Presentation on theme: "The NICE experience Christine Baldwin"— Presentation transcript:
1 The NICE experience Christine Baldwin Division of Medicine, Imperial College London& The Royal Marsden Hospitals, LondonPEN Group Annual Conference,London, August 2006
2 StructureProcessType of evidenceImplications for dietitians
3 The need for this guideline Malnutrition is commonNutritional provision in hospital and community may be inadequateProvision of nutritional support requires complex decisionsWide variation in nutritional care standards
4 Topic nomination“to develop a guideline on appropriate methods of feeding patients who:are still capable of deriving some of their nutritional requirements by conventional feeding and/orhave difficulty swallowingincluding the use of nutritional supplements and enteral and parenteral feeding methods”DoH and Welsh Assembly
5 The process (1) Proposal National Collaborating Centre for Acute Care (NCCAC)Scopestakeholders
6 The process (2) Guideline Development Group: Clinicians GP Dietitians (2)Speech & Language TherapistNursesPatient Groupspharmacists
7 Development of clinical questions The process (3)Development of clinical questions
8 Clinical questions P atients I ntervention C omparison O utcomes Malnourished patientsI nterventionMore food or nutritional supplementC omparisonNo interventionO utcomesmortality
9 Process (4) Literature search Review of papers Extraction of data on identified outcomes
10 Process (5) Development of guidelines from evidence base 1st consultation2nd consultationFinal guideline producedStakeholder commentsStakeholder comments
11 The guideline www.nice.org.uk Quick reference guide (a summary) NICE guideline (all of the recommendations)Full guideline (all of the evidence and rationale)Information for the public (a plain English version)NOTES 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.
12 Changing clinical practice Department of Health has asked NHS organisations to work towards implementing the guidelinesCompliance will be monitored by the Healthcare CommissionNICE guidelines are based on the best available evidence
13 Aims of the guidelineAuthoritative evidence-based guidelines on nutritional support :‘Who?When?What?How ?’excluding children and immunonutrition
14 Valid evidenceSystematic review of multiple randomised controlled trials (RCTs)Large RCTsNon-randomised, case-control studiesNon-experimental studies from more than one centreOpinions based on clinical evidence
15 Problems of evidence (1) Study designWhich studies are includedHeterogeneityStudy qualityDefinition of malnutritionInterventions
16 Problems of evidence (2) Wanted: volunteers for randomized, placebo controlled trial
17 No evidence availableNICE found no RCTs with the introduction of screening as the intervention that then looked at either change in process or clinical measures as outcomes.
18 NICE argument:Even if evidence proves that nutrition support is effective, it does not necessarily follow that screening for malnourishment is of benefit
19 Potential Solutions Formal Consensus Techniques (but lack of time) Potential benefits of nutrition support may be better addressed by non-RCT techniques (but NICE lack the resources)Formal Consensus Techniques(but lack of time)NICE recognized our problems and allowed some Guidance based on first principles
20 Nutritional screening InpatientsOutpatientsResidents of care homesAttendees of GP surgeriesshould all be screened for risk of malnutrition (D (GPP))
21 Grading of evidence A B C D D (GPP) meta-analysis or good quality RCT extrapolated evidence from good quality RCTs or meta-analysis of cohort studiesCDD (GPP)good practice point
22 Recommendations 77 recommendations 10 priorities for implementation 5 research recommendationsGrade A = 8Grade B = 9Grade D (GPP) = 60
23 Key priorities for implementation 10 recommendations:Screening (3)Identification (2)Nutritional support (1)Education (4)
24 Nutritional screening InpatientsOutpatientsResidents of care homesAttendees of GP surgeriesshould all be screened for risk of malnutrition (D (GPP))
25 Screening Two most important features: linked to effective treatment pathwayleads to beneficial outcome
27 Implications (2) Who will carry out screening? Need adequate numbers of dietitiansWho will raise awareness? referralsavailable to see patientsprovide training
28 Implications (3) Research recommendation: Would a screening programme for all patients impact on clinical outcomes (LOS, QOL, complications), compared with no screening?
29 Education“Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training” to enable accurate data collection (D (GPP))
31 Implications (2) Research recommendation: “Further research is needed to ascertain whether an educational intervention … for all healthcare professionals … would have an affect on patient care [LOS, QOL, complications], compared to no formal education.”
32 Oral nutritional intervention “Healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition.” (A)
35 Implications (1)Can dietitians see all the patients that need intervention?Which intervention?develop policiestraining to ensure consistency
36 Implications (2) Research recommendation: Benefits to patients at nutritional risk offered sip feeds vs dietary counselling:survivalcomplication rateLOSQOLcost
37 Consider enteral tube feeding (ETF): if patient malnourished/at risk of malnutritiondespite the use of oral interventionsandhas a functional and accessible gastrointestinal tractuse the most appropriate route of accessand mode of deliveryNOTES FOR PRESENTERSFor the purposes of this guideline, enteral tube feeding refers to the delivery of a nutritionally complete feed (containing protein or amino acids, carbohydrate with or without fibre, fat, water, minerals and vitamins) directly into the gut via a tube. The tube is usually placed into the stomach, duodenum or jejunum via either the nose, mouth or the direct percutaneous route. Enteral tube feeding is not exclusive and can be used in combination with oral and/or parenteral nutrition. Patients receiving enteral tube feeding should be reviewed regularly to enable re-instigation of oral nutrition when appropriate. Most enteral feeding tubes are introduced at the bedside but some are placed surgically, at endoscopy or using radiological techniques, and some are inserted in the community.Enteral tube feeding should be considered for patients who are malnourished or at risk of malnourishment, who can’t be fed orally and who have a working and accessible gut.Whenever possible the patient should be aware of why this form of nutrition support is necessary, how it will be given, for how long, and the potential risks involved. There may be considerable ethical difficulties in deciding if it is in a patient’s best interests to start a tube feed.stop when the patient is established on adequateoral intake from normal foodsurgical patients may have different needs
38 Enteral feeding“Healthcare professionals should consider enteral tube feeding in people who are malnourished or at risk of malnutrition, respectively, and have:(D (GPP))inadequate or unsafe oral intake, anda functional, accessible gastrointestinal tract ”
39 Elective enteral feeding No evidence of clinical benefits“Enteral tube feeding should not be given to people unless they are malnourished or at risk of malnutrition and have; inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract, or they are taking part in a clinical trial.” (A)
40 Surgical patients: early post-op ETF ETF vs nil by mouth“General surgical patients should not have [ETF] within 48 hours post-surgery ...” (A)23 RCTs: combined results do not support the use of early ETF
41 Are they NICE guidelines? Not perfect BUT they do raise the profile of nutritional care and oblige organizations to take it seriously.
42 Challenge and opportunity for dietitians SummaryChallenge and opportunity for dietitians
43 Acknowledgements Joanna Prickett Dietitian, All members of the Guideline Development GroupNorth Bristol NHS Trust
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