Nutrition

1. Nutrition Ruth Newton Nutrition team pharmacist/NMP Lead for Medical education Countess of Chester Current Chair of BPNG

2. Outline • Introduction • Theory part one • Incidence of malnutrition • Guidance • Politics • Practical Part two • Nutrition Screening and Assessment • Ways of delivering Nutritional support • Cases • Professionals form a variety of backgrounds • Both a technical and clinical viewpoint

3. What is a drug?

4. Part one

5. Incidence of malnutrition in hospitals • Kings Fund Report January 1992 : Up to 50% surgical patients and 44% of medical patients malnourished on admission. • Nutritional support could reduce hospital and save £266 million / year. • McWhirter and Pennington BMJ 1994 308(9)… • 200 out of 500 patients malnourished on admission. • 112 lost mean of 5.4% weight during admission. • 10 given nutrition support gained weight – 7.9%.

6. Malnutrition in Hospitals • Prevalence of Malnutrition on Admission to 4 Hospitals in England. Malnutrition Prevalence Group. Edington et al 2000 Clinical Nutrition Jun 19(3): 191 – 5 • 1 in 5 patients malnourished on admission. • Increased length of stay. • Increased infection. • More new prescriptions.

7. Appropriate Nutritional Support • Appropriate nutritional support can reduce morbidity, hospital stay and costs. • But inappropriate use of nutritional support can increase morbidity and costs (Roberts & Levine Nutr Clin Pract1992, 5, 227 - 30) • Nutritional assessment: targeting right patients. • Deciding the most appropriate method. • Estimation of nutritional requirements. • Feeding regimens and monitoring. • So if we have a patient we suspect may be malnourished….

8. Prevention Assessment Monitoring Suitable follow-up Treatment Appropriate treatment Minimise complications Duty of Care Multi-disciplinary

9. Organisation of Nutritional Support in Hospitals NST Primary medical team Ward staff

10. Trust drivers affecting nutrition strategy

11. “Spoonful of Sugar” “….pharmacy work should prioritise specialities or areas with highest likely risk for example ITU, paediatrics, antibiotics and parenteral nutrition.”

12. Nutrition Support Teams • Kings Fund Report • Specialist Team • Reduce malnutrition in hospitals • Prevention of further complications • Monitor patients • Handover

13. Nutrition Support Teams • Nutritional assessment • Route of nutritional support- working with other teams involved • Estimate requirements • Monitoring • Literature searches- protocols • Education

14. Is it that easy????? “ Its only food”

15. Why do things go wrong? What does hospital food taste like?

16. What goes wrong? • Appetite • Tray time • Menu choice

17. Exercise: Diet history • Take a diet history from the person next to you • Record absolutely everything from the person sitting next to you

18. August 2017 • Key Priorities • Nutrition support considered at risk patients • Eaten little or nothing for 5 days and/or unlikely to eat for next 5 days • Poor absorptive capacity, high nutrient losses, increased needs, swallowing problems

19. Types of patients • No textbook patient

20. Why do pharmacy get involved? • Drug • Formulation • Route • Prevention of side effects • Monitoring • Cost • DUR

21. What is a drug?

22. Conclusions Part 1 • Appropriate nutritional support reduces morbidity and costs • Inappropriate increases risks and complications • Good screening ensures appropriate nutritional support targeted to the right patients

23. Practical Support- Part 2

24. August 2017 Key Priorities Nutrition support considered at risk patients Eaten little or nothing for 5 days and/or unlikely to eat for next 5 days Poor absorptive capacity, high nutrient losses, increased needs, swallowing problems Patient group

25. Routes to administer • Diet • Supplementation • Diet • Artificial route • Enteral • Parenteral • Indications vary according to age

26. Screening and assessment • Several ways of determining a patient’s nutritional status • Some more practical than others • Reliable, repeatable and validated • BMI, %weight loss, MUST • Skinfold thickness, grip strength

28. Refeeding syndrome • Those who have not feed for >7 days • Glucose infusion • Shift of electrolyte into cells e.g. potassium, magnesium, phosphate. • Decrease of extracellular ions very quickly • Causes heart attack and shock

29. Body Composition • Based on average person

30. Oral • How? • Fortify food • Milk • Cream • Sweets • Supplement e.g. ensures, milkshakes

31. Taste quiz

32. Enteral • Short or long term • Gastric- bolus or drip feed • NG tube • Careful at exit site hole diameter • Gastrostomy • Jejunal- drip feed only as no reservoir • NJ • Jejunostomy • Look at osmolality of drug you are administering • Cause diarrhoea reduces time for drug to be absorbed

33. Tube selection

34. Parenteral Nutrition • Peripheral • Venflon • Central • Hickman • Single lumen line CVP • PICC • Caution if multi-lumen line and drug interactions • Midline • PIC

35. Requirements • Macro and micronutrients • Calories- split • Fluid!

36. How to formulate a prescription • Jigsaw- feed plus prescription • Start with nutritional requirements- • macro and fluid • Look at products available and try to use whole components • Add trace elements and vitamins • Add electrolytes • Stability • Flow rate and route

37. Ethics • Evidence based • Patient wellbeing • Primary and secondary care • Do not prolong life or death

38. Decisions • 60 year old patient • RTA • No gut function as such as first • Recovers after 3 weeks TPN requires PEG to continue to meeting requirements • Long term prognosis good • Would you place a PEG?

39. Monitoring • Keep an eye on things • Adjust accordingly • Keep an eye on things • Adjust accordingly • Keep an eye on things • Adjust accordingly • Keep an eye on things • Adjust accordingly • Keep an eye on things • Adjust accordingly • Keep an eye on things • Adjust accordingly • Keep an eye on things • Adjust accordingly

40. Weaning off • Gradual • Appropriate • Monitor BMs

41. One size fits all • Not like other drugs • Reduce the doses don’t always fit • Fancy foods • Immuno-nutrition • Gluten free • Low cal /high fat • High cal/ low fat • Before you get started on started on volume, fatty acids and prematurity

42. Today • 60% Hospitals have NST • 50-80% all PN is as ready to use bags • 33% bags are not complete • Clinical risk

43. Summary- part two NS should be provided in a complete form in terms of patient requirements to minimise complications

44. How do we achieve this? Technical Clinical

45. Summary • Nutrition often cross directorates • More efficient to have one pharmacist looking after all patients to minimise delay in ordering • Clinical skills looking at other factors relating to drug therapy • Technical knowledge; stability etc. • Patient receives most appropriate drug via the most suitable route at the optimum rate