Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre for Public Health - NICE

Today…. Implementing the nutrition support guideline Consider the key priorities for improvement The 5 key research questions Potential for a national approach to conducting research on nutrition support

Nutrition support in adults Launched February 2006 You can add your own organisation’s logo alongside the NICE logo DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.

Tools to assist implementation NICE – short version – summary of the recommendations Full version – purchased via the NCC-AC Quick Reference guide Information for the public Implementation guidance Audit criteria Slide set Cost impact tool

Implementation, Implementation NICE has only recently in the last year been involved in developing guidance for implementation… Why – it was not NICE’s original remit Why – awareness that guidance on implementation is needed

Access the guideline online Quick reference guide – a summary www.nice.org.uk/CG032quickrefguide NICE guideline – all of the recommendations www.nice.org.uk/CG032niceguideline Full guideline – all of the evidence and rationale www.nice.org.uk/CG032fullguideline Information for the public – a plain English version www.nice.org.uk/CG032publicinfo NOTES FOR PRESENTERS The 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 on 0870 1555 455. Please refer to the accompanying implementation advice for the policy context and useful links.

Access tools online Costing tools costing report costing template Audit criteria Implementation advice Available from: www.nice.org.uk/cg032 NOTES FOR PRESENTERS This guideline is supported by a number of implementation tools, all of which are accessible via the NICE website.

Who is involved or considering ways to implement the guideline?

Understanding why this guideline was proposed can assist implementation Topics proposed – public, clinicians Where there are known problems, variation in practice Proposals via the Department of Health Why this guideline – - because it is well recognised that many patients are malnourished - debate about the efficiency of oral sip feeds

Why should the guideline be implemented? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations to work towards implementing guidelines Compliance will be monitored by the Healthcare Commission NOTES FOR PRESENTERS NICE 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.

How was the guideline developed? 2 ½ years of development Multi disciplinary Guideline Development Group (15) Technical team (10) Stakeholders (100+) Evidence searched: screening, oral, enteral, parenteral, dysphagia, monitoring, nutrition support teams Evidence searched: All populations

Making sense of the evidence Searched for RCT’s Studies in pockets – Intensive Care, Surgery Difficult to make recommendations for specific populations e.g. orthopaedic, oncology Many problems with the studies Heterogeneity Indications for intervention differed between studies Controls Starting times Routes of support Duration of support Outcome measures

Making Recommendations Definite evidence – for 17 recommendations In the absence of evidence - informal consensus - formal consensus - screening

Issues in Nutrition Support WHO ? WHEN ? WHAT ? HOW ?

Focus of recommendations is on ‘Nutritional Status’ not setting…. Guideline useful for patients in Hospital and the Community

Organisation of nutrition support SCREEN RECOGNISE TREAT ORAL ENTERAL PARENTERAL NOTES FOR PRESENTERS When screening - don’t forget risk assessment MONITOR AND DOCUMENT REVIEW

Implementing the guideline 77 recommendations made but…. 10 Key Priorities for Implementation

The whole team makes it happen – 4 of the Key Priorities Healthcare professionals involved in patient care should receive education and training on nutrition support All people who need nutrition support should receive coordinated care from a multidisciplinary team Acute trusts should employ at least one specialist nutrition support nurse Hospital trusts should have a nutrition steering committee working within the clinical governance framework NOTES FOR PRESENTERS To 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 support options for nutrition support (oral, enteral and parenteral) potential risks and benefits ethical and legal concepts when 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.

Screening Where When Hospital inpatients On admission and repeated weekly Hospital outpatients First clinic appointment and when there is clinical concern Care homes On admission and when there is clinical concern General practice Initial registration, when there is clinical concern and opportunistically, e.g. flu jabs, long term condition clinics NOTES FOR PRESENTERS Routine 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’

Suggested actions Clearly identify who is responsible for screening in all care settings including care homes Ensure staff have access to and are using appropriate screening and assessment tools Ensure staff have access to appropriate equipment in the hospital and community setting, e.g. weighing scales that are regularly serviced NOTES FOR PRESENTERS The 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.

Recognise who is malnourished Malnourished = one or more of the following: BMI of less than 18.5 kg/m² unintentional weight loss greater than 10% within the last 3-6 months BMI of less than 20 kg/m² and unintentional weight loss greater than 5% within the last 3-6 months NOTES FOR PRESENTERS Once 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 www.dh.gov.uk).

