PAT/T 43 v.1 Page 1 of 21 Please Note: This policy is currently under review and is still fit for purpose. Nutrition and Hydration Policy for Adults in Hospital This procedural document supersedes: PAT/PA 25 v.1 – Hospital Nutrition and Hydration Policy. Transferred from ‘Patient Administration’ section to ‘Treatments/Investigations’ section. Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. If, for exceptional reasons, you need to print a policy off, it is only valid for 24 hours. Author/reviewer: (this version) Vera Todorovic – Consultant Dietition in Clinical Nutrition, Nutrition and Dietetic Services Date written/revised: November 2012 Approved by: Nutritional Steering Committee and Policy Approval and Compliance Group (on behalf of the Patient Safety Review Group) Date of approval: 8 May 2013 Date issued: 12 June 2013 Next review date: November 2015 – Extended to November 2017 Target audience: Trust wide
Transcript
PAT/T 43 v.1
Page 1 of 21
Please Note: This policy is currently under review and is still fit for purpose.
Nutrition and Hydration Policy for Adults in
Hospital
This procedural document supersedes: PAT/PA 25 v.1 – Hospital Nutrition and Hydration Policy. Transferred from ‘Patient Administration’ section to ‘Treatments/Investigations’ section.
Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. If, for exceptional reasons, you need to print a policy off, it is only valid for 24 hours.
Author/reviewer: (this version)
Vera Todorovic – Consultant Dietition in Clinical Nutrition, Nutrition and Dietetic Services
Date written/revised: November 2012
Approved by: Nutritional Steering Committee and
Policy Approval and Compliance Group (on behalf of the Patient Safety Review Group)
Date of approval: 8 May 2013
Date issued: 12 June 2013
Next review date: November 2015 – Extended to November 2017
Target audience: Trust wide
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Amendment Form Please record brief details of the changes made alongside the next version number. If the procedural document has been reviewed without change, this information will still need to be recorded although the version number will remain the same.
Version
Date Issued
Brief Summary of Changes
Author
Version 2
12 June 2013
Changed sections from ‘Patient Administration’ to ‘Treatments/ Investigations’ section.
Updated and transferred to new style format.
Vera Todorovic
Version 1
May 2008
This is a new policy, please read in full.
Vera Todorovic
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Contents
Section
Page No.
1 Introduction 4
2
Purpose
2.1 Rationale for Optimising the Nutritional Care of Hospital Patients
2.2 Prevalence of Malnutrition is Common in the Hospital Setting
2.3 Obesity
4
4
5
6
3 Duties and Responsibilities 6
4
Procedure
4.1 Nutritional Care of Patients
4.2 Steps in the Nutritional Care Process
4.3 Nutritional Screening and Assessment
4.4 Provision of Food, fluid and Nutrition to Patients
4.5 Types of Nutritional Support
4.6 Hydration
4.7 Dealing with Food Refusal
4.8 Addressing the Nutritional Needs of Patients who Lack Capacity
4.9 Discharge of Patients Requiring Continuing Nutritional Support
8
8
8
9
9
9
10
10
10
5 Training/Support 10
6 Monitoring Compliance with the Procedural Document 11
7 Definitions 11
8 Equality Impact Assessment 12
9 Associated Trust Procedural Documents 12
10 References 12
Appendices
Appendix 1 Key Documents and Standards Relating to Nutrition 13
Chart 1 Flow Chart for Nutritional Care of Patients in Hospital 20
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1. INTRODUCTION
Providing patients with optimal nutritional care is an integral part of their treatment and provision of appropriate food and fluids to meet their needs is essential to maximise individual health outcomes. Over the last decade, there has been increasing concern over the high incidence of malnutrition, in particular under nutrition that exists in the hospital population and a growing interest in improving the overall nutritional care experience for the patient together with delivery of appropriate nutritional care to improve clinical outcomes. Malnutrition has the potential to affect the whole hospital population and can adversely affect clinical outcomes for patients Hospitals have a responsibility for ensuring that appropriate systems and processes are in place to both identify and manage patients who fall into these categories as well as ensuring that all patients have access to food and hydration appropriate to their needs. This policy should be read in conjunction with ‘A Practical Guide to Nutritional Support for Adults PAT/T 35’ which has been developed to help all practitioners who work with patients to understand the steps involved in providing the best nutritional care for patients in their care and how this may be achieved.
