bsna parenteral nutrition survey presentation of results
TRANSCRIPT
BSNA Parenteral Nutrition SurveyGAINING AN INSIGHT INTO HEALTHCARE PROFESSIONALS’ VIEWS ON PARENTERAL NUTRITION
What is Parenteral Nutrition?
1
Parenteral nutrition is administered to improve the nutritional status of a patient
• Parenteral nutrition (PN) is the provision of nutrients and fluid to a patient by an intravenous route.
• PN is a complex and well established form of artificial nutrition support. It may provide the only way to meet a patient’s nutritional requirements, where patients have an inaccessible or non-functioning gastro-intestinal system.
• PN can be administered via a peripheral or central line.
• More information on PN can be found on the BSNA website:link here.
Executive Summary
• British Specialist Nutrition Association (BSNA) conducted anonline survey on PN among 204 HCPs (HCPs), includingdietitians, pharmacists, nurses, gastroenterologists,oncologists and intensive care specialists.
• The survey highlighted four important factors for improvingthe use of PN: perception, confidence to manage, the abilityto prescribe and training for HCPs.
• Moving forward the BSNA welcomes further developmentsinto these areas to improve the role of PN in care settings.
2
Objective and methodologyObjective: To gain an insight into HCPs’ views on PN
• Online survey with 204 HCPs in the UK.
• Robust sample including dietitians, pharmacists, gastroenterologists, nurses, intensive care specialists and oncologists.
• The questionnaire was made up of 20 quantitative questions and 11 qualitative questions.
• Questionnaires were distributed through professional associations and HCPs’ magazines.
3
Participant demographics by profession and work place
Profession Count Percentage
(%)
Dietitian 128 62.7
Pharmacist 50 24.5
Nurse 13 6.4
Gastroenterologist 10 4.9
Intensive Care Specialist 2 1.0
Oncologist 1 0.5
Total 204 100
Work Location Count Percentage (%)
Teaching Hospital 96 47
District General Hospital
93 46
Other 9 4
Community 6 3
Total 204 100
• 204 HCPs answered the survey, theirprofessions were as follows:
• Dietitians (62.7%)• Pharmacists (24.5%)• Nurses (6.4%)• Gastroenterologists (4.9%)• Intensive Care Specialists (1%)• Oncologists (0.5%)
• And their work locations included:
• Teaching Hospital (47%)• District General Hospital (46%)• Community (3%)• Other (4%)
Other, work locations included: Children's Hospital,Community/Acute based in teaching hospital, all of the above,retired, academic institution, home and healthcare, GP andhospital.
4
The majority of participants were dietitians working in either a district general or teaching hospital
The number of patients receiving PN seen by HCPs per week
24%
36%
18%
9% 10%
2%
0
5
10
15
20
25
30
35
40
0 to 2 2 to 5 5 to 10 10 to15 15 plus other
Perc
enta
ge o
f H
CPs
(%
)
• The majority of HCPs (60%) saw <5 patients receiving PN per week.
• 18% saw 5 to 10 patients receiving PN per week and 10% saw over 15 patients receiving PN a week.
• Of the HCPs managing patients receiving PN, 31% were managing patients on PN in the home setting.
5
HCPs typically manage 2-5 patients per week with PN
Types of patient receiving PN
8%
16%
45%
76%
82%
0 10 20 30 40 50 60 70 80 90
Other
Vascular accidents
Non-surgical with GI complications - e.g.oncology, multiple organ failure
Gastroenterological - e.g. chronicmalabsorption, short bowel syndrome,
inflammatory bowel disease, sclerodoma
Surgical interventions with GI complications -e.g. oncology, inflammatory bowel disease
Percentage (%)
• The majority of HCPs were managing patients receiving PN due to either surgical interventions with gastrointestinal complications (82%) or gastroenterological reasons, ie. chronic malabsorption, short bowel syndrome or IBD (76%).
• 45% HCPs managed patients receiving PN for non-surgical, GI complications and 16% managed patients requiring PN following a vascular accident.
• Of the 8% HCPs reporting ‘other’, they managed paediatric patients (eg. premature neonates, oncology, cardiac), renal patients and intensive care patients receiving PN.
6
The majority of patients receive PN for gastroenterological reasons
*Participants could select more than one option.
The nutritional support given to patients
60%16%
6%
18%
PN only
PN in combination with enteral tubefeeding
PN in combination with enteral tubefeeding and oral nutritional intake
PN in combination with oralnutritional intake (no enteral tubefeeding)
Pie Chart shows the average percentage of participant’s patients receiving PN, EN and Oral Nutrition
HCPs were asked: Of the patients they were currently managing with PN, what percentage were receiving:
On average HCPs reported that 60% of patients they managed received PN as their only source of nutrition.
HCPs reported that 18% of their patients were receiving a combination of PN with oral nutrition.
HCPs reported that 16% of the patients they managed received a combination of PN with enteral tube feed.
HCPs reported that 6% of the patients they managed received PN in combination with enteral and oral nutrition.
