1. Dietitians, Nutrition Screening and Nutrition Support Dietetic Services Central Manchester University Hospitals NHS Foundation Trust

2. What we will cover Role of the Dietitian Malnutrition Nutrition Screening Red tray Protected mealtimes Nutrition Support

3. What is a Dietitian? Qualified health professionals Assess, diagnose and treat diet and nutrition problems Individually or at public health level Use scientific research which is translated into practical guidelines for patients Title can only be used by those appropriately trained Must be registered with the Health Professions Council

4. Role of the hospital Dietitian Assess nutritional status & requirements –Consider: medical condition, medications, symptoms, weight, anthropometry, social factors, biochemistry, nutrition intake Advise on the most appropriate feeding route Advise on nutrition source Advise on therapeutic diets Advise on feeding related complications Communicate advice effectively Develop resources Education & training Audit & research

5. What is malnutrition? “A condition arising from an inadequate or unbalanced diet” Encompasses: Undernutrition resulting from insufficient food intake Specific nutrient deficiencies e.g. iron Imbalance due to disproportionate intake

6. Malnutrition Prevalence of malnutrition in hospital has been quoted as 40% (McWhirter & Pennington, 1994) Recent survey (n=175 hospitals, 9336 patients) - 28% of patients at risk of malnutrition (BAPEN, 2007). In 2006 malnutrition in the UK cost in excess of £7.3 billion, double the projected £3.5 billion cost of obesity (BAPEN, 2006) People in hospital are at risk of becoming malnourished or further malnourished 239 patients reported to have died because of malnutrition in English hospitals in 2007

7. Causes of malnutrition Task 1 1.Split into 4 groups. 2.Each group should choose one of the following risk factors: Age Psychological Disease Hospital 3.Discuss between yourselves how the risk factor can contribute to the development of malnutrition.

8. Causes of malnutrition Age Decreased appetite Taste changes – decrease in number of taste buds, medication Immobility – unable to shop / cook Social / economic circumstances Education e.g. elderly man with poor cooking skills Report by Age Concern (2006) found older people admitted to hospital: –60% are at risk of malnutrition –40% are malnourished –Amongst those aged 80+ the prevalence of malnutrition is 5 times greater than those aged under 50

9. Causes of malnutrition Psychological Low in mood / depression Organic conditions e.g. dementia Bereavement / loneliness Eating disorders e.g. anorexia nervosa

10. Causes of malnutrition Disease Malignancy – treatment, drugs Stroke – dysphagia, alertness Digestion / absorption problems Surgery – increased requirements Alcoholism

11. Causes of malnutrition Hospital Dislike of hospital food Meal interruptions for tests / NBM Inadequate hospital food provision Unable to feed oneself Difficulty in understanding and filling in menus

12. Impact of malnutrition Malnutrition results in: Increased admissions to hospital Loss of body weight, muscle stores Impaired immune function Increased need for medications Delayed wound healing Increased risk of pressure sores Impaired respiratory / cardiac function Reduced mobility Gut atrophy Apathy and depression General sense of weakness and illness Increased length of stay in hospital Increased mortality

13. Nutrition Screening The process of identifying patients who are malnourished or at risk of malnutrition, so that intervention and treatment can be implemented early, aiming to improve clinical outcome

14. Malnutrition Universal Screening Tool (MUST) Nationwide recommendation from the British Association of Parenteral and Enteral nutrition All patients undergo screening on ADMISSION and WEEKLY thereafter Launched June 2007 Trust-wide; reviewed and updated 2010. Nutrition screening tool and nutrition care plan combined Objective screening tool: uses BMI and percentage weight loss to determine risk of malnutrition Daily care plan to be used for all those who score one and above

15. Integrated Care Plan Action Document Screen

16. Case studies – Part A Task 2 1.Split into 4 groups. 2.Using the case study provided, complete the following task Calculate the MUST score. What would you do based on the score? Is it appropriate to refer to the Dietitian? If so, what would you write on the referrals?

17. Score 0 - low risk of malnutrition Repeat score weekly. If BMI > 30 Discuss options with patient. Refer to GP to organise weight management programme in community.

18. Scores 1 - at moderate risk of malnutrition Start 3 days food charts. Offer build up shakes and soups Offer alternatives if meals are missed. Note if assistance required to eat & drink. Note if red tray is required.

19. Daily care plan Should be completed on a daily basis. Put an X in the appropriate box. If you can not complete action you can write the reason why in the variance box. This is so a record is kept if care is not given. This could be NBM, distressed, theatre, investigations. If action is not applicable write N/A in the box.