2. PURPOSE
The purpose of this guidance is to highlight the processes involved in optimising the nutritional care of patients during their hospital stay.
2.1 Rationale for Optimising the Nutritional Care of Hospital
Patients
Addressing poor nutritional care of patients is highlighted as a priority in several key documents and the Trust is committed to ensuring that all the recommended standards and guidance are addressed. The following documents provide the framework within which the Trust is working to improve the nutritional care of its patients.
NICE Guidance on Nutrition Support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (2006)
NICE Quality standard 24: Quality standard for nutrition support in adults (2012 )
Care Quality Commission (CQC): Outcome 5 Nutrition
Essence of Care: Nutrition Benchmark (2010)
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10 key characteristics of good nutritional care in hospitals. Council of Europe Resolution on Food and Nutritional Care in Hospitals (2007)
NHS Kidney Care Hydration Matters (2012 )
PLACE (2013 ). Assessments relate to provision of safe and appropriate food and drink for patients and assistance when required at mealtimes within an environment conducive to eating and drinking.
Summaries of the key recommendations from these guidance documents are detailed in Appendix 1.
2.2 Prevalence of Malnutrition is Common in the Hospital Setting
It has been estimated that at any one time more than 3 million people in the UK are at risk of malnutrition (undernutrition) and, yet it continues to be an under-recognised and under-treated problem. Furthermore, the public health expenditure on disease-related malnutrition in the UK in 2007 was calculated to be in excess of £13 billion per annum, about 80% of which was in England 1. This is a heavy burden and cost to bear not only for individuals, but for health and social care services, and society as a whole. It is estimated that 28-34% of patients coming into hospital are undernourished. 3,4,5
Data from studies in outpatient clinics suggests that 16-21%patients are at risk of malnutrition (medium and high risk calculated from ‘MUST’) with those at risk experiencing significantly more hospital admissions and significantly longer length of hospital stay 3,4,5 .
Malnutrition can arise at all ages from a wide range of acute and chronic diseases, as well as psychosocial factors (e.g. social isolation, bereavements) The most vulnerable nutritionally at risk groups include those with chronic diseases, the elderly, those recently discharged from hospital, and those who are poor or socially isolated.1,2
With severe acute diseases, there is rapid loss of appetite, weight and body function. It may take weeks or months for full recovery, partly because of inadequate nutrition.
Weight loss usually begins before admission, deteriorates further in hospital, and may continue to deteriorate for a period after discharge from hospital
Malnutrition can detrimentally affect virtually every system of the body. Randomised controlled studies and meta-analyses suggest that nutritional support of undernourished individuals can reduce mortality, complications after illness, length of hospital stay, readmission rates to hospital, decrease costs of care and improve well-being.6
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2.3 Obesity
Obesity is a major clinical and public health issue and for patients in hospital this can adversely affect clinical outcomes. Identifying individuals who fall into this category and providing them with help and support at an appropriate time in their clinical care is an important role of the healthcare professional. (See A Practical Guide to Nutritional Support Weight Management Sheet in the Practical Guide to Nutrition Support for Adults PAT/T 35 v.2).
3. ROLES AND RESPONSIBILITIES IN THE PROVISION OF
NUTRITION
Key responsibilities and duties of staff Delivering excellent nutritional care to patients that are being cared for is a complex process and relies on good co-ordination. Standards of care need to be set, acted upon, audited and monitored and all staff within the Organisation have some responsibility to ensure that this happens. Nutritional support therefore needs to be delivered via catering, ward nurses and the patient’s medical team, supported by specialist advice and an authoritative, specialist-derived management structure which fosters excellence and responsiveness to external drivers.
Reproduced with kind permission BAPEN (Organisation of Nutritional Support in Hospitals (2012) www.bapen.org.uk ). Please refer to the BAPEN website for further detailed information on how the domains above link together and highlight key responsibilities for the organisation of hospital nutrition within each domain.
