Parenteral Nutrition Policy for Adults

Transcription

1 Parenteral Nutrition Policy for Adults East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 1 of 24

2 Policy Title: Parenteral Nutrition Policy for Adults Executive Summary: To optimise the nutritional care of adult inpatients under the care of East Cheshire NHS Trust who are considered for or given parenteral nutrition (PN). Supersedes: Parenteral Nutrition Policy for Adults - CNSG002 (i.e. Version 1) Description of Amendment(s): Introduction reworded for clarity regarding appropriate use. NCEPOD guidance on case note documentation added Addition of Emergency Starter Regimen for use where out of hours commencement cannot be avoided. Policy body and daily PN prescription form amended to reflect that Additrace and Cernevit are now added in Aseptics to the PN solution (rather than on the ward.) Blood monitoring schedule formats redesigned for clarity. This policy will impact on: All staff caring for adult inpatients of East Cheshire NHS Trust (ECT) in particular doctors, nurses, dietitians and pharmacists. Financial Implications: Improvements in nutritional care will reduce costs and risks associated with suboptimal patient nutrition. Avoidance of inappropriate use of PN will minimise PN-associated medical complications and ensure cost-effective nutritional care. Policy Area Trust Wide Document Reference ECT Version Number 2 Effective Date September 2017 Issued By Kath Senior, Executive Director of Nursing, Performance & Quality Review Date August 2020 Author Version 2 : Karen Allsopp, (Specialist Dietitian), Dr. David Oleesky (Consultant Chemical Pathologist ) & Dr Lutfi Sulaiman (Chairman of Clinical Nutrition Steering Group - CNSG) Version 1: Amanda Hamilton (Specialist Dietitian), Lis Street (Deputy Chief Pharmacist) and the CNSG Impact Assessment Date: July 2017 APPROVAL RECORD Committees / Group Date Consultation: Clinical Nutrition Steering Group September 2017 Approved by Director: Kath Senior September 2017 Ratified by: Clinical Nutrition Steering Group September 2017 East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 2 of 24

3 Table of Contents 1. Introduction 5 2. Purpose 5 3. Roles and Responsibilities Medical Staff 3.2 Nursing Staff 3.3 Dietitian 3.4 Ward Pharmacist 3.5 Aseptic Pharmacist 3.6 Pathology Department 3.7 Infection Prevention and Control Team 4. Processes and Procedures Planning Criterion and Contraindications Referral Process Patients admitted who are on Home Parenteral Nutrition (HPN) 4.2 Prescription Composition of PN Storage of PN bags Administering PN 4.3 Line Access and Subsequent Line Management Parenteral Access Routes Central Access Peripheral Access 4.4 Monitoring Standard Laboratory Monitoring Schedule Management of Metabolic Complications Deranged Electrolytes Deranged Liver Function Tests (LFTs) Nutritional, Anthropometric & Clinical Monitoring 4.5 Assessing Continuation of PN 5. Monitoring Compliance with the Document References 14 East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 3 of 24

4 7. Appendices Page NICE Algorithm for decision making between Enteral and Parenteral Nutrition 2. Request to Start PN Form (for completion by Consultant/Registrar) 3. Nutritional Assessment and PN Regimen Form (for completion by Dietitian) 4. PN Prescription Form (for completion by Doctor F1/F2) 5. PN Preparations Available at ECT and their composition 6. PN Laboratory Monitoring Record Sheet 7. Emergency Starter PN Regimen East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 4 of 24

