Dietetics EPA1 Assessing critically ill patients requiring enteral nutrition support

This EPA includes collection, analysis and interpretation of relevant information to establish nutritional risk and inform decision making in future steps.

Context: Adult patients in the critical care setting requiring oral or enteral nutrition

Limitations: Does not include assessment of patients requiring parenteral nutrition

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EPA overview information
Required knowledge and skills
  1. C3Framework Shared AHP Competencies

  2. C3Framework Dietetics Domains:

    • Assessing Nutritional Risk
    • Biochemistry
    • Effects of Critical Illness on Nutritional Interventions
    • Metabolic Response
    • Refeeding Syndrome
    • Gastrointestinal Function
    • Estimating Targets
    • Nutritional Routes
    • Nutritional Products
Assessment to measure progress
  • Anonymised patient records of patient assessments
  • Supervision documentation
  • Reflective reports
Basis for formal entrustment decisions

An entrustment decision should be made by an experienced critical care dietitian after observing this EPA completed on more than one patient.

Use the EPA Completion Template (PDF, 88KB) for this.

Previously completed EPAs:
If you have completed any previous EPAs, select them here
to highlight where competencies have already been met.

Shared AHP competencies

Competency description Self assessment Senior assessment


Infection Prevention and Control:

Able to demonstrate knowledge of general infection control prevention and control including hand hygiene, aprons, masks and aseptic non-touch technique


Patient Emergency Management:

Has completed Basic Life Support Training as per local trust policy


Describes how they would summon help in an emergency and locate crash bells


Describes how to call a medical emergency call via switch


Describes own role and expected contribution in medical emergency eg. Basic Life Support, providing assistance to MDT as able


Patient ID:

Demonstrates positive patient identification and awareness of allergies


Monitoring Vital Signs:

Demonstrates how to monitor vital signs (Temp, HR, SpO2, RR, blood pressure, MAP)


Interprets observations in an ICU setting, considering trends and normal ranges for all (Temp, HR, SpO2, RR, blood pressure)


Able to troubleshoot difficulties with taking vital signs eg. poor trace on pulse oximeter, missing ECG leads, positional sensitivity of arterial line


Awareness of who to escalate concerns to in relation to patient safety with recognition of different levels of urgency and reporting to different staff members dependent on situation



Can describe the bed numbering, storage location of safety equipment, location of offices and other key areas within the critical care unit


Can describe the shift patterns and handover process of other MDT members


Able to identify key MDT members by their role, including critical care nurses, nurse in charge, consultant on call


Demonstrates how to locate the local protocols and guidelines relevant to own role


Has an awareness of key ICU meetings relevant to role e.g. MDT meetings, handovers, safety briefings, teaching sessions.


Can identify standard ICU bedspace equipment and location of equipment necessary for role



Communication with patient:

Describe barriers to communication in ICU including those associated with PPE, illness and ICU interventions.


Awareness of communication aids with patients to overcome communication barriers i.e. PPE + oral intubation


Communication with family + friends:

Describe the support services available to help liaise with family including family support nurses, PALS, psychology services as appropriate.


Describe barriers to communication with family and methods to improve this


Knows importance of confidentiality and consent to share information with friends and family


Communication with colleagues:

Awareness of peer support and psychological support



Local IT Training:

Demonstrates how to access and document in patient records using local IT systems


Demonstrates how to view results and imaging on local IT systems


Moving and Handling

Awareness of Falls prevention and who to escalate to if concerned regarding falls risks


Compliant with Manual Handling training as per local trust policy.


Non-technical skills


Demonstrate working in an MDT by building and maintaining relationships with other professions


Aware of the roles and responsibilities of other members of the MDT


Clarifies, accepts and executes tasks delegated by the team leader


Explains the importance of highlighting safety issues / concerns to a member of your team in a prompt manner


Uses appropriate level of assertiveness for the clinical situation


Demonstrates a logical and systematic handover using local format


Outline how to escalate and to whom if there are patient / safety concerns


Identify and respond to patient / staff safety issues appropriately


Clinical Assessment and Basic Life Support


Demonstrate ways to open up airway using simple manoeuvres (inc. repositioning, head tilt chin lift, jaw thrust)


Demonstrates how to deliver manual ventilation using two person bag-valve-mask (BVM) technique


Recognise and escalate airway compromise in a tracheostomised patient


Mouth care:

Demonstrates how to perform and document oral hygiene



Knows the types of oxygen delivery system and their limitations (including reservoir mask, simple face mask, venturi system and nasal cannulae)


Demonstrates how to deliver oxygen urgently (including reservoir mask, simple face mask, venturi system and nasal cannulae)


Describe how to escalate or de-escalate oxygen therapy in a step wise manner eg. nasal cannulae to face mask.


