NCEPOD PN Study

Melanie Baker Senior Specialist Dietitian, Leicester

Expert on NCEPOD PN Study

Session Overview

• NCEPOD– Who are they– Remit and Function

• Parenteral Nutrition– Why?– Links with recent / current initiatives – PN NCEPOD study

NCEPOD

National Confidential Enquiry into Patient Outcome & Death

• Reviews the management of patients• Undertakes confidential surveys • Publishing results to… Improve the quality of medical and surgical

care.

NCEPOD

• Independent (of DoH and professional bodies) charity

• 90% funded by the DoH via the NPSA• Steering Group with representatives from

– Various medical royal colleges – NPSA - NICE– Coroner Society - Institute of Healthcare Mg– Scottish Audit of Surgical Mortality

NCEPOD

National Confidential Enquiry into Patient Outcome & Death

• Covers England, Wales, NI, Isle of Man, Jersey, Guernsey

• All hospitals – NHS, private

History

National Confidential Enquiry into Patient Outcome & Death

• 20 years old• 1982 Confidential Enquiry into Peri-

operative Deaths.• Moved from reviewing the care of surgical

patients to cover all specialities.

Audit? No

• Typically review services where there are no agreed standards by which current practice can be audited against.

• NCEPOD asks– what standard does the service current

achieve– by identifying the key components of the

service

Research? No

• NCEPOD does not evaluate new treatments• COREC

– Ethical approval not needed• Confidentiality

– Complies with Data Protection Act 1998– Complies with Health and Social Act 2001

• Section 60 – Secretary of State for Health authorises the use of Pt identifiable data without consent

• PIAG– Reviewed current practices

Data Collection:Survey

• Clinicians complete individual patient surveys– Evidence of CPD– Opportunity of review/reflect on clinical practice– Compliance

• Concerning cases– Discussed with NCEPOD’s Lead Co-ordinator and

Chief Executive. Only very bad practice is referred back to the Trust Medical Director & consultant involved (support by the GMC)

Studies to date

• Death in acute hospitals• Elective & Emergency Surgery in the

Elderly

• Scoping our Practice– “The PEG study”– Highlighted poor selection and high morbidity

and mortality rates with PEG– Has significantly influenced practice

Parenteral Nutrition

Why?

Why now?

Parenteral Nutrition

• Generally given to the sickest patients, with associated morbidity and mortality.

• Indications– Failure of gut function (with obstruction, ileus,

dysmotility, fistulae, surgical resection or severe malabsorption) to a degree that prevents adequate gastrointestinal absorption of nutrients

– Persisted or persisting (> 5 days)(NICE, 2006)

Parenteral Nutrition

• Current practice is extremely variable:

– Assessment of need– % of hospitals with Nutrition Support Teams– How NST function / composition– Pharmacy / PN bag options– Central line care– Management of associated clinical problems

Recent / Current Initiatives

NICE Nutrition Support in Adults, 2006

HIFNET

NICE

• All acute trusts should have a MDT nutrition support team.

• Patients prescribed standarised PN should have their nutritional requirements determined by HCP with the relevant skills & training.

HIFNET

• Intestinal failure– Type I

– Type II

– Type IIIHIFNET

Type II IF

• Severely ill patients in hospital who require complex abdominal surgery and management of their nutrition/electrolytes over weeks – months.

• Normally associated with sepsis and patients normally require intensive care for some of their hospital stay.

• Classified depending on length on time PN is required

• Estimated prevalence is 18 patients/million population requiring PN for > 14days

Type III IF

• Chronic, metabolically stable patients who require HPN

• Estimated as– 14.6 patients/million population, – 2 patients/million new (BANS, 2006 data)

Sector 1 – Local

• NICE compliant for nutritional support services

• Could provide some aspects of care (?HPN) if can demonstrate expertise

Sector 2 - Regional• Assume primary responsibility for the management of patients with type II

and III IF• At least 2 NNS• Dedicated MDT outpatient clinic (at least monthly)• Designated ward area for HPN patients• Availability of pharmacy compounding facilities• Experience of managing patients on HPN• Nutrition Support Team – Lead Clinician, Dietitian, NNS, Pharmacist (with

support for daily cover during times of absence) Page 77– Weekday WR– Weekly team meeting

• Daily cover with out of hours arrangements • 24 hour telephone advice capability• Available access to dedicated clinical area for inpatients with nursing staff

trained• Availability of vascular access and imaging expertise• Appropriate biochemical monitoring

Sector 3 – Supra-regional (Type II/III with surgical

capability)• Assume primary responsibility for the management of patients with

type II and III IF• Co-ordinate shared care with other units

• In addition to Sector 2• Surgical expertise / Availability of individual specialist surgical teams• Appropriate facilities and expertise in interventional radiology, intensive

care, stoma/wound care• Designated ward area for Type II IF patients – with DIRECT admission• Provision of services for

– Persistent acute IF > 6weeks not resolving and complicated by venous access problems– Multiple fistula in a dehisced abdominal wound– <30cm residual small bowel– Persistent severe intra-abdominal sepsis– Resistant metabolic complications (from high outputs)– Recurrent venous access problems

• Specialist advice available at weekends and out of hours• Joint surgical WR/meeting and surgical availability for joint outpatient

reviews.

Sector 4 – National IF units

• Existing (NSCAG) funded services– St Marks (London)– Hope (Salford) – with improved links to sector 3 (and ?2

centres)

Improving the quality of medic a l and s urgic a l c are

NCEPODPARENTERAL NUTRITION STUDY

Improving the quality of medic a l and s urgic a l c are

NCEPOD

• AIM – to identify areas where the care of patients receiving PN might have been improved– Indication

– Type of PN / access

– Assessment of need / Prescription

– Nutrition Support Team

– Complications

Improving the quality of medic a l and s urgic a l c are

NCEPOD – Expert Group.

• Representatives were identified from key professional bodies

– BAPEN

– NNNG

– PENG

– BPNG

• Group met with NCEPOD Clinical Co-ordinators

– Brainstormed and agreed proposal

– Questionnaires developed, drafted and agreed

– Pilot sites identified

Improving the quality of medic a l and s urgic a l c are

Parenteral Nutrition Survey

• Each Trust has a local NCEPOD reporter, who was sent an ORGANISATION questionnaire

– Is there a nutrition support team (?members / function)

– Who is responsible for prescribing the PN

– Who decided on the composition

– Options for PN formulations (including out of hours)

– Line insertion

– Policies and guidelines – Nursing Care / CRS

Improving the quality of medic a l and s urgic a l c are

Clinical Questionnaire

• Each trust had to identify All inpatients (neonatal, Paed and Adult) receiving PN from 01.01.08 – 31.03.08

• Clinical questionnaire (sent to primary consultant or other) to complete for the following:– Indication for PN

– Nutrition support prior to PN

– Who assessed the patient (member of NST?)

– PN formulation / who prescribed / who monitored

– Complications

– Duration and Outcome

– Sent back with copies of the case notes / dietetic records

Improving the quality of medic a l and s urgic a l c are

What now

• Questionnaires being received thick and fast!

• ADVISORY GROUP– review every case – questionnaires and case notes - and fill out a

separate advisor’s form.

– Not all advisors review all cases but all cases reviewed by the advisors

• Initial results will be discussed with the Expert group November 2009

• Report Published mid 2010