Download terms of reference

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
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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 multidisciplinary 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
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• 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
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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
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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)
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• 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
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2. SOUTH TEES HOSPITALS NHS TRUST
NUTRITION STEERINGCOMMITTEE
TERMS OF REFERENCE
1.
Report to:-
1.1
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.
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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.
4.1
The chair of the group should be the Director of Nutrition and
Dietetic Services
Individuals may be co-opted for specific projects.
4.2
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
6.1
The minutes will be approved by the whole Committee at the next
meeting.
Any member of staff may raise an issue with the Chair. The Chair
6.2
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
7.1
7.2
8.
Meetings will be held no less than quarterly in each accounting
year.
Extraordinary meetings may be called by the Chair or at the request
of any member via the Chair.
Duties and Responsibilities
8.1 Each meeting will be structured with a pre-determined agenda.
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8.2
Apologies will be required from those members who are unable to
attend and minutes will be sent.
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.
9.
8.3
Monitor the work of other groups, Committees, Forums, etc relating
to nutritional care.
8.4
Review trends and/or issues arising from other internal and external
groups.
8.5
Recommendations arising from the work of any nutritional care
groups will be considered at the Governance Committee for debate
and approval.
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.
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3.
GOVERNANCE STRUCTURE
TRUST BOARD
GOVERNANCE COMMITTEE
CLINICAL EFFECTIVENESS COMMITTEE
NUTRITION STEERING COMMITTEE
Catering
Sub-Group
Enteral
Feeding
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Parenteral
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
Georgia Payne, Clare
Feeding
Alexander, Liz Audsley, Kate
Lamballe, John
Greenway/Registrar, S&LT,
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 Georgia Payne, Ruth
Group
Weatherall, Maxine Easby,
Viv Matthews, Philippa
Rosenbrier, Sharon Brewster,
Tracy Allston, Paula Hynd
Naso-gastric feeding
Anne Sutcliffe, Judith
group
Connor, Sallyanne Mckinney,
Alison Smith, Audrey Kirby,
Gill Hunt, Julie Pagan
Assisted feeding group Judith Connor, Linda Irons,
Liz Audsley,Gill Everson,
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Nutrition Screening
Infection Control
Issues
Halina Baker,Melanie Crofts,
Alison Smith,Emma
Cox,Angela Kelly
Adult – Kate Lamballe,
Linda Irons, Paula Hynd,
Savitha Shyam Sundar
Paediatric – Ruth
Weatherall, Alison Smith
Rachel Edson, Hue Hoang,
Kate Lamballe, Mel Gannon,
Control of Infection Nurse
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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&LT, 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.
13


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.
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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.
15
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
16
5
NICE GUIDANCE CG32 - PROGRESS REPORT MAY 08
17
Key priorities
Nutritional Screening
 Introduce MUST screening
tool into all in-patient areas
Update
Action
As from 1st November all
nutrition support referrals
required MUST score
First audit of MUST tool
completed on 1/3rd wards
Continue to rollout programme of
audit
Act on results of
audit and target
poorly performing
areas with further
training
MUST session included
in monthly nurse update
training targeting junior
nursing staff and HCAs.

Group set up to link into Primary
care to set up pathway of care
for patients identified at risk by
out-patient screening.
Enteral Feeding
 Introduced Refeeding policy –
agreed by CESC Nov06



Continue discussions
with primary care
Need to introduce
into out-patient
areas – agree
appropriate areas
Placed on Pathfinder
Sept 07
Audit compliance
Sept 08
Naso-gastric feeding – group
established to review existing
policies. Placement of nasogastric tubes to be produced as
a care bundle.
Revised adult and
paediatric naso-gastric
feeding policies to go to
N&MGC
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.
Introduction of MUST
tool should reduce need
for supplement
prescription by medics
NPSA Patient Safety Alert 19:
promoting safer measurement
and administration of liquid
medicines via oral and other
enteral routes

To be compliant with NICE
Present audit
results to NMGC
To be progressed
by NNS
Supplement audit
to be repeated
following
introduction of
MUST
Summer 08
Task group met, agreed
on replacement syringes
to ensure compliance
Arranging event for staff
to bring along tubes in
use in Trust to test
compatibility with new
syringes
Replace syringe
with suitable
single use
alternative by
March 08
Delay because of
manufacturing
problem. Risk alert
to go out when
supply date given
Draft competency
package
produced
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Complete pack
and pilot on Wds
21/23/neuro/
community
guidance Trust requires a
comprehensive package for
patients discharged home on
enteral feeds