5 1. Introduction 1.0NTRODUCTION All clinical staff at East Cheshire NHS Trust (ECT) have a crucial role to play in achieving good nutritional care. Parenteral nutrition (PN) is the administration of nutrient solutions via a central or peripheral vein. PN should be given only when it is not possible to meet the patient s requirements via oral intake or enteral tube feeding. PN may be indicated in patients with a non-functioning gut however, it carries some risk of complications. Where gut function is inadequate to allow full requirements to be met enterally, wherever possible trophic enteral feeding should be given alongside the PN (i.e. a small volume at a slow rate of tube feeding, to maintain gut-mediated immunity and other benefits.) Decisions about appropriate nutrition for each individual patient need to be evidence-based and undertaken via a multi-disciplinary approach. Each patient requires an individual medical and nutritional assessment before commencing PN. Observation for any abnormal trend in clinical condition and for complications arising from PN is vital and requires skill, knowledge and expertise. PN is not recommended if the intention is to use it for less than five days. Shorter courses of PN are associated with poor outcomes and are contrary to BAPEN guidelines. Inappropriate use of PN can be worse than no nutrition. 2. Purpose The aim of the policy is to ensure that PN is administered: When nutritional needs cannot be met via the oral or enteral route in order to prevent disease related malnutrition and complications related to poor nutritional status. Safely with minimisation of complications. 3. Roles and Responsibilities The Executive Director of Nursing, who is a member of the Trust Board, has overall responsibility for the provision of nutrition within ECT. The Clinical Nutrition Steering Group (CNSG) is responsible for the oversight of nutrition within ECT and is currently directly accountable to the Trust Quality Forum. For further information regarding roles and responsibilities in the provision of nutrition, refer to the East Cheshire NHS Trust CNSG 001 Nutrition Policy for Adult Inpatients. All clinical service team managers are responsible for ensuring compliance with this policy within their unit/team and that staff are competent in the practice and attend appropriate training. All Trust employees involved in PN are responsible for ensuring that they are competent in the procedures used and deliver practice to the policy standards. East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 5 of 24

6 Certain professional groups and departments have specific responsibilities: 3.1 Medical Staff Medical staff have a responsibility to consider patients for PN if the gut is obstructed, not functioning or inaccessible. They are responsible for Documenting the reason for PN in the patient s casenotes (NCEPOD 2010) Completing PN prescription forms: form A (Appendix 2) and Form C (Appendix 4) Submitting the PN prescription forms to pharmacy by 12pm Laboratory monitoring according to the recommended schedules (Appendix 5) Once the decision has been made to commence PN, medical staff must adhere to the guidance found within policy and the attached appendices. The patient s consultant has overall responsibility for the decision to request PN and its administration, but line insertion can be delegated to a specialist with expertise in this field if appropriate. 3.2 Nursing Staff If the decision has been made to use PN as the appropriate route for nutrition support, nursing staff must adhere to the guidance found within the policy. Nursing staff must ensure that the patients receiving PN are monitored appropriately (see section and Appendix 5) and follow Trust guidance in relation to appropriate line care. Additional support can be obtained from the Clinical Site Co-ordinator, Critical Care Outreach or Night Sisters. 3.3 Dietitian Dietitians have a responsibility to ensure that each referred patient has a plan for adequate and appropriate nutritional support. Patients who are identified as requiring PN should be referred to Nutrition and Dietetics immediately on extension 1126, with a message left on this number, stating the date and time of referral, if the phone is not answered. Once referred, the dietitian is responsible for assessing the patient s nutritional requirements and making a recommendation for the PN prescription on Form B (See Appendix 3). In conjunction with medical and nursing staff, the dietitian is responsible for assessing whether PN should be continued, at least weekly. 3.4 Ward Pharmacist Ward pharmacists are responsible for checking that the indication for PN is appropriate and clinically checking the PN prescription, ensuring that the PN Policy has been adhered to. East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 6 of 24

7 3.5 Aseptic Pharmacist Aseptic services pharmacists must check that the prescription has been completed appropriately, that the PN regimen prepared is chemically and physically stable and that the PN has been dispensed accurately, according to the prescription. 3.6 Pathology Department The Pathology Department is responsible for providing laboratory test results and advice to support clinicians and other health professionals in optimising the provision of nutrition to patients. The biochemistry department has a particular responsibility for the provision of tests required for the monitoring of PN. 3.7 Infection Prevention and Control Team The Infection Prevention and Control Team is responsible for investigating any PN line infections and providing advice to minimise their occurrence. 4. Processes and Procedures 4.1 Planning Criterion and Contraindications Criterion for PN A non-functional, inaccessible or perforated GI tract. Contraindications to PN a) Patients in whom oral or enteral nutrition can meet nutrient requirements b) Patients on the End of Life pathway in most instances A low serum albumin is not a criterion for PN. For further guidance, please refer to enteral and parenteral decision-making algorithm in Appendix 1. (Taken from the full version of NICE guidance CG032, 2006) It is also recommended that PN is used in those patients who have intestinal failure which has persisted for at least 7 days, or is likely to persist for at least 7 days before significant improvement. PN is inappropriate if the likely duration of administration is less than 5 days. Parenteral nutrition commencement is not a clinical emergency and the decision to commence PN should be made in discussion with the dietitian and pharmacist during normal working hours. East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 7 of 24

