Levels of evidence (1-4) and grading of recommendations (A- D [GPP]) are defined at the end of the "Major Recommendations" field.
Organisation of Nutrition Support in Hospital and the Community
D (GPP) - All healthcare professionals who are directly involved in patient care should receive education and training, relevant to their post, on the importance of providing adequate nutrition.
D (GPP) - Education and training should cover:
- nutritional needs and indications for nutrition support
- options for nutrition support (oral, enteral and parenteral)
- ethical and legal concepts
- potential risks and benefits
- when and where to seek expert advice
D (GPP) - Healthcare professionals should ensure that care provides:
- food and fluid of adequate quantity and quality in an environment conducive to eating
- appropriate support, for example, modified eating aids, for people who can potentially chew and swallow but are unable to feed themselves
D (GPP) - Healthcare professionals should ensure that all people who need nutrition support receive coordinated care from a multidisciplinary team (the composition of this team may differ according to setting and local arrangements).
D (GPP) - All acute hospital trusts should have a multidisciplinary nutrition support team which may include: doctors (for example gastroenterologists, gastrointestinal surgeons, intensivists or others with a specific interest in nutrition support), dietitians, a specialist nutrition nurse, other nurses, pharmacists, biochemistry and microbiology laboratory support staff, and other allied healthcare professionals (for example, speech and language therapists).
D (GPP) - All hospital trusts should have a nutrition steering committee working within the clinical governance framework.
D (GPP) - Members of the nutrition steering committee should be drawn from trust management, and include senior representation from medical staff, catering, nursing, dietetics, pharmacy and other healthcare professionals as appropriate, for example, speech and language therapists.
D (GPP) - All acute hospital trusts should employ at least one specialist nutrition support nurse.
D (GPP) - The specialist nutrition support nurse should work alongside nursing staff, as well as dietitians and other experts in nutrition support, to:
- minimise complications related to enteral tube feeding and parenteral nutrition
- ensure optimal ward-based training of nurses
- ensure adherence to nutrition support protocols
- support coordination of care between the hospital and the community
Screening for Malnutrition and the Risk of Malnutrition in Hospital and the Community
D (GPP) - Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training.
D (GPP) - All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients.
D (GPP) - Hospital departments who identify groups of patients with low risk of malnutrition may opt out of screening these groups. Opt-out decisions should follow an explicit process via the local clinical governance structure involving experts in nutrition support.
D (GPP) - People in care homes should be screened on admission and when there is clinical concern.
D (GPP) - Screening should take place on initial registration at general practice surgeries and when there is clinical concern, (Clinical concern includes, for example, unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes or prolonged intercurrent illness.) Screening should also be considered at other opportunities (for example, health checks, flu injections).
D (GPP) - Screening should assess body mass index (BMI) [BMI is weight (kg)/height(m2) (weight in kilograms divided by height in metres squared)] and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this.
Indications for Nutrition Support in Hospital and the Community
D (GPP) - Nutrition support should be considered in people who are malnourished, as defined by any of the following:
- a BMI of less than 18.5 kg/m2
- unintentional weight loss greater than 10% within the last 3 to 6 months
- a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3 to 6 months
D (GPP) - Nutrition support should be considered in people at risk of malnutrition who, as defined by any of the following:
- have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer
- have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism
D (GPP) - Healthcare 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. Potential swallowing problems should be taken into account.
Healthcare professionals involved in starting or stopping nutrition support should:
- obtain consent from the patient if he or she is competent
- act in the patient's best interest if he or she is not competent to give consent
- be aware that the provision of nutrition support is not always appropriate. Decisions on withholding or withdrawing of nutrition support require a consideration of both ethical and legal principles (both at common law and statute including the Human Rights Act 1998)
D (GPP) - When such decisions are being made guidance issued by the General Medical Council ("Withholding and withdrawing life prolonging treatments: good practice in decision making," 2005) and the Department of Health (Good Practice in Consent Advisory Group, 2001) should be followed.
D (GPP) - Healthcare professionals should ensure that people having nutrition support, and their carers, are kept fully informed about their treatment. They should also have access to appropriate information and be given the opportunity to discuss diagnosis and treatment options.
