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The NICE experience
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  1. The NICE experience Christine Baldwin Division of Medicine, Imperial College London & The Royal Marsden Hospitals, London PEN Group Annual Conference, London, August 2006

  2. Structure • Process • Type of evidence • Implications for dietitians

  3. The need for this guideline • Malnutrition is common • Nutritional provision in hospital and community may be inadequate • Provision of nutritional support requires complex decisions • Wide variation in nutritional care standards

  4. Topic nomination “to develop a guideline on appropriate methods of feeding patients who: • are still capable of deriving some of their nutritional requirements by conventional feeding and/or • have difficulty swallowing including the use of nutritional supplements and enteral and parenteral feeding methods” DoH and Welsh Assembly

  5. The process (1) • Proposal • National Collaborating Centre for Acute Care (NCCAC) • Scope stakeholders

  6. The process (2) Guideline Development Group: • Clinicians • GP • Dietitians (2) • Speech & Language Therapist • Nurses • Patient Groups • pharmacists

  7. The process (3) Development of clinical questions

  8. Clinical questions • P atients • Malnourished patients • I ntervention • More food or nutritional supplement • C omparison • No intervention • O utcomes • mortality

  9. Process (4) • Literature search • Review of papers • Extraction of data on identified outcomes

  10. Process (5) • Development of guidelines from evidence base • 1st consultation • 2nd consultation • Final guideline produced Stakeholder comments Stakeholder comments

  11. The guideline • Quick reference guide (a summary) • NICE guideline (all of the recommendations) • Full guideline (all of the evidence and rationale) • Information for the public (a plain English version) www.nice.org.uk

  12. Changing clinical practice • Department of Health has asked NHS organisations to work towards implementing the guidelines • Compliance will be monitored by the Healthcare Commission • NICE guidelines are based on the best available evidence

  13. Aims of the guideline • Authoritative evidence-based guidelines on nutritional support : • ‘Who? • When? • What? • How ?’ excluding children and immunonutrition

  14. Valid evidence • Systematic review of multiple randomised controlled trials (RCTs) • Large RCTs • Non-randomised, case-control studies • Non-experimental studies from more than one centre • Opinions based on clinical evidence

  15. Problems of evidence (1) • Study design • Which studies are included • Heterogeneity • Study quality • Definition of malnutrition • Interventions

  16. Problems of evidence (2) Wanted: volunteers for randomized, placebo controlled trial

  17. No evidence available NICE found no RCTs with the introduction of screening as the intervention that then looked at either change in process or clinical measures as outcomes.

  18. NICE argument: Even if evidence proves that nutrition support is effective, it does not necessarily follow that screening for malnourishment is of benefit

  19. Potential Solutions • Potential benefits of nutrition support may be better addressed by non-RCT techniques (but NICE lack the resources) • Formal Consensus Techniques • (but lack of time) NICE recognized our problems and allowed some Guidance based on first principles

  20. Nutritional screening • Inpatients • Outpatients • Residents of care homes • Attendees of GP surgeries should all be screened for riskof malnutrition (D (GPP))

  21. Grading of evidence

  22. Recommendations • 77 recommendations • 10 priorities for implementation • 5 research recommendations • Grade A = 8 • Grade B = 9 • Grade D (GPP) = 60

  23. Key priorities for implementation • 10 recommendations: • Screening (3) • Identification (2) • Nutritional support (1) • Education (4)

  24. Nutritional screening • Inpatients • Outpatients • Residents of care homes • Attendees of GP surgeries should all be screened for riskof malnutrition (D (GPP))

  25. Screening Two most important features: • linked to effective treatment pathway • leads to beneficial outcome

  26. Implications (1) Numbers of: • hospital inpatients (n=11,157) • hospital outpatients (n=10,823) • community

  27. Implications (2) • Who will carry out screening? • Need adequate numbers of dietitians • Who will raise awareness? •  referrals • available to see patients • provide training

  28. Implications (3) Research recommendation: Would a screening programme for all patients impact on clinical outcomes (LOS, QOL, complications), compared with no screening?

  29. Education “Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training” to enable accurate data collection(D (GPP))

  30. Implications (1) • Staff training: • Clear procedures • medical staff • nursing staff • management

  31. Implications (2) Research recommendation: “Further research is needed to ascertain whether an educational intervention … for all healthcare professionals … would have an affect on patient care [LOS, QOL, complications], compared to no formal education.”

  32. Oral nutritional intervention “Healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition.” (A)

  33. The debate Dietary advice vs Nutritional supplements vs Dietary advice + nutritional supplements

  34. Implications (1) • Can dietitians see all the patients that need intervention? • Which intervention? • develop policies • training to ensure consistency

  35. Implications (2) Research recommendation: Benefits to patients at nutritional risk offered sip feeds vs dietary counselling: • survival • complication rate • LOS • QOL • cost

  36. Consider enteral tube feeding (ETF): if patient malnourished/at risk of malnutrition despite the use of oral interventions and has a functional and accessible gastrointestinal tract use the most appropriate route of access and mode of delivery stop when the patient is established on adequate oral intake from normal food surgical patients may have different needs

  37. Enteral feeding “Healthcare professionals should consider enteral tube feeding in people who are malnourished or at risk of malnutrition, respectively, and have: (D (GPP)) • inadequate or unsafe oral intake, and • a functional, accessible gastrointestinal tract ”

  38. Elective enteral feeding No evidence of clinical benefits “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.” (A)

  39. Surgical patients:early post-op ETF ETF vs nil by mouth “General surgical patients should not have [ETF] within 48 hours post-surgery ...” (A) • 23 RCTs: combined results do not support the use of early ETF

  40. Are they NICE guidelines? Not perfect BUT they do raise the profile of nutritional care and oblige organizations to take it seriously.

  41. Summary Challenge and opportunity for dietitians

  42. Acknowledgements • Joanna Prickett Dietitian, • All members of the Guideline Development Group North Bristol NHS Trust