INTRODUCTION PART TO THE ESPEN GUIDELINES ON ENTERAL NUTRITIONManaging the Patient Journey through Enteral Nutritional Care
Introduction
Nutritional care is a concept which includes several different aspects and these must be managed in a seamless way to ensure that the right patients receive the right nutritional support at the right time and in the right place. This does not happen by accident, and success depends on careful management supported by an effective infrastructure. The key elements contributing to this are:
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Implementing basic routines for nutritional care.
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Identifying patients’ nutritional needs.
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Providing individualised nutritional care when appropriate.
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Making the most of hospital food.
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Choosing the right products.
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Multi-professional working.
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Communication and documentation.
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Organisation and logistics.
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Financial management.
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Education.
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Training.
Section snippets
Implementing basic routines for nutritional care
Guidelines for nutritional screening, support, care and documentation should be implemented in every department and ward. Continuous training programmes must be in place to support this and a regular audit programme will identify any shortfalls which should be addressed.
Identifying patients’ nutritional needs
Nutritional depletion and the risk of further deterioration are frequently either unrecognised or ascribed to the disease state and this is not a new situation.1, 2, 3 Nutritional screening is the first step in the more complex nutritional assessment process and to avoid unnecessary depletion all patients should be screened to identify potential nutritional risk. Ideally, this should be started in the community setting4 and then repeated on admission to hospital. A variety of simple screening
Providing individualised nutritional care when appropriate
It is fundamental that nutritional care is based on each patient's individual nutritional requirements and preferences. Any patient who is undernourished or at risk of undernutrition should have a nutritional care plan. Each proposed action or intervention should be planned and documented in the nutritional care plan, in the same way as any other part of the medical and nursing treatment is documented.
Making the most of hospital food
There is widespread evidence of undernutrition among hospital patients3, 15, 16, 17, 18, 19 and many attempts have been made to redress this.20, 21, 22, 23, 24, 25, 26 In some cases, national governments are supporting initiatives to ensure that proactive nutritional management is embedded within the clinical care agenda.27, 28, 29, 30 The Council of Europe has also passed a resolution in this context.31 This paper covers all aspects of nutritional care provision and makes important
Choosing the right products
There will be occasions when food alone is insufficient to meet individual nutritional requirements and alternative feeding methods must be considered. A range of access routes is available and, similarly, there are many different products which can be used.
Multi-professional working
This is fundamental, and team working is equally important at all stages throughout the patient journey (Fig. 3). Although the concept of a clinical nutritional support team (NST) is now well recognised, these do not always exist in practice. In essence the key roles are:
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Physician/surgeon: Diagnosis and clinical management of the underlying condition including the responsibility for integrating appropriate nutritional support.
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Nurse: Care of the patient relating to the intended administration of
Communication
This has to be at the centre of care delivery simply because so many people are involved in what can be a very complex process. Patients (together with their relatives/carers) may move through a range of nutritional interventions provided in a variety of ward settings which are managed by different clinical teams before being discharged back into the community. Assumptions can be made, verbal messages can be misinterpreted or forgotten and mistakes can result at any stage during the patient
Organisation and logistics
Patients rarely seem to stay in one place, for a variety of very good reasons. Continuity of care is often taken for granted but this can be extremely difficult to ensure. Another aspect of nutritional support provision that is often overlooked (until it is too late) is the need to have the right supplies in the right place at the right time. This involves a lot of organisation which has to be in place on a timely basis and includes aspects such as appropriate ordering mechanisms, stock
Financial management
Nutritional support, includes the provision of:
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Essential nutrients to meet the fundamental requirements of the body.
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Nutritional components with biochemical and pharmacological properties which modify body disturbances and/or functions.
Nutritional support, therefore constitutes an important part of clinical care and treatment.
EN covers a spectrum of interventions and generates many different costs which may be charged in a number of ways and arrangements between countries vary significantly.
Education
Physicians and nurses as well as other staff should receive education in clinical nutrition on a continuing basis. The Council of Europe Resolution31 makes several recommendations in this respect including the need for undergraduate as well as post graduate programmes. Furthermore, the importance of educating non-clinical staff, e.g., catering managers, dietetic/nutrition assistants and ward staff involved in food service is emphasised.
Training
Consistent and safe practice is fundamental if patients are to have confidence in the system that is supporting them. This means that, not only must all hospital staff be familiar with the local range of enteral feeding practices, but so also must any community based staff who are involved in looking after the patient once they have been discharged from hospital. Training protocols for TF need to include the following aspects as a minimum:
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Use of equipment including feeding pumps and the feeding
Summary
Nutritional care is a fundamental component of clinical treatment and care. Optimising quality of life while concurrently meeting individual nutritional needs has to be the endpoint for patients receiving any form of nutritional care. This can only be achieved by following best practice55 and adopting an integrated and multi-professional approach to enteral nutritional throughout the patient journey.56 This in turn will be more successful if hospital/healthcare management is involved in the
Glossary
- Nutritional care
- is used, for this chapter only, to cover normal and fortified food, oral nutritional supplements (ONS) and tube feeding (TF) in its entirety
- Enteral nutrition (EN)
- ONS and TF
- Nutritional support
- EN, parenteral nutrition and food fortification
- Normal food
- normal diet as offered by the catering system of a hospital including special diets, e.g. gluten-free, lactose-free
- Fortified food
- normal food enriched with specific nutrients
- Formula
- any feed/ formulation that is used for EN
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