BSNA Parenteral Nutrition Survey GAINING AN INSIGHT INTO HEALTHCARE - - PowerPoint PPT Presentation

BSNA Parenteral Nutrition Survey

GAINING AN INSIGHT INTO HEALTHCARE PROFESSIONALS’ VIEWS ON PARENTERAL NUTRITION

What is Parenteral Nutrition?

1

Parenteral nutrition is administered to improve the nutritional status of a patient

• Parenteral nutrition (PN) is the provision of nutrients and fluid

to a patient by an intravenous route.

• PN is a complex and well established form of artificial nutrition
• support. It may provide the only way to meet a patient’s

nutritional requirements, where patients have an inaccessible

• r non-functioning gastro-intestinal system.
• PN can be administered via a peripheral or central line.
• More information on PN can be found on the BSNA website:

link here.

Executive Summary

• British Specialist Nutrition Association (BSNA) conducted an
• nline survey on PN among 204 HCPs (HCPs), including

dietitians, pharmacists, nurses, gastroenterologists,

• ncologists and intensive care specialists.
• The survey highlighted four important factors for improving

the use of PN: perception, confidence to manage, the ability to prescribe and training for HCPs.

• Moving forward the BSNA welcomes further developments

into these areas to improve the role of PN in care settings.

2

Objective and methodology

Objective: To gain an insight into HCPs’ views on PN

• Online survey with 204 HCPs in the UK.
• Robust sample including dietitians, pharmacists,

gastroenterologists, nurses, intensive care specialists and

• ncologists.
• The questionnaire was made up of 20 quantitative

questions and 11 qualitative questions.

• Questionnaires were distributed through professional

associations and HCPs’ magazines.

3

Participant demographics by profession and work place

Profession Count Percentage (%) Dietitian 128 62.7 Pharmacist 50 24.5 Nurse 13 6.4 Gastroenterologist 10 4.9 Intensive Care Specialist 2 1.0 Oncologist 1 0.5 Total 204 100 Work Location Count Percentage (%) Teaching Hospital 96 47 District General Hospital 93 46 Other 9 4 Community 6 3 Total 204 100

• 204

HCPs answered the survey, their professions were as follows:

• Dietitians (62.7%)
• Pharmacists (24.5%)
• Nurses (6.4%)
• Gastroenterologists (4.9%)
• Intensive Care Specialists (1%)
• Oncologists (0.5%)
• And their work locations included:
• Teaching Hospital (47%)
• District General Hospital (46%)
• Community (3%)
• Other (4%)

Other, work locations included: Children's Hospital, Community/Acute based in teaching hospital, all of the above, retired, academic institution, home and healthcare, GP and hospital.

4

The majority of participants were dietitians working in either a district general or teaching hospital

The number of patients receiving PN seen by HCPs per week

24% 36% 18% 9% 10% 2%

5 10 15 20 25 30 35 40

0 to 2 2 to 5 5 to 10 10 to15 15 plus

• ther

Percentage of HCPs (%)

• The majority of HCPs (60%) saw <5 patients

receiving PN per week.

• 18% saw 5 to 10 patients receiving PN per

week and 10% saw over 15 patients receiving PN a week.

• Of the HCPs managing patients receiving PN,

31% were managing patients on PN in the home setting.

5

HCPs typically manage 2-5 patients per week with PN

Types of patient receiving PN

8% 16% 45% 76% 82%

10 20 30 40 50 60 70 80 90

Other Vascular accidents Non-surgical with GI complications - e.g.

• ncology, multiple organ failure

Gastroenterological - e.g. chronic malabsorption, short bowel syndrome, inflammatory bowel disease, sclerodoma Surgical interventions with GI complications - e.g. oncology, inflammatory bowel disease Percentage (%)

• The majority of HCPs were managing patients receiving PN due to either

surgical interventions with gastrointestinal complications (82%) or gastroenterological reasons, ie. chronic malabsorption, short bowel syndrome

• r IBD (76%).
• 45% HCPs managed patients receiving PN for non-surgical, GI complications

and 16% managed patients requiring PN following a vascular accident.

• Of the 8% HCPs reporting ‘other’, they managed paediatric patients (eg.

premature neonates, oncology, cardiac), renal patients and intensive care patients receiving PN.

6

The majority of patients receive PN for gastroenterological reasons

*Participants could select more than one option.

The nutritional support given to patients

60% 16% 6% 18%

PN only PN in combination with enteral tube feeding PN in combination with enteral tube feeding and oral nutritional intake PN in combination with oral nutritional intake (no enteral tube feeding) Pie Chart shows the average percentage of participant’s patients receiving PN, EN and Oral Nutrition

HCPs were asked: Of the patients they were currently managing with PN, what percentage were receiving:

• On average HCPs reported that 60% of patients they managed

received PN as their only source of nutrition.

• HCPs reported that 18% of their patients were receiving a

combination of PN with oral nutrition.

• HCPs reported that 16% of the patients they managed received

a combination of PN with enteral tube feed.