What to Give in Hospital and the Community
D (GPP) - Healthcare professionals who are skilled and trained in nutritional requirements and methods of nutrition support should ensure that the total nutrient intake (total intake includes intake from any food, oral fluid, oral nutritional supplements, enteral and/or parenteral nutrition support and intravenous fluid) of people prescribed nutrition support accounts for:
- energy, protein, fluid, electrolyte, mineral, micronutrients (the term micronutrient is used throughout to include all essential vitamins and trace elements) and fibre needs
- activity levels and the underlying clinical condition – for example, catabolism, pyrexia
- gastrointestinal tolerance, potential metabolic instability and risk of refeeding problems
- the likely duration of nutrition support
D (GPP) - For people who are not severely ill or injured, nor at risk of refeeding syndrome, the suggested nutritional prescription for total intake should provide all of the following:
- 25 to 35 kcal/kg/day total energy (including that derived from protein [This level may need to be lower in people who are overweight, BMI>25. When using parenteral nutrition it is often necessary to adjust total energy values listed on the manufacturer's information which may not include protein energy values.])
- 0.8 to 1.5 g protein (0.13 to 0.24 g nitrogen)/kg/day
- 30 to 35 ml fluid/kg (with allowance for extra losses from drains and fistulae, for example, and extra input from other sources – for example, intravenous drugs)
- adequate electrolytes, minerals, micronutrients (allowing for any pre-existing deficits, excessive losses or increased demands) and fibre if appropriate
D (GPP) - The prescription should be reviewed according to the person's progress, and care should be taken when:
- using food fortification which tends to supplement energy and/or protein without adequate micronutrients and minerals
- using feeds and supplements that meet full energy and nitrogen needs, as they may not provide adequate micronutrients and minerals when only used in a supplementary role
- using pre-mixed parenteral nutrition bags that have not had tailored additions from pharmacy
D (GPP) - Nutrition support should be cautiously introduced in seriously ill or injured people requiring enteral tube feeding or parenteral nutrition. It should be started at no more than 50% of the estimated target energy and protein needs. It should be built up to meet full needs over the first 24 to 48 hours according to metabolic and gastrointestinal tolerance. Full requirements of fluid, electrolytes, vitamins and minerals should be provided from the outset of feeding.
D (GPP) - People who have eaten little or nothing for more than 5 days should have nutrition support introduced at no more than 50% of requirements for the first 2 days, before increasing feed rates to meet full needs if clinical and biochemical monitoring reveals no refeeding problems.
D (GPP) - People who meet the criteria in the table below entitled "Criteria for determining people at high risk of developing refeeding problems" should be considered to be at high risk of developing refeeding problems.
Criteria for Determining People at High Risk of Developing Refeeding Problems
Patient has one or more of the following:
- BMI less than 16 kg/m2
- unintentional weight loss greater than 15% within the last 3 to 6 months
- little or no nutritional intake for more than 10 days
- low levels of potassium, phosphate or magnesium prior to feeding
Or patient has two or more of the following:
- BMI less than 18.5 kg/m2
- unintentional weight loss greater than 10% within the last 3 to 6 months
- little or no nutritional intake for more than 5 days
- a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics
|
D (GPP) - People at high risk of developing refeeding problems (see table above) should be cared for by healthcare professionals who are appropriately skilled and trained and have expert knowledge of nutritional requirements and nutrition support.
D (GPP) - The prescription for people at high risk of developing refeeding problems should consider:
- starting nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4 to 7 days
- using only 5 kcal/kg/day in extreme cases (for example, BMI less than 14 kg/m2 or negligible intake for more than 15 days) and monitoring cardiac rhythm continually in these people and any others who already have or develop any cardiac arrhythmias
- restoring circulatory volume and monitoring fluid balance and overall clinical status closely
- providing immediately before and during the first 10 days of feeding: oral thiamin 200 to 300 mg daily, vitamin B compound (co) strong 1 or 2 tablets, three times a day (or full dose daily intravenous vitamin B preparation, if necessary) and a balanced multivitamin/trace element supplement once daily.