8 Appropriate conditions where PN may be used include: Extended non-absorption of enteral nutrition, e.g. protracted ileus Gastrointestinal perforation Short bowel syndrome Extensive Crohn s disease unable to meet nutrient absorption High output gastrointestinal fistula Radiation enteritis Intractable vomiting Mucositis following chemotherapy Referral Process It has been demonstrated that a multidisciplinary approach to PN can improve patient care while reducing complications and costs. The referral pathway is based on completion of a specific PN referral form by the Consultant/Registrar (Form A, Appendix 2), which requires clinical, dietetic and pharmacy input. If PN is considered an appropriate route for nutrition, the relevant sections of the PN request form should be completed by a Consultant or Registrar responsible for the patient s care, including the indication for PN, likely duration and route of administration. A referral should then be made to the Department of Nutrition & Dietetics on extension 1126 and to the Pharmacist. The dietitian will complete the nutrition assessment on the PN request form (Form B, Appendix 3) and make recommendations for the PN regimen, including the run rate and bag, to enable the appropriate prescription form (Form C, Appendix 3) to be completed by the doctor after consultation with the ward pharmacist Patients admitted who are on Home Parenteral Nutrition (HPN) If a patient on PN is admitted to Macclesfield District General Hospital (MDGH), the centre managing their HPN should be contacted for advice about the prescription and line care. The regional centre is the Intestinal Failure Unit at Salford Royal Hospital, Salford (Tel: ). 4.2 Prescription The Consultant or Registrar completes the form Request to start Parenteral Nutrition Form A (Appendix 2) on Day 1 only The dietitian will recommend a PN regimen after making a nutritional assessment by completing Form B (Appendix 3) on Day 1 only. This should be attached to the back of the medication chart. Prescription forms (PN form C, Appendix 3) will be completed daily by the doctor in liaison with the ward pharmacist, and sent to the pharmacy for dispensing. It should be delivered to the pharmacy before 12 noon on the day it is required. On a Friday, three forms should be completed one each for the Friday, Saturday and Sunday. Out of hours PN is not normally available as malnutrition is the culmination of a gradual process and cannot be considered an emergency. If the Consultant requests PN to be started out of hours, then the Consultant is responsible for the safe prescribing and administration of PN. (See appendix 6 Emergency PN Regimen for Adults.) More detailed information is available in Pharmacy SOP DISP014, but key points are outlined below. East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 8 of 24

9 4.2.1 Composition of PN An all-in-one parenteral bag is used at ECT. This contains a combination of amino acid solution, fat emulsion, glucose solution, water and fat-soluble vitamins, trace elements, minerals, electrolytes and water. Blank bags are available which require the infusion of vitamin and minerals (Additrace and Cernevit) separately. No modification of PN bags, such as adding extra electrolytes, is currently possible. See Appendix 4 for bags available at ECT Storage of PN bags PN should be stored in a drug refrigerator and has a limited storage life. Occasional minor separation of the emulsion may be visible. Always agitate the bag gently before use. Protect PN from strong light using the silver bag covers supplied by pharmacy. Once removed from the refrigerator the bag should be warmed to room temperature before use. Use the manufacturer s specific guidance for storage and warming Administering PN The PN bag will arrive on the ward late afternoon or early evening. PN will be given at the rate according to dietician recommendation (as documented in patient s notes and on Form B, Appendix 3) and stated on the prescription and printed on the bag. All PN mixtures will be administered intravenously through a volumetric pump with occlusion and air in line alarms. See section 4.3 for guidance regarding line insertion and care. Continuous administration of PN should be offered as the preferred method of infusion in severely ill patients. Gradual change from continuous to cyclical delivery should be considered in patients requiring PN for more than 2 weeks or whose liver function tests are significantly elevated. Cyclical delivery of PN may be considered when using short term peripheral venous cannulae with planned routine catheter changes. Bags should be changed every 24 hours. 4.3 Line Access and Subsequent Line Management Appropriate line access, insertion and care of lines are crucial considerations in the care of patients receiving PN. Care should be taken regarding the route of administration and in particular catheter choice, in relation to ph, tonicity and long-term compatibility of the PN formulations, in order to avoid administration or stability problems. Only healthcare professionals competent in catheter placement should undertake placement of catheters and they should be aware of the importance of monitoring and managing these safely. All clinical (medical and nursing) staff who care for patients with intravenous lines must be familiar with the Trust s policies for: Aseptic [Non Touch] Technique (ANTT) Intravenous Insertion and Ongoing Care East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 9 of 24

