence we are then requested to keep ordering bags because PN is already in progress. The fact that doctors primarily decide when PN is started and stopped helps to explain why nearly two thirds of patients were inadequately weaned off PN, before they were receiving an adequate oral/enteral intake. Only 15 patients (28%) were weaned from PN on to artificial enteral feeding – 30 patients (56%) were weaned from PN directly on to oral diet/fluids. It is extremely unlikely that a patient who previously received their nutritional requirements via PN will suddenly be able to take at least 50% of their requirements orally, particularly when these patient’s are likely to have had recent surgery/trauma and/or been very poorly. There is also a lack of multi-disciplinary discussion around the appropriateness of PN and the access route used for feeding. For example, thrombophlebitis/poor venous access was a problem for 50% of the peripheral PN patients – if there had been multi-disciplinary discussion prior this being commenced, some of these patients could have been identified as having poor peripheral access, hence peripheral PN would not have been the route of choice. In addition, patients who have relatively high nutritional requirements are generally unable to have these met through a peripheral PN bag due to osmolality. Hence, these should be identified before PN is started in order to assess the most appropriate route. Some of the problems with inappropriate referrals for PN/wastage/patients not meeting requirements through their PN regime is probably related to lack of awareness/knowledge around nutritional support and PN. For example, alternative routes of feeding, access routes for PN, appropriate lines and knowledge around ‘specifically-made’ PN regimes There are many health professionals (including medical and nursing staff) involved in PN, all with varying levels of knowledge and expertise in this specialised field. At present, any Dietitian can be involved in the ordering and monitoring of PN with differing levels of competency.
In view of the lack of multi-disciplinary discussion around PN, each health professional is working very much on there own and hence, decisions are made without agreement from everybody involved, for example, the decision to suddenly stop PN. The lack of experience and expertise may also explain why the decision to commence PN is not always questioned – why does nobody question the inappropriateness of commencing a dying patient on PN?
Inconsistencies with the use of PN within specialities.
The audit highlighted the lack of consistency within specialities on the use of PN and the lack of standards/protocols for the nutritional management of certain conditions. For example, not all Urology Consultants use PN following radical cystectomy or cystoprostatectomy – why isn’t a more uniform approach used? Why do only a small number of pancreatitis patients receive the recommended jejunal feeding, whereas the vast majority are still receiving PN?
Limitations of the audit.
1) It was difficult to assess all complications as I was reliant on what was documented in the medical and nursing notes. Not all information needed was recorded. All wards/areas vary greatly in where and how they document issues relating to PN patients.
2) I had wanted to look at the number of catheter/cannula changes patients required throughout the duration of PN. However, it was often difficult to obtain this information as it wasn’t always documented – particularly if the change occurred overnight or over a weekend.
3) It was often unclear why patients were commenced on PN hence there may have been an assumption made for some of the patients as to why the PN route was used.
4) The wastage figures were obtained from manufacturing as the bags had frequently gone from the wards before I had managed to locate them. Some of the unused bags were used on other patients, hence aren’t included in the wastage figures.
5) I had tried to look at too many issues during the PN audit and not all of the information collected was useful.
6) Although I had tried to list as many responses as possible for each question there were some responses that weren’t covered, hence the large proportion of responses under ‘other’ for diagnosis and rationale PN use.
Recommendations.
1. To recruit an extended scope practitioner in Parenteral Nutrition for adult patients, with particular emphasis on critical care and training and education within the Trust..
2. To widen the range of standard bags currently available.
3. To develop out-of-hours policies on Parenteral Nutrition.
4. To develop policies on Indications for PN use in the Trust – this would need to be developed as part of a multi-disciplinary team.
5. To conduct a smaller audit in conjunction with the Northern Nutrition Network as part of a benchmarking exercise with other Acute Trusts in the region.
7b
8
8a
THE JAMES COOK UNIVERSITY HOSPITAL
TRUSTWIDE AUDIT
Audit of Trust’s Nutritional Standards
Normal Menu
November 2007
Auditors:
Linda Irons Director, Nutrition & Dietetic Services, STHT
Christine Crawford Performance manager, Sovereign
Val Jones Endeavour
Supported by: Jennifer Ellis, Aimee Newton, Emma Cox, Deborah Smith
(Dietitians STHT)
| 1. Background & Aims |
| |
|This is the third audit of the Trust’s Nutritional Standards. The audit includes, within its scope, re-audit of the |
|recommendations from the previous audit dated November 06 |
| |
|The purpose of the audit is: |
| |
|To ensure the Normal Menu provided by Sovereign Hospital Services meets the Trusts’ Nutritional Standards for Adults (See |
|Table 1 below). |
| |
|Table 1: Trusts’ Nutritional Standards for Normal Diets - revised 2007 |
| |
|Nutrient |
|Nutritional Standard |
| |
| |
|Energy |
|(30Kcals/kg body weight) |
| |
|1900 - 2550 Kcals per day |
|Minimum 2150 kcals per day |
| |
|Protein |
|(1 – 1.2g protein/kg body weight) |
| |
|70 - 90g per day |
|Minimum 70g protein per day |
| |
| |
|Energy from fat |
| |
|Energy from fat = 35% - 40% |
| |
| |
|Energy from Carbohydrate |
|50% |
| |
| |
|Non-Starch Polysaccharide (NSP) |
|12 - 24g per day |
| |
| |
|Salt |
|6g |
| |
| |
|Vitamin C |
|40mg per day |
| |
| |
|Folate |
| |
|200μg per day |
| |
| |
|Iron |
|8.7mg (males aged 19 – 50 years) |
|14.8mg (females aged 19 – 50 years) per day |
