1 HYWEL DDA LOCAL HEALTH BOARD. RESTRICTED NOT YET APPROVED. Adult Parenteral Nutrition Guidelines Standards For 7,8,11,13,14,15,16, Policy Number: 338 Supercedes: Healthcare Services No/s 18, 19. Version Date Of Reviewer Completed Approved Date New Review No: Review: Name: Action: by: Approved: Date: Rachel Lewis & Clinical Policy April 2013 April 2015. Linda Morgan Review Group Guidance to support the safe and appropriate administration of Parenteral Brief Summary of Document: Nutrition in adults patients within secondary care. Policy 008: Policy for consent to examination and treatment Policy 209: Hywel Dda Adult Refeeding Guidelines Policy : Hywel Dda Enteral feeding policy To be read in conjunction with: NICE CG32 Nutrition Support for adults . Oral Nutrition support, enteral tube feeding and Parenteral Nutrition . NCEPOD (2010) A mixed Bag An enquiry into the care of hospital patients receiving Parenteral Nutrition Freedom Of Classification: Clinical Category: Policy Information Open Status Caroline Director of Authorised by: Job Title Signature: Oakley Nursing HYWEL DDA LOCAL HEALTH BOARD.
2 Responsible Rachel Lewis Job Clinical Lead Dietitian Officer/Author: Linda Morgan Title: Clinical Nutrition Nurse Specialist Nutrition and Dept Base Glangwili Hospital Dietetics Contact Details: Tel No 01267 227067 E-mail: ORGANISATION DEPARTMENT. Scope WIDE DIRECTORATE ONLY COUNTY ONLY . Administrative/ Allied Health Estates Professionals Ancillary Maintenance . Staff Group Scientific &. Medical & Dental Nursing Professional Other . Please indicate the name of the individual(s)/group(s) or committee(s) involved in the consultation process and state date agreement obtained. Individual(s) Date(s). Parenteral Nutrition working July 2012. CONSULTATION group July 2012. Nutrition support Clinical Group(s) focus group Date(s). Nutrition and Hydration Steering group Committee(s) Date(s). RATIFYING AUTHORITY. (in accordance with the KEY. Schedule of Delegation). COMMENTS/. A = Approval POINTS TO NOTE.
3 Required Date Approval NAME OF COMMITTEE Obtained FR = Final Ratification Clinical Policy Review Group FR. Group Rachel Lewis Date Equality Impact 22nd April completing Assessment Equality impact Linda Morgan Undertaken 2013 assessment Jackie Hooper Please enter any keywords to be Parenteral Nutrition , Enteral feeding, Nutrition Support, used in the policy search system to enable staff to locate this policy Refeeding syndrome Database No: 338 Page 2 of 46 Version Adult Parenteral Nutrition Guidelines HYWEL DDA LOCAL HEALTH BOARD. Document Implementation Plan Through a co-ordinated launch of the policy facilitated by the county Nutrition groups (for local launch) and the NSG (for launch to key professional groups). How Will This Policy Be Implemented? The policy will be adopted by the professions involved with its development once approved; this will support incremental implementation of the policy Who Should Use The Document?
4 All members of the multi-disciplinary team involved with nutritional care Training needs will be identified by the relevant professional leads;. What (if any) meeting the training needs will depend on the specific need. Training/Financial Financial: This policy supports the appropriate use of PN and therefore Implications are there is unlikely to be an increased cost associated with implementing Associated with this this policy. Optimal PN provision and related care may reduce costs by document? ensuring PN is only used in appropriate circumstances, reducing line infections and optimising nutritional care Action By Whom By When Approved guideline sent for signing Rachel Lewis Signed guideline made active on Policy intranet Coordinator Active guideline advertised via global e- Dietetics What are the Action mail Plan/Timescales for Awareness sessions across the health implementing this policy?
5 Dietetics board Cascade of guideline through locality Dietetics Nutrition groups Post graduate teaching sessions in Dietetics each locality Promotion of guideline via Nutrition Dietetics steering groups Database No: 338 Page 3 of 46 Version Adult Parenteral Nutrition Guidelines HYWEL DDA LOCAL HEALTH BOARD. Contents 1. 6. 2. POLICY STATEMENT .. 6. 3. SCOPE .. 6. 4. AIM .. 6. 5. OBJECTIVE .. 6. 6. NUTRITIONAL ASSESSMENT .. 7. Nutritional screening .. 7. Consent to treatment .. 8. Withdrawing PN .. 10. 7. DEFINITION OF Parenteral Nutrition .. 10. Total Parenteral Nutrition (TPN).. 10. Supplementary Parenteral Nutrition (SPN) .. 10. 8. INDICATIONS OF Parenteral Nutrition .. 10. 9. CONTRAINDICATIONS .. 11. Precautions of use .. 11. 10. ROUTES OF ACCESS .. 12. Types Of Lines .. 12. 11. STARTING Parenteral Nutrition .. 13. Assessment .. 13. Referral and prescription .. 14. Patients admitted who are on Home Parenteral Nutrition (HPN).
