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Background: Over a third of hospitals in the United Kingdom have a nutrition support team (NST). A NST may need to prove that it gives its hospital financial and quality benefits.
Aims: To determine the cost benefits of a hospital nutrition team.
Methods: A NST that worked across the directorates of a teaching hospital started on 1st November 1999. Retrospective data was collected about all patients given parenteral nutrition (PN) the previous year. Prospective data was collected about all patients assessed and managed by the NST during its first year.
Results: In the pre-team year 82 patients were given PN for a mean of 8 days with a catheter-related sepsis rate of 75% (mean 11 PN patient days/infection). In the NST year 133 referrals were for parenteral feeding; of these, 78 received PN, 37 nasojejunal feeding, 13 nasogastric feeding and 5 oral diet/supplements. The mean duration of PN was 10 days and the incidence of catheter-related sepsis fell gradually to 7% (mean 125 PN patient days/infection) during the last 3 months. Tangible cost savings (includes all equipment and medication costs but excludes nursing, medical and laboratory time, and bed occupancy costs) for the 55 patients in whom PN was avoided was calculated as £43,938 assuming 8 days of PN at £99/day. If the previous catheter-related sepsis rate of 75% had continued there would have been 36 more catheter-related infections. This would have given an estimated tangible cost of £8,496 (assuming £235/infection). Other cost benefits include a team-led service for bedside parenteral feeding-line and naso-jejunal tube insertion, reduced wastage of PN bags, increased use of standard PN bags and less frequent blood tests.
Conclusions: Although our NST did not significantly reduce the number of patients receiving PN; it show tangible cost savings of at least £52,434 in its first year by enterally feeding (mainly via nasojejunal tube) 41% of patients referred for PN and by reducing the number of patients developing catheter-related sepsis. This saving is enough to justify the salary of a nutrition nurse specialist and dietitian.
144. NUTRITION TEAMS FUNCTIONING AS GATE-KEEPERS FOR INTRAVENOUS FEEDING IMPROVE THE COST AND QUALITY OF SERVICE
Background: Intravenous feeding or parenteral nutrition (PN) is expensive and associated with a greater risk of complications than enteral feeding. The multidisciplinary nutrition support teams (NSTs) can advise on patient care and have been shown to improve cost and quality of care. However, NSTs act only in an advisory capacity in most hospitals in UK, with no documented evidence that such a function significantly influences prescribing practice by clinicians.
Aim: To assess whether a NST with prescribing authorisation on the use of PN can further improve cost and quality of nutrition support services.
Methods: A prospective audit was carried out on all PN requested +/- provided in non ITU patients over two 8-month periods: Sep 97 to Apr 98 and Sep 98 to Apr 99—the former when the NST was “advisory” and the latter when it had its prescribing mandate. Data recorded include indications for PN, duration of PN, and line sepsis. The PN provided was categorised into “appropriate”, “inappropriate” or “avoidable” according to previously published guidelines (J Parenter Enteral Nutr 1986;10:441–5). The costing data based on raw materials only was estimated to be £45 for a bag of PN over 24 hours.
Results: 110 referrals were made in the 1997/8 period and 72 in 1998/9. Of these 108(98%) and 45(62.5%) patients were fed intravenously, with 2(1.8%) and 27(37.5%) inappropriate requests refused respectively (p<0.0001). The proportion of “inappropriate” or “avoidable” PN were 47% and 24% for the two time periods (p<0.05). The total number of feeding days was 1082 and 544, at a cost of £48,690 and £24,480 respectively, leading to a saving of £24,210 over 8 months. Of those refused PN, there was a total of 291 days of alternative (enteral or oral) nutrition support at an estimated cost of £1309. Proven feeding line sepsis were 7(6.5%) and 2(4.5%) respectively.
Conclusion: NSTs controlling access to the use of intravenous feeding improve the cost and quality of nutrition support service.
