Download Nutrition Policy Adults

Nutrition Policy ADULTS
Version
6
Name of responsible (ratifying)
committee
Hospital Food Group
Date ratified
19 November 2014
Document Manager (job title)
Head of Nutrition and Dietetics
Date issued
10 March 2015
Review date
01 December 2017
Electronic location
Clinical Policies
Related Procedural Documents
Key Words (to aid with searching)
Nutrition; obesity; food service; Malnutrition; Diet;
Patient care; Patient feeding; Nurses; Health
service staff
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
6
19/11/14
Document aligning to ‘The Hospital Food Standards
Panel’s Report on Standards for food and Drink in
NHS Hospitals
Hospital Food
Group
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 1 of 35
CONTENTS
QUICK REFERENCE GUIDE ................................................................................................................ 3
1. INTRODUCTION .............................................................................................................................. 4
2. PURPOSE ........................................................................................................................................ 4
3. SCOPE ............................................................................................................................................. 5
4. DEFINITIONS ................................................................................................................................... 5
5. DUTIES AND RESPONSIBILITIES................................................................................................... 5
6. PROCESS ...................................................................................................................................... 12
7. TRAINING REQUIREMENTS ......................................................................................................... 13
8. REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................... 13
9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS ................................................................................................................................... 134
APPENDICES:
Appendix A: Membership of the Hospital Food Group
Appendix B: Nursing competency
Appendix C: Guidelines for Food Service at Ward Level
Appendix D: Protected Mealtime guideline
Appendix E: Screening tools: Malnutrition Universal Screening Tool (MUST), Wessex Renal
& Transplant Service Nutrition Screening Tool (NST), First Line Action Plan (FLAP)
Appendix F: Guideline for Mealtime volunteers
Appendix G: Guideline for use of Red Tray
Appendix H: Other supporting policies: POLICY FOR THE PROVISION AND MANAGEMENT OF
PARENTERAL NUTRITION IN ADULTS IN HOSPITAL; PHT POLICY FOR THE INSERTION AND
MAINTENANCE OF FINE BORE NASO-GASTRIC FEEDING TUBES IN ADULTS; Enteral Tube
Administration Policy (Adults): Refeeding Guidelines; Provision of parenteral nutrition when pharmacy is
closed
Appendix I: What foods may I bring in to hospital?
Appendix J: Definitions of Oral Intake
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 2 of 35
QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate
the need for the document author and others involved in the process to be aware of and follow
the detail of this policy.
1. Portsmouth Hospitals Trust has a responsibility to ensure patients receive adequate
nutrition to meet their needs.
2. All patients (adults) should be screened for the presence of malnutrition on admission and
their status reviewed regularly throughout their stay, by use of an appropriate screening tool.
3. Nutritional care is a multi - disciplinary responsibility. Consideration should be given to
dietary preferences and cultures. Where oral nutrition is compromised consideration should
be placed on the use of nutritional support.
4. All patients should have a nutrition care plan documented following their nutrition
screening.
5. Patients requiring a special therapeutic diet, diet of ethnic requirement, altered texture diet
or dietary supplements should have their requirements noted on the care planning document.
6. Provision of a balanced diet including specialised and ethnic diets is the responsibility of
Soft FM provision under the guidance of the Trust’s dietitians.
7. The use of protected mealtimes, red tray use and assistance of mealtime helpers are there
to support patient’s nutritional intake.
8. Training opportunities will be made available for all staff responsible for providing patient
care (nursing staff, support staff, medical staff, allied health professionals, soft FM provision,
volunteers)
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 3 of 35
1. INTRODUCTION
 In England the NHS Plan states that by 2004 all hospitals will have a ’hospital nutrition
policy to improve the outcome of care for patients’.
 Nationally approximately 30% of adults and 15% of children admitted to hospital are
undernourished and many others become so during their stay (BAPEN, 2009).
 Malnutrition is a potentially serious complication of illness, which is associated with
increased morbidity, mortality and length of stay in hospitals (Norman et al., 2008)
 The importance of eating well and good nutritional support cannot be overestimated.
Delivering food in an appetising manner, at the correct temperature and of an appropriate
consistency, is important.
 For people with swallowing difficulties there may also be issues of safety related to eating
and drinking (BAPEN 1994, Espen, 2006, Royal College of Physicians 2002, Edington et al.
2000).
 This policy was developed from a need to address the issues of nourishing patients in
hospital, addressing Care Quality Commission, British Association of Enteral and Parenteral
Nutrition and national research.
 Estimates of a saving of £26,095 per 100,000 head of population are quoted from the
introduction of screening and treatment of malnourished patients (HSJ, Dec. 09)
2. PURPOSE
2.1 The purpose of this policy is to ensure that all people in hospital or Trust residential
settings receive appropriate nutrition in a form that is acceptable to the individual and meets
their nutritional needs. It is intended to reinforce the importance of nutrition to the health of all
patients and staff.
2.2 Nutritional care is a significant factor in the prevention of disease as well as its treatment
NSF For Older Persons (DoH,2001); Cancer Plan-Improved outcomes: Cancer strategy
(2012); Essence of Care (DoH, 2001); Hungry to be Heard Campaign from Age Concern
(2006); Combating Malnutrition BAPEN (2009); Malnutrition in Community and Hospital
Settings (Patients Association, 2011), The Hospital Food standards Panel’s Report on
standards for Food and drink in NHS hospitals DoH/ Age UK (2014); Healthier and more
sustainable catering: Nutrition Principles- Public Health England (2014)
2.3 A healthy diet has to fulfill two objectives: it must provide sufficient energy and nutrients to
maintain normal physiological functions, permitting growth and replacement of body tissues; it
must offer the best protection against the risk of or further risk of disease; the maintenance of
a healthy weight and reduce the adverse clinical impact of malnourishment on patients.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 4 of 35
3. SCOPE
This policy applies to the nutritional needs of all in-patients within the Trust. It will be followed
by all members of staff involved at any stage of the food chain.
Nutrition is managed at Portsmouth Hospitals through the following structure
Trust Board
Governance and Quality
Committee
Patient Experience Steering
Group & Patient
Environment Partnership
Group
Nutrition
Group
Steering
Hospital Food Group
IIn the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such
circumstances, staff should take advice from their manager and all possible action must be
taken to maintain ongoing patient and staff safety’
4. DEFINITIONS
Nutrition is the supplying or receiving of nourishment
Malnutrition is the broad term used to describe under or over nutrition, dietary imbalance or
nutritional deficiencies.