- providing oral, enteral or intravenous supplements of potassium (likely requirement 2 to 4 mmol/kg/day), phosphate (likely requirement 0.3 to 0.6 mmol/kg/day) and magnesium (likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unless pre-feeding plasma levels are high. Pre-feeding correction of low plasma levels is unnecessary
Monitoring of Nutrition Support in Hospital and the Community
D (GPP) - Healthcare professionals should review the indications, route, risks, benefits and goals of nutrition support at regular intervals. The time between reviews depends on the patient, care setting and duration of nutrition support. Intervals may increase as the patient is stabilised on nutrition support.
D (GPP) - People having nutrition support in hospital should be monitored by healthcare professionals with the relevant skills and training in nutritional monitoring.
D (GPP) - Healthcare professionals should refer to the protocols for nutritional, anthropometric and clinical monitoring, shown in Table 3 of the original guideline document, when monitoring people having nutrition support in hospital.
D (GPP) - Healthcare professionals should refer to the protocols for laboratory monitoring, shown in Table 4 of the original guideline document, when monitoring people having nutrition support in hospital. Table 4 of the original guideline document is particularly relevant to parenteral nutrition. It could also be selectively applied when enteral or oral nutrition support is used, particularly for people who are metabolically unstable or at risk of refeeding syndrome. The frequency and extent of the observations given may need to be adapted in acutely ill or metabolically unstable people.
D (GPP) - People having parenteral nutrition in the community need regular assessment and monitoring. This should be carried out by home care specialists and by experienced hospital teams (initially at least weekly), using observations marked * in Table 3 of the original guideline document. In addition, they should be reviewed at a specialist hospital clinic every 3 to 6 months. Monitoring should be more frequent during the early months of home parenteral nutrition, or if there is a change in clinical condition, when the full range of tests in Tables 3 and 4 of the original guideline document should be performed. Some of the clinical observations may be checked by patients or carers.
D (GPP) - People having oral nutrition support and/or enteral tube feeding in the community should be monitored by healthcare professionals with the relevant skills and training in nutritional monitoring. This group of people should be monitored every 3 to 6 months or more frequently if there is any change in their clinical condition. A limited number of observations and tests from Table 3 of the original guideline document should be performed. Some of the clinical observations may be checked by patients or carers. If clinical progress is satisfactory, laboratory tests are rarely needed.
D (GPP) - If long-term nutrition support is needed patients and carers should be trained to recognise and respond to adverse changes in both their well-being and in the management of their nutritional delivery system.
Oral Nutrition Support in Hospital and the Community
People with Dysphagia
D (GPP) - People who present with any obvious or less obvious indicators of dysphagia listed in the table below, titled " Indicators of dysphagia" should be referred to healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders.
Indicators of Dysphagia
| Obvious Indicators of Dysphagia |
Less Obvious Indicators of Dysphagia |
| Difficult, painful chewing or swallowing |
Change in respiration pattern |
| Regurgitation of undigested food |
Unexplained temperature spikes |
| Difficulty controlling food or liquid in the mouth |
Wet voice quality |
| Drooling |
Tongue fasciculation (may be indicative of motor neurone disease) |
| Hoarse voice |
Xerostomia |
| Coughing or choking before, during or after swallowing |
Heartburn |
| Globus sensation |
Change in eating habits – for example, eating slowly or avoiding social occasions |
| Nasal regurgitation |
Frequent throat clearing |
| Feeling of obstruction |
Recurrent chest infections |
| Unintentional weight loss – for example, in people with dementia |
Atypical chest pain |
D (GPP) - Healthcare professionals should recognise that people with acute and chronic neurological conditions and those who have undergone surgery or radiotherapy to the upper aero-digestive tract are at high risk of developing dysphagia.
D (GPP) - When managing people with dysphagia, healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should consider:
- the risks and benefits of modified oral nutrition support and/or enteral tube feeding
- the factors listed in the table below, titled "Factors to be considered before modification of nutrition support and hydration in people with dysphagia"
Factors to Be Considered Before Modification of Nutrition Support and Hydration in People with Dysphagia
Recurrent chest infections
Mobility
Dependency on others for assistance to eat
Perceived palatability and appearance of food or drink
Level of alertness
Compromised physiology
Poor oral hygiene
Compromised medical status
Metabolic and nutritional requirements
Vulnerability (for example, immunocompromised)
Comorbidities
|
D (GPP) - People with dysphagia should have a drug review to ascertain if the current drug formulation, route and timing of administration remains appropriate and is without contraindications for the feeding regimen or swallowing process.