145. A TWO YEAR AUDIT ON PERCUTANEOUS ENDOSCOPIC GASTROSTOMY: IS THE NUTRITION SUPPORT TEAM GENERATING MORE WORK?
Percutaneous endoscopic gastrostomy (PEG) is increasingly being used as a means of providing nutritional support. One of the many roles of a nutrition support team (NST) is to assess patient suitability for PEG placement. We examined the patient outcomes following PEG, comparing the results before and after formation of the hospital NST. We also examined the outcomes of those patients who were rejected for PEG. All patients referred for PEG over a 12 month period after the formation of the NST were included in this audit prospectively. Their suitability for PEG was assessed by the NST. A retrospective study was also conducted examining the patient outcomes of all the PEG placed in the 12 month period immediately prior to the formation of the NST when all PEG requests were accepted without prior assessmentt37. 74 out of 204 requests (36%) for PEG were rejected. 40% of patients in this group died within 7 days of being assessed and 26% were able to eat.
Our results confirmed that the demand for PEG has increased. However, the formation of NST did not improve patient outcomes following PEG placement, but there was a large number of inappropriate referrals. This could be due to a combination of an increase in awareness of clinical nutrition and an increase in pressure on acute hospital beds leading to more patients being referred even though they were more ill. Despite this, the NST is an important gatekeeper to inappropriate referrals. All doctors placing PEGs should be involved in assessing patient suitability rather than simply assuming the role of a technician.
146. HUNGRY IN HOSPITAL? A CROSS SECTIONAL STUDY
Concern has been expressed by the Association of Community Health Councils for England and Wales regarding patients going hungry in hospitals. We attempted to ascertain whether the problem existed in our hospital. On a single day, all elderly (over 75) patients on our 2 care of elderly wards, were given a questionnaire on humger. This comprised of how hungry they had been during their stay, graded as mild, moderate or severe, and whether they were distressed by hunger, and how their hunger in hospital compared with their hunger when at home. A body mass index (BMI) was also performed on all participating patients. Those patients with problems of cognition or who were moribund, were excluded from the study.
Results: 50 patients were assessed. The average duration of stay in hospital was 13.4 days. 13 patients were not at all hungry, 23 patients were slightly hungry and 14 patients were very hungry. None were distressed by hunger. 3 patients were more hungry in hospital, 21 patients were less hungry and 26 felt no difference in hunger between home and hospital. In percentage terms, 72% of our patients felt well fed. Just 6% felt more hungry in hospital as compared to home, and reassuringly, only 3% had anthropometric signs of malnutrition.
Conclusion: This cross sectional study on a single day has shown that the majority of patients on our wards are not going hungry. This is reassuring. One of the reasons could be the close collaboration between catering staff and the nutrition team. In addition, nursing staff are made available at all times during the serving of meals, to provide assistance and encouragement.
147. MID UPPER ARM CIRCUMFERENCE IS PREFERABLE TO BODY MASS INDEX AS AN INDEX OF HOSPITAL UNDERNUTRITION
A nutritional supplementation trial gave us the opportunity to assess the nutrition of 1561 patients on emergency admission to medical (1097), surgical (335) and orthopaedic (129) services of the Royal London Hospital. Because no significant benefit occurred and the confidence intervals for difference in mean length of stay for supplements vs placebo were narrow (-2 to 1.2 days) we have used the data to compare anthropometric measures as predictors for length of stay and mortality. Patients acutely admitted to the 15 relevant wards were identified. They were weighed and their height and mid non-dominant upper arm circumference (MUAC) measured, and their weight three months prior to admission estimated. MUAC measurements were obtained in 95% (848m, 635f) patients, but, because weight and/or height could often not be measured for clinical reasons, BMI could be assessed in only 44% (408m, 285 f). Weight loss data were obtained in 509 patients. These measurements combine to demonstrate that 18.1% of patients were undernourished (At least one of : BMI < 20kg/m2 or MUAC < 25cm or loss of weight >10%). The relationship between BMI & MUAC was different in men and women (p=0.006 for sex) and was affected by age. The regression equations were for men : BMI=1.02 x MUAC + 0.03 x age - 6.7, (R2 =0.77), and for women BMI = 1.10 x MUAC + 0.023 x age - 8.0, (R2 =0.76). We examined statistically how hospital length of stay and death during the admission was predicted by MUAC, and by BMI and MUAC analysed separately in those patients for whom both were available. Those in whom it was possible to measure BMI had a mean(sd) MUAC of 29.4 ± 4.6 whereas those in whom BMI could not be obtained had a mean (sd) MUAC 29.9 ± 4.8 so the inability to measure BMI did not bias MUAC results. In all cases MUAC produced a more statistically significant prediction of mortality and length of stay than BMI.
