Nutritional supportthrough the eyes of our patientsPlus: BAPEN update, Elevator interview, PEN Group study day feedback, Nutritional challenges in critical care and more …

linesNewsletter of the Parenteral and Enteral Nutrition Group of the British Dietetic Association

SPRING 2012 | 38

PEN Group website: www.peng.org.uk | BAPEN website: www.bapen.org.ukg r o u pB A P E N

Dear Members Welcome to the Spring 2012 edition ofPENlines! The heat is rising not only from a weather point of view but also in our day to day working environment and it is important that we keep ahead of the game.

Through the PENG website we try to keep you, as PENG members, up to date with some of the activity that PENG are involved in and this year is no exception. Some key conferences that PENG are involved in include DDF in June and the Annual PENG study day in December. Through working together with both the BDA and you as members we are keen to share dietetic best practice and outcome measures in nutritional support through this year’s PENG Award - see page 10 for details.

We have also started to work more closely with other BDA specialist interest groups, NNNG and PINNT.

You will have noticed some changes to the PENG website over the past couple of months and you can now join our yahoo group email and ask fellow PENG members questions, share ideas and so on – just go to the membership section and sign up!

We want to make PENlines as relevant to you as possible so please keep the ideas

coming in, meanwhile I hope you enjoy this edition and look forward to hearing from you.

Kate HallPENlines Editor

Address for correspondenceKate HallCommunications Officer, PEN GroupLangland House90 BroadwayChilton PoldenTA7 9EQ

Email: communications.peng@bda.uk.com

Closing date for next edition30th June 2012

Note: The views expressed in PENlines are those of the individuals concerned and not necessarily the official views of the BDA. Items in PENlines are for the guidance of the PEN Group members of the BDA: before using any information, members are advised to seek the advice of manufacturers.

AcknowledgementsThe PEN Group would like to thankNutricia Advanced Medical Nutrition for their financial support in thesponsorship and distribution of PENlines.

2

PEN Group Committee 2012Name Position

Anne Holdoway Chair

Vera Todorovic Vice Chair

Kate Hall Communications Officer

Arlene Barton Secretary

Sarah Ragoo Treasurer

Emma Forsyth Meetings Organiser

Carole-Anne Fleming Education Officer

Pete Turner BAPEN Link Officer

PEN Group Membership

How to join?PEN Group membership renewal or annual subscription

remains unchanged this year at £20 incl VAT. Being a PEN Group member offers you, as a dietitian, many benefits including:

For dietitians to become a new PEN Group member or renew membership please go to the PEN Group website www.peng.org.uk

• Subsidised rates at the PEN Group meetings and the Clinical Update Course• Subsidised rate for the Pocket Guide to Clinical Nutrition (and free updates)• Reduced cost of BAPEN membership, plus dietetic representation at BAPEN• Minimum of 2 copies per year of PENlines • Electronic updates, including abstracts from meetings and clinical reviews• Access to the PEN Group membership section of the website

www.peng.org.uk - which has recently been updated with voting poll, interactive Yahoo Group email and this year will undergo more developments to meet the needs of members • Facility to ask fellow PEN Group members their best practice or advice through the membership email address: peng@bda.uk.com • CPD opportunity to serve on the committee or work with them on individual projects.

BDA (CED) and PENG

Working in partnership

Laura King, Business Support Officer, BDA

The BDA CED and PEN Group are currently working together to review the CED courses, ‘Building a Working Knowledge of Parenteral Nutrition’ and ‘Building on the Skills and Knowledge of Enteral Nutrition’.

The two courses are one day trainingcourses aimed at Band 5 dietitians or dietitians that are new to the area. The courses are delivered through the CED network of franchise centres and have been delivered very successfully in the last few years. We have commissionedfour expert dietitians to review the courses and they will be working together with members of the PENG committee to ensure the courses are up to date, and comments from previous delegates and facilitators have been taken into account.

The courses will be delivered from Summer 2012. If you or a colleague are interested in attending one of the courses, please e-mail the CED on ced@bda.uk.com or look out for dates in Dietetics Today.

Section 13.8 – Refeeding Syndrome: Table 13.3 Suggests that Pabrinex is required o.d. for 10 days for high risk patients where the IV route is being utilised. Within my Trust we would only give 1 day for those on TPN or 2 days for enteral feeds? Table 13.3 recommends that you give thiamin for 10 days in high risk patients. This is based on the recommendations from NICE Clinical Guideline 32 Nutrition Support in Adults 2006. This was a GPP recommendation and therefore the opinion of the panel rather than being based on hard evidence.

