A Mixed Bag
Dr Alison Culkin
Research Dietitian
Intestinal Failure & Home Parenteral Nutrition
St 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
Dietitian
Nurse
Patient
Doctor
Surgeon
Patient
Doctor
Pharmacist
Intensivist
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