Links with Hospital Nutrition and NST to adapt hospital policy to directorate use and to develop directorate nutrition policy

• Specialist requirements
• Training and education
• Governance and audit
• Budgets

Diagram showing areas of responsibilities for Directorates

Patient’s primary medical team

Must play a co-ordinating role between nutritional and other medical and surgical treatments and ensure that their patients receive excellent nutritional screening, assessment and care.

1. Acknowledges the importance of the involvement of all doctors/surgeons in nutritional care as, for example, emphasised by the Royal College of Physicians and PMETB.
2. Develops, fosters and encourages an awareness of the benefits of appropriate nutritional management and treatment, before during and after hospital admission, whether surgical or medical.
3. Considers the patients’ mental and physical ability to eat, the integrity of gastrointestinal function including motility, digestion and absorption, the metabolism and excretory function in the context of a diagnosis.
4. Prescribes treatment, taking into consideration drug nutrient interactions, surgical needs etc
5. Takes note of and applies nutritional screening, and assesses and monitors nutrition employing  clinical, biochemistry/haematology/microbiology information. Includes documentation of nutrition-related issues in records.
6. Decides in liaison with NST, nurses, dietitians etc on the optimal approach to each patient’s nutritional needs and ensures informed consent.
7. Liaises with patient and patient’s relatives: provides major source of information to patient and relatives in respect of all aspects of treatment, including nutrition.
8. Leads on ethical decisions in conjunction with NST and ward nurses, taking into consideration family/carer views including interpretation of advance directives.
9. Includes nutritional aspects of care in plans for  discharge and out-patient follow up
10. Includes nutrition when liaising with primary healthcare professionals.

Ward Nurses

Are the crucial “final common pathway” of nearly all patient-centred, ward-based care. For Nutrition they should adhere to standards set by Hospital Nutrition Steering Committee which may be adapted locally by Specialist Unit governance. They work in close co-operation with the patient’s principal medical team and the nutrition support team. Together with them they:

1. Maintain an ongoing policy towards the nutritional support of patients which has continuity in the context of staff turnover.
2. Employ routine nutritional screening including assessment of nutritional risk and the ability of the patient to eat.
3. Maximise use of available facilities and options to achieve enjoyable, psychosocially beneficial, nutritionally effective meals and food intake.
4. Take responsibility for individual patient’s food intake and co-ordinate a protected mealtimes policy at ward level.
5. Help with food choices
6. Help with feeding as appropriate
7. Monitor/keep records of food intake when necessary
8. Are alert to unsafe feeding
9. Provide food, and in conjunction with dietitians, supply artificial nutritional supplements
10. Provide expert safe delivery and monitoring of artificial nutritional support.
11. Deliver enteral and parenteral nutrition skillfully, closely following hospital protocols and guidance
12. Monitor enteral and parenteral nutrition – fluid balance, blood/urine glucose, diabetic charts, microbiology
13. Prevent (cross) infection.
14. Liaise with patient and patient’s relatives
15. Employ timely discharge planning and liaise  with the community.

Other specialist teams

A major challenge in organising excellent nutrition support is to bring groups together in a common cause to provide the highest quality nutritional care for the patient. It is a major challenge for a clinical team to organise in such a way that it works efficiently with other teams with subtly differing agendas.

Each specialist area in a large hospital may have its own governance, structure and  nutrition  protocols but these must be in line with overall hospital or institutional policy.

Nutrition Support services link importantly to :

• Radiology (central line insertion, Radiologically Inserted Gastrostomy  insertion)
• Endoscopy (Feeding tubes, Percutaneous Endoscopic Gastrostomy, Percutaneous Endoscopic Jejunostomy insertions) will be crucial to practice organisation.
• Speech And Language Therapy will be crucial allies in the care of patients with (potentially) unsafe swallow.
• Nurse led catheter insertion services may link directly or indirectly with nutrition nurse specialists. Liaison over policy development will be vital.
• Infection control team and microbiology: particularly relevant to parenteral nutrition – there needs to be tight coherence in  policies.
• Biochemistry services
• Home enteral or parenteral feeding services