A Mixed Bag

Dr Alison CulkinResearch Dietitian

Intestinal Failure & Home Parenteral NutritionSt Mark’s Hospital

Harrow

Key Finding – Quality of Care

How to Address? ● Government targets

– 4 hour wait in A&E – 2 week cancer wait– 18 week out patient wait

● Financial penalties for Trusts not adhering to good practice?

● No National Service Framework● Not a National Quality Board key issue● Not inspected by the Care Quality Commission● Not part of General practice Quality Outcome

framework

How to Address?

● Health and Social Care Act 2008 “Meeting nutritional needs” with “sufficient

food and drink and a choice of food and drink to meet diverse needs”

● Article 3 Human Rights Act 1998: Inhuman treatment “No one shall be subjected to torture or to

inhuman or degrading treatment or punishment”.

Key Finding – Consideration of Enteral Nutrition & Inappropriate PN

How to Address?• Nasal bridles• Reduced delay in gastrostomy insertion• Endoscopy slots for NJ insertion• Protocols regarding peri-operative enteral

tube placement• Feeding & bowel protocols• Nutrition Team Autonomy• Nutrition team input ↓Inappropriate PN

referrals from 16.5% to 8.9% p=0.002 (Sriram et al 2010 Nutrition 26:735-739)

Key Finding - Delays• Mean days without enteral nutrition =7days

(range 0-90)

How to Address?• Nutrition team and/or dietitian involvement in

surgical ward rounds, ICU, HDU, All PN

• Measures in place to minimise post operative treatment contributing to the requirement for PN

• Nutrition link nurses

• Awareness of time without nutrition

• Rapid access to parenteral feeding devices & appropriately trained staff to insert device

Key Finding - Assessment

Key Finding - Assessment

Key Finding - Composition

• Majority of surgical trainees felt they had adequate knowledge but level of knowledge did not justify confidence (Adwad et al 2010 Clin Nutr 29:243-248)

Key Finding - Composition

40% of hospitals have no nutrition team

Key Finding - Prescribing

40% of hospitals have no nutrition team

How to Address?• Independent Prescribing for Dietitians

– Experts in nutritional assessment & assessing risk of refeeding syndrome

– Experts in calculating nutritional requirements– Regular monitoring & reassessment– Weaning to enteral nutrition

• On call at weekend?

• Need to be proactive

Key Finding - Monitoring

Key Finding - Complications

49% Avoidable

How to Address?

Dietitian

DoctorNurse

Pharmacist

Patient Surgeon Doctor

Intensivist

Dietitian

Patient

Nutrition Team NCEPOD Report

How to Address?• Robust policies & procedures

• Audit

• Research

• Best practice guidelines

How to Address?

• Clinical governance

• Clinical risk

• Incident forms

• Repeat NCEPOD report?

Hurdles, Ammunition & Rocket Fuel

NCEPOD