| |
| |
| |
| |
|To ensure all foods are available, well presented and meet the minimum portion size standard |
| |
|To ensure all dishes are palatable with a good flavour |
| |
| |
|To ensure all hot foods are served at the appropriate temperature |
| |
| |
|To ensure all foods are served within their ‘use by’ date |
| |
| |
| |
| 2. STANDARD/OBJECTIVE OF CARE TO BE |
|MEASURED |
| |
|Assessment of achievement of the Normal Menu to meet the Trusts’ Nutritional standard by weighing and nutritional analysis|
|of food provided to our patients |
| 3. METHOD |
|Menu cards were completed for a number of bogus patients selecting food choices for a 24 hour period. These choices were |
|made ensuring all dishes and combinations of food had been selected allowing the auditors to analyze all foods on the |
|menu. Only the auditors were aware of the audit date and bogus patient names. Meals were sent up to one ward where there |
|were a number of empty beds/bays and which would therefore have capacity on the regeneration trolley for additional trays.|
|The auditors visited the ward at each meal and snack time to undertake the weighing and assessment. |
|The food items received were weighed, recorded and then nutritionally analysed using ‘Microdiet’ a computer package for |
|nutrient analysis. |
|Subjective comments were made on appearance, portion size and quality of the food provided. |
|Temperature and food dates were also recorded. |
| 4. FINDINGS |
| |
|Table 2: Did the Patient's Normal Menu Meet the Nutritional Standards for South Tees Hospitals NHS Trust? |
| |
|Nutritional Standard |
|Met? |
|Actual Nutrient Content 2007 |
| |
| |
|1900 - 2550 Kcals per day |
|Minimum 2150 kcals per day |
|Yes |
|2424kcals |
| |
|70 - 100g Protein per day |
|Minimum 70g protein |
|Yes |
|90g |
| |
|35% - 40% Energy from fat |
| |
|Yes |
|40% |
| |
|50% Energy from Carbohydrate |
| |
|Yes |
|45% |
| |
|12 – 24g fibre per day (Southgate) |
|Yes |
|27.2g |
| |
|6g Salt per day |
| |
|Yes |
|6g |
| |
|40mg Vitamin C per day |
| |
|Yes |
|67.5mg |
| |
|200μg Folate per day |
|Yes |
|226μg |
| |
| |
|8.7mg (males aged 19 – 50 years) – 14.8mg (females aged 19 – 50 years) Iron per day |
| |
|Yes for males |
|No for females |
|13.5 mg |
| |
| |
| |
|Nutritional Standards |
|The Trusts’ Nutritional standards were met for all nutrients with the exception of iron requirements for females aged 19 –|
|50 years. (See Table 2). The iron content, at 13.5mg (91% DRV), was however a significant improvement on the previous |
|audit in November 06 when the iron content was 12.1mg (81% DRV) per day. On 2 patient days the food choices allowed for an|
|adequate iron intake i.e. exceeding the 14.8mg so appropriate choices would lead to increased iron consumption. Liver is |
|available on the menu on other days of the week further boosting iron intake. |
| |
|Food Availability |
|Results of the audit show that 100% food offered on the menu was available on the day of the audit. This is a significant|
|improvement over last years audit when only 88% of food items were available |
| |
|On the elderly care wards the full selection of breakfast choices were not offered to all patients. This was a decision |
|taken by the housekeepers as they felt some patients were overwhelmed by the range of choices and got confused easily. |
|They always offered cereal, toast and cooked breakfast first. |
| |
|There was a good selection of mid morning and mid afternoon snacks available in contrast to the audit carried out last |
|year. |
| |
|Food Presentation |
|It was agreed by all auditors that the presentation of the food was generally good with effective use of garnish where |
|appropriate, an improvement on the previous years audit when only 93% of food was acceptably presented. |
| |
|Food Temperature and Date Code |
|All hot foods met with the standard for minimum temperature |
| |
|All foods audited were within their ‘use by’ date. |
| |
|Food taste |
|The flavours of the foods presented were acceptable to all auditors with the exception of the rice pudding where a couple |
|of the tasters felt there was a strong flavour of nutmeg which may be overpowering. |
| |
| |
| |
| |
| |
|. |
| |
|Portion Size |
| |
|An assessment has been made where the portion size is dependant on the accuracy of servers within the CPU not where foods |
|are pre-packaged or already portioned e.g. bread, certain cereals, biscuits |
| |
| |
|Compliance with portion sizes was very high for the audit period. Only 2 food items were shown to weigh less than the |
|portion sizes agreed with Sovereign. These were the roast beef sandwich where there was inadequate beef, and custard. The |
|bowls used to hold puddings are too small to allow for 100g custard to be added without spillage. |
| |
|A number of items were in excess of 40% above the recommended portion size. This may result in over facing patients with |
|too large portions and incurring unnecessary cost to Sovereign. These foods include porridge and rice pudding. The sponges|
|tended to be over-portion which, if reduced, may allow for larger servings of custard to be added to the bowl. |
| |
| |
| |
|Portion sizes: |
| |
| |
|Food name |
|Actual portion size g |
|Standard portion size g |
|% difference |
| |
|Breakfast |
| |
| |
|Porridge |
|220 |
|150 |
|+ 46% |
| |
| |
|Baked beans |
|96 |
|85 |
|+ 13% |
| |
| |
|Scrambled egg |
|119 |
|85 |
|+ 40% |
| |
|Lunch |
| |
| |
|Mushroom soup |
|187 |
|180 |
|+ 4% |
| |
|Tuna mayo for salad |
|131 |
|84 |
|+ 55% |
| |
| |
|Cottage cheese for salad |
|116 |
|84 |
|+38% |
| |
|Egg mayo sandwich |
|77 |
|75 |
|+ 3% |
| |
|Beef sandwich |
|69 |
|72 |
|- 4% |
| |
|Banana cake |
|78 |
|50 |
|+ 56% |
| |
| |
|Custard |
|81 |
|100 |
|--- |
| |
|Fruit mousse |
|56 |
|50 |
|+ 12% |
| |
| |
|Jelly |
|106 |
|100 |
|+ 6% |
| |
| |
|Evening meal |
| |
| |
|Butter bean & bacon soup |
|199 |
|180 |
|+ 10% |
| |
|Potatoes |
|125 |
|112 |
|+ 11% |
| |
| |
|Vegetables |
|98 |
|90 |
|+ 9% |
| |
| |
|Pasta carbonara |
|214 |
|170 |
|+ 26% |
| |
|Steak & kidney pie |
|196 |
|160 |
|+ 23% |
| |
|Fish in breadcrumbs |
|125 |
|100 |
|+ 25% |
| |
|Mixed bean casserole |
|152 |
|150 |
|+ 1% |
| |
|Turkey for salad |
|118 |
|84 |
|+ 40% |
| |
| |
|Cheese savoury sandwich |
|110 |
|80 |
|+ 37% |
| |
|Rice pudding |
|213 |
|150 |
