The NCEPOD The NCEPOD report on Parenteral Parenteral Nutrition June 2010 Dr Mike Stroud FRCP Chair British Association for Parenteral & Enteral Nutrition Senior Lecturer in Medicine & Nutrition, IHN S i L t i M di i & N t iti IHN Consultant Gastroenterologist, Southampton Chair of NICE GDG on Nutrition Support
A multi-disciplinary charity committed to raising awareness of malnutrition and options for its treatment; and examining i f i d i i impacts on health outcomes, resource utilization and health/social care budgets. tili ti d h lth/ i l b d t
CAUSES OF MALNOURISHMENT Poor diet - age, poverty, junk, Conscious level exercise, alcohol Depression Anorexia Dysphagia Obstruction Obstruction Vomiting Pancreatic failure Pancreatic failure Liver processing Jaundice Malabsorption I Increased Metabolic demands d M b li d d Food intake, absorption, losses and demands
Effects of Undernutrition Psychology – depression & apathy Ventilation - loss of muscle & hypoxic l & h i Immunity – Increased risk responses of infection li liver fatty change, f tt h Decreased Cardiac output functional decline necrosis, fibrosis Renal function Renal function - loss of loss of ability to excrete Impaired wound Na & H2O healing Hypothermia Impaired gut integrity and integrity and Loss of strength immunity Anorexia ? Micronutrient deficiency
Complications of abdominal operations for malignant disease Meguid et al., Am J Surg 156, 1988 g , g , 100 % 90 90 p 80 a 70 t 60 i 50 Well nourished e e 40 40 Malnourished n 30 t 20 s 10 0 Complication Rate Complication Rate Post-Operative Post Operative Mortality
Nutritional |Care and Nutritional |Care and Quality - the BAPEN Agenda 2009/10 Agenda 2009/10 – a framework for Commissioners and Providers to establish Malnutrition Matters Meeting Quality Standards in Nutritional Care N t iti l C safe quality care Ailsa Brotherton, Nicola Simmonds standards in nutritional standards in nutritional and Mike Stroud on behalf of the BAPEN Quality Group care from food and supplements at one end supplements at one end of the spectrum to the hi hl highly specialised PN at i li d the other.
BAPEN Toolkit BAPEN Toolkit F Four key tenets: k t t • Screen to identify nutritional care needs followed by d t il d detailed assessment t • 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) % 100 Decision Box b 95 o o 90 d 85 y 80 80 Catabolic Catabolic w 75 Complete starvation e 70 Partial starvation i i 65 g 60 h 55 t 50 0 10 20 30 40 50 60 70 Days
A Patient’s Journey A Patient’s Journey GP % GP 100 OP b IP 95 o o NBM for Ix NBM f I 90 Surgery d 85 y 80 80 Catabolic Catabolic w 75 Complete starvation e 70 Partial starvation i i 65 g 60 h 55 Not going Not going t 50 well - Friday 0 10 20 30 40 50 60 70 Days
Nutrition support in adults: 2006 adults: 2006
Nutrition support SCREEN SCREEN RECOGNISE RECOGNISE TREAT TREAT ORAL ENTERAL PARENTERAL MONITOR MONITOR REVIEW
Parenteral nutrition Parenteral nutrition if patient malnourished/at risk of malnutrition a non functional, and has either inadequate or unsafe oral inadequate or unsafe oral inaccessible or perforated or enteral nutritional intake gastrointestinal tract introduce progressively and monitor closely use the most appropriate route of access and mode of delivery stop when the patient is established on adequate oral intake from normal food or enteral tube feeding D
Wanted – starving IF volunteers t l for PN RCTs for PN RCTs The Evidence IF i t t d W
IBO parenteral for enteral for enteral Evidence nutrition nutrition and
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 and others have said for some time BAPEN NICE d h h id f i 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 – Should be level 2 patients h ld b l l i ?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 • Active education about the role of PN, its A i d i b h l f PN i complications and side effects • All hospitals should have a PN proforma All h i l h ld h PN f • 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 – to monitor practice and secure improved standards t it ti d i d t d d – 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 implement fully the recommendations from l t f ll th d ti f this NCEPOD report and those from the Delivery Board of the Nutrition Action Plan D li B d f h N i i A i Pl – political leadership for malnutrition and risk – a public and professional awareness campaign on the impact of poor nutritional status on health outcomes
BAPEN Agenda 2019/11 Safet in N tritional Care Safety in Nutritional Care BAPEN BAPEN will ensure top-level leadership through an ill t l l l d hi th h All Party Parliamentary Group on Nutritional Care and Hydration . with parliamentary and professional partners with parliamentary and professional partners S Screening i Catering g Ai Aim - To ensure that safe nutritional care of all T th t f t iti l f ll Oral Nutrition Supplements types continues to make its way up political, ETF ETF professional and practical agendas for the benefit of Under-hydration and IV fluids patients and people of all ages across primary, p p p g p y, PN secondary and community settings.
Thank k you Th
Recommend
More recommend