MUST is the Malnutrition Universal Screening Tool used throughout the Trust to screen for
malnutrition.
CNNs are the clinical nutrition nurses.
SALTs are the speech and language therapists
5. DUTIES AND RESPONSIBILITIES
The executive committee of the Trust is responsible for ensuring delivery of a safe and
nutritious catering service.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 5 of 35
The Hospital Food Group (HFG) will provide a report to the patient experience committee
quarterly. The HFG will also report to the patient environment and partnership group monthly,
regarding matters pertaining to food service and delivery.
Oral Nutrition - General
All health care professionals have a duty to ensure that patients are fed a diet to meet their
nutritional requirements. As such mealtimes should be conducive to eating and appropriate
food provided for individuals. All staff should assist patients in choosing an appropriate diet to
meet their needs (nutritional, behavioural and cultural).
All healthcare professionals have a duty to screen for and treat malnutrition and ensure that
the patient’s basic nutritional needs are met. Once started nutritional treatment should be
regularly reviewed to determine whether it remains appropriate. All healthcare professionals
should assess patients’ dietary preferences and ensure that any special requirements,
whether through food choice, food access, equipment or ability to self-feed, are acknowledged
and addressed.
Artificial nutrition should not be used in circumstances where life is prolonged only to maintain
an unacceptable quality of life. The decision to commence artificial nutrition should be multi
professional in consultation with the patient and family. Where there is doubt referral to the
Trust’s ethics committee should be considered.
The decision made should take into consideration that artificial nutrition is legally classified as
medical intervention and can therefore be withdrawn (BMA 2000). The outcome of any
decision must be documented in the medical and nursing notes.
Nutritional care is a multi-disciplinary responsibility (BAPEN 1994). There is an advisory group
within the Trust who have the responsibility for the development, implementation and
reviewing of standards of nutritional care. This is the Hospital Food Group. Composition of the
Hospital Food Group is set out in Appendix A
Nutrition Support
Nutrition support should be considered in patients who have:





eaten little or nothing for more than five days or longer or
have a poor absorptive capacity and/or
high nutrient losses and/or
increased nutritional needs from causes such as catabolism and / or
a MUST score of ≥2
All healthcare professionals directly involved in patient care should receive education and
training on nutrition, appropriate to their role at the start of their employment and thereafter in
yearly updates.
Nutritional care provided to patients should ensure the provision of:
 adequate quantity and quality of food and fluid in a conducive environment (NICE 2006,
Care Quality Commission, 2010)
 appropriate support e.g. modified eating aids, assistance to eat (NICE 2006)
Portsmouth Hospitals Trust adheres to the standards set out in:
 Annual PLACE audit (DoH, 2012)
 CQC outcome 5 (CQC, 2010)
 Hospital Food Standards for Food and Drink in NHS Hospitals (DoH, 2014)
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 6 of 35
The standards as laid out in the above document have been adopted as appropriate for
Portsmouth Hospitals NSH Trust. These are listed below.
Standard
1. Everyone using healthcare and care services is
screened to identify those who are malnourished
or at risk of becoming malnourished.
Method of assessment
Electronic assessment – dashboard
audit.
2. Everyone using care services has a personal
care support plan and where possible has had
personal input, to identify their nutritional care and
fluid needs and how they are to be met.
Back to the floor audit
Weekly documentation audit
3. The care provider must include specific
guidance on food and beverage services and
nutritional care in its service delivery and
accountability arrangements.
Nutrition policy, Soft FM Contract
4. People using care services are involved in the
planning and monitoring arrangements for food
service and beverage/drinks provision.
PLACE assessment
5. An environment conducive to people enjoying
their meals and being able to safely consume
their food and drinks is maintained (NB this can
be known as ‘Protected Mealtimes’).
PLACE assessment & Protected
mealtime annual audit
6. All staff/volunteers have the appropriate skills
and competencies needed to ensure that the
nutritional and fluid needs of people using care
services are met. All staff/volunteers receive
regular training on nutritional care and
management.
Oral nutrition competency; volunteer
training; Annual Programme of nutrition
training
7. Facilities and services are designed to be
flexible and centred on the needs of the people
using them.
PLACE assessment & Patient
environment group meetings
8. The care-providing organisation has a policy for
food service and nutritional care, which is centred
on the needs of people using the service.
Performance in delivering that care effectively
is managed in line with local governance and
regulatory frameworks.
Nutrition policy in place (version 6 to
date)
9. Food service and nutritional care is provided
safely.
Protected mealtime audit, Soft FM audit &
PLACE assessment
10. Everyone working in the organisation values
the contribution of people using the service and all
others in the successful delivery of nutritional care.
Protected mealtime audit & PLACE
assessment
Hospital Food group established in 1988
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
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11. Dietitian to be involved in menu planning and
menu content and dietary permissions of items on
the menu should be displayed
Part of the SOFT FM contract. Menus
have diet permissions in place
12. Calculation of the nutritional quality / inc. recipe
analysis etc., should occur
Forms part of the above
13. Protected mealtimes, red tray use, nutrition &
dementia care operated within the service
Protected mealtimes audit yearly
14. Research and audit on nutritional issues and
food service are completed
Audit programme in place
15. Fluid intake is part of the hospital policy
PHT nutrition policy
16. The hospital supports healthier eating for staff
PHT nutrition policy
MEDICAL RESPONSIBILITIES
Medical staff is responsible for the diagnosis and management of malnutrition and for the
referral on to other professions. Doctors should lead the team regarding decisions on
appropriate feeding, investigations according to diagnosis and prescription of fluids.
Consideration should be placed on the ethical issues regarding the provision of food and fluid
to all patients. In the case of fluids see the section below under nursing responsibilities.
NURSING RESPONSIBILITIES
ORAL NUTRITION
The responsibility of registered nurses is listed in the nutrition competency listed in Appendix
B. All registered nurses should complete this competency.
Food service should adhere to the guidelines set out in guidelines for food service at ward
level listed in appendix C.
The Trust supports the use of protected mealtimes and the use of red trays in assisting
patients to eat their meals. See Appendix D and G.
Volunteers are trained for the role of mealtime assistants and their tasks are set out in
Appendix F.
Cessation of oral nutrition and fluids whether for a physical reason or for that of a clinical
procedure should be communicated to all professionals following the guidelines as set out in
Appendix J
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 8 of 35
HYDRATION
All patients will be adequately hydrated. It is the responsibility of the registered nurse and
medical practitioner to:
 Ensure that patients are receiving an adequate amount of fluid to maintain hydration. This
may be in the region of 2 litres per day for adults. Requirements may differ according to
height, weight, medical condition and ambient temperature. A minimum of 7 drinks should be
provided daily (6 via soft FM and 1 via nursing staff).
