Presentation on theme: "Implementation of NICE guidelines and the Research questions"— Presentation transcript:
1Implementation of NICE guidelines and the Research questions Susan Murray(National Collaborating Centre for Acute Care, Royal College of Surgeons)Centre for Public Health - NICE
2Today…. Implementing the nutrition support guideline Consider the key priorities for improvementThe 5 key research questionsPotential for a national approach to conducting research on nutrition support
3Nutrition support in adults Launched February 2006You can add your own organisation’s logo alongside the NICE logoDISCLAIMERThis slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
4Tools to assist implementation NICE – short version – summary of the recommendationsFull version – purchased via the NCC-ACQuick Reference guideInformation for the publicImplementation guidanceAudit criteriaSlide setCost impact tool
5Implementation, Implementation NICE has only recently in the last year been involved in developing guidance for implementation…Why – it was not NICE’s original remitWhy – awareness that guidance on implementation is needed
6Access the guideline online Quick reference guide – a summaryNICE guideline – all of the recommendationsFull guideline – all of the evidence and rationaleInformation for the public – a plain English versionNOTES FOR PRESENTERSThe guideline is available in a number of formats. You can download them from the NICE website or order hard copies of the quick reference guide or information for the public by calling the NHS Response Line onPlease refer to the accompanying implementation advice for the policy context and useful links.
7Access tools online Costing tools costing report costing template Audit criteriaImplementation adviceAvailable from:NOTES FOR PRESENTERSThis guideline is supported by a number of implementation tools, all of which are accessible via the NICE website.
8Who is involved or considering ways to implement the guideline?
9Understanding why this guideline was proposed can assist implementation Topics proposed – public, cliniciansWhere there are known problems, variation in practiceProposals via the Department of HealthWhy this guideline –- because it is well recognised that many patients are malnourished- debate about the efficiency of oral sip feeds
10Why should the guideline be implemented? NICE guidelines are based on the best available evidenceThe Department of Health asks NHS organisations to work towards implementing guidelinesCompliance will be monitored by the Healthcare CommissionNOTES FOR PRESENTERSNICE clinical guidelines aim to ensure that promotion of good health and patient care in the NHS are in line with the best available evidence of clinical effectiveness and cost effectiveness. Guidelines help healthcare professionals in their work, but they do not replace their knowledge and skills.Standards for better health, issued in July 2004 by the Department of Heath, identifies core and developmental standards for NHS organisations. Core standard C5 states that healthcare organisations should take into account nationally agreed guidance when planning and delivering treatment and care. Implementation of clinical guidelines forms part of developmental standard D2 which states that patients should receive effective treatment and care that conforms to nationally agreed best practice, particularly as defined in NICE guidance.
11How was the guideline developed? 2 ½ years of developmentMulti disciplinary Guideline Development Group (15)Technical team (10)Stakeholders (100+)Evidence searched: screening, oral, enteral, parenteral, dysphagia, monitoring, nutrition support teamsEvidence searched: All populations
12Making sense of the evidence Searched for RCT’sStudies in pockets – Intensive Care, SurgeryDifficult to make recommendations for specific populations e.g. orthopaedic, oncologyMany problems with the studiesHeterogeneityIndications for intervention differed between studiesControlsStarting timesRoutes of supportDuration of supportOutcome measures
13Making Recommendations Definite evidence – for 17 recommendationsIn the absence of evidence- informal consensus- formal consensus - screening
14Issues in Nutrition Support WHO ?WHEN ?WHAT ?HOW ?
