Nutrition Protocol

This Protocol has been developed by multidisciplinary staff at the Christie Hospital

GUIDELINES
•All patients will have a nutritional assessment carried out on admission, the nutritional assessment form will then be kept at the end of the bed with the patients care plans.
•The form should be used for one admission only.
•Referrals will be made at the discretion of the registered nurse, although a score of 15 on the nutritional assessment form indicates referral to the dietitian, this may not always be appropriate e.g. if the patient is receiving palliative care. It may also be necessary to refer a patient with a score lower than 15.
•Initial assessment on each admission must be carried out by a registered nurse, ongoing assessment may be undertaken by an unregistered member of staff who has received appropriate training, although overall accountability rests with the registered nurse. If undertaken by an unregistered nurse, a countersignature will be required.

STANDARD NUTRITION PROTOCOL

•All patients will have a nutritional assessment undertaken on admission by a registered practitioner to identify their nutritional requirements and the advice/care required to maintain or promote their nutritional status.
•Ongoing assessment may be undertaken by a registered practitioner or unregistered staff who has received the necessary training. Overall accountability lies with the registered practitioner.
•Patients/carers will be offered the opportunity to be involved in the planning, implementation and evaluation of nutritional care, to encourage promotion of their own nutritional health and expression of individual preferences.
•All patients with a nutritional assessment score of over 15 will be referred to the Dietitian. (See guidelines on page 1 for possible exceptions)
•The nutritional care provided should be given according to the nutritional assessment score. All patients will continue to have their nutritional state monitored according to the nutritional assessment guidelines (minimum of once a week).
•All staff must follow food safety guidelines as laid down by Christie Hospital N.H.S Trust.
•The environment should be conducive to patient eating and take into account
cultural/ethnic and specific needs

INTRODUCTION

This protocol is to be used in conjunction with the Christie Hospital Nutrition Standard, Nutrition Policy, Nutritional Assessment Form and Care Plan, and other relevant care plans.

Nutrition is an essential part of patient care that is often taken for granted. For the majority of people nutritional needs are met by an adequate diet. However, some patients are unable to meet their requirements. Nutritional support is therefore necessary and a well organised multi-disciplinary team approach is essential to ensure that it is effective.

Nutritional Assessment and Care Planning

•All patients should have a nutritional assessment undertaken by a registered practitioner on admission This should then be recorded on the nutritional assessment form, and the patient reassessed on a regular basis (minimum weekly).
•If the total score on assessment is 0-5, no action is required but a nutritional assessment should be continued weekly.
•If the total score on the nutritional assessment is over 5, the nutritional care plan should be initiated.
•If the total score is 5-10, provide the patient with the copy of ‘eating to help yourself’ and encourage the patient to eat more or take a fortified diet and nourishing drinks, if they are able to eat/drink/tolerate (see section 1.51 of Nutrition Policy File). Repeat nutritional assessment weekly. There is no need to refer to the dietitian at this stage.
•If the total score is 10-15, provide the patient with a copy of ‘eating to help yourself’, encourage nutritional supplements (see section 2 of Nutrition Policy File). Nutritional assessment should be carried out twice weekly. No need to refer to dietitian at this stage
•If total score is over 15, the patient should be referred to the dietitian and other members of the multi-disciplinary team as required and commence the advised nutritional support (see sections 3 and 4 of the Nutrition Policy File for enteral and parenteral feeding). Repeat nutritional assessment twice weekly.
•If nutritional score above 10 commence on food intake chart for 3 days. Recording a patient’s actual intake on a food intake chart can be useful to assess whether their requirements are being met through normal meals or whether nutritional support is necessary. It can also highlight a need for consistency changes i.e. soft texture, liquidised meals or fluids only. This can be undertaken by a registered practitioner or unregistered staff who have received the necessary training. Again overall accountability lies with the registered practitioner.