• HCPs reported that 6% of the patients they managed received

PN in combination with enteral and oral nutrition.

7

PN is typically the only source of nutrition given to patients

The primary decision makers for prescribing PN

• 39% of the responses reported dietitians as a Trust’s primary decision maker for

prescribing PN (73% respondents to this question were dietitians).

• Respondents also considered gastroenterologists (23%) pharmacists (17%) as primary

decision makers.

* Participants could select more than one option

Respondents also remarked that:

• A consultant was the primary decision maker

(13%).

• A surgeon (5%), a biochemist (4%) or

chemical pathologist (4%) would be consulted.

8

The multidisciplinary team is responsible for the decision to prescribe PN

Percentage (%) 39%

23% 17%

9% 9% 1%

10 20 30 40 50 60 70 80 90 100

Dietitian Gastroenterologist Pharmacist Intensive Care Specialist Nutrition Nurse Specialist Nurse

Level of involvement with Nutrition Support Team by profession

7% 9% 2% 7% 37%

3% 4% 5% 12%

2% 2% 2 2% 4% 1 1 Other (please specify) There is no Nutrition Support Team and I am directly involved in the management of… I refer patients to the Nutrition Support Team when PN is indicated, but have no further… I am indirectly involved with the Nutrition Support Team when a patient in my care is… I am directly involved as a member of the Nutrition Support Team in the management of…

Dietitian Pharmacist Nurse Gastroenterologist

56% 13% 3% 15% 13%

• 77% of respondents reported that their Trust has a

nutrition support team responsible for PN.

• The majority of participants stated that they were

directly involved as a member of the Nutrition Support Team (56%).

• 90% of gastroenterologists are directly involved as a

member of the Nutrition Support Team for PN.

• 15% of participants reported that there is no Nutrition

Support Team and that they are directly involved in the management of patients receiving PN.

• Those that reported ‘other’ stated that that they either

cover the dietitian’s role on the support team when required or that they didn’t work for a Trust (Scotland).

*Percentages are calculated based on the whole sample (204) 9

The majority of HCPs are directly involved with their Trusts’ nutrition support team

Level of involvement

HCPs ’ Views on the appropriate use of PN

• The majority (72%) of HCPs viewed PN as useful but that it should be

used appropriately.

• 18% believe that PN can be invaluable for improving nutritional

status of patients.

• 9% HCPs agreed that PN should not be prescribed unless

gastrointestinal function is severely limited.

10

HCPs believe that PN is a useful tool, when used appropriately

Appropriateness of PN

9% 72% 18%

20 40 60 80 PN should not be prescribed unless gastrointestinal function is severely limited PN may be useful but should be used appropriately PN can be invaluable for improving nutritional status of patients

Percentage (%)

Considering PN for a patient

11

HCPs would consider PN for a patient with a non-functional or inaccessible GI tract

• The majority of HCPs (97%) would consider PN when a patient has a non-

functional or inaccessible gastro-intestinal tract.

• 65% would consider PN for a patient that is malnourished and has

unsafe/ inadequate oral/ enteral nutrition intake.

• 32% HCPs would consider PN for a patient that is nil by mouth and

received no enteral feeding for more than 3 days.

*Participants could select more than one option

32% 42% 58% 65% 97%

20 40 60 80 100 120 when a patient has been nil by mouth and no enteral feeding for more than 3 days when a patient is able to meet some but not all of their needs via oral/enteral nutritional intake when a patient might not be able to tolerate oral/enteral nutrition in the short to medium term (e.g. peri-operatively,

• r commencing chemotherapy)

when a patient is malnourished and has unsafe/inadequate

• ral/enteral nutritional intake

when a patient has a non-functional or inaccessible gastro- intestinal tract Percentage (%)

Count Guideline Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Percentage of total (%) NICE Clinical Guideline 32 on Nutrition Support in Adults (2006) 1 1 7 8 27 104 148 73% ESPEN Guidelines on PN (2009) 1 7 7 25 109 149 73% NCEPOD report 'A mixed bag: An enquiry into the care of hospital patients receiving PN' (2010) 2 7 6 24 93 132 65% NICE Quality Standard 24 on Nutrition Support in Adults (2012) 1 2 8 8 18 88 125 61% Strategic Framework for Intestinal Failure and Home PN Services for Adults in England (2008) 8 2 8 52 70 34%

HCPs’ familiarity with reports/guidelines on PN

12

HCPs are most familiar with the NICE and ESPEN guidance on PN

HCPs views on the balance of information provided by current guidance

13 7% 18% 75%

20 40 60 80

Too much focus on the positive aspects of parenteral nutrition Too much focus on negative aspects of parenteral nutrition The balance is about right

According to HCPs the current guidelines on PN have a balanced view

• The majority of HCPs (75%) believe that the current guidelines on PN strike a balance that is just

right.