10 These policies are available on the ECT Intranet Parenteral Access Routes PN should be administered via a central vein with peripheral access only being used in exceptional circumstances. Catheter insertion should be planned and performed using aseptic precautions. Catheters must be managed with appropriate aseptic techniques and inspected on a regular basis Central Access Central access is preferred and should normally be used for those patients requiring medium or long term PN (i.e. for more than 7 days.) The catheters can be inserted into subclavian, jugular or brachial veins, either directly into the vein or tunneled; this should be carried out by a skilled/trained clinician, who will decide which is the most appropriate access route. The number of lumens required on the catheter will depend on the clinical situation, e.g. critically ill patients may need a multi-lumen line for giving PN (via a dedicated lumen), drug infusions and central venous pressure monitoring. Patients requiring long term PN (e.g. 28 days) should be referred for insertion of a Hickman or PICC line by fax to the anesthetic office (ext. 3209). This service is currently provided by Dr Lutfi Sulaiman (Consultant Anesthetist); referrals should be marked for his attention. An X-ray should be requested to confirm correct placement of the catheter tip before administering PN Peripheral Access PN can be given via a large peripheral vein for a maximum of 7 days, e.g. for patients requiring short-term PN (5-7 days) and who have no need for central access, but requires close care and attention: Use of venflons as a means of access for PN should be used with caution where venous access is poor, as it carries a risk of thrombophlebitis. The osmolarity of the solution must be compatible with peripheral administration. A separate small cannula should be used, for PN only. It is recommended that the catheter site is changed every 24 hours. Cyclical delivery of parenteral nutrition should be considered, with planned routine catheter change, i.e. deliver PN over 18 hours, remove the cannula post infusion and replace with a new cannula in the other arm. East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 10 of 24

11 4.4 MONITORING Standard Laboratory Monitoring Schedule The following parameters should be measured at the frequency shown: PARAMETER WEEK ONE (OR UNTIL STABLE) WEEK TWO (OR WHEN STABLE) UREA & ELECTROLYTES (including DAILY TWICE WEEKLY CREATININE), CALCIUM, PHOSPHATE & MAGNESIUM & MAGNESIUM GLUCOSE DAILY TWICE WEEKLY LIVER FUNCTION TESTS, GAMMA GT & C-REACTIVE PROTEIN THREE TIMES WEEKLY WEEKLY FULL BLOOD COUNT THREE TIMES WEEKLY WEEKLY PROTHROMBIN TIME THREE TIMES WEEKLY WEEKLY FERRITIN, FOLATE, VITAMIN B12 BASELINE 3-MONTHLY if on long-term support VITAMIN D (25-Hydroxycholecalciferol) VITAMINS A & E (Retinol & Tocopherol) COPPER, ZINC SELENIUM BASELINE ONLY IF SUSPECT DEFICIENCY BASELINE ONLY IF SUSPECT DEFICIENCY BASELINE ONLY IF SUSPECT DEFICIENCY BASELINE ONLY IF SUSPECT DEFICIENCY 6-MONTHLY if on long-term support 6-MONTHLY if on long-term support FORTNIGHTLY AT 2 and 4 WEEKS, & THEN MONTHLY MANGANESE NOT REQUIRED AT 1 MONTH, & THEN MONTHLY ALUMINIUM NOT REQUIRED 6-MONTHLY if CKD Stages 4-5 A separate sheet should be used to record that these tests have been done (appendix 5). This sheet should not be used for recording results due to the risk of transcription errors; results are available for look up on the Clinisys LabCentre Browser Management of Metabolic Complications Complications may occur with PN, particularly abnormal electrolytes, raised liver function tests and raised blood glucose levels as the feeding route bypasses normal homeostatic mechanisms in the gastrointestinal tract Deranged Electrolytes Low electrolyte levels may be managed by giving separate infusions (although be careful of fluid overload). See ECT Intranet Clinical Guidelines Fluid & Electrolytes. East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 11 of 24