20. Scores 2 or more – at high risk of malnutrition Refer to dietitian stating score on CWS referral. Start 3 day food charts. Offer build up shakes or soups (ward kitchen stock) Offer alternatives to meals. When the dietitian sees the patient they will tick & initial the box. Start on red tray.

21. Red Tray Care Pathway Three main aspects: –Preparation, Assistance to eat and drink, Completion of meals Remember the vulnerable patient in need of help and support at mealtimes Encourage and assist patients where necessary Dietary intake may be improved with extra attention at mealtimes Tell patients and relatives the benefits of the red tray system Remove red tray ONLY after recording food consumption Assess and weigh patients regularly YOU can improve the patients mealtime experience!

22. Protected Meal Times Part of the Better Hospital Programme (2006) Introduced to most wards in our Trust in June 2006 Is the time over lunch and evening meal when activities on the ward should stop Enables ward staff to focus entirely on patients nutritional needs at each meal time It is encouraged that other health professionals and relatives are not allowed on the ward at this time Families allowed on to help with feeding

23. Case studies – Part B Task 2 1.Using the previous case study, recalculate the MUST score after considering the new information you have been given: What would you do based on the score? Is it appropriate to refer to the Dietitian? If so, what would you write on the referrals?

24. Nutrition Support Defined as the provision of adequate nutritional intake by means other than the eating of normal meals. The extent of nutrition support can vary from supplementing an inadequate diet to providing the sole source of nutrition. Nutrition support can be given as: –Oral nutrition support –Enteral tube feeding –Intravenous nutrition (BAPEN)

25. Oral Nutritional Support (ONS) Indications for ONS Malnourished according to screening tool Unable to meet their nutritional requirements with normal diet and have a functioning GI tract Provision of extra nutrition via the mouth, either through: Energy / nutrient dense foods and drinks And/or Nutritional supplements

26. Food counts! Nourishing SnackCalories (Kcals)Protein (g) A portion of butter700 A portion of jam260 Cereal with milk and sugar29010 1 slice of toast with marg and jam1552 Half a sandwich1508 Cheese and biscuits2509 Digestive biscuits (x2)1402 Yoghurt (full fat)1609 Trifle1854 Kit Kat (4 finger)2504 Bag of crisps1302 Milky coffee1606 Glass of whole milk1306 Build-Up Soup and bread27011 Build-Up Shake23016

27. Common supplements used at the MRI SupplementSupplyDescription Build up shakes / soup - Do not need to be prescribed Ward stockPowder supplement made into a milk shake with fresh milk or a soup with hot water Fortisip Bottle - Need to be prescribed Ward stock1.5kcal/ml milk shake style Fortisip Compact Need to be prescribed Ward stock2.4kcal/ml milk shake style Fortijuice Need to be prescribed Ward stock1.5kcal/ml juice style Forticreme complete Need to be prescribed Ward stockPudding style – gives 200kcal per pot

28. Common supplements used at the MRI SupplementSupplyDescription Calogen Need to be prescribed Ward stockHigh fat supplement Calogen extra Need to be prescribed Non-stock Dietitian must order High fat supplement with protein and carbohydrate with added vitamins and minerals Scandishake Need to be prescribed Ward stockPowder supplement made into a milk shake with fresh milk Procal shot Need to be prescribed Non-stock Dietitian must order Energy dense supplement with fat, protein and carbohydrate Liquigen Need to be prescribed Non-stock Dietitian must order Medium chain fat emulsion for patients with fat malabsorption

29. Improving the supplement experience Give in addition to food, not instead of Open and place within reach Store in fridge No lumps! Positive encouragement Offer in a cup or beaker Can add milk / water

30. Indications for enteral feeding Malnourished and unable to meet requirements with diet or supplements and have a functioning GI tract NBM or reduced oral intake e.g. dysphagia, ITU, trachy patients, some head and neck surgery Patients with increased requirements who need supplementary feeding in addition to the oral route e.g. cystic fibrosis

31. Feeding tubes Short term Naso-gastric tube Naso-jejunal tube Long term: Percutaneous endoscopic gastrostomy Radiologically inserted gastrostomy Jejunostomy Percutaneous endoscopic gastrostomy with jejunal extension Percutaneous endoscopic jejunostomy

32. Out of hours enteral feeding regimen Three feeding regimens Based on weight Two day regimens In nutrition support guidelines folder and on the intranet: Home page → Policies → Nutrition

33. Parenteral Nutrition Also known as total parenteral nutrition (TPN) Used in patients whose GI tract is not functioning / not available Range of patient including: GI surgical, critically ill, haematology

34. Supplement taster session …YOUR TURN TO TRY!