15Focus of recommendations is on ‘Nutritional Status’ not setting…. Guideline useful for patients in Hospital and the Community
16Organisation of nutrition support SCREENRECOGNISETREATORALENTERALPARENTERALNOTES FOR PRESENTERSWhen screening - don’t forget risk assessmentMONITOR AND DOCUMENTREVIEW
17Implementing the guideline 77 recommendations made but….10 Key Priorities for Implementation
18The whole team makes it happen – 4 of the Key Priorities Healthcare professionals involved in patient care should receive education and training on nutrition supportAll people who need nutrition support should receive coordinated care from a multidisciplinary teamAcute trusts should employ at least one specialist nutrition support nurseHospital trusts should have a nutrition steering committee working within the clinical governance frameworkNOTES FOR PRESENTERSTo help with implementing the guideline, NICE has set out a number of recommendations with regard to organisational structure and the needs of personnel. Healthcare workers in hospital and the community who are directly involved in patient care should receive training relevant to their post, on the importance of providing adequate nutrition. As a minimum, education and training should cover:nutritional needs and indications for nutrition supportoptions for nutrition support (oral, enteral and parenteral)potential risks and benefitsethical and legal conceptswhen and where to seek expert advice.Patients having nutrition support should be cared for by a multidisciplinary team. This team may include doctors (for example gastroenterologists, gastrointestinal surgeons, intensivists or others with a specific interest in nutrition support), dietitians, a specialist nutrition nurse, other nurses, pharmacists, biochemistry and microbiology laboratory support staff, and other allied healthcare professionals (for example, speech and language therapists).Hospital trusts should have a nutrition steering committee working within the clinical governance framework. Members of this committee should be drawn from trust management and include senior representation from medical staff, catering nursing, dietetics, pharmacy and speech and language therapy.This guideline is particularly relevant for primary care organisations, acute trusts and mental health trusts responsible for the commissioning and delivery of adult healthcare services. As a result, joint commissioning arrangements are likely to be important in planning the implementation of this guideline.
19Screening Where When Hospital inpatients On admission and repeated weeklyHospital outpatientsFirst clinic appointment and when there is clinical concernCare homesOn admission and when there is clinical concernGeneral practiceInitial registration, when there is clinical concern and opportunistically, e.g. flu jabs, long term condition clinicsNOTES FOR PRESENTERSRoutine nutritional ‘screening’ should result in early identification of patients who might have otherwise been missed. The 'Malnutrition Universal Screening tool' (MUST) is an easy to use, valid nutritional screening tool with clear criteria. This or an equivalent has been widely recommended in an attempt to improve quality of nutritional care in hospitals and other care settings.If patients agree to ‘screening’, then the outcome should be documented - including where appropriate decisions on how to pursue the diagnosis underlying any malnutrition or risk of malnutrition, intervention plans to combat the malnutrition and timelines for review and or re measurement. The ‘screening’ should therefore help to establish reliable pathways of care for patients with malnutrition including provision of support, advice for junior clinicians, access to dietitians, provision of adequate follow-up, and attention to continuity of care across sector boundaries (e.g. malnourished patients discharged to the community).People should be screened on initial registration with their GP and at other times, eg flu injections. All hospital patients should be screened on admission and weekly. All hospital outpatients should be screened at their first appointment. People in care homes should be screened on admission.All should be screened on clinical concern, which includes, for example, unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes, or prolonged intercurrent illness.Some hospital departments may opt out of screening – this must be approved by local clinical governance structures involving experts in nutrition support.use a screening tool that includes BMI, percentage unintentional weight loss and consideration of the time over which nutrient intake has been reduced or likelihood of future impaired intake e.g. ‘MUST’
20Suggested actionsClearly identify who is responsible for screening in all care settings including care homesEnsure staff have access to and are using appropriate screening and assessment toolsEnsure staff have access to appropriate equipment in the hospital and community setting, e.g. weighing scales that are regularly servicedNOTES FOR PRESENTERSThe person responsible for screening – whether in the hospital or the care home – should be clearly identified. Staff should be properly equipped to do the screening – that is, they should be using the appropriate tools for screening (for example, the Malnutrition Universal Screening Tool) and have access to any necessary equipment, which should be maintained in good working order (for example, weighing scales).Following recognised protocols for screening should therefore identify those in need of help.
