Care groups are responsible for developing appropriate needs led local procedures.

Transcription

1 SECTION: SECTION 1 PATIENT CARE POLICY AND PROCEDURE NO: 1.23 NATURE AND SCOPE: SUBJECT: POLICY - TRUSTWIDE NUTRITION AND HYDRATION This policy details the Trust s responsibility to ensure it delivers good quality practice in meeting the nutrition and hydration needs of its service users. Care groups are responsible for developing appropriate needs led local procedures. DATE OF LATEST RATIFICATION: FEBRUARY 2018 RATIFIED BY: EXECUTIVE LEADERSHIP TEAM IMPLEMENTATION DATE: FEBRUARY 2018 REVIEW DATE: JANUARY 2021 ASSOCIATED TRUST POLICIES AND PROCEDURES: Management of Dysphagia (Swallowing Difficulties) Trust Wide Medicines Code Mental Capacity Act Advance Decisions and Advance Statements & 8.11a Insertion and Confirmation of the Placement of a Nasogastric Tube in Infants, Children, Young People and Adults ISSUE 4 FEBRUARY 2018

2 NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST NUTRITION AND HYDRATION POLICY CONTENTS 1.0 Introduction 2.0 Policy Principles 2.1 Screening 2.2 Hydration 2.3 In-patient Meals 2.4 Supporting service users who have difficulty with eating and drinking and those at high risk Dysphagia Medication Service users with diagnosed eating disorders Food and fluid refusal Artificial Hydration and Nutritional Support Palliative Care Obesity 3.0 Responsibilities 4.0 Training 5.0 Relevant Trust Policies 6.0 Target Audience 7.0 Monitoring Compliance 8.0 Equality Impact Assessment 9.0 Review Date 10.0 Consultation 11.0 Implementation 12.0 Legislation Compliance 13.0 Source Documents 14.0 Champion and Expert Writer Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Malnutrition Universal Screening Tool ( MUST ) Nutritional Intake Charts and audit tool Refeeding Syndrome Equality Impact Assessment Tool Record of Changes ISSUE 4 FEBRUARY

3 1.0 INTRODUCTION NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST NUTRITION AND HYDRATION POLICY ISSUE 4 FEBRUARY Nutrition And Hydration Nottinghamshire Healthcare NHS Foundation Trust recognises its responsibility to ensure service users receive adequate nutrition and hydration whilst in its care. 1.2 Poor hydration and nutrition increases morbidity and mortality, prolongs length of stay in health care environments and increases costs of care. 1.3 This policy describes good quality practice required to meet the nutrition and hydration needs of its service users. 1.4 The Trust recognises that good quality practice requires a collective response from clinicians of all disciplines working in partnership with catering staff and individual service users. 2.0 POLICY PRINCIPLES 2.1 Screening A nutrition screening tool will be utilised to identify the level of patients nutritional risk. This will normally be the Malnutrition Universal Screening Tool ( MUST see Appendix 1), although some clinical areas may use an alternative appropriate validated tool as agreed by the Trust Nutrition and Hydration Expert Forum. At the current time there is no validated tool for use with children with mental health problems All service users who are an inpatient will be nutritionally screened by ward staff within the agreed local timescale as set out in a local procedure Community service users will be screened where clinically appropriate Service users identified on screening to be at nutritional risk will have an appropriate care plan, which will include advice and additional support by appropriately trained staff, for example dietitians and speech and language therapists. 2.2 Hydration Service users should have access to fresh water at all times unless clinically inappropriate in which case this should be recorded in their care plan Service users who are at risk of poor or over-hydration due to physical/mental health problems, their medication, refusing fluids or because they are in seclusion should have their fluid intake monitored. Local procedures and the Trust Nutritional Intake chart should be followed (appendix 2) In severe cases where a patient requires intravenous or subcutaneous fluids then assistance should be sought from the nearby secondary care providers and an admission sought. 2.3 In-patient Meals Food will be nutritious, meeting national standards set for nutritional content, and served in an appropriate and appetising manner All food preparation will comply with food safety legislation.

