Management of Nutrition (In-Patient) (Guidelines)

When a stroke patient is admitted to hospital, screening for risk of under nutrition should be completed within 6 hours using the Malnutrition Universal Screening Tool (MUST) developed by the Malnutrition Advisory Group Available on: www.bapen.org.ukand click on ‘MUST’

• This should be carried out by an appropriately trained healthcare professional

• Scores obtained by completing the risk tool indicate the action to be taken

• 0 – Low Risk - Routine Care and repeat screen weekly

• 1 – Medium Risk - Complete 3 day food chart. Refer if required to dietician.  Repeat weekly

• 2 – High Risk -  Refer immediately to dietitian. Aim to improve and increase nutritional intake. Repeat weekly

• Repeat screening should be completed weekly in acute areas and at least monthly intervals thereafter if in continuing care

• Dysphagic patients / patients with swallowing problems unable to meet their nutritional requirements orally should be considered for initial Nasogastric (NG) Feeding.
• This should be considered within 72 hours.
• This decision should be recommended by the multi-disciplinary team in consultation with the patient and their carers/family. Consent of the patient should be obtained. In the absence of capacity the Consultant will make the decision with the family.
• Once NG feeding is initiated refer to the NHS Highland Policy for Enteral Feeding in Adults
• Consider the use of nasal bridles where tubes are being dislodged.
• If NG feeding unsuccessful, see Percutaneous Endoscopic Gastrostomy (PEG) Feeding.
• Transfers of patients with NG feeding / tubes to Community Hospitals must be discussed and notified at least 4 days prior to discharge from the Stroke Unit
• Stroke Unit staff are available 24hrs in the absence of dietitian for support and advice regarding NG feeding / tube insertion/removal.

If NG feeding is unsuccessful, or artificial nutritional support is required for more than 4 weeks, then feeding via Percutaneous Endoscopic Gastrostomy (PEG) is recommended.

The decision to place a PEG should balance risks and benefits.  These should be clearly explained to the patient so an informed choice can be made. The senior clinician holds responsibility when capacity is lacking as laid down in the Adults with Incapacity Act 2000.

• Information leaflets should be given to the patient / family  for PEG insertion.
• Referrals should be made to:
  • Belford - Surgical team
  • Caithness - Surgical team
  • Lorn and District - Surgical team
  • Raigmore - GI team
• Once PEG feeding started refer to the NHS Highland Policy on Enteral Feeding in Adults.
• Patients who are to be discharged with a PEG should be provided with appropriate equipment, information and support. Contact numbers for key contacts should be provided.
• All discharges should be notified to the dietician at least 4 days prior to discharge/transfer.
• Care should be transferred to primary care staff under the supervision of a dietitian.
• Training on dealing with PEGS at home should be provided by the ward team/ nutrition specialist nurse/ PEG at home Team prior to discharge home
• Information booklets should be provided for all patients being discharged
• For further information about discharge refer to PEG Guidelines.