Summary of local key responsibilities relating to the organisation of the Trust’s nutritional services
Key groups Role
Chief Executive and Trust executive team
Ensure that a robust strategic nutrition action plan is in place for the Trust together with appropriate governance structures to ensure that standards of nutritional care are met and that risk management issues are addressed.
Nutrition steering committee Develop strategic nutrition action plans for the Trust together with annual work plans and work streams
Clinical governance committee Ensure that the outputs and outcomes from the nutrition steering committee are discussed and appropriate action taken where needed.
Nutrition action group ( matrons ) Develop the operational action plans taken from the key priorities identified by the nutrition steering committee and ensure that these are delivered at ward level.
Nutrition link nurses Act as the champions and leads relating to the nutritional care of patients at ward level. Ensure that the operational action plans developed are in place at ward level and that staff are routinely trained and updated in the relevant processes.
Ward managers and Ward staff Ward managers ensure that all patients nutritional requirements are met and care planning and monitoring is in place for all patients for whom it is required. They ensure that nutritional standards and processes are adhered to and lead on the nutrition ward accreditation process.
Dietitians Dietitians are the principal source of evidence-based information on food and nutrition and are important contributors and leaders of the nutritional care process. They provide nutritional advice and expertise for patients and staff in all units of the hospital, including catering and lead on the development of nutrition education and training programmes.
Catering Develops menus in conjunction with the dietetic department and patients to ensure that all patients nutrition and hydration needs can be addressed. Processes are in place to ensure the safety of food provided
Pharmacy Input to nutritional care of patients via ward pharmacists, procurement and via drug advisory services. Advise on parenteral nutrition composition and compatibilities and ensuring aseptic processes for preparation are adhered
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to. Advise on drug delivery via enteral tubes and on drug-nutrient interactions. Key role in monitoring and auditing compliance within these feeding systems.
Patients Patients should be encouraged to take a positive approach to improving their nutrition and should be given information about what to expect and what to ask about when they come into hospital.
4. PROCEDURE
4.1 Nutritional Care of Patients
4.2 Steps in the Nutritional Care Process
For the summary flowchart detailing the process, see chart 1.
4.3 Nutritional Screening and Assessment
Nutritional screening is the first step in identifying patients who may be at nutritional risk or potentially at risk and benefit from appropriate nutritional intervention. It is a rapid, simple and general procedure used by nursing, or medical staff at first contact with the patient so that clear guidelines for action can be implemented.
The ‘Malnutrition Universal Screening Tool‘ (‘MUST’) is used across the Trust and is part of the combined risk screening and assessment bundle and documentation that is used by all wards. Ref WPR23080. Management Guidelines have been developed locally
All patients (except children) should be screened within 24 hours of admission to the ward. Patients are categorised as low, medium or high risk. The management guidelines associated with the Tool are used to develop a nutritional care plan for individual patients and this information is documented in the combined screening and assessment documentation.
Nutritional assessment is a more detailed, more specific, and in-depth evaluation of a patient’s nutritional state carried out by the Dietitian. The assessment process allows more specific dietary care plans to be developed by the Dietitian for the individual patient. The management guidelines in the Trust’s combined risk screening and assessment document indicate at what stage the Dietitian should be contacted for advice.
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Patients who require a more detailed nutritional assessment will be referred to the Nutrition and Dietetic Service as per the Trust’s ‘MUST’ management guidelines.
4.4 Provision of Food, Fluid and Nutrition to Patients
Protected mealtimes
The therapeutic role of food within the healing process cannot be underestimated and food and the service of food are an essential part of a patient’s treatment. Nationally the concept of Protected Mealtimes has been developed to improve the patient’s experience around mealtimes and the Trust has developed its own policy PAT/PA 16, which is in operation across all wards in the Organisation. The privacy and dignity of patients at mealtimes should also be considered. There are patients who may feel uncomfortable eating and drinking in the presence of others (e.g. they have functional disabilities ) and where this is the case this should be reflected in the patients care plan so that all staff involved at mealtimes are aware of the support required for that individual.