 Sufficient oral fluids should be placed within reach of the patient
 Ensure drinks are of a suitable temperature i.e. a cup of tea is hot, a supplement drink is
chilled and are in a suitable drinking vessel that the patient is able to manage e.g. patients
with CVA, dementia.
 Open tops of bottles etc., and assist the patient in drinking fluids as required.
 Maintain a fluid chart if fluid intake is of concern and report to the nurse in charge. Ensure
measurable amounts are recorded clearly and regularly. Record both intake and output.
Information on the quantity of fluid in various drinking vessels is available via the dietitian’s
intranet page.
 If the patient has swallowing difficulties ensure SALT (Speech & Language Therapy)
recommendations regarding thickened fluids are followed. If the patient declines to drink
thickened fluid this must be recorded in the patient notes. Ensure all staff are aware of patient
needs.
 It is the responsibility of the nurse to highlight to the medical team the patient who is unable
to take sufficient levels of oral fluids to maintain their hydration or who is NBM so that
alternative methods of fluid administration must be sought and the direction of the medical
team by naso-gastric tube, intravenous fluids or subcutaneous fluids.
Fasting prior to surgery or other intervention / investigation.
The intake of oral fluids during a restricted fasting period
 Intake of water up to two hours before induction of anaesthesia for elective surgery is safe
in healthy adults, and improves patient wellbeing. Other clear fluid (that allows newsprint to
be read through the drink); clear tea and black coffee (without milk) can be taken up to two
hours before induction of anaesthesia in healthy adults.
 Tea and coffee with milk are acceptable up to six hours before induction of anaesthesia.
The volume of administered fluids does not appear to have an impact on patients’ residual
gastric volume and gastric pH, when compared to a standard fasting regimen. Therefore,
patients may have unlimited amounts of water and other clear fluid up to two hours before
induction of anaesthesia.
The intake of solid food during a restricted fasting period
 A minimum preoperative fasting time of six hours is recommended for food (solids and
milk). Confectionary and sweets are solid food.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 9 of 35
Delayed operations
 If an elective operation is delayed, consideration should be given to giving the patient a
drink of water to prevent excessive thirst and dehydration. The two hour rule still applies after
this drink.
 Should an operation or procedure be delayed for 6 hours then the patient should be
allowed at eat and the fasting period recommenced 6 hours before the time of the allotted
intervention. If a meal is not available at that time, then the housekeeper should be asked to
provide a meal or contact the Soft FM helpdesk.
 Remember two consecutive days of fasting can mean a patient has missed 5 out of 6
meals and could increase the risk of re-feeding syndrome when food is introduced regularly.
Emergency surgery/ procedures
Adults undergoing emergency surgery should be treated as if they have a full stomach. If
possible, the patient should follow normal fasting guidance to allow gastric emptying.
Postoperative resumption of oral intake in healthy adults
When ready to drink, patients should be encouraged to do so, providing there are no medical,
surgical or nursing contraindications. Oral food should be provided as appropriate. In
between meal service time contact the ward housekeeper for food provision.
CATERING SERVICE
Responsibilities of the Catering Service (Soft FM services)
The Hospital Food Standards – Food and Drink in Hospitals (2014) sets out the criteria for
catering provision for patients. To meet the requirements of these initiatives the catering
department are responsible for ensuring that provision is made to address the nutritional,
social, cultural and religious needs of all patients.
Soft FM provider:
 Will work with Trust health professionals to ensure the provision of appropriate nutrition for
hospital in-patients.
 Are responsible for providing patient meals via a cook-chill meal service.
 Are responsible for ensuring that patients are able to select from a wide choice of menu
items at breakfast, lunch and evening meal services meeting PLACE standards. They must
provide a choice of portion size and meals suitable for all dietary needs, including food of
modified consistency for patients with swallowing difficulties and ethnic meal requirements.
 Are responsible for ensuring that “Snack bag” meals are available for patients who miss a
meal due to late admission, diagnostic treatment, etc. The snack box will comprise of a
sandwich, fruit, ambient yogurt and biscuit/cake. Out of hours the sandwich will be replaced
by a savoury biscuit and soup sachet.
Ensure temperature of drinks is tolerable and provide 7 drinks per day plus extra drinks as
required.
 Are responsible for ensuring that snack items of biscuits, cake and yogurt are offered as a
choice of snack in between breakfast and lunch and lunch and evening meal. These items
should be offered on a tray for patient selection to assist those with cognitive impairment.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 10 of 35
THE DIETETIC SERVICE
Responsibilities of the dietetic service
The dietitian will:
 Respond to appropriate written/electronic referrals where nursing staff have nutritionally
screened and followed the appropriate action plan. The department supports 95% referrals will
be seen in one working day and all referrals within 2 working days.
 Review and monitor patients and adjust the therapeutic nutritional advice accordingly.
Dietitians will liaise with their community counterparts when patients are to be discharged,
ensuring a seamless service.
 Document an action plan and liaise with other multidisciplinary staff as appropriate.
 Check menus devised by Soft FM services to ensure they meet nutritional needs of
patients, needs of those on special diets etc. Dietitians will work with Soft FM services on the
production of special diet menus specific to individual needs of patients.
 Train staff in the nutritional screening of patients, basic nutrition and the use of special
dietary products.
 Chair the hospital food group and attend the nutrition steering group.
OTHER STAFF GROUPS
 Hospital Food Group - is accountable to the Patient Experience Group and the Patient
Environment Partnership Group. The group supports the ‘Hospital Food Chain’ including
people, processes and departments throughout the hospital in getting food to patients. The
group works collaboratively with Soft FM on matters of food service and acts in the interests of
nutrition from a clinical and an environmental angle.
 Nutrition Steering Group– is a management body attended by representatives of
interested parties and members of the nutrition support team. It oversees policies and
guidelines relating to artificial nutrition and is responsible for the development and coordination of nutrition support services working to the Hospital Food Group.
 Ward Team – work together to support patient’s nutritional status by highlighting issues
regarding feeding and hydration in relation to the patient’s diagnosis. Should ask the patient
what they would like for their next meal (one meal prior to that meal) and make sure patients
are happy with their meal service. Specialist equipment such as large handled cutlery, non slip
mats, feeder cups should be purchased and provided by the ward team.
