Table 3.

Nutritional care process strategies from guidelines and opinion articles.

Nutritional care process	Strategies	References
Identification and assessment	Nutrition screening and assessment should be undertaken using validated tools e.g. MUST, NRS-2002, Subjective Global Assessment, Mini Nutritional Assessment for geriatric patients, NUTRIC score for ICU patients, GLIM criteria, MNA-SF, or a local validated tool	[9,10,12,[14], [15], [16],[18], [19], [20]]
	Estimation of risk by assessing oral intake and potentially impacting symptoms	[17]
	Consider at nutritional risk if BMI <22 kg/m2 and/or weight loss in the last three months and/or reduced food intake	[21]
	Alternative measures (in the absence of measurements of weight and/or height): •patient or family reported values of height, previous weight and weight loss •measurement of ulna length and mid arm circumference •subjective criteria e.g. loose clothing, history of decreased food intake, reduced appetite, reported dysphagia or underlying psycho-social or physical disabilities •Patients Association Nutrition Checklist (based on self-report)	[15,[17], [18], [19]] [36]
	Discharge: •Reassess nutritional risk on discharge and handover to community •Ongoing dietary counselling and individualised nutrition plans in nutritionally high risk, frail, sarcopenic, post ICU or critical care recovery patients •Ongoing assessment of muscle mass	[[15], [16], [17], [18]]
Diagnosis	Identify malnutrition: •Focus on immunocompromised, older adults, poly-morbid, malnourished individuals, people with underlying long term conditions (diabetes), ICU patients, patients who are unable to eat •Identify dysphagia – particular attention to patients discharged from ICU (post-extubation dysphagia) •Identify refeeding syndrome	[9,10,14,16,17,19,20]
Treatment strategies	Use protocols, algorithms, existing local policies or pathways to direct nutritional support once nutrition risk status is established.	[10,16,17,19,21]
	Link with existing pathways e.g. NICE rehabilitation pathway or community malnutrition pathway	[16,17,19] [37]
	Ward-based strategies: •High energy, high protein, easy to chew menu options •Snack boxes •Snack rounds •Symptom relief •Taste or smell changes - Strong-flavoured foods •Dry mouth - sugar-free fruit sweets	[16]
	ICU stepdown: •Maintain enteral nutrition until review by a dietitian •Use supplemental enteral feeding or ONS if required •Offer ONS after rehabilitation •Educate ward staff about optimising nutrition •Enteral feeding regimens structured around physiotherapy sessions	[16,17]
	ONS criteria: Hospital: •Early high protein nutritional supplementation (20 g/day) in all nutritionally high-risk patients •To meet nutritional targets •Poor appetite and inadequate eating •Dysphagia •Dysphagia – texture adapted diets according to advice of SLT Community: •Food intake (including food fortification) does not meet nutritional goals and if there is significant unplanned weight loss, and where the UK ACBS criteria are met •Consider self-purchase and use of powdered ONS options (consider patient's ability to manage preparation at home) •Assess level of independence including access to food and availability of help from family or neighbours	[9,10,12] [21] [17] [11] [20] [9,20] [15] [14,16,19] [15]
	Energy and protein provision: •400–600 kcal/day, ≥30 g protein/day from ONS •600–900 kcal/day, 35–55  g/d protein from ONS Give protein in periodic doses	[9,10] [21] [17]
	Artificial nutrition: Consider EN if oral intake: •<half of energy and protein requirements met orally for 3–7 days •<65% for malnourished patients •<50–60% for 3 days •where ONS intake is less than two bottles on two consecutive days •Consider PN if EN not tolerated	[9,10,20]< [10] [20] [21] [9,10,12,17,20,21]
	Nutritional requirements: Energy: •25-30 kcal/kg/day	[9,10,12,16,20,21]
	Protein: •1–2 g/kg body weight	[9,12,20,21]
	Adjust according to nutritional status, physical activity level, disease status, comorbidities, and tolerance	[9,20]
	Caution for refeeding syndrome	[9,10,16]
	On discharge: •Provide resources e.g. BDA Older Adults Factsheets and Guide to Nutrition and Hydration in Older Age	[14]
	•Continue ONS if intake severely impacted, ongoing breathlessness, fatigue or if using a mask or nebulisers, or medium/high risk of malnutrition	[9,16,19]
	•Review by a dietitian to establish need for ongoing ONS and to ensure prescriptions meet the UK ACBS indications	[16]
	•Arrange community dietitian or GP review and communicated in writing	[15]
	•Artificial nutrition if patient has ongoing severe swallowing dysfunction, neurological dysfunction, or gastrointestinal dysfunction	[17]
Implementation	MDT working: •Team could include clinical psychologists, speech and language therapists, physiotherapists, occupational therapists, and dietitians •Nurses for patients at risk of pressure ulcers •Podiatrists for diabetic foot injuries •Falls prevention •Mental health services	[9,10,14,15,17,19,20] [9,14,15,17,19,20]
Monitoring and review	Body weight, BMI, food intake, compliance to dietary advice and ONS, blood tests, clinical condition, and functional tests (such as sit to stand), self-reported activity, progress towards agreed goals and ability to undertake activities of daily living.	[15,19,20]
	Monitor prescription compared to delivery of EN and PN; avoid under and overfeeding.	[17]
	Prescription of ONS for at least one month (post discharge) and regular monitoring if compliance is in question	[9]
	Frequency: During hospitalisation: •weekly for low to moderate nutrition risk •every 2–7 days for high risk	[10]<
	Community: •1 week to 3 months intervals	[19]
Evaluation	No guidance

NICE: National Institute for Health and Care Excellence; ACBS: Advisory Committee on Borderline Substances; BAPEN: British Association of Parenteral and Enteral Nutrition; BDA: British Dietetic Association; BMI: Body Mass Index; EN: Enteral Nutrition; ICU: Intensive Care Unit; MNA-SF: Mini-Nutritional Assessment-Short Form; MUST: Malnutrition Universal Screening Tool; NRS-2002: Nutrition Risk Score 2002; ONS: Oral Nutritional Supplements; PN: Parenteral Nutrition; GLIM: Global Leadership Initiative on Malnutrition; NUTRIC: Nutrition Risk in Critically ill; MDT: multidisciplinary team; SLT: Speech and language therapy.