The route depends on the clinical condition of the patient. If the patient is on TPN and/or have poor gut function, Pabrinex™ should be given for 10 days. Poor gut function is very subjective but could include short bowel or malabsorption conditions. Patients with alcoholic enteropathy or severe malnutrition may have impaired thiamin absorption and would probably require i.v supplementation.

The recommendation is for thiamin for 10 days (along with other vitamins) so it is possible that you may start with Pabrinex™ but decide that they are able to absorb oral/enteral products and switch to an oral or enteral product.

Why have the recommended nitrogen requirements changed in the new Pocket Guide? The recommendations have not changed, we have simply included recommendations by other organisations. The nutritional requirements section (Chapter 3) does not mention using 0.4gN per kg for wound healing but includes details of the NICE and ESPEN guidelines for nitrogen requirements in the table numbered 3.6. This chapter also includes a sentence that explicitly states that clinicians should only aim to provide up to 0.3gN/kg in “uncomplicated depletion or the anabolic phase

post injury”. There is information on how to detect whether or not a patient is metabolically stressed (page 3.4 of Chapter 3) which goes on to state that a patient is likely to be moving into the recovery phase as the relevant parameters return to the normal range.

What reference is there to concerns relating to refeeding in the requirements chapter? The requirements chapter makes it very clear on pages 3.2 and 3.3 that, in sick individuals, energy requirements are likely to be similar to, or lower than those for a healthy individual of the same age and gender. All the relevant statements are referenced to the SACN draft report. The chapter also cautions against over-feeding in the third paragraph of the stress factors section on page 3.4.

Why are there no estimates of electrolyte requirements suggested in the ‘Fluid requirements in obesity’? This section was included at the request of dietitians and other clinicians who regularly use the handbook. No estimates for electrolyte requirements in obese individuals were identified in the literature. It was therefore not possible to develop evidence based recommendations. Dietitians are unlikely to be solely responsible for the management of fluid and electrolytes in sick, obese individuals. In the absence of clinical data it was felt inappropriate to include more detail.

Pocket Guide to Clinical Nutrition

Your views and feedback corner 1 We recently had a query from Vicky Williams asking fellow PENG members for their experiences of developing a Nil by Mouth policy to prevent people spending long inappropriate times NBM when they should be fed. Vicky had a great response from you and wanted to say a BIG thank you. The responses are presently being collated and will soon be published on the PEN Group website and in a future edition of PEN lines. Should anyone have a similar query or like to contact Vicky please email her directly: Victoria.Williams@eht.nhs.uk

2 Another PEN Group member Katie Richards, Senior Dietitian from The Royal Hospital for Neuro-disability asks: “What are you currently doing for patients with requirements less than 1000kcal perday and which patient groups they would you use a 800kcal feed for?” Please can you reply direct to Katie via her email address: krichards@rhn.org.uk

We asked some of the authors of the new chapters to answer some of the questions you have asked since the launch of the 4th edition of the Pocket Guide:

3

It is a great honour to be writing this section in my new role as Chair of PENG. Having recently prepared the PENG Annual report for the BDA, this task provided the

opportunity to reflect on last year’s achievements and formalise plans for the coming year. Further details of this year’s objectives are available on the PENG website, it promises to be an exciting year ahead.

With a new year starting and as the new Chair of PENG I would like to take this opportunity to acknowledge the immense amount of work that the committee members undertake particularly in their own personal time. Special mention must be given to Judy Beeston who supported the PENG for many, many years acting as the PENG administrator up until July 2011. I would also like to acknowledge the considerable amount of work that Vera Todorovic undertook not only as Chair but also on delivering the 4th edition of the Pocket Guide to Clinical Nutrition on time in November2011; the demands for the Pocket Guide since launch (in excess of 2000 have been despatched), reflect the huge success of this invaluable resource for Dietitians. Thank you too to all the authors who provided the expert knowledge in updating this valuable guide that supports Dietitians in their everyday practice.

Thanks must also be expressed to Pete Turner, Carole-Anne Fleming, Ailsa Kennedy and Emma Forsyth for their ongoing expertise in delivering high quality educational events including the BAPEN conference, PENG study days and the Clinical Update course; the latter of which could not be delivered without the expert input from the Clinical Update Tutors and more recently which has been helped and facilitated by QMU.