4 2.3.3 If a service user is at risk of dysphagia then food should be provided at a safe and consistent texture, as advised by Speech and Language Therapists, in accordance with The International Dysphagia Diet Standardisation Initiative (IDDSI). See The menu will cater for the various needs and requirements of service users, taking in to account clinical, dietary, cultural and religious needs. Dietetic oversight should be sought for clinical need where necessary Nutritional analysis of menus will take place Trust wide when menus are introduced, reviewed or changed and service users will be provided with information, including allergy content risk in a format that complies with accessible communication standards to support them to make appropriate food choices Standardised food and fluid charts will be utilised to document fluid and nutritional intake in those patients deemed at hydration or nutritional risk (appendix 2) Many areas in the Trust operate a protection of meal times policy to allow service users to eat without interruption. Service Users will not be interrupted for nonessential clinical care or investigations. In discussion with the nurse in charge, relatives/carers who normally provide support and assistance at meals times to individual service users and who express a desire to continue with this will be welcomed to assist their relative at meal times Where service users have opportunity to access food in the Trust e.g. vending machines and on-site shops, the provision should fall in line with local initiatives and guidance regarding nutrition and healthy eating. 2.4 Supporting service users who have difficulty with eating and drinking and those at high risk Service Users requiring assistance to eat or drink will be offered this in a manner commensurate with their needs, including modified food or fluid consistency, adapted eating/drinking aids where required and ensuring dentures are used where appropriate Dysphagia All members of the multi-disciplinary team will be able to identify service users who have eating drinking and swallowing difficulties and following appropriate local procedures as required by the Trust Policy 1.09 Management of Dysphagia (Swallowing Difficulties). Where there are specific concerns about service users swallowing needs a referral should be made to Speech and Language Therapy Medication Occasionally some service users will be prescribed medication that may have side effects on their appetite and metabolism. Advice should always be available to service users about potential side effects of medication and how to report them. (See Trust Wide Medicines Code 19.01) Service users with diagnosed eating disorders Service users with a diagnosed eating disorder will be assessed and treated in line with appropriate clinical guidelines and pathways Food and fluid refusal ISSUE 4 FEBRUARY

5 Service users who refuse food or fluid will be managed according to local food and fluid refusal procedures. Offered and refused food or fluid must always be documented Artificial Hydration and Nutritional Support Most patients coming into hospital are able to drink normally and manage a normal diet during their hospital stay. Some patients however need additional nutritional support to help meet their nutritional requirements and this could be provided by; Dietitian support In cases of undernutrition in adults as indicated by a MUST score on RIO of 2 or above, or on Systm1 of 4 or above, then a referral to a dietitian must be made. In cases below these thresholds the first line advice available on RIO or Systm1 should be followed. In community cases the Guidelines for Prescribing Oral Nutritional Supplements in Adults, Nottingham Area Prescribing Committee should be followed encouraging Food First nutritional support Use of oral nutritional supplements Prescribed oral nutritional supplements should be given as prescribed dose and managed in line with `MUST` management guidelines or care plan in line with the relevant local health community guidance which should be included within local procedures. Enteral feeding The Trust Policy for Insertion and Confirmation of the Placement of a Nasogastric Tube in Infants, Children, Young People and Adults should be followed in all cases. NICE Guidance C32 Nutritional Support in Adults and local procedures, should be followed when service users are at risk of refeeding syndrome (Appendix 3). Service users who require long term enteral feeding will be assessed and managed by appropriately trained nursing staff (currently provided in the community by NUTRICIA) and dietitians in accordance with the crossorganisational Nottingham City and County policy and procedure for giving medicines, feeds and flushes via an enteral feeding tube and use, re-use, cleaning and disposal of enteral feeding equipment for adults Parenteral nutrition Palliative Care None of the above are exclusive and more than one approach may be needed. Where service users are receiving palliative care either within Trust premises or under our care in their own home, decisions about artificial hydration and nutritional support should be made by the multi-disciplinary team. Consideration should be given to any advance statements and decisions made by the service user (see Trust Policies 8.13, 8.11 and 8.11a). Further good practice guidance is available in the Royal College of Physicians publication Oral Feeding Difficulties and Dilemmas ISSUE 4 FEBRUARY