ENVIRONMENT
•The environment should be conducive to patient eating.
•Where appropriate a dining room or table should be used, if not ensure the patient is well positioned to eat.
•Cultural/ethnic and specific needs must be taken into account
•All attempts should be made to avoid sounds, sights and smells that may be unacceptable to patients whilst eating.
•Food will be served from a trolley and patients who are able to will walk to the trolley and choose their meal. All patients should be made aware of this and the usual ward routine at mealtimes on admission.
•The ward waiter/waitress, where available will be responsible for setting up the trolley and ensuring items are served at the correct temperature.
•A nurse should be available at mealtimes to advise on patients requiring special diets or portion sizes or any other requirements.(Special diets should be pre-ordered by the ward staff)
•It is the responsibility of all staff giving out meals to ensure that the food is well presented and cutlery and crockery in good condition.
•The nurse should ensure that patients who may have difficulty walking to the trolley are provided with a meal, and also patients who are in side rooms have meals (waiter/waitress will not go into side-rooms except on Nathan House and A.L.U. where all patients are in individual rooms.
•Patients may need further assistance with eating and drinking and this can be provided by all members of the nursing team. Where possible the patient should be re- educated to feed themselves. This should be done in collaboration with the multi-disciplinary team, the patient and the carer where appropriate.

FOOD SAFETY
•The past 20 years have seen a rise in the number of cases of food poisoning, with campylobacter sp. overtaking salmonella sp. as the principal cause of bacterial gastro-enteritis. All food contains micro-organisms and it is only by careful handling, cooking and storage that food poisoning can be prevented.
•Hospital patients are especially vulnerable to the effects of food poisoning due to immunosupression caused by the therapies received and the effects of the illness itself.
•Hospitals are expected to comply with the same food safety legislation as any public caring establishment.
•Patients should be advised on the risks of food poisoning and their prevention as outlined in the “food safety” booklet (M.A.F.F., 1992)
•Patients food from home.
Wherever possible patients should be discouraged from bringing food that requires refrigeration. Under no circumstances should patients be allowed to bring food from home that requires keeping warm. Only under exceptional circumstances can food brought in by patients or their families that require refrigeration be permitted. This should be covered and clearly labelled with the patients name and dated. Patients must be advised of these conditions when admitted to hospital.

•If the food is not eaten 5 days after storage or has passed its used by date it must be discarded into the bin. Once opened, it should be discarded after 48 hours. The patient must be informed of this.
•Certain food products carry a higher risk of bacterial contamination and patients should be advised to avoid these whilst receiving treatment, e.g. raw/ undercooked eggs and meat; any pate, soft or blue-veined cheeses; unpasteurised milk products and any unwashed fruit, vegetables or salad.
•Patients should be strongly advised not to consume take-aways whilst in hospital.
•Additional food safety dietary advice is required for those patients with leukaemia or undergoing stem cell/bone marrow transplantation and this can be found in the ALU Patient Handbook.

ROLES AND RESPONSIBILITIES
•The registered practitioner must undertake the initial assessment of the patient on admission. Ongoing assessment and score may then be undertaken by the registered practitioner or unregistered staff who have received the appropriate training, but overall accountability lies with the registered practitioner.
•The registered practitioner refers the patient to appropriate members of the multi-disciplinary team, and involves patient/ carers and members of the multi-disciplinary team in the planning, intervention and evaluation of patient care.
•The registered practitioner ensures that the care plan is individualised and continuously updated to accurately reflect ongoing nutritional requirements.
•The registered practitioner should ensure any patients requiring special diets are provided with them.
•Food intake charts can be completed by registered/ unregistered practitioners, patients or carers, however overall responsibility lies with the registered practitioner.
•All staff are responsible for ensuring all patients are provided with a meal.
•All staff are responsible for ensuring all patients are given the assistance they require.
•All staff handling food are responsible for food safety/hygiene.
•All staff should ensure food is well presented and cutlery and crockery is in good condition.
•All staff have a responsibility to ensure the environment is conducive to patient eating and takes into account cultural/ethnic and specific needs.

RATIONALE

Malnutrition
A study of 500 new patients admitted to a U.K. hospital demonstrated that 40% of patients were malnourished on admission and that two thirds of those who were reassessed on discharge had lost weight during their stay.(McWhirther and Pennington 1994)

Malnutrition is defined as a wasting condition resulting from a deficiency in energy(calories) and protein. It has long been recognised that patients who are malnourished take longer to recover from surgery or illness and have higher mortality rates (Hill et al 1977). It is also associated with an increase in cost (Robinson et al 1987, Reily et al 1988).

