Shared learning database

 
Organisation:
City Healthcare Partnership CIC
Published date:
June 2013

Implementing NICE Clinical Guideline 32 Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition. By supporting staff in care homes we achieved improvements in nutritional management of patients and the reduction in the number of Health Care Professionals consultations for these patients.

Does the example relate to a general implementation of all NICE guidance?
No
Does the example relate to a specific implementation of a specific piece of NICE guidance?
No

Example

Aims and objectives

Malnutrition continues to be a significant clinical and public health problem, estimated to cost £13 billion a year (1) Consequences if left untreated include; mortality, morbidity and impaired physical health (2) In the UK 41% of individuals in care homes are at risk of malnutrition (3). The aim of this project was to implement NICE guidance surrounding nutrition screening and appropriate malnutrition management according to risk in care homes and to determine if savings could be generated. A dedicated nurse undertook a baseline audit to determine the prevalence of malnutrition risk, documentation of nutrition information and care plans, screening practices, use of nutrition support and healthcare use. NICE guidance was then introduced through implementing a local policy for screening and managing malnutrition, which included monthly nutritional screening of all residents along with initiation and review of nutritional management plans as appropriate. The implementation was led by a dedicated nurse, allowing for consistency of screening and documentation. Education was provided to care home staff to ensure nutritional management plans were provided to residents that were appropriate to risk. In order to evaluate effectiveness of the project an audit after implementing NICE guidance was undertaken on the same residents in each care home.

References:
(1) Elia M, Stratton RJ. Calculating the cost of disease-related malnutrition in the UK in 2007 (public expenditure only). In Elia & Russell; Combating Malnutrition: Recommendations for Action. A report from the advisory group on Malnutrition led by BAPEN. page 39-46. 2009. BAPEN.
(2) Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing; 2003.
(3) Russell CA, Elia M. Nutrition Screening Survey in the UK and Republic of Ireland in 2011: Hospitals, Care Homes and Mental Health Units. 2011. BAPEN.

Reasons for implementing your project

The City Health Care Partnership (CHCP CIC) care home medicines management support team had identified that there was a risk of residents residing in care homes who were not being screened to assess their nutritional status and malnutrition risk, and subsequently a risk that residents were not managed appropriately. Nutricia and CHCP CIC worked in partnership to improve practice and implement NICE guidance by recommending the use of the 'Malnutrition Universal Screening Tool' ('MUST') and standardised nutritional management plans in 5 care homes across the city of Hull

How did you implement the project

A dedicated nurse undertook a baseline audit to determine the prevalence of malnutrition risk, documentation of nutrition information and care plans, screening practices, use of nutrition support and healthcare use. This was recorded over a 3 month period across 5 care homes.

'MUST' was then implemented across the 5 care homes by a dedicated nurse supported by the care home medicines support team. This included monthly nutritional screening of all residents along with initiation and review of nutritional management plans as appropriate. Nutritional management plans included monthly screening for all residents, food fortification strategies for medium risk, and food fortification and oral nutritional supplements for residents at high risk according to 'MUST'. Referrals were made to a Dietitian if no improvement was seen in a resident after 4-6 weeks. The plans were very similar the guidelines within 'Managing Adult Malnutrition in the Community' produced by a multi-professional consensus panel published in 2012 (www.malnutritionpathway.co.uk). In addition care home staff were also educated on providing the nutritional management plans and kitchen staff were provided with food fortification training.

By designing and planning the project and including all key stakeholders from the outset, this, ensured the success of the project. The main barrier faced during the project was reluctance by GPs to stop or start oral nutritional supplements (ONS) for those patients when it was appropriate to do so. One reason for this is that the medicines management team in the PCT were previously working with GPs to reduce the prescribing costs of ONS which led to some GPs being unwilling to prescribe. Our care home support technician visited these GPs to explain the rationale behind the request for ONS and in every case this resulted in the patient receiving appropriate treatment.

Key findings

Improvements made by implementing NICE guidance were demonstrated by:
- Increase of patients screened (from around 35% to 100%)
- Increase in frequency of nutritional screening
- Residents identified at high risk managed more effectively
- Reduced hospitals admissions by around 40%
- Reduced infections requiring antibiotics by around 30%
- Reduced Pressure ulcers by around 55%
- Reduced GP contact by around 3%
- Reduced Health care professionals contact by around 25%

Through undertaking the base line audit and re audit after implementing the NICE guidance we were able to show a cost saving per resident which would also show an improvement in quality of life and care.

The audit data is due to be presented at the ESPEN Congress in September 2013 and we plan to write up the data for full publication later this year. An executive summary can be found under the supporting material.

Key learning points

Due to the success of the project we would make the following recommendations to any other organisations wanting to undertake a similar project.
- Plan your project including timelines and outcomes
- Involve key stakeholders from the beginning to ensure 'buy in'
- Be realistic in your goals
- Monitor effectiveness through audit
- Share results with key stakeholders
- Think about how you will sustain any positive results
Using one dedicated nurse and one dedicated care home support technician helped to ensure consistency and also meant that there was very little issue with problems such as staff turnover and screening calculation inaccuracies.

Contact details

Name:
Richard Maddison
Job:
Medicines Development Manger
Organisation:
City Healthcare Partnership CIC
Email:
richard.maddison1@nhs.net

Sector:
Primary care
Is the example industry-sponsored in any way?
Yes

Nutricia worked collaboratively with CHCP CIC care home medicines management support team Hull, to support the process of developing, setting up and implementing the nurse led service for identifying and managing malnutrition in local care homes