Nutrition Policy BHT Pol 112 Version 4 June 2018

NUTRITION POLICY Version 4.0

Once printed off, this is an uncontrolled document. Please check the intranet for the

most up to date copy.

Version: 4

Approved by: Nursing, Midwifery and Therapy Professional Board

Date approved: 24th April 2018

Ratified by: Executive Management Committee

Date ratified: 25th May 2018

Author: Liz Pryke, Head of Nutrition & Dietetics Liz Anderson, Nutrition Nurse Specialist

Lead Director Carolyn Morrice, Chief Nurse

Name of Responsible Individual/Committee: Nutrition Steering Committee

BHT Document reference: BHT Pol 112

Date Issued: June 2018

Review Date: June 2021

Target audience: All clinical staff

Location

Equality Impact Assessment 24.4.18

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Document History Nutrition Policy

Version Issue Reason for change Authorising body Date

1 0 New policy Nursing and Midwifery Board 17th March 2008

March 2008

2 0 Nursing and Midwifery Board 17th March 2008

March 2008

3 0 Risk Monitoring Group 21st February 2011

February 2011

4 0 Updated policy Nursing, Midwifery & Therapy Board 23rd April 2018

April 2018

Associated documents

BHT Ref Title Location/Link

Guideline 65 Identifying Adult Patients at Risk of Under Nutrition and Dehydration

http://swanlive/sites/default/files/guideline_65.pdf

Guideline 209 Adult Parenteral Nutrition http://swanlive/sites/default/files/guideline_209.pdf

BHT Pol 111 Protected Mealtimes Policy http://swanlive/sites/default/files/bht_pol_111_v1.2_rvw_12_2017.pdf

Guideline 276 Refeeding Syndrome http://swanlive/sites/default/files/guideline_276.pdf

Guideline 298 Adult Enteral Tube Feeding http://swanlive/sites/default/files/guideline_298.pdf

Guideline 689 Adult Oral Nutritional Support http://swanlive/sites/default/files/guideline_689.pdf

Strategy S033 Food and Drink Strategy http://swanlive/sites/default/files/bht_s033_food_and_drink_strategy_v1.0_rvw_05_2019.pdf

Guideline 389 Weighing and Measuring Neonates, Infants and

Children

http://swanlive/sites/default/files/guideline_389.pdf

Guideline 815 Palliative Feeding for Comfort http://swanlive/sites/default/files/guideline_815.pdf

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Contents

Section No

Title Page No

1 Introduction 4

2 Organisational Responsibilities 4

3 On Admission 5

4 During Hospital Stay 6

5 Catering Service 7

6 Education 8

7 Discharge Process 8

8 End of Life 9

9 Monitoring Effectiveness of the Policy 9

10 Consultation and Ratification 9

11 References 10

Appendices

Appendix A Nutrition Committee Terms of Reference 11

Appendix B Malnutrition Universal Screening Tool (MUST) 13

Appendix C Spinal Nutritional Screening Tool (SNST) 15

Appendix D Screening Tool for Assessment of Malnutrition in Paediatrics (STAMP) 16

Appendix E Royal Marsden Nutritional Screening Tool 17

Appendix F Ward Food and Drink Record Chart 19

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1. Introduction

Malnutrition costs the UK health economy more than £19 billion a year and affects one in four people admitted to care settings (Elias 2015). It is most prevalent in the community, but nutritional status often deteriorates when patients are admitted to hospital because of acute injury or illness that can impair swallowing, appetite and gastric absorption. People in the community with long term health conditions such as chronic obstructive pulmonary disease (COPD), stroke and other neurological disorders are also at a heightened risk of malnutrition

due to the impact of their illness on ability to take in food and fluid (Anderson 2017). The Hospital Food Standards Panel Report (Department of Health 2014) recommends that all NHS hospitals adhere to and be compliant with the Ten Key Characteristics of Good Nutritional Care (Council of Europe, 2003); this includes ensuring an environment that is conducive to patients being able to enjoy their meals uninterrupted. Good nutrition and hydration is part of the Care Quality Commission’s Fundamental Standards (CQC, 2015) and all care settings are expected to demonstrate how they put nutrition and hydration at the heart of patient care.

The consequences of malnutrition include vulnerability to infection, delayed wound healing,

impaired function of heart and lungs, decreased muscle strength, depression and ultimately

premature death (Elias and Russell 2009).

It is therefore important that those who are malnourished or at risk are identified early, as

patients with malnutrition stay in hospital for much longer, are 3 times as likely to develop

complications after surgery, and have higher a mortality rate (Leach et al 2013).

