The overall aim of the initiative was to audit the compliance of dietetic care provided to adults with disease-related malnutrition and those requiring home enteral feeding against the NICE CG32 and QS24 recommendations with a view to making any improvements required to ensure excellent quality and consistency of care by the team.

The objectives were:

• Annual audit to benchmark the level of care against each relevant NICE CG32 recommendation.
• Annual action plan based on the audit findings to include any improvement required in the dietetic assessment and care planning tools, and any improvement required by the dietitians in completing these.
• Dissemination of the audit findings and action plan to the team and wider service.
• As time evolved the action plan had to include taking into account the change from paper patient records to electronic records, and changes of service provision to best meet the needs of the population and rising numbers of referrals.

The initial clinical audit commenced in 2009 as part of a Trust and team initiative to benchmark the care being provided to patients receiving home enteral feeding and those with disease-related malnutrition against the then recently published NICE CG32 guidance which directly relates to the core purpose of the team. This guidance (and QS24), covers identifying and caring for adults who are malnourished or at risk of malnutrition and offers advice on how oral and enteral feeding should be started, administered and stopped with an emphasis on patient-centred care.

Given that the results of this initial audit did not demonstrate a very good level of compliance in all aspects, an improvement plan was implemented as the team's aspiration was, and still is, to provided excellent quality care. It was logical therefore to continue to audit the success of the improvement plan on an annual basis and the audit has evolved to measure, not only the parameters relating to the NICE guidance, but also additional local quality standards. After each audit a new action plan is produced in order to improve the quality of the patient consultation with a particular emphasis on effective and timely patient-centred care.

Data is collected annually and retrospectively from a randomly selected set of patient records completed over the previous 12 months for 10% of the caseload. Data was collected originally by dietetic students and now by team members collating from each others records. This data is submitted to a selected member of the team (rotated on an annual basis) who analyses it for compliance against the parameters. This approach allows all team members to be involved in the audit and promotes a commitment from all to improving the quality of care. The aim is to achieve 95% compliance for each parameter. In times of short staffing this audit and subsequent improvement plan have still taken place, such is the importance placed on it.

With time the audit content has evolved with data being collected on an increasing number of parameters, such as auditing the records to capture the clinical reasoning e.g. assessing that the individualised care plan in place relates to the dietetic problem; where there is a risk of re-feeding syndrome identified the plan demonstrates it is being acted upon.

After each audit the team discuss the findings and agree the improvement plan. An annual patient experience survey is done.

The baseline audit in 2009 demonstrated that no parameters had 95% compliance with CG32 guidance. Consultations took place in a timely manner, but the content was not always encompassing recommendations e.g. micronutrient status. As a result the assessment tools used by the team were expanded to include all parameters required and the dietitians asked to complete all sections fully.

The dietitians were encouraged when peer reviewing to feedback about the consultation with relation to the NICE guidance ensuring evidence based practice. As a result there was a marked improvement seen in the compliance in the subsequent five audits to 50% parameters achieving 95% compliance. The audit findings for 2014 demonstrated a down turn in compliance (36%). This reflected the introduction of an electronic patient system and laptops to use in patient homes. Alongside initial technical difficulties, the team also had staffing difficulties and required locum support.

Improvements to laptops and the electronic tools has ensured that the electronic record has become successfully embedded into practice and there has been year on year improvement in the audit findings with 2018 demonstrating 83% parameters achieving 95% compliance thus indicating consistent evidence-based care. The patient experience survey RAG rated as green.

• Ensure all the team is engaged with the purpose of any audit/improvement programme. Involving all in the data collection from their peers records over the last 2 years has promoted a significant improvement in their own records and a large improvement in overall team performance, so moving forwards would do this from the outset.
• To continue to improve the quality of care over time, the parameters being measuring need to evolve to push the level of quality achieved further.
• The audits have demonstrated that significant changes to processes or staffing can affect the quality of care detrimentally. The impact needs to be considered at the planning stage.
• The introduction of an electronic patient record system, while in the short term caused some issues in quality of care, has supported further improvement in the quality of assessments. it has enabled mandatory fields to be added to the tool which must be considered and completed before the tool can be saved thus improving compliance.
• Audit data, as well as being able to prove a service's worth to commissioners, can be used to demonstrate the effect of issues e.g. increased referrals on quality of care and assist in requesting extra provision of resource.

This project describes the benefits of patients being seen by Speech and Language Therapists and Dietitians whilst they have radiotherapy (plus or minus chemotherapy) to minimise the morbidity associated with oncology treatments to the head and neck. The paper describes the individual and operational benefits of this clinical intervention, including reduced weight loss, and admissions to hospital as well as a shortened length of stay for patients who were admitted.   