 Clinical Nutrition Nurse Specialists – are responsible following a referral for selecting the
most appropriate route of feeding and management of the chosen route. They provide training
to nursing staff on the use of MUST, artificial nutrition and are the liaison between the hospital
food group and the nutrition champions at ward/ unit level. They work closely with the dietetic
service.
 Speech and Language Therapists – are responsible following a referral for assessing
oro-motor and pharyngeal musculature and for advising on appropriate food and fluid textures
to ensure the safest possible swallow.
 Pharmacists – are responsible for supplying and advising on parenteral nutrition and for
advising on any interactions between nutrients and drugs.
 Catering Staff – are responsible for ensuring that balanced meals and special diets are
available to meet patient’s clinical requirements and needs.
 Mealtime volunteers – should assist patients who require help in selecting their preferred
meal, cut food and assist in helping people to eat. They should receive training before
beginning this role and regular updates whilst undertaking this role (Appendix F).
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 11 of 35
 Housekeepers - the housekeeper is the conduit between soft FM food delivery and
patients’ food service. They will ensure that orders for special diets, dietary products are sent
to the catering department by 9am each day. They will provide snack bags and /or toast when
patients have missed a meal. Should the food available at meal times not be suitable for the
patient then the housekeeper will find an alternative. Orders for red trays, or dietary items
etc., should be put through the housekeeper. In the absence of the housekeeper contact
should be made through the Soft FM helpdesk on:6321
All staff listed, but especially Dietitians, Speech and Language Therapists, Clinical
Nutrition Nurse Specialists have a responsibility to provide education and training to others
to assist all staff to fulfill their role in the provision of good nutrition and the prevention of
malnutrition.
6. PROCESS
 An individual patient assessment of dietary preferences/requirements will take place on
admission and be reviewed every 5 days during the patient’s length of stay.
 All patients should be screened on admission for the presence or likelihood of malnutrition
using MUST (adult general wards), Wessex Regional Renal screening tool (Wessex regional
renal unit) or through BMI calculation through pregnancy (maternity). MUST is available on
handheld screening devices for the adult wards within PHT.
 All patients should be weighed (wherever possible) within 24 hours of admission and
thereafter every 5 days. If weighing is not possible a reason must be documented in the notes
and an alternate assessment using mid upper arm circumference can be made to provide a
BMI assessment. The weight should be documented in the medical notes or on handheld
device.
 All patients will be screened for their malnutrition risk score using the MUST screening tool
as part of the nursing documentation within 24 hours of admission or if available the MUST
score should be calculated on the nutritional screening page of the handheld device. This
should be repeated every 5 days, or as the handheld system dictates. (See Appendix E).
 A nutritional care plan will be devised based on the MUST score, using guidance listed on
the screening tool. Following screening a care plan should be drawn up using FLAP (see
Appendix E)
 If the patient is deteriorating and not responding to the action plan then referral should be
made to the dietitians, as dictated by the screening tool.
 Patients requiring a special therapeutic diet, diet of ethnic requirement, altered texture diet
or dietary supplements should have their requirements noted on the care planning document.
Specific orders for dietary items and special diets etc. should be given to the housekeeper 24
hours in advance wherever possible. These requests should be delivered by the housekeeper
to the catering department daily. Out of hours requests should be made via the Soft FM
helpdesk.
 Patients will be provided with the necessary equipment and assistance in accordance with
information set out in this policy (see appendix C and D), to ensure that they can receive
adequate nutrition.
 Patients requiring artificial feeding including parenteral nutrition will be fed according to the
Trust guidelines (Appendix H)
 Patients on the Wessex Regional Renal unit will be screened using the specific screening
tool to highlight malnutrition in their care group. See Appendix E. A nutrition care plan will be
drawn up as directed.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 12 of 35
 Food should be plated at ward level by housekeeping staff under direction of a trained
member of staff, who should advise on portion size and special dietary requirements. Meals
should be given to the patient by nursing staff aware of the clinical needs of the patient.
 Patients should be encouraged to be ready of meals by sitting upright as much as possible
and having a clear over-bed tray ready for the meal tray.
 Patients should be encouraged to use the hand wipe provided for cleaning their hands
before eating their meal.
 All patients that require assistance with eating or where their intake requires monitoring
should be served their food on a red tray, and receiving help from clinical staff or trained
voluntary staff. (Appendix G)
 Patients wishing to have food brought in from their home should be given a copy of
‘Bringing Food into Hospital’ (Appendix I) in accordance with Appendix C.
 Patients who are known to have dementia should be encouraged to take snacks in
between meals.
7. TRAINING REQUIREMENTS
Training opportunities will be made available for all staff responsible for providing patient care
(nursing staff, support staff, medical staff, allied health professionals, soft FM provision,
volunteers) to include:
Nursing staff and HCSW’s
As part of Patient Safety Day, nutrition champion study days, RN induction Programme,
Preceptorship courses.
Mealtime Volunteers
Specific training provided by dietitians.
Medical staff
Included as part of their induction programme.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Age Concern (2006) Hungry 2 be heard
(http://www.ageconcern.org.uk/AgeConcern/hungry2bheard_overview.asp)
BAPEN (1994). Nutritional Support in Hospitals. British Association of Parenteral and Enteral
Nutrition
BAPEN (2009) Combating Malnutrition: recommendation for action. British Association of
Parenteral and Enteral Nutrition
British Medical Association (2000) Withdrawing and Withholding Life Prolonging Treatment:
Guidance for Decision Making, 2nd Edition BMJ Books London
(www.bmjpg.com/withwith/ww.htm)
Care Quality Commission (2010) National Standards. http://www.cqc.org.uk/public/nationalstandards
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 13 of 35
DoH (2012) Improving Outcomes a: A strategy for Cancer Department of Health
DoH(2001) National Service Framework for Older People – Department of Health
DoH (2014) Hospital Food Standards Panel’s report on standards for Food and Drink in NHS
Hospitals- Department of Health
Edington J et al (2000) Prevalence of Malnutrition to Four Hospitals in England Clinical
Nutrition (2000) 19(3):191-195
ESPEN. (2006) Dysphagia and Nutritional Management Clin Nutr 25:330-360.
Health Service Journal (2009). Malnutrition costs
NICE (2006) National Institute for Health and Clinical Excellence. Nutrition support in adults:
oral nutrition support, enteral feeding and parenteral nutrition Clinical guideline 32
Patients Association (2011) Malnutrition in community and hospital settings
Public Health England (2014) Healthier and More Sustainable Catering: Nutrition Principles.
RCP (2002) Nutrition and Patients A Doctor’s Responsibility. Royal College of Physicians
Downloadable information.
