Dietitians, Nutrition Screening and Nutrition Support

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Dietitians, Nutrition Screening and Nutrition
Support

• Dietetic Services
• Central Manchester University Hospitals NHS
  Foundation Trust

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What we will cover

• Role of the Dietitian
• Malnutrition
• Nutrition Screening
• Red tray
• Protected mealtimes
• Nutrition Support

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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

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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

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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

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Malnutrition

• Prevalence of malnutrition in hospital has been
  quoted as 40 (McWhirter Pennington, 1994)
• Recent survey (n175 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

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Causes of malnutrition

• Task 1
• Split into 4 groups.
• Each group should choose one of the following
  risk factors
• Age
• Psychological
• Disease
• Hospital
• Discuss between yourselves how the risk factor
  can contribute to the development of
  malnutrition.

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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

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Causes of malnutrition

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

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Causes of malnutrition

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

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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

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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

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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

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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

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Integrated Care Plan
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Case studies Part A

• Task 2
• Split into 4 groups.
• 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?

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Score 0 - low risk of malnutrition

• Repeat score weekly.
• If BMI gt 30 Discuss options with patient.
• Refer to GP to organise weight management
  programme in community.

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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.

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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.

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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.

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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!
  

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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

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Case studies Part B

• Task 2
• 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?

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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)

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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

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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
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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
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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
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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

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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

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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

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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

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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

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Supplement taster session

• YOUR TURN TO TRY!