Implementation of NICE guidelines and the Research questions

1. Implementation of NICE guidelines and the Research questions Susan Murray (National Collaborating Centre for Acute Care, Royal College of Surgeons) Centre for Public Health - NICE

2. Today…. • Implementing the nutrition support guideline • Consider the key priorities for improvement • The 5 key research questions • Potential for a national approach to conducting research on nutrition support

3. Nutrition support in adults Launched February 2006

4. Tools to assist implementation • NICE – short version – summary of the recommendations • Full version – purchased via the NCC-AC • Quick Reference guide • Information for the public • Implementation guidance • Audit criteria • Slide set • Cost impact tool

5. Implementation, Implementation • NICE has only recently in the last year been involved in developing guidance for implementation… • Why – it was not NICE’s original remit • Why – awareness that guidance on implementation is needed

6. Access the guideline online • Quick reference guide – a summary www.nice.org.uk/CG032quickrefguide • NICE guideline – all of the recommendations www.nice.org.uk/CG032niceguideline • Full guideline – all of the evidence and rationale www.nice.org.uk/CG032fullguideline • Information for the public – a plain English version www.nice.org.uk/CG032publicinfo

7. Access tools online • Costing tools • costing report • costing template • Audit criteria • Implementation advice • Available from: www.nice.org.uk/cg032

8. Who is involved or considering ways to implement the guideline?

9. Understanding why this guideline was proposed can assist implementation • Topics proposed – public, clinicians • Where there are known problems, variation in practice • Proposals via the Department of Health • Why this guideline – • - because it is well recognised that many patients are malnourished • - debate about the efficiency of oral sip feeds

10. Why should the guideline be implemented? • NICE guidelines are based on the best available evidence • The Department of Health asks NHS organisations to work towards implementing guidelines • Compliance will be monitored by the Healthcare Commission

11. How was the guideline developed? • 2 ½ years of development • Multi disciplinary Guideline Development Group (15) • Technical team (10) • Stakeholders (100+) • Evidence searched: screening, oral, enteral, parenteral, dysphagia, monitoring, nutrition support teams • Evidence searched: All populations

12. Making sense of the evidence • Searched for RCT’s • Studies in pockets – Intensive Care, Surgery • Difficult to make recommendations for specific populations e.g. orthopaedic, oncology • Many problems with the studies • Heterogeneity • Indications for intervention differed between studies • Controls • Starting times • Routes of support • Duration of support • Outcome measures

13. Making Recommendations • 77 recommendations • Definite evidence – for 17 recommendations • In the absence of evidence • - informal consensus • - formal consensus - screening

14. Issues in Nutrition Support WHO ? WHEN ? WHAT ? HOW ?

15. Focus of recommendations is on‘Nutritional Status’ not setting…. Guideline useful for patients in Hospital and the Community

16. Organisation of nutrition support SCREEN RECOGNISE TREAT ORAL ENTERAL PARENTERAL MONITOR AND DOCUMENT REVIEW

17. Implementing the guideline 77 recommendations made but…. 10 Key Priorities for Implementation

18. The whole team makes it happen – 4 of the Key Priorities • Healthcare professionals involved in patient care should receive education and training on nutrition support • All people who need nutrition support should receive coordinated care from a multidisciplinary team • Acute trusts should employ at least one specialist nutrition support nurse • Hospital trusts should have a nutrition steering committee working within the clinical governance framework

19. Screening • use a screening tool that includes BMI, percentage unintentional weight loss and consideration of the time over which nutrient intake has been reduced or likelihood of future impaired intake e.g. ‘MUST’

20. Suggested actions • Clearly identify who is responsible for screening in all care settings including care homes • Ensure staff have access to and are using appropriate screening and assessment tools • Ensure staff have access to appropriate equipment in the hospital and community setting, e.g. weighing scales that are regularly serviced

21. Recognise who is malnourished • Malnourished = one or more of the following: • BMI of less than 18.5 kg/m² • unintentional weight loss greater than 10% within the last 3-6 months • BMI of less than 20 kg/m² and unintentional weight loss greater than 5% within the last 3-6 months

22. Recognise who is at risk • At risk of malnutrition= one or more of the following: • eaten little or nothing for more than 5 days and/or likely to eat little or nothing for the next 5 days or longer • poor absorptive capacity, are catabolic and/or have high nutrient losses and/or have increased nutritional needs

23. When and what to give • Health Care professionals should consider using oral, enteral or parenteral nutrition support alone or in combination, for people who are either malnourished or at risk of malnutrition, as defined above. • Potential swallowing problems should be taken into account

24. For patients with Dysphagia… don’t forget the guidance • Dysphagia- a key issue in the remit for the guideline • No studies found on the benefits of modifying textures • Working party of Speech therapists agreed recommendations • Focus- obvious and less obvious indicators of dysphagia • Caution on use of modifying textures of food and fluid