Containing a training
checklist based on
tracheostomy pathway.
Updating patient
information for discharge
dealing with
troubleshooting and
monitoring entral feeding
at home. Adult and
paediatric version
PEG feeding
Producing PEG care
guidelines for use at
ward level. Out for
comment within PEG
group
PEG displacement
guidelines produced for
A&E and MAU
hospital in
SUMMER 08
To go to NMGC
following
completion of pilot.
For Clinical
Effectiveness
Committee
approval
Re-audit Oct 08
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 PN use
- Standard referral form for
Parenteral Nutrition
- Guidelines for appropriate
lines and line care
Guidelines for indications
for use of PN
completed. Agreed by
NSC. For ratification by
CESC
To go on
Pathfinder.
Request guidance
from CESC on
disseminating
guidance
Referral form for PN
agreed by NSC
To introduce once
formal Nutrition
team in place
Production of Nutrition
Handbook for F1 and F2
doctors by Pharmacy
and Dietetics
On-going part of
F1 and F2 training
Education & Training




Input into doctors induction.
JG to investigate
Accessing specialty
lunchtime meetings
Contact Nurse reader at
Teesside Uni. LI to progress
To approach Academic
Division re: medical training
opportunities
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Setting regional
objectives for
nutrition training
for all levels of
medical staff to fit
in with national
review
Nutrition Team
 Setting up meetings with
appropriate drug/feed
companies to look at funding
opportunities, working with
John Greenaway, supported
by Nursing Director


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.
Unsuccessful beyond
training monies.
Business case for
Nutrition Nurse Specialist
provisionally approved at
FMG
Agreed contract
which includes
‘added value’
sponsorship for up
to 5 years. Now
need to agree
costings and
membership
Finally agreed
funding, going out
to advert
Group meeting regularly,
not functioning as
Nutrition team
Established TPN working
group with remit as above.
Audits
 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.
Protected mealtimes
policy approved
Introduction of new bulk
meal service across
JCUH
Need processes in place
to ensure patients
receive nutritionally
adequate meals, are
assisted with feeding
where required and
optimize the mealtime
experience.
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Monitoring of pilot
wards by Trust
staff
Training
programme for
nursing staff and
Sovereign staff
Programme of
audit to ensure
nutritional
adequacy
Audit protected
mealtimes 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)
21
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
22
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.
23
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
24
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
25
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’
26
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).
27
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.’
28
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.
29
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).
30
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.
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%).
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.
31
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.
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.
32
Use of standard and specially made bags compared to requirements.
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.
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%).
33
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.
Inappropriate use of PN.
34
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.
35
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.
36
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
37
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?
38
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.
39
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
40
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)
41
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
42
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?
1900 - 2550 Kcals per day
Minimum 2150 kcals per day
70 - 100g Protein per day
Minimum 70g protein
35% - 40% Energy from fat
Yes
2424kcals
Yes
90g
Yes
40%
50% Energy from Carbohydrate
Yes
45%
12 – 24g fibre per day (Southgate)
6g Salt per day
Yes
Yes
27.2g
6g
40mg Vitamin C per day
Yes
67.5mg
200μg Folate per day
Yes
226μg
43
Actual Nutrient
Content 2007
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
44
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 Standard
size g
portion size g
Breakfast
% difference
Porridge
220
150
+ 46%
Baked beans
96
85
+ 13%
Scrambled egg
119
85
+ 40%
187
180
+ 4%
131
84
+ 55%
116
84
+38%
77
75
+ 3%
69
78
72
50
- 4%
+ 56%
Lunch
Mushroom
soup
Tuna mayo for
salad
Cottage cheese
for salad
Egg mayo
sandwich
Beef sandwich
Banana cake
45
- -
Custard
81
100
Fruit mousse
56
50
+ 12%
Jelly
106
100
+ 6%
Evening meal
Butter bean &
bacon soup
Potatoes
199
180
+ 10%
125
112
+ 11%
Vegetables
98
90
+ 9%
Pasta carbonara
Steak & kidney
pie
Fish in
breadcrumbs
Mixed bean
casserole
Turkey for
salad
Cheese savoury
sandwich
Rice pudding
214
196
170
160
+ 26%
+ 23%
125
100
+ 25%
152
150
+ 1%
118
84
+ 40%
110
80
+ 37%
213
150
+ 42%
Vanilla sponge
74
50
+ 48%
46
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)
47
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.
48
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 nonfunctioning 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
49
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).
50
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.
51
● 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-ofhours 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.
www.nice.org.uk/CG032NICEguideline
Thomas, B and Bishop, J (2007) Manual of Dietetic Practice. 4th edition.
Oxford. Blackwell Publishing Ltd. pp113-119
52
9c
Protocol for
Refeeding syndrome
and referrals for
enteral/parenteral
nutrition (adults only)
53
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
54
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.
55
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.
56
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:
2
• BMI less than 16 kg/m
• unintentional weight loss greater than 15% within the last 3–6 months
• little or no nutritional intake for more than 10 days
• low levels of potassium, phosphate or magnesium prior to feeding.
Or patient has two or more of the following:
2
• BMI less than 18.5 kg/m
• unintentional weight loss greater than 10% within the last 3–6 months
• little or no nutritional intake for more than 5 days
• a history of alcohol abuse or drugs including insulin, chemotherapy,
antacids or diuretics.
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).
57
Step 2
Moderately Low Levels
 If K 2.5–3.5 mmol/l give SandoK: 2 tablets 3 x
per day for up to 7 days
 If Phos 0.32-0.8 mmol/l give Phosphate Sandoz:
2 tablets 3 x per day for 7 days
 If Mg 0.5-0.7 mmol/l give Magnesium
Glycerophosphate: 1 tablet 3 x per day (12mmol
total magnesium) or 1 sachet daily (10mmol
total magnesium) for 4 days
(Out of hours the above drugs are available from the
emergency drug cupboard)
Check Blood:
K
Ca
Phos
Mg
Severely Low Levels