12 High electrolyte levels should be managed carefully. Electrolyte levels in the Triomel solutions are fairly low, so will rarely cause raised electrolyte levels, unless a patient has renal impairment, which can cause accumulation. General principles in managing raised electrolytes in PN patients a. Slightly raised No change Review daily b. Moderately raised Reduce rate of current PN (vitamins separately) Review daily c. Severely raised Consider switching to an electrolyte-free bag not routinely stocked Infuse other electrolytes separately (to avoid complications associated with low levels) Give Additrace and Cernevit separately Review daily The options should be discussed with the dietitian and consultant and a decision made based on the individual patient requirements Deranged Liver Function Tests (LFTs) If results demonstrate deranged LFTs: First ensure that the patient is not being overfed, as this can cause raised LFTs. However, long-term PN can cause increases in LFTs due to the long chain triglyceride (LCT) content. A patient with chronic liver failure may still be given PN, but should be monitored closely. Increased levels are reversible and rarely require intervention. However, the following may be beneficial: Cyclical feeding (e.g. 16 hours on and 8 hours off ) Consider switching to a fat-free bag - not routinely stocked Consider a PN with a different fat formulation (e.g. a medium chain triglyceride / long chain triglyceride formulation) - not routinely stocked The options should be discussed with the dietitian and consultant and a decision made based on the individual patient requirements. East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 12 of 24

13 4.4.5 Nutritional, Anthropometric & Clinical Monitoring The NICE guidance (2006) recommends that the following parameters are measured at the frequency shown A. Nutritional PARAMETER FREQUENCY RATIONALE Nutrient intake from oral, enteral or parenteral nutrition (including any change Daily initially, reducing to twice weekly when stable To ensure that patient is receiving nutrients to meet requirements and that current method of feeding is still the most appropriate. To allow alteration of intake as indicated in conditions that are affecting food intake) Actual volume of feed Daily initially, reducing to To ensure that patient is receiving correct delivered Fluid balance charts (enteral and parenteral) B. Anthropometric twice weekly when stable Daily initially, reducing to twice weekly when stable volume of feed. To allow troubleshooting To ensure patient is not becoming over/under hydrated PARAMETER FREQUENCY RATIONALE Weight Daily if concerns regarding fluid balance, otherwise weekly reducing to monthly To assess ongoing nutritional status, determine whether nutritional goals are being achieved and take into account both body fat and muscle BMI Start of feeding and then monthly Mid-arm circumference Monthly, if weight cannot be obtained or is difficult to interpret Triceps skinfold thickness C. Parenteral nutrition Monthly, if weight cannot be obtained or is difficult to interpret PARAMETER FREQUENCY RATIONALE Catheter entry site Daily Signs of infection/inflammation Skin over position of catheter tip (peripherally fed people) Daily Signs of thrombophlebitis D. Clinical condition PARAMETER FREQUENCY RATIONALE General condition Daily To ensure that patient is tolerating feed and that feeding and route continue to be appropriate Temperature/blood Daily initially, then as Sign of infection/fluid balance pressure Drug therapy needed Daily initially, reducing to monthly when stable Appropriate preparation of drug (to reduce incidence of tube blockage). To prevent/reduce drug nutrient interactions. These parameters should be recorded in the usual charts or in the patient notes. East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 13 of 24

14 4.5 Assessing Continuation of PN The NICE guidance (2006) recommends that assessment is done as follows: LONG-/SHORT-TERM GOALS FREQUENCY RATIONALE Are goals being met? Daily initially, reducing to twice weekly and then progressively to 3 6 monthly, unless clinical condition changes Are goals still appropriate? Daily initially, reducing to twice weekly and then progressively to 3 6 monthly, unless clinical condition changes To ensure that feeding is appropriate to overall care of patient To ensure that feeding is appropriate to overall care of patient The following should also be noted: PN should not be discontinued before an alternative method of nutrition support has been established. When the patient is ready to start oral or enteral nutrition, this should be introduced slowly. The dietitian will advise on the most appropriate method of nutritional support, i.e. enteral feeding or oral diet, including nutritional supplements. PN should always be titrated down before halting the infusion, to prevent rebound hypoglycemia. 5. Monitoring Compliance with the Document This policy will be audited regularly against NICE guidance Nutrition support in adults (CG 032, 2006). NCEPOD report A Mixed Bag: An enquiry into the care of hospital patients receiving parenteral nutrition (2010). (Provides a list of audit criteria.) This will be done as part of the CNSG planned audit programme. 6. References NICE guidance Nutrition support in adults (CG 032, 2006). NCEPOD report A Mixed Bag: An enquiry into the care of hospital patients receiving parenteral nutrition (2010). ECT Infection Control - Aseptic Technique Policy [ATP]. ECT Infection Control - Intravenous Insertion and Ongoing Care Policy [IVIOGC]. ECT Pharmacy SOP DISP014 Supply of Parenteral Nutrition (PN) to adult wards. East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 14 of 24