6 14. Composition of PN .. 14. Storage .. 15. 15. Rate of 15. Undesired effects of 16. 12. CONNECTING AND DISCONNECTING PN INFUSION .. 16. 13. FLUSHING A CENTERAL LINE FOR 17. 14. GIVING MEDICATION .. 17. 15. OUT OF HOURS PN .. 17. 16. MONITORING .. 17. Clinical monitoring .. 17. Laboratory 18. Other Monitoring: .. 19. 17. COMPLICATIONS .. 20. Metabolic complications .. 20. Catheter related complications .. 21. 18. DISCONTINUING PN .. 21. Unplanned stops in PN .. 22. 19. LONG TERM PN .. 22. 20. 22. 21. TRAINING .. 23. 22. IMPLEMENTATION .. 24. 23. FURTHER INFORMATION .. 24. 24. CLINICAL POLICIES .. 24. 25. REVIEW .. 24. 26. REFERENCES .. 24. 27. APPENDIX 1: ENTERAL & Parenteral 25. 28. APPENDIX 2: REFEEDING 26. 29. APPENDIX 3: Adult Parenteral Nutrition REFERRAL PROCESS .. 28. Database No: 338 Page 4 of 46 Version Adult Parenteral Nutrition Guidelines HYWEL DDA LOCAL HEALTH BOARD.
7 30. APPENDIX 4: Adult Parenteral Nutrition REFERRAL FORM .. 29. 31. APPENDIX 5: Adult Parenteral Nutrition PHARMACY REQUEST FORM .. 31. 32. APPENDIX 6: Adult Parenteral Nutrition PHARMACY CHANGE OF. REGIMEN FORM .. 31. 33. APPENDIX 7: COMPOSITION OF COMPOUNDED PN BAGS .. 33. 34. APPENDIX 8: COMPOSITION OF VITAMINS, MINERALS AND TRACE ELEMENTS..34. 35. APPENDIX 9: GUIDELINE FOR CONNECTING A Parenteral Nutrition . INFUSION .. 35. 36. APPENDIX 10: GUIDELIENE FOR DISCONNECTIONG AND FLUSHING AFTER A. Parenteral Nutrition INFUSION .. 41. Database No: 338 Page 5 of 46 Version Adult Parenteral Nutrition Guidelines HYWEL DDA LOCAL HEALTH BOARD. 1. INTRODUCTION. Parenteral Nutrition (PN) is the administration of nutrients by the intravenous route. It is a well established technique of providing artificial Nutrition support to patients who have an inaccessible or non-functioning gut.
8 Parenteral Nutrition is a high risk intravenous therapy, the use of which must be supervised and monitored by suitably trained staff. It should not be given without appropriate forethought and planning. 2. POLICY STATEMENT. To establish consensus within Hywel Dda Health board on the management of Adult patients requiring PN. 3. SCOPE. This clinical policy is for use with all Adult patients requiring PN within Hywel Dda Health board. It should be used by dietitians, registered nursing staff, chemical pathologist, pharmacists, doctors, allied health professionals (AHPs) and students alike within the scope of the individual's clinical competence. 4. AIM. To ensure that PN is considered in appropriate Adult patients in order to prevent and treat disease related malnutrition and complications related to poor nutritional status. To minimise clinical risk and promote the safe and appropriate administration of PN to all Adult patients.
9 To ensure a co-ordinated multi-disciplinary approach to PN within Hywel Dda Health board 5. OBJECTIVE. To provide guidance on identifying patients at nutritional risk and early identification of Patients' requiring PN. To recommend best practice for the safe administration and monitoring of PN. Database No: 338 Page 6 of 46 Version Adult Parenteral Nutrition Guidelines HYWEL DDA LOCAL HEALTH BOARD. 6. NUTRITIONAL ASSESSMENT. Half of all patients admitted to hospital are suffering from malnutrition (BAPEN, 2011). The consequences of malnutrition are diverse, and can affect all organs in the body. Failure to provide adequate Nutrition is both a cause and consequence of ill health, which can lead to immune dysfunction, disordered physiological function and delayed wound healing. Nutritional screening All patients admitted to hospital should be screened for malnutrition within the first 24hours of admission using the agreed Hywel Dda Health Board nutritional screening tool and re- screened on a weekly basis.
10 Any patient with existing malnutrition or those screened as being at high risk of malnutrition must have a Nutrition care plan in place and be highlighted to the responsible consulting team. Always consider risk of Refeeding syndrome (RFS) in patients with existing malnutrition or at high risk (further information of refeeding syndrome available in the appendix 2). Organisation of Nutrition support (NICE., 2006). Screen Recognise Treat Oral Enteral Parenteral Monitor & Review Refer to appendix 1 for further information on selecting the most appropriate means of providing Nutrition support for patients. Database No: 338 Page 7 of 46 Version Adult Parenteral Nutrition Guidelines HYWEL DDA LOCAL HEALTH BOARD. Consent to treatment Patient consent All patients with a poor nutritional status should be actively involved in decision making regarding their nutritional plan. The Royal College of Physicians (2010) state Those with intact cognitive function who are unable to eat or drink must be involved in decision making as their perception of the process resulting from absence of food will be different from those with absent cognitive function'.