4.5 Types of Nutritional Support
Most patients coming into hospital are able to drink normally and manage a normal diet during their hospital stay. Some patients however need additional nutritional support to help meet their nutritional requirements and this could be provided by
Food fortification/food enrichment
Use of snacks and /or oral nutritional supplements (ONS)
Enteral tube feeds
Parenteral nutrition None is exclusive and more than one approach may be needed.
Some patients will have problems swallowing and they must be referred to the appropriately trained professional e.g. Speech and Language Therapist, The correct textures for food and fluid can then be prescribed for that patient and appropriate arrangements made to ensure the patients nutritional requirements are met.
Wherever possible the aim is to re establish the patient back onto normal oral diet.
4.6 Hydration
Hydration of the patient is as important as ensuring adequate food intake and the Trust is committed to ensuring that where appropriate patients are encouraged to take a range of fluids through the day and intake is
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documented in their care plans. If patients are unable to tolerate oral fluids the use of alternative routes e.g. enteral, IV for the provision of fluids should be discussed with the patient’s clinical team. Each ward area has copies of the ‘Volume in Vessels’ poster and the information should be referred to when documenting oral fluid intake in care plans to ensure standardisation of recording.
Detailed guidance on methods of nutritional support, issues relating to Dysphagia, infection control, monitoring and complications that may arise because of nutritional support are found in The Practical Guide to Nutrition Support for Adults PAT/T 35 v.2.
4.7 Dealing with Food Refusal
An individual who continually refuses to eat or drink / refuse to open their mouth is at high risk of dehydration and malnutrition. The appropriateness of artificial support (e.g. nasogastric or PEG feeding) including the ethical issues involved should be discussed by the multidisciplinary team as part of the patient’s clinical review.
4.8 Addressing the Nutritional Needs of Patients who Lack Mental
Capacity
If a patient lacks capacity and is unable to make safe and appropriate food and fluid choices for themselves they may be putting themselves at nutritional risk and compromising their health outcomes. Appropriate intervention should be taken, taking into consideration the requirements of the Mental Capacity Act (2005) and the Trust policy PAT/PA 19). The course of action taken should always be in the best interest of the patient.
4.9 Discharge of Patients Requiring Continuing Nutritional Support
Patients will be screened prior to discharge and the ‘MUST’ score included in their discharge documentation. Patients with a high 'MUST' score should have this highlighted to the General Practitioner.
5. TRAINING/ SUPPORT
Education and training programmes are in place for staff relating to the nutritional care of patients. These are led by the Department of Dietetics and Nutrition and programmes are developed on an annual basis. Matrons and ward managers are responsible for ensuring that their members of staff receive relevant education and training.
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6. MONITORING COMPLIANCE WITH THE PROCEDURAL
DOCUMENT
The Nutrition Steering Committee and the Nutrition & Dietetic department in conjunction with the Audit department will determine the annual audit cycle relating to the nutritional care of patients.
What is being Monitored
Who will carry out
the Monitoring
How often
How Reviewed/
Report to
Nutrition screening on admission and discharge
All wards monthly
monthly
Collated on nutrition metrics dashboard. Data shared quarterly with NAG and actions directed to ward managers.
Nutrition care planning on discharge
All wards monthly
monthly
Collated on nutrition metrics dashboard. Data shared quarterly with NAG and actions directed to ward managers.
Protected mealtimes
Twice yearly by all wards
Twice yearly
Collated on nutrition metrics dashboard. Data shared quarterly with NAG and actions directed to ward managers.
Hydration of patients
Twice yearly by all wards
Twice yearly
Fluid record charts in ward accreditation portfolio
Food textures appropriate for the needs of patients with swallowing difficulties
SALT, Catering and dietetics
annually
Report to NAG and Nutrition Steering Committee
7. DEFINITIONS
BAPEN British Association for Parenteral and Enteral Nutrition
‘MUST’ ‘Malnutrition Universal Screening Tool’
NAG Nutrition Action Group
NJ Naso jejunal
PEG Percutaneous endoscopic gastrostomy
NG Nasogastric
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PICC Peripherally inserted central catheter
PLACE Patient Led Assessment of the Care Environment
SALT Speech and language Therapy
8. EQUALITY IMPACT ASSESSMENT
An Equality Impact Assessment (EIA) has been conducted on this procedural document in line with the principles of the Equality Analysis Policy (CORP/EMP 27) and the Fair Treatment For All Policy (CORP/EMP 4).
