Transcript Slide 1

Dietitians, Nutrition Screening
and Nutrition Support
Dietetic Services
Central Manchester University Hospitals NHS Foundation Trust
What we will cover
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Role of the Dietitian
Malnutrition
Nutrition Screening
Red tray
Protected mealtimes
Nutrition Support
What is a Dietitian?
• Qualified health professionals
• Assess, diagnose and treat diet and nutrition
problems
• Individually or at public health level
• Use scientific research which is translated into
practical guidelines for patients
• Title can only be used by those appropriately
trained
• Must be registered with the Health Professions
Council
Role of the hospital Dietitian
• Assess nutritional status &
requirements
– Consider: medical condition,
medications, symptoms,
weight, anthropometry, social
factors, biochemistry, nutrition
intake
• Advise on feeding related
complications
• Communicate advice
effectively
• Develop resources
• Advise on the most
appropriate feeding route
• Education & training
• Advise on nutrition source
• Audit & research
• Advise on therapeutic diets
What is malnutrition?
“A condition arising from an inadequate or
unbalanced diet”
Encompasses:
• Undernutrition resulting from insufficient food
intake
• Specific nutrient deficiencies e.g. iron
• Imbalance due to disproportionate intake
Malnutrition
• Prevalence of malnutrition in hospital has been quoted as 40%
(McWhirter & Pennington, 1994)
• Recent survey (n=175 hospitals, 9336 patients) - 28% of patients
at risk of malnutrition (BAPEN, 2007).
• In 2006 malnutrition in the UK cost in excess of £7.3 billion, double
the projected £3.5 billion cost of obesity (BAPEN, 2006)
• People in hospital are at risk of becoming malnourished or further
malnourished
• 239 patients reported to have died because of malnutrition in
English hospitals in 2007
Causes of malnutrition
Task 1
1. Split into 4 groups.
2. Each group should choose one of the following risk
factors:
• Age
• Psychological
• Disease
• Hospital
3. Discuss between yourselves how the risk factor can
contribute to the development of malnutrition.
Causes of malnutrition
Age
• Decreased appetite
• Taste changes – decrease in number of taste buds,
medication
• Immobility – unable to shop / cook
• Social / economic circumstances
• Education e.g. elderly man with poor cooking skills
• Report by Age Concern (2006) found older people
admitted to hospital:
– 60% are at risk of malnutrition
– 40% are malnourished
– Amongst those aged 80+ the prevalence of malnutrition is 5
times greater than those aged under 50
Causes of malnutrition
Psychological
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Low in mood / depression
Organic conditions e.g. dementia
Bereavement / loneliness
Eating disorders e.g. anorexia nervosa
Causes of malnutrition
Disease
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Malignancy – treatment, drugs
Stroke – dysphagia, alertness
Digestion / absorption problems
Surgery – increased requirements
Alcoholism
Causes of malnutrition
Hospital
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Dislike of hospital food
Meal interruptions for tests / NBM
Inadequate hospital food provision
Unable to feed oneself
Difficulty in understanding and filling in menus
Impact of malnutrition
Malnutrition results in:
• Increased admissions to hospital
• Loss of body weight, muscle stores
• Impaired immune function Increased need for medications
• Delayed wound healing
• Increased risk of pressure sores
• Impaired respiratory / cardiac function
• Reduced mobility
• Gut atrophy
• Apathy and depression
• General sense of weakness and illness
• Increased length of stay in hospital
• Increased mortality
Nutrition Screening
• The process of identifying patients who
are malnourished or at risk of
malnutrition, so that intervention and
treatment can be implemented early,
aiming to improve clinical outcome
Malnutrition Universal Screening Tool
(MUST)
• Nationwide recommendation from the British Association of
Parenteral and Enteral nutrition
• All patients undergo screening on ADMISSION and WEEKLY
thereafter
• Launched June 2007 Trust-wide; reviewed and updated 2010.
• Nutrition screening tool and nutrition care plan combined
• Objective screening tool: uses BMI and percentage weight loss to
determine risk of malnutrition
• Daily care plan to be used for all those who score one and above
Integrated Care Plan
Screen
Action
Document
Case studies – Part A
Task 2
1. Split into 4 groups.
2. Using the case study provided, complete the
following task
• Calculate the MUST score.
• What would you do based on the score?
• Is it appropriate to refer to the Dietitian? If
so, what would you write on the referrals?
Score 0 - low risk of malnutrition
• Repeat score weekly.
• If BMI > 30 Discuss options with patient.
• Refer to GP to organise weight
management programme in community.
Scores 1 - at moderate risk of malnutrition
• Start 3 days food charts.
• Offer build up shakes and soups
• Offer alternatives if meals are missed.
• Note if assistance required to eat & drink.
• Note if red tray is required.
Daily care plan
• Should be completed on a daily basis.
• Put an X in the appropriate box.
• If you can not complete action you can write the reason
why in the variance box.
• This is so a record is kept if care is not given.
• This could be NBM, distressed, theatre, investigations.
• If action is not applicable write N/A in the box.