• 18% HCPs think that current guidelines put too much focus on the negative aspects of PN

whereas 7% think that there is too much focus on the positive aspects of PN. “I suspect what are lacking are solid robust clinical trial on PN and most

• f the guidelines are based on expert opinion.”

“American and European guidelines differ in terms of when to start PN.”

Percentage (%)

Availability of PN training at Trust level

Pie chart show participants’ responses when asked whether their Trust provided any training on PN (n=204). 14

Participants said that they received PN training from an external body, eg. BPNG, BDA. 55 participants said that they received PN training in-house. 13 said that PN training was given to those in the Trust that required it.

20% HCPs reported no PN training at Trust level

“Trust guidelines available; no formal training unfortunately.”

Yes 80% No 20%

What would help HCPs to develop more knowledge and confidence about PN?

• HCPs agreed that the following training-aids would help

them develop more knowledge and confidence about PN;

• Online tutorials (60%),
• Practical training courses (58%),
• More detailed guidance (54%),
• A report including best practice case-studies (46%),
• A professional magazine or journal publication (38%).

15

HCPs would value detailed training and guidance on PN

*Respondents could select more than one response

7% 38% 46% 54% 58% 60% 10 20 30 40 50 60 70 Other Professional magazine

• r journal publications

A report including best practice case-studies Guidance which provides more detail than is currently available, e.g. NICE, ESPEN guidelines Practical training course Online tutorials and/or website information dedicated to PN

Percentage (%)

HCPs’ Perceptions of PN

16

• Whilst 94% HCPs agreed that PN should be considered for all patients with a non-

functioning, inaccessible or perforated gastrointestinal tract, only 60% agreed that PN should be considered for all patients with malnutrition and with inadequate/unsafe oral/ enteral nutritional intake.

• HCPs had mixed views over whether there was a minimum length of time for the duration

in which PN can be given.

• Only 18% HCPs consider PN invaluable.
• Gastroenterologists were slightly less aware of the appropriate use of PN compared with
• ther HCPs.

HCPs were asked to describe how much they agreed with the following….

17

PN should be considered for all patients who are malnourished – by profession

10% 3% 1% 50% 22% 20% 6% 7% 100% 50% 22% 20% 13% 7% 11% 22% 50% 58% 44% 45% 33% 26% 43% 36% Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• According to NICE clinical guidelines 32 (2006): ‘HCPs should

consider PN in people who are malnourished or at risk of malnutrition, respectively, and meet either of the following criteria:

• Inadequate or unsafe oral and/or enteral nutritional intake
• A non-functional, inaccessible or perforated (leaking)

gastrointestinal tract.’[2].

• 81% of HCPs disagreed that PN should be considered for all

patients who are malnourished.

• Dietitians were more strongly in disagreement with the

statement compared with other professions; 43% of dietitians strongly disagreed compared with 26% of pharmacists.

• 10% of nurses expressed that they strongly agreed with the

statement compared with 3% of pharmacists and 0% dietitians.

8% agree 81% disagree

18

PN should be considered for all patients who are malnourished – by work location

1% 1% 1% 10% 11% 7% 50% 8% 13% 11% 80% 41% 45% 45% 20% 50% 40% 30% 36% Other Community District General Hospital Teaching Hospital Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• HCPs working in district general hospitals were more likely to

disagree with the statement; PN should be considered for all patients who are malnourished (81% disagreed, 40% strongly).

• HCPs working in a community setting (50%) most strongly

disagreed with the statement.

• The views of HCPs from teaching hospitals and district

general hospitals were more closely aligned.

8% agree 81% disagree

19

PN should be considered for all patients with malnutrition and with inadequate/unsafe oral/ enteral nutritional intake – by profession

22% 28% 12% 15% 100% 33% 67% 44% 44% 43% 45% 33% 11% 22% 11% 19% 17% 33% 22% 11% 17% 21% 20% 5% 4%

Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• NICE Clinical Guideline 32 (2006) states that: ‘HCPs should

consider PN in people who are malnourished or at risk of malnutrition, and have inadequate or unsafe oral and/or enteral nutritional intake’ [2].

• Although the majority (61%) of HCPs agreed that PN should be

considered for all patients with malnutrition and with inadequate/ unsafe oral/ enteral intake, 24% HCPs disagreed (4% strongly disagreed).

60% agree 24% disagree

20

PN should be considered for all patients with malnutrition and with inadequate/unsafe oral/ enteral nutritional intake – by work location

20% 15% 16% 16% 40% 50% 41% 49% 45% 20% 22% 11% 17% 50% 22% 16% 19% 20% 6% 4% Other Community District General Hospital Teaching Hospital Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• HCPs working in a community setting were more likely to

report disagreeing that PN should be considered for all patients with malnutrition and with inadequate/unsafe oral/ enteral nutritional intake (50%) than those working in teaching hospitals (22%) and district general hospitals (22%).