Thank you to Kate Hall who has made a considerable impact in her role as Communications Officer, as is evident from PENlines, and has put considerable effort into ensuring that our members are actively engaged and regularly updated. Thank you and welcome to the 2 newestmembers to the PENG committee: Sarah Ragoo who did a sterling job in temporarily handling the membership and who has since effortlessly taken on the role of Treasurer and Arlene Barton who has an enviable skill in recording our minutes and who also represents the PENG on the BAPEN Education and Training Committee.

I would like to welcome Jaki Dickson to our members who is now supporting the PENG as Administrator. And finally I am delighted to announce the co-option of Katie Hamer, to the PENG committee who brings her skills and expertise in HETF to the committee and with whom we hope to develop HETF intiatives in conjunction with the HETF network. Key objectives for 2012 have been covered in parts of this edition of PENlines.

There is lots in store for 2012. As a committee we aim to facilitate and support an active network of Dietitians and we hope members make the most of new initiatives using technology tofacilitate further development of a vibrant clinical network, supporting the profession and developing services through sharing best practice, innovation and through stimulating discussion and debate.

Anne HoldowayChair PEN Group

Words from the Chair…Parenteral Enteral Nutrition Group (PENG)

Queen Margaret UniversityEDINBURGHg r o u p

@New Email Addresses

To get in touch with PENG committeemembers, direct your query more quickly to the right person:

For general enquiries please email: peng@bda.uk.com.

For specific membership, pocket guide, education or communications related queries please contact one of the following new email addresses which will help to answer your query more quickly and effectively:

• Membership queries emaill: membership.peng@bda.uk.com• Pocket Guide queries email: pocketguide.peng@bda.uk.com• Education queries email: education.peng@bda.uk.com• Communications query or passing on information you would like to communicate to PENG membership email: communications.peng@bda.uk.com

BDA Branches and Specialist Interest Groups MeetingDate: 17th May 2012Venue: Birmingham

DDFDate: 18th - 20th June 2012Venue: Arena Convention Centre, LiverpoolInfo: www.bapen.org.uk

PEN Group Clinical Update Course 2012 Date: 25th - 28th June 2012Venue: Queen Margaret’s University, EdinburghInfo: www.peng.org.uk

Joint BAPEN, Nutrition Society and PENG study days Date: 3rd - 4th December 2012Venue: TBCInfo: www.peng.org.uk www.bapen.org.uk

Diary dates

4

Nutritional support experience the 360 degree journey PENG | www.peng.org.uk

Being a Dietitian working in the area of nutritional support opens up many opportunities and challenges in a variety of clinical settings and specialities. As Dietitians our clinical expertise allows us to advise fellow healthcare professionals and importantly patients on the ideal methodto meet an individual’s nutritional needs taking their personal situation into account. This article summarises some of the experiences from Dietitians working in nutritional support and is accompanied by a patient’s perspective and insights from a GP.

Community nutritional support“After eight years of working in variousareas of acute dietetics, covering surgery, critical care, parenteral feeding and gastroenterology, I switched to take up a post in the community. Having been in post for 4 months now as a SpecialistPrescribing Dietitian in the south Derbyshire area I recognise that my previous experience laid solid foundations to help deal with the new challenges. I now work much more independently, spend more time with medicines management pharmacists and in GP practices; this has broadened my Dietetic knowledge and further developed my multi-disciplinary team-working skills. I am beginning to appreciate the differences between the primary and secondary care and the contrasting roles that Dietitians play in managing malnutrition in each setting.”

“Achievements to date include referrals for those warranting more intense advice and changes in prescribing practices resulting in the appropriate nutritional management for people at risk of malnutrition. Working effectively with Medicines Management has been key to improving knowledge and understandingof disease related malnutrition, its causes, consequences and effective treatments and demonstrating that our practice isbased on evidence with proven outcomes.”

“Being the only Dietitian in this speciality in the area means that clinical supervisionis limited locally, therefore membership of specialist Dietetic groups such as PENG and the opportunity of going to relevant clinical update meetings has become even more important to me.