7
PN is typically the only source of nutrition given to patients
The primary decision makers for prescribing PN
• 39% of the responses reported dietitians as a Trust’s primary decision maker for prescribing PN (73% respondents to this question were dietitians).
• Respondents also considered gastroenterologists (23%) pharmacists (17%) as primary decision makers.
* Participants could select more than one option
Respondents also remarked that:• A consultant was the primary decision maker
(13%).• A surgeon (5%), a biochemist (4%) or
chemical pathologist (4%) would be consulted.
8
The multidisciplinary team is responsible for the decision to prescribe PN
Percentage (%)
39% 23% 17% 9% 9%
1%
0 10 20 30 40 50 60 70 80 90 100
Dietitian
Gastroenterologist
Pharmacist
Intensive Care Specialist
Nutrition Nurse Specialist
Nurse
Level of involvement with Nutrition Support Team by profession
7%
9%
2%
7%
37%
3%
4%
5%
12%
2%
2%
2
2% 4%
1
0
1
Other (please specify)
There is no NutritionSupport Team and I amdirectly involved in the
management of…
I refer patients to theNutrition Support Team
when PN is indicated,but have no further…
I am indirectly involvedwith the Nutrition
Support Team when apatient in my care is…
I am directly involved asa member of the
Nutrition Support Teamin the management of…
Dietitian
Pharmacist
Nurse
Gastroenterologist
56%
13%
3%
15%
13%
77% of respondents reported that their Trust has anutrition support team responsible for PN.
The majority of participants stated that they weredirectly involved as a member of the Nutrition SupportTeam (56%).
90% of gastroenterologists are directly involved as amember of the Nutrition Support Team for PN.
15% of participants reported that there is no NutritionSupport Team and that they are directly involved in themanagement of patients receiving PN.
Those that reported ‘other’ stated that that they eithercover the dietitian’s role on the support team whenrequired or that they didn’t work for a Trust (Scotland).
*Percentages are calculated based on the whole sample (204)
9
The majority of HCPs are directly involved with their Trusts’ nutrition support team
Leve
l of
invo
lvem
ent
HCPs ’ Views on the appropriate use of PN
• The majority (72%) of HCPs viewed PN as useful but that it should be used appropriately.
• 18% believe that PN can be invaluable for improving nutritional status of patients.
• 9% HCPs agreed that PN should not be prescribed unless gastrointestinal function is severely limited.
10
HCPs believe that PN is a useful tool, when used appropriately
Ap
pro
pri
aten
ess
of
PN
9%
72%
18%
0 20 40 60 80
PN should not be prescribed unless gastrointestinalfunction is severely limited
PN may be useful but should be used appropriately
PN can be invaluable for improving nutritional status ofpatients
Percentage (%)
Considering PN for a patient
11
HCPs would consider PN for a patient with a non-functional or inaccessible GI tract
• The majority of HCPs (97%) would consider PN when a patient has a non-functional or inaccessible gastro-intestinal tract.
• 65% would consider PN for a patient that is malnourished and has unsafe/ inadequate oral/ enteral nutrition intake.
• 32% HCPs would consider PN for a patient that is nil by mouth and received no enteral feeding for more than 3 days.
*Participants could select more than one option
32%
42%
58%
65%
97%
0 20 40 60 80 100 120
when a patient has been nil by mouth and no enteral feedingfor more than 3 days
when a patient is able to meet some but not all of their needsvia oral/enteral nutritional intake
when a patient might not be able to tolerate oral/enteralnutrition in the short to medium term (e.g. peri-operatively,
or commencing chemotherapy)
when a patient is malnourished and has unsafe/inadequateoral/enteral nutritional intake
when a patient has a non-functional or inaccessible gastro-intestinal tract
Percentage (%)
Count
Guideline OncologistIntensive Care
SpecialistGastroenterologist Nurse Pharmacist Dietitian Total
Percentage of total (%)
NICE Clinical Guideline 32 on Nutrition Support in Adults (2006) 1 1 7 8 27 104 148 73%
ESPEN Guidelines on PN (2009) 0 1 7 7 25 109 149 73%
NCEPOD report 'A mixed bag: An enquiry into the care of hospital patients receiving PN' (2010)
0 2 7 6 24 93 132 65%
NICE Quality Standard 24 on Nutrition Support in Adults (2012) 1 2 8 8 18 88 125 61%
Strategic Framework for Intestinal Failure and Home PN Services for Adults in England (2008)
0 0 8 2 8 52 70 34%
HCPs’ familiarity with reports/guidelines on PN
12
HCPs are most familiar with the NICE and ESPEN guidance on PN
HCPs views on the balance of information provided by current guidance
13
7%
18%
75%
0 20 40 60 80
Too much focus on the positiveaspects of parenteral nutrition
Too much focus on negativeaspects of parenteral nutrition
The balance is about right
According to HCPs the current guidelines on PN have a balanced view
• The majority of HCPs (75%) believe that the current guidelines on PN strike a balance that is just right.