148. PATIENT SURVIVAL AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY
Background/Aims: Percutaneous endoscopic gastrostomies (PEG) are commonly used to feed patients with a functioning gut and an inadequate oral intake. This study reviews the indications, outcomes and documented complications of PEG inserted over 9 years (1991–1999).
Methods: A standard pull technique was used for PEG insertion. Prophylactic antibiotics were not used. Data were collected from computerized endoscopy records and patient case records.
Results: 419 patients had PEG insertion, the number increasing from 2 in 1991 to 82 in 1999. The proportion of patients with cerebrovascular accidents (CVA) remained constant. Ear, nose and throat (ENT) patients constituted an increasing proportion. 4 patients developed leakage around the PEG site and 3 had entry site infections in the first 2 months. 8 patients developed aspiration pneumonitis in the 2 months following PEG insertion. 30-day mortality following PEG insertion was 21.3% with wide variability (CVA 26.3%, Multiple Sclerosis (MS) 4.3%, HIV 0%). Patients with a CVA had a 1-year survival of 49% (median survival 6 months, range 0–102) following the procedure. Patients with trauma had 1-year survival of 96% (median survival 46 months, range 4–77) and median PEG duration 2 months (range 0–14). HIV patients had a 1-year survival of 22% (median survival 5.5 months, range 1.5–18). Patient survival was better in the trauma (p<0.001) and MS (p<0.05) groups than other groups.
Conclusions: The majority of PEG tubes are placed in patients with CVA who have a poor survival. Patients with a CVA need to be carefully selected prior to PEG placement.
149. MALNUTRITION IN PATIENTS WITH NEUROLOGICAL DYSPHAGIA ON LONG TERM PEG FEEDING
Introduction:Percutaneous endoscopic gastrostomy (PEG) has become an increasingly popular method of feeding patients with neurological dysphagia. Concerns have been raised that this group of patients may become even more malnourished whilst being fed in the community.
Aim: To see whether patients with neurological dysphagia, fed in the community are at risk of developing malnutrition.
Patients/Method: Patients with neurological dysphagia fed in the community for more than 6 months, via PEG alone, were identified. Data were collected on 24 patients. A history and physical examination was followed by nutritional assessment and anthropometric measurements including height, weight, body mass index (BMI), mid arm circumference (MAC), triceps skin fold thickness (TSF), mid arm muscle circumference (MAMC). Samples were obtained for FBC, haematinics, U&E, LFT, Ca, PO4, cholesterol, prothrombin time, selenium, copper, zinc, vitamin A, D, & E, and PTH.
Results: The mean age was 69 years (range:33–91). Mean duration of feeding was 15 months (range: 6–42). Of the 24 patients, 16 (67%) were found to have anthropometric and/or biochemical evidence of malnutrition of whom 6 (25%) had evidence of both. 8 patients (33%) had anthropometric evidence of malnutrition, 3 (12%) had severe malnutrition (BMI<16, MAMC or TSF<5thpercentile), 4 (17%) were moderately malnourished (BMI<18, MAMC or TSF<5th percentile) and 1 (4%) was mildly malnourished (BMI<20, MAMC or TSF<15th percentile). 8 patients (33%) were anaemic but with normal haematinics, 15 (62.5%) had elevated urea, 10 (42%) had low albumin and zinc was low in 12 patients (50%). The rest of the measured biochemical parameters were normal.