D (GPP) - Healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should regularly monitor and reassess people with dysphagia who are having modified food and liquid until they are stable.
Indications for Oral Nutrition Support
A - Healthcare professionals should consider oral nutrition support (oral nutrition support includes any of the following methods to improve nutritional intake: fortified food with protein, carbohydrate and/or fat, plus minerals and vitamins; snacks; oral nutritional supplements; altered meal patterns; the provision of dietary advice) to improve nutritional intake for people who can swallow safely and are malnourished (see definition above in "Indications for Nutrition Support in Hospital and the Community") or at risk of malnutrition (see definition above in "Indications for Nutrition Support in Hospital and the Community").
D (GPP) - Healthcare professionals should ensure that the overall nutrient intake of oral nutrition support offered contains a balanced mixture of protein, energy, fibre, electrolytes, vitamins and minerals.
D (GPP) - If there is concern about the adequacy of micronutrient intake, a complete oral multivitamin and mineral supplement providing the reference nutrient intake for all vitamins and trace elements should be considered by healthcare professionals with the relevant skills and training in nutrition support who are able to determine the nutritional adequacy of a patient's dietary intake.
D (GPP) - Oral nutrition support should be stopped when the patient is established on adequate oral intake from normal food.
Oral Nutrition Support for Surgical Patients
B - Peri-operative oral nutrition support should be considered for surgical patients who can swallow safely and are malnourished.
A - Healthcare professionals should consider giving post-caesarean or gynaecological surgical patients who can swallow safely, some oral intake within 24 hours of surgery.
A - Healthcare professionals should consider giving post-abdominal surgery patients who can swallow safely, and in whom there are no specific concerns about gut function or integrity, some oral intake within 24 hours of surgery. The patient should be monitored carefully for any signs of nausea or vomiting.
Enteral Tube Feeding in Hospital and the Community
In this guideline, enteral tube feeding refers to the delivery of a nutritionally complete feed (as specified in Chapter 9 of the original guideline document) via a tube into the stomach, duodenum or jejunum.
Indications for Enteral Tube Feeding
D (GPP) - Healthcare professionals should consider enteral tube feeding in people who are malnourished or at risk of malnutrition respectively, and have:
- inadequate or unsafe oral intake, and
- a functional, accessible gastrointestinal tract
A - Enteral tube feeding should not be given to people unless they are malnourished or at risk of malnutrition and have; inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract, or they are taking part in a clinical trial.
D (GPP) - Enteral tube feeding should be stopped when the patient is established on adequate oral intake.
Enteral Tube Feeding for Surgical Patients
B - Surgical patients who are: malnourished and have; inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract and are due to undergo major abdominal procedures, should be considered for pre-operative enteral tube feeding.
A - General surgical patients should not have enteral tube feeding within 48 hours post-surgery unless they are malnourished or at risk of malnutrition and have; inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract.
Route of Access
A - People in general medical, surgical and intensive care wards who are malnourished or at risk of malnutrition and have; inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract should be fed via a tube into the stomach unless there is upper gastrointestinal dysfunction.
D (GPP) - People who are malnourished or at risk of malnutrition and have inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract, with upper gastrointestinal dysfunction (or an inaccessible upper gastrointestinal tract) should be considered for post-pyloric (duodenal or jejunal) feeding.
D (GPP) - Gastrostomy feeding should be considered in people likely to need long-term (4 weeks or more) enteral tube feeding.
A - Percutaneous endoscopic gastrostomy (PEG) tubes which have been placed without apparent complications can be used for enteral tube feeding 4 hours after insertion.
People with Dysphagia
A - In the acute setting, for example following stroke, people unable to swallow safely or take sufficient energy and nutrients orally should have an initial 2 to 4 week trial of nasogastric enteral tube feeding. Healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should assess the prognosis and options for future nutrition support.
Mode of Delivery
B - For people being fed into the stomach, bolus or continuous methods should be considered, taking into account patient preference, convenience and drug administration.