Being an active member of such specialist groups allows networking, obtaining vital peer support, and building on specialistknowledge so that I can continue to innovate the nutritional service and as a result improve the individual patient’s nutritional care experience.” Sarah Ragoo, South Derbyshire

Nutritional support through the eyes of our patients“My advice as an individual requiring life-long nutritional support and as Chair of PINNT, is to remember that your clients are people first and patients second. This is true whether oral, enteral or parenteral nutrition is needed. Focussing on the individual as a person helps ensures that shared decision making is at the heart of care, taking into account matters such as when and where that person might prefer to feed, whether they would like to go out and about, engage in social situations independent of their nutritional supportrequirements. Remembering such individuality the Dietitian can engage with their patient / carer to understand their personal preferences and maintain as much “normality” in their lives and daily routines as possible. While there are a wide range of support groups designed to provide information directly to patients in relation to underlying condition(s), PINNT are able to offer genuine support and understanding for people while they adapt to their new way of life. We are personally experienced in providing support to patients and their families asPINNT is run by patients and carers, andwe have direct knowledge of the challenges they face. We offer a complimentary service, advice and support for the practical aspects of home artificial nutrition that healthcare professionals are unable to fully appreciate. Furthermore PINNT is keen to support industry and healthcare professionals including Dietitians, to provide a higher level of service and understanding to those requiring nutritional support.” Carolyn Wheatley, Chair PINNT www.pinnt.co.uk

The value of the PENG Pocket Guide and PENG in shaping practice in critical care“Like many, when I went to the wards I made sure I had my PENG pocket guide. Working in critical care I quickly realised just how much more the guide could

provide me with over and above theenergy equations. Providing effectivenutritional treatment in critical care must be evidence based. Critical care staff often have their own opinion and the level of Gastric Residual Volumes in determining whether your patient was absorbing their enteral nutrition, was just one example of an area for much debate. Early in post I was surprised at the inconsistency and lack of protocols. I was fortunate to attend the PEN Group Clinical Update within the first 6 months of starting my post and the experience totally changed my attitude and practice allowing me to implement nutrition policies on my unit. I gained the knowledge and confidence through the support network that being a PENG member can access and was shown how to use the pocket guide in my role and promote the importance of evidence based nutrition. Having the knowledge and evidence to underpin my practice demonstrated to the critical care team the value added by the Dietitian and supported the case for additional Dietetic resources.” Emma Forsyth, Sunderland

Home Enteral Nutrition Support – empowering patients“The home enteral nutrition team in Lewisham provides expert support for people of all ages to enable safe management of eating, drinking and tube feeding at home, with the aim of rehab if appropriate. Empowering patients to control their feeding and to develop personalised care plans is key to delivering successful patient related outcomes and has been shown to reduce emergency admissions associated with problems such as blockages and dislodgement. As patients can be seen in a variety of settings from their own homes, nursing homes, day centres and schools, a working day can be very diverse. “Lewisham HEN Team, PENlines Autumn 2011

5

The home enteral feeding service in Sheffield also demonstrates how “Dietitians are ideally placed to lead the provision of an effective and responsive service, if it has the correct skills and experience, and the relevant clinical and nursing support required.” Sean White and Gary Simpson are aware that in “an increasingly difficult financial climate it is vital that Dietitians understand the service from top to bottom, identifying areas where efficiencies can be made while preserving the highest level of support for patients, and translating this to commissioners at every opportunity. Good, relevant data collection and reporting is the basis for this, as well as pushing through service improvements in response to identified gaps or client/HCP feedback.” Sean White and Gary Simpson, Sheffield, PENlines Autumn 2011

Views from a GPRachel Pryke, a GP in Worcester and the Nutrition Champion for the RCGP reflected in a recent interview with PENG the need for Dietitians to communicate and promote to GPs the benefits of Dietetic intervention including our impact on clinical outcomes and explaining how we can support GPs (adapted from elevator interview with Dr Rachel Pryke, GP and RCGP Clinical Champion for Nutrition and Health in PENlines Autumn 2011). Dr Pryke highlighted that the care of patients on enteral and parenteral nutrition was generally led by Dietitians and district nursing colleagues and that her “own confidence in managing such patients is low, reflecting an absence of training throughout my medical career. “

Dr Pryke urged Dietitians to “share knowledge at every opportunity – most GPs will have had minimal nutrition training but are typically happy to learn about giving better patient care; for example:- make clinic letters educational as well as factual, perhaps by reminding the GP about recommended monitoring or explaining reasoning behind management decisions.”