6 2.4.8 Obesity 3.0 RESPONSIBILITIES Obesity is a major clinical and public health issue and for patients in hospital this can adversely affect clinical outcomes. Identifying individuals who fall into this category and providing them with help and support at an appropriate time in their clinical care in line with clinical guidelines is an important role of the healthcare professional. 3.1 All members of the multi-disciplinary team have a duty to ensure that a service user s nutritional and hydration needs are recognised and addressed, and that they are supported in making informed choices regarding their dietary needs. This should include liaison with the dietitian and/or Catering Department where necessary and appropriate. 3.2 General Managers are responsible for ensuring local procedures and pathways are in place to support this policy and that sufficient staff are trained in the use of the MUST screening tool (or agreed alternative). 3.3 Facilities staff are responsible for ensuring that meals are appropriately nutritious and comply with all relevant food safety legislation where the Trust has responsibility for meal provision. Where services are contracted General Managers are responsible for ensuring service specifications meet the policy requirement. 3.4 Dietitians are responsible for providing specialist assessment, treatment and advice for those service users referred to them with complex needs. Dietetic services will be available to facilitate the delivery of training in the use of nutrition screening tools and for supporting Facilities staff in menu planning and the development of information about the nutritional value of in-patient meals. It is acknowledged that in some areas access to dietitians is limited. 3.5 Speech and language therapists assess, diagnose and manage swallowing difficulties. Swallowing difficulties may occur at the oral, pharyngeal and oesophageal stages of deglutition (RCSLT 1996). This includes any difficulty arising from positioning food in the mouth, through the oral movements such as biting, chewing and sucking food, to the actual process of swallowing. If appropriate intervention and support is not received, dysphagia has a severe impact on the health, nutrition and quality of life of individuals. Speech and language therapists advise on the safest viscosity of food and/or drink for a patient with dysphagia using the International Dysphagia Diet Standardisation initiative (IDDSI). 3.6 The Trust Physical Healthcare Committee is responsible for setting standards and monitoring performance in nutrition and hydration care, utilising the expertise of the Trust Nutrition and Hydration Expert Forum. 3.7 The Trust Nutrition and Hydration Expert Forum supports clinicians in providing evidencebased practice and advice relating to nutrition and hydration, escalating concerns and making recommendations to the Trust Physical Healthcare Committee. 4.0 TRAINING 4.1 General Managers are responsible for ensuring that sufficient staff are provided with training in the use of the MUST screening tool (or agreed alternative) and the appropriate action to take when a service user is identified as having a nutrition or hydration need. This may not always be face to face, with e-learning and champion models currently in development. 4.2 Dietitians are responsible for providing training jointly identified and agreed with, and resourced by General Managers. This should be inclusive of facilities staff as appropriate. ISSUE 4 FEBRUARY

7 ISSUE 4 FEBRUARY Nutrition And Hydration Specialist dietetic assessment and treatment will only be provided by appropriately trained dietitians. 4.4 Heads of Facilities and General Managers are responsible for ensuring that facilities staff and other staff preparing and serving food receive food safety training commensurate with their work activities. 5.0 RELEVANT TRUST POLICIES/PROCEDURES Management of Dysphagia (Swallowing Difficulties) Trust Wide Medicines Code Mental Capacity Act Advance Decisions and Advance Statements & 8.11a 6.0 TARGET AUDIENCE 6.1 All staff involved in the provision of food to and the treatment of service users, particularly in inpatient areas. 7.0 MONITORING COMPLIANCE 7.1 Compliance with this policy is monitored by PLACE, MICE and documentation audit. 7.2 Where this is a CQUIN target performance will also be monitored by the Trust Board and commissioners with information collected on RiO or SystmOne. 7.3 Ulysses Incident reports will be reviewed by the Trust Nutrition and Hydration Expert Forum, who will escalate concerns and recommendations to the Trust Physical Healthcare Committee. 7.4 Facilities have responsibility for monitoring food safety standards against current legislation using the Food Safety Audit Tool. 7.5 Responsibility for monitoring Trust performance against external standards, guidelines and benchmarks is delegated to the Trust Physical Healthcare Committee. 8.0 EQUALITY IMPACT ASSESSMENT 8.1 Following the screening exercise it has been determined that a full EIA is not necessary. No negative impact has been identified for any of the strands. Positive impacts have been identified for race, disability and religion/belief because provision for these groups as having identified dietary needs is made in the policy. 9.0 REVIEW DATE 9.1 This policy will be reviewed every 3 years or in the light of organisational change 10.0 CONSULTATION 10.1 Members of the Trust Nutrition and Hydration Expert Forum and Leadership Team IMPLEMENTATION 11.1 Responsibility for assessing the implementation of this policy rests with General Managers and Heads of Services. They will be required to identify and carry out such preparation as necessary to confirm that staff understand the expectations on them and that they are both competent and confident to discharge these.