25. Obvious indicators Difficult, painful chewing/swallowing Regurgitation of undigested food Difficulty controlling food/fluid in mouth Drooling Hoarse voice Coughing or choking before, during or after swallowing Feeling of obstruction Less obvious indicators Change in respiration pattern Unexplained temperature spikes Wet voice quality Tongue fasciculation Heart burn Throat clearing Recurrent chest infections Atypical chest pain Indicators of Dysphagia

26. If the person has dysphagia • Recognise co-morbidities that increase the risk of dysphagia • People who present with any obvious or less obvious indicators of dysphagia should be referred to healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders • People with dysphagia should be given a drug review to ascertain if the current drug formulation, route and timing of administration remains appropriate and without contraindications

27. Don’t be overwhelmed by the guideline?

28. Why guidelines are not implemented? • Don’t know or forget about the guideline • Don’t agree with the recommendations • Isolation – professionals disagree with the recommendations • Psychological – ‘the patients wont like it…’ • Limited resources – time, money, skills • Organisational issues – barriers to change • Some recommendations easy to implement and require one person compared to others requiring a team approach to bring about change

29. Don’t know or forget about the guideline Don’t agree with the recommendations Isolation – professionals disagree with the recommendations Psychological – ‘the patients wont like it…’ Limited resources – time, money, skills Organisational issues – barriers to change Some recommendations easy to implement and require one person compared to others requiring a team approach to bring about change Promote – raise awareness – posters, talks Team approach – steering group to decide on strategies to improve clinician and patient confidence and adherence Solutions

30. What can dietitians do to assist implementation?

31. Dietitians are some of the key people who could assist implementation of the guideline? • Awareness and understanding about the potential number of patients who are malnourished or at risk? • Concerned that variation in practice is not effective • The guideline is a useful tool that can influence practice and improve the delivery of nutrition support • Dietitians have the knowledge and experience to have a vital impact on education and developing systems to improve the delivery of nutrition support

32. Suggested actions • Identify an implementation group… strategy… • Raise awareness of the guideline recommendations and why it is needed among all staff directly involved in patient care • Include nutrition support within induction programmes • Identify staff training needs and provide training using externally commissioned and ‘in-house’ programmes • Review service protocols and care pathways • Audit current practice

33. Research Recommendations • Several research recommendations were proposed • 5 were identified key research questions • these were areas where the GDG had the greatest difficulty to propose a recommendation due to the paucity of evidence in that clinical area • and if research is conducted in these areas this would potentially improve NICE guidance and ultimately patient care in the future

34. The 5 key research recommendations • Education • Screening • Oral nutritional supplements • Monitoring • Enteral tube feeding

35. The research recommendations • Formal educational intervention for all health care professionals v no formal education • Nutritional screening programme v no screening programme • - in primary care, • - care homes (dementia), • - inpatients, • - outpatients • Which components of nutritional monitoring are clinical and cost effective?

36. The research recommendations • Oral nutritional supplements • v dietary modification/food fortificatn • v dietary modification/food fortification +/- dietary counselling • Enteral tube feeding v no enteral tube feeding • in people with dementia and dysphagia

37. Which ones would you be interested in being involved with? • Education • Screening • Oral nutritional supplements • Monitoring • Enteral tube feeding

38. What would the study be like? • Scenario: Screening – has never been done in an outpatient setting • Outpatient: Aim to screen patients attending out patients on Mon, Tues and Thurs • What to do: trained nurse or researcher • Weight, height, history of food intake – patient reports reduction or improvement in appetite • Clearly define (measures)

39. Outcomes for the research questions • change in nutritional status • hospital admissions, hospital duration • GP visits • complications • survival • quality of life • cost effectiveness

40. NICE and the key research questions • NICE will consider the 5 key research questions • Propose and lobby potential funders – via the NHS R+D • NICE will also support and back proposals/protocols for the research recommendations and emphasise their importance and the potential need to improve the evidence in a guideline

41. Research, money resources – proving the case • While considering a protocol for a research question • Conduct an audit of the area of interest (example to be inserted) • this will help raise the profile that the problem probably continues and add to the case that research is needed • Don’t run off in enthusiasm and try to conduct a study on your own • Do become involved in setting the agenda for research there is a fundamental problem out there…. Poor infrastructure for delivering nutrition support

42. Proposals for setting up research • national approach to study design – several centres agree on a well developed protocol for study (BAPEN, PENG, BDA) • number of centres carry out studies – increase patient number • potentially quicker to produce evidence and influence the update of the guideline • national coordinator • focus on useful and meaningful outcomes

43. How many will benefit from this guideline?

44. Everyone has a part to play • This guideline should: • help healthcare professionals recognise malnourished patients and those at risk • guide healthcare professionals to choose the best method of nutrition support • reduce the number of people with malnutrition • Set the agenda for further research in nutrition support