• 18% HCPs think that current guidelines put too much focus on the negative aspects of PN whereas 7% think that there is too much focus on the positive aspects of PN.
“I suspect what are lacking are solid robust clinical trial on PN and most of the guidelines are based on expert opinion.”
“American and European guidelines differ in terms of when to start PN.”
Percentage (%)
Availability of PN training at Trust level
Pie chart show participants’ responses when asked whether theirTrust provided any training on PN (n=204).
14
Participants said that they received PN training from an external body, eg. BPNG, BDA.
55 participants said that they received PN training in-house. 13 said that PN training was given
to those in the Trust that required it.
20% HCPs reported no PN training at Trust level
“Trust guidelines available; no formal training unfortunately.”
Yes80%
No20%
What would help HCPs to develop more knowledge and confidence about PN?
• HCPs agreed that the following training-aids would help them develop more knowledge and confidence about PN;
• Online tutorials (61%),
• Practical training courses (58%),
• More detailed guidance (54%),
• A report including best practice case-studies (46%),
• A professional magazine or journal publication (38%).
15
HCPs would value detailed training and guidance on PN
*Respondents could select more than one response
7%
38%
46%
54%
58%60%
0
10
20
30
40
50
60
70
Other Professional magazineor journal publications
A report including bestpractice case-studies
Guidance whichprovides more detail
than is currentlyavailable, e.g. NICE,
ESPEN guidelines
Practical trainingcourse
Online tutorials and/orwebsite information
dedicated to PN
Per
cen
tage
(%
)
HCPs’ Perceptions of PN
16
• Whilst 94% HCPs agreed that PN should be considered for all patients with a non-functioning, inaccessible or perforated gastrointestinal tract, only 60% agreed that PN should be considered for all patients with malnutrition and with inadequate/unsafe oral/ enteral nutritional intake.
• HCPs had mixed views over whether there was a minimum length of time for the duration in which PN can be given.
• Only 18% HCPs consider PN invaluable.
• Gastroenterologists were slightly less aware of the appropriate use of PN compared with other HCPs.
HCPs were asked to describe how much they agreed with the following….
17
PN should be considered for all patients who are malnourished – by profession
10%
3%
1%
50%
22%
20%
6%
7%
100%
50%
22%
20%
13%
7%
11%
0
22%
50%
58%
44%
45%
33%
26%
43%
36%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• According to NICE clinical guidelines 32 (2006): ‘HCPs should consider PN in people who are malnourished or at risk of malnutrition, respectively, and meet either of the following criteria:
• Inadequate or unsafe oral and/or enteral nutritional intake • A non-functional, inaccessible or perforated (leaking)
gastrointestinal tract.’[2].
• 81% of HCPs disagreed that PN should be considered for all patients who are malnourished.
• Dietitians were more strongly in disagreement with the statement compared with other professions; 43% of dietitians strongly disagreed compared with 26% of pharmacists.
• 10% of nurses expressed that they strongly agreed with the statement compared with 3% of pharmacists and 0% dietitians.
8% agree 81% disagree
18
PN should be considered for all patients who are malnourished – by work location
1%
1%
1%
10%
11%
7%
50%
8%
13%
11%
80%
41%
45%
45%
20%
50%
40%
30%
36%
Other
Community
District GeneralHospital
Teaching Hospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• HCPs working in district general hospitals were more likely to disagree with the statement; PN should be considered for all patients who are malnourished (81% disagreed, 40% strongly).
• HCPs working in a community setting (50%) most strongly disagreed with the statement.
• The views of HCPs from teaching hospitals and district general hospitals were more closely aligned.
8% agree 81% disagree
19
PN should be considered for all patients with malnutrition and with inadequate/unsafe oral/ enteral nutritional intake – by profession
22%
28%
12%
15%
100%
33%
67%
44%
44%
43%
45%
33%
11%
22%
11%
19%
17%
33%
22%
11%
17%
21%
20%
5%
4%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• NICE Clinical Guideline 32 (2006) states that: ‘HCPs should consider PN in people who are malnourished or at risk of malnutrition, and have inadequate or unsafe oral and/or enteral nutritional intake’ [2].
• Although the majority (61%) of HCPs agreed that PN should be considered for all patients with malnutrition and with inadequate/ unsafe oral/ enteral intake, 24% HCPs disagreed (4% strongly disagreed).
60% agree 24% disagree
20
PN should be considered for all patients with malnutrition and with inadequate/unsafe oral/ enteral nutritional intake – by work location
20%
15%
16%
16%
40%
50%
41%
49%
45%
20%
22%
11%
17%
50%
22%
16%
19%
20%
6%
4%
Other
Community
District GeneralHospital
Teaching Hospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• HCPs working in a community setting were more likely to report disagreeing that PN should be considered for all patients with malnutrition and with inadequate/unsafe oral/ enteral nutritional intake (50%) than those working in teaching hospitals (22%) and district general hospitals (22%).