Essence of Care – Nutrition Available at:
www.cgsupport.nhs.uk/downloads/Essence_of_Care/Evidence_Sources_Nutrition.pdf
Nutrition Support in Adults (NICE guidance) – Available at:
http://www.nice.org.uk/CG32
MUST screening tool Available at:
www.bapen.org.uk/must_tool.html
9. EQUALITY IMPACT ASSESSMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 14 of 35
10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum
requirement
to be
monitored
Nutrition
screening &
care
planning
Lead
Tool
Frequency of
Report of
Compliance
Reporting
arrangements
Lead(s) for acting on
Recommendations
By Dashboard
compliance &
documentation audit
Director of Nursing
Head of Nutrition and
Dietetics
CSC Heads of
Nursing
MUST tool via
Hand held
device
Monthly
Red Tray
use and
Protected
mealtimes
Head of
Nutrition and
Dietetics
Audit via ward
visit
Yearly
Food
Hygiene and
Safety
Food
service and
environment
Portsmouth CC
& PLACE team
Assessment /
audit
Yearly
Audit report to:
As above
 Hospital Food Group
By report to:
 Soft FM services &
Trust
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Chief Executive
Head of Soft FM
services
Page 15 of 35
Appendix A
Composition of the Hospital Food Group
Dietetics (chair)
Nursing representatives from all Clinical Service Centres
Provider of soft FM services
Voluntary services
Clinical Nutrition Nurse Specialist
Speech and Language Therapy
Facilities monitoring team
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 16 of 35
Appendix B Nursing Competency
Competency Statement: Care of a patients Oral Nutrition (Adults)
Competency Indicators
1st
Level
After obtaining consent from
the patient (as appropriate)
a) Understand importance of
and correctly undertake
Malnutrition Universal
Screening Tool* (MUST)
nutrition screening

Weight

Height

BMI on Vitalpac
b) Inform Health Care
Professional (HCP) of patients’
MUST* score.
c) Provide information to
patients, relatives and
significant others regarding
nutritional care provided
d) Record information/
intervention accurately in
patients record to include:
- MUST* score
- Nutrition care plan
- Food Charts
- Fluid charts
Nutrition
Policy
- Weight charts
Version:
6
e) Able to access information
Issue
March
eg dietDate:
sheets,10
menus,
from2015
Achieved
Assessor
Signature
Competency Indicators
2nd Level
After obtaining consent from
the patient (as appropriate)
Level 1+
a) Interpret information from
MUST* score and nursing and
medical assessment identifying
risk factors and nutritional
needs in collaboration with the
relevant HCP
b) Implement and evaluate
local MUST* management
guidelines e.g. First Line Action
Plan (FLAP).
c) Identifies patients requiring
special and modified diets,
contributing to ensure patients’
needs are met.
d) Able to provide patient with
appropriate written resources
e.g. diet sheets, special diet
menus.
e) Involve patient, relative and
significant other, informing
them of plan and potential
outcomes.
f) Recognise when patients
require referral onto other HCP
including Dietitian, Speech and
Review Date: 01 December 2017 (unless requirements change)
Achieved
Assessor
Signature
Competency Indicators
3rd level
After obtaining consent from
the patient (as appropriate)
Level 1 and 2+
a) Ensure that all patients
have MUST* completed and
that an appropriate plan of
care is provided by the
relevant HCP
b) Ensure that PHT policies,
guidelines and procedures
are adhered to by staff.
c) Promote 100%
compliance with MUST
screening on Vitalpac and
develop and implement
action plans to improve
compliance
d) Ensure clinical area has
appropriate
resources/equipment to
undertake screening e.g
scales, height chart.
e) Ensure clinical area has
Nutrition Champions and that
time and resources are
allocated for this role.
f) Lead multi-disciplinary
discussion involving patient,
Page 17 of 35
Achieved
Assessor
Signature
Competency Indicators
4th level
In collaboration with other
HCP’s i.e. Dietitian, Speech
Therapists, Catering
a) Undertake and facilitate
audit, set Trust wide
standards, policies and
procedures for oral nutrition,
based on expert knowledge,
relevant research and
experience.
b) Dissemination of changes
in response to national and
organisational
strategies/priorities.
c) Lead regular reviews of
equipment in use and update
as required
d) Act as an expert resource
advising, teaching and
supporting members of the
Portsmouth NHS Trust.
e) Provide formal and
informal training to Trust
staff.
f) Coordinate and facilitate
the Nutrition Champion Role
g) Representation on
Hospital Food Group
Achieved
Assessor
Signature
Dietitians department intranet
site as use appropriately.
f) Able to order meals,
snacks, beverages, special
diets, supplements, resources
e.g., special diet menus.
g) Assist in meal provision,
working collaboratively with
housekeeper.
h) Identify patients
requiring greater
assistance e.g. use of
red tray.
h) Understands the
importance of and supports the
ward with the implementation
of protected mealtimes:
environment is conducive to
eating and patient is ready to
eat, e.g. hand washing offered,
patient positioned correctly,
appropriate utensils available.
i) Report significant changes
and refer to relevant HCP.
j) Understands Nutrition
Champion role and is able to
identify Nutrition Champion,
working proactively to support
Nutrition.
k) Adheres to PHT
policies/guidelines and
procedures relating to Nutrition
and attends essential training
in Nutrition.
Optional
l) Undertake Nutrition
Language Therapist, Diabetes
Nurse Specialist. Able to action
referral correctly.
g) Participate in multidisciplinary discussion
involving patient, relative and
significant others, in the ethical
issues regarding patients
nutrition
h) Contributes to discharge
planning process in relation to
patients’ oral nutrition.
Optional
i) Undertake Nutrition
Champion role acting as ward
lead for Nutrition, representing
ward and disseminating
information to colleagues,
undertake audit and attend
study days and attend annual
Nutrition Champion study day.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
relative and significant
others, in the ethical issues
regarding patients nutrition.
g) Ensures ward resources
pertaining to nutrition are
available and up to date.
h) Facilitate learning and
practice development within
clinical area and ensure staff
receive essential training in
nutrition
i) Raise any issues relating
to oral nutrition to the
Hospital Food Group via the
appropriate representative or
attend Hospital Food Group
representing clinical area.
Page 18 of 35
Champion role in association
with level 2 Nutrition Champion
and attend annual study day
* Renal Unit do not use MUST
– substitute with renal
screening tool
Education resources to support your development
1..Ward Nutrition Champions
2..Nutrition Nurses and Dietitian
3..Patient Safety and Quality study day
6..Annual Nutrition Champion
study day
7. Nutrition Support Study Day(via ESR)
Name:
Author: Lesley Gregory/Jo Pratt Department: Dietetics/Clinical Nutrition Nurses
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Review Date:
Page 19 of 35
Record of Achievement.