|+ 42% |
| |
| |
|Vanilla sponge |
|74 |
|50 |
|+ 48% |
| |
| |
| |
| 5. DISCUSSION |
| |
|There has been a significant change in approach to auditing the nutritional standards and other criteria during 2007. It was agreed that in |
|order to make the changes necessary to improve the service a three partner approach was required. All work that has been undertaken this year |
|to improve on the 2005/6 audit findings has included representatives from the Trust, Sovereign and Endeavour. |
|This has proven to be a very powerful approach with significant changes driven through resulting in the pleasingly successful audit findings. |
|Throughout the year regular mini-audits have been undertaken with actions followed through by Sovereign. These include: |
|replacing unsuccessful dishes on the menu |
|training of staff at ward level and in the CPU |
|greater involvement of CPU staff in the audit process |
|feedback to all groups of staff |
| |
|Results show that: |
|- All the Trusts’ Nutritional Standards were met except iron for females aged 19 – 50 years. |
|- All hot food available at ward level met the standards for temperature. |
|- All foods on the menu were available at ward level and the presentation and taste of the food was good. |
|- With a couple of minor exceptions portion sizes were adhered to. |
|- The range of choice available on the menu allow the majority of patients to meet their nutritional requirements |
| |
| |
|6. ACTION PLAN |
| |
| |
|Whilst we need to achieve local nutritional standards it is important that future audits consider those elements of national policy relating to|
|nutrition. These include: |
|-PEAT – the revised PEAT assessments now include 6 modernisation aims to replace the Better Hospital Food (BHF) targets. |
|-Standards for Better health |
|-Recommendations from the Council of Europe Report |
|It is recommended the catering sub-group of the trust’s Nutritional Steering Committee proceed with the production of an assurance matrix. This|
|matrix will allow the organisation to assess its compliance against recommendations from national guidance relating to the delivery of good |
|nutritional care e.g. NICE guidance CG32, Council of Europe resolution food and nutritional care in hospitals (2007), Improving nutritional |
|care DOH October 07 |
| |
|7. PRESENTATION AND DISSEMINATION OF RESULTS |
Date: March 08
Forum: Catering Services Project Board (Malcolm Lavin, Anne Anderson, Linda Irons)
9
GUIDELINES FOR INDICATIONS FOR USE OF PARENTERAL NUTRITION AND REFERRALS FOR PARENTERAL NUTRITION (ADULTS ONLY).
Produced by: South Tees Parenteral Nutrition Group
Date: January 2008.
Date of Review: January 2009.
9d
Guidelines for Indications for use of Parenteral Nutrition.
What is Parenteral Nutrition?
Parenteral Nutrition (PN) is a method of providing nutrients directly into the circulatory system via a dedicated venous catheter (Thomas and Bishop, 2007). PN is an expensive method of nutritional support and is associated with metabolic and infectious complications if not administered and monitored correctly.
Indications for Parenteral Nutritition.
The indications for PN are diminishing as the evidence from scientific and clinical studies on the benefits of enteral feeding continues to increase and the techniques for providing enteral nutrition improve (Thomas and Bishop, 2007).
PN should only be used when the patients gastrointestinal tract is non-functioning or inaccessible (NICE, 2006) or it has not been possible to meet nutritional requirements via the enteral route (Thomas and Bishop, 2007). Particular instances where PN may be used are:
• Severe Pancreatitis with ileus
• Severe mucositis following chemotherapy that prevents enteral access being established
• High output small bowel fistula
• Anastamotic breakdown following intestinal resection
• Intestinal obstruction
• Short bowel syndrome (likely to require long-term home PN)
• Hypermetabolic disorders or major surgery when GI tract expected to be unusable for 5-7 days
• Intractable vomiting
• Severe malnutrition and a non-functioning GI tract
Careful consideration should be given to the likely duration of PN before it is initiated and the most appropriate route of administration. There may be minimal benefit in a patient receiving PN for only a few days (BAPEN, 1996).
Appropriate route of administration.
Indications for using a Central venous catheter are (NICE, 2006):
● Patient is likely to require longer-term PN (more than 7 – 14 days).
● Patient already has suitable central venous access with a lumen that can be used solely for feeding.
● Patient has no suitable veins for peripheral feeding.
● Patient requires specialised PN feeds (for example, fluid restricted) that cannot be given into smaller peripheral veins.
Indications for using a Peripheral venous cannula, for example, a 20G (pink) or 22G (blue) venflon are (NICE, 2006):
● Patient requires short-term PN (less than 7-14 days).
● The patient has no need for central access for other reasons.
● Patient has suitable veins for peripheral feeding.
Care needs to be taken with the stability and composition of PN formulations administered peripherally (NICE, 2006).
Delivery and management of PN.
Nutritional requirements should be assessed by healthcare professionals, for example, dietitians, with the relevant skills and training in the prescription of nutritional support (NICE, 2006).
Parenteral Nutrition should be introduced progressively and monitored closely, with no more than 50% of estimated nutritional requirements being administered for the first 24 to 48hours (NICE, 2006). This rate may need to be reduced even further if a patient is at risk of refeeding syndrome. (Please refer to the Trusts refeeding protocol for identification and management of this condition).
Micronutrients and trace elements should always be added to parenteral nutrition, particularly if the patient is at risk of refeeding syndrome, with additional electrolytes being given as needed (NICE, 2006).
Continuous administration of parenteral nutrition should be given as the preferred method of infusion in severely ill people who require parenteral nutrition (NICE, 2006).
Cyclical delivery of parenteral nutrition may be considered when using peripheral venous cannulae (NICE, 2006).
Dietetic referrals for Parenteral Nutrition.
