Patient Safety – Nutrition · gluten free and lactose free 12/20/2016. Page 19. Portsmouth...

QAH HospitalPortsmouth Hospitals NHS Trust 12/20/2016

Patient Safety – Nutrition

QAH HospitalPortsmouth Hospitals NHS Trust

Objectives• The importance of ‘MUST’ and how often to complete• Understanding the first line action plan (FLAP) for ward

patients at risk of malnutrition• The range of nutritional supplements available and when

each one can be used• To appreciate that if oral intake has not improved after 5-7

days then to discuss a plan with medical staff e.g. NG feeding

• To know when and how to refer to the dietitians• 30 minutes

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Introduction – Nutrition in hospital

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Why is Preventing Malnutrition Important?

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Pressure ulcers

Increased length of stay

Decreased Immunity

£19.6 Billion

Increased risk of falls and fractures

Increased mortality

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Disease/Nutrition Intake Score

Weight Loss Score

BMI Score

Add Scores together to determine overall risk of malnutrition

Step 5Implement appropriate

management guidelines

BAPEN ‘MUST’ (Malnutrition Universal Screening Tool)


Nutritional Screening – ‘MUST’ To be completed every 5-7d (VitalPAC will prompt intermediate reviews if indicated)

Score: 0 LOW risk = observe

Score: 1MEDIUM risk = monitor

Use weight chart to monitor weight

Score: 2HIGH risk = TREAT

Initiate FLAP!

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Case study patient: Mrs Jones

• 90 years old Admitted with exacerbated COPD Lives with husband at home Normally independent with ADLs Her weight has dropped from 58kg to 52kg (10% weight loss) She does not know her height- estimated 1.52m (5ft) BMI= 22.5kg/m2 Not eaten properly for last 5 days

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Mrs Jones

•BMI >20 score = 0•Weight loss 10% score = 1

•Acute disease effect score = 2•Total 3= high risk

……. Plan: Initiate FLAP

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If MUST score >2 initiate FLAP (First Line Action Plan)

•Encourage ‘H’ high calorie options from main menu•High protein diet•Trial with supplement drinks •Monitor intake with food charts, fluid balance charts complete ‘MUST’ score every 5 days

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If patient is referred to the dietitian before FLAP has been initiated:

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Turn FLAP into a Care Plan

• FLAP needs to be personalised for each patient

• Mrs Jones has a sweet tooth and enjoys puddings and milky drinks

• She needs encouragement with eating and drinking

• What would you offer her?

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From the information, make a nutrition care plan anddocument this in the yellow nursing care plans


Extras available for patients…

Snack boxes •Can collect from main kitchen on B Level between

06:30 – 19:30

•Sandwich, fruit juice, yoghurt, digestive biscuits, fruit

•Calshake, made with fresh milk on the ward•Ice Cream•Fresubin Powder Extra•Cheese & biscuits•Cake and biscuits from the tea trolley

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Nutritional Supplements

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*high in protein*

*high in protein*


• What nutritional supplement would be most appropriate for a

diabetic patient who requires them?

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• Fresubin Protein Energy

• 24g CHO per 200ml bottle

• Fresubin Jucy • 67g CHO per 200ml

bottle

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NB Fresubin stage 1 and 2 also have 24g CHO per 200ml bottle


• Which fat emulsion supplement, provides energy, but does not

provide any protein, vitamins or minerals?

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• Use under guidance of dietitian

• Should be used in conjunction with a nutritionally complete supplement (e.g. Fresubin 2kcal)

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* NB all Fresenius products (except 5kcal shots) contain fish oils (the carrier for vitamin A is fish gelatine) and milk protein and is therefore not suitable for strict vegetarian/ Vegan diets

Please discuss this with patients before offering the supplements if they are known to be vegetarian/ Vegan.

All are Halal / kosher Certified


True or False1.Mrs Jones needs to have supplements prescribed in order to trial them2.Mrs Jones needs to be seen by a dietitian in order to have nutritional supplements3.Mrs Jones has a score of 0 for her BMI on the ‘MUST’, therefore she shouldn’t trial supplements4.All the Fresenius nutritional supplements are gluten free and lactose free

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True or False

1. Mrs Jones needs to have supplements prescribed in order to trial them …FALSE

2. Mrs Jones needs to be seen by a dietitian in order to have nutritional supplements …FALSE

3. Mrs Jones has a score of 0 for her BMI on the ‘MUST’, therefore she shouldn’t trial supplements …FALSE

4. All the Fresenius nutritional supplements are gluten free and lactose free …TRUE

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If Mrs Jones does not like the milky nutritional supplements, what

alternatives could you offer her?

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Possible Answers:

• Meritene Soup – 50g sachet made with 150ml hot water

• Fortified soup from menu

• Fresubin Jucy

• Fresubin 2kcal Crème and YoCrème

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Mrs Jones: 3 days into admission

You notice Mrs Jones is having problems with swallowing her food, resulting in coughing and reduced

intake. The Speech and Language Therapist recommends thickened fluids

What supplements are suitable for dysphagic patients requiring thickened fluids?

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•Fresubin stage 1 and 2• Fresubin 2kcal crème• Fresubin Yocrème

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Mrs Jones: 5 days into admission:

•Lost further 2kg: wt now 50kg (13.7% loss)•Eaten minimal amounts for last 5 days•‘MUST’ score increases from 3 to 4

(BMI=0 + wt loss=2 + acute disease =2)

•Implemented FLAP with no improvement•Medical condition starts to deteriorate•Doctors decide to NG feed.

Its 8pm on Friday, what do you do next?....

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NG Feeding

When to choose the Refeeding Starter Regime?•Consider at risk if:

•BMI <18.5• a poor nutritional intake for >5 days

•unintentional weight loss >10% within 3-6months•Discuss with the patient’s doctor if unsure which regimen to use

•Do not start NG feeding until Thiamine has been prescribed•Refeeding syndrome policy

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Out of hours starter regimes for when NGT first inserted;

•Standard starter regime- for patients 40kg and over

•Refeeding Starter Regime-for those who are at risk of Refeeding Syndrome(or <40Kg)


When to choose the Refeeding Starter Regime?

•Consider at risk if:•BMI <18.5• a poor nutritional intake for >5 days•unintentional weight loss >10% within 3-6months

Discuss with the patient’s doctor if unsure which regimen to use

Do not start NG feeding until Thiamine has been prescribed

Refeeding syndrome policy


Food SafetyAll clinical staff have to be mindful of food safety:

•Hands must be washed before food service•All patients should be encouraged/ helped to use the ‘wet wipe’ PRIOR to eating their meal•Blue plastic aprons must be worn and hair tied back•Cutlery used for main course should not be re-used for dessert

Refrigerators in the beverage bay/ ward kitchen are the ward/ department’s responsibility:•Food stored in ward fridges should be labelled with the patients name and used within 24 hours if they are not sealed•The temperature of the fridge should be recorded to ensure it is under 40C

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Referring Patients to the Dietitian

As of 13th June 2016 please refer via ICE

(We are no longer accepting verbal/telephone referrals)

•If it’s a swallow problem contact SLT for swallow ax•If it’s a tube problem i.e. tube insertion, poor compliance, blocked tubes contact Nutrition Nurses (x5918)

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Any Questions?

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Patient Safety – Nutrition · gluten free and lactose free 12/20/2016. Page 19. Portsmouth...

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