Her thoughts on controversies and challenges in the area of appropriate nutritional care were that “Effective team working requires thinking ‘outside the box’ and establishing

our individual elements of responsibility, thus gradually refining our roles to reflect our clinical strengths.”

More can be read about this interview in PENlines Autumn 2011 edition, but it is clear that there is a great opportunity for Dietitians to educate GPs whether based in a hospital, care home or community setting and for us, as Dietitians, to be more effective in communicating the Dietetic clinical outcomes and sharing best practice with each other and other healthcare professional colleagues.

Acknowledgement The PENG Pocket Guide to Clinical Nutrition is written by Dietitians for Dietitians, PENG are grateful to the authors who contributed to the latest update to produce the 4th edition which is available to purchase via the PENG website www.peng.org.uk. PENG are also grateful to those who contributed to this article which outlines the challenges and opportunities in the field of nutritionalsupport. The PEN Group of the BDA acts as an umbrella support group for those Dietitians involved in nutritional support from oral to enteral to parenteral - in other words a continuum of nutritional care. Should you wish to find out more about the new activities PEN Group will be embarking upon, including clinical outcome measures please contact us at peng@bda.uk.com

New groups are forming in disease specific areas and we look forward to working with other specialist groups where topics overlap.

Thanks to the named authors and several authors who contributed to PENlines Autumn 2011 for their contributions to this summary.

Nutritional Challenges in Critical Care by Emma Forsyth, RD

Estimating nutritional requirements can be adifficult enough job but the extra stress that the critical care population face can lead you in

many directions. Dietitian’s workingin critical care will face the daily dilemma of calculating requirements and providing a tailored feeding regimen, taking all factors into consideration. The fear of under and overfeeding is evident as we check and double check our calculations. We are often told through literature that we need to ‘get it right’ in this patient group when providing nutritional treatment as harm can be caused if too much or too little is given, but often we find that we are not the only professional providing calories.

What about the ‘nutrition’ provided from other sources? What about the fat energy provided from a sedative commonly used in critical care? As many of the ITU doctors are finding the need for increased levels of these sedatives to effectively manage the patients, we, as Dietitians, are commonly put in the position of having to amend our carefully calculated regimen to accommodate the extra calories in a bid to avoid overfeeding our patients.

But what about the risk of underfeeding specific macro and micronutrients by reducing or amending the regimen?Should we stand strong and recommend to the medics that they use another drug that does not pose a nutritional issue?

There are nutritional products availableon the market to provide certain nutrients to our patients which are often used in this scenario but what about the infection control risk in this vulnerable group?

Would you like to add to this debate then please join and visit the Yahoo Group through the PENG website member’s section www.peng.org.uk

g r o u p

6

A Great ResponseThe venue was highly rated due to itslocation being next to the BAPEN conference and the good availability of accommodation. The length of each session was described as ‘just right’. The cost of the event was highlighted as ‘great value due to the quality of speakers,provision of handouts and inclusion of food and refreshments’.

Delegates were asked if they could suggest future topics and we were inundated with ideas:

• Long term PN management in hospital• Establishing outcomes in nutritional support• More community based nutritional support topics• Using acid-base balance in clinical practise• New lipid emulsions in PN• Drug interactions with enteral feeds• Management of refeeding syndrome in hospital and community• Sip feed prescribing• Management of high output stomas• Enhanced recovery – surgery• Enteral feeding in stroke

Evaluation of PENG Study Day 2011

The launch of the Pocket Guide at the PENG Annual meeting in November 2011 was a successful event. This meeting was unique due to the presenceof the key authors of the updated chapters. The delegates were treated to an opportunity of understanding the practical application of the guide from the author’s point of view.

The meeting also provided an ideal way of networking with the authors as well as other Dietitian’s working in the field of nutrition support, sharing practice and ideas leading to sound, evidence based outcomes.

PEN Group “Late” Summer Meeting

Feedback from Delegates Holiday Inn Harrogate, Monday 28th November 2011

“I plan to use the new energy equations

when estimating patient’s nutritional

requirements”

“I plan to look into establishing outcomes

in my role”

“I will look more into nitrogen balance during

my assessment of patients”

The lucky PEN Group Award winners were announced at the Late Summer PEN Group Meeting in November where each winner was presented with their Award and certificate.