15 7. Appendices 1 Algorithm for Enteral and Parenteral Nutrition 2 Request to Start PN Form (by Consultant/Registrar) 3 Nutritional Assessment and Regimen Form (by Dietitian) 4 PN Prescription Form (by Doctor F1/F2) 4 PN Preparations Available at ECT and their composition 5 PN Laboratory Monitoring Record Sheet 6 Emergency Starter PN Regimen East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 15 of 24

16 Appendix 1 (imported from NICE Clinical Guideline 032, 2006) East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 16 of 24

17 Appendix 2 PN Form A REQUEST TO START PARENTERAL NUTRITION (PN) To be completed by a Consultant or Registrar on Day 1 only (Please pass to the Pharmacist before 12pm) Name: DOB:.. NHS No:... Hospital No:. Ward:.. Consultant: Potential indication for PN A non-functional, inaccessible or perforated GI tract Contraindications to PN patients in whom oral or enteral nutrition can meet nutrient requirements patients on the End of Life pathway in most instances A low serum albumin by itself is not an indication for PN Out of hours PN commencement is not recommended as the decision to start TPN should be made following discussion by the multidisciplinary team malnutrition cannot be considered an emergency and is the culmination of a gradual process inappropriate PN may increase the risk of complications including thrombosis, sepsis and metabolic disturbance Is the Gastrointestinal Tract inaccessible/obstructed/non-functioning? Could enteral nutrition by any route be established within 5 days? Yes/No Yes/No Reason(s) for requesting Parenteral Nutrition:... Likely duration of Parenteral feeding: 5-14 days days >28 days Route of administration: Is a central line in place? Yes/No If yes, what type of central line is in place? Date of most recent blood results: (to include urea & electrolytes, calcium, magnesium & phosphate).... / /. Refer the patient asap to the Nutrition and Dietetics department on ext Done Signature:. Name.. Designation: Date: / / East Cheshire NHS Trust: CNSG002 Parenteral Nutrition Policy for Adults Page 17 of 24

18 Appendix 3 PN Form B NAME: DOB: ADDRESS: NHS NO: Nutritional Assessment and Recommended Regimen To be completed by a Dietitian on Day 1 only. Send to Pharmacy CONSULTANT: WARD: Weight kg Estimated / Actual Date... /... /. B.M.I... kg/m² Estimated / Actual MUST Score: Is oedema or ascites present? Yes\No If Yes estimated dry weight..kg Is patient at high risk of the refeeding syndrome (as defined by NICE criteria below)? Yes\No One or more of the following: BMI less than 16 kg/m2 unintentional weight loss greater than 15% within the last 3-6 months little or no nutritional intake for more than 10 days low levels of potassium, phosphate or magnesium prior to feeding. Two or more of the following: BMI less than 18.5 kg/m2 unintentional weight loss greater than 10% within the last 3-6 months little or no nutritional intake for more than 5 days history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics Energy requirements Nitrogen requirement Standard Fluid requirement.. Bag Type: Triomel. Day Rate Hours Rate Hours Off ml/day Day 1 Day 2 Day 3 Day 4 Day 5 & onwards Signature. Name.. Designation Date / / When this form is returned to the ward, attach to the back of the medication chart

