Managing adult malnutrition in the community Including a pathway for the appropriate use of oral nutritional supplements (ONS) Supported by the Supported by the Endorsed by the Royal College Supported by the Endorsed by the Primary Care British Dietetic Association National Nurses Nutrition Group of General Practitioners Royal College of Nursing Pharmacists Association Endorsed by the British Association for Endorsed by the British Endorsed by the Pharmaceutical Endorsed by the Primary Care Endorsed by the Royal Parenteral and Enteral Nutrition Pharmaceutical Nutrition Group Services Negotiating Committee Society for Gastroenterology Pharmaceutical Society www.malnutritionpathway.co.uk
Managing adult malnutrition in the community • A practical guide to support General Practitioners and community healthcare professionals to identify and manage individuals at risk of disease-related malnutrition • Includes a pathway for the appropriate use of oral nutritional supplements (ONS) www.malnutritionpathway.co.uk
Managing adult malnutrition in the community Developed by a multi-professional panel with expertise and an interest in malnutrition. Based on evidence, clinical experience and accepted t r i t i o n M a l n u A d u l t n a g i n g M a best practice i t y m m u n t h e C o i n Including a pathway for the appropriate use of oral nutritional supplements (ONS) Produced by a multi-professional consensus panel Contents: • Malnutrition overview • Identification of malnutrition using nutrition screening • Managing malnutrition according to risk category • Pathway for using ONS in the management of malnutrition (high risk) Endorsed by the Primary Care Supported by the Endorsed by the Royal College Pharmacists Association Supported by the Royal College of Nursing Supported by the of General Practitioners National Nurses Nutrition Group British Dietetic Association • Optimising oral intake Endorsed by the Royal Endorsed by the Primary Care Endorsed by the Pharmaceutical Pharmaceutical Society Endorsed by the British Society for Gastroenterology Endorsed by the British Association for Services Negotiating Committee Pharmaceutical Nutrition Group Parenteral and Enteral Nutrition www.malnutritionpathway.co.uk www.malnutritionpathway.co.uk
Panel members Dr Ailsa Brotherton Iain McGregor - Senior Research Fellow, - Former chair of the Royal Honorary Secretary of College of Nursing Older the British Association People’s Forum. Training for Parenteral and Manager (Scotland and North Enteral Nutrition East England), Four Seasons Health Care Anne Holdoway (chair) Barbara Parsons - Specialist Dietitian and Independent Practitioner. Chair - Head of Pharmacy Practice at of the England Board of the the Pharmaceutical Services British Dietetic Association. Negotiating Committee Chair of the Parenteral and Enteral Nutrition (PEN) Group of Dr Rachel Pryke the British Dietetic Association - General Practitioner. Royal College of General Pamela Mason Practitioners Clinical Champion - Community pharmacy for Nutrition and Nutrition Consultant. and Health Member of the British Pharmaceutical Nutrition Group www.malnutritionpathway.co.uk
Professional groups supporting ‘Managing Adult Malnutrition in the Community’ Supported by the Supported by the Endorsed by the Royal College Supported by the Endorsed by the Primary Care British Dietetic Association National Nurses Nutrition Group of General Practitioners Royal College of Nursing Pharmacists Association Endorsed by the British Association for Endorsed by the British Endorsed by the Pharmaceutical Endorsed by the Primary Care Endorsed by the Royal Pharmaceutical Nutrition Group Parenteral and Enteral Nutrition Services Negotiating Committee Society for Gastroenterology Pharmaceutical Society www.malnutritionpathway.co.uk
Introduction • Malnutrition (under-nutrition) is a common and costly problem 1 • Public health expenditure in excess of £13 billion per year • Malnutrition prevalence: 2 Nursing Home • 10% of people in GP surgeries 3 Residential Home • 46% of nursing home residents 3 • 41% of residential home residents GPs Surgery | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 0 5 10 15 20 25 30 40 50 Malnutrition Prevalence % www.malnutritionpathway.co.uk