Parenteral Nutrition is never an emergency. The administration of Parenteral Nutrition out-of-hours using standard bags which are not nutritionally complete and cannot have additions made, may increase the risks of complications including sepsis and metabolic disturbances. Patients at risk of refeeding syndrome need to have a detailed nutritional assessment, with adequate testing and correcting of electrolytes before feeding is initiated (please refer to the Trusts refeeding protocol).
● Requests for Parenteral Nutrition need to be received before 12noon Mon to Thurs. Any requests received after this time will not be seen and assessed by a Dietitian until the following morning, hence will not receive a Parenteral bag until then.
● Requests for Parenteral Nutrition need to be received before 11:00hours on a Friday. Any requests received after this time will not receive a Parenteral bag or dietetic assessment until the following Monday morning.
● The best and safest nutritional care that staff can give to potential Parenteral Nutrition patients out-of-hours is to ensure electrolytes (including potassium, phosphate, magnesium and calcium) are measured daily, including a Saturday and Sunday, with appropriate vitamin and electrolyte replacement in preparation for feeding – please refer to the refeeding protocol for further advice.
● IV dextrose above 5% should not be used to provide fluid if the patient is at risk of refeeding syndrome as this will exacerbate the problem.
● Pharmacy will no longer dispense Parenteral Nutrition bags out-of-hours or via the on-call pharmacist (unless exceptional circumstances).
References.
British Association of Parenteral and Enteral Nutrition (1996) Current Perspectives on Parenteral Nutrition in Adults. Maidenhead, Berks. BAPEN
National Institute for Health and Clinical Excellence (Feb 2006) Nutrition Support in Adults – oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. .uk/CG032NICEguideline
Thomas, B and Bishop, J (2007) Manual of Dietetic Practice. 4th edition. Oxford. Blackwell Publishing Ltd. pp113-119
[pic]
9c
Protocol for
Refeeding syndrome and referrals for enteral/parenteral nutrition (adults only)
TABLE OF CONTENTS
Referrals for enteral nutrition page 3
Referrals for parenteral nutrition page 4
Protocol for re-feeding syndrome page 5
IV Drug Information page 9
Emergency enteral feeding regime page 12
REFERRALS FOR ENTERAL TUBE FEEDING (ADULTS ONLY).
All new patients requiring enteral tube feeding must be referred to the dietetic department at JCUH (ext. 4777) or the Friarage (ext. 2012) for full nutritional assessment prior to commencing feeding. Out of dietetic hours (evenings and weekends), please refer to the refeeding protocol and amended emergency feeding regime for all new enteral tube feeding patients. The following guidelines are in place for any patient requiring nasogastric, nasojejunal, gastrostomy or jejunal feeding:
• All referrals must be made before 4pm Monday to Friday and will therefore be seen on the day of referral.
• Referrals made after 4pm Monday to Thursday will not be seen until the following day.
• Referrals made after 4pm on a Friday will not be seen until the following Monday morning (or Tuesday if a bank holiday weekend).
• All referrals must have had bloods taken in the previous 48 hours and must include potassium, phosphate, calcium and magnesium.
• Any new patients requiring enteral tube feeding out of dietetic working hours should follow the refeeding protocol and amended emergency feeding regime until the patient is fully assessed by the Dietitian.
• IV dextrose above 5% should not be used to provide additional fluid if the patient is at risk of re-feeding syndrome, as this will exacerbate the problem.
• The dietitian should be involved and informed of any patients being considered for enteral tube feeding.
REFERRALS FOR PARENTERAL NUTRITION (ADULTS ONLY).
Parenteral Nutrition is never an emergency. Malnutrition is a culmination of a number of factors which have developed gradually over a period of time, hence the treatment of malnutrition and refeeding syndrome is a complex process (refer to refeeding protocol). The administration of Parenteral Nutrition out-of-hours using standard bags which are not nutritionally complete and cannot have additions made, may increase the risks of complications including sepsis and metabolic disturbances. Patients at risk of refeeding syndrome need to have a detailed nutritional assessment, with adequate testing and correcting of electrolytes before feeding is initiated.
● Requests for Parenteral Nutrition need to be received before 12noon Mon to Thurs. Any requests received after this time will not be seen and assessed by a Dietitian until the following morning, hence will not receive a Parenteral bag until then.
● Requests for Parenteral Nutrition need to be received before 11:00hours on a Friday. Any requests received after this time will not receive a Parenteral bag or dietetic assessment until the following Monday morning.
● The best and safest nutritional care that staff can give to potential Parenteral Nutrition patients out-of-hours is to ensure electrolytes (including potassium, phosphate, magnesium and calcium) are measured daily, including a Saturday and Sunday, with appropriate vitamin and electrolyte replacement in preparation for feeding – please refer to the refeeding protocol for further advice.
● IV dextrose above 5% should not be used to provide fluid if the patient is at risk of re-feeding syndrome as this will exacerbate the problem.
● Pharmacy will no longer dispense Parenteral Nutrition bags out-of-hours or via the on-call pharmacist.
Protocol for Refeeding Syndrome for Adults
Step 1: Initial Referral to Dietitian - Identify “at risk” patients
Referrals can be accepted from medical and nursing staff.
Acceptable criteria for referral:
|Patient has one or more of the following: |
|• BMI less than 16 kg/m2 |
|• 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. |
|Or patient has two or more of the following: |
|• BMI less than 18.5 kg/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. |
Refer the patient to the dietitian on admission on ext: 4777 (JCUH) or ext: 2012 (Friarage), stating that the patient is at risk of refeeding syndrome and the reason for refeeding risk.
Malnutrition is a long term problem which can not be corrected overnight.
Aggressive feeding can do more harm to the patient with malnutrition than withholding feeding or introducing feed slowly.
Even if the patients bloods are normal this does not exclude them from being at risk of refeeding syndrome.
Be aware that IV dextrose above 5% may exacerbate the refeeding syndrome.
Step 2
Follow step 2 of the pathway until the dietitian assesses the patient (refer to the flowchart).
* NOTE: Vitamin B co strong and Forceval capsules cannot be crushed and administered via enteral feeding tubes.
Step 3: Dietetic Assessment
A detailed Dietetic assessment will be performed within 24 working hours of referral (if we are informed the patient is a refeeding syndrome risk).