60% agree 24% disagree
21
PN should be considered for all patients in intensive care – by profession
20%
3%
2%
11%
8%
2%
4%
100
50%
22%
20%
11%
16%
16%
56%
40%
50%
40%
42%
50%
11%
20%
28%
42%
36%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• 78% HCPs disagreed (42% disagreed, 36% strongly disagreed) that PN should be considered for all patients in intensive care.
• Dietitians and intensive care specialists were more likely to strongly disagree (42% and 50% respectively).
6% agree 78% disagree
22
PN should be considered for all patients in intensive care – by work location
4%
2%
6%
1%
4%
50%
17%
16%
16%
80%
41%
43%
42%
20%
50%
36%
36%
36%
Other
Community
District General Hospital
Teaching Hospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• The majority of HCPs disagreed that PN should be considered for all patients in intensive care (78%).
• Views of HCPs working in teaching and district general hospitals were very similar.
6% agree 78% disagree
23
PN should be considered for all patients with a non-functioning, inaccessible or perforated gastrointestinal tract – by profession
100%
22%
50%
33%
53%
47%
100%
78%
40%
58%
41%
47%
10%
6%
4%
4%
3%
2%
2%
Oncologist
Intensive Care Specialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• Nice Clinical Guidelines 32 (2006) states that: ‘HCPs should consider PN in people who are malnourished or at risk of malnutrition and have a non-functional, inaccessible or perforated (leaking) gastrointestinal tract.’ [2].
• 94% of HCPs agreed that PN should be considered for all patients with a non-functioning, inaccessible or perforated gastrointestinal tract (47% strongly agreed).
• A greater proportion of dietitians (53%) strongly agreed with the statement compared with pharmacists (33%) and gastroenterologists (22%).
94% agree2% disagree
24
PN should be considered for all patients with a non-functioning, inaccessible or perforated gastrointestinal tract – by work location
20%
50%
43%
53%
47%
40%
50%
51%
43%
47%
20%
4%
4%
4%
20%
2%
2%
Other
Community
District GeneralHospital
TeachingHospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• HCPs working in teaching hospital settings were more likely to strongly agree (53%) with the statement that PN should be considered for all patients with a non-functioning, inaccessible or perforated gastrointestinal tract.
• 20% of HCPs from other* healthcare settings disagreed that PN should be considered for all patients with a non-functioning, inaccessible or perforated GI tract compared with 2% overall.
• No HCPs working in a district general hospital teaching hospital or in a community setting disagreed with this statement.
* Children's Hospital, Community/Acute based in teaching hospital, all of the above, retired,academic institution, home and healthcare, GP and hospital
94% agree2% disagree
25
PN should be considered for all patients peri-operatively – by profession
1%
1%
100%
5%
4%
11%
40%
17%
12%
14%
50%
33%
50%
58%
48%
49%
50%
56%
10%
25%
34%
32%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• NICE Clinical Guidelines 32 (2006) states that ‘HCPs should consider supplementary peri-operative PN in malnourished surgical patients who are malnourished or at risk of malnutrition’ [2].
• According to this survey, 81% HCPs disagreed that PN should be considered for all patients peri-operatively.
• 32% HCPs strongly disagreed with this statement.
• More gastroenterologists (56%) reported that they strongly disagreed that PN should be considered for all patients peri-operatively compared with pharmacists (25%), dietitians (34%) and nurses (10%).
5% agree81% disagree
26
PN should be considered for all patients peri-operatively – by work location
1%
1%
6%
1%
4%
12%
18%
14%
100%
100%
51%
44%
49%
31%
35%
32%
Other
Community
District GeneralHospital
Teaching Hospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• 79% of HCPs working at a teaching hospital and 82% working at a district general hospital disagreed that PN should be considered for all patients peri-operatively.
5% agree 81% disagree
27
It is not appropriate for patients receiving PN to have enteral/oral nutritional intake – by profession
10%
1%
10%
2%
2%
100%
22%
11%
7%
9%
11%
40%
56%
35%
38%
100%
67%
40%
33%
56%
51%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• 89% HCPs disagreed (51% strongly disagreed) that it is not appropriate for patients receiving PN to have enteral/oral nutritional intake.
• 20% of nurses said that they agreed (10% strongly agreed) that it is not appropriate for patients receiving PN to have enteral/oral nutritional intake.
• 100% intensive care specialists (n=2) strongly disagreed with the statement.
3% agree 89% disagree
28
It is not appropriate for patients receiving PN to have enteral/oral nutritional intake – by work location
1%
1%
4%
2%
50%
8%
9%
9%
60%
41%
34%
38%
40%
50%
51%
53%
51%
Other
Community
District GeneralHospital
Teaching Hospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• The majority of HCPs (89%) agreed that it is appropriate for patients receiving PN to have enteral/oral nutritional intake.
3% agree 89% disagree
29
PN should be maintained while oral/enteral feeding is established – by profession
11%
30%
14%
21%
19%
100%
44%
60%
64%
63%
62%
100%
33%
19%
13%
15%
11%
10%
3%
4%
5%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• The majority of health care professionals agreed that PN should be maintained while oral/ enteral feeding is established (81%).