60% agree 24% disagree

21

PN should be considered for all patients in intensive care – by profession

20% 3% 2% 11% 8% 2% 4% 100 50% 22% 20% 11% 16% 16% 56% 40% 50% 40% 42% 50% 11% 20% 28% 42% 36% Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• 78% HCPs disagreed (42% disagreed, 36% strongly

disagreed) that PN should be considered for all patients in intensive care.

• Dietitians and intensive care specialists were more likely

to strongly disagree (42% and 50% respectively).

6% agree 78% disagree

22

PN should be considered for all patients in intensive care – by work location

4% 2% 6% 1% 4% 50% 17% 16% 16% 80% 41% 43% 42% 20% 50% 36% 36% 36% Other Community District General Hospital Teaching Hospital Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• The majority of HCPs disagreed that PN should be

considered for all patients in intensive care (78%).

• Views of HCPs working in teaching and district general

hospitals were very similar.

6% agree 78% disagree

23

PN should be considered for all patients with a non-functioning, inaccessible or perforated gastrointestinal tract – by profession

100% 22% 50% 33% 53% 47% 100% 78% 40% 58% 41% 47% 10% 6% 4% 4% 3% 2% 2% Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• Nice Clinical Guidelines 32 (2006) states that: ‘HCPs

should consider PN in people who are malnourished or at risk of malnutrition and have a non-functional, inaccessible or perforated (leaking) gastrointestinal tract.’ [2].

• 94% of HCPs agreed that PN should be considered for all

patients with a non-functioning, inaccessible or perforated gastrointestinal tract (47% strongly agreed).

• A greater proportion of dietitians (53%) strongly agreed

with the statement compared with pharmacists (33%) and gastroenterologists (22%).

94% agree 2% disagree

24

PN should be considered for all patients with a non-functioning, inaccessible or perforated gastrointestinal tract – by work location

20% 50% 43% 53% 47% 40% 50% 51% 43% 47% 20% 4% 4% 4% 20% 2% 2% Other Community District General Hospital Teaching Hospital Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• HCPs working in teaching hospital settings were more likely to strongly

agree (53%) with the statement that PN should be considered for all patients with a non-functioning, inaccessible or perforated gastrointestinal tract.

• 20% of HCPs from other* healthcare settings disagreed that PN should

be considered for all patients with a non-functioning, inaccessible or perforated GI tract compared with 2% overall.

• No HCPs working in a district general hospital teaching hospital or in a

community setting disagreed with this statement.

* Children's Hospital, Community/Acute based in teaching hospital, all of the above, retired, academic institution, home and healthcare, GP and hospital

94% agree 2% disagree

25

PN should be considered for all patients peri-operatively – by profession

1% 1% 100% 5% 4% 11% 40% 17% 12% 14% 50% 33% 50% 58% 48% 49% 50% 56% 10% 25% 34% 32% Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• NICE Clinical Guidelines 32 (2006) states that ‘HCPs should

consider supplementary peri-operative PN in malnourished surgical patients who are malnourished or at risk of malnutrition’ [2].

• According to this survey, 81% HCPs disagreed that PN should be

considered for all patients peri-operatively.

• 32% HCPs strongly disagreed with this statement.
• More gastroenterologists (56%) reported that they strongly

disagreed that PN should be considered for all patients peri-

• peratively compared with pharmacists (25%), dietitians (34%)

and nurses (10%).

5% agree 81% disagree

26

PN should be considered for all patients peri-operatively – by work location

1% 1% 6% 1% 4% 12% 18% 14% 100% 100% 51% 44% 49% 31% 35% 32% Other Community District General Hospital Teaching Hospital Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• 79% of HCPs working at a teaching hospital and 82%

working at a district general hospital disagreed that PN should be considered for all patients peri-

• peratively.

5% agree 81% disagree

27

It is not appropriate for patients receiving PN to have enteral/oral nutritional intake – by profession

10% 1% 10% 2% 2% 100% 22% 11% 7% 9% 11% 40% 56% 35% 38% 100% 67% 40% 33% 56% 51%

Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• 89% HCPs disagreed (51% strongly disagreed) that it is not

appropriate for patients receiving PN to have enteral/oral nutritional intake.

• 20% of nurses said that they agreed (10% strongly agreed) that

it is not appropriate for patients receiving PN to have enteral/oral nutritional intake.

• 100% intensive care specialists (n=2) strongly disagreed with

the statement.

3% agree 89% disagree

28

It is not appropriate for patients receiving PN to have enteral/oral nutritional intake – by work location

1% 1% 4% 2% 50% 8% 9% 9% 60% 41% 34% 38% 40% 50% 51% 53% 51%

Other Community District General Hospital Teaching Hospital Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• The majority of HCPs (89%) agreed that it is appropriate

for patients receiving PN to have enteral/oral nutritional intake.

3% agree 89% disagree

29

PN should be maintained while oral/enteral feeding is established – by profession

11% 30% 14% 21% 19% 100% 44% 60% 64% 63% 62% 100% 33% 19% 13% 15% 11% 10% 3% 4% 5% Oncologist Intensive Care Specialist Gastroenterologist Nurse

Pharmacist Dietitian Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• The majority of health care professionals agreed that PN

should be maintained while oral/ enteral feeding is established (81%).