Conclusions: A significant proportion of these patients are malnourished highlighting the need for regular biochemical and dietetic assessment of nutritional status.
150. SHOULD THE FOOD INTAKE OF PATIENTS ADMITTED TO ACUTE HOSPITAL SERVICES BE ROUTINELY ISS="suppl_1" SUPPLEMENTED? A RANDOMISED PLACEBO CONTROLLED TRIAL
151. OSTEOPOROSIS AND INFLAMMATORY BOWEL DISEASE—ARE GUIDELINES FOR DIETARY CALCIUM BEING MET?
Background: In January 2000 Guidelines for Treating and Preventing Osteoporosis in Coeliac Disease and Inflammatory Bowel Disease (IBD) were published in the international journal Gut. These guidelines recommend that all patients with IBD should achieve a calcium intake of 1500 mg/day. This figure is more than double the Reference Nutrient Intake (RNI) for calcium set for the adult population in the U.K. (DoH, 1991&1998) and may be difficult to achieve by diet alone. Our aim was to establish the intake of dietary calcium in patients with IBD and compare with the RNI for adults of 700 mg/day and the recent Osteoporosis guidelines.
Methods: 52 patients with IBD; 32 patients with ulcerative colitis and 20 patients with Crohn's disease, age range 26 yrs—69 yrs, 21 males, and 31 females were recruited from Gastroenterology outpatient clinics. Dietary calcium was determined using a 10-day weighed food intake and subsequent analysis using McCance and Widdowson dietary data.
Results: Median calcium intakes for patients with ulcerative colitis and Crohn's disease were 735 mg/day (range = 350 mg/day—1500 mg/day) and 810 mg/day (range = 550 mg/day—1270 mg/day) respectively. There was no significant difference between median intakes for males and females. Although the median exceeded the RNI of 700 mg/day, 20 % of patients with Crohn's disease, 34 % of patients with ulcerative colitis and all following a milk-free diet (4/32 ulcerative colitis patients) failed to achieve this lower figure. Only those consuming up to a pint a day of milk plus other dairy products achieved an intake > 1000 mg/day (9/52) and only one of these patients achieved an intake of 1500 mg/day. In total, 98% (51/52) failed to achieve the 1500 mg/day target. These preliminary results therefore suggest that patients with IBD are unlikely to achieve a calcium intake of 1500 mg/day from diet alone.
Conclusions: Further education and advice to improve intake of dietary calcium is required for patients with IBD if the new guidelines are to be achieved. Many patients may require calcium supplements.
152. NOT ALL DIETARY FIBRES ARE EQUAL: SELECTION OF POTENTIAL CANCER-PREVENTATIVE FIBRES BY INHIBITION OF GALACTOSE-BINDING LECTINS
Background: It is becoming clear that there is no simple relationship between total fibre intake and colon cancer risk. We have previously shown that intake of galactose-containing dietary fibre is protective against colorectal cancer (Gut 1997;41(suppl 3):A124) and suggested that this effect is mediated via inhibition of proliferative dietary and microbial lectins which bind the galactose that shows increased mucosal expression on oncofetal carbohydrate antigens in colon cancer and pre-cancer (Gastroenterology 1998;114:44). We have now compared dietary fibres for their ability to inhibit the galactose-binding peanut lectin (PNA) in vitro in order to select those which might prove most protectivein vivo.
Methods and results: Various concentrations of dietary fibres were incubated with 0.5 ml 4μg/ml PNA in PBS for 1h on a roller shaker. After centrifugation the supernatant was tested for the ability of PNA to agglutinate sialidase treated (galactose-exposed) human red blood cells. 1 mg each of plantain, polygalacturonic acid and apple fibre showed 93.8%, 87.5 and 50% inhibition of lectin activity respectively. The supernatants from the fibre incubations were freeze dried and run on SDS-PAGE with appropriate lectin controls to assess the concentration of unbound lectin. Of a wide variety of dietary fibres tested, plantain fibre had the highest inhibitory potency for PNA, followed by polygalacturonic acid, apple and grapefruit fibre. Fibres from wheat bran, soya, green beans, carrots, broccoli and red cabbage were found to be non inhibitory. Plantain fibre also bound to and inhibited other galactose-binding lectins: Amaranthus caudatus agglutinin, Jacalin andAgaricus bisporus agglutinin as assessed by haemagglutination inhibition assays and SDS-PAGE.
