implementation of nice guidelines and the research questions susan murray (national collaborating...
TRANSCRIPT
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
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
Access tools online
Costing tools
•costing report•costing template
Audit criteria
Implementation advice
Available from: www.nice.org.uk/cg032
Who is involved or considering ways to implement the guideline?
Understanding why this guideline was proposed can assist
implementationTopics 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
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
• 77 recommendations
•Definite evidence – for 17 recommendations
• In the absence of evidence
- informal consensus
- formal consensus - screening
Issues in Nutrition Support
WHEN ?
WHAT ?
HOW ?
WHO ?
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
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
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
• 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
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
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
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
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
• 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
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