One of the major causes of malnutrition is an inadequate food intake. It is important to remember that patients can become malnourished without appearing underweight. However, the weighing of patients is one of the most effective indicators.
•Some patients may be unable to eat anything at all. Other patients might be unable to eat sufficient food to meet dietary requirements, e.g.
*Chewing and swallowing difficulties
*Sore mouth/throat
*Anorexia
*Nausea

Patients in either group may have increased requirements for nutrients due to increased metabolic rate, e.g. major sepsis, trauma, surgery and cancer cachexia.
Protein and energy malnutrition results in wasting of body protein and fat stores in order to be metabolised as fuel. The process is known as catabolism.

•The effects of this depletion are summarised below:
Skeletal muscle mass is lost reducing muscular strength and activity levels. This in turn increases the risk of thrombo- embolism and pressure sores.

•Thoracic muscle depletion reduces muscular strength depressing respiratory rates and increasing the risk of chest infections.
•Visceral proteins (e.g. Albumin) become depleted, with increased risk of oedema.
•Protein depletion impairs nearly every aspect of the immune response reducing the ability to fight infections.
•Gut atrophy reduces the ability of the gut to absorb nutrients.
•An increase in toxicities to chemotherapy.
•Prolonged recovery time e.g. post-operative wound breakdown and impaired wound healing.
•Reduced mental state leading to apathy and depression

Assessment

Norton (1996) discussed the importance of ensuring that patients are nutritionally assessed. The Chief Nursing Officer, Department of Health, England initiated the production of a comprehensive resource pack, “Eating Matters” (Bond 1997), as a result of concern at national level that the nutritional needs of patients in hospital are not always addressed. This concern includes recognition that methods of assessment need to be improved. National benchmarking initiatives are currently being introduced in relation to this most fundamental aspect of nursing care.

Bloch (2000) pointed out that, ‘Oncology nurses are in a key position to provide support to patients and families with regard to nutritional issues. Of paramount importance is their contribution to ongoing assessment of nutritional status and early intervention to meet nutritional needs.’

After reviewing the literature, Cunningham and Bell (2000) recommend that every patient should have an early and periodic assessment of nutritional status so that nutritional therapy when indicated can be iniated early.

Nutritional support

Many clinical studies have generated conclusive findings regarding benefits of nutritional support for a wide range of hospital patients.
•Rana et al, 1992, found that patients undergoing gastrointestinal surgery when given nutritional supplements had a significantly lower incidence of serious complications (e.g. pneumonia, wound infections) in comparison to a non-supplemented group.
•Keele et al, 1997, showed in a follow up to the Rana study that supplemented patients maintained their hand grip strength and had significantly less complications in comparison to the control group.
•Larsson et al, 1990, revealed that medical geriatric patients receiving nutritional supplementation either maintained or improved their nutritional status and had a reduced mortality rate.

REFERENCES

Bloch, A. (2000) Nutrition Support in Cancer, Seminars in Oncology Nursing, 16, 2, 122-127.

Bond, S. (1997) Eating Matters, Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne.

Cunningham, R.S., Bell, R. (2000) Nutrition in Cancer: An Overview, Seminars in Oncology Nursing, 16, 2, 90-98.

Hill, G.L., Blackell, R.L., Pickford, I. Et al (1977) Malnutrition in Surgical Patients: an unrecognised problem, Lancet, 1, 689-692.

Keele, A.M., et al. (1997) Two phase randomised controlled clinical trial of post-operative Oral Dietery Supplements in Surgical Patients. Gut, 40 (3), 393-399.

McWhirther, J.P., Pennington, C.R., (1994) Incidence and recognition of malnutrition in hospital, British Medical Journal, 308, 945-948.

Norton, B. (1996) Nutritional Assessment, Nursing Times, 92, (26), 71-79.

Rana, S.K., Bray, J., Menzies- Gow, N., Jameson, J., Payne- James,J.J., Frost, P., Silk, D.B.A. (1992) Short Term Benefits of Post-Operative Oral Dietary Supplements in Surgical Patients, Clinical Nutrition, 11, 337-344.

Reily, J.R., Hull, S.F., Albert, N. et al (1988) Economic impact of malnutrition: a meal system for hospitalised patients, Journal of Parenteral and Enteral Nutrition, 12, 371-376.

Robinson, G., Goldstein, M., Levine, G.M. (1987) Impact of Nutritional Status of D.R.G. Length of Stay, Journal of Parenteral and Enteral Nutrition, 11, 49-51.