Conclusions: Dietary fibers from plantain, apple and grapefruit can bind to and inhibit galactose-binding lectins including PNA. These fibres should now be tested in vivo for their ability to prevent colonic neoplasia.
153. IMPACT OF DIETARY COMPLIANCE ON NUTRITIONAL STATUS IN ADULT COELIAC DISEASE
Introduction: Malabsorption in patients with coeliac disease (CD) is frequently followed by vitamin and mineral deficiencies and a decline in body fat and muscle mass. These parameters have been shown to improve following the institution of a gluten free diet (GFD). The degree to which dietary compliance affects nutritional status in patients with CD has not previously been examined.
Methods: 21 adult patients (9 men mean age 53.5 years, 13 women mean age 52.5 years) with a diagnosis of CD, made by small bowel biopsy, for greater than 1 year, were identified. All patients were under follow up in a Gastroenterology clinic and were under dietetic follow up with regard to GFD. Patients with co-morbidity affecting nutritional status were excluded. Nutritional status was assessed with the following measurements: - body mass index (BMI), triceps skin folds (TSF), mid-arm circumference (MAC) and mid-arm muscle circumference (MAMC). Additionally the following haematological and biochemical parameters were assessed: - haemoglobin, vitamin B12, serum and erythrocyte folate, ferritin, albumin, calcium and vitamin D. Dietary compliance was assessed by an interview administered questionnaire, 24 hour recall of diet and serum IgA anti-endomysial antibodies (AEA).
Results: 8 patients were considered to be non-compliant with GFD, all were AEA positive. There was no statistical difference in any of the nutritional parameters between the compliant and non-compliant group. However, when comparing the whole study population with standardised reference ranges there were significant reductions in MAC (p < 0.01 men, p < 0.001 women) MAMC (p < 0.01 men, p <0.05 women) and TSF in women (p < 0.01).
Conclusions: Patients with CD are at risk of nutritional deficiencies as a consequence of malabsorption. We have demonstrated that reductions in body fat and muscle mass may persist after diagnosis and institution of GFD. However, within the confines of our small study population, we have failed to demonstrate any significant differences between patients who strictly adhere to GFD, when compared with those who continue to ingest gluten. This suggests that all patients with CD require ongoing nutritional and dietetic follow up after the institution of a GFD.
154. ASSESSMENT OF CALCIUM INTAKE OF PATIENTS WITH COELIAC DISEASE
Introduction: A reduced intake of calcium is a major factor in the genesis of osteoporosis which commonly occurs in patients with coeliac disease (CD), is a risk factor for fractures and is potentially treatable. Within a non-coeliac population 25% of calcium is derived from bread and cereals but many coeliacs have a reduced intake of both these foods and also ingest less milk. We studied calcium intake in patients with CD who were established on a strict gluten free diet (GFD).
Methods: 20 patients with CD attending a coeliac clinic for an annual review were chosen at random. Their ages ranged from 25–77 years and 16 were women. The time on GFD ranged from 2–15 years. Calcium intake was assessed by a dietitian who used a ready “ready reckoner” form.
Results: Intake of calcium varied from 360–2623 mg/day. 70% of patients ingested less than 1054 mg/day while in 45% the intake was below 860 mg/day. The main reasons for the low calcium intakes were a reduced intake of bread and milk and a reduced consumption of cheese containing dishes such pizza and pasta.