19 Appendix 4 PN Form C ADULT PARENTERAL NUTRITION (PN) PRESCRIPTION To be completed daily by the Doctor (any Grade) NAME: DOB: ADDRESS: NHS NO: CONSULTANT: WARD: Instructions Please complete daily Mon-Fri and pass to the Pharmacist before 12pm. (On a Friday three forms one each for Friday, Saturday and Sunday one also for Monday if a Bank Holiday.) Before starting PN on Day 1 Request Form for Parenteral Nutrition (Form A) must have been be completed by a Consultant or Registrar For recommended regimen, see Nutritional Assessment and Regimen Form B completed by the dietitian on Day 1 and attached to the back of the medication chart. The PN bag will be sent to the ward by 6pm. File returned prescriptions in the patient s notes Reason for PN : Type of line :. Prescription for / /.(date) PN Regimen: Triomel... Vol ml/day Infusion Rate:.. ml/hr x..hrs &. ml/hr x hrs Prescribing Dr s Signature: Print Name: Prescriber ID: Clinical Pharmacist Signature: Batch Number: Nurse s Signature: PN Set Up By: Time Started: Off x hrs Designation: Date: Bleep No: Released By: Checked By: Time Finished: PN Bags are stable for a maximum of 24hrs at room temperature (72 hrs if refrigerated) Please change after 24hrs and discard any remaining solution Cernevit and Additrace are added to each bag by Aseptics. These provide the daily requirements of vitamins and trace elements respectively.

20 Appendix 4 (continued) Triomel PN Bags N4-700E N7 1140E N9-1070E Peripheral/ Central Peripheral/ Central Central Central Available Size 1500ml 2000ml 1500ml 2000ml 1000ml 2000ml Nitrogen (g) Total Calories (Kcal) Non-Protein Calories (Kcal) Glucose Calories (Kcal) Lipid Calories (Kcal) Sodium (mmol) Potassium (mmol) Magnesium (mmol) Calcium (mmol) Phosphate (mmol) (incl. lipid source) In cases where the prescription is sent to Aseptics after 12pm, it might not be possible for the Additrace and Cernevit to be added to the bag by Aseptics. In such cases, Aseptics will contact the doctor to request Additrace and Cernevit be written up by the doctor on the medication chart for that day, so that Aseptics can send the vials to be given by the nursing staff. This will also apply on bank holiday weekends which are four days long (e.g. Easter) as addition of Additrace and Cernevit to the bag for the fourth day would lead to it expiring before use. Other PN Formulation bags are available to order from Baxter with 48 hour notice

21 Appendix 5 Adult TPN Laboratory Monitoring Week 1 (or until stable) NAME DOB HOSPITAL NO. SEX CONSULTANT WARD [Use addressograph label if available] Daily tests Day and Date: U&E/Creatinine, Calcium, Phosphate & Magnesium Glucose (Fl. Ox. tube) Day 1/3/5 tests Day and Date: Liver Function tests (LFT), Gamma GT & CRP Full Blood Count Prothrombin time Baseline tests (if done*) Date: Ferritin, B12/Folate Vitamin D Vitamins A & E** Copper & Zinc*** Selenium * Baseline levels of Trace Elements and Fat-soluble Vitamins (A/E/D) are NOT needed unless deficiency is suspected ** Separate SST Vacutainer (BD) protected from light required for Vitamins A & E *** Dark blue top (Trace Element) Vacutainer (BD) required for Copper and Zinc Note: This sheet should be used to record that these tests have been done, but should not be used for recording results due to the risk of transcription errors; results are available for look up on the Clinisys LabCentre Browser.

22 Appendix 5 (continued) Adult TPN Laboratory Monitoring Week 2 (or once stable) NAME DOB HOSPITAL NO. SEX CONSULTANT WARD [Use addressograph label if available] Twice weekly tests Day and Date: U&E/Creatinine, Calcium, Phosphate & Magnesium Glucose (Fl.Ox. tube) Twice weekly tests Day and Date: U&E/Creatinine, Calcium, Phosphate & Magnesium Glucose (Fl.Ox. tube) Weekly tests Day and Date: Liver Function tests (LFT), Gamma GT & CRP Full Blood Count Prothrombin Time Fortnightly tests Day and Date: xxxxx xxxxx xxxxx xxxxx xxxxx xxxxx xxxxx xxxxx Copper and Zinc* xxxxx xxxxx xxxxx xxxxx Selenium xxxxx xxxxx xxxxx xxxxx xxxxx Manganese** xxxxx xxxxx xxxxx xxxxx xxxxx xxxxx * Dark blue top (Trace Element) Vacutainer (BD) required for Copper and Zinc ** Separate EDTA (lilac top) Vacutainer (BD) required for Manganese Note: This sheet should be used to record that these tests have been done, but should not be used for recording results due to the risk of transcription errors; results are available for look up on the Clinisys LabCentre Browser.