This years awards went to Kay Baxter and Fiona Struthers, ICU Dietitians from the NHS Forth Valley for their application entitled ‘Estimating Nutritional Requirements in the Obese Patient’; and Kirsty-Anna McLaughlin and Anne Holdoway, from the Dietetic Department, Royal National Hospital Rheumatic Diseases Bath and the Dietetic Department, Royal United Hospital Bath respectively, for their application entitled ‘Energy required for weight maintenance in traumatic brain injury rehabilitation patients versus predictor equations.’

Congratulations to the winners of this years awards which were kindly sponsored by Fresenius-Kabi and Abbott Nutrition. On behalf of the PEN Group committee I would also like to thank those other PEN Group members who applied for the PENG Award this year - it is always difficult judging the Awards because of the high calibre of applicants. The judging for the PEN Group Awards was carried out independently by 3 judges and each applicant was blinded and the judges used a set judging criteria.

Award winners Kay Baxter & Fiona Struthers left, Kirsty-Anna McLaughlin & Anne Holdoway right.

“I am going to update the ITU team on

the advancements in the feeding protocol recommendations and

that a higher level of aspirate is ok!”

“I was interested in the practise of

bedside NJ placements”

“I am keen to try out using calf circumference”

“I am moving into a specialist renal post next

month so found this session very useful”

PEN Group Award Winners 2011

“I will be more aware of overfeeding”

7

8

BAPEN UPDATE

Let’s be the generation to eliminate avoidable malnutrition Ailsa Brotherton, BAPEN’s Honorary Secretary provides an update on recent BAPEN activities including a ‘Call to Action’ to Dietitians

B

2012 is a really exciting year for BAPEN and its core groups as the national focus on malnutrition is reaching new heights. The Nutritionand Hydration Action Alliance (name yet to be

confirmed) is in the process of being established and 2012 will also see the launch of a Malnutrition Task Force aiming to set ambitious goals for improving nutritional care for older people. Combined with the fact that 2012 sees for the first time in the UK an event that specialises in bringing together experts in the field of digestive diseases and nutrition taking place in Liverpool, (17th to 20th June 2012) and BAPEN’s planned launch of new guidance towards the end of the year, 2012 really should result in significant quality improvements in nutritional care at a national level. The challenge of course is to replicate excellent practice at pace and scale at regional and local levels and this, we recognise, is particularly challenging given the changing landscape of the NHS and the proposed new commissioning arrangements.

The Nutrition and Hydration Action AllianceAn update from Rhonda Smith

Building on plans from 2011 to set up an All Party Parliamentary Group, more than 40 MPs and Peers are potential supporters of promoting nutrition and hydration as we go forward to develop an action and implementation plan for the Alliance. Whilst this newly forming Alliance is being ‘housed’ by BAPEN to provide the practical and legal frame-work that such an Alliance requires to get established, it will be led by the growing number of stakeholder groups and organisations that have joined and are committing to supporting the overall cause of ‘delivery of excellent nutrition and hydration for everyone. Dr Mike Stroud, immediate past Chair of BAPEN, and currently leading the NICE guidance group on fluid management, is the Chair of the Alliance. The aim is for the Alliance is to represent organisations across the UK and to help drive implementation in all four home nations.

Draft documents will be available soon, one a strategy document for the Alliance itself followed by a draft of a national Nutrition and Hydration strategy for which we will seek the support of the Department of Health in each home nation.

If anyone would like more information about the development of the Allianceor your organisation would like to join please phone Rhonda Smith. Tel: 07887-714957.

The Malnutrition Task ForceAge UK, WRVS, Apetito and Nutricia have joined together to create and fund a Malnutrition Task Force under the leadership of Chair, Dianne Jeffrey CBE. The Task Force will work closely with BAPEN and will focus urgently on ending preventable malnutrition among older people, and in doing so reduce unnecessary public sector costs. The task force will set ambitious goals to improve nutritional care for older people across all settings and will work collaboratively with leading experts to map current best practice in each setting. The Task Force has the support of Government and the Department of Health.