Patients diagnosed with and treated for H&NC require management  from  the multi-disciplinary team (MDT) that includes Dietitians and Speech and Language Therapists (SLTs) to optimise their function and to maintain their health and wellbeing, before, during and after treatment. The NICE clinical guidelines CSG6 (2004), NG36 (2016) and head and neck quality standard 146 support this concept, and detail the requirement for SLT and dietitians from diagnosis to discharge.    NICE CG32 (2006) and QS24 make recommendations for adults requiring oral nutritional support, enteral and parenteral nutrition in both the hospital and community setting.  For patients with H&NC this support also includes screening for risk of malnourishment and required support from health care professionals able to manage their nutrition, hydration and wellbeing. NICE CG32 also states that patients who need nutritional support should receive coordinated care as they are at risk of developing refeeding symptoms.   

Prior to August 2018, our cancer centre provided two sessions (7.5 hours) of dietetic support and no SLT service to patients during radiotherapy (plus or minus chemotherapy) as their main or combined treatment for H&NC.  The dietitians providing this limited service noted that patients deteriorated quickly during treatment and the main point of intervention for both services was as patients were admitted to hospital. The SLT support and intervention was crisis driven and reactive, only assessing patients when they were admitted to the ward during treatment.  The dietitians, SLT and wider MDT were aware that this was a gap in the service and left patients vulnerable to poor nutrition and hydration and impacted on swallow function, leading to reduced oral intake, potential weight loss, increased complications and poor rehabilitation post-radiotherapy. When patients were admitted to hospital during and post-treatment it was possible to identify weight-loss of more than 10% from baseline as a concerning factor. The therapy team believed that by providing proactive clinical interventions during their radiotherapy treatment, it would be possible to reduce the number of patients who would require admitting to hospital, and for those who were to shorten the length of stay.

Therapy services wrote a business case that sought dietetic and SLT funding to manage patients during their oncology treatment for H&NC, describing the potential benefit to patients’ care. Financial modelling based on predicted activity included 1.2 whole time equivalent (wte) dietitians and 0.6 wte SLT band 6 should be funded.  The 1.2 wte dietitians and 0.6 wte SLT would be reabsorbed into the establishment if no positive benefit could be demonstrated after a year’s pilot of this intervention.

The business case was agreed in part (0.8.0 wte Dietetics and 0.6 wte SLT). The appointed therapists were able to identify the key clinics, days and members of the MDT to work with, to improve communication, joint working and identifying critical time-points in the week to influence how patients on treatment were supported. New members of staff established observation and collaborative working with other HCPs oncologists, radiographers, clinical nurse specialists and administrative teams who had managed until this point without the specific therapies being part of the team.  Establishing real clinical space, IT access, means of documenting efficiently key information, and respect for one another’s professional boundaries was vital and actively acknowledged by the dietetic and SLT teams. 

The total number of patients treated by the oncology centre for H&NC has remained constant (n=220) over the last two years.  The oncological treatments offered, the technical way of delivering them and the consultants caring for the patients has also remained unchanged. Figure 1 and 2 describe the pre and post investment numbers of patients referred and their average length of stay.  See attachment for details.

Table 1 (see attachment) demonstrates a 54-82 bed days saved per month because of the dietetic and SLT input to the on treatment H&N radiotherapy outpatient clinics.   It is not possible to combine both services saving in bed days because some of the patients are known to both services. 

Dietetic health care professionals will aim to minimise the amount of weight loss that patients have to 10% or under.  If this is possible there is evidence that patients have an improved quality of life and a better functional recovery.  Table 2 demonstrates (see attachment) that in the pre-investment group 45% (n=33) of the patients who were admitted had lost more than 10% of their baseline weight this reduced to  39% of a smaller total group  (n=22) in the  post-investment group.

The work has highlighted the value of consistently collecting anthropometric measures on patients as a way of identifying the functional impact on patients’ recovery.

 Feedback from the health care professionals include:

Encouraging patients to maintain their swallow function even if just by drinking water rather than stopping any swallowing of oral intake is vital.  We have been able to notice sudden changes in pain levels and react quickly to this.

It means that if a tube is needed it’s in a planned way rather than as an urgent hospital admission.

Working with SLT colleagues we have been able on numerous occasions to identify those patients who have swallowing difficulties and therefore at a greater risk of not meeting their needs orally. This helps early discussion and allows concerns to be discussed and has enabled NG tube placement to take place pre-emptively rather than as an emergency.

It keeps patients out of hospital and helps to keep them “well” to carry on with their treatment rather than just “falling across the finish line.”