• Gastroenterologists showed a lower level of agreement,

(55% agreed); 11% disagreed with the statement.

81% agree 5% disagree

30

PN should be maintained while oral/enteral feeding is established – by work location

50% 22% 16% 19% 60% 64% 61% 62% 20% 50% 10% 19% 15% 20% 5% 4% 5% Other Community District General Hospital Teaching Hospital Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• The majority of HCPs working in teaching hospitals (77%)

and district general hospitals (86%) agreed that PN should be maintained while oral/enteral feeding is established.

81% agree 5% disagree

31

PN should be stopped when a patient can be given enteral nutrition – by profession

50% 25% 22% 12% 14% 100% 56% 50% 28% 41% 39% 22% 25% 44% 22% 27% 50% 22% 6% 21% 17% 4% 3% Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• According to Nice Clinical Guidelines 32 (2006): ‘PN should

be stopped when the patient is established on adequate oral and/or enteral support’ [2].

• 53% HCPs agreed that PN should be stopped when a patient

can be given enteral nutrition.

• More nurses (75%) agreed that PN should be stopped when a

patient can be given enteral nutrition compared with pharmacists (50%), dietitians (53%) and gastroenterologists (56%).

• 44% pharmacists reported that they neither agreed nor

disagreed that a patient should not continue PN once they are able to receive enteral nutrition.

53% agree 20% disagree

32

PN should be stopped when a patient can be given enteral nutrition – by work location

40% 13% 14% 14% 20% 50% 41% 38% 39% 20% 25% 29% 27% 20% 18% 15% 17% 50% 2% 3% 3%

Other Community District General Hospital Teaching Hospital Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• 50% HCPs working in a community setting strongly disagreed

that PN should be stopped when a patient can be given enteral nutrition, whereas only 18% HCPs from teaching hospitals disagreed (3% strongly) and 20% from district general hospitals (2% strongly).

53% agree 20% disagree

33

22% 10% 22% 5% 10% 100% 22% 20% 28% 29% 28% 100% 11% 20% 19% 15% 17% 44% 40% 22% 43% 38% 10% 8% 7% 7% Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

There is no minimum length of time for the duration in which PN can be given – by profession

• According to NICE Clinical Guidelines: ‘There is no minimum length
• f time for the duration of PN’ [2].
• Mixed views were reported among HCPs as to whether there is a

minimum length of time for the duration in which PN can be given; in total 38% agreed and 45% disagreed.

38% agree 45% disagree

34

There is no minimum length of time for the duration in which PN can be given – by work location

20% 16% 4% 10% 60% 50% 30% 24% 28% 17% 19% 17% 50% 33% 45% 38% 20% 5% 9% 7% Other Community

District General Hospital Teaching Hospital Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• HCPs working in a teaching hospital were more likely to disagree

that there is no minimum length of time for the duration in which PN can be given compared with HCPs working in a district general hospital (54% and 38% respectively).

• Views among HCPs working in a community setting were split,

half agreed that there is no minimum length of time for the duration in which PN can be given however the other half of participants disagreed.

38% agree 45% disagree

35

Patients receiving PN should be monitored daily – by profession

50% 33% 50% 51% 44% 45% 100% 50% 56% 30% 29% 36% 36% 3% 10% 7% 11% 10% 17% 9% 11% 10% 1% 1%

Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• NICE Clinical Guidelines state that: ‘PN should be [introduced

progressively and] closely monitored’ [2].

• The majority of HCPs agreed (81%) that a patient receiving PN

should be monitored daily.

• 17% pharmacists and 20% nurses disagreed that patients

receiving PN require daily monitoring.

81% agree 12% disagree

36

Patients receiving PN should be monitored daily – by work location

40% 50% 51% 40% 45% 50% 35% 39% 36% 5% 10% 7% 60% 9% 10% 11% 1% 1% 1% Other Community District General Hospital Teaching Hospital Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• HCPs in district general teaching hospitals less

strongly agreed that patients should be monitored daily compared to those working in district general hospitals (40% and 51% respectively).

• 100% HCPs working in a community setting agreed

that patients receiving PN should be monitored daily.

• The majority (60%) of HCPs working in other* care

settings disagreed that patients should be monitored daily.

* Children's Hospital, Community/Acute based in teaching hospital, all of the above, retired, academic institution, home and healthcare, GP and hospital

81% agree 12% disagree

37

PN should be withdrawn in a planned and stepwise manner – by profession

22% 50% 36% 50% 45% 100% 100% 33% 50% 58% 40% 45% 22% 6% 9% 8% 22% 1% 2% Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• According to NICE Clinical Guidelines: ‘Withdrawal (from PN)

should be planned and stepwise with a daily review of the patient's progress’ [2].

• The majority (90%) of HCPs agreed that PN should be

withdrawn in a planned stepwise manner.