BAPEN’s nutritional screening weeks have clearly demonstrated that malnutrition is a significant public health issue which must be addressed in the community – where it starts [BAPEN 2011]. Nutritional care is a multi-disciplinary responsibility and the Trust supports the contribution of all staff groups. This policy has been developed to try and ensure that all patients have their nutritional

requirements recognised and met.

It also important to promote healthy eating for some patients, staff and visitors, and, for those who eat in staff restaurants, a variety of healthier eating choices should be available (Department of Health 2014). 2. Organisational Responsibilities

The Trust will have a Nutrition Steering Committee that reports to the Nursing, Midwifery and Therapy Professional Board [Appendix 1 – Nutrition Steering Committee Terms of Reference].

The Trust will have a Nutrition Support Team, the team will comprise Specialist Pharmacist, Specialist Dietitian, Nutrition Nurse Specialist and Consultant.

All inpatient units will have a Nutrition Link Practitioner and there will be a Nutritional Lead for the community integrated team, who will attend regular Nutrition Link Practitioner Meetings [chaired by the Nutrition Nurse Specialist] and be responsible for disseminating information back to their ward/work area.

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3. On Admission

a) Nutritional Screening

All adult inpatients will be nutritionally screened within 24 hours of admission and paediatric inpatients screened within 48 hours of admission, to try and identify those who are or are at risk of becoming malnourished [NICE 2006/Department of Health 2014).

Screening tools used:

o Adult patients - MUST [Malnutrition Universal Screening Tool - Appendix B]

o Adult patients with spinal injuries - SNST [Spinal Nutritional Screening Tool – electronic tool on Spinal IMS – Appendix C]

o Paediatric patients (Ward 3 and St Francis) - STAMP [Screening Tool for the Assessment of Paediatrics - Appendix D]

o Oncology outpatients – Royal Marsden Nutritional Screening Tool – Appendix E

All community patients will be nutritionally screened using MUST and have a Waterlow Assessment completed at first assessment on admission to the caseload. If they have a MUST of 1 or 2, then the appropriate action plan should be followed.

Palliative care patients will be individually assessed and individualised care plans will be developed.

The majority of maternity patients who are in hospital for a short length of time are not nutritionally at risk; therefore they will be nutritionally screened at the direction of clinical staff.

All patients in critical care will be nutritionally assessed by a Dietitian.

Details of nutritional screening and action plans should be documented in the individual patient’s clinical notes or patient held documentation in the community.

All patients should be weighed on admission and have their height recorded. If this is not possible the reason why should be documented in the patient’s notes.

A patient specific care plan will be written, implemented and monitored by nursing staff.

Community patients may require the assistance of carers or family for meal preparation and feeding, and individualised care plans should be negotiated with the patient and their carer or family.

Appropriately trained professionals will carry out nutritional screening. It is the responsibility of the ward manager or case manager to decide who has the responsibility for screening and ensure they are appropriately trained.

Suitable equipment for measuring weight will be available in all inpatient clinical areas. If weight and height cannot be reliably measured, alternative measurements or a subjective score can be used.

If a patient is at risk of refeeding syndrome they should be discussed with the ward Dietitian and Trust guidelines followed [see Guideline 276].

Inpatients will be re-screened weekly or sooner if the patient’s condition changes. Community patients will be rescreened according to MUST guidelines or sooner if the patient's condition changes.

Children: All children will be weighed on admission and weekly thereafter. This will be interpreted by a doctor, nurse or Dietitian [see Guideline 389 Weighing and Measuring Neonates, Infants and Children].

Vulnerable adults: Any adult who is considered at risk from poor nutrition, for

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example those with learning, physical or sensory disability or those who suffer from depression or any type of dementia, should be screened on admission and if necessary be referred to the appropriate MDT member. An appropriate plan of care should be drawn up for them and consultation should be sought from the patient and carer. Meals should not be selected for these patients without their input – every effort should be made to find out their likes and dislikes and menus chosen by them accordingly. Patients with on specialist dementia wards will be reviewed regularly by the ward Dietitian and speech therapist

Patients attending the day units will be nutritionally screened on their first visit and then if their condition changes.

Patients attending chemotherapy units will be nutritionally screened on their first visit and then if their condition changes.

All patients attending outpatient clinics will be weighed [specific clinics may excluded from this, as agreed by Nutrition Committee]. Children attending outpatient clinics will have their weight and height recorded.

b) Referral

All adult patients requiring parenteral nutrition should be referred to the Nutrition Support Team for initial assessment and advice [Guideline 209 Adult Parenteral Nutrition].

