Nutrition support in adults

February 2006

Changing clinical practice

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

Malnutrition

Malnutrition is a state in which a deficiency of nutrients

such as energy, protein, vitamins and minerals causes

measurable adverse effects on tissue composition,

function or clinical outcome

Prevalence

Estimates vary depending upon the screening tool used

Using body mass index (BMI <20 kg/m² ):

• 10-40% of adults in hospitals and care homes are underweight

• <5% underweight in the general population at home

The need for this guideline

Malnutrition is common

It increases a patient’s vulnerability to ill health

Nutrition in the home or in hospital may not be adequate

Decisions on providing nutrition support are complex

There is a wide variation in nutritional care standards

Nutrition support

Methods to improve or maintain nutritional intake:

• oral nutrition support – e.g. food, fortified food, sip feeds

• enteral tube feeding – delivery of a nutritionally complete feed directly into the gut via a tube

• parenteral nutrition – delivery of complete nutrition intravenously

Organisation of nutrition support

SCREEN

RECOGNISE

TREAT

ORAL ENTERAL PARENTERAL

MONITOR AND DOCUMENT

REVIEW

What needs to happen

Screen

Recognise who is malnourished and who is at risk

Treat: oral, enteral, parenteral

Monitor and review

needs a multidisciplinary team –

where do you fit in?

St. Bartholomew’s Hospital/Science Photo Library

The whole team makes it happen

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

Suggested actions

Identify an implementation group

Raise awareness of the guideline recommendations 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

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

Normal provision

When unwell, normal food and drink with physical help to eat if required, will often suffice

If this fails, is impractical or unsafe, measures to provide nutrition support may be indicated

This nutrition support may be alone or in combination:

•Oral•Enteral•Parenteral

What to give

The total nutrient intake of people prescribed nutrition support should account for:

• energy, protein, fluid, electrolyte, mineral, micronutrients and fibre needs

• activity levels and the underlying clinical condition

• gastrointestinal tolerance, potential metabolic instability and risk of refeeding problems

• the likely duration of nutrition support

Consider oral nutrition support

and

stop when the patient is established on adequateoral intake from normal food

surgical patients may have different needs

if patient malnourished/at risk of malnutrition

can swallow safely and gastrointestinal tract is working

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

High risk of refeeding problems

One or more of the following:

• BMI less than 16 kg/m

• unintentional weight loss greater than 15% within the last 3-6 months

• little or no nutritional intake for more than 10 days

• low levels of potassium, phosphate or magnesium prior to feeding

Two or more of the following:

• BMI less than 18.5 kg/m

• unintentional weight loss greater than 10% within the last 3-6 months

• little or no nutritional intake for more than 5 days

• a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

High risk of refeeding problems

Consider:

• starting nutrition support at 10 kcal/kg/day max

• increasing levels slowly

• restoring circulatory volume and monitoring fluid balance and clinical status

• providing thiamin and multivitamin/trace element supplement

• providing extra potassium, phosphate and magnesium

Consider enteral tube feeding

and

use the most appropriate route of access and mode of delivery

stop when the patient is established on adequateoral intake from normal food

surgical patients may have different needs

has a functional and accessible gastrointestinal tract

if patient malnourished/at risk of malnutritiondespite the use of oral interventions

Consider parenteral nutrition

use the most appropriate route of access and mode of delivery

stop when the patient is established on adequateoral intake from normal food or enteral tube feeding

surgical patients may have different needs

and has either

introduce progressively and monitor closely

if patient malnourished/at risk of malnutrition

a non-functional, inaccessible or perforated

gastrointestinal tract

inadequate or unsafe oral or enteral nutritional intake

Monitoring

Review indications, route, risks, benefits and goals of nutrition support at regular intervals

Frequency is dependent upon the patient, mode of feeding, care setting and duration of nutrition support

Review and update monitoring protocols in hospital setting, e.g. nutritional, anthropometric, clinical and laboratory

Support in the communitySupported by a co-ordinated multidisciplinary team and receive an individualised care plan

Given training and information on:

•management of delivery systems and the regimen and how to troubleshoot common problems

•delivery of equipment, ancillaries and feed

Given routine and emergency telephone contact numbers for appropriate healthcare professionals

Given contact details for relevant support groups, charities and voluntary organisations

Everyone has a part to play

This guideline should:

•help healthcare professionals recognise malnourished patients and those at risk

•guide healthcare professionals to chose the best method of nutrition support

•reduce the number of people with malnutrition

Access tools online

Costing tools

•costing report•costing template

Audit criteria

Implementation advice

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

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