Before the on treatment support from the two services patients were not able to come to the post treatment clinics within the first month of finishing their treatments because they were too unwell to attend.  More patients are less frail at their first presentation in the post-treatment clinics.  These clinics have fewer patients needing to attend per clinic which means those that are attending you can see more holistically. 

Feedback from patients includes:

“The service was brilliant, everyone was involved from the off and I felt totally supported throughout.”

“Having you as a team, always available, compared to just coming in and out of the treatment room each day, ………..if we had any questions you made yourself available for us. You feel someone is there for you every day.”

“There weren’t any surprises, everything you said would happen did happen”

When dietetics and SLT work collaboratively, benefits to the individual patient and the service can be demonstrated. There are individual benefits associated with not being admitted to hospital and a reduced length of stay, along with a reduction in percentage reduction of body weight loss. This has the potential to impact positively on nutrition, hydration, quality of life, well-being and recovery from treatment.

It is important to appreciate the specific value of each individual therapy team, and the collaboration with the MDT to develop practice ensuring safe effective care that is of a high quality. 

To the knowledge of the team there is no previous work that has demonstrated the impact of investing in dietetic and SLT services concurrently, to improve parameters including individual patient outcomes and operational parameters such as length of stay and number of admissions.

It is a reasonable assumption that the introduction of the two therapy groups at this point in the patient pathway can influence both the individual care of the patients and their overall pathway by reducing the number of emergency admissions and allowing services to continue with their elective planned oncology admissions.  As a therapy team we can attribute the reduction of the inpatient admissions and length of stay to the introduction of the two services.

Report to clinical, operational and financial trust leads that the investment has had a positive impact on the care of patients and their care pathway. 

Discuss the service impact with the oncology service, and analysing the data further to consider impact on other specific patient groups such as those with palliative disease. A review of the data associated with the H&NC patients admitted has started now to show that those patients had prolonged length of stay are palliative patients. Our teams believe if they could review patients whilst they are on their palliative treatment there may be an influence on a patient’s length of stay.

The aim of the project is to help reduce unplanned hospital admissions by introducing an ‘increased awareness model’ for carers. The handbook maps to the dedicated page for carers on the NICE web pages, and the information within the handbook links to a number of NICE Guidance and Quality Standards.

Carers need a basic awareness of health related conditions and an understanding of why simple aspects of care and daily living are important in keeping a person at their optimum health. They need to have the underpinning knowledge to:

• Understand the range of normal, for health topics in the handbook
• Have increased awareness of the importance of certain aspects of care
• Recognise when someone is unwell or not coping
• Know how to make ‘Every Contact Count’ by understanding their role in health promotion (NHS 2012)
• Identify when to refer to a professional or other service, for more support and advice; thus reducing potential complications.

It was considered there would also be an improvement in the quality of care delivered and therefore reduce the number of Safeguarding issues raised through improved clinical effectiveness through early intervention and enhance patient/service user experience.

In 2013/14 there were a number of delayed discharges from our local hospitals due to the number of people needing to be discharged with complex health needs. This was putting increasing pressure on health and social care services. The delay was due to home care support workers not having the knowledge and skills to care for people with complex needs i.e. Percutaneous Endoscopic Gastrostomy (PEGS)..

The above situation highlighted that carers who are on the frontline of delivering day to day care, need to have an increased knowledge base and core competencies to support their work, and not only help delayed discharges but may help to prevent hospital admissions. Nationally this has also been recognised in the Francis Report (2013) and the Cavendish Review (2013). Every support worker is now encouraged to undertake the minimum training of the Care Certificate that was introduced in March 2015. The Care Certificate covers 15 core standards and informs induction training for all carers. It was felt that the Care Certificate could be expanded to cover fundamental care needs to help prevent people being cared for deteriorating and requiring hospital admission.

The original idea was to provide training to carers working in care homes, both residential and nursing as well as home care sector within Brighton and Hove. Data from the local authority indicates that there are at least 156 Home Care, Care Home (with and without nursing), supported living, hostels, and in house providers in the city. Brighton and Hove’s demographics indicate that there is a population of 288,155, with a population profile which is younger than the rest of the UK, with 21% under 20 yrs, 62% between 20-59 yrs, 11% between 60-74 yrs, and 6% over 75 yrs of age.  The City’s population is predicted to get older with the greatest increase expected in those aged between the 60-74 and 75 plus age groups (JNSA 2019).