Lines and attachments:

Recognise different lines and their location relevant to local population (eg arterial lines, central line, vas-cath)



Identify enteral feeding tube in situ, whether it is connected to feed and whether the feed pump is running


Knows to discuss plans with nursing staff prior to moving or reposition a patient with NG feed running


Aware of events which can displace feeding tubes and to escalate accordingly


Describes how to check enteral feeding length and escalates if tube length has changed


Describe how to recognise dysphagia and an escalation plan including referral to SLT


Demonstrates how to assist patients with eating and drinking


Have an awareness of modified diets or thickened fluids in line with SLT recommendations



Demonstrate how to categorise neurological status using the AVPU scoring


Describe factors that may cause or contribute to delirium


Describes how to recognise delirium


Demonstrates how to complete a CAM-ICU score


Demonstrates an understanding of non-pharmacological management of delirium


Demonstrates knowledge of the Mental Capacity Act, when capacity assessment is indicated, how to assess capacity and when specialist communication support is required eg. referral to SLT



Demonstrates how to use pain faces or a similar visual analog scale


Demonstrates an understanding on the impact of pain on patient presentation eg. agitation


Demonstrates an understanding of the impact of pain medication on patient presentation eg. sedative effect



Demonstrates an understanding of RASS (or alternative sedation) scoring system


Able to access and read using ICU drug charts


Demonstrates an awareness of common ICU sedative medications


Demonstrates a basic knowledge of common ICU medications and their role e.g. sedatives, vasopressors, inotropes


Core competencies

Competency description Self assessment Senior assessment

Assessing Nutritional Risk

Describes the different nutritional screening tools which are validated for use in the critically ill


Describes the limitations of using screening tools in the critically ill


Describes nutritional screening method used in local hospital


Able to suggest appropriate methods to gain anthropometry for patients


Able to perform basic anthropometric measurements (i.e. MUAC, Ulna, Estimated weight and heights, handgrip strength)


Identifies the advantages and disadvantages of anthropometric measurements


Has knowledge of equipment available at local hospital



Able to recognise abnormal biochemistry and describe the following:

  • Causes (medical and nutritional)
  • Implications
  • Different electrolyte targets in the critically unwell

Able to interpret abnormal biochemistry


Effects of Critical Illness on Nutritional Interventions

Aware of how critical illness affects the major organs


Aware of the principles of organ support


Aware of how organ failure / organ support can impact nutritional status


Aware of how sedatives / paralysis and impact on gut function


Aware of how lipid based sedatives and calorie content


Aware of how vasopressors / inotropes and increased risk of gut ischaemia


Aware of how renal replacement therapy and fluid balance goals


Metabolic Response

Able to describe the metabolic phases of critical illness


Has an awareness of:

  • Blood glucose targets in the critically ill;
  • Why these blood glucose targets are recommended;
  • Local guidelines on blood glucose management.

Refeeding Syndrome

Able to describe refeeding in the critical care setting


Gastrointestinal (GI) Function

Able to describe the structure of the gut and identify where key nutrients are absorbed


Demonstrates an understanding of how surgery / insults to the gut may affect the absorption of nutrients


Able to describe how gastrointestinal function is assessed


Estimating Targets

Has an awareness of gold standard methods of calculating nutritional requirements


Has an awareness of predictive equations available for estimating nutritional requirements


Has an awareness of limitations of methods used to calculate nutritional requirements


Has an awareness of metabolic phases and impact on calculations of nutritional requirements


Nutritional Routes

Describes barriers to oral intake


Describes enteral feeding routes including indications and contraindications


Describes what feeding tubes / insertion methods are available locally


Describes local policy for confirming location of enteral feeding tubes


Describes indications and implications of oro-gastric feeding


Describes appropriate use of restraints (i.e. nasal bridles and mittens)


Describes long-term feeding tube indication and local referral process


Describes indication for parenteral nutrition and local escalation process


Has awareness of the increased risk of dysphagia in the critically ill


Has awareness of the local dysphagia screening protocol


Has awareness of the patients who require immediate speech and language therapy (SLT) input rather than nurse led screening


Nutritional Products

Able to list enteral feeding products available in trust and indications of use


Has awareness of local ‘out of hours’ protocols