21Recognise who is malnourished Malnourished = one or more of the following:BMI of less than 18.5 kg/m²unintentional weight loss greater than 10% within the last 3-6 monthsBMI of less than 20 kg/m² and unintentional weight loss greater than 5% within the last 3-6 monthsNOTES FOR PRESENTERSOnce a person has been screened, the decision of whether to give nutrition support can be made. Nutrition support should be considered for people who are malnourished or at risk of malnourishment.All healthcare professionals involved in starting or stopping nutrition support should be aware of the ethical and legal considerations surrounding patient consent and withdrawing or withholding support, bearing in mind that the provision of nutrition support is not always appropriate. Guidance issued by the General Medical Council and the Department of Health should be followed. You can see their websites for details (www.gmc-uk.org and
22Recognise who is at risk At risk of malnutrition = one or more of the following:eaten little or nothing for more than 5 days and/or likely to eat little or nothing for the next 5 days or longerpoor absorptive capacity, are catabolic and/or have high nutrient losses and/or have increased nutritional needsNOTES FOR PRESENTERSPeople who are at risk of malnutrition, and who should also be considered for nutrition support, will have one or more of the following:have eaten little or nothing for more than 5 days and/or likely to eat little or nothing for the next 5 days or longerhave poor absorptive capacity, are catabolic and/or have high nutrient losses and/or have increased nutritional needs.Once people have been identified as needing treatment, they should be treated according to the type of treatment that would best suit their needs.
23When and what to giveHealth Care 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
24For patients with Dysphagia … don’t forget the guidance Dysphagia- a key issue in the remit for the guidelineNo studies found on the benefits of modifying texturesWorking party of Speech therapists agreed recommendationsFocus- obvious and less obvious indicators of dysphagiaCaution on use of modifying textures of food and fluid
25Indicators of Dysphagia Obvious indicatorsDifficult, painful chewing/swallowingRegurgitation of undigested foodDifficulty controlling food/fluid in mouthDroolingHoarse voiceCoughing or choking before, during or after swallowingFeeling of obstructionLess obvious indicatorsChange in respiration patternUnexplained temperature spikesWet voice qualityTongue fasciculationHeart burnThroat clearingRecurrent chest infectionsAtypical chest pain
26If the person has dysphagia Recognise co-morbidities that increase the risk of dysphagiaPeople who present with any obvious or less obvious indicators of dysphagia should be referred to healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disordersPeople with dysphagia should be given a drug review to ascertain if the current drug formulation, route and timing of administration remains appropriate and without contraindicationsNOTES FOR PRESENTERSSome people may not be able to swallow properly, which means that oral feeding wouldn’t be appropriate.Healthcare professionals need to be aware of the signs of dysphagia and recognise comorbidities that increase the risk of dysphagia. Patients with dysphagia should have a drug review to make sure that the drug, route and timing of administration is appropriate to their situation and without contraindications.People with acute and chronic neurological conditions and those who have undergone surgery or radiotherapy to the upper-aero-digestive tract are at high risk of developing dysphagia.Any patient with dysphagia should be referred to healthcare professionals with the relevant skills and training in the diagnosis, assessment and management of swallowing disorders.
28Why guidelines are not implemented? Don’t know or forget about the guidelineDon’t agree with the recommendationsIsolation – professionals disagree with the recommendationsPsychological – ‘the patients wont like it…’Limited resources – time, money, skillsOrganisational issues – barriers to changeSome recommendations easy to implement and require one person compared to others requiring a team approach to bring about change
29Solutions Don’t know or forget about the guideline Don’t agree with the recommendationsIsolation – professionals disagree with the recommendationsPsychological – ‘the patients wont like it…’Limited resources – time, money, skillsOrganisational issues – barriers to changeSome recommendations easy to implement and require one person compared to others requiring a team approach to bring about changePromote – raise awareness – posters, talksTeam approach – steering group to decide on strategies to improve clinician and patient confidence and adherence
30What can dietitians do to assist implementation?
