The NCEPOD
report on
Parenteral
Nutrition
June 2010
Dr Mike Stroud FRCP
Chair British Association for Parenteral & Enteral Nutrition
Senior Lecturer in Medicine & Nutrition, IHN
Consultant Gastroenterologist, Southampton
Chair of NICE GDG on Nutrition Support
A multi-disciplinary charity committed to
raising awareness of malnutrition and
options for its treatment; and examining
impacts on health outcomes, resource
utilization and health/social care budgets.
CAUSES OF MALNOURISHMENT
Conscious level
Depression
Anorexia
Poor diet - age, poverty, junk,
exercise, alcohol
Dysphagia
Obstruction
Vomiting
Pancreatic failure
Liver processing
Jaundice
Malabsorption
Increased Metabolic demands
Food intake, absorption, losses and demands
Effects of Undernutrition
Ventilation - loss of
muscle & hypoxic
responses
Psychology –
depression & apathy
Immunity – Increased risk
of infection
liver fatty change,
functional decline
necrosis, fibrosis
Decreased Cardiac output
Renal function - loss of
ability to excrete
Na & H2O
Impaired wound
healing
Hypothermia
Impaired gut
integrity and
immunity
Loss of strength
Anorexia
? Micronutrient deficiency
Complications of abdominal
operations for malignant disease
Meguid et al., Am J Surg 156, 1988
%
p
a
t
i
e
n
t
s
100
90
80
70
60
50
Well nourished
40
M alnourished
30
20
10
0
C omplication R ate
P ost-Operative
M ortality
Nutritional |Care and
Quality - the BAPEN
Agenda 2009/10
– a framework for
Commissioners and
Providers to establish
safe quality care
standards in nutritional
care from food and
supplements at one end
of the spectrum to the
highly specialised PN at
the other.
Malnutrition Matters
Meeting Quality Standards in
Nutritional Care
Ailsa Brotherton, Nicola Simmonds
and Mike Stroud
on behalf of the
BAPEN Quality Group
BAPEN Toolkit
Four key tenets:
• Screen to identify nutritional care needs followed by
detailed assessment
• Care pathways in place with appropriate monitoring
• Training for all staff to appropriate levels
• Management structures in place to support the
delivery of safe nutritional care of the highest quality
Starvation & Weight loss
(After Allison)
%
b
o
d
y
w
e
i
g
h
t
100
95
90
85
80
75
70
65
60
55
50
Decision Box
Catabolic
Complete starvation
Partial starvation
0
10
20
30
40
50
60
70
Days
A Patient’s Journey
%
b
o
d
y
w
e
i
g
h
t
GP
GP
100
95
90
85
80
75
70
65
60
55
50
OP
IP
NBM for Ix
Surgery
Catabolic
Complete starvation
Partial starvation
Not going
well - Friday
0
10
20
30
40
50
60
Days
70
Nutrition support in
adults: 2006
Nutrition support
SCREEN
RECOGNISE
TREAT
ORAL
ENTERAL
MONITOR
REVIEW
PARENTERAL
Parenteral nutrition
if patient malnourished/at risk of malnutrition
a non functional,
inaccessible or perforated
gastrointestinal tract
and has either
inadequate or unsafe oral
or enteral nutritional intake
introduce progressively and
monitor closely
use the most appropriate route of access and mode of delivery
stop when the patient is established on adequate
oral intake from normal food or enteral tube feeding
D
The Evidence
Wanted – starving IF volunteers
for PN RCTs
Evidence
for enteral
and
parenteral
nutrition
IBO
The NCEPOD
report on
Parenteral
Nutrition
June 2010
BAPEN’s Response
• Dismay
• Congratulations and welcome
– solid evidence that many hospitals deliver unsafe
artificial nutrition to vulnerable adults and babies.
– Generally irrefutable data confirming what
BAPEN NICE and others have said for some time
i.e standards in nutritional care must be
improved to ensure all patients receive quality,
safe and equal treatment from staff who are
appropriately trained and supervised
? NSTs surely BAPEN NSTs
PN needed in Intestinal Failure –
Should be level 2 patients
?IFU
Finding
%
%
Appropriate indication
71.3
28.7
Delay in identification
16
84
Delay in starting
9
91
Nutrition Team involved
52.7
47.3
Off the shelf with no additions
42.7
57.3
Adequate monitoring
56.7
43.3
Inappropriate additional IV fluids
21
79
Difficulties with definition and
methodology
• Refeeding syndrome
• Catheter related sepsis
But its bad!
NCEPOD Recommendations
• PN should only be given when necessary
• When PN is needed recognise early and take action
• Patient assessment should be robust and purpose and
goal documented
• Regular documented clinical and biochemical
monitoring
• Additional IV fluids only if necessary
• Active education about the role of PN, its
complications and side effects
• All hospitals should have a PN proforma
• Catheter and organizational
BAPEN’s Recommendation’s
• All acute hospitals must have multi-disciplinary NSTs
with Senior Clinical Leadership
• All acute hospitals should have simple rolling system of
PN registration and audit
– to monitor practice and secure improved standards
– this could be delivered by extending BAPEN’s existing
BANS database covering long-term home PN patients
and it would support work by HIFNET - the newly
established commissioning, management and clinical
framework dealing with intermediate and long-term PN
This needs political will and DH support
BAPEN's Challenge
• We challenge the Coalition Government to
implement fully the recommendations from
this NCEPOD report and those from the
Delivery Board of the Nutrition Action Plan
– political leadership for malnutrition and risk
– a public and professional awareness campaign
on the impact of poor nutritional status on
health outcomes
BAPEN Agenda 2019/11
Safety in Nutritional Care
BAPEN will ensure top-level leadership through an
All Party Parliamentary Group on
Nutritional Care and Hydration.
with parliamentary Screening
and professional partners
Catering
Aim - To ensure that safe nutritional care of all
Oral Nutrition
types continues
to make itsSupplements
way up political,
ETFagendas for the benefit of
professional and practical
andacross
IV fluids
patients Under-hydration
and people of all ages
primary,
secondary and community
PNsettings.
Thank
you