• Only 55% of gastroenterologists agreed that PN should be

withdrawn in a planned manner and over 20% disagreed.

90% agree 2% disagree

38

PN should be withdrawn in a planned and stepwise manner – by work location

60% 50% 45% 44% 45% 40% 50% 43% 48% 45% 10% 8% 8% 2% 1% 2% Other Community District General Hospital Teaching Hospital Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• Only 2% HCPs disagreed that PN should be withdrawn in a

planned and stepwise manner.

90% agree 2% disagree

39

PN should only be administered via a dedicated central line – by profession

50% 44% 40% 42% 29% 43% 100% 11% 30% 33% 26% 27% 11% 20% 17% 12% 13% 50% 33% 6% 14% 13% 10% 3% 4% 4%

Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• NICE Clinical Guidelines 32 (2006) states that: ‘PN can be given via

a dedicated peripherally inserted central catheter as an alternative to a dedicated centrally placed central venous catheter’.

• ESPEN Guidelines state that: ‘Central venous access (i.e. Venous

access which allows delivery of nutrients directly into the superior vena cava or the right atrium) is needed in most patients who are candidates for PN’ [3].

• The majority (70%) of HCPs agreed that PN should only be

administered via a dedicated central line, however 33% of gastroenterologists disagreed and 10% nurses strongly disagreed.

• Pharmacists were most likely to agree that PN should only be

administered via a dedicated central line (75% agreed).

70% agree 17% disagree

40

PN should only be administered via a dedicated central line – by work location

20% 47% 41% 43% 40% 50% 20% 33% 27% 20% 14% 11% 13% 20% 50% 12% 13% 13% 6% 3% 4% Other Community District General Hospital Teaching Hospital Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• More HCPs working in a community setting (50%) disagreed that

PN should only be administered via a dedicated central line compared with teaching (16%) and district general hospital (18%).

70% agree 17% disagree

41

Catheter care is essential when administering PN to a patient to avoid infection – by profession

100% 100% 70% 82% 81% 81% 100% 20% 18% 15% 16%

3%

2% 1% 1% 10% 1%

Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• According to NICE Clinical Guidelines 32 (2006): ‘All catheters

used for PN should then be monitored and cared for by suitably trained and experienced individuals’ [2].

• Whilst the vast majority (81%) of HCPs strongly agreed that

catheter care is essential when administering PN to a patient to avoid infection, 10% nurses strongly disagreed with this statement.

97% agree 2% disagree

42

Catheter care is essential when administering PN to a patient to avoid infection – by work location

80% 50% 83% 81% 81% 20% 50% 15% 15% 16%

1% 3% 2% 1% 1% 1% 1%

Other Community District General Hospital Teaching Hospital Total

Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• 97% HCPs strongly agreed that catheter care is essential

when administering PN to a patient to avoid infection (81% strongly agreed and 16% agreed).

97% agree 2% disagree

43

Fluid balance should be closely monitored when a patient is receiving PN – by profession

50% 78% 70% 72% 77% 75% 100% 50% 11% 10% 28% 21% 22%

11% 10% 1% 2% 1% 1% 10% 1% 1%

Oncologist Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• According to NICE Clinical Guidelines 32 (2006): ‘PN usage

inevitably contributes a significant fluid load and it is essential that fluid balance is monitored careful in all patients receiving PN’ [2].

• 97% HCPs agreed (75% strongly) that fluid balance should be

closely monitored when a patient is receiving PN, however 10% nurses strongly disagreed.

97% agree 2% disagree

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Fluid balance should be closely monitored when a patient is receiving PN – by work location

60% 50% 78% 73% 75% 40% 50% 19% 23% 22%

1% 3% 2% 1% 1% 1% 1% 1%

Other Community District General Hospital Teaching Hospital Total Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree

• The majority (75%) of HCPs strongly agreed that

fluid balance should be closely monitored when a patient is receiving PN, this finding was relatively consistent across care settings.

97% agree 2% disagree

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HCPs’ Confidence with PN

46

• Teaching and district general hospitals are aligned in their levels of knowledge.
• Overall gastroenterologists and dietitians reported feeling more confident with PN than

pharmacists.

• HCPs are more confident at assessing for, and managing PN, in comparison to planning a

patient’s discharge, or training a patient to self administer PN.

How confident do HCPs feel at PN commencement ….

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Reported confidence at assessing whether PN is appropriate for a patient – by profession

100% 89% 38% 22% 58% 51% 11% 50% 53% 40% 41% 14%

1%

4% 13% 6%

2%

6%

1% 2%

Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Very confident Somewhat confident Not very confident Not at all confident N/A

• 98% of dietitians and 100% of medics feel confident

at assessing whether PN is appropriate for a patient.

• Pharmacists and nurses are less confident by

comparison.