All patients requiring enteral nutrition should be referred to the Dietitian on weekdays (starter NG regimens are available in ward nutrition folders/intranet for out-of-hours) [Guideline 298 Adult Enteral Tube Feeding]. For community hospital and community patients established on enteral feeding, a community Dietitian will be available to advise and support patients and carers.

Patients with symptoms of neurological dysphagia or swallowing difficulties should be referred to the Speech and Language Therapy team.

For all patients who are at risk of refeeding syndrome follow Trust guidelines [Guideline 276 Refeeding Syndrome] and discuss with ward Dietitian.

Those patients requiring referral to a Dietitian should be referred using the

appropriate acute or community dietetic referral form and a nutritional screening tool score should be included on the referral [MUST, SNST or STAMP]. Any member of the multi-disciplinary team can make a referral.

Any patients with complex feeding issues such as difficult to place NG tubes, blocked enteral feeding tubes, or cases where there are ethical or clinical concerns about a patient’s nutritional care should be referred to the Nutrition Nurse Specialist.

For all inpatients who require a special therapeutic/ethnic diet, ward staff should contact their identified catering department (this will vary between sites, it may be the Helpdesk, catering department or catering staff at ward level). If the patient is following a complicated therapeutic diet or requires education please also refer for dietetic advice. Patients requiring education on weight management may be seen as an outpatient.

4. During Hospital Stay

Ward staff will be responsible for ensuring that a meal has been ordered for every patient that is eating.

All staff – clinical and non-clinical should be aware of and adhere to Protected Mealtimes in Hospitals Policy (BHT Pol 111).

Ward staff will be responsible for ensuring that the patient is ready for their meal

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[immediate area clear, hand wipes available, position of patient etc.].

Hand wipes will be provided to assist patients with hand hygiene prior to eating.

Adequate numbers of appropriately trained staff must be available at mealtimes to ensure patients who require help with eating and drinking receive sufficient assistance.

Nursing staff should ensure that patients who require a special therapeutic diet are served with appropriate food/fluids.

Nursing staff should ensure that all ward and domestic staff involved in serving food/drinks to patients are aware of patients who require special therapeutic diets.

Patients should be helped whilst their meals are hot and appetising.

Patients who require support with eating and drinking should be clearly identified, e.g. red tableware system – see Guideline 65 Identifying Patients at Risk of Under Nutrition and Dehydration.

Patients who require food and/or fluid intake to be monitored must have informative, accurate and up-to-date food/fluid charts kept [Trust Food Record Chart - Appendix F].

Ward staff should ensure that patients are provided with suitable aids to facilitate independent feeding [e.g. special cutlery, plates].

Patients should be offered a replacement meal if they miss their meal for any reason and can access snacks at ward level.

Every effort should be made to ensure that patients are able to enjoy their meal with dignity and privacy.

In the home:

o Where patients are unable to self-manage their nutrition needs, case managers should liaise with social care and/or families to ensure that the patient's nutritional needs are met in the home.

o Advice should be given regarding food fortification and the use of aids for eating and drinking if necessary.

5. Catering Service

24 hour catering service is available and patients will have access to:

o Hot/cold drinks and light refreshments (e.g. biscuits, cereal etc.).

o Snack boxes/light bites/hot meals are available to patients who have missed a meal (this provision will vary between sites)

Daily menus for patient choice are available.

Daily meal programme will consist of:

Early morning drink

Breakfast including drink Midmorning drink and snack*

Lunch and drink

Afternoon drink and snack*

Supper and drink

Evening drink

[* snacks will be provided at least twice daily]

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Meals/snacks/drinks will meet the estimated average requirement for energy [SACN 2011] and reference nutrient intake for protein, vitamins and minerals for the nutritionally well [DH 1991] or PENG recommendations for protein nutritionally vulnerable individuals [PENG 2011].

Patients with cultural or religious dietary requirements will be catered for.

Patients who require a special therapeutic diet will be catered for.

Breastfeeding mothers who are staying with their children whilst inpatients will be supplied with sufficient food and drinks from the patient menu to support breast feeding.

Facilities should be made available which encourage parents of young children to be resident during their stay. Parental separation anxiety in children inhibits nutritional and fluid intake. Parents are also very helpful in that they know what and when their child will eat, they usually want to feed and monitor intake and will assist staff if their child is not eating/drinking enough.

Patients should receive food presented in a way that is appealing and appetising.

Patients should be involved in planning/monitoring arrangements for food service provision.

Food and drinks should be served at the correct temperature for patient preference and meet the safety standards at all times.

Suitable crockery and utensils should be available at ward level.

All staff serving or handling food and drink will receive appropriate training to do so.

All patients will have access to a full colour menu in order that they can make an informed choice.

