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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

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Page 1: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 2: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 3: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Nutrition support in adults

Launched February 2006

Page 4: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 5: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 6: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 7: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Access tools online

Costing tools

•costing report•costing template

Audit criteria

Implementation advice

Available from: www.nice.org.uk/cg032

Page 8: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Who is involved or considering ways to implement the guideline?

Page 9: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 10: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 11: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 12: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 13: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Making Recommendations

• 77 recommendations

•Definite evidence – for 17 recommendations

• In the absence of evidence

- informal consensus

- formal consensus - screening

Page 14: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Issues in Nutrition Support

WHEN ?

WHAT ?

HOW ?

WHO ?

Page 15: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Focus of recommendations is on ‘Nutritional Status’

not setting….

Guideline useful for patients in Hospital and the Community

Page 16: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Organisation of nutrition support

SCREEN

RECOGNISE

TREAT

ORAL ENTERAL PARENTERAL

MONITOR AND DOCUMENT

REVIEW

Page 17: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Implementing the guideline

77 recommendations made but….

10 Key Priorities for Implementation

Page 18: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 19: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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’

Page 20: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 21: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 22: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 23: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 24: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 25: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 26: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 27: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Don’t be overwhelmed by the guideline?

Page 28: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 29: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 30: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

What can dietitians do to assist implementation?

Page 31: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 32: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 33: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 34: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

The 5 key research recommendations

Education

Screening

Oral nutritional supplements

Monitoring

Enteral tube feeding

Page 35: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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?

Page 36: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 37: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Which ones would you be interested in being involved with?

Education

Screening

Oral nutritional supplements

Monitoring

Enteral tube feeding

Page 38: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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)

Page 39: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

Outcomes for the research questions

- change in nutritional status

- hospital admissions, hospital duration

- GP visits

- complications

- survival

- quality of life

- cost effectiveness

Page 40: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 41: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 42: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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

Page 43: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

How many will benefit from this guideline?

Page 44: Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre

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