D (GPP) - For people in intensive care, nasogastric tube feeding should usually be delivered continuously over 16 to 24 hours daily. If insulin administration is needed it is safe and more practical to administer feeding continuously over 24 hours.
Motility Agents
A - For people in intensive care with delayed gastric emptying who are not tolerating enteral tube feeding, a motility agent should be considered, unless there is a pharmacological cause that can be rectified or suspicion of gastrointestinal obstruction.
D (GPP) - People in other acute care settings who have delayed gastric emptying and are not tolerating enteral tube feeding should also be offered a motility agent unless there is a pharmacological cause that can be rectified or suspicion of gastrointestinal obstruction.
D (GPP) - If delayed gastric emptying is severely limiting feeding into the stomach, despite the use of motility agents, post-pyloric enteral tube feeding and/or parenteral nutrition should be considered.
Management of Tubes
D (GPP) - People requiring enteral tube feeding should have their tube inserted by healthcare professionals with the relevant skills and training.
D (GPP) - The position of all nasogastric tubes should be confirmed after placement and before each use by aspiration and pH graded paper (with X-ray if necessary) as per the advice from the National Patient Safety Agency (NPSA) 2005. Local protocols should address the clinical criteria that permit enteral tube feeding. These criteria include how to proceed when the ability to make repeat checks of the tube position is limited by the inability to aspirate the tube, or the checking of pH is invalid because of gastric acid suppression.
D (GPP) - The initial placement of post-pyloric tubes should be confirmed with an abdominal X-ray (unless placed radiologically). Agreed protocols setting out the necessary clinical checks need to be in place before this procedure is carried out.
Parenteral Nutrition in Hospital and the Community
Indications for Parenteral Nutrition
D (GPP) - Healthcare professionals should consider parenteral nutrition in people who are malnourished or at risk of malnutrition, respectively, and meet either of the following criteria:
- inadequate or unsafe oral and/or enteral nutritional intake
- a non-functional, inaccessible or perforated (leaking) gastrointestinal tract
Prescription
D (GPP) - Parenteral nutrition should be introduced progressively and closely monitored, usually starting at no more than 50% of estimated needs for the first 24 to 48 hours. Parenteral nutrition can be withdrawn once adequate oral or enteral nutrition is tolerated and nutritional status is stable. Withdrawal should be planned and stepwise with a daily review of the patient's progress.
D (GPP) - Patients who need parenteral nutrition should have their nutritional requirements determined by healthcare professionals with the relevant skills and training in the prescription of nutrition support. Before using most parenteral nutrition products, micronutrients and trace elements should be added and additional electrolytes and other nutrients may also be needed. Additions should be made under appropriate pharmaceutically controlled environmental conditions before administration.
D (GPP) - Parenteral nutrition should be stopped when the patient is established on adequate oral and/or enteral support. There is no minimum length of time for the duration of parenteral nutrition.
Parenteral Nutrition for Surgical Patients
B - Healthcare professionals should consider supplementary peri-operative parenteral nutrition in malnourished surgical patients who have an inadequate or unsafe oral and/or enteral nutritional intake or a non-functional, inaccessible or perforated (leaking) gastrointestinal tract
B - Peri-operative supplementary parenteral nutrition should not be given to surgical patients unless they are malnourished or at risk of malnutrition and have an inadequate or unsafe oral and/or enteral nutritional intake or a non-functional, inaccessible or perforated (leaking) gastrointestinal tract.
B - If intestinal tolerance persistently limits enteral tube feeding in surgical or critical care patients, parenteral nutrition should be used to supplement or replace enteral tube feeding.
Route of Access
B - In hospital, parenteral nutrition can be given via a dedicated peripherally inserted central catheter as an alternative to a dedicated centrally placed central venous catheter. A free dedicated lumen in a multi-lumen centrally placed catheter may also be used.
B - Administration of parenteral nutrition via a peripheral venous catheter should be considered for patients who are likely to need short-term parenteral nutrition (less than 14 days) who have no need for central access for other reasons. Care should be taken in catheter choice and in attention to pH, tonicity and long-term compatibility of the parenteral nutrition formulations in order to avoid administration or stability problems.