Staff

For those who work within the Trust and eat in the restaurants on the site [where available], a variety of healthier eating options should be available to enable staff to choose a well-balanced diet (see Trust Food and Drink Strategy (S033))

6. Education

The Nutrition Nurse Specialist/Nutrition and Dietetic Department will ensure that a robust training programme is maintained throughout the Trust. This will target all nurses, other health professionals and housekeepers. This will include liaison with patient experience groups, senior nursing groups and the university to ensure that nutritional care is given the highest priority. All nutrition programmes and study days will be audited and fed back to the Nutrition Steering Committee. (NICE Guidelines 2006). 7. Discharge Process

Any special dietary requirement or nutritional risk should be part of the nursing/medical discharge summary and clearly reported to any relevant healthcare professional in the community [and carer as appropriate].

Community discharge process: If a nutritional risk remains on discharge from the caseload self-management advice or advice to carers or family should be provided.

When patients are discharged home on enteral nutrition [nasogastric/gastrostomy/jejunostomy feeds] locally agreed guidelines should be followed to ensure transition from hospital to home is managed effectively. Adequate

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notice of discharge will allow effective training and equipment for home to be arranged (See Guideline 298 Adult Enteral Feeding).

Patients discharged home on enteral nutrition [nasogastric/gastrostomy/jejunostomy feeds] will be given training suited to their needs before discharge, to allow them to manage the feed safely at home.

Patients discharged home feeding via a nasogastric tube will require special arrangements to be made by the discharging ward for care of the tube and to manage tube feeding.

Patients who are being considered for home parenteral nutrition should be referred to the Nutrition Support Team for arrangements to be made.

8. End of Life

Buckinghamshire Healthcare NHS Trust believes (as per Leadership Alliance for the Care of

Dying People 2014) that where patients at the end of their life are concerned, we have “one

chance to get it right”. To this end, we will ensure that an individual plan of care, which will

most appropriately meet the needs of the individual whilst respecting the views of the carers

and the families, will be made. When the patient is unable to make their own decisions

about their nutritional care, due to lack of mental capacity, a best interest meeting will be

held with the carers/family to discuss how the individual’s nutritional needs can be met.

(Guideline 815 Palliative Feeding for Comfort).

9. Monitoring the Effectiveness of the Policy

PLACE (Patient Led Assessments of the Care Environment) inspections.

Patient satisfaction surveys

Formal catering monitoring

Audits of nutritional screening/appropriate equipment/Red Tray/Protected Mealtimes / NG tube placement/discharge process

Feedback from patient experience groups

Breaches to be reported via incident reporting system (monitored quarterly by Nutrition Steering Committee)

Trust Quality Improvement Programme (QIP)

Perfect Ward app

10. Consultation and Ratification

The consultation for this Policy will include:

Members of the Nutrition Steering Committee

Members of Nursing, Midwifery and Therapy Professional Board

Matrons

Managers (including departmental managers which may be affected – such as Speech and Language Therapy/Nutrition and Dietetics/Infection Control)

Property Services/Catering

Patient Experience Group

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11. References

Anderson L (2017) Assisting patients with eating and drinking to prevent malnutrition. Nursing Times Vol113 Issue 11 pp 23-25

BAPEN (2011) Nutrition screening survey in the UK and Republic of Ireland in 2010

British Dietetic Association (BDA) (2017) The Nutrition and Hydration Digest:

Care Quality Commission (2015). The Fundamental Standards. Meeting nutritional and hydration needs. http://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-14-meeting-nutritional-hydration-needs

Council of Europe Resolution on Food and Nutritional Care in Hospitals [Nov 2003]

Department of Health (1991) Committee on medical aspects of food policy (COMA). Dietary Reference Values

Department of Health (2014). The Hospital Food Standards Panel’s report on standards for food and drink in NHS Hospitals https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/523049/Hospital_Food_Panel_May_2016.pdf

Elias (2015) The cost of malnutrition in England and potential cost savings from nutritional interventions (short version). On behalf of the Malnutrition Action Group of BAPEN and the National Institute for Health Research Southampton Biomedical Research Centre. http://www.bapen.org.uk/pdfs/economic-report-short.pdf

Leach RM et al (2013) Nutrition and fluid balance must be taken seriously. British Medical Journal; 346: 801.

Leadership Alliance for the Care of Dying People (2014) One Chance to Get it Right https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/323188/One_chance_to_get_it_right.pdf

National Institute for Health and Care Excellence (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Clinical Guidelines 32. Bit.ly/NICENutrition2006

NPSA (2009) 10 Key Characteristics of good nutritional and hydration care

PENG (2011) Parenteral and Enteral Group of the BDA.