We faced challenges with finance and governance which stopped the project progressing, but not wanting to give up, we became innovative and creative and instead of delivering training we designed a Stop Look Care Handbook. This easy to read handbook details, why different aspects of observation and care areimportant, what to monitor and what action to take

Following the setback with being unable to move forward with the original idea of training, we progressed with the development of the Handbook.

We developed the Handbook within our working roles, working with a number of organisations for both clinical expertise and evaluation of the handbook;

• Brighton and Hove City Council – IT support and encouragement
• Sussex Community Foundation Trust – clinical knowledge

Carers Centre (unpaid carers/service users) – suggestions on content and evaluation of handbook

• Brighton Sussex University Hospital – clinical knowledge
• Skills for Care – support, advice and encouragement
• Home Care Providers – expert advice regarding boundaries of care
• Sussex Foundation Partnership Trust – clinical knowledge
• Third sector organisations – expert advice

We relied on professionals supporting the project to research best practice and used NICE guidance and quality standards to ensure the correct information was being delivered.An application was made to the Better Care Fund for support with publishing and printing of the handbook, however eventually the funds were supported by our line manager at the Brighton and Hove CCG.

The cost of the 44 page handbooks was £1307.00 for 2000 copies in 2016. 

It was hoped this Handbook would also be a passport for carers, so they could move between organisations within the city demonstrating they had Stop Look Care knowledge.  At the time there was a reported estimated 30% turnover rate of carers within the City

We evaluated the impact of the Handbook by asking carers to complete a questionnaire prior to receiving the Stop Look Care handbook, a follow up questionnaire was sent out 4-10 weeks later.

We received 143 responses from the first questionnaire, and 40 responses from the second questionnaire. Engagement was difficult for the second survey as carers already had the handbook; initially the handbook was used as an incentive for people to engage.

Results from the second questionnaire indicated that 97% of carers reported that they found the Handbook a useful reference tool, with all carers finding they felt more confident in all topics covered after reading table 1.  Carers reported that 5 people had been referred on, with two carers reporting they felt this prevented a hospital admission. 

Table 1- Carers increase in confidence following receiving and reading the book (See supporting Material)

Five key outcomes and implications of the project

• Increased knowledge and confidence for carers in basic health needs
• Improved signposting to multidisciplinary agencies
• Admission avoidance
• Improved patient care
• Sharing of good practice Locally and Nationally

It is hard to determine if this an cost effective initiative, however by identifying and treating any health concerns at an early stage. By increasing the knowledge of carers from all sectors you are empowering them and improving the quality of care delivered therefore improving peoples outcomes, hopefully reducing the financial burden of poor health outcomes.

Locally our A&E and non elective admissions have dropped since the implementation of the Stop Look Care handbook, however this was one initiative of many being introduced in our area, so difficult to define if specifically related to the project.

Verbal and written feedback locally and nationally is that it is a useful tool that supports good quality of care.

The Stop Look Care project won the Nursing Times award for Care of Older People 2018.

The handbook has been adopted as good practice in many areas across the UK, please see table 2.

Table 2 – Areas around the UK who have asked to adopt the handbook (see supporting Material)

 The Local Workforce Action Board are keen to introduce a Stop Look Care training package across the STP to bring together training and create a standard of education around clinical aspects of care to support the Care Certificate.

NHS South Kent Coast has adapted this into an electronic version and are in the process of developing a training app to support this.

We would advise that it is important to follow your conviction, if you believe something is right and should be changed or implemented then don’t give up and stick with it. When there are a lack of resources be innovative and creative. 

Don’t have too many people involved when trying to create or implement something, as this can hinder the project with too many different ideas. Bring different people in as and when you need them.

The success of the Stop Look Care handbook has also been due to our willingness to share with others. We believe if something is useful and helps to improve someone’s care, or if it gives a care worker / carer more confidence in looking after someone, then we want it to be adopted and freely used elsewhere.

It was beneficial having service users involved in the development of the handbook. They were able to make suggestions on the content of the book /which we included.

NICE Clinical Guideline 32, states all people living in the community receiving enteral tube feeding should be supported by a multi-disciplinary team, including dietitians. NICE Quality Standard 24 also recommends the implementation of appropriate services within the community to support patients who are enterally fed.

This project aims to evidence the benefits of a community Home Enteral Feeding Service in terms of cost savings, from appropriate review of supplies and feeds along with patient outcome benefits.