92% confident 6% not confident

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Reported confidence at ensuring the prescription for PN is appropriate to meet a patient's nutritional needs – by profession

50% 33% 13% 47% 67% 58% 50% 56% 63% 36% 28% 33% 11% 13% 8% 2% 4% 6% 3% 3% 13% 3% 1% 2% Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Very confident Somewhat confident Not very confident Not at all confident N/A

• 91% of HCPs feel confident at ensuring a PN

prescription is appropriate to meet a patient’s nutritional needs.

• Dietitians were more likely to feel very confident

(67%) compared to pharmacists (47%), gastroenterologists (33%) and nurses (13%).

91% confident 7% not confident

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Reported confidence at commencing a patient on PN (including safe and appropriate catheter access and infusion rate) – by profession

100% 89% 75% 31% 54% 52% 11% 25% 39% 35% 34%

8% 5% 5% 14% 4% 5% 8% 3% 4%

Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total

Very confident Somewhat confident Not very confident Not at all confident N/A

• Whilst the majority (86%) of HCPs reported feeling confident

at commencing a patient on PN, including safe and appropriate access of infusion rate, pharmacists by comparison to other HCPs feel less confident (22% report not very/not at all confident).

86% confident 10% not confident

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How confident do HCPs feel at PN monitoring and management….

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Reported confidence at monitoring fluid balance and biochemical markers – by profession

100% 89% 75% 47% 57% 58% 11% 25% 44% 39% 38%

3% 3% 2% 6% 1% 1% 1%

Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Very confident Somewhat confident Not very confident Not at all confident N/A

1

• The vast majority (96%) of HCPs feel confident

(58% very confident, 38% somewhat) at monitoring fluid balance and biochemical markers.

• Gastroenterologists reported being most

confident (89% very confident) followed by nurses (75%), dietitians (57%) and pharmacists (47%).

96% confident 3% not confident

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Reported confidence at adjusting PN prescriptions to meet changing patient needs – by profession

50% 67% 38% 47% 64% 59% 50% 22% 25% 42% 30% 32% 11% 4% 4% 13% 8% 2% 25% 3% 1% 2% Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian

Total

Very confident Somewhat confident Not very confident Not at all confident N/A

• 94% dietitians feel confident (somewhat/very) at

adjusting prescriptions to meet changing patients needs compared to pharmacists (89%), closely followed by gastroenterologists (89%).

• Nurses were least likely to report feeling confident

(63%), however a quarter of nurses (25%) reported that this was not applicable to them.

91% confident 6% not confident

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Reported confidence at managing complications (e.g. re-feeding, catheter-related infections, liver dysfunction) – by profession

100% 89% 50% 22% 37% 38% 11% 50% 50% 51% 48% 17% 7% 8% 8% 4% 4% 3% 2% 2%

Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Very confident Somewhat confident Not very confident Not at all confident N/A

• 100% nurses and medics are confident in managing

complications in relation to PN (e.g. re-feeding, catheter related infections, liver dysfunction), however dietitians and pharmacists reported feeling less confident (88% and 72%, respectively reported confidence).

86% confident 12% not confident

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How confident do HCPs feel at planning patient discharge on PN….

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Reported confidence at training a patient to manage and self administer PN – by profession

11% 38% 2% 4% 22% 25% 11% 1% 5% 33% 17% 7% 10% 22% 13% 39% 41% 38% 100% 11% 25% 33% 49% 43% Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian

Total Very confident Somewhat confident Not very confident Not at all confident N/A

• Nurses (63%) and gastroenterologists (66%) reported

feeling more confident at training patients to manage and self administer PN than the other HCPs. Dietitians and pharmacists are less confident at this (3% and 11% respectively).

• A noteworthy proportion of HCPs (43%) reported that the

question was not applicable to them, particularly dietitians (49%) and pharmacists (33%).

9% confident 48% not confident

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Reported confidence at discharge planning for patients being discharged home on PN – by profession

44% 13% 11% 15% 16% 22% 25% 17% 14% 16% 22% 13% 14% 11% 12% 11% 13% 31% 26% 25% 100% 38% 28% 34% 32%

Intensive Care Specialist Gastroenterologist Nurse Pharmacist Dietitian Total Very confident Somewhat confident Not very confident Not at all confident N/A

• Only 32% HCPs reported being confident at discharge

planning for patients being discharged home on PN.

32% confident 37% not confident

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HCPs’ views on how to improve the way PN is prescribed and managed

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Improvements in PN prescribing and management would include: dietetic and pharmacist prescribing, increases in homecare, better education for HCPs, clear guidance with robust evidence and 7 day availability. Dietetic and pharmacist prescribing

“Dietitians and pharmacists having greater control over prescriptions and dietitians becoming prescribers -

• ne would hope then there would be

less scope for inappropriate delays or rushing to prescribe PN..” “More health care professionals being able to prescribe e.g. dietitians,

• pharmacists. More home PN

especially in malignant diseases.” “Allow dietitians to prescribe!”

Increases in homecare

“Changing the attitudes with respect to patients who have a malignancy. This requires changing the attitudes

• f oncologists. In Europe this is the

largest group of patients who receive home PN. In England it is

• ne of the smallest groups.”