Russell C A, Elia M (2008) Nutrition screening survey in the UK in 2007, BAPEN

Russell C A, Elia M (2009) Nutrition screening survey in the UK in 2008 BAPEN

SACN (2011) Dietary Reference Values for Energy. PHE

Spinal Nutrition Screening Tool: http://swanlive/sites/default/files/nutrition_care_plans_how_to.pdf

Appendix A: Nutrition Steering Committee – Terms of Reference Appendix B: Malnutrition Universal Screening Tool (MUST) and Action Plans WZZ1072 Appendix C: Spinal Screening Tool (SNST) Appendix D: Screening Tool for Assessment of malnutrition in Paediatrics (STAMP) Appendix E: Royal Marsden Nutritional Screening Tool Appendix F: Ward Food and Drink Record Chart WZZ 1570

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Appendix A

Adult Nutrition Steering Committee

Terms of Reference

1. Name of Group

The Nutrition Steering Committee is a sub-committee of the Nursing, Midwifery and Therapy Professional Board.

For matters relating to the nutrition products on the Bucks Formulary and guidelines describing them, the Nutrition Steering Committee also acts as a subgroup of the Bucks Formulary Management Group (FMG)

2. Purpose of Committee

As per NICE (2006) and BAPEN (2010) it is desirable for all Trusts to have a Nutrition Steering Committee whose purpose it is to provide professional guidance on nutritional issues which are relevant to the Trust and wider community. 3. Key Tasks

3.1 To develop the Trust’s Nutrition Policy, Trust’s Food and Drink Strategy and Action Plan

3.2 To monitor and support the implementation of the Nutrition Policy and Food and Drink Strategy.

3.3 To provide a forum for raising the profile of nutrition within the Trust

3.4 To discuss and, where appropriate, implement national nutritional priorities and guidelines (including NICE guidelines)

3.5 To support educational and continued professional development in nutrition to all grades of staff.

3.6 To make decisions about the choice of nutrition products to be included in the Bucks Formulary. This includes:

Reviewing evidence of efficacy, safety, cost impact and convenience of new and existing nutrition formulary products in order to make decisions.

Giving due consideration of the importance of choosing products which promote seamless care across primary and secondary care (if this is appropriate).

3.7 To review and agree guidelines, care pathways and shared care protocols relating to nutrition / effective use of nutrition products.

3.8 To investigate any incident reports related to provision of nutrition in the Trust.

3.9 To facilitate and monitor the nutritional content and quality of meals supplied to the Trust.

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4. Membership

Membership is open to representatives from the following areas:

Consultant Gastroenterologist (Chair)

Consultant Surgeon

Dietetics – acute, community, Bucks CCG

Property Services – representing trust catering

Medicine Management (Bucks CCG’s)

Nursing – Matron from each division.

Nutrition Specialist Nurse

PALS (representing patients)

Pharmacy - BHT

Speech and Language Therapy

5. Frequency of Meetings

The Nutrition Steering Committee shall meet quarterly, alternating between Stoke Mandeville and Wycombe Hospital sites.

6. Quorum

A quorum shall be 5 members from 3 professional groups.

If members are unable to attend they should send an appropriate deputy to attend on their behalf if possible.

Prescribing Support Dietitian (from Medicines Management, Bucks CCG) must be present at meetings where decisions are to be made regarding changes to the Bucks Formulary and joint guidelines which describe the use/place in therapy of these products.

7. Reporting Arrangements

Minutes of the meeting to be reported to Nursing, Midwifery and Therapy Professional Board and Bucks Formulary Management Group (when formulary / guideline issues are discussed). Nutrition Steering Committee decisions in this regard will be noted at each subsequent FMG meeting.

Agenda and any supporting papers to be sent out to each member of the committee one week before the date of the meeting

8. Links to other committees

Nutrition Link Nurse Meeting Catering Quality Review Group at Wycombe Domestic Service Review Group at Stoke Mandeville Food and Drink Strategy Working Group Patient Dining Group (SMH) Quality and Safety Committee April 2018 Review date: April 2020

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Appendix B Malnutrition Universal Screening Tool (MUST)

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Appendix C Spinal Nutritional Screening Tool (SNST) – click on link to access: http://swanlive/sites/default/files/finalsci_screening_tool_acutesci_dtnsapril2008.doc See also: http://swanlive/sites/default/files/nutrition_care_plans_how_to.pdf

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Appendix D Screening Tool for Assessment of Malnutrition in Paediatrics (STAMP)

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Appendix E Royal Marsden Nutritional Screening Tool

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Appendix F Ward Food and Drink Record Chart

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