• The Dietitian will confirm if the patient is a refeeding syndrome risk and complete a nutritional assessment.
• Food / enteral feeding / parenteral feeding should be commenced as per dietitians instructions.
• Accurate food record and fluid balance charts need to be completed.
• Patients are only to be given foods and feed recommended by the dietitian as additional nutrition may harm the patient.
• Parenteral nutrition bags will not be available from pharmacy out-of-hours or via the on-call pharmacist.
• It is not necessary to wait until blood levels are normal prior to feeding but feed must be commenced very slowly (Dietitian will provide regimen)
Step 4: Discharge from Refeeding syndrome protocol
When the patient has achieved full nutritional requirements (aim to do this within 7 days) and has normal and stable bloods (K, Mg, Ca, Phos) the patient can be discharged from the refeeding protocol following a joint decision of the multidisciplinary team and documented in the medical notes. If, at any point the patient meets criteria again they should be treated as a new patient on the refeeding syndrome protocol.
Patients who are discharged from hospital: GPs may not be aware of the refeeding syndrome, therefore please do not discharge a patient on phosphate, magnesium or potassium supplements without transferring the management and blood monitoring of this to the GP first, by telephone or letter.
References.
1) Nice Clinical Guideline No 32: Nutrition Support in Adults: oral nutrition support, enteral tube feeding and parenteral nutrition. February 2006.
2) Solomon and Kirby, JPEN 1990
3) Brooks et al Pharmacotherapy, 1995
4) Hodgson, Endocrin. & metab. Clin.N.Am, 1993
5) PENG group of the BDA Pocket guide to clinical nutrition 2004
6) Clinical nutrition 2005: Refeeding syndrome and nutrition support, Callum Livingstone
IV drug information for administration of Pabrinex and the treatment of severely low phosphate/magnesium/potassium.
Phosphate (Addiphos)
NICE guidance for IV replacement of phosphate
0.3 to 0.6mmol phosphate / kg / day (7)
At JCUH we keep 20ml vials of addiphos on ward 5 HDU. As addiphos contains potassium it must be booked out from the ward by two members of staff as per the potassium policy.
One 20ml vial of addiphos contains; phosphate 40mmol, potassium 30mmol, sodium 30mmol (5)
The replacement doses of phosphate required are;
|≤ 29kg body weight |Give 10mls addiphos over a minimum of 1 hour 30 mins (1,7) |
| |Dilute in 100mls dextrose 5% or normal saline 0.9% (5) |
| | |
| |Dose is 20mmol phosphate, 15mmol potassium (5,7) |
|30-49kg body weight |Give 12.5mls addiphos over a minimum of 2 hours (1,7) |
| |Dilute in 100mls dextrose 5% or normal saline 0.9% (5) |
| | |
| |Dose is 25mmol phosphate, 18.75mmol potassium (5,7) |
|≥ 50kg body weight |Give 15mls addiphos over a minimum of 2hours 15 mins (1,7) |
| |Dilute in 100mls dextrose 5% or normal saline 0.9% (5) |
| | |
| |Dose is 30mmol phosphate, 22.5mmol potassium (5,7) |
Potassium infusion rate must not exceed 10mmol K per hour (1)
Magnesium
NICE guidance for IV replacement of magnesium;
0.2mmol magnesium / kg / day (7)
At JCUH we keep 10ml vials of 50% magnesium sulphate (one 10ml vial contains 20mmol magnesium per vial (6)) on ward 5 HDU.
Magnesium sulphate 50% solution MUST BE DILUTED BEFORE USE (6)
The replacement doses of magnesium required are;
|≤ 49kg body weight |Give 5mls of 50% magnesium sulphate (7) |
| |Dilute in 500mls dextrose 5% or normal saline 0.9% (2) |
| | |
| |Dose is 15mmol magnesium sulphate (6,7) |
| | |
|≥ 50kg body weight |Give 10mls of 50% magnesium sulphate (7) |
| |Dilute in 500mls dextrose 5% or normal saline 0.9% (2) |
| | |
| |Dose is 30mmol magnesium sulphate (6,7) |
Up to 160mmol Mg (80mls of a 50% solution) may be given over 5 days (6)
Potassium
NICE guidance for IV replacement of potassium:
2 to 4mmol potassium / kg / day (7)
The replacement doses of potassium required are:
|≤ 29kg body weight |Dose is 60mmol potassium given over a minimum of 6 hours (1,7) |
|30-49kg body weight |Dose is 80mmol potassium given over a minimum of 8 hours (1,7) |
|≥ 50kg body weight |Dose is 100mmol potassium given over a minimum of 10 hours (1,7) |
Potassium infusion rate must not exceed 10mmol K per hour (1).
Potassium is also included in addiphos. The doses given here take account of this and the total potassium replacement assumes patients receive potassium from BOTH potassium and phosphate (addiphos) replacement.
PRE-DILUTED BAGS OF POTASSIUM CHLORIDE SHOULD BE USED IN PREFERENCE TO DILUTING VIALS WHENEVER POSSIBLE !!!!
Infusion fluids containing potassium chloride are available in the following amounts. Those highlighted as * can be obtained on ward 5 HDU.
|Potassium containing fluid |Bag size |Potassium (K+ content) |
|*Potassium chloride 0.3% Glucose 5% |500mls |20mmol |
|*Potassium chloride 0.3% Glucose 5% |1000mls |40mmol |
|Potassium chloride 0.3% Sodium chloride 0.9% |500mls |20mmol |
|Potassium chloride 0.3% Sodium chloride 0.9% |1000mls |40mmol |
|Potassium chloride 0.45% Sodium chloride 0.9% |1000mls |60mmol |
IN EXTREME CIRCUMSTANCES ONLY
At JUCH we keep 15% potassium in 10ml vials (20mmol in 10mls) (3)
This concentration MUST be diluted by at least 50 times with a suitable diluent (3) i.e: one 10ml vial should be diluted with 500mls diluent
Dextrose 5% or normal saline 0.9% can be used to dilute potassium. (2)
It is important to make sure infusions are completely mixed before giving (2)
USE PRE-DILUTED POTASSIUM INFUSIONS WHENEVER POSSIBLE.
