Overview
The Sunnybrook Clinical Nutrition Resource Handbook (CNRH) is a curated collection of evidencebased guidelines, protocols, and reference tools designed to support clinicians, dietitians, nurses, and allied health professionals working within the Sunnybrook Health Sciences Centre and affiliated sites. First published in 2018, the handbook has become a central resource for delivering consistent, highquality nutrition care across acute, subacute, and community settings.
Nutrition is a fundamental component of patient recovery, yet everyday practice can be hampered by fragmented information, variable documentation standards, and the rapid evolution of clinical research. The CNRH addresses these challenges by providing a single, easily accessible repository that integrates current best practice with Sunnybrookspecific workflows.
Who Its For
The handbook is intended for:
- Registered dietitians and nutrition assistants
- Physicians and surgical teams
- Nurses, especially those in bedside and transitional care
- Pharmacists involved in nutrientdrug interactions
- Rehabilitation therapists (physical, occupational, speechlanguage)
- Students and trainees rotating through Sunnybrook
Because the content is aligned with Ontarios healthsystem standards and the institutions policies, it also serves as a reference point for external partners and community providers who collaborate with Sunnybrook on discharge planning.
Structure & Content
The handbook is organized into five main parts, each built around a clinical pathway:
- Screening & Assessment Tools for malnutrition risk (e.g., MUST, NRS2002), anthropometric methods, biochemical markers, and diet history techniques.
- Diagnosis & Classification Definitions of undernutrition, refeeding syndrome, sarcopenia, and diseasespecific needs (oncology, renal, criticalcare).
- Intervention Planning Stepbystep algorithms for oral, enteral, and parenteral nutrition; menu planning; therapeutic diets; and micronutrient supplementation.
- Monitoring & Evaluation Frequency of reassessment, outcome indicators (weight change, functional status, biochemical trends), and documentation templates.
- Discharge & Continuity of Care Guidelines for transition to home, community services, and followup nutrition appointments.
Each chapter begins with a brief clinical vignette, followed by:
- Evidence summary with citation links
- Stepwise flowcharts
- Standardised order sets
- Checklists for safety and compliance
- Patienteducation handouts
Key Features
EvidenceBased Content
All recommendations are grounded in the latest systematic reviews, clinical practice guidelines from the Canadian Nutrition Society, ASPEN, and ESPEN, and internal audit data. Each recommendation includes a strength rating (AD) and a quality of evidence indicator.
Interactive Digital Format
The handbook is hosted on Sunnybrooks intranet, allowing users to search by keyword, filter by patient population, or access printable PDFs. Embedded videos demonstrate feeding tube placement, oral care techniques, and patient counseling strategies.
Integrated Decision Support
When a clinician orders nutrition support through the electronic medical record (EMR), contextual prompts link directly to the relevant handbook section, reducing errors and ensuring adherence to protocol.
Multidisciplinary Alignment
Each pathway includes specific roles and responsibilities for all team members, promoting clear communication and shared accountability.
PatientCentered Materials
Plainlanguage handouts, bilingual (English/French) nutrition guides, and culturally appropriate meal planning sheets are incorporated to support education at the bedside.
Practical Use in Daily Workflow
1. Initial Screening On admission, nurses complete the validated screening tool within the EMR. A score 2 triggers an automatic alert to the dietetics team.
2. Assessment Request The dietitian logs into the handbook, selects the Adult Acute Care Assessment module, and follows the stepwise checklist to collect data.
3. Order Set Selection For patients requiring enteral nutrition, the clinician chooses the Standard 1.5kcal/ml Formula order set, which autopopulates polymer type, rate, and monitoring parameters.
4. Ongoing Monitoring Daily weight, serum electrolytes, and feeding tolerance are recorded in a standardized table linked to the handbooks monitoring chart.
5. Discharge Planning The Transition to Home pathway guides the team through medication reconciliation, provision of a personalized meal plan, and referral to community dietitians.
Feedback loops are built into the system: after discharge, the outcome data are entered into a qualityimprovement dashboard that informs future revisions of the handbook.
Updates & Resources
The handbook undergoes a formal review every two years. An interdisciplinary editorial board, comprising leaders from dietetics, medicine, nursing, pharmacy, and quality improvement, evaluates new literature, policy changes, and user feedback.
Recent additions (2024 edition) include:
- Guidance on nutrition in patients receiving immunotherapy
- Revised protein targets for critically ill patients based on the 2023 ESPEN consensus
- COVID19 longhaul nutrition recommendations
- Expanded cultural diet options for Indigenous and South Asian populations
All staff receive an email notification when a new version is published, and a short elearning module is offered to highlight major changes.