• Gastroenterologists showed a lower level of agreement, (55% agreed); 11% disagreed with the statement.
81% agree5% disagree
30
PN should be maintained while oral/enteral feeding is established – by work location
50%
22%
16%
19%
60%
64%
61%
62%
20%
50%
10%
19%
15%
20%
5%
4%
5%
Other
Community
District GeneralHospital
TeachingHospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• The majority of HCPs working in teaching hospitals (77%) and district general hospitals (86%) agreed that PN should be maintained while oral/enteral feeding is established.
81% agree 5% disagree
31
PN should be stopped when a patient can be given enteral nutrition – by profession
50%
25%
22%
12%
14%
100%
56%
50%
28%
41%
39%
22%
25%
44%
22%
27%
50%
22%
6%
21%
17%
4%
3%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• According to Nice Clinical Guidelines 32 (2006): ‘PN should be stopped when the patient is established on adequate oral and/or enteral support’ [2].
• 53% HCPs agreed that PN should be stopped when a patient can be given enteral nutrition.
• More nurses (75%) agreed that PN should be stopped when a patient can be given enteral nutrition compared with pharmacists (50%), dietitians (53%) and gastroenterologists (56%).
• 44% pharmacists reported that they neither agreed nor disagreed that a patient should not continue PN once they are able to receive enteral nutrition.
53% agree 20% disagree
32
PN should be stopped when a patient can be given enteral nutrition – by work location
40%
13%
14%
14%
20%
50%
41%
38%
39%
20%
25%
29%
27%
20%
18%
15%
17%
50%
2%
3%
3%
Other
Community
District GeneralHospital
TeachingHospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• 50% HCPs working in a community setting strongly disagreed that PN should be stopped when a patient can be given enteral nutrition, whereas only 18% HCPs from teaching hospitals disagreed (3% strongly) and 20% from district general hospitals (2% strongly).
53% agree 20% disagree
33
22%
10%
22%
5%
10%
100%
22%
20%
28%
29%
28%
100%
11%
20%
19%
15%
17%
44%
40%
22%
43%
38%
10%
8%
7%
7%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
There is no minimum length of time for the duration in which PN can be given – by profession
• According to NICE Clinical Guidelines: ‘There is no minimum length of time for the duration of PN’ [2].
• Mixed views were reported among HCPs as to whether there is a minimum length of time for the duration in which PN can be given; in total 38% agreed and 45% disagreed.
38% agree 45% disagree
34
There is no minimum length of time for the duration in which PN can be given – by work location
20%
16%
4%
10%
60%
50%
30%
24%
28%
17%
19%
17%
50%
33%
45%
38%
20%
5%
9%
7%
Other
Community
District GeneralHospital
Teaching Hospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• HCPs working in a teaching hospital were more likely to disagree that there is no minimum length of time for the duration in which PN can be given compared with HCPs working in a district general hospital (54% and 38% respectively).
• Views among HCPs working in a community setting were split, half agreed that there is no minimum length of time for the duration in which PN can be given however the other half of participants disagreed.
38% agree 45% disagree
35
Patients receiving PN should be monitored daily – by profession
50%
33%
50%
51%
44%
45%
100%
50%
56%
30%
29%
36%
36%
3%
10%
7%
11%
10%
17%
9%
11%
10%
1%
1%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• NICE Clinical Guidelines state that: ‘PN should be [introduced progressively and] closely monitored’ [2].
• The majority of HCPs agreed (81%) that a patient receiving PN should be monitored daily.
• 17% pharmacists and 20% nurses disagreed that patients receiving PN require daily monitoring.
81% agree 12% disagree
36
Patients receiving PN should be monitored daily – by work location
40%
50%
51%
40%
45%
50%
35%
39%
36%
5%
10%
7%
60%
9%
10%
11%
1%
1%
1%
Other
Community
District GeneralHospital
Teaching Hospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• HCPs in district general teaching hospitals less strongly agreed that patients should be monitored daily compared to those working in district general hospitals (40% and 51% respectively).
• 100% HCPs working in a community setting agreed that patients receiving PN should be monitored daily.
• The majority (60%) of HCPs working in other* care settings disagreed that patients should be monitored daily.
* Children's Hospital, Community/Acute based in teaching hospital, all of theabove, retired, academic institution, home and healthcare, GP and hospital
81% agree 12% disagree
37
PN should be withdrawn in a planned and stepwise manner – by profession
22%
50%
36%
50%
45%
100%
100%
33%
50%
58%
40%
45%
22%
6%
9%
8%
22%
1%
2%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• According to NICE Clinical Guidelines: ‘Withdrawal (from PN) should be planned and stepwise with a daily review of the patient's progress’ [2].
• The majority (90%) of HCPs agreed that PN should be withdrawn in a planned stepwise manner.
• Only 55% of gastroenterologists agreed that PN should be withdrawn in a planned manner and over 20% disagreed.