The Digestive Disorders Federation (DDF)17th - 20th June 2012 Liverpool An update from Anne Holdoway

DDF is a landmark 4 day meeting. It is the first combined UK meeting of four leading UK organisations; the British Society of Gastroenterology (BSG), Association of Upper Gastrointestinal Surgeons (AUGIS), British Associationfor Parenteral and Enteral Nutrition (BAPEN) and British Association for the Study of the Liver (BASL). As the DDF meeting replaces the annual meeting of each of the four organisations, the DDF offers an outstanding programme which reflects the state of the art nature of healthcare today. The DDF aims to bring together experts in the field to ensure that healthcare is underpinned by the best available evidence. The size of the event also enables the organisers to offer highly competitive delegate rates - £55* per day!* Join BAPEN to qualify for these fantastic rates

The DDF programme is likely to appeal to Dietitians working in many specialties with scientific topics including medical and surgical management of Inflammatory Bowel Disease, Liver, Pancreatic and Small Bowel Transplantation, Intestinal Failure, the management of obesity, probiotics, pseudoobstruction, neuro-endocrine tumours, cystic disease of the pancreas to name a few. Embracingthe government’s agenda to put patients at the centre of our care, there will be a Public Engagement Event ‘Nutrition Question Time’. Such patient forums are a unique opportunity to gain direct feedback from patients and the medicalcharities which represent them. In conjunction with a key symposium ‘Organisation of Nutritional Care’, nutrition will be firmly on the agenda. We look forward to meeting you in Liverpool.

Launch of new BAPEN Guidance Diary Date: 3rd and 4th December.

BAPEN’s Education and Training committee is working collaboratively with BAPEN’s core groups to produce multidisciplinary good practice guidance which will be launched in December 2012. Further details to follow in future editions of PENlines but save the diary dates now.

CALL TO ACTIONWe need Dietitians to get involved in BAPEN at a regional level, to engage with your local clinical commissioninggroups to ensure that good nutritional care is commissioned for all. Now is the time for Dietitians to seize the opportunities that will be created by the new commissioning structures.

B A P E N

During the 10 years I’ve been in post (and probably before then) members have been seeking advice and direction on measuring dietetic outcomes. We originally set up a joint working group of members from the previous BDA Research and Clinical GovernanceCommittees; and whilst it didn’t produce a final guidance document looking back at this the approach that we took was well ahead of its time in that it took a patient-centered approach.

Reflecting on this background to dieteticoutcome measurements led me to thinking that dietetic outcome measurements could be described as a ‘wicked problem’. To put it bluntly, considerable time and effort had been spent discussing it and trying various approaches out, but there wasn’t much to show for it. Dietetic outcome measurements seemed to be a truly ‘wicked problem’ because it was difficult to define what exactly they were and there really didn’t seem to be any clear single solution. Some dietetic departmentscontinued to work on developing local measures using a variety of approaches with varying levels of success.

The publication of the DH (England) Eq-uity and Excellence: Liberating the NHS (July 2010) White paper put the measurement of health outcomes firmly back on the dietetic agenda. Although this is English policy, improving the quality of care is a long-term and ongoing priority for each of the UK Countries. Whilst different approaches are taken, there is commonality around three key themes which are patient experience, safety and effectiveness.

The BDA rose to the challenge of setting up a working group and consulting you, as BDA members, who were very much our critical friends along the journey of producing the framework sharing their experience and perspective to build the model.

In 2011 the BDA Outcomes Framework and Model (2011) was published http://members.bda.uk.com/profdev/profpractice/outcomes/Outcomes-Model110414.pdf

Key to this model is understanding what you want to achieve, to quote Rick Wilson “Does the end justify the means?”I would personally like to thank Anne Holdoway as Chair of the 2011 BDAC Planning Group for having the vision to devote day 2 of BDAC to outcomes. This gave us a tremendous platform to launch the framework and start to try it out. PEN Group was one of 11 SpecialistGroups who rose to the challenge of running a 40 minute workshop to try the approach out for the first time - thank you Carole-Anne!

What we learnt from these workshops was that before you start as a team youneed an appreciation of both the National and Local drivers for outcome measurements. Time is needed to understand the principles, and then more time to discuss the issues and uncertainties. Outcome measurements are not an exact science it is an emerging one.

So what has happened post-BDAC?It’s exciting times with a growing interestand engagement across the profession at Local, Regional and National levels. Whilst there are some key principles the application of the model to individual practices and services has to be worked through at a local level. It needs time (and more time) and commitment to start to work through the process and start to put it into place. Quite simply start off slowly, it’ll never be perfect and it needs to keep evolving.

Here’s a list of those who are working actively developing dietetic outcome measures, or are about to start. I’m sure there are many more so apologies if I haven’t listed you and please get intouch with us to share your experiences.

