The NCEPOD report on Parenteral Nutrition June 2010 Dr Mike Stroud FRCP Chair British Association for Parenteral & Enteral Nutrition 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 options for its treatment; and examining impacts on health outcomes, resource utilization and health/social care budgets.

Food intake, absorption, losses and demands

Malnutrition Matters Meeting Quality Standards in Nutritional Care Ailsa Brotherton, Nicola Simmonds and Mike Stroud on behalf of the BAPEN Quality Group Nutritional |Care and Quality - the BAPEN Agenda 2009/10 – a framework for Commissioners and Providers to establish safe quality care standards in nutritional care from food and supplements at one end of the spectrum to the highly specialised PN at the other.

BAPEN Toolkit Four key tenets: Screen to identify nutritional care needs followed by 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

Starvation & Weight loss (After Allison) Catabolic Complete starvation Partial starvation Decision Box % b o d y w e i g h t Days

A Patient’s Journey Catabolic Complete starvation Partial starvation % b o d y w e i g h t Days GP OP IP NBM for Ix Surgery Not going well - Friday

Nutrition support in adults: 2006

RECOGNISE TREAT ORALENTERALPARENTERAL MONITOR REVIEW Nutrition support SCREEN

Parenteral nutrition 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 and has either introduce progressively and monitor closely if patient malnourished/at risk of malnutrition a non functional, inaccessible or perforated gastrointestinal tract inadequate or unsafe oral or enteral nutritional intake D

The Evidence Wanted – starving IF volunteers for PN RCTs

Evidence for enteral and parenteral nutrition IBO

The NCEPOD report on Parenteral Nutrition June 2010

BAPEN’s Response Dismay Congratulations and welcome –solid evidence that many hospitals deliver unsafe artificial nutrition to vulnerable adults and babies. –Generally irrefutable data confirming what 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 – Should be level 2 patients ?IFU

Finding% Appropriate indication Delay in identification1684 Delay in starting991 Nutrition Team involved Off the shelf with no additions Adequate monitoring Inappropriate additional IV fluids2179

Difficulties with definition and methodology Refeeding syndrome Catheter related sepsis But its bad!

PN should only be given when necessary When PN is needed recognise early and take action Patient assessment should be robust and purpose and goal documented Regular documented clinical and biochemical monitoring Additional IV fluids only if necessary Active education about the role of PN, its complications and side effects All hospitals should have a PN proforma Catheter and organizational NCEPOD Recommendations

All acute hospitals must have multi-disciplinary NSTs with Senior Clinical Leadership All acute hospitals should have simple rolling system of PN registration and audit –to monitor practice and secure improved standards –this could be delivered by extending BAPEN’s existing 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 BAPEN’s Recommendation’s This needs political will and DH support

BAPEN's Challenge We challenge the Coalition Government to implement fully the recommendations from this NCEPOD report and those from the Delivery Board of the Nutrition Action Plan –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 Safety in Nutritional Care BAPEN will ensure top-level leadership through an All Party Parliamentary Group on Nutritional Care and Hydration. with parliamentary and professional partners Aim - To ensure that safe nutritional care of all types continues to make its way up political, professional and practical agendas for the benefit of patients and people of all ages across primary, secondary and community settings. Screening Catering Oral Nutrition Supplements ETF Under-hydration and IV fluids PN

Thank you