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

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 DoctorNurse Pharmacist Patient SurgeonDoctor Intensivist Dietitian Patient 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 NCE POD