The purpose of the EIA is to minimise and if possible remove any disproportionate impact on employees on the grounds of race, sex, disability, age, sexual orientation or religious belief. No detriment was identified.
A copy of the EIA is available on request from the HR Department.
9. ASSOCIATED TRUST PROCEDURAL DOCUMENTS
PAT/T 35 - A Practical Guide to Nutrition Support for Adults PAT/PA 16 - Protected Mealtimes Policy PAT/PA 19 - Mental Capacity Act 2005 Policy and Procedure PAT/PA 28 - Privacy and Dignity Policy
10. REFERENCES
1. Elia M, Russell CA. Combating malnutrition: Recommendations for action: A
report from the Advisory Group on Malnutrition led by BAPEN, 2009 2. Elia M, Screening for malnutrition: a multidisciplinary responsibility.
Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults. MAG, a Standing Committee of BAPEN (ISBN 1 899467 70 X) 2003.
3. Russell CA, Elia M. Nutrition screening survey in the UK in 2007.A report by BAPEN., 2008.
4. Russell CA, Elia M. Nutrition screening survey in the UK in 2008.A report by BAPEN., 2009.
5. Russell CA, Elia M. Nutrition screening survey in the UK and Republic of Ireland in 2010 .A report by BAPEN., 2011.
6. Elia M. (chairman & editor),Stratton R,Russell C,Green C,Pang F.The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. A report by The Health Economic Group of The British Association for Parenteral and Enteral Nutrition (BAPEN). BAPEN, 2005.
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APPENDIX 1
Key documents and standards relating to nutrition Nutrition support in adults; Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (2006)
Key priorities for implementation
Key clinical priorities
Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training.
All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients. People in care homes should be screened on admission and when there is clinical concern.
Hospital departments who identify groups of patients with low risk of malnutrition may opt out of screening these groups. Opt-out decisions should follow an explicit process via the local clinical governance structure involving experts in nutrition support.
Nutrition support should be considered in people who are malnourished, as defined by any of the following:
− a body mass index (BMI) of less than 18.5 kg/m2
− unintentional weight loss greater than 10% within the last 3–6 months
− a BMI of less than 20 kg/m2
and unintentional weight loss greater than 5% within the last 3–6 months.
Nutrition support should be considered in people at risk of malnutrition, defined as those who have:
− eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for 5 days or longer − a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism.
Healthcare 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
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Key organisational priorities
All healthcare professionals who are directly involved in patient care should receive education and training, relevant to their post, on the importance of providing adequate nutrition.
Healthcare professionals should ensure that all people who need nutrition support receive coordinated care from a multidisciplinary team.
All acute hospital trusts should employ at least one specialist nutrition support nurse.
All hospital trusts should have a nutrition steering committee working within the clinical governance framework
NICE Quality standard 24: Quality standard for nutrition support in adults (2012)
Quality statements
Statement 1 People in care settings are screened for the risk of malnutrition using a validated screening tool.
Statement 2 People who are malnourished or at risk of malnutrition have a management care plan that aims to meet their nutritional requirements.
Statement 3 All people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable) documented and communicated in writing within and between settings.
Statement 4 People managing their own artificial nutrition support and /or their carers are trained to manage their nutrition delivery system and monitor their wellbeing.
Statement 5 People receiving nutrition support are offered a review of the indications, route, risks, benefits and goals of nutrition support at planned intervals.
The CQC guidance explains how their reviewers use observations to gather information during their visits, to help assess whether a provider is meeting the Outcome. The full document can be downloaded at:
People being screened to identify the risk of malnutrition using formal screening tools. Look for:
Presence of screening tools (for example, MUST).
Nutrition score recorded in the notes.
Nutrition score recorded in the care/treatment plan.
People being weighed.
MNN2
Coordination of nutrition care and treatment with other providers (with or across other services). Look for:
Handover/communication at transfer.