90% agree 2% disagree
38
PN should be withdrawn in a planned and stepwise manner – by work location
60%
50%
45%
44%
45%
40%
50%
43%
48%
45%
10%
8%
8%
2%
1%
2%
Other
Community
District GeneralHospital
Teaching Hospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• Only 2% HCPs disagreed that PN should be withdrawn in a planned and stepwise manner.
90% agree 2% disagree
39
PN should only be administered via a dedicated central line – by profession
50%
44%
40%
42%
29%
43%
100%
11%
30%
33%
26%
27%
11%
20%
17%
12%
13%
50%
33%
6%
14%
13%
10%
3%
4%
4%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• NICE Clinical Guidelines 32 (2006) states that: ‘PN can be given viaa dedicated peripherally inserted central catheter as an alternativeto a dedicated centrally placed central venous catheter’.
• ESPEN Guidelines state that: ‘Central venous access (i.e. Venousaccess which allows delivery of nutrients directly into the superiorvena cava or the right atrium) is needed in most patients who arecandidates for PN’ [3].
• The majority (70%) of HCPs agreed that PN should only beadministered via a dedicated central line, however 33% ofgastroenterologists disagreed and 10% nurses strongly disagreed.
• Pharmacists were most likely to agree that PN should only beadministered via a dedicated central line (75% agreed).
70% agree 17% disagree
40
PN should only be administered via a dedicated central line – by work location
20%
47%
41%
43%
40%
50%
20%
33%
27%
20%
14%
11%
13%
20%
50%
12%
13%
13%
6%
3%
4%
Other
Community
District GeneralHospital
Teaching Hospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• More HCPs working in a community setting (50%) disagreed that PN should only be administered via a dedicated central line compared with teaching (16%) and district general hospital (18%).
70% agree 17% disagree
41
Catheter care is essential when administering PN to a patient to avoid infection – by profession
100%
100%
70%
82%
81%
81%
100%
20%
18%
15%
16%
3%
2%
1%
1%
10%
1%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• According to NICE Clinical Guidelines 32 (2006): ‘All catheters used for PN should then be monitored and cared for by suitably trained and experienced individuals’ [2].
• Whilst the vast majority (81%) of HCPs strongly agreed that catheter care is essential when administering PN to a patient to avoid infection, 10% nurses strongly disagreed with this statement.
97% agree 2% disagree
42
Catheter care is essential when administering PN to a patient to avoid infection – by work location
80%
50%
83%
81%
81%
20%
50%
15%
15%
16%
1%
3%
2%
1%
1%
1%
1%
Other
Community
DistrictGeneralHospital
TeachingHospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• 97% HCPs strongly agreed that catheter care is essential when administering PN to a patient to avoid infection (81% strongly agreed and 16% agreed).
97% agree 2% disagree
43
Fluid balance should be closely monitored when a patient is receiving PN – by profession
50%
78%
70%
72%
77%
75%
100%
50%
11%
10%
28%
21%
22%
11%
10%
1%
2%
1%
1%
10%
1%
1%
Oncologist
Intensive CareSpecialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• According to NICE Clinical Guidelines 32 (2006): ‘PN usage inevitably contributes a significant fluid load and it is essential that fluid balance is monitored careful in all patients receiving PN’ [2].
• 97% HCPs agreed (75% strongly) that fluid balance should be closely monitored when a patient is receiving PN, however 10% nurses strongly disagreed.
97% agree 2% disagree
44
Fluid balance should be closely monitored when a patient is receiving PN – by work location
60%
50%
78%
73%
75%
40%
50%
19%
23%
22%
1%
3%
2%
1%
1%
1%
1%
1%
Other
Community
District GeneralHospital
TeachingHospital
Total
Strongly Agree Agree Neither Disagree nor Agree Disagree Strongly Disagree
• The majority (75%) of HCPs strongly agreed that fluid balance should be closely monitored when a patient is receiving PN, this finding was relatively consistent across care settings.
97% agree 2% disagree
45
HCPs’ Confidence with PN
46
• Teaching and district general hospitals are aligned in their levels of knowledge.
• Overall gastroenterologists and dietitians reported feeling more confident with PN thanpharmacists.
• HCPs are more confident at assessing for, and managing PN, in comparison to planning apatient’s discharge, or training a patient to self administer PN.
How confident do HCPs feel at PN commencement ….
47
Reported confidence at assessing whether PN is appropriate for a patient – by profession
100%
89%
38%
22%
58%
51%
11%
50%
53%
40%
41%
14%
1%
4%
13%
6%
2%
6%
1%
2%
Intensive Care Specialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Very confident Somewhat confident Not very confident Not at all confident N/A
• 98% of dietitians and 100% of medics feel confident at assessing whether PN is appropriate for a patient.
• Pharmacists and nurses are less confident by comparison.