To verify competence please ensure that you have the appropriate level signed as a record of your achievement in the boxes below.
Level 1
Level 2
Level 3
Level 4
Date
Date
Date
Date
Signature of Educator/ Trainer
Signature of Educator/ Trainer
Signature of Educator/ Trainer
Signature of Educator/ Trainer
Date:
Date:
Date:
Date:
Signature of Assessor
Signature of Assessor
Signature of Assessor
Signature of Assessor
m)
References to Support Competency




Great Britain. National Institute for Health and Clinical Excellence (2006). Nutrition Support in Adults (Clinical Guideline 32) London : NICE
DoH (2012) New Principles for Hospital Food – Department of Health www.dh.gov.uk/health/2012/10/hospital-food/
Stratton RJ., et al. (2007) Malnutrition in Hospital inpatients and outpatients. British Journal of Nutrition.
Nutrition Policy, Portsmouth Hospitals NHS Trust
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 20 of 35
Appendix C
Guidelines for Food Service at Ward Level
This policy applies to all staff (all disciplines, job roles) caring for
inpatients within Portsmouth Hospitals Trust
Food hygiene regulations are laid down in the NHS executives ‘Hospital Catering Delivery’
and conform to statutory regulations.
All staff working in a ward or clinical area involved in provision of any food, drink or dietary
supplement will be classed as food handlers
Access to ward kitchens:
The regeneration kitchen on each ward is an area supervised by Soft FM services and access
for ward staff is at the discretion of Soft FM services.
The pantry kitchen in ward areas should allow no access to patients or their visitors.
Food handling:
All staff taking food to a patient should have washed their hands and have clothing protected
by a blue plastic apron.
Beverage production:
Should be undertaken by ward staff when patients have missed routine beverage times or the
late night beverage. Hands should be washed and clothing covered by a plastic apron.
Special Dietary Products:
Should be checked by a trained member of staff, and if the product needs to be decanted,
administered in any way then hands should be washed and clothing covered by a plastic
apron.
Food brought in by patients, visitors and staff:
Should be labelled with the name of the recipient and date the food was brought in. Food
should be stored in the refrigerator and discarded after 24 hours. Bringing Food Into Hospital
is a leaflet which sets out guidelines for patients and their relatives. Only low risk foods
(biscuits, sweets) should be kept in the bedside locker.
Refrigerators:
Refrigerators in the beverage area should be checked DAILY by the nurse in charge for
maintenance, temperature, cleanliness and stock rotation. All food dated over 24 hours
should be discarded. All open food should be covered and discarded after 24 hours. Long-life
foods should be discarded at the sell by date. Temperatures of the refrigerator should be
listed on the log sheet and maintained for all staff to see. High temperatures should be
reported to ward manager
Volunteers:
Those helping with food service and assistance in feeding should have received training in
food service/hygiene. Rules of hand-washing and clothing covering still apply.
Meal Distribution:
Soft FM staff will inform ward staff when food is ready for service. This will be at the same
time every day. Each ward has a specific time allocated.
Soft FM staff will check the temperature of food prior to service and record this temperature.
They will have laid trays with cutlery, napkin etc.
Food will be served from the trolley in a discrete area of the ward by a member of the patients
services team, under the direction of a qualified member of the clinical team. Each patient’s
meal request will be provided from the nursing team and the food plated up accordingly.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 21 of 35
Where possible the food will be given to the patient immediately and the patient will be ready
for their meal.
Where patients require assistance in feeding foods will be cut up, food delivery etc will be
undertaken.
No meals should be ‘put by’ for patients who are off the ward or unable to eat their meal at the
food service time. Any food not consumed within one hour of meal service should be
discarded.
Snack bags are provided for patients who miss their meals. If a snack bag is unacceptable
(due to texture etc.) the housekeeper will obtain a meal replacement from the catering
department.
Disposal of waste food will be undertaken by the Soft FM staff. Out of hours waste food
should be discarded in a black plastic bag.
Food trolleys, beverage trolleys etc should be cleaned by Soft FM staff.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 22 of 35
Appendix D
Protected Mealtimes: Guideline
Protected Mealtimes are a period of time over breakfast, lunch and supper when all
non-urgent clinical activity stops. All essential and urgent activity will be met.
This guideline is for all staff both ward based and those visiting wards. It should be the
aim of all nursing, support staff and housekeeping staff to ensure the ward is ready for
mealtimes.
Core aims:
 To encourage anything that supports and assists patients to eat.
 To plan activities to ensure that nursing and support staff are available to assist at
mealtimes.
 To ensure that patients eat their meal is the responsibility of the whole healthcare
team.
 To discourage anything that interferes with the meal time.
As such each ward area should:
 Establish changes in practices e.g. times of ward rounds, visiting times, etc.
 Obtain agreement with all regular ward visitors e.g. allied health professionals,
porters, etc., that interruptions will be minimal at mealtimes
 Agree a start date when the ward will observe a protected mealtime policy
 Provide information for patients, relatives, staff and other departments
Patient Area:
 Remind visitors and healthcare staff that patients are easily distracted from their meal and
find being watched whilst eating off-putting. Those patients where visitors, carers are
available at mealtimes they should support the patient in finishing their meal.
 A quiet and relaxed atmosphere should be created by closing the ward entrance doors and
the door to the day room. If patients are using the day room to eat their meal then ensure the
room is welcoming, clean and tidy.
 Reduce the noise from any unnecessary equipment e.g. cleaning equipment, radio and
television.
 Ensure notices are displayed to inform everyone visiting the ward of the protected
mealtime policy and the time of the main meals.
 To ensure that patients needs are met, staff should organise themselves at the beginning
of the mealtime to establish who will answer patient call buttons, telephones and assist in food
service.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 23 of 35
 Make sure that the patient is ready to eat, offer the patient the opportunity to use the toilet
before eating and washing hands in preparation for eating and remember to repeat the
process after meals.
 Make sure that the environment encourages eating, clearing the bed tray to make space
for the patient’s meal, removing items to prevent distraction.
 Providing assistance in cutting food, pouring drinks, removing wrappers etc.
 For those patients who require help in eating this should be undertaken by a qualified
member of staff.
 Patients who are eating poorly, who require help in eating, cutting food etc., should have
their meals placed on a red tray.
