Dietitians, Nutrition Screening and Nutrition Support

Dietetic Services

Central Manchester University Hospitals NHS Foundation Trust

What we will cover

• Role of the Dietitian

• Malnutrition

• Nutrition Screening

• Red tray

• Protected mealtimes

• Nutrition Support

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

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

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

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

Causes of malnutrition

Task 11. 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.

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

Causes of malnutrition

Psychological• Low in mood / depression• Organic conditions e.g. dementia• Bereavement / loneliness• Eating disorders e.g. anorexia nervosa

Causes of malnutrition

Disease• Malignancy – treatment, drugs• Stroke – dysphagia, alertness• Digestion / absorption problems• Surgery – increased requirements• Alcoholism

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

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

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

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

Integrated Care Plan

Action

Document

Screen

Case studies – Part A

Task 21. 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?

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.

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.

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.

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.

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!

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

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?

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)

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

Food counts!Nourishing Snack Calories (Kcals) Protein (g)

A portion of butter 70 0

A portion of jam 26 0

Cereal with milk and sugar 290 10

1 slice of toast with marg and jam 155 2

Half a sandwich 150 8

Cheese and biscuits 250 9

Digestive biscuits (x2) 140 2

Yoghurt (full fat) 160 9

Trifle 185 4

Kit Kat (4 finger) 250 4

Bag of crisps 130 2

Milky coffee 160 6

Glass of whole milk 130 6

Build-Up Soup and bread 270 11

Build-Up Shake 230 16

Common supplements used at the MRI

Supplement Supply Description

Build up shakes / soup

- Do not need to be prescribed

Ward stock Powder supplement made into a milk shake with fresh milk or a soup with hot water

Fortisip Bottle

- Need to be prescribed

Ward stock 1.5kcal/ml milk shake style

Fortisip Compact

Need to be prescribed

Ward stock 2.4kcal/ml milk shake style

Fortijuice

Need to be prescribed

Ward stock 1.5kcal/ml juice style

Forticreme complete

Need to be prescribed

Ward stock Pudding style – gives 200kcal per pot

Common supplements used at the MRI

Supplement Supply Description

Calogen

Need to be prescribed

Ward stock High 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 stock Powder 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

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

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

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

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

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

Supplement taster session

…YOUR TURN TO TRY!