92% confident 6% not confident
48
Reported confidence at ensuring the prescription for PN is appropriate to meet a patient's nutritional needs – by profession
50%
33%
13%
47%
67%
58%
50%
56%
63%
36%
28%
33%
11%
13%
8%
2%
4%
6%
3%
3%
13%
3%
1%
2%
Intensive Care Specialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Very confident Somewhat confident Not very confident Not at all confident N/A
• 91% of HCPs feel confident at ensuring a PN prescription is appropriate to meet a patient’s nutritional needs.
• Dietitians were more likely to feel very confident (67%) compared to pharmacists (47%), gastroenterologists (33%) and nurses (13%).
91% confident 7% not confident
49
Reported confidence at commencing a patient on PN (including safe and appropriate catheter access and infusion rate) – by profession
100%
89%
75%
31%
54%
52%
11%
25%
39%
35%
34%
8%
5%
5%
14%
4%
5%
8%
3%
4%
Intensive Care Specialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Very confident Somewhat confident Not very confident Not at all confident N/A
• Whilst the majority (86%) of HCPs reported feeling confident at commencing a patient on PN, including safe and appropriate access of infusion rate, pharmacists by comparison to other HCPs feel less confident (22% report not very/not at all confident).
86% confident 10% not confident
50
How confident do HCPs feel at PN monitoring and management….
51
Reported confidence at monitoring fluid balance and biochemical markers – by profession
100%
89%
75%
47%
57%
58%
11%
25%
44%
39%
38%
3%
3%
2%
6%
1%
1%
1%
Intensive Care Specialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Very confident Somewhat confident Not very confident Not at all confident N/A
1
• The vast majority (96%) of HCPs feel confident (58% very confident, 38% somewhat) at monitoring fluid balance and biochemical markers.
• Gastroenterologists reported being most confident (89% very confident) followed by nurses (75%), dietitians (57%) and pharmacists (47%).
96% confident3% not confident
52
Reported confidence at adjusting PN prescriptions to meet changing patient needs – by profession
50%
67%
38%
47%
64%
59%
50%
22%
25%
42%
30%
32%
11%
4%
4%
13%
8%
2%
25%
3%
1%
2%
Intensive Care Specialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Very confident Somewhat confident Not very confident Not at all confident N/A
94% dietitians feel confident (somewhat/very) at adjusting prescriptions to meet changing patients needs compared to pharmacists (89%), closely followed by gastroenterologists (89%).
Nurses were least likely to report feeling confident (63%), however a quarter of nurses (25%) reported that this was not applicable to them.
91% confident6% not confident
53
Reported confidence at managing complications (e.g. re-feeding, catheter-related infections, liver dysfunction) –by profession
100%
89%
50%
22%
37%
38%
11%
50%
50%
51%
48%
17%
7%
8%
8%
4%
4%
3%
2%
2%
Intensive Care Specialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Very confident Somewhat confident Not very confident Not at all confident N/A
• 100% nurses and medics are confident in managing complications in relation to PN (e.g. re-feeding, catheter related infections, liver dysfunction), however dietitians and pharmacists reported feeling less confident (88% and 72%, respectively reported confidence).
86% confident 12% not confident
54
How confident do HCPs feel at planning patient discharge on PN….
55
Reported confidence at training a patient to manage and self administer PN – by profession
11%
38%
2%
4%
22%
25%
11%
1%
5%
33%
17%
7%
10%
22%
13%
39%
41%
38%
100%
11%
25%
33%
49%
43%
Intensive Care Specialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Very confident Somewhat confident Not very confident Not at all confident N/A
• Nurses (63%) and gastroenterologists (66%) reported feeling more confident at training patients to manage and self administer PN than the other HCPs. Dietitians and pharmacists are less confident at this (3% and 11% respectively).
• A noteworthy proportion of HCPs (43%) reported that the question was not applicable to them, particularly dietitians (49%) and pharmacists (33%).
9% confident 48% not confident
56
Reported confidence at discharge planning for patients being discharged home on PN – by profession
44%
13%
11%
15%
16%
22%
25%
17%
14%
16%
22%
13%
14%
11%
12%
11%
13%
31%
26%
25%
100%
38%
28%
34%
32%
Intensive Care Specialist
Gastroenterologist
Nurse
Pharmacist
Dietitian
Total
Very confident Somewhat confident Not very confident Not at all confident N/A
• Only 32% HCPs reported being confident at discharge planning for patients being discharged home on PN.
32% confident 37% not confident
57
HCPs’ views on how to improve the way PN is prescribed and managed
58
Improvements in PN prescribing and management would include: dietetic and pharmacist prescribing, increases in homecare, better education for HCPs, clear guidance with robust evidence and 7 day availability.
Dietetic and pharmacist prescribing
“Dietitians and pharmacists having greater control over prescriptions
and dietitians becoming prescribers -one would hope then there would be less scope for inappropriate delays or
rushing to prescribe PN..”
“More health care professionals being able to prescribe e.g. dietitians,
pharmacists. More home PN especially in malignant diseases.”
“Allow dietitians to prescribe!”
Increases in homecare
“Changing the attitudes with respect to patients who have a malignancy. This requires changing the attitudes of oncologists. In Europe this is the
largest group of patients who receive home PN. In England it is
one of the smallest groups.”