In October 2017, when the 6 month Home Enteral Feeding project began, the caseload had never received any formal review. The caseload is ever changing, for a number of reasons

• New patients following placement of a feeding tube
• Adults transitioning from paediatrics
• Patients who have undergone cancer treatment and are discharged from oncology services
• Tube removals/patients dying
• Patients moving into the area with existing tube feeding regime
• Patients with a prophylactic device in situ, who may begin to require feed via the tube

Blackpool Teaching Hospitals currently holds the enteral feeding contract with Abbott Nutrition, who offer a delivery service for ancillaries and feeds. All feeds are prescribed by the GP on an FP10 and the ancillaries are funded via the CCG High Dependency budget, of which dietetics has no management. There has been no review process, from which appropriate alterations to provision of feed and ancillaries can be based. During the 6 month period, there has been a process of review for the caseload, in order to ensure supplies of both feeds and ancillaries are appropriate.

Areas of overspend have been highlighted, with alterations to feed prescriptions and ancillaries made. Closer links with practice pharmacists have been developed in order to support appropriate prescribing and reduce wastage. Following placement of a feeding tube, a patient is currently discharged from hospital with 7 days’ supply of feed, with an initial months’ supply delivered to the discharge address soon after. Following discharge, the suitability of the chosen feeding regime can often alter, requiring consideration of differing feeds and associated products. Without a pathway for review, these patients may not receive suitable alternatives and prescriptions may be wasted. The process of review should follow a formal pathway, based around NICE Clinical Guideline 32, which recommends 3-6 monthly review, in order to ensure the patient remains stable and in receipt of appropriate feeds and supplies.

• Increased workload for hospital dietitians in returning to trouble-shooting the caseload
• Lack of expertise available to provide support around budget queries

•              Increased risks for district nursing in area where expertise is lacking

A number of stakeholders were affected by the implementation of a Specialist Home Enteral Feeding Service and early outreach to them was critical to ensure project success. These stakeholders included: Blackpool, Fylde and Wyre Clinical Commissioning Groups (CCG’s), Medicines Management teams, Procurement, GP practices, Nutrition Nurse Specialist (BTH), Blackpool Teaching Hospitals NHS Trust and Abbott Nutrition.

The home enteral feeding dietitian successfully met with pharmacists in Blackpool to engage their support in reviewing feeds. She also met with commissioners to discuss their high dependency costs which also included enterally fed patients and the costs that could be reduced.

A brief summary of the process:

• Complete at least 1 review of all enterally fed clients in their own home.
• Complete 2 to 3 reviews of a small, specific cohort, in order to measure specific outcomes.
• Review of current prescribing practices in the local area.
• Review current contractual agreement.

During the 6 month project period there have been a number of risks highlighted, both relating to patients and professionals alike. Numerous cost savings have been achieved, along with improvements in quality of life outcomes and the development of support mechanisms, aimed at ensuring patients and carer's are supported. This follows the recommendation in NICE CG32 for Close liaison between the multidisciplinary team and patients and carer's regarding diagnoses, prescription, arrangements and potential problems which is essential.

At present there are around 30 patients with a balloon retained device in situ. These devices require a 7 day check of the volume of water retained in the balloon. The project has enabled risks to be highlighted with regards to gaps in provision of this service, along with a lack of competency and understanding of the task required.

The development of a training package has been undertaken, in order to offer support to nursing staff and carer's with regards to troubleshooting and care of feeding tubes. The provision of regular education and updating knowledge is an essential part of supporting tube fed patients safely.

Should the Home Enteral Feeding Role not continue, there will be ongoing risks which would impact upon patient care, staff safety, professional colleagues (e.g General Practitioners), the Teaching Hospitals Trust and the CCG. These risks include:

• Lack of ongoing patient review
• Lack of troubleshooting in order to reduce hospital admissions
• Lack of training for healthcare colleagues
• Lack of support for practice pharmacy colleagues
• Lack of assessment for new tube feeding discharges

A business case for permanent funding has been submitted to local CCG partners with the outcome awaited.

• Costs have been significantly reduced (£42K in 6 months) and patient experience anecdotally improved. Cost reductions were identified form a budget that funded ancilliary equipment associated with enteral feeding. Pharmacy colleaguers also observed reduction in spend on feed on FP10 prescription. A report of patient experience helped show the benefit of the service and one patient stated “Could we keep the service! Much easier to discuss problems than trying to reach someone by phone and then having to speak to someone who has never met and doesn’t understand son’s needs”.

Engaging stakeholders at the start of a project is key to its success and overcoming barriers encountered along the way, these stakeholders have become valuable allies in securing funding for a permanent role to care for enterally fed patients in the community.

• Implementing NICE guidance can truly result in cost savings as described in a recent BAPEN report
• Consideration needs to be given within secondary care as to the right patient to receive enteral nutrition, as when the patient gets home they cannot always cope with such a device. This learning needs to be fed to acute colleagues at BTH.