D (GPP) - Tunnelling subclavian lines is recommended for long-term use (more than 30 days).
B - Catheters do not have to be tunnelled for short-term use (less than 30 days).
Mode of Delivery
B - Continuous administration of parenteral nutrition should be offered as the preferred method of infusion in severely ill people who require parenteral nutrition.
B - Cyclical delivery of parenteral nutrition should be considered when using peripheral venous cannulae with planned routine catheter change.
D (GPP) - A gradual change from continuous to cyclical delivery should be considered in patients requiring parenteral nutrition for more than 2 weeks.
Management of Catheters
D (GPP) - Only healthcare professionals competent in catheter placement should be responsible for the placement of catheters and they should be aware of the importance of monitoring and managing these safely (National Collaborating Centre for Nursing and Supportive Care, 2003).
Supporting Patients in the Community
D (GPP) - Healthcare professionals should ensure that patients having enteral or parenteral nutrition in the community and their carers:
- are kept fully informed and have access to appropriate sources of information in formats, languages and ways that are suited to an individual's requirements. Consideration should be given to cognition, gender, physical needs, culture and stage of life of the individual
- have the opportunity to discuss diagnosis, treatment options and relevant physical, psychological and social issues
- are given contact details for relevant support groups, charities and voluntary organisations
Enteral Tube Feeding
D (GPP) - All people in the community having enteral tube feeding should be supported by a coordinated multidisciplinary team, which includes dietitians, district, care home or homecare company nurses, General Practitioners (GPs), community pharmacists and other allied healthcare professionals (for example, speech and language therapists) as appropriate. Close liaison between the multidisciplinary team and patients and carers regarding diagnoses, prescription, arrangements and potential problems is essential.
D (GPP) - Patients in the community having enteral tube feeding and their carers should receive an individualised care plan which includes overall aims and a monitoring plan.
D (GPP) - Patients in the community having enteral tube feeding and their carers, should receive training and information from members of the multidisciplinary team on:
- the management of the tubes, delivery systems and the regimen, outlining all procedures related to setting up feeds, using feed pumps, the likely risks and methods for troubleshooting common problems and be provided with an instruction manual (and visual aids if appropriate)
- both routine and emergency telephone numbers to contact a healthcare professional who understands the needs and potential problems of people on home enteral tube feeding
- the delivery of equipment, ancillaries and feed with appropriate contact details for any homecare company involved
Parenteral Nutrition
D (GPP) - All people in the community having parenteral nutrition should be supported by a co-ordinated multidisciplinary team, which includes input from specialist nutrition nurses, dietitians, GPs, pharmacists and district and/or homecare company nurses. Close liaison between the multidisciplinary team and patients and carers regarding diagnoses, prescription, arrangements and potential problems is essential.
D (GPP) - People in the community having parenteral nutrition and their carers should receive an individualised care plan which includes overall aims and a monitoring plan.
D (GPP) - People in the community having parenteral nutrition and their carers should receive training and information from members of the multidisciplinary team on:
- the management of the delivery systems and the regimen, outlining all procedures related to setting up feeds, using feed pumps, the likely risks and methods for troubleshooting common problems and be provided with an instruction manual (and visual aids if appropriate)
- routine and emergency telephone numbers to contact a healthcare professional with the relevant competencies (specialist nutrition nurse, pharmacist)
- the arrangements for the delivery of equipment, ancillaries and feed with appropriate contact details for any homecare company involved
Definitions:
Evidence Categories
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++ High-quality systematic reviews of case-control or cohort studies
High-quality case-control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case-control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2- Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal
3 Non-analytical studies (for example, case reports, case series)
4 Expert opinion, formal consensus
Recommendation Grades
A - At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++, and is directly applicable to the target population, or
A systematic review of RCTs or a body of evidence that consists principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
Evidence drawn from a NICE technology appraisal
B - A body of evidence that includes studies rated as 2++, is directly applicable to the target population and demonstrates overall consistency of results, or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence that includes studies rated as 2+, is directly applicable to the target population and demonstrates overall consistency of results, or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4, or
Extrapolated evidence from studies rated as 2+, or
Formal consensus
D (GPP) - A good practice point (GPP) is a recommendation for best practice based on the experience of the Guideline Development Group
