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Dietitians, Nutrition Screening and Nutrition Support Dietetic Services Central Manchester University Hospitals NHS Foundation Trust What we will cover • • • • • • 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 • • • • Low in mood / depression Organic conditions e.g. dementia Bereavement / loneliness Eating disorders e.g. anorexia nervosa Causes of malnutrition Disease • • • • • Malignancy – treatment, drugs Stroke – dysphagia, alertness Digestion / absorption problems Surgery – increased requirements Alcoholism Causes of malnutrition Hospital • • • • • 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 0 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 • • • • • • • 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 • • • • 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!