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NCEPOD REPORT – A MIXED BAG – PUBLISHED… Major Deficiencies in Artificial Nutrition given in Hospitals Identified by National Enquiry.


A national enquiry has found major deficiencies in the way hospitals are giving artificial or parenteral nutrition (PN) to sick adult patients and vulnerable premature babies causing avoidable complications, according to the findings in a new study from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).


Lead report author Dr James Stewart, NCEPOD Clinical Co-ordinator and a Consultant Gastroenterologist, said: “We found that adults are often given this treatment when it is not needed. Care must be improved in the provision of artificial nutrition across all patient groups.” Parenteral nutrition is the method used to


feed patients intravenously when they are unable to absorb sufficient nutrition through their gastrointestinal tract. It is also a mainstay of treatment for premature babies.


Co-author Dr David Mason, NCEPOD Clinical Co-ordinator and Consultant Anaesthetist, said:


Key findings


Adults • Good practice was found in only a fifth (19% of 877 case reviews)


• PN was administered for an inappropriate clinical reason in nearly a third of cases reviewed (29% of 808), and assessment and monitoring was inadequate in half


• Complications were avoidable in half of the adult cases (49% of 164).


Key recommendations


• Clinicians need to recognise a patient’s need for PN early


• Where PN is needed it should be administered without delay


• PN should only be given when all other feeding methods have been considered and excluded


• Regular clinical and biochemical monitoring of the patient should be mandatory.


Premature babies


• Good practice was identified in a quarter of cases (24% of 264)


• In almost a third of cases (28% of 252) there were delays in recognising the need for PN and then further delays in starting PN in 17% of cases (36/210)


• In 37% of cases reviewed (178) the first PN administered was considered inadequate for the babies’ needs


• Complications were avoidable in a fifth (19% of 32) of premature babies on PN.


Key recommendations


• The need for PN should be considered early for premature babies


• Once a decision to administer PN is taken it should be started immediately


• The first PN must be adequate for babies’ needs


• The National Institute for Health and Clinical Excellence (NICE) should develop guidelines on nutritional support for neonates and children.


“Premature babies may receive insufficient nutrition for their energy requirements” and called for “those responsible for the provision of PN to pre-term babies to develop greater consensus on its use.”


A Mixed Bag reviewed the hospital care of 877 adult and 264 neonatal patients who were given PN, and found good practice in less than a quarter of all cases.


The enquiry also found clear evidence of poor care and documentation when feeding catheters (central venous catheters – CVCs) were inserted. Dr Stewart stated that: “CVC insertion is an


invasive procedure that carries well recognised risks, which means that it must be properly documented.’’ He called for: “Improvements in education around CVC insertion and care.” NCEPOD Chairman Bertie Leigh said: “It is


deeply depressing that the quality of care is so often unsatisfactory. Indeed, in discussion with the NCEPOD Steering Group the scale of disappointment verged on disbelief.”


He called on the new Government to appoint


a Nutrition Tsar to: “Harness the energies of all those involved in artificial nutrition.”


BAPEN Welcomes the Evidence contained in the NCEPOD Artificial Nutrition Enquiry Report


Dr Mike Stroud, Chair of BAPEN states: “The NCEPOD Report ‘A Mixed Bag’ * provides solid evidence that many hospitals are currently delivering unsafe artificial nutrition to the most vulnerable adults and babies. The irrefutable data confirm what BAPEN


and other organisations such as NICE have been saying for some time – that 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. Artificial or parenteral nutrition (PN) is


tube feeding delivered intravenously and is used where the gut is inaccessible or unable to absorb sufficient nutrition. It is an invasive and complex procedure which requires input from a multi-disciplinary team to deliver the specialist training, supervision and monitoring needed to avoid the inappropriate use and avoidable complications identified in the NCEPOD Report. Previous evidence1


has already established


that improved nutritional care is delivered when a hospital has a multi-disciplinary Nutrition Support Team (NST), a practice that BAPEN and its members have long championed. Although we have not had the opportunity to examine the data from each hospital site, we are confident that examples References:


of better practice were observed where such teams were in place.” Dr Mike Stroud continues: “BAPEN supports the recommendations set out in the NCEPOD Report, particularly those concerned with training of staff in decision-making and monitoring. However, in response BAPEN makes two further recommendations: 1. All acute hospitals should have multi- disciplinary NSTs in place to oversee PN prescription and management in line with previous recommendations from NICE and BAPEN.


2. A rolling system of registration and audit of all patients on PN should be established to monitor practice and hence secure improved standards in PN usage and on-going care. This registration and audit system could be delivered by extending BAPEN’s existing BANS database2


which currently covers patients on long-term home PN, to cover all PN patients, both in and out of hospital. BAPEN would welcome support to develop this idea in partnership with the DH. The system would also support the work of the newly established commissioning and management framework that deals with intestinal failure and longer-term PN known as HIFNET.”3


* The majority of members of the Expert Group who advised NCEPOD on the study are members of BAPEN and more than half the Advisors who reviewed the cases are also members.


1. NICE, 2006: Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition http://guidance.nice.org.uk/CG32


Lennard-Jones J 1992, A positive approach to nutrition as treatment, Kings Fund, London • 2. BANS British Artificial Nutrition Survey the unique national audit of clinical nutrition practice, managed and currently funded solely by BAPEN, has made vital contributions to the planning and delivery of high quality nutritional care in the UK • 3. HIFNET, the Home Intestinal Failure Network, brings the multidisciplinary team including medical and surgical clinicians together to improve standards, share good practice and highlight challenges in the long term management of intestinal failure and PN. A commissioning framework has recently been established endorsed by NHS specialised commissioning, the Royal College of Physicians and Royal College of Surgeons of England with BAPEN members.


For further information about NCEPOD or to download a copy of ‘A Mixed Bag’, visit:www.ncepod.org.uk


BAPEN In Touch No.58 August 2010 4


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