Shared learning database

Type and Title of Submission


A Partnership approach to improving the nutritional care of our patients




Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG032 - Nutrition support in adults

Category(s) that most closely reflects the nature of the submission:

Implementation policy

Is the submission industry-sponsored in any way?


Description of submission


The aim of the initiative was to improve the nutritional care of our patients across a large 2-site trust in a consistent, replicable and evidence based manner using the NICE guidance as a catalyst for change, engaging all disciplines within the organisation. All activity would be co-ordinated through a Trust Nutritional Steering Committee whose agenda has focused around the NICE guidance CG32 Nutritional Support in Adults incorporating actions from the Essence of Care audit, Inpatient Survey and the annual audit of nutritional standards for catering. The Nutritional Steering Committee would be supported within the clinical governance framework through links with Clinical Effectiveness Committee and NICE Action Group


1. To establish a multi-disciplinary Nutritional Steering Group with working groups to deliver specific elements of NICE guidance i.e. Catering, Oral & Enteral Feeding, Naso-gastric & PEG groups, Nutritional screening, Assisted feeding, Infection Control, Parenteral Nutrition The Nutritional Steering committee membership to include Dietetic, Nursing, Medical, Speech and Language therapy, Pharmacy, Catering, PFI partners and patient representatives. 2. To address areas of non-compliance with NICE guidance (see supporting information) specifically nutritional screening, assisted feeding, Protected Mealtimes, referral practice, parenteral nutrition through agreed action plan ratified by the Trusts Clinical Effectiveness Committee 3. To deliver programme of audit to monitor implementation (see supporting information)


The Trust Board ratified a Nutrition Strategy in 2004, the aim of which was to ensure: The strategy proposed a 5 year action plan addressing: - Delivery of Nutritional Care - Clinical Risk - Resources - Innovations in Practice As we entered Year 3 of the action plan progress had been slow with pockets of good practice across the organization but no coordinated approach. There had not been a buy-in by all disciplines and success relied on enthusiastic individuals within specific areas of practice. This enthusiasm needed to be harnessed and used to achieve widespread change in practice. The lack of consistent and widespread change was reflected in a series of audits carried out prior to the publication of the NICE guidance. The completion of the Essence of Care (EOC) audit with results of the In-patient survey provided further impetus to continue to improve the delivery of nutritional care to our patients. A report was presented to the Clinical Effectiveness committee, NICE Action Group and Nursing & Midwifery Governance Committee highlighting the Trusts level of compliance against the NICE guidance and identifying areas for improvement. Key findings included: - Nutritional screening A nutritional screening tool is currently in use across the organisation recommending screening on admission and at weekly intervals. Results of the EOC audit indicated screening occurred in 50% or less clinical areas. - Treatment of Malnutrition: Oral The EOC audit highlighted issues around barriers to successful assisted feeding practice at ward level. These included lack of staff available at mealtimes and difficulty in identifying patients requiring assisted feeding. - Treatment of malnutrition: Parenteral Local and regional audits indicated that PN practice was poor in comparison with other organizations and we were non-compliant with a number of NICE recommendations - Workforce The organisation had no nutrition nurse specialist or Nutrition Team


Nutrition Steering Committee established since May 2006, meets quarterly. Terms of reference attached. Sub-groups active with specific actions allocated. 2. Outcome of actions of sub-groups - Patient meals met nutritional standards in 2007 - Protected mealtimes policy �?? launched May 08 - Introduction of red napkin scheme to identify patients requiring assistance with feeding - Nutrition screening tool introduced in all clinical areas following extensive programme of training - Revised naso-gastric policies for adults and paediatrics - Re-feeding protocol produced - Parenteral Nutrition guidelines and referral form introduced - Improved discharge communication for community staff and GPs - Successful Nutrition Study day held in September 07 - Nutrition education introduced as part of our F1 and F2 medical training programme - Funding identified for Nutrition team for 5 year period - Advert to go out for Nutrition Nurse Specialist in Sept 08 3. Audit results Audit undertaken in following areas: - Nutritional Screening:- MUST screening tool now used on 78% compared to EOC finding in 2006 of 50% - Nutritional Standards for catering :- all standards met - Referral practice

Results and evaluation

Progress is monitored through programme of audit and feedback reports to Trust Clinical Effectiveness Committee and NICE action group. Nutritional initiatives also included as part of In-patient survey and PEAT audits. An on-going programme for audit is in place. Plans include: Re-feeding policy compliance Autumn 08 Use of MUST screening tool October 08 Nutritional Standards November 08 Protected Mealtime policy Spring 09 The effectiveness of the Nutrition Nurse Specialist post will be monitored as will the role of the Nutrition Team once in place and established.

Key learning points

1. To have top down support for the project at Trust Board level. The medical director has been an excellent champion 2. To have a high profile:- present at as many influential groups as possible 3. Get the right people i.e. the enthusiasts from as many relevant disciplines as possible irrespective of grade to help implement change 4. Use nurses to influence nursing practice, medics to influence medics etc 5. Keep focused on the action plan - don't get diverted 6. Never make any assumptions that something is in place because it has been agreed Trust-wide. Need to focus on specific clinical areas and audit 7. Use all methods of communication

View the supporting material

Contact Details

Name:Linda Irons
Job Title:Director, Nutrition and Dietetic Services
Organisation:South Tees Hospitals NHS Trust
Address:The James Cook University Hospital
Town:Marton Rd
Postcode:TS4 3BW
Phone:01642 854777


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This page was last updated: 01 October 2008

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.