Introduction • Groups at risk of malnutrition include 4 : Chronic disease COPD, cancer, inflammatory bowel disease, gastrointestinal disease, renal or liver disease Chronic progressive Dementia, neurological conditions (Parkinson’s disease, MND) disease Acute illness Where food is not being consumed for more than 5 days (this is often seen in the acute setting and is rare in the community) Debility Frailty, immobility, old age, depression, recent discharge from hospital Social issues Poor support, housebound, inability to cook and shop, poverty • Malnourished individuals have poorer clinical outcomes and greater healthcare use, impacting on the health economy 5,6 Healthcare use Clinical outcomes www.malnutritionpathway.co.uk
Consequences of Malnutrition 4,5,6 • Impaired immune system, wound healing and recovery • Reduced muscle strength and poorer clinical outcomes • More hospital admissions/re-admissions • Longer hospital stay • Greater healthcare needs in the community www.malnutritionpathway.co.uk
UK Guidance National Institute for Health and Clinical Excellence (NICE) NICE CG32: Nutrition support in adults 7 • Nutritional screening to identify malnutrition • action should be taken to manage risk (A-grade evidence) • 2 common oral nutrition support strategies are: Issue date: February 2006 Nutrition support in adults Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition • dietary advice to increase nutrient content of diet • oral nutritional supplements (ONS) • Despite available guidance, malnutrition Clinical Guideline 32 Developed by the National Collaborating Centre for Acute Care remains under-detected and under-treated 1 . • UK GPs acknowledge that a clear evidence based pathway for identifying and managing malnutrition is required 8 www.malnutritionpathway.co.uk
Key UK Guidance around managing malnutrition National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 32: Nutrition support in adults. NICE 2006 • Set of guidelines, based on evidence. Includes specific guidance on screening for malnutrition in all care settings, provision of nutrition support and monitoring. Note: full guidance contains a costing report Issue date: February 2006 Nutrition support in adults and a systematic review. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition http://guidance.nice.org.uk/CG32 Clinical Guideline 32 Developed by the National Collaborating Centre for Acute Care Essential standards of quality and safety. Reg. 14 of the Health and Social Care Act 2008. Meeting Nutritional Needs, outcome 5. Care Quality Commission 2009 Guidance about compliance Essential standards of quality and safety • Where food and hydration are provided to service users the registered person must ensure that service users are protected from the risk of inadequate nutrition and dehydration. • Nutritional screening is carried out to identify those at risk of poor nutrition or dehydration, action is taken where any risk of poor nutrition of dehydration is identified What providers should do to comply with the section 20 http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdf regulations of the Health and Social Care Act 2008 March 2010 Essence of care: Benchmarks for food and Drink. Department of Health 2010 Essence of Care • 10 factors are outlined in the Food and Drink section, including Screening and assessment, planning 2010 implementation, evaluating implementation of care and monitoring. Each section provides guidance and some best practice examples. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_119969 www.malnutritionpathway.co.uk
Managing malnutrition – cost implications • Tackling malnutrition can improve nutritional status, clinical outcomes and healthcare use 7 • NICE have shown substantial cost savings can result from identifying and managing malnutrition 9 • NICE CG32 is ranked the 3rd top clinical guideline to produce savings 9 Estimated saving Clinical Guidance Short title Why does this guidance save money? per £100,000 Revised recommendations cost more in drugs, outweighed by Hypertension (partial predicted number of cardiovascular events avoided through -446,627 CG34 update of CG18) hypertension control Long-acting reversible The additional cost of providing these methods is offset by the costs CG30 contraception of unplanned pregnancies (reduced terminations or reduced births). -214,681 Costs arising from improving screening, assessment and treatment of malnourished patients are offset by Nutrition support reduced complications, reduced GP and outpatient CG32 -28,472 in adults appointments, reduced admissions and reduced length of hospital stay. Accurate detection of high blood pressure will reduce the Hypertension (update) inappropriate use of antihypertensive drugs, which will outweigh -20,464 CG127 the additional costs of diagnoses. www.malnutritionpathway.co.uk
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