“More use in palliative care and more home PN.”
“Change in home care companies and availability of nursing and compounding capacity of HPN
companies.”
Better education for HCPs
“More training to Doctors/surgeons/anaesthetists.”
“More training that is suitable.”
“Multi disciplinary training.”
“ongoing training.”
“Education to Surgical and Intensive care medics. More
support for non-medical nutrition support teams from gastroenterologists.”
“Education for surgical teams following surgery. not all will develop ileus. Education for
prescribers.”
Clear guidance with robust evidence
“More research in specific patient groups.”
“Large scale well designed research studies More focused and evidence based
guidelines on the appropriate use and management of PN.”
“Clear guidance and sound evidence.”
“Solid RCT and robust research which showed how PN can be performed safely and may be safer than EN. More research
and evidence based practice.”
“Increasing evidence base of the benefits.”
7 day availability
“Available 7 days per week. More evidence supporting
use of PN.”
“7 day working.”
“Available 7 days a week instead of mon-fri.”
“7 day working and HIFNET.”
Conclusions
59
The survey highlighted four important factors forimproving the awareness of PN: perception, confidenceto manage, the ability to prescribe and training forHCPs.
These conclusions will be explained in detail over thenext four slides.
Ultimately a combination of initiatives which cover theaforementioned factors will lead to an improvedknowledge and use of PN.
Conclusions: Perception• The survey highlighted that 94% HCPs agreed that PN ‘should be considered for all patients with a non-functioning,
inaccessible or perforated gastrointestinal tract’.
• Yet, only 60% agreed that PN ‘should be considered for all patients with malnutrition and with inadequate/unsafe oral/ enteral nutritional intake’.
• Both statements are from the NICE clinical guideline 32 (2006), this highlights the need for greater clarification of the current guidelines.
Varying interpretation of current guidelines
• 23% of multidisciplinary teams are made up of gastroenterologists, however:
• Only 55% agreed that ‘PN should be maintained while oral/ enteral feeding is established’,
• Only 55% agreed that ‘PN should be withdrawn in a planned and stepwise manner’,
• 33% disagreed that ‘PN should be administered via a dedicated central line’,
• Therefore if the perception of PN is to improve amongst HCPs, gastroenterologists need greater awareness of the appropriate use of PN.
Gastroenterologists need greater awareness of the appropriate use of
PN
• Despite 72% of HCPs viewing PN as useful when used appropriately, only 18% HCPs surveyed consider PN invaluable for improving nutritional status of patients.
PN is not considered invaluable among 82% of participants
• Current NICE guidelines state “there is no minimum length of time for the duration of PN”, however only 38% of participants agreed with this statement.” This highlights inconsistency across care settings.
Mixed views on minimum treatment length
60
Conclusions: Confidence to manage
• Amongst the survey participants, confidence levels on PN management were generally high, however clear variances were seen between the different professions.
• Dietitians and gastroenterologists, reported feeling more confident in the management of PN than pharmacists.
• Nurses’ confidence levels vary considerably across the stages of PN management.
Confidence levels vary among HCPs…
• All HCPs reported relatively high levels of confidence in the assessment, management and monitoring of patients receiving PN.
• However, low levels of confidence for training a patient to self-administer or preparing for discharge were reported.
• As PN is used in community settings, further training on preparing patients for the independent use of PN is needed.
…but across all professions, levels are considerably reduced for preparing patients
for the independent use of PN
• Teaching and District General Hospital staff are aligned in their views on the management of PN.
Similar views reported among Teaching and District General hospital staff
61
Conclusions: Ability to prescribe
• 39% of participants reported that the dietitian was the Trust’s primary decision maker for prescribing PN, however this was self-reported among 73% of participants.
• A qualitative take on management of PN highlighted the participants support for dietitians to prescribe PN.
Dietitians appear to be the primary decision makers
• The feedback from the respondents suggests that PN is used in patient types which fall under reimbursement (ie. intestinal failure).
PN is mainly used for patients with intestinal failure
62
Conclusions: Training
• 20% of HCPs reported receiving no training for administering PN.
• There is a desire amongst HCPs for more formal training that is competency based at a trust level.
• Online training is the preferred mode of delivery but practical training courses and more detailed guidance are also preferred methods amongst the majority of survey participants.
Demand for formal training
• Survey participants stated there was a lack of clear guidance and robust data in the current guidelines. Clear guidance still lacking
63
References
1. Braga, M., Ljungqvist, O., Soeters, P., Fearon, K., Weimann, A., & Bozzetti, F. (2009). ESPEN guidelines on parenteral nutrition: surgery. Clinical nutrition, 28(4), 378-386.
2. NICE Clinical Guidelines 32 (2006) Oral nutrition support, enteral tube feeding and parenteral nutrition
3. Pittiruti, M., Hamilton, H., Biffi, R., MacFie, J., & Pertkiewicz, M. (2009). ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clinical Nutrition, 28(4), 365-377.
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