Pabrinex
|For all patients |Use equal volumes of ampoule number 1 and ampoule number 2 (4) |
| |Dilute in 100mls of dextrose 5% or normal saline 0.9% (4) |
| |Infusion should be given over 30 minutes (4) |
Infusion should be used within 4 hours of reconstitution (4)
FACILITIES FOR TREATING ANAPHYLAXIS MUST BE AVAILABLE WHENEVER PABRINEX IS ADMINISTERED (4)
References
1) BNF (website accessed as )
2) Ed. Trissel LA. Handbook on injectable drugs. 11th edition. 2001.
3) Sterile Potassium Chloride (15%w/v) BP. Product packaging. B. Braun Melsungen AG.
4) ABPI. Medicines compendium 2006. Datapharm communications Ltd.
5) Fresenius Kabi. Addiphos information. September 2004.
6) Auden McKenzie (Pharma Division) Ltd. Magnesium sulphate 50% w/v Solution for Injection.
7) NICE clinical guideline no.32. Nutritional support in adults, Feb 2006.
EMERGENCY ENTERAL FEEDING REGIMEN (ADULTS ONLY)
Instructions for use: This is an interim feeding regimen to be followed if the patient is referred for tube feeding after 4.00pm on a weekday OR if the patient requires feeding over a weekend when the department is closed.
PLEASE REFER TO REFEEDING PROTOCOL PRIOR TO COMMENCING THIS REGIME
Name: ____________________________ Ward: __________________
|STAGE |(1) |
|FEED |OSMOLITE |
| |500 ml bottle |
|REGIMEN AND DATE |25 ml per hour X 16 hours (ie 400ml) |
| | |
| |8 HOURS REST |
| | |
| |To flush with 50 ml sterile water pre and post feed * |
|TOTAL VOLUME (ml) |500 |
|ENERGY (Kcal) |404 |
|PROTEIN (g) |16 |
|SODIUM (mmol) |15.32 |
|POTASSIUM (mmol) |15.16 |
|PHOSPHATE (mmol) |8.7 |
|MAGNESIUM (mmol) |3.28 |
*NB: This regime may not meet the patient’s fluid requirements. Please check desired fluid intake with the doctors and increase flushes of sterile water via tube accordingly in order to meet fluid requirements. IV dextrose above 5% should not be used to provide extra fluid if the patient is at risk of refeeding syndrome as this will exacerbate the problem.
• Refer to the dietitian on next working day.
• Once opened, do not allow feed to hang for more than 24 hours.
• Change giving set every 24 hours for gastrostomy and nasogastric feeding.
• Change the giving set every 12 hours for jejunostomy feeding or with each feed bottle change, if using more than 1 bottle of feed for the feeding period.
• Flush the feeding tube using 50ml or 60ml bladder syringe. Avoid using the plunger.
• CONTINUE WITH THE ABOVE REGIME UNTIL SEEN BY THE DIETITIAN.
NUTRITION AND DIETETIC DEPARTMENT
JCUH Ext: 4777 (with answer machine)
Friarage Ext: 2012
9e
Request to start PN Form
SOUTH TEES NHS TRUST
Request to Start Parenteral Nutrition (PN) Form
This form must by fully completed before your patient can receive PN. Once it is fully completed, contact the Dietetic Department on Extension 54777, Fax 54138 (JCUH), or Extension 62012, Fax 64523 (FHN). All PN requests must be received before 12.00 noon Monday to Thursday, or before 11.00 am on Fridays in order to receive PN for that day.
Surname:_________________________________ First Name:___________________________
Hospital No: ________________________ Male/Female: __________ DOB: ________________
Ward: ______________JCUH/FHN (please delete) Consultant:________________________________
1) Current weight: _____ kg (date: ___________) Height: _______ cm (date:__________ )
(or estimated weight _______kg)
2) Have baseline bloods been taken (including potassium, phosphate and magnesium)?
Yes/No (please circle)
3) Type of line inserted? Peripheral/Central. (If central, has it been confirmed? Yes/No)
Peripheral cannula Peripheral mid-line Central line, eg PICC, Hickman
Other (please state)__________________
4) Main clinical diagnosis: ____________________________________________________________
5) Secondary diagnosis: ______________________________________________________________
6) Reason for PN request: ____________________________________________________________
7) Number of days since last received full oral/enteral/parenteral feeds? ______________ days
Other relevant information: (please tick relevant boxes)
Bowel surgery resection Bowel surgery other Drugs affecting GI tract
Transplant organ Cardiac surgery Radiation
Ventilation Liver disease Sepsis
Renal
Other intervention (please state)_________________________________________________________
If fluid restricted, what volume will be allowed for feeding? ______________mls/24hours
Any electrolyte abnormalities to be aware of? _________________________________________________
______________________________________________________________________________________
Any other relevant information? ____________________________________________________________
______________________________________________________________________________________
REQUIRES A CONSULTANT SIGNATURE ONLY
NAME: ____________________________________________________ Grade: ____________________
(Printed in BLOCK CAPITALS)
Signature: __________________________________ Date: _____________________ Bleep No. ______
9a
Document No:
*All Sites
PROTECTED MEALTIMES POLICY AND GUIDANCE FOR ASSISTED FEEDING
|TITLE |Protected Mealtimes Policy and Guidance for Assisted Feeding |
|SUMMARY | |
|DATE OF REVIEW | |
|APPROVED VIA | |
|DISTRIBUTION |For distribution to all wards and departments via Risk Management Ext 53520 |
|RELATED DOCUMENTS | |
|AUTHOR(S)/FURTHER INFORMATION |Judith Connor Clinical Matron Directorate of Cardiology |
|THIS DOCUMENT REPLACES |N/A |
ISSUED BY:
Chief Executive
ISSUE DATE:
Protected Mealtimes Policy
Introduction
This policy provides a framework for best practice at mealtimes for our patients. The needs and interests of the patients are the driving force of this policy and the implementation and monitoring of this policy will be captured through the Essence of Care Benchmarking process.