Conclusions: This study has highlighted the high proportion of patients with CD who, although on a strict GFD, are at increased risk of developing osteopenia and osteoporosis because of low intakes of calcium. Such patients, especially those ingesting less than 860 mg of calcium per day, are potentially at increased risk of fracture, particularly of the neck of the femur which can be life-threatening. This emphasises the need for an annual review of patients so that dietary advice can be given to those with inadequate intakes. Calcium supplements are a valuable source of calcium for those who cannot tolerate an increase in calcium containing foods. If calcium intake can be increased to 1500 mg/day, the recommended amount for coeliacs, the bone density of patients with CD may improve with a reduction in the fracture risk.
155. ORAL NUTRITIONAL ISS="suppl_1" SUPPLEMENTATION IS EFFECTIVE IN THE MAINTENANCE OF REMISSION IN CROHN'S DISEASE
Background: Enteral feeding with either elemental or polymeric diets is an established primary therapy for active Crohn's disease. However, the role of supplementing normal food with elemental diet in the long-term management of Crohn's disease has hitherto not been explored.
Patients and methods: Thirty-nine consecutive patients with Crohn's disease in clinical remission were studied. Twenty-one patients (Group 1) received oral nutritional supplementation, taken in addition to their normal diet. Their outcome (relapse rate, CDAI, inflammatory markers) was compared with eighteen patients (Group 2), who were maintained on normal unrestricted diet over an observational period of 12 months.
Results: Seventeen patients (81%) tolerated the nutritional supplementation. On an intention to treat basis 10 patients (48%) remained in remission for 12 months, compared to four out of eighteen (22%) patients in Group 2, p <0.0003. Their CDAI and CRP remained stable while the weight and BMI improved during the period of nutrition therapy. Seven patients in Group 1 and 14 in Group 2 relapsed at a mean of 7.4 ± 0.9 and 6.2± 0.4 months respectively. The response to nutrition supplement was independent of age, gender, disease duration or location. Four patients (19%) were intolerant to enteral feeding.
Conclusion: Nutritional supplementation is safe, well tolerated and effective in the long term management of patients with quiescent Crohn's disease.
156. ENTERAL NUTRITION BY NASOJEJUNAL TUBE IN HYPEREMESIS GRAVIDARUM
Introduction: Hyperemesis gravidarum (HEG) is a common disorder that can involve severe malnutrition with potentially life-threatening complications. Parenteral nutrition (PN) is often used, however it is expensive, has a number of potentially serious complications, and enteral nutrition (EN) has been suggested as an alternative. EN when given by nasogastric tube in HEG exacerbates the nausea and vomiting and risks aspiration. Although post-pyloric placement of feeding tubes has been suggested to avoid some of these hazards, generally this has necessitated radiation exposure; recently naso-enteral tubes have been placed endoscopically and some have used percutaneous endoscopic gastrojejunostomy.
Method: We have successfully used blind-placed nasojejunal (NJ) tubes in two patients with hyperemesis, avoiding the risks of both endoscopy and radiation. Both tubes were self-propelling ‘Bengmark’ tubes, which have a coil at the end to aid transpyloric passage. Both patients were dehydrated, had electrolyte imbalance, ketonuria and weight loss and both had been hospitalised for weeks. Both returned to normal weight while being enterally fed, one patient returned to oral feeding but the second required tube feeding until after her delivery. Both had normal deliveries and healthy, normal babies at term. The average time the tubes remained in place was 19 days, although we believe that as experience accumulates tubes will be kept in longer and there is still improved cost-effectiveness over PN. Both patients were discharged despite dependence on EN with important psychological benefits in addition to the obvious resource advantages.
Comment: PN has more serious and more frequent side-effects that EN, although there are no studies comparing PN to EN in pregnancy or HEG. PN is expensive; the mean cost of nutritional support is generally estimated at 4–10 times greater in PN than in EN. EN in HEG has traditionally been dependent on intensive nursing back-up; however, as a result of our success with the tubes our nutrition support team has adopted NJ feeding by Bengmark tube as the preferred method of nutrition in hyperemesis gravidarum.
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