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National Collaborating Centre for Acute Care (UK). Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. London: National Collaborating Centre for Acute Care (UK); 2006 Feb. (NICE Clinical Guidelines, No. 32.)

12Audit criteria

CriterionExceptionDefinition of terms
To determine the risk of malnutrition:
  • hospital inpatients are screened on admission and this is repeated weekly
  • hospital outpatients are screened at their first clinic appointment and at subsequent appointments where there is clinical concern
  • people in care homes should be screened on admission and when there is clinical concernA clear process should be established for documenting the outcomes of screening (that is, ‘nutritional risk score’) and the subsequent actions (that is, ‘nutritional care plan’) taken if the patient is recognised as malnourished or at risk of malnutrition.
Hospital departments considered to have people at low risk of malnutrition. They will have specifically opted out of screening having followed an explicit process to do so via the local clinical governance structure and involving experts in nutrition support.

Subsequent screening of people in care homes if there is no clinical concern about risk of under nutrition.
A simple screening tool should be used that includes BMI (or other estimate, for example mid-arm circumference when weight cannot be measured), percentage weight loss, and considers the time over which nutrient intake has been reduced (for example the malnutrition universal screening tool,(‘MUST’).
Examples for clinical concern; people with fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes or prolonged intercurrent illness).
Documentation in patient records that consideration has been given as to whether the patient presents with any indications for malnutrition or risk of malnutrition and a record of whether options of nutrition support have been considered for people who present with:
  • a BMI less than 18.5 kg/m2,
  • unintentional loss of greater than 10% body weight within the previous 3–6 months,
  • a BMI less than 20 kg/m2 and more than 5% unintentional body weight loss within the previous 3–6 months,
  • the patient has eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer
  • the patient has poor absorptive capacity, is catabolic and or has high nutrient losses and or have increased nutritional needs.
There should be clear documentation in patient records that patients who present with the indications for nutrition support Chapter 5 are considered for oral nutrition support as indicated in Chapter 8 and or enteral tube feeding as indicated in Chapter 9 or parenteral nutrition as indicated in Chapter 10.
There should be documentation that healthcare workers directly involved in patient care in the hospital and community settings have received training in nutrition support (relevant to their post) on:
  1. the nutritional needs and indications for nutrition support
  2. the options available for providing nutrition support (oral, enteral and parenteral, routes, mode of access, prescription)
  3. ethical and legal concepts relating to nutrition support
  4. the potential risks and benefits of the different methods of nutrition support – for example refeeding syndrome
  5. when and where to seek expert advice
Healthcare professionals who are recognised experts in the field of nutrition support as recognised within the local clinical governance structure.

Healthcare workers who are not directly involved in patient care.
This should take place at the start of their employment and there after biannually.
In patients who receive nutrition support there should be clear documentation of which health care professionals have been involved in the prescription, administration and monitoring. Records should be kept of important outcome measures such as frequency of GP visits, hospital duration, complications e.g. infections.People not prescribed nutrition support
In acute hospitals trusts the nutrition steering committee should support at least one hospital specialist nutrition support nurse who should work alongside nursing staff, dietitians and other experts in nutrition support to facilitate ongoing training of ward staff who care for people on nutrition support. A system of documenting hospital staff adherence to nutrition support protocols should be established for each patient prescribed nutrition support, along with data collection on complications related to the use of nutrition support – for example, poor tolerance of feeds or tubes, infections rate, site of infection.GP practiceNutrition Steering Committee working within the clinical Governance framework may include representatives from medical staff, dietetics, nursing, pharmacy, catering and management.
Senior managers of hospitals should maintain clear documentation of the outcomes of nutrition steering committees meetings. They should attempt to record the benefits of their work such as clinicians adherence to nutrition support protocols that have been developed and agreed by the nutrition steering committee.
To determine the risk of malnutrition:
  • hospital inpatients are screened on admission and this is repeated weekly
  • hospital outpatients are screened at their first clinic appointment and at subsequent appointments where there is clinical concern
  • people in care homes should be screened on admission and when there is clinical concernA clear process should be established for documenting the outcomes of screening (that is, ‘nutritional risk score’) and the subsequent actions (that is, ‘nutritional care plan’) taken if the patient is recognised as malnourished or at risk of malnutrition.
Hospital departments considered to have people at low risk of malnutrition. They will have specifically opted out of screening having followed an explicit process to do so via the local clinical governance structure and involving experts in nutrition support.

Subsequent screening of people in care homes if there is no clinical concern about risk of under nutrition.
A simple screening tool should be used that includes BMI (or other estimate, for example mid-arm circumference when weight cannot be measured), percentage weight loss, and considers the time over which nutrient intake has been reduced (for example the malnutrition universal screening tool,(‘MUST’).

Examples for clinical concern; people with fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes or prolonged intercurrent illness).
Documentation in patient records that consideration has been given as to whether the patient presents with any indications for malnutrition or risk of malnutrition and a record of whether options of nutrition support have been considered for people who present with:
  • a BMI less than 18.5 kg/m2,
  • unintentional loss of greater than 10% body weight within the previous 3–6 months,
  • a BMI less than 20 kg/m2 and more than 5% unintentional body weight loss within the previous 3–6 months,
  • the patient has eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer
  • the patient has poor absorptive capacity, is catabolic and or has high nutrient losses and or have increased nutritional needs.
There should be clear documentation in patient records that patients who present with the indications for nutrition support, Chapter 5, are considered for oral nutrition support as indicated in Chapter 8 and or enteral tube feeding as indicated in Chapter 9 or parenteral nutrition as indicated in Chapter 10.
There should be documentation that healthcare workers directly involved in patient care in the hospital and community settings have received training in nutrition support (relevant to their post) on:
  1. the nutritional needs and indications for nutrition support
  2. the options available for providing nutrition support (oral, enteral and parenteral, routes, mode of access, prescription)
  3. ethical and legal concepts relating to nutrition support
  4. the potential risks and benefits of the different methods of nutrition support – for example refeeding syndrome
  5. when and where to seek expert advice
Healthcare professionals who are recognised experts in the field of nutrition support as recognised within the local clinical governance structure.

Healthcare workers who are not directly involved in patient care.
This should take place at the start of their employment and thereafter biannually.
In patients who receive nutrition support there should be clear documentation of which health care professionals have been involved in the prescription, administration and monitoring. Records should be kept of important outcome measures such as frequency of GP visits, hospital duration, complications e.g. infections.People not prescribed nutrition support
In acute hospitals trusts the nutrition steering committee should support at least one hospital specialist nutrition support nurse who should work alongside nursing staff, dietitians and other experts in nutrition support to facilitate ongoing training of ward staff who care for people on nutrition support. A system of documenting hospital staff adherence to nutrition support protocols should be established for each patient prescribed nutrition support, along with data collection on complications related to the use of nutrition support – for example, poor tolerance of feeds or tubes, infections rate, site of infection.GP practiceNutrition Steering Committee working within the clinical Governance framework may include representatives from medical staff, dietetics, nursing, pharmacy, catering and management.
Senior managers of hospitals should maintain clear documentation of the outcomes of nutrition steering committees meetings. They should attempt to record the benefits of their work such as clinicians adherence to nutrition support protocols that have been developed and agreed by the nutrition steering committee.
Copyright © 2006, National Collaborating Centre for Acute Care.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of National Collaborating Centre for Acute Care to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

Cover of Nutrition Support for Adults
Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition.
NICE Clinical Guidelines, No. 32.
National Collaborating Centre for Acute Care (UK).

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