The protected mealtimes philosophy is an initiatve of the Better Hospital Food Programme and has the support of many national organisations such as the British Dietetic Association (BDA), with supporting reports from the Hospitals Caterers Association (HCA,2004), British Association of Parenteral and Enteral Nutrition (BAPEN), Royal College of Physicians (RCP,2002) and the Department of Health(DOH,2003).
Mealtimes are not only a vehicle to provide patients with adequate nutrition but also provide an opportunity to support social interaction amongst patients. The therapeutic role of food within the healing process cannot be underestimated and many now regard food and the service of food as an essential part of treatment. However, food even of the highest quality is only of value if the patient actually eats it.
Up to 40% of adults show signs of malnutrition on admission to hospital and often their stay exacerbates the condition ( McWhirter and Pennington, 1994). Certain groups of patients, such as the elderly, have particular dietry and eating requirements that need to be met to prevent malnutrition and to aid recovery.
The ward environment, presentation of food and the timing and content of meals are important elements in encouraging patients to eat well. The importance of mealtimes needs to be re-emphasised and ward based staff given the opportunity to focus on the nutritional and eating requirements of the patients at mealtimes.
For the purpose of this policy mealtimes constitutes the lunch period only : 1200 – 1300hrs.
Purpose
The aim of this policy is to improve the ‘meal experience’ for the patients by:
• Allowing mealtimes which are protected from unnecessary and avoidable interruptions
• Providing an environment conducive to eating
• Facilitating staff to provide patients with help with meals
This can be achieved by:
• Limiting ward based activities, clinical (eg drug rounds) and non clinical (eg cleaning) to those that are relevant to mealtimes or essential to undertake at that time
• Limiting unwanted traffic through the ward such as supplies deliveries and Estates work
• Creating a quiet and relaxed atmospherein which patients are afforded time to enjoy meals
• Providing an environment conducive to eating that is welcoming, clean and tidy
• Ensuring that mealtimes are a social activity for patients wherever possible
• Focusing ward activities into the service of food, providing patients with support at mealtimes
• Emphasising to all staff, patients and visitors the importance of mealtimes as part of care and treatment for patients
• Restricting visiting over the meal time period
Scope
This policy is intended to be used in all in-patient areas. It is not the intention to restrict or stifle the care of patients but to ensure that patients are given the best opportunity to have their nutritional needs met.
Responsibilities
Co-operation between clinical staff and the service provider is essential to the success of this policy. Ward based staff from the service provider should be seen as key personnel in communicating and liaising between catering , clinical staff and patient and visitors.
Clinical Matron
• The Clinical Matron must work with the Ward/ Department Managers to develop staff awareness via training and communication of the Essence of Care Food and Nutrition benchmark with particular emphasis on the importance of patient nutrition and the environmental impact on food consumption.
• Encourage medical staff and other healthcare professionals to avoid consultations between the hours of 1200 -1300hrs
Ward / Department Managers
• Ward based teams must organise their staffing and negotiate their own mealtimes to maximised the number of staff available to deliver and assist patients with food.
• Stop non- emergency ward based activities ( where clinically appropriate) during mealtimes to enable the nursing staff and food service staff to work together in providing assistance and support to patients at mealtimes.
• Interruptions such as ward rounds, drug rounds and therapy should only occur ( during mealtimes) when clinically essential and no other time is available.
• Display notices outside of the ward, to inform staff and patients of the protected mealtime period.
Nursing and Support Staff
• All tables should be cleaned and suitably prepared prior to the service of food and beverages, removing all non essential items
• Offer the patient the opportunity to use the toilet prior to mealtime if appropriate.
• Give all patients the opportunity to wash their hands before the meal is served
• Make sure the patient is comfortable and in an appropriate position ( see appendix 1) All food should be in appropriate reach to the patient
• Make food a priority during mealtimes, providing assistance and encouragement, using red napkins to identify patients who require assistance
• Be aware of how much the patient has eaten, complete documentation if appropriate, reporting any concerns to senior nurse and dietician
Acknowledgements
This Policy has been developed by a multidisciplinary working party which came together following the Essence of Care Food and Nutrition Benchmark.
The members were the following:
Halina Baker
Melanie Crofts
Linda Irons
Gill Everson
Liz Audsley
Emma Cox
Alison Smith Clinical Matron for Paediatrics / Neonates
Angela Kelly Clinical Matron for Elderly Care
Judith Connor Clinical Matron for Cardiology
References
BAPN (1999) Hospital food as treatment. British Association for Parenteral and Enteral Nutrition
BDA (2003) British Dietetic Association
DoH (2003) Essence of Care. Patient Focussed Benchmarks for Clinical Governance. Department of health: London
HCA (2004) Hospital Caterers Campaign for Protected Mealtimes
McWhirter JP and Pennington CR (1994) Incidence and recognition of malnutrition in hospital. British Medical Journal, vol. 308, pp945-948
RCP (2002) A Doctors Resonsibility. Royal College of Physicians: London
9b
[pic][pic]
Positioning
Positioning is a very important aspect of feeding. Feeding can be very challenging and the alignment
of the head and trunk is extremely important. Aligning the patient’s head and trunk before feeding begins is beneficial to the patient, and not only makes eating a pleasant experience but minimises the
risk to the person (1). This also makes it easier for a carer if involved in the process.
The correct positioning of the patient is essential as the head will be more stable and the oral structures
involved in swallowing will function to minimise risk, improve nutritional intake and prevent aspiration
(2), in vulnerable individuals eg those with swallowing difficulties following stroke and the frail elderly.
The inability to self - feed is an important risk factor for aspiration pneumonia (3). Normal eaters have
a great deal of redundancy built into their nervous system that helps them to compensate regardless
of the position they are in as they eat or drink. For example when your body is twisted when we talk
to someone over our shoulder while we are eating, we are normally able to compensate and swallow
safely. Patients with dysphagia due to a stroke or degenerative disease show lack of redundancy and
are frequently unable to compensate when their position is incorrect for swallowing. Lying or sitting
in bed with the head tilted back during feeding, for example could lead to aspiration and serious
complications.
The most important elements of positioning are:
1. Head position - the head should be in the midline with the chin tilted slightly downwards.
An active chin tuck may be advised in cases where the patient has difficulty swallowing (4).