Recognise 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 longer poor absorptive capacity, are catabolic and/or have high nutrient losses and/or have increased nutritional needs NOTES FOR PRESENTERS People 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 longer have 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.

When and what to give Health 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

For patients with Dysphagia … don’t forget the guidance Dysphagia- a key issue in the remit for the guideline No studies found on the benefits of modifying textures Working party of Speech therapists agreed recommendations Focus- obvious and less obvious indicators of dysphagia Caution on use of modifying textures of food and fluid

Indicators of Dysphagia Obvious indicators Difficult, painful chewing/swallowing Regurgitation of undigested food Difficulty controlling food/fluid in mouth Drooling Hoarse voice Coughing or choking before, during or after swallowing Feeling of obstruction Less obvious indicators Change in respiration pattern Unexplained temperature spikes Wet voice quality Tongue fasciculation Heart burn Throat clearing Recurrent chest infections Atypical chest pain

If the person has dysphagia Recognise co-morbidities that increase the risk of dysphagia People 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 disorders People with dysphagia should be given a drug review to ascertain if the current drug formulation, route and timing of administration remains appropriate and without contraindications NOTES FOR PRESENTERS Some 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.

Don’t be overwhelmed by the guideline?

Why guidelines are not implemented? Don’t know or forget about the guideline Don’t agree with the recommendations Isolation – professionals disagree with the recommendations Psychological – ‘the patients wont like it…’ Limited resources – time, money, skills Organisational issues – barriers to change Some recommendations easy to implement and require one person compared to others requiring a team approach to bring about change

Solutions Don’t know or forget about the guideline Don’t agree with the recommendations Isolation – professionals disagree with the recommendations Psychological – ‘the patients wont like it…’ Limited resources – time, money, skills Organisational issues – barriers to change Some recommendations easy to implement and require one person compared to others requiring a team approach to bring about change Promote – raise awareness – posters, talks Team approach – steering group to decide on strategies to improve clinician and patient confidence and adherence

What can dietitians do to assist implementation?

Dietitians 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 effective The guideline is a useful tool that can influence practice and improve the delivery of nutrition support Dietitians have the knowledge and experience to have a vital impact on education and developing systems to improve the delivery of nutrition support

Suggested 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 care Include nutrition support within induction programmes Identify staff training needs and provide training using externally commissioned and ‘in-house’ programmes Review service protocols and care pathways Audit current practice NOTES FOR PRESENTERS This 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 members service users and carer representatives partner 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.

Research Recommendations Several research recommendations were proposed 5 were identified key research questions these were areas where the GDG had the greatest difficulty to propose a recommendation due to the paucity of evidence in that clinical area and if research is conducted in these areas this would potentially improve NICE guidance and ultimately patient care in the future

The 5 key research recommendations Education Screening Oral nutritional supplements Monitoring Enteral tube feeding

The research recommendations Formal educational intervention for all health care professionals v no formal education Nutritional screening programme v no screening programme - in primary care, - care homes (dementia), - inpatients, - outpatients Which components of nutritional monitoring are clinical and cost effective?

The research recommendations Oral nutritional supplements v dietary modification/food fortificatn v dietary modification/food fortification +/- dietary counselling Enteral tube feeding v no enteral tube feeding in people with dementia and dysphagia

Which ones would you be interested in being involved with? Education Screening Oral nutritional supplements Monitoring Enteral tube feeding

What would the study be like? Scenario: Screening – has never been done in an outpatient setting Outpatient: Aim to screen patients attending out patients on Mon, Tues and Thurs What to do: trained nurse or researcher Weight, height, history of food intake – patient reports reduction or improvement in appetite Clearly define (measures)

Outcomes for the research questions change in nutritional status hospital admissions, hospital duration GP visits complications survival quality of life cost effectiveness

NICE and the key research questions NICE will consider the 5 key research questions Propose and lobby potential funders – via the NHS R+D NICE 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

Research, money resources – proving the case While considering a protocol for a research question Conduct 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 needed Don’t run off in enthusiasm and try to conduct a study on your own Do become involved in setting the agenda for research there is a fundamental problem out there…. Poor infrastructure for delivering nutrition support

Proposals 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 number potentially quicker to produce evidence and influence the update of the guideline national coordinator focus on useful and meaningful outcomes

How many will benefit from this guideline?

Everyone has a part to play This guideline should: help healthcare professionals recognise malnourished patients and those at risk guide healthcare professionals to choose the best method of nutrition support reduce the number of people with malnutrition Set the agenda for further research in nutrition support NOTES FOR PRESENTERS We 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.