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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? Inappropriate PN

  • 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 Inappropriate PN

  • Mean days without enteral nutrition =7days (range 0-90)


How to address3
How to Address? Inappropriate PN

  • 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 Inappropriate PN


Key finding assessment1
Key Finding - Assessment Inappropriate PN


Key finding composition
Key Finding - Composition Inappropriate PN

  • 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 Inappropriate PN

40% of hospitals have no nutrition team


Key finding prescribing
Key Finding - Prescribing Inappropriate PN

40% of hospitals have no nutrition team


How to address4
How to Address? Inappropriate PN

  • 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 - Monitoring Inappropriate PN


Key finding complications
Key Finding - Complications Inappropriate PN

49% Avoidable


How to address5
How to Address? Inappropriate PN

Dietitian

Dietitian

Nurse

Doctor

Surgeon

Doctor

Patient

Patient

Pharmacist

Intensivist

Nutrition Team

NCEPOD Report


How to address6
How to Address? Inappropriate PN

  • Robust policies & procedures

  • Audit

  • Research

  • Best practice guidelines


How to address7
How to Address? Inappropriate PN

  • Clinical governance

  • Clinical risk

  • Incident forms

  • Repeat NCEPOD report?


Hurdles ammunition rocket fuel
Hurdles, Inappropriate PNAmmunition & Rocket Fuel

NCEPOD