The chin tuck is protective for most people as the epiglottis forms a protective shelf over
the vocal folds as the patient swallows. Many patients have difficulties with swallowing
due to lack of cough or awareness of food passing the vocal folds. They are also unable
to clear their airways effectively which makes them especially vulnerable to aspiration.
If a patient is in bed, the head of the bed should be raised to at least 30 - 45 degrees,
which will allow the patient to sit upright (as close to 90° as possible). If the patient is
to be placed supine, then feeding should stop one hour prior to this (5).
2. Body position - the best body position for eating is the position we typically assume when
we eat at the table: feet on the floor or other hard surface, hips and knees at 90, the head
in midline with the spine, and the back erect. The chin should be slightly tilted down.
Stabilisation is enhanced and posture better maintained when the elbows rest on the table
or lap tray and the feet are placed on a firm surface (6). The position should be as natural
and comfortable as possible for the patient. For patients in bed optimal positioning can be
achieved by tilting the bed as close to 90° as possible with pillows used for trunk support.
In conclusion, all members of the team must work to ensure the correct alignment of the head and
body of the patient during feeding to make the process pleasurable but safe.
1. Herman JH, Lange ML. Seating and positioning to manage spasticity after brain injury. NeuroRehabilitation. 1999; 12: 105 - 117.
Bibliographic Links (Context Link)
2. Ekberg O. Posture of the head and pharyngeal swallowing. Acta Radiol Diagn. 1986 ; 27: 691 - 696. Bibliographic Links (Context Link)
3. Langmore S, Skarupski KA, Park PS, Fires BE. Predictors of aspiration pneumonia in nursing home residents. Dysphagia. 2002; 17: 298 - 307.
Bibliographic Links (Context Link)
4. Castell JA, Castell DO, Schultz AR, Georgeson S. Effect of head positioning on the dynamics of the upper esophageal sphincter and pharynx.
Dysphagia. 1993; 8: 1 - 6. Bibliographic Links (Context Link)
5. Dent M. hospital - acquired pneumonia: The “Gift” that keeps on taking. Lippincott Williams & Wilkins, Inc. 2004; 34: 48 - 51. Ovid (Context Link)
6. Griggs BA. Nursing management of swallowing disorders. In: Groher ME, ed. Dysphagia: Diagnosis and Management. 3rd ed. Boston, Mass:
Butterworth - Heinemann; 1997: 313 - 336. (Context Link)
MI CC1708
9f
South Tees Hospitals NHS Trust
TPN CARE BUNDLE
To promote evidence based practice the aim is for compliance with 3 elements of TPN care bundle.
To reduce risk of infection:
• Use of a dedicated line or cannulae for purpose of TPN
• Replace tubing at end of bag infusion or within 24 hours (whichever is shortest)
• There should be no 3-way tap or ports to enable injections in line, ie the giving set should connect directly to the designated lumen
To promote safe administration:
• TPN must be administered via a volumetric pump
• Bag should be light protected
• The fluid should only be administered by personnel assessed able to give IV drug therapy
• PN to be administered to the correct patient using a PN prescription sheet and be recorded on the drug chart
To monitor blood sugar levels:
• All patients receiving TPN should have their blood sugars recorded 12 hourly
• Patients requiring continuous infusion of sliding scale insulin therapy should have their blood sugars recorded 2 hourly
• Critical care patients receiving TPB (but not insulin therapy) should have their blood sugars recorded 4 hourly
|Element |Yes |No |Comment |
|Prevention of infection | | | |
|Safe Administration | | | |
|Blood sugar monitoring | | | |
|TOTAL COMPLIANCE | | | |
References
NICE Clinical Guideline 32 – Nutrition Support in Adults Feb 06
ALLWOOD.M & MARTIN.H 2000. The Photo degradation of vitamins A and E in parenteral nutrition mixtures during infusion. Clinical Nutrition 19,5,p339-342
D.o.H 2001. Guidelines for preventing infections associated with the insertion and maintenance of central venous catheters. Journal of Hospital Infection 47(supplement) S47 – S67
MALONE,M. IN Walker, R & Edwards,C. (Eds) 1999. Clinical Pharmacy and Therapeutics (second edition): Parenteral Nutrition p 65-81
SCALES, K. 1993. Practical and professional aspects of IV therapy. Professional Nurse Supplement 12.8 S3-S5
SCOTT, A. SKERRATT, S & ADAMS,S. 1998. Nutrition for the Critically Ill –A Practical Handbook Arnold Publishers P 152
We acknowledge the work of the Essex Critical Care Network in the production of this Care Bundle
-----------------------
TRUST BOARD
GOVERNANCE COMMITTEE
CLINICAL EFFECTIVENESS COMMITTEE
NUTRITION STEERING COMMITTEE
Parenteral
Enteral Feeding
Catering
Sub-Group
[pic]
[pic]
[pic]
[pic]
[pic]
Ref: Parenteral and Enteral Nutrition Group: A Pocket Book to Clinical Nutrition, 3rd Edition 2004
Monitor - K, Phos, Ca, Mg daily for the first week until stable and then twice weekly and act on as appropriate
Mon-Fri: Start feeding/diet immediately as per dietitians regimen (slow rate).
Out of hours/weekend: For moderately low levels follow emergency regimen.
For severely low levels out of hours withhold feeding until dietitian review.
Give all patients (prior to and for 10 days after commencing feeding):
Dose of Thiamine 200mg daily (morning)
*Vitamin B co strong 1 tablet 3 times per day and *Forceval capsule 1 tablet per day
OR
Pabrinex: 1 pair of ampoules daily for 48 hours
Normal blood Levels
Supplement B vitamins as below
Severely Low Levels
• K ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- espen guideline on home parenteral nutrition
- parenteral nutrition pocketbook
- parenteral nutrition manual for adults in health care
- espen guidelines on parenteral nutrition central venous
- parenteral nutrition clinical guideline
- organ transplant surveys interpretive guidelines
- total parenteral nutrition in
- organization of nutritional support within hospitals
- intestinal failure referral form
- south tees hospitals nhs trust nice