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A Mixed Bag

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

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A Mixed Bag

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  1. A Mixed Bag Dr Alison Culkin Research Dietitian Intestinal Failure & Home Parenteral Nutrition St Mark’s Hospital Harrow

  2. Key Finding – Quality of Care

  3. 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

  4. 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”.

  5. Key Finding – Consideration of Enteral Nutrition & Inappropriate PN

  6. 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)

  7. Key Finding - Delays • Mean days without enteral nutrition =7days (range 0-90)

  8. 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

  9. Key Finding - Assessment

  10. Key Finding - Assessment

  11. 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)

  12. Key Finding - Composition 40% of hospitals have no nutrition team

  13. Key Finding - Prescribing 40% of hospitals have no nutrition team

  14. 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

  15. Key Finding - Monitoring

  16. Key Finding - Complications 49% Avoidable

  17. How to Address? Dietitian Dietitian Nurse Doctor Surgeon Doctor Patient Patient Pharmacist Intensivist Nutrition Team NCEPOD Report

  18. How to Address? • Robust policies & procedures • Audit • Research • Best practice guidelines

  19. How to Address? • Clinical governance • Clinical risk • Incident forms • Repeat NCEPOD report?

  20. Hurdles, Ammunition & Rocket Fuel NCEPOD

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