31Dietitians are some of the key people who could assist implementation of the guideline? Awareness and understanding about the potential number of patients who are malnourished or at risk?Concerned that variation in practice is not effectiveThe guideline is a useful tool that can influence practice and improve the delivery of nutrition supportDietitians have the knowledge and experience to have a vital impact on education and developing systems to improve the delivery of nutrition support
32Suggested actions Audit current practice Identify an implementation group… strategy…Raise awareness of the guideline recommendations and why it is needed among all staff directly involved in patient careInclude nutrition support within induction programmesIdentify staff training needs and provide training using externally commissioned and ‘in-house’ programmesReview service protocols and care pathwaysAudit current practiceNOTES FOR PRESENTERSThis guideline spans both primary and secondary care as well as other services and organisations, making its implementation particularly complex. Because of this it is a good idea to identify multiple leads to share the implementation work and ensure seamless care. These leads are likely to be prominent figures that will champion the guideline and inspire others and are committed to working collaboratively across care settings and multi disciplinary working.It might be helpful to identify a group, with members who specialise in nutrition support, to examine implementation issues in depth and support the implementation leads. This group might be part of existing structures or networks, such as a nutrition steering group. In most cases it is better to avoid setting up new structures to manage the implementation of this guideline if there is a current structure that already works effectively.In order to ensure seamless care is provided across the acute, primary and community care settings, this group might need to include:healthcare professionals in primary, secondary and community care, e.g. dietitians, speech and language therapists, community nurses, gastroenterologists, pharmacists, specialist nutrition nurses and GPs, public health, palliative care team membersservice users and carer representativespartner organisations, e.g. social care.Service protocols and care pathways should be reviewed to see whether coordinated multidisciplinary care is provided within and across care settings.[You can add implementation issues that are specific to your trust, e.g. commissioning]We will now look at the different steps in caring for people with nutrition problems, beginning with screening.
33Research Recommendations Several research recommendations were proposed5 were identified key research questionsthese were areas where the GDG had the greatest difficulty to propose a recommendation due to the paucity of evidence in that clinical areaand if research is conducted in these areas this would potentially improve NICE guidance and ultimately patient care in the future
34The 5 key research recommendations EducationScreeningOral nutritional supplementsMonitoringEnteral tube feeding
35The research recommendations Formal educational intervention for all health care professionals v no formal educationNutritional screening programme v no screening programme- in primary care,- care homes (dementia),- inpatients,- outpatientsWhich components of nutritional monitoring are clinical and cost effective?
36The research recommendations Oral nutritional supplementsv dietary modification/food fortificatnv dietary modification/food fortification +/- dietary counsellingEnteral tube feeding v no enteral tube feedingin people with dementia and dysphagia
37Which ones would you be interested in being involved with? EducationScreeningOral nutritional supplementsMonitoringEnteral tube feeding
38What would the study be like? Scenario: Screening – has never been done in an outpatient settingOutpatient: Aim to screen patients attending out patients on Mon, Tues and ThursWhat to do: trained nurse or researcherWeight, height, history of food intake – patient reports reduction or improvement in appetiteClearly define (measures)
39Outcomes for the research questions change in nutritional statushospital admissions, hospital durationGP visitscomplicationssurvivalquality of lifecost effectiveness
40NICE and the key research questions NICE will consider the 5 key research questionsPropose and lobby potential funders – via the NHS R+DNICE will also support and back proposals/protocols for the research recommendations and emphasise their importance and the potential need to improve the evidence in a guideline
41Research, money resources – proving the case While considering a protocol for a research questionConduct an audit of the area of interest (example to be inserted)this will help raise the profile that the problem probably continues and add to the case that research is neededDon’t run off in enthusiasm and try to conduct a study on your ownDo become involved in setting the agenda for research there is a fundamental problem out there…. Poor infrastructure for delivering nutrition support
42Proposals for setting up research national approach to study design – several centres agree on a well developed protocol for study (BAPEN, PENG, BDA)number of centres carry out studies – increase patient numberpotentially quicker to produce evidence and influence the update of the guidelinenational coordinatorfocus on useful and meaningful outcomes
44Everyone has a part to play This guideline should:help healthcare professionals recognise malnourished patients and those at riskguide healthcare professionals to choose the best method of nutrition supportreduce the number of people with malnutritionSet the agenda for further research in nutrition supportNOTES FOR PRESENTERSWe began by looking at some of the reasons why a guideline on malnutrition was produced. In a nutshell, malnutrition is common, and there is currently no clear standard for treatment.This guideline makes recommendations on screening, identifying those who are malnourished or at risk, the different options for nutrition support, and monitoring the progress of those treated. It will affect people both in the hospitals and in the community. Successful implementation will involve many different teams working together, and each one has an important role to play. Relevant personnel will be trained.If these recommendations are taken on board, and each person plays their part, improving the nutritional status of patients will be made possible.