Visits by other professionals (for example, dieticians, occupational therapists, speech therapists).
Staff communicating all requirements related to the provision of culturally/ethically/physically sensitive food/menus (for example, halal, vegetarian, gluten free).
MNN3
People identified as 'at risk' or needing support are being monitored. Look for:
Signs/alerts showing that they require assistance/are at risk.
Food intake charts being monitored, completed and reviewed by staff during/following mealtimes.
Fluid intake charts being monitored, completed and reviewed by staff during/following mealtimes.
Staff supporting and communicating with people in a sensitive manner that meets their needs and requirements.
Weight being recorded weekly.
Repeated screening.
MNN4
Food preparation. Look for:
People being enabled/allowed to prepare food for themselves.
Staff washing their hands before and during food preparation.
Prepared meals that include all major food groups (for example, starch, protein, fibre, fat/sugar).
Staff having access to all equipment needed for the safe preparation of food (boards, knives, gloves, etc).
Ensuring that foods are separated in accordance with individual cultural and ethical preferences (for example, halal food should not come into contact with non-halal food, food prepared for vegan diets should not come into contact with animal products).
Temperature of food being checked.
Staff who are preparing the food being aware of those requiring alerts.
Sample the prepared food yourself.
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MNN5
The environment in which food and drink is served. Look for:
People being allowed to eat where they want to, unless for safety reasons they require specific arrangements or positioning.
Staff being friendly and actively encouraging people to eat and drink independently if appropriate.
Sufficient staff being around to provide support and assistance to those who need help to eat and drink.
Any unnecessary interruptions during mealtimes.
The environment being clean and tidy.
People being invited and supported to wash their hands before a meal, where they wish to do so.
A pleasant atmosphere, conducive to eating (for example, no unpleasant odours).
Special equipment available for those who need it (for example, adapted crockery or cutlery).
The food served meeting the person’s needs and requirements.
Nobody having to wait unduly for their meal.
Drinking water available.
Drinking water being changed at regular intervals.
People being offered a range of drinks (for example, juice, squash, tea, coffee).
Volume capacity of cups or beakers on the record/poster/notices etc. for reference.
People able to reach food and drink.
People being helped or encouraged to drink between meals.
Staff observing for signs of under or over-hydration – by touching or assessing skin.
People who receive clinical nutrition being observed for dry lips – having their oral hygiene attended to.
People having their human rights and their dignity respected.
Staff enabling and supporting visitors and relatives to help people to eat and drink.
MNN6
People are not interrupted during mealtimes – unless they wish to be or an emergency arises. Look for:
Meals being served at the agreed time.
Signs/posters displaying protected meal time is underway.
Setting being closed to all unnecessary visitors.
Staff asking people about their reasons for not eating or drinking during mealtimes.
People being given enough time to eat.
Cleaning not occurring during the meal service or when people are eating, unless there is a safety risk present.
MNN7
Food delivery, handling and storage. Look for:
Food handling policy on display.
Food hygiene policy on display.
Those handling food washing their hands.
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Policies and procedures being followed for the safe handling, storage and labelling of food (including vegetarian and halal food).
MNN8
People are offered choice. Look for:
People being given an informed choice, i.e. using a menu, lists, verbal descriptions, pictures, photographs.
Staff being able to respond to a request for a replacement meal that is appropriate to the person’s individual needs.
A range of replacement meals being offered that include the provision of culturally sensitive choices (for example, halal) and for reasons associated with special physical needs (for example, dysphagia).
People not waiting too long for a meal of their choice.
People preparing food for themselves.
Relatives providing alternative meals.
Staff checking whether people eat their food and recording this in the person’s care plan.