“More use in palliative care and more home PN.” “Change in home care companies and availability of nursing and compounding capacity of HPN companies.”

Better education for HCPs

“More training to Doctors/surgeons/anaesthetists.” “More training that is suitable.” “Multi disciplinary training.” “ongoing training.” “Education to Surgical and Intensive care medics. More support for non-medical nutrition support teams from gastroenterologists.” “Education for surgical teams following surgery. not all will develop ileus. Education for prescribers.”

Clear guidance with robust evidence

“More research in specific patient groups.” “Large scale well designed research studies More focused and evidence based guidelines on the appropriate use and management of PN.” “Clear guidance and sound evidence.” “Solid RCT and robust research which showed how PN can be performed safely and may be safer than EN. More research and evidence based practice.” “Increasing evidence base of the benefits.”

7 day availability

“Available 7 days per week. More evidence supporting use of PN.” “7 day working.” “Available 7 days a week instead of mon-fri.”

“7 day working and HIFNET.”

Conclusions

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The survey highlighted four important factors for improving the awareness of PN: perception, confidence to manage, the ability to prescribe and training for HCPs. These conclusions will be explained in detail over the next four slides. Ultimately a combination of initiatives which cover the aforementioned factors will lead to an improved knowledge and use of PN.

Conclusions: Perception

• The survey highlighted that 94% HCPs agreed that PN ‘should be considered for all patients with a non-functioning,

inaccessible or perforated gastrointestinal tract’.

• Yet, only 60% agreed that PN ‘should be considered for all patients with malnutrition and with inadequate/unsafe
• ral/ enteral nutritional intake’.
• Both statements are from the NICE clinical guideline 32 (2006), this highlights the need for greater clarification of

the current guidelines.

Varying interpretation of current guidelines

• 23% of multidisciplinary teams are made up of gastroenterologists, however:
• Only 55% agreed that ‘PN should be maintained while oral/ enteral feeding is established’,
• Only 55% agreed that ‘PN should be withdrawn in a planned and stepwise manner’,
• 33% disagreed that ‘PN should be administered via a dedicated central line’,
• Therefore if the perception of PN is to improve amongst HCPs, gastroenterologists need greater awareness of the

appropriate use of PN.

Gastroenterologists need greater awareness of the appropriate use of PN

• Despite 72% of HCPs viewing PN as useful when used appropriately, only 18% HCPs surveyed consider PN

invaluable for improving nutritional status of patients.

PN is not considered invaluable among 82% of participants

• Current NICE guidelines state “there is no minimum length of time for the duration of PN”, however only 38% of

participants agreed with this statement.” This highlights inconsistency across care settings.

Mixed views on minimum treatment length

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Conclusions: Confidence to manage

• Amongst the survey participants, confidence levels on PN management were generally

high, however clear variances were seen between the different professions.

• Dietitians and gastroenterologists, reported feeling more confident in the management of

PN than pharmacists.

• Nurses’ confidence levels vary considerably across the stages of PN management.

Confidence levels vary among HCPs…

• All HCPs reported relatively high levels of confidence in the assessment, management and

monitoring of patients receiving PN.

• However, low levels of confidence for training a patient to self-administer or preparing for

discharge were reported.

• As PN is used in community settings, further training on preparing patients for the

independent use of PN is needed.

…but across all professions, levels are considerably reduced for preparing patients for the independent use of PN

• Teaching and District General Hospital staff are aligned in their views on the management of

PN.

Similar views reported among Teaching and District General hospital staff

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Conclusions: Ability to prescribe

• 39% of participants reported that the dietitian was the Trust’s primary decision maker for

prescribing PN, however this was self-reported among 73% of participants.

• A qualitative take on management of PN highlighted the participants support for dietitians

to prescribe PN.

Dietitians appear to be the primary decision makers

• The feedback from the respondents suggests that PN is used in patient types which fall

under reimbursement (ie. intestinal failure).

PN is mainly used for patients with intestinal failure

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Conclusions: Training

• 20% of HCPs reported receiving no training for administering PN.
• There is a desire amongst HCPs for more formal training that is competency based at a trust level.
• Online training is the preferred mode of delivery but practical training courses and more detailed

guidance are also preferred methods amongst the majority of survey participants.

Demand for formal training

• Survey participants stated there was a lack of clear guidance and robust data in the current guidelines.

Clear guidance still lacking

63

References

1. Braga, M., Ljungqvist, O., Soeters, P., Fearon, K., Weimann, A., & Bozzetti, F. (2009). ESPEN guidelines on parenteral nutrition: surgery. Clinical nutrition, 28(4), 378-386. 2. NICE Clinical Guidelines 32 (2006) Oral nutrition support, enteral tube feeding and parenteral nutrition 3. Pittiruti, M., Hamilton, H., Biffi, R., MacFie, J., & Pertkiewicz, M. (2009). ESPEN Guidelines

• n Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of

complications). Clinical Nutrition, 28(4), 365-377.

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