ncepod pn study - peng · 2014-07-07 · ncepod national confidential enquiry into patient outcome...
TRANSCRIPT
NCEPOD PN Study
Melanie Baker Senior Specialist Dietitian, Leicester
Expert on NCEPOD PN Study
Session Overview
• NCEPOD– Who are they– Remit and Function
• Parenteral Nutrition– Why?– Links with recent / current initiatives – PN NCEPOD study
NCEPOD
National Confidential Enquiry into Patient Outcome & Death
• Reviews the management of patients• Undertakes confidential surveys • Publishing results to… Improve the quality of medical and surgical
care.
NCEPOD
• Independent (of DoH and professional bodies) charity
• 90% funded by the DoH via the NPSA• Steering Group with representatives from
– Various medical royal colleges – NPSA - NICE– Coroner Society - Institute of Healthcare Mg– Scottish Audit of Surgical Mortality
NCEPOD
National Confidential Enquiry into Patient Outcome & Death
• Covers England, Wales, NI, Isle of Man, Jersey, Guernsey
• All hospitals – NHS, private
History
National Confidential Enquiry into Patient Outcome & Death
• 20 years old• 1982 Confidential Enquiry into Peri-
operative Deaths.• Moved from reviewing the care of surgical
patients to cover all specialities.
Audit? No
• Typically review services where there are no agreed standards by which current practice can be audited against.
• NCEPOD asks– what standard does the service current
achieve– by identifying the key components of the
service
Research? No
• NCEPOD does not evaluate new treatments• COREC
– Ethical approval not needed• Confidentiality
– Complies with Data Protection Act 1998– Complies with Health and Social Act 2001
• Section 60 – Secretary of State for Health authorises the use of Pt identifiable data without consent
• PIAG– Reviewed current practices
Data Collection:Survey
• Clinicians complete individual patient surveys– Evidence of CPD– Opportunity of review/reflect on clinical practice– Compliance
• Concerning cases– Discussed with NCEPOD’s Lead Co-ordinator and
Chief Executive. Only very bad practice is referred back to the Trust Medical Director & consultant involved (support by the GMC)
Studies to date
• Death in acute hospitals• Elective & Emergency Surgery in the
Elderly
• Scoping our Practice– “The PEG study”– Highlighted poor selection and high morbidity
and mortality rates with PEG– Has significantly influenced practice
Parenteral Nutrition
Why?
Why now?
Parenteral Nutrition
• Generally given to the sickest patients, with associated morbidity and mortality.
• Indications– Failure of gut function (with obstruction, ileus,
dysmotility, fistulae, surgical resection or severe malabsorption) to a degree that prevents adequate gastrointestinal absorption of nutrients
– Persisted or persisting (> 5 days)(NICE, 2006)
Parenteral Nutrition
• Current practice is extremely variable:
– Assessment of need– % of hospitals with Nutrition Support Teams– How NST function / composition– Pharmacy / PN bag options– Central line care– Management of associated clinical problems
Recent / Current Initiatives
NICE Nutrition Support in Adults, 2006
HIFNET
NICE
• All acute trusts should have a MDT nutrition support team.
• Patients prescribed standarised PN should have their nutritional requirements determined by HCP with the relevant skills & training.
HIFNET
• Intestinal failure– Type I
– Type II
– Type IIIHIFNET
Type II IF
• Severely ill patients in hospital who require complex abdominal surgery and management of their nutrition/electrolytes over weeks – months.
• Normally associated with sepsis and patients normally require intensive care for some of their hospital stay.
• Classified depending on length on time PN is required
• Estimated prevalence is 18 patients/million population requiring PN for > 14days
Type III IF
• Chronic, metabolically stable patients who require HPN
• Estimated as– 14.6 patients/million population, – 2 patients/million new (BANS, 2006 data)
Sector 1 – Local
• NICE compliant for nutritional support services
• Could provide some aspects of care (?HPN) if can demonstrate expertise
Sector 2 - Regional• Assume primary responsibility for the management of patients with type II
and III IF• At least 2 NNS• Dedicated MDT outpatient clinic (at least monthly)• Designated ward area for HPN patients• Availability of pharmacy compounding facilities• Experience of managing patients on HPN• Nutrition Support Team – Lead Clinician, Dietitian, NNS, Pharmacist (with
support for daily cover during times of absence) Page 77– Weekday WR– Weekly team meeting
• Daily cover with out of hours arrangements • 24 hour telephone advice capability• Available access to dedicated clinical area for inpatients with nursing staff
trained• Availability of vascular access and imaging expertise• Appropriate biochemical monitoring
Sector 3 – Supra-regional (Type II/III with surgical
capability)• Assume primary responsibility for the management of patients with
type II and III IF• Co-ordinate shared care with other units
• In addition to Sector 2• Surgical expertise / Availability of individual specialist surgical teams• Appropriate facilities and expertise in interventional radiology, intensive
care, stoma/wound care• Designated ward area for Type II IF patients – with DIRECT admission• Provision of services for
– Persistent acute IF > 6weeks not resolving and complicated by venous access problems– Multiple fistula in a dehisced abdominal wound– <30cm residual small bowel– Persistent severe intra-abdominal sepsis– Resistant metabolic complications (from high outputs)– Recurrent venous access problems
• Specialist advice available at weekends and out of hours• Joint surgical WR/meeting and surgical availability for joint outpatient
reviews.
Sector 4 – National IF units
• Existing (NSCAG) funded services– St Marks (London)– Hope (Salford) – with improved links to sector 3 (and ?2
centres)
Improving the quality of medic a l and s urgic a l c are
NCEPODPARENTERAL NUTRITION STUDY
Improving the quality of medic a l and s urgic a l c are
NCEPOD
• AIM – to identify areas where the care of patients receiving PN might have been improved– Indication
– Type of PN / access
– Assessment of need / Prescription
– Nutrition Support Team
– Complications
Improving the quality of medic a l and s urgic a l c are
NCEPOD – Expert Group.
• Representatives were identified from key professional bodies
– BAPEN
– NNNG
– PENG
– BPNG
• Group met with NCEPOD Clinical Co-ordinators
– Brainstormed and agreed proposal
– Questionnaires developed, drafted and agreed
– Pilot sites identified
Improving the quality of medic a l and s urgic a l c are
Parenteral Nutrition Survey
• Each Trust has a local NCEPOD reporter, who was sent an ORGANISATION questionnaire
– Is there a nutrition support team (?members / function)
– Who is responsible for prescribing the PN
– Who decided on the composition
– Options for PN formulations (including out of hours)
– Line insertion
– Policies and guidelines – Nursing Care / CRS
Improving the quality of medic a l and s urgic a l c are
Clinical Questionnaire
• Each trust had to identify All inpatients (neonatal, Paed and Adult) receiving PN from 01.01.08 – 31.03.08
• Clinical questionnaire (sent to primary consultant or other) to complete for the following:– Indication for PN
– Nutrition support prior to PN
– Who assessed the patient (member of NST?)
– PN formulation / who prescribed / who monitored
– Complications
– Duration and Outcome
– Sent back with copies of the case notes / dietetic records
Improving the quality of medic a l and s urgic a l c are
What now
• Questionnaires being received thick and fast!
• ADVISORY GROUP– review every case – questionnaires and case notes - and fill out a
separate advisor’s form.
– Not all advisors review all cases but all cases reviewed by the advisors
• Initial results will be discussed with the Expert group November 2009
• Report Published mid 2010