Plans for Spread:

The project findings have been shared with local commissioners, primary care pharmacy teams, GPs at the CCG, service managers within BTH and will be shared at a caring and compassion event locally at BTH.

Championing the importance of good nutritional care is the purpose of this dietetic service.

Aims:

• To gain an understanding of compliance with ‘Nutrition Support for Adults’ guidelines by doctors and dietitians.
• To understand how many patients were being discharged with refeeding medications unnecessarily.

Objective:

• To identify key learning areas for the hospital to lead to safer and cost effective  care when treating Refeeding Syndrome in line with the NICE guidelines.

St George’s Hospital is a large teaching hospital in South London, with nearly 1000 beds (acute medical, surgical, cardiac and neurosciences specialities). Change/audit was needed as:

• The trust’s refeeding guidelines were out of date and not following NICE recommendations
• The knowledge and management of refeeding syndrome needs to be improved in doctors (2).
• The old guideline flow chart was limited to tube fed patients
• It was not cost effective and in orally fed patients £4.68 was being wasted over three days due to IV medications being recommended

Therefore this audit assessed baseline practice against the ‘Nutrition Support for Adults’ guidelines.

Checking the appropriate biochemistry is a key element of managing refeeding syndrome; it had been noted in a previous audit that the appropriate refeeding bloods were not being checked on the weekend. Due to this, dietitians often have to request via biochemistry to add on phosphate and magnesium, thus highlighting doctors were not following dietetic plans to test and replace.

Dietetics worked collaboratively with pharmacy to update the Trust’s nutrition support policy, this included NICE's ‘Nutrition Support for Adults’ guidelines along with a flow chart of actions (Figure 5). To audit the compliance of the new guideline, we created an extensive excel sheet with drop down boxes to limit typing errors and to assist with analysing the results.

The excel document was divided into sections:

Specific Patient Information:

• Patients route of nutrition
• Date identified at risk
• Level of refeeding risk
• Length of stay.

Dietitian Recommendations:

• Specific refeeding medication prescriptions (Thiamine, Vitamin B co strong and Multivitamin)
• Name, duration and frequency
• Frequency of checking relevant biochemistry (Magnesium, Phosphate and Potassium)
• Documentation of verbally informing the doctors.

Biochemistry:

• Were relevant baseline bloods checked?
• Were the relevant bloods checked for the first three days post baseline bloods?
• Were the relevant bloods then checked three times a week for two weeks?
• When the baseline bloods were low, were they replaced correctly within 24 hours?

Medications:

• Was Pabrinex/Thiamine was given prior to feeding/ prescribed within 24 hours?
•  Were the medications (Thiamine, Pabrinex, Vitamin B co strong and Multivitamin) prescribed as per the Dietitian’s plan?
• Were the correct frequencies and dose’s prescribed? - Were the replacement of the baseline bloods correct?

Discharge:

• Were the Refeeding medications on the Discharge summary post completing the 10 day course? Dietitians collected data from their caseloads once patients were identified as at risk. The results were then analysed and translated into graphs.

The challenges were:

• The amount of data that needed to be collected for one patient.
• Having to obtain and sort through previous paper notes as some wards used electronic documentation and some used paper notes.
• Determining if Pabrinex/thiamine was given immediately before feeding started. This was overcome by an organised and methodical approach along with managerial support. It is unknown if Pabrinex/thiamine was given before feeding started however we did audit if it was prescribed within 24 hours.

The project did not incur costs and all resources were able to be provided by the hospital free of charge.

The initial aims and objectives were achieved. It was clear to see that the ‘Nutrition Support for Adults’ guidelines are not being followed by doctors (96% out of 51 patients) and dietitians (90% out of 51 patients). Refeeding medication was also being inappropriately put on the patient’s discharge medications (see below).

 It was noticed areas whereby cost savings could occur;

• Intravenous Pabrinex, partly due to the old guidelines, was being prescribed to patients who could have cheaper oral medication. In this audit, when all the patients were grouped together, it found that there would have been a £78 per day saving if the NICE CG32 guidelines had been followed.
• 8 out of 54 patients also had their refeeding medications put onto their discharge medications despite having completed the 10 day prescription resulting in further costs in the community.

Further improvements are needed in encouraging dietitian’s to be more specific with their recommendations for refeeding medications to prevent prescribing errors. We found that 45% of the dietitian’s medical note plans requested the correct medication names however did not document specific guidelines as per NICE CG32 recommendations. Within the 45%, only 20% of dietitian’s requested the correct (dose, frequency and duration).

Refeeding prescription.

