The NCEPOD The NCEPOD report on Parenteral Parenteral Nutrition - - PowerPoint PPT Presentation

The NCEPOD The NCEPOD report on Parenteral Parenteral Nutrition June 2010

Dr Mike Stroud FRCP Chair British Association for Parenteral & Enteral Nutrition S i L t i M di i & N t iti IHN Senior Lecturer in Medicine & Nutrition, IHN Consultant Gastroenterologist, Southampton Chair of NICE GDG on Nutrition Support

A multi-disciplinary charity committed to raising awareness of malnutrition and i f i d i i

• ptions for its treatment; and examining

impacts on health outcomes, resource tili ti d h lth/ i l b d t utilization and health/social care budgets.

CAUSES OF MALNOURISHMENT

Conscious level Depression Poor diet - age, poverty, junk, exercise, alcohol Anorexia Dysphagia Obstruction Obstruction Vomiting Pancreatic failure Pancreatic failure Liver processing Jaundice Malabsorption I d M b li d d Increased Metabolic demands

Food intake, absorption, losses and demands

Effects of Undernutrition

Ventilation - loss of l & h i Psychology – depression & apathy Immunity – Increased risk

• f infection

muscle & hypoxic responses li f tt h Renal function loss of Decreased Cardiac output liver fatty change, functional decline necrosis, fibrosis Renal function - loss of ability to excrete Na & H2O Impaired wound healing Hypothermia Impaired gut integrity and integrity and immunity Loss of strength Anorexia ? Micronutrient deficiency

Complications of abdominal

• perations for malignant disease

Meguid et al., Am J Surg 156, 1988 g , g ,

90 100

%

70 80 90

p a

40 50 60 Well nourished

t i e

20 30 40 Malnourished

e n t

10 Complication Rate Post-Operative

s

Complication Rate Post Operative Mortality

Nutritional |Care and Nutritional |Care and Quality - the BAPEN Agenda 2009/10 Agenda 2009/10 – a framework for

Malnutrition Matters Meeting Quality Standards in N t iti l C

Commissioners and Providers to establish

Nutritional Care

Ailsa Brotherton, Nicola Simmonds and Mike Stroud

safe quality care standards in nutritional

• n behalf of the

BAPEN Quality Group

standards in nutritional care from food and supplements at one end supplements at one end

• f the spectrum to the

hi hl i li d highly specialised PN at the other.

BAPEN Toolkit BAPEN Toolkit

F k t t Four key tenets:

• Screen to identify nutritional care needs followed by

d t il d t detailed assessment

• Care pathways in place with appropriate monitoring
• Training for all staff to appropriate levels
• Management structures in place to support the

delivery of safe nutritional care of the highest quality delivery of safe nutritional care of the highest quality

Starvation & Weight loss Starvation & Weight loss

(After Allison)

95 100

Decision Box % b

• 80

85 90 Catabolic

• d

y

70 75 80 Catabolic Complete starvation Partial starvation

w e i

55 60 65

i g h

50 10 20 30 40 50 60 70

t Days

A Patient’s Journey A Patient’s Journey

95 100

% b

• GP

GP OP IP NBM f I 80 85 90 Catabolic

• d

y

NBM for Ix Surgery 70 75 80 Catabolic Complete starvation Partial starvation

w e i

55 60 65

i g h

Not going 50 10 20 30 40 50 60 70

t

Not going well - Friday

Days

Nutrition support in adults: 2006 adults: 2006

Nutrition support

SCREEN RECOGNISE SCREEN RECOGNISE TREAT TREAT ORAL ENTERAL PARENTERAL MONITOR MONITOR REVIEW

Parenteral nutrition Parenteral nutrition

if patient malnourished/at risk of malnutrition and has either a non functional, inadequate or unsafe oral inaccessible or perforated gastrointestinal tract inadequate or unsafe oral

• r enteral nutritional intake

introduce progressively and monitor closely use the most appropriate route of access and mode of delivery stop when the patient is established on adequate

• ral intake from normal food or enteral tube feeding

D

The Evidence W t d t i IF l t Wanted – starving IF volunteers for PN RCTs for PN RCTs

Evidence for enteral for enteral and parenteral nutrition nutrition

IBO

The NCEPOD The NCEPOD report on Parenteral Parenteral Nutrition June 2010

BAPEN’s Response p

• Dismay
• Dismay
• Congratulations and welcome

g

– solid evidence that many hospitals deliver unsafe artificial nutrition to vulnerable adults and babies artificial nutrition to vulnerable adults and babies. – Generally irrefutable data confirming what BAPEN NICE d h h id f i BAPEN NICE and others have said for some time i.e standards in nutritional care must be improved to ensure all patients receive quality, safe and equal treatment from staff who are appropriately trained and supervised

? NSTs surely BAPEN NSTs

PN needed in Intestinal Failure – h ld b l l i Should be level 2 patients ?IFU

Finding % % Appropriate indication 71.3 28.7 Delay in identification 16 84 Delay in starting 9 91 Nutrition Team involved 52.7 47.3 Off the shelf with no additions 42.7 57.3 Adequate monitoring 56.7 43.3 Inappropriate additional IV fluids 21 79

Difficulties with definition and Difficulties with definition and methodology methodology

• Refeeding syndrome

Refeeding syndrome

• Catheter related sepsis

But its bad! But its bad!

NCEPOD Recommendations

• PN should only be given when necessary
• When PN is needed recognise early and take action
• When PN is needed recognise early and take action
• Patient assessment should be robust and purpose and

goal documented goal documented

• Regular documented clinical and biochemical

monitoring monitoring

• Additional IV fluids only if necessary

A i d i b h l f PN i

• Active education about the role of PN, its

complications and side effects All h i l h ld h PN f

• All hospitals should have a PN proforma
• Catheter and organizational

BAPEN’s Recommendation’s

• All acute hospitals must have multi-disciplinary NSTs

p p y with Senior Clinical Leadership

• All acute hospitals should have simple rolling system of

PN registration and audit t it ti d i d t d d – to monitor practice and secure improved standards – this could be delivered by extending BAPEN’s existing BANS database covering long-term home PN patients BANS database covering long-term home PN patients and it would support work by HIFNET - the newly established commissioning, management and clinical framework dealing with intermediate and long-term PN

This needs political will and DH support

BAPEN's Challenge g

• We challenge the Coalition Government to

i l t f ll th d ti f implement fully the recommendations from this NCEPOD report and those from the D li B d f h N i i A i Pl Delivery Board of the Nutrition Action Plan

– political leadership for malnutrition and risk – a public and professional awareness campaign

• n the impact of poor nutritional status on

health outcomes

BAPEN Agenda 2019/11 Safet in N tritional Care Safety in Nutritional Care

BAPEN ill t l l l d hi th h BAPEN will ensure top-level leadership through an

All Party Parliamentary Group on Nutritional Care and Hydration.

with parliamentary and professional partners

S i

with parliamentary and professional partners Ai T th t f t iti l f ll

Screening Catering

Aim - To ensure that safe nutritional care of all types continues to make its way up political,

g Oral Nutrition Supplements ETF

professional and practical agendas for the benefit of patients and people of all ages across primary,

ETF Under-hydration and IV fluids

p p p g p y, secondary and community settings.

PN

Th k Thank you