 All staff should make sure that patients are able to consume their meal.
Provision of food:
 Housekeeping staff should inform nursing staff when they are ready to serve meals.
 Nursing staff should be available at the meal trolley to accept food for individual patients
 Use of the red tray should be dictated by nursing staff
 Discourage visiting during mealtimes unless visitors are able to help patients eat their
meals.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 24 of 35
Appendix E
Screening Tools
MUST (Screening Tool) see page 23 & 24. MUST is also available on Vital Pac for those areas that use it.
Wessex Renal and Transplant Service Nutrition Screening Tool see page 26.
First Line Action Plan (FLAP) – Nutrition care plan see page 28.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 26 of 35
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 27 of 35
WESSEX RENAL & TRANSPLANT SERVICE NUTRITION SCREENING TOOL (NST)
Nutritional Screening should be completed for all patients, on admission to hospital
and then every five days.
Please score your patient (from 1-4) according to each of the following criteria and total. Depending on
the score your patient will be classified as having low, medium or high risk of malnutrition. Once you
have classified your patient you should follow the recommendations on the following page to ensure
their nutritional needs are being met.
Date and Time of Completion:
/
/ ……
Date Re-screening Due:
Medical Condition
Post major surgery (including post transplant surgery), severe infection, multiple
injuries, burns >15%, pressure sores, ulcers, delayed wound healing, severe pain
Cancer, gastrointestinal disease, unstable dialysis patients, conditions affecting
food intake, long bone fractures, burns<15%, numerous periods/greater than 24
hours NBM, acute renal failure
Post minor surgery, moderate infection e.g. UTI, chest infection, unstable diabetes,
stable dialysis patients.
Non-dialysis patients with uncomplicated medical conditions e.g. asthma, MI, CVA
with no interruption in food intake.
/
Score
4
3
2
1
Dietary Intake
TPN, enteral feeding such as NG/NJ/PEG, nil by mouth, refuses meals and/or
drinks
Leaves most meals, reluctant to drink
Eats only small meals/snacks, modified consistency
Eats most meals
4
3
2
1
Ability to Eat
Unable to take food and/or fluids orally
Chewing and swallowing difficulties
Requires help to be fed, cutting & transferring food to mouth (e.g. poor eyesight)
Able to eat and/or drink independently
4
3
2
1
Gut Function
Severe diarrhoea over previous 48 hours (more than 4 episodes/day)
and/or vomiting, gut not functioning
Diarrhoea over previous 48 hours (4 or less episodes/day) and/or vomiting,
constipation or impaction
Feels nauseous
Normal gut functioning
4
3
2
1
Mental Condition
Comatose
Confused, depressed, uncooperative with eating
Apathetic, mildly confused
Alert, orientated, cooperative
4
3
2
1
Weight
4
Emaciated
3
Underweight, dehydrated, oedematous, flesh weight loss of more than 3.5kg in last
2 months
2
Flesh weight loss of less than 3.5kg in last 2 months
1
Usual weight and stable
Name:
Signature:
Designation:
Total Score:
Please circle the relevant classification from the options below:
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 28 of 35
/
Low Risk = 6-7
Moderate risk = 8-12
High risk = 13+
Once you have scored your patient you should follow the relevant care plan
detailed below:
LOW RISK
 Monitor weight.
 Provide appropriate menus dependent on dietary requirements, e.g.
diabetic, low potassium if level >5.5 or usually follows, high protein
etc.
 Monitor oral intake and any reasons this may be limited.
 Re-screen in five days.








MODERATE RISK
Monitor weight.
Provide appropriate menus dependent on dietary requirements as
per ‘low risk’.
Ensure food record charts are accurately completed including
quantities of meals eaten.
Provide assistance with menu completion and encourage between
meals snacks.
Provide help with eating and drinking as required.
Ensure dentures are used if applicable.
If patient is not finishing meals please offer two supplement drinks
per day – Fresubin Energy, ProvideXtra, Fortisip Yogurt-style,
hospital milkshakes. This applies to all patients (ARF/HD/PD/Tx)
except pre-dialysis – please discuss these with the Dietitian.
Re-screen in five days.
HIGH RISK
 Follow the steps for moderate risk.
 Refer to Dietitian – details as below.
 Re-screen in five days.





The following patients should be referred to the Dietitian
regardless of Nutrition Screening Score:
Patients requiring enteral feeding – NG/NJ/PEG etc.
Patients requiring parenteral feeding – TPN etc.
New HD/PD/Tx patients.
Pre-dialysis patients requiring specialised supplementation or advice.
Patients who require supplements or dietary advice for home.
Referral to the Dietitians:
Please leave a message with patient details and reason for
referral on ext. 1014 or bleep your allocated ward Dietitian.
Please note this tool is adapted from the Frimley Park NHS Trust Nutrition Screening Tool.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 29 of 35
First Line Action Plan advice from Dietitian
Please document receipt of this fax in your medical notes entry and file this faxed
record in the patient’s medical notes/bed end notes
Patient Name:
Number:
DOB:
Hospital
The above patient was referred to a dietitian on ________and on discussion with a staff nurse
over the telephone, the following advice was deemed appropriate. Please convert advice into a
Care Plan for Patient.
NOTE: The advice given below is general as the Dietitian has not reviewed the patient’s
medical notes.
 Commence Food & Fluid Charts
(Please use a Red Tray for this patient at mealtimes).
 Encourage high energy ‘H’ options from the menu
 Offer High Protein Diet


2 x puddings with meals
Additional sandwiches with meals



Build-Up Soup at lunchtime
Fresubin Cremes x2 per day
1 pint Full Fat (Blue top) Milk
Daily
 Offer patient’s nutritional supplements if deemed
appropriate by patients medical team (see ward poster)
 Weigh patient and complete ‘MUST’ every 5-7 days
Current weight:
Current MUST Score:
 If patient has history of poor intake/severe weight loss/weighs
<40kg
please refer to PHT Refeeding Syndrome Guidelines (see pharmacy
intranet home page  medicines information 
Drug therapy guidelines)
Nutrition PolicyFollow up:
Version: 6 Unless re-referred for tube feeding/further advice, this patient will NOT
Issue Date: 10beMarch
2015up by the Dietitians
followed
Review Date: 01 December 2017 (unless requirements change)
Page 30 of 35
Appendix F
Guideline for mealtime volunteers
 Any patient requiring assistance in selecting food, cutting up, unwrapping food, loading
forks or spoons and helping to transfer food and drink to the mouth will be identified by the
Nurse in Charge at each visit. Any special instructions will be given with an opportunity for
the Volunteer to clarify i.e. if the patient is on a food and fluid chart or requires a special
therapeutic diet.