8 11.2 The policy will be placed on the Nottinghamshire NHS Foundation Trust intranet site Responsibility for developing local procedures lies with Associate Directors of Nursing Quality and Patient Experience Reference to this policy and local procedures will be made at training on the use of screening tools LEGISLATION COMPLIANCE 12.1 This policy has been considered in the context of relevant legislation including the Health and Safety at Work Act (1974) and the Mental Capacity Act (2005) SOURCE DOCUMENTS NICE Guidance on Nutrition Support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (2006) NICE Quality standard 24: Quality standard for nutrition support in adults (2012) Care Quality Commission (CQC): Outcome 5 Nutrition Essence of Care: Nutrition Benchmark (2010) 10 key characteristics of good nutritional care in hospitals. Council of Europe Resolution on Food and Nutritional Care in Hospitals (2007) NHS Kidney Care Hydration Matters (2012) PLACE (2013) Assessments relate to provision of safe and appropriate food and drink for patients and assistance when required at mealtimes within an environment conducive to eating and drinking. International Dysphagia Diet Standardisation initiative (IDDSI) 14.0 IDENTIFICATION OF CHAMPION AND EXPERT WRITER 14.1 The Champion of this policy is Julie Attfield, Executive Director of Nursing and the Expert Writer is Catherine Pope, Associate Director Allied Health Professionals, Local Partnerships. ISSUE 4 FEBRUARY

9 APPENDIX 1 ISSUE 4 FEBRUARY

10 ISSUE 4 FEBRUARY Nutrition And Hydration 1.23

11 ISSUE 4 FEBRUARY Nutrition And Hydration 1.23

12 ISSUE 4 FEBRUARY Nutrition And Hydration 1.23

13 ISSUE 4 FEBRUARY Nutrition And Hydration 1.23

14 ISSUE 4 FEBRUARY Nutrition And Hydration 1.23

15 Please affix patient label Patient Name: Date of birth: NHS / K Number: APPENDIX 2 FLUIDS ONLY INPUT/OUTPUT CHART (Using the measured jug system) Date Location / Ward: Type of drink Fresh water jug (1000mls) Oral Input Amount offered Mls drank from water jug:- Fresh water jug (1000mls) Mls drank from water jug:- Fresh water jug (1000mls) Mls drank from water jug:- Amount drank Subcut / IV Fluids / Tube Flush State type of fluid Volume Started Volume Infused Urine Output Vomit / Other Oral Subcut/IV/Peg Urine Other Totals:- Subcut/I.V. FLUIDS:- Enter fluid and volume of bag in started column at start time. When infusion completed enter in Infused column at end time. At midnight, calculate how much has been infused and enter the amount in Infused column at 24.00hrs. The remainder still to be infused is to be entered in the Started column on a new chart at 00.00hrs Cup = 150mls Beakers = 200mls Sips = e.g mls ISSUE 4 FEBRUARY

16 Please affix patient label Patient Name: Date of birth: NHS / K Number: FLUID INPUT/OUT CHART APPENDIX 2 All fluids hot drinks and water, be recorded Date Location / Ward: Type of drink Fresh water jug (1000mls) Oral Input Amount offered Mls drank from water jug:- Totals:- Amount drank Subcut / IV Fluids / Tube Flush State type of fluid Volume Started Volume Infused Urine Output Vomit / Other Oral Subcut/IV/Peg Urine Other Subcut/I.V. FLUIDS:- Enter fluid and volume of bag in started column at start time. When infusion completed enter in Infused column at end time. At midnight, calculate how much has been infused and enter the amount in Infused column at 24.00hrs. The remainder still to be infused is to be entered in the Started column on a new chart at 00.00hrs Cup = 150mls Beakers = 200mls Sips = e.g mls ISSUE 4 FEBRUARY

17 Please affix patient label Patient Name: Date of birth: NHS / RIO / K Number: FOOD ONLY - INTAKE CHART APPENDIX 2 All offered food, supplements, milky drinks and snacks to be recorded Date Current Weight: Location / Ward: MEAL Breakfast FOOD OFFERED State portion size full portion or half portion FOOD CONSUMED NIL 1/4 1/2 3/4 ALL Signed: (Print name and designation) Mid Morning Lunch Mid Afternoon Teatime. Night-time Other ISSUE 4 FEBRUARY