Scores 2 or more – at high risk of
malnutrition
• Refer to dietitian stating score on CWS referral.
• Start 3 day food charts.
• Offer build up shakes or soups (ward kitchen stock)
• Offer alternatives to meals.
• When the dietitian sees the patient they will tick & initial
the box.
• Start on red tray.
Red Tray Care Pathway
• Three main aspects:
– Preparation, Assistance to eat and drink, Completion of meals
Remember the vulnerable patient in need of help and support
at mealtimes
Encourage and assist patients where necessary
Dietary intake may be improved with extra attention at
mealtimes
Tell patients and relatives the benefits of the red tray system
Remove red tray ONLY after recording food consumption
Assess and weigh patients regularly
YOU can improve the patients mealtime experience!
Protected Meal Times
• Part of the Better Hospital Programme (2006)
• Introduced to most wards in our Trust in June 2006
• Is the time over lunch and evening meal when activities
on the ward should stop
• Enables ward staff to focus entirely on patients
nutritional needs at each meal time
• It is encouraged that other health professionals and
relatives are not allowed on the ward at this time
• Families allowed on to help with feeding
Case studies – Part B
Task 2
1. Using the previous case study, recalculate the
MUST score after considering the new
information you have been given:
• What would you do based on the score?
• Is it appropriate to refer to the Dietitian? If
so, what would you write on the referrals?
Nutrition Support
• Defined as the provision of adequate nutritional intake
by means other than the eating of normal meals.
• The extent of nutrition support can vary from
supplementing an inadequate diet to providing the sole
source of nutrition.
• Nutrition support can be given as:
– Oral nutrition support
– Enteral tube feeding
– Intravenous nutrition
(BAPEN)
Oral Nutritional Support (ONS)
Indications for ONS
• Malnourished according to screening tool
• Unable to meet their nutritional requirements with normal
diet and have a functioning GI tract
Provision of extra nutrition via the mouth, either through:
• Energy / nutrient dense foods and drinks
And/or
• Nutritional supplements
Food counts!
Nourishing Snack
Calories (Kcals) Protein (g)
A portion of butter
70
0
A portion of jam
26
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Cereal with milk and sugar
290
10
1 slice of toast with marg and jam
155
2
Half a sandwich
150
8
Cheese and biscuits
250
9
Digestive biscuits (x2)
140
2
Yoghurt (full fat)
160
9
Trifle
185
4
Kit Kat (4 finger)
250
4
Bag of crisps
130
2
Milky coffee
160
6
Glass of whole milk
130
6
Build-Up Soup and bread
270
11
Build-Up Shake
230
16
Common supplements used at the MRI
Supplement
Supply
Description
Build up shakes / soup
- Do not need to be
prescribed
Ward stock
Powder supplement made into a milk
shake with fresh milk or a soup with hot
water
Fortisip Bottle
- Need to be prescribed
Ward stock
1.5kcal/ml milk shake style
Fortisip Compact
Need to be prescribed
Ward stock
2.4kcal/ml milk shake style
Fortijuice
Need to be prescribed
Ward stock
1.5kcal/ml juice style
Forticreme complete
Need to be prescribed
Ward stock
Pudding style – gives 200kcal per pot
Common supplements used at the MRI
Supplement
Supply
Description
Calogen
Need to be prescribed
Ward stock
High fat supplement
Calogen extra
Need to be prescribed
Non-stock
Dietitian must
order
High fat supplement with protein and
carbohydrate with added vitamins and
minerals
Scandishake
Need to be prescribed
Ward stock
Powder supplement made into a milk
shake with fresh milk
Procal shot
Need to be prescribed
Non-stock
Dietitian must
order
Energy dense supplement with fat,
protein and carbohydrate
Liquigen
Need to be prescribed
Non-stock
Dietitian must
order
Medium chain fat emulsion for patients
with fat malabsorption
Improving the supplement experience
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Give in addition to food, not instead of
Open and place within reach
Store in fridge
No lumps!
Positive encouragement
Offer in a cup or beaker
Can add milk / water
Indications for enteral feeding
• Malnourished and unable to meet requirements with
diet or supplements and have a functioning GI tract
• NBM or reduced oral intake e.g. dysphagia, ITU, trachy
patients, some head and neck surgery
• Patients with increased requirements who need
supplementary feeding in addition to the oral route e.g.
cystic fibrosis
Feeding tubes
Short term
• Naso-gastric tube
• Naso-jejunal tube
Long term:
• Percutaneous endoscopic gastrostomy
• Radiologically inserted gastrostomy
• Jejunostomy
• Percutaneous endoscopic gastrostomy with jejunal extension
• Percutaneous endoscopic jejunostomy
Out of hours enteral feeding regimen
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Three feeding regimens
Based on weight
Two day regimens
In nutrition support guidelines folder and on the
intranet:
Home page → Policies → Nutrition
Parenteral Nutrition
• Also known as total parenteral nutrition (TPN)
• Used in patients whose GI tract is not functioning / not
available
• Range of patient including: GI surgical, critically ill,
haematology
Supplement taster session
…YOUR TURN TO TRY!