In the 10 out of 51 patients whereby the dietitian’s plan was correct, 7 doctors mirrored the recommendations. It is advised that Pabrinex/thiamine should be given ‘immediately before’ feeding. Whilst this was unable to be obtained, we did audit if it was prescribed in the first 24 hours. The dietitian recommended for Pabrinex/thiamine to be prescribed to 48 patients and it was found that 62% of patients received this within this time frame (Figure 6).

Checking baseline bloods is an important part of the refeeding syndrome pathway to determine if the patient has low potassium, magnesium or phosphate. In total, 70% of patients had their phosphate and magnesium checked within 24 hours of being identified as at risk and potassium was checked in 91% of cases.

Correct replacement of biochemistry when a patient is in Refeeding Syndrome is an area that needs further education to the doctors. For example, out of the 12 cases whereby the patient’s magnesium was low, it was incorrectly replaced in 9 patients (Figure 7). Being identified as 'at risk' and potassium checked occured in 91% of cases.

• The key, unexpected, learning was that when following the NICE ‘Nutrition Support in Adults’ guidelines correctly as opposed to the old trust guidelines, cost savings can be made. This work also created a great opportunity to liaise with pharmacy and work together to create positive change and build better relationships for future work.
• This audit provides a baseline forum for discussion with doctors to improve practice; the results will be presented at trust audit days, dietetic department meetings and care group meetings. Doctors have fed back that for ease of reference they would prefer the flowchart stipulating the NICE guidelines to be inserted into their ‘grey reference book’, which is now electronic and accessible on mobile devices.
• A key point from this audit is that updating and auditing dietetic guidelines results in improved dietetic practice:

• 5th January – 13th September: 7/33 doctors were advised to use the old guidelines
• 20th September – 8th November: 1/18 doctors were advised to use the old guidelines. It is also important to share resources to prevent recreating documents and wasting time.

Our data also shows that 10 out of 54 patients were discharged prior to finishing their refeeding medication. This would correlate with data which shows that length of hospital stay has decreased and there is more pressure to discharge earlier due to capacity pressures. Therefore, is it efficient to expect GPs to manage refeeding syndrome in the community, particularly to reduce unnecessary continuation of thiamine. Overall, it was a successful audit and another audit will be conducted on one year to see if practice has improved.

References:

1. Crook M, Hally V & Panteli J. The importance of the refeeding syndrome. Nutrition. 2001; 17, 632-7.
2. Harrison W, Haddick R.A. Knowledge of refeeding syndrome amongst foundation year doctors. Gut 2015; 64: 0017-5749.
3. Europa. Average length of stay for hospital in-patients 2010 and 2015. Available from: http://ec.europa.eu/eurostat/statisticsexplained/images/5/57/Average_length_of_stay_for_hospital_in-patients%2C_2010_and_2015_%28days%29_HLTH17.png). [Accessed: 23^rd January 2018]

The overall aim of this project was to improve the quality of provision of nutrition support services to patients across North Derbyshire, whilst ensuring the appropriate prescription of ONS.

• Raise awareness of the importance of nutrition risk screening, using the Malnutrition Universal Screening Tool (MUST).
• Improve the quality of the nutritional care provided to patients at nutritional risk, in line with NICE Quality Standard QS24.
• Raise awareness of the local nutrition support pathway, emphasising a food first approach.
• Review and assess the current ONS provision to ensure appropriate evidence based ONS provision, in line with NICE Clinical Guideline CG32.

Malnutrition remains a significant public health concern, affecting more than 3 million people in the UK (Elia and Russell, 2009), with an enormous cost to the UK health economy. The use of oral nutrition supplements has been identified to be clinically effective at reducing malnutrition; however as these items can be costly to prescribe, their use should be monitored on a regular basis.

Despite an abundance of national and local guidance, anecdotal evidence suggests that these products are still being prescribed inappropriately within primary care. Nationally, it has been estimated that more appropriate prescribing could generate a 20% reduction in ONS prescriptions, resulting in annual cost savings of almost £27 million, equating to approximately £44,000 per 100,000 patients (PrescQIPP, 2017).

Across the North Derbyshire Clinical Commissioning Group (CCG) and Hardwick CCG, the expenditure on ONS was approximately £1.1 million during 2014-2015 across the 51 general practices. This cost has increased substantially year-on-year, with an annual increase of 20-24% from the 2012/2013 financial year.

In light of this continued growth, the appropriateness and cost-effectiveness of current ONS prescribing practices was considered. Following discussions between local General Practitioners, North Derbyshire medicines management team and the nutrition and dietetic department at Chesterfield Royal Hospital NHS Foundation Trust (CRHFT), it was agreed that prescribing support dietitians (PSDs) were best placed to assess the appropriateness of current prescriptions, due to their skills and knowledge in the provision of nutrition support.

References Elia, M., and Russel, C. A. (2009) Combating malnutrition; Recommendations for Action. Available at: http://www.bapen.org.uk/pdfs/reports/advisory_group_report (PDF)  PrescQIPP (2017)

Guidelines for the appropriate prescribing of oral nutritional supplements (ONS) for adults in primary care (PDF). 

In 2012, the initial concept for the Nutritional Support Project was developed. To prove its worth, a limited number of general practices were audited to look at the potential cost savings which could be made. This data allowed us to estimate potential cost saving figures across the wider area.

After the initial data was collected in 2012, numerous meetings were held between the Dietitians, CCG stakeholders and finance departments. Agreement was reached in 2014 that CRHFT would provide funding for 1 full-time band 6 dietitian and that the funding for a further full-time band 6 dietitian would be split between North Derbyshire CCG and Hardwick CCG. As a result of the joint funding, it was agreed that that savings generated from these posts would be split between CRHFT and the CCGs. Funding was initially granted for a fixed period of 2 years. After the 2 year review, this funding was made permanent. It was agreed that 2 full times dietitians were required in order to meet the project aim and objectives.

The medicines management technicians generated searches for all patients receiving ONS on repeat prescription or who had an acute issue of ONS within the past six months. The PSD’s then attended general practices to review the medical journal entries and correspondence of these patients on SystmOne or EMIS. The following patients were excluded from the audits: patients under the age of 18, patients with gastrostomy feeds, patients who had passed away, patients who had their ONS discontinued by the General Practitioner (GP) or who had transferred general practices.

Decisions were then made as to whether ONS prescriptions should be continued, discontinued or reviewed if further information was required. Where further information was required, we conducted a telephone or home assessment. We rectified inappropriate ONS prescriptions by changing to a more clinically and/or cost effective alternative, increasing or reducing the dose, or discontinuing ONS where indicated.

All of our decisions were based on national guidance from NICE and BAPEN, local prescribing guidelines, clinical judgement and patient preferences. Where we found appropriate ONS prescriptions, we continued these and documented a recommended plan for their ongoing management.

We calculated annualised cost savings per practice following the audit, and disseminated these to each general practice via a written report. We also offered verbal feedback (including training) to all practices. This innovative project differs from similar initiatives across the country, because it includes all of the 51 general practices across both CCGs in the audit and review process, rather than focusing solely on the highest spending practices. This approach was taken to provide an equitable service to all general practices across the county.

We conducted the audit in all 51 general practices in North Derbyshire over an 18 month period. After we applied the exclusion criteria, 1430 patients were included in the audit process. Of these, 57% (n=812) continued with their repeat prescription for ONS, 18% of (n=256) ONS prescriptions were stopped as they were no longer clinically indicated, and 12% (n=169) of ONS prescriptions were changed to a more appropriate alternative. 15% (n=209) of ONS prescriptions were acute issues only, therefore these remained unchanged due to their acute nature. Some patients with multiple ONS prescriptions fitted into more than one category, hence the total percentage equating to 102%.

The results indicated that approximately 30% of ONS prescriptions were inappropriate for the patient’s existing nutritional needs. This highlighted that the NICE CG32 and QS24 standards have not consistently been adhered to across North Derbyshire.

From the project we generated substantial cost savings of £182,203.36, which were split equally between the two CCGs and CRHFT. This equates to £46,000 per 100,000 patients, exceeding the benchmark set by PrescQIPP of £44,000 per 100,000 patients.

Following the evaluation of the initial project cycle, it is now being repeated to identify whether the substantial cost savings generated have been sustained. Preliminary findings have identified similar savings per practice from the re-audit cycle, suggesting that further support is needed to generate sustained improvements in ONS prescribing practices in primary care.

This worthwhile project has provided a better understanding of the prevalence of malnutrition and current prescribing practices across North Derbyshire. We gave tailored, general practice specific feedback to all practices and offered training, in order to promote adherence to NICE CG32, QS24 and the local nutrition pathway.

The uptake of training has been lower during the second audit cycle; therefore we need to provide additional encouragement to general practices to continue to accept training. We will be attending prescribing lead meetings to provide feedback to key GP’s in the area to ensure prescribing lead GP’s are aware of the current issues and guidelines. The project has been disseminated to other dietitians through publication in complete nutrition (September 2017). To generate sustained improvements in prescribing practices, SystemOne and EMIS prescribing tools are being developed for primary care staff in conjunction with the North Derbyshire medicines management team.