Essence of care (2010) : Benchmarks for Food and Drink
Agreed patient-focused outcome: Patients are enabled to consume food and drink (orally) which meets their needs and preferences
Factor Benchmark of best practice
1 Promoting health People are encouraged to eat and drink in a way that promotes health
2 Information People and carers have sufficient information to enable them to obtain food and drink
3 Availability People can access food and drink at any time according to their needs and preferences
4 Provision People are provide with food and drink that meets their individual needs and preferences
5 Presentation People’s food and drink is presented in a way that is appealing to them
6 Environment People feel the environment is conducive to eating and drinking
7 Screening and assessment
People who are screened on initial contact and identified at risk receive a full nutritional assessment
8 Planning, implementation, evaluation and revision of care
People’s care is planned, implemented, continuously evaluated and revised to meet individual needs and preferences for food and drink
9 Assistance People receive the care and assistance they require
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with eating and drinking
10 Monitoring People’s food and drink intake is monitored and recorded
NHS Kidney Care Hydration Matters (2012 )
Correct hydration saves lives. Monitoring fluid status is essential basic care for all patients. Making sure that patients are adequately hydrated is one of the most important things that healthcare professionals can do to help prevent acute kidney injury (AKI).
Top tips for hospital health professionals
Encourage patients to drink small amounts of water regularly throughout the day, particularly those worried about incontinence issues.
Assist patients by ensuring that they can reach - and lift - their cup or glass.
Refresh water jugs regularly so that water is always available and appealing.
Associate fluid intake with specific moments, such as meal times and medication rounds, to ensure patients are drinking enough.
Identify patients at particular risk of poor hydration.
Monitor the hydration status of patients by using fluid charts.
Review hydration status as a routine part of ward rounds and handovers.
Council of Europe Resolution: Food and Nutritional Care in Hospitals (2003 )
10 Key Characteristics of good nutritional care in hospitals
1 All patients are screened on admission to identify the patients who are malnourished or at risk of becoming malnourished. All patients are re-screened weekly.
2 All patients have a care plan, which identifies their nutritional care needs and how they are to be met.
3 The hospital includes specific guidance on food services and nutritional care in its Clinical Governance arrangements.
4 Patients are involved in the planning and monitoring arrangements for food service provision.
5 The ward implements Protected Mealtimes to provide an environment conducive to patients enjoying and being able to eat their food.
6 All staff have the appropriate skills and competencies needed to ensure that patient’s nutritional needs are met. All staff receive regular training on nutritional care and management.
7 Hospital facilities are designed to be flexible and patient centred with the aim of providing and delivering an excellent experience of food service and nutritional care 24 hours a day, every day.
8 The hospital has a policy for food service and nutritional care which is patient
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centred and performance managed in line with home country governance frameworks.
9 Food service and nutritional care is delivered to the patient safely
10 The hospital supports a multi-disciplinary approach to nutritional care and values the contribution of all staff groups working in partnership with patients and users
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CHART 1 - FLOW CHART FOR NUTRITIONAL CARE OF PATIENTS IN HOSPITAL
Nutritional Care Profile
Patient Admitted to Hospital
Nutritional Screening within 24 hours of Admission using ‘MUST’ (not paediatrics )
Nutritional Risk Low,medium (M),high(H)
low Yes M or H
Gastro intestinal tract functioning Normal food and Hydration (and monitoring
of food and fluid intake where appropriate)
Yes
Texture Modified diet
Special diet if required
Follow ward policy if assistance at mealtimes is required
Parenteral Nutrition
Yes Normal food and hydration + additional
snacks and oral nutritional supplements as required, to meet nutritional needs. Cautious approach with introduction of food in high risk patients. See Practical Guide to Nutrition Support for Adults for further guidance.
Refer to ‘MUST’ management guidelines to determine level of intervention,monitoring arrangements and appropriate referral to dietitian.
Enteral Nutrition
Able to swallow
Yes
Able to tolerate oral nutrition
Central line Peripheral line
No
PEG NG NJ
SALT /medical staff assessment
Liaison with dietitian and ward staff re appropriate method of feeding
Regular review to check that appropriate feeding method is used
Medical team to address hydration
Regular review of GI Function
PICC
Regular review of ability to tolerate oral nutrition
No
No
other
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For all patients the Trust adheres to Standards relating to the Nutritional Care of patients in hospital and these include:-
respecting the need to Protect Mealtimes and minimise unnecessary interruptions at this time
ensuring that patients who require help during the day with food and drink are given that help
striving to ensure that patients have a pleasant environment in which to eat their meals