 Exclusions :- Patients with high risk of choking
Patients being nursed in a side room or any patient being barrier nursed
 The patient should be introduced and verbally consent to being helped to eat by a
volunteer ensuring that the concepts of dignity and privacy are maintained at all times.
 If the patient lacks ability to verbally consent, then other means should be sought by the
registered nurse to ensure that they are aware that they are to receive assistance with their
food as it is in their best interests to receive nutrition.
 The volunteer when attending the ward at mealtimes must wear a specific tabard with
‘Mealtime Volunteer’ embroidered upon and cover with a blue plastic apron as per Trust
infection control policy. Patients will be offered hand washing and volunteers will meet food
and hand hygiene regulations throughout their visit.
 The volunteer will introduce themselves; ask the patient if they would like to wash their
hands prior to their meal, or assist in providing a hand wipe for this purpose.
 The volunteer will check that the patient have dentures in place and is wearing glasses
and hearing aid if appropriate.
 The volunteer will receive the meal from the nursing staff for the patient then sit on a
chair beside the patient to be assisted and discuss the patients preferences for eating prior
to starting, including whether to use a fork or spoon, plastic or metal, use of condiments etc.
 The assistance can be in the form of preparing food to eat, cutting up, uncovering food
plates as well as physically feeding the patient, as some patients prefer to actually feed
themselves if they are able. Offering fluids as required. To assist at a level deemed
appropriate. Older patients with delirium and dementia should be offered fluids in a cup
rather than a beaker with a spout, as this will assist their recall of the mechanism of
drinking. However, they should not be left alone with hot drinks in case of spillage. Some
people with delirium and dementia may find it difficult to remember what to do with utensils
and may prefer ‘finger foods’
 Assistance with completion of their menu may also be helpful.
 Give verbal handover to Nurse in Charge on completion of the meal. To ensure that the
nursing staff are aware of the dietary intake of the patient involved, in addition to recording
on intake sheet if required.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 31 of 35
Appendix G
Red trays are a means to highlight patients who either need help with managing their diet, or
who are not eating well and their total food intake needs to be monitored.
RED TRAY GUIDELINES
Patient admitted/change in condition
↓
Consider if red tray is appropriate?
Food Record Chart
Patient unable to feed themselves/reduced ability to eat
Risk of malnutrition (MUST>2)
↓
Patient and relatives informed if patient falls into a high nutritional risk category
↓
Identify those patients requiring a red tray according to ward’s protocol
(For example red square/T on ward notice board)
↓
Nursing staff checks the whiteboard to see who requires a red tray and ticks box on
patient selection form
↓
Suitable meal served on red tray
↓
Those with red trays will
a) Require assistance with feeding
b) Will require monitoring of intake
↓
Check to see if food record chart completed before removing red tray
↓
Red tray status reviewed daily
MUST score <2
Food Record Chart discontinued
Patient able to feed themselves
↓
On discharge if still at risk notify dietitians for follow up at home
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 32 of 35
Appendix H
Clinical policies aligned to this policy:
Available in the Clinical Policies section of the Intranet:
 POLICY FOR THE PROVISION AND MANAGEMENT OF PARENTERAL NUTRITION IN ADULTS IN
HOSPITAL
 PHT POLICY FOR THE INSERTION AND MAINTENANCE OF FINE BORE NASO-GASTRIC
FEEDING TUBES IN ADULTS
 ENTERAL TUBE ADMINISTRATION POLICY (ADULTS)
Within the Pharmacy homepage guidelines on the management of re-feeding syndrome
http://pharmweb/publications/guidelines/Refeeding%20Syndrome%20Guideline.pdf
And the management of parenteral nutrition when pharmacy is closed
http://pharmweb/publications/parenteralnutritionguidelines.pdf
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 33 of 35
Appendix J
Definitions regarding patient oral intake.
Nil By Mouth – NBM Absolute
A patient care instruction advising that the patient is prohibited from ingesting food,
beverage, water or medicine through the mouth. It is used in cases where the patient
MUST not take food and/or fluids by mouth due to clinical safety concerns relating to
the possibility of aspiration into the lungs eg stricture, neurological damage where
swallow has not been assessed etc. Medications should also NOT be taken orally
when this sign is displayed.
Ensure that the date and time of the NBM directive is displayed. Remember to
provide mouth care.
NBM will be displayed as a red sign with one lines going across the sign
diagonally.
NBM
This is more commonly used in the fasting process prior to procedure. Some oral
medications can be taken this way (although guidance should be taken), sips of clear
fluid can also be allowed. Mouth care should be provided.
NBM will be displayed in a blue sign with one line making a diagonal cross.
SIPs Only
A patient is NBM and able to accept sips of fluid to a maximum of 15-30ml (0.5 – 1 fl
oz) per hour. Use of ice cubes would provide this. Administration of drugs orally via
this route should be considered in conjunction with the medical and pharmacy teams,
as it is possible that SIPS of fluid can be accepted but medication cannot. Mouth care
should be provided.
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 34 of 35
Clear Fluids – written on magnetic bed headboard
A clear fluid is one through which newsprint can be read. For example water, dilute
fruit cordials, weak black tea. They may or may not be a fluid restriction alongside this
direction.
Restricted fluids - written on magnetic bed head board
This will denote a total volume of fluid to be accepted by the patient over a given
period of time (normally 24 hours). The total volume should be displayed on the
directive above the bed and on the fluid chart for that patient, with the amount that is
expected to be taken hourly eg 50ml.
It should also state the type of fluids allowed: clear fluids, thickened fluids.
Thickened fluids
Stages 1 – 3 should be advised by speech and language therapy or a nurse trained in
dysphagia competency. Administration of medicines with thickened fluids should be
considered by pharmacy and medical staff.
Stage 1: consistency fluid should be prepared so that it
· Can be drunk through a straw
· Drunk from a cup
· Leave a thin coat on the back of a spoon
Stage 2: consistency fluid should be prepared so that it
Cannot be drunk through a straw
Can be drunk from a cup
Leaves a thick coat on the back of a spoon
Stage 3: consistency fluid should be prepared so that it
Cannot be drunk through a straw
Cannot be drunk from a cup
Needs to be taken with a spoon
Nutrition Policy
Version: 6
Issue Date: 10 March 2015
Review Date: 01 December 2017 (unless requirements change)
Page 35 of 35