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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

A Mixed Bag

Dr Alison Culkin

Research Dietitian

Intestinal Failure & Home Parenteral Nutrition

St Mark’s Hospital

Harrow

how to address
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 address1
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”.

how to address2
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
Key Finding - Delays
  • Mean days without enteral nutrition =7days (range 0-90)
how to address3
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 composition
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 composition1
Key Finding - Composition

40% of hospitals have no nutrition team

key finding prescribing
Key Finding - Prescribing

40% of hospitals have no nutrition team

how to address4
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
how to address5
How to Address?

Dietitian

Dietitian

Nurse

Doctor

Surgeon

Doctor

Patient

Patient

Pharmacist

Intensivist

Nutrition Team

NCEPOD Report

how to address6
How to Address?
  • Robust policies & procedures
  • Audit
  • Research
  • Best practice guidelines
how to address7
How to Address?
  • Clinical governance
  • Clinical risk
  • Incident forms
  • Repeat NCEPOD report?
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