18 Please affix patient label Patient Name: Date of birth: NHS / K Number: FLUID INPUT/OUT CHART APPENDIX 2 All fluids hot drinks and water, be recorded Date Location / Ward: Type of drink Fresh water jug (1000mls) Oral Input Amount offered Mls drank from water jug:- Totals:- Amount drank Subcut / IV Fluids / Tube Flush State type of fluid Volume Started Volume Infused Urine Output Vomit / Other Oral Subcut/IV/Peg Urine Other Subcut/I.V. FLUIDS:- Enter fluid and volume of bag in started column at start time. When infusion completed enter in Infused column at end time. At midnight, calculate how much has been infused and enter the amount in Infused column at 24.00hrs. The remainder still to be infused is to be entered in the Started column on a new chart at 00.00hrs Cup = 150mls Beakers = 200mls Sips = e.g mls ISSUE 4 FEBRUARY

19 Please affix patient label Patient Name: Date of birth: NHS / RIO / K Number: FOOD ONLY - INTAKE CHART APPENDIX 2 All offered food, supplements, milky drinks and snacks to be recorded Date Current Weight: Location / Ward: MEAL Breakfast FOOD OFFERED State portion size full portion or half portion FOOD CONSUMED NIL 1/4 1/2 3/4 ALL Signed: (Print name and designation) Mid Morning Lunch Mid Afternoon Teatime. Night-time Other ISSUE 4 FEBRUARY

20 Please affix patient label Patient Name: Date of birth: NHS / K Number: Date APPENDIX 2 FLUIDS ONLY INPUT/OUTPUT CHART (Using the measured jug system) Location / Ward: Type of drink Fresh water jug (1000mls) Oral Input Amount offered Mls drank from water jug:- Fresh water jug (1000mls) Mls drank from water jug:- Fresh water jug (1000mls) Mls drank from water jug:- Amount drank Subcut / IV Fluids / Tube Flush State type of fluid Volume Started Volume Infused Urine Output Vomit / Other Oral Subcut/IV/Peg Urine Other Totals:- Subcut/I.V. FLUIDS:- Enter fluid and volume of bag in started column at start time. When infusion completed enter in Infused column at end time. At midnight, calculate how much has been infused and enter the amount in Infused column at 24.00hrs. The remainder still to be infused is to be entered in the Started column on a new chart at 00.00hrs Cup = 150mls Beakers = 200mls Sips = e.g mls ISSUE 4 FEBRUARY

21 FOOD RECORD CHART AUDIT TOOL FRC = Food record chart Answer Yes / No Ward / Area being audited: Date of audit: Auditor: 1 Is the following entered on the FRC? Patient name NHS number DOB Weight Date 2 Is the correct FRC in use? 3 Has all food offered been completed? Breakfast Mid morning Lunch Mid afternoon Teatime Night time 4 Has the amount of food consumed been completed? Breakfast Mid morning Lunch Mid afternoon Teatime Night time 5 Has all fluids offered been completed? Patient ISSUE 4 FEBRUARY

22 Breakfast Mid morning Lunch Mid afternoon Teatime Night time 6 Has all fluid volume consumed been completed? Breakfast Mid morning Lunch Mid afternoon Teatime Night time 7 Has each entry been signed for? Breakfast Mid morning Lunch Mid afternoon Teatime Night time Comments: Q1 /5 Q2 /1 Q3 /6 Q4 /6 Q5 /7 Q6 /7 Q7 /7 % Total % score: ISSUE 4 FEBRUARY

23 APPENDIX 3 REFEEDING SYNDROME Refeeding syndrome describes the cascade of metabolic and electrolyte imbalances that occur as a result of feeding a patient who has been starved for a prolonged period. This can lead to abnormally low serum levels of potassium, phosphate and magnesium, which may result in cardiac arrhythmias and death. Reference: NS702 Fletcher J (2013) Parenteral nutrition: indications, risks and nursing care. Nursing Standard. 27, 46, Date of submission: December ; date of acceptance: February ISSUE 4 FEBRUARY

24 APPENDIX 4 EQUALITY IMPACT ASSESSMENT (EIA) SCREENING TOOL (Towards an Equality and Recovery Focused Organisation) A. Name of policy/procedure/strategy/plan/function etc. being assessed: Nutrition and Hydration B. Brief description of policy/procedure/strategy/ plan/function etc. and reason for EIA: C. Names and designations of EIA group members: D. List of key groups/organisations consulted: E. Data, Intelligence and Evidence used to conduct the screening exercise: This policy details the Trust s responsibility to ensure it delivers good quality practice in meeting the nutrition and hydration needs of its service users Catherine Pope Associate Director AHP Local Partnerships/ Clinical Director Members of the Trust Nutrition and Hydration Expert Forum Members of the Trust Nutrition and Hydration Expert Forum including nurses, dieticians, speech and language therapists and facilities staff. Documents described in sections 5 and 13 and knowledge of EIA group members ISSUE 4 FEBRUARY