23 Appendix 6 Emergency PN Regimen for ADULTS Out of hours initiation of PN is to be avoided wherever possible. (See ECT PN Policy for details.) For use only: When Consultant or Registrar has documented approval for starting PN in the casenotes and completed PN Form A 1. When the dietitian is not available (Saturday, Sunday and Bank Holidays) For the first 2-3 days of PN only. Not suitable for use after this period. Process 1. Please phone a referral through to Nutrition & Dietetics on x 1126 for assessment in hours. 2. Prescribe thiamine as Pabrinex 1 pair of ampoules i.v. 1800h once daily for two days. The first of these should be given no less than 30 minutes before the patient begins the first day s PN. (However, if the patient is on the Alcohol Withdrawal Protocol, please give Pabrinex according to that protocol instead.) 3. Prescribe Additrace one vial and Cernevit one vial i.v.: each 1800h daily whilst on out of hours PN. 4. Arrange baseline and subsequent bloodsets as per ECT PN monitoring schedule. (See PN Policy, Appendix 5, for full details) 5. Prescribe Triomel N9 PN solution according to the table following. Complete one PN prescription form (PN Form C 2 ) for each out of hours day 6. Adjust iv fluid orders as needed. PN will not meet full fluid requirements for most patients. Patient s Body Weight Day 1 only Triomel N9 Days 2 & 3 only Triomel N kg 7 ml/h x 24 h 14 ml/h x 24 h kg 8 ml/h x 24 h 16 ml/h x 24 h kg 10 ml/h x 24 h 20 ml/h x 24 h kg 11 ml/h x 24 h 22 ml/h x 24 h kg 14 ml/h x 24 h 28 ml/h x 24 h kg 16 ml/h x 24 h 32 ml/h x 24 h kg 19 ml/h x 24 h 38 ml/h x 24 h kg 22 ml/h x 24 h 44 ml/h x 24 h kg 25 ml/h x 24 h 44 ml/h x 24 h 100 kg and over 27 ml/h x 24 h 44 ml/h x 24 h 7 kcal/d/kg body weight 14 cal/d/kg body weight 1 Appendix 2 of PN Policy 2 Appendix 4 of PN Policy

24 Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Parenteral Nutrition Policy Details of person responsible for completing the assessment: Name: Karen Allsopp on behalf of Dr Lutfi Sulaiman Position: Specialist Dietitian/Consultant Anaesthetist Team/service: Nutrition and Dietetics State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) To ensure appropriate, safe use of Parenteral Nutrition meeting nutritional requirements in individuals for whom the enteral route is not possible. NICE CG032 Nutrition Support in Adults NCEPOD 2010 A Mixed Bag 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally.

25 Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common 3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC.

26 No 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) No 2.3 Does the information gathered from indicate any negative impact as a result of this document? 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No Explain your response: If explanation and discussion required with patient/carers and their first language is not English, staff will follow the trust interpretation policy GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No Explain your response: No difference to general population DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes No Explain your response: : If explanation and discussion required with patient/carers and they need this in another format due to visual or hearing impairment or learning disabilities, staff will follow the trust interpretation policy. There are communication boxes in wards and departments with support equipment, including a hospital communications book for people with limited understanding. AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes No Explain your response: Older patients are more likely to have Gastrointestinal disorders and require PN. The decision to give/continue PN may be influenced by the infirmity of the patient and comorbidities but not by his/her age per se. LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? Yes No

27 Explain your response: No difference to general population. RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes No Explain your response: Any specific requirements due to religion/belief would be noted and the content of feeds checked against these requirements. CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes No Explain your response: See above sections where information might be needed to be given to a carer in another format or language. OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes No Explain your response: There are no other additional groups that may be adversely affected by this document. 4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? Yes No b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children: Adult Parenteral feeding only. 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? Consultation has been taken with representatives of the key groups involved in implementation of the document

28 6. Date completed: July 2017 Review Date: Aug Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved That the document has no adverse impact? Reaudit of patients, to include those considered for but not given PN, with comparison of their ages and the ages of those actually receiving PN 8. Approval At this point, you should forward the template to the Trust Equality and Diversity Lead Approved by Trust Equality and Diversity Lead: Date: