Blackpool Teaching hospitals (BTH) is an acute and community provider of care based in the North west of England. BTH historically did not monitor the progress of patients discharged into the Blackpool, Wyre and Fylde area who were enterally fed. The organization also did not review enterally fed patients transferring there from other areas of the country. Instead, BTH relied on their contracted enteral feed supplier to review patients on their behalf and highlight any potential risks.
People's nutritional status is affected by a number of different factors and can therefore change rapidly. Regular review of the nutrition support care plan by a care professional enables the plan to be adapted to best meet the current needs of the person. This project enabled a dietitian to undertake planned reviews of patients in the area, to ascertain the appropriateness of their artificial nutritional provision.
Historically there was no planned clinical review of the enterally fed patients in the community. There are in excess of 150 patients locally who are in receipt of a tube feed, of these approximately 100 were adults. The project was funded internally from vacancy monies to offer all home enterally fed patients a review of their nutritional care as per NICE Quality Standard QS24.
Aims and objectives
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.
Reasons for implementing your project
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
How did you implement the project
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”.
Key learning points
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.