Normal blood
Levels
Supplement B
vitamins as below
K <2.5mmol/l
Phos <0.32mml/l
Mg <0.5mmol/l
Replace IV
Refer to IV Drug Information guide
DO NOT START FEEDING UNTIL
S/B DIETITIAN
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
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.
Monitor - K, Phos, Ca, Mg daily for the first week until stable and then twice weekly
and act on as appropriate
* NOTE: Vitamin B co strong and Forceval capsules cannot be crushed and administered via enteral feeding tubes.
Ref: Parenteral and Enteral Nutrition Group: A Pocket Book to Clinical Nutrition, 3 rd Edition 2004
58
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.
59
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
60
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)
61
≥ 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 chloride 0.3% Glucose 5%
*Potassium chloride 0.3% Glucose 5%
Potassium chloride 0.3% Sodium chloride
0.9%
Potassium chloride 0.3% Sodium chloride
0.9%
Potassium chloride 0.45% Sodium chloride
0.9%
62
500mls
1000mls
500mls
Potassium (K+
content)
20mmol
40mmol
20mmol
1000mls
40mmol
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 BNF.org)
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.
63
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: ____________________________
STAGE
FEED
REGIMEN AND DATE
Ward: __________________
(1)
OSMOLITE
500 ml bottle
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)
ENERGY (Kcal)
PROTEIN (g)
SODIUM (mmol)
POTASSIUM (mmol)
PHOSPHATE (mmol)
MAGNESIUM (mmol)
500
404
16
15.32
15.16
8.7
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.
64
NUTRITION AND DIETETIC DEPARTMENT
JCUH Ext: 4777 (with answer machine)
Friarage Ext: 2012
65
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:
____________________________________________________________
66
7)
Number of days since last received full oral/enteral/parenteral feeds?
______________ days
Other relevant information: (please tick relevant boxes)
Bowel surgery resection
GI tract
Transplant organ
Ventilation
Renal
Bowel surgery other
Drugs affecting
Cardiac surgery
Liver disease
Radiation
Sepsis
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: __________________________________
Bleep No. ______
67
Date: _____________________
9a
Document No:
*All Sites
PROTECTED MEALTIMES POLICY AND
GUIDANCE FOR ASSISTED FEEDING
TITLE
SUMMARY
DATE OF REVIEW
APPROVED VIA
DISTRIBUTION
RELATED DOCUMENTS
AUTHOR(S)/FURTHER
INFORMATION
THIS DOCUMENT REPLACES
Protected Mealtimes Policy and Guidance for
Assisted Feeding
For distribution to all wards and departments via
Risk Management Ext 53520
Judith Connor
Cardiology
N/A
Clinical Matron Directorate of
ISSUED BY:
Chief Executive
ISSUE DATE:
68
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:
69



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
70
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
71
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
72
9b
73
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.
74
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
75
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
76
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
77