25 F. Equality Strand Does the proposed policy/procedure/ strategy/ plan/ function etc. have a positive or negative (adverse) impact on people from these key equality groups? Please describe Race Gender Inclu. Transgender and Pregnancy & Maternity Disability Religion/Belief Sexual Orientation Incl. Marriage & Civil Partnership Age Positive impact, because the policy will be based on clinical, dietary and religious need, and when appropriate will consider cultural preference No impact, because the policy will be applicable to all service users based on clinical need Are there any changes which could be made to the proposals which would minimise any adverse impact identified? What changes can be made to the proposals to ensure that a positive impact is achieved? Please describe Have any mitigating circumstances been identified? Please describe Areas for Review/Actions Taken (with timescales and name of responsible officer) Not applicable Not applicable Author to review in 3 years Not applicable Not applicable As above Positive impact because the policy will be based on clinical and dietary need Not applicable Not applicable As above As race Not applicable Not applicable As above As gender Not applicable Not applicable As above As gender Not applicable Not applicable As above Social Inclusion* 1 As gender Not applicable Not applicable As above Community Cohesion* 2 As gender Not applicable Not applicable As above Human Rights* 3 As gender Not applicable Not applicable As above ISSUE 4 FEBRUARY

26 * 1 for Social Inclusion please consider any issues which contribute to or act as barriers, resulting in people being excluded from society e.g. homelessness, unemployment, poor educational outcomes, health inequalities, poverty etc. * 2 Community Cohesion essentially means ensuring that people from different groups and communities interact with each other and do not exclusively live parallel lives. Actions which you may consider, where appropriate, could include ensuring that people with disabilities and non-disabled people interact, or that people from different areas of the City or County have the chance to meet, discuss issues and are given the opportunity to learn from and understand each other. * 3 The Human Rights Act 1998 prevents discrimination in the enjoyment of a set of fundamental human rights including: The Right to a Fair Trial; Freedom of Thought, Conscience and Religion; Freedom of Expression; Freedom of Assembly and Association; and the Right to Education. G. Conclusions and Further Action (including whether a full EIA is deemed necessary and agreed date for completion) H. Screening Tool Consultation End Date I. Name and Contact Details of Person Responsible for EIA (tel. , postal) J. Name of Group Approving EIA (i.e. Directorate E&D Group; Divisional Workforce, Equality & Diversity Group; Trustwide E&D Subcommittee; or Divisional Policy & Procedures Group) Following the screening exercise it has been determined that a full EIA is not necessary. No negative impact has been identified for any of the strands. Positive impacts have been identified for race, disability and religion/belief because provision for these groups as having identified dietary needs is made in the policy. 5pm on Tuesday 6 February 2018 Catherine Pope Associate Director AHP, Local Partnerships/Clinical Director Catherine.pope@nottshc.nhs.uk Equality and Diversity Subcommittee of the Board of Directors ISSUE 4 FEBRUARY

27 APPENDIX 5 Policy/Procedure for: Nutrition and Hydration Issue: 04 Status: Author Name and Title: APPROVED Catherine Pope, Associate Director for Allied Health Professionals Issue Date: 26 FEBRUARY 2018 Review Date: JANUARY 2021 Approved by: EXECUTIVE LEADERSHIP TEAM (14/02/2018) Distribution/Access: NORMAL RECORD OF CHANGES DATE AUTHOR C Pope C Pope C Pope POLICY/ PROCEDURE 1.23 (Issue 1) 1.23 (Issue 2) 1.23 (Issue 3) DETAILS OF CHANGE Minor updates to Sections 2.4, 7, 13 and Appendices Additions to section 2.4.6, and 3.5 and minor amendments throughout to update titles, including renumbering. Addition of source documents. Changes and additions to sections 2.2, 2.3, 2.4 and 7, and reference to new Trust policy Insertion and Confirmation of the Placement of a Nasogastric Tube in Infants, Children, Young People and Adults ISSUE 4 FEBRUARY