IMPLEMENTATION AND MONITORING OF STANDARDS FOR NUTRITIONAL SUPPORT.

Dr Alastair McKinlayAberdeen Royal Infirmary

Standards versus guidelines.

Guidelines provide guidance.

Do not have to be followed.

"Guidelines are not tramlines."

Can be aspirational.May incorporate new thinking.

Should have a structured approach to evidence.

The quality of evidence is not always guaranteed.Evidence should be graded.The best evidence base for nutrition and nutritional care remains NICE. (CG32)

NICE Guidance

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account......

It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual,.......in consultation with them and their families and carers or guardian.

Standards are different.

Standards define an expected performance.

They are usually intended to be compulsory.They inevitably become a framework against which performance is judged.

Some aspect of inspection or review of compliance is usually required.

In Scotland we have had nutritional care standards since 2003.

2003: Food, Fluid and Nutritional care in Hospitals.Supported by an implementation plan.

Inspection.

Inspection of all Health Boards by a multidisciplinary team,

Including Lay Members.Evidence from visits to individual wardsMinutes of Board Meetings

Review of policies and standard operating Procedures. Results very mixed

Outcome: 2006

Some Boards quite advanced.Others barely started.

What was achieved?

2007 -2010Paul Martin and Ros Moore, Chief Nursing Officers took ownership.

Significant input of resource.

Nutritional champions in all Boards.

2011: Revisited and substantial progress.

Food in Hospitals

First published in 2008.Revised 2016National catering specification and database.

The issue of change management.

Large scale visits very expensive.Were they producing a lasting change?

Familiar with last minute preparations for a visit.Use of soft money to put temporary services in place.

Temporary or Permanent Results?

A new fashion.

Change Science.Short cycle improvement projects.Tests of changeMany directed at local levels and wards

National Level

National Nutritional Care Advisory Board.

FFNC standards revised 2014Expanded to include all NHS settings

Agreed an need for standards for Complex Nutritional care.

Published in 2016.Have been available for use in Older People in Acute Hospitals visits.

Very little evidence that it has been cited.

Complex Care Standards

Standard 1: Policy and strategy

Each NHS board’s strategic hydration and nutritional care group, as defined in the Food, Fluid and Nutritional Care Standards, is responsible for ensuring that systems are in place, which ensure that patients who require complex nutritional care are safely and effectively managed

Remind Chief Execs?

Complex Care Standards

Standard 2: Assessment and plan of care

Each NHS board ensures patients considered for complex nutritional care have a multidisciplinary assessment.

Share how we do it?Electronic patient record

Complex Care Standards

Standard 3: Enteral tube feeding

Each NHS board ensures the safe and effective delivery of enteral tube feeding.

Patient Safety?

Complex Care Standards

Standard 4: Parenteral nutrition

Each NHS board ensures the safe and effective delivery of parenteral nutrition.

Safety and Networking.Could we deliver a Voluntary National policy?

Complex Care Standards

Standard 5: Supporting patients

Each NHS board ensures patients are informed, involved and supported in all stages of their care.

Realistic Medicine

Complex Care Standards

Standard 6: Staff education and training

Each NHS board ensures staff have the knowledge, skills and experience to deliver complex nutritional care safely and effectively.

Work with NES?

Where are we now?

We have the necessary tools.We do not have a Quality Improvement Organisations that wants to use them.Nutritional care has been seen in Scotland as a predominantly nursing issue.It is not seen as a medical issueHas not been incorporated into the Patient Safely Program.

Why?

Where do we go next?

Not all doom and gloom!

The standards are still there.Listed on NHS QlS website.

Still active.

The nutrition community is still very active.

Long history of networkingWillingness to share.

BAPEN (Scotland) still active.

Core of motivated people.

Many hospitals are using 'MUST.'

Still have a network of nutrition teams.

We have not been limited in our activities

Prevalence of Parenteral Nutrition in some areas is approaching 70/100000..

Realistic Medicine

Acceptance by Scottish Government that we need to do things differently.

Empowering individual patients.Keeping people in their own homes.Safe and effective practice

How can we further reduce the burden and harm that patients experience from over-investigation and overtreatment? How can we reduce unwarranted variation in clinical practice to achieve optimal outcomes for patients? How can we ensure value for public money and prevent waste? How can people (as patients) and professionals combine their expertise to share clinical decisions that focus on outcomes that matter to individuals? How can we work to improve further the patient- doctor relationship?

How can we better identify and manage clinical risk? How can all doctors release their creativity and become innovators improving outcomes for people they provide care for?

Renew our vision

Work with nonGovernment agencies

Old ageAge UKHelp the Aged

Cancer charities.Marie CurieMacmillan

Paediatric charities

Focus on Patient safety

Pressure SoresHighlight risks of poornutritional support

NG tubesPEGsLine care

Re-examine costs.

BAPEN and other economicanalyses.

Summary.

At present there is no centrally coordinated initiative to improve nutrition.The Standards are there, we are expected to comply.Renew our vision.Focus on key Government priorities

Patient safetyRealistic medicineValue for money

Remember our history.