• Welsh Managers, London Managers, North West Region Dietitians

• The Renal, Gastroenterology, Food Allergy and Intolerance and PENG Specialist Groups

• The Home Enteral Feeding Network

Top tips on developing dietetic outcome measurements:• Keep it simple• Be clear why you are doing this• Allow plenty of time, if you get stuck leave it and come back to it• Discuss, discuss, discuss• If you don’t know what your expected outcome is, question why you are doing it• Start to collect something• There are no rights or wrongs• Even poor outcomes will give you important information about your service• Identify the barriers

Remember the methodology is only just emerging and dietitians are well ahead of the game here.

Please share what you are doing with me so we can share it across the membership email:i.darnley@bda.uk.com

Dietetic outcome measurementthe story so far Ingrid Darnley, BDA Policy Officer Clinical Quality

A P E N

Dietetic Outcomes and Nutritional Support

PENG are supporting the Home Enteral Feeding (HEF) network in developing home enteral feeding outcomes and will be attending the meeting in June at the BDA.

9

WHY should you apply? In recognition of how difficult it can be to obtain funding to attend study days, the PENGcommittee, working collaboratively with our colleagues in industry, have designed the 2012 PENG Award to provide 4 fully funded places to the BAPEN Meeting December 2012 (including the PENG study days), allowing more dietitians to win and help to support your attendance at such an important meeting.

WHAT is the PENG 2012 Award? This year’s PENG Award, focuses on submissions demonstrating use of dietetic outcome measures in nutritional support. To be considered for an Award we invite you to tell us about your best practice; show us what measures you use in demonstrating dietetic outcomes, outline how you communicate this to your fellowhealthcare colleagues and demonstrate whether this has helped secure funding for any dietetic posts? Have you carried out audits which would be useful to share? Have you got a patient case study which illustrates the importance of dietetic outcome measures? Have you carried out any research in the area of dietetic outcomes in nutritional support? – If yes, we would like to hear from you…

WHO can apply? PENG are looking for FOUR dietitians who are members of the *PENG who can demonstrate measuring dietetic outcomes in nutritional support. We are looking for original contributions and sharing best practice to help us, as a Specialist Group, demonstrate and communicate the clinical benefits of dietetic intervention in the area of nutritional support.

HOW can you apply? Simply write a short summary of your audit, or innovative practice or case study, to show how you have measured dietetic outcomes and integrated this into improving patient care. Your submission should be in the form of an abstract with title, authors, introduction/background, results, discussion, conclusion and references on one page of A4. Submit along with your contact details including your PENG NUMBER to the PENG education email address:education.peng@bda.uk.com by August 31st 2012. All applications will be judged according to set criteria and the lucky winners will be notified by the end of September 2012. We will hold the Award ceremony at the main PENG meetingin December where the winners will have an opportunity to present their work.

PENG Award 2012

Applications for PENG Award 2012 are now open, deadline 31st August 2012.

*Not a member of the PENG - not a problem - go to the PENG website www.peng.org.uk for details on how to join or email membership.peng@bda.uk.com

10

Do you carry out audits, have an interesting

case study to share, are you innovative in dietetic

practice?

Would you like to win a fully funded place at the

BAPEN meeting December 2012 incorporating the Annual

PENG study day?

If you answer “YES” and are a current PENG member*

– then why not apply for the PENG Award 2012?

Are you able to demonstrate measuring

a dietetic outcome?

Would you like a chance to showcase

your success?

BAPEN Annual Conference, November 2011

Summary of the Critical Care Session Symposium 3 – Feeding decisions in Critical CareChair – Dr Sheldon Cooper

SPEAKER 1 Dr Richard Beale

Key Nutritional Challenges

The main area for discussion in this session was the benefits of early nutrition in critical care. Dr Beale highlighted that it is shown that patients should be fed as soon as practical, ideally within 24 hours of admission to critical care. The type of nutrition needed still requires discussion. He stated that critical care in 2011 has better infection control, better blood glucose management and better line management therefore is PN safer?

The concept of trophic feeding, other-wise known as underfeeding, was introduced to the audience. Work done in this area showed that patients who were fed fully suffered more complications such as higher gastric residual volumes, diarrhoea and abdomen distension therefore is it better to feed trophic?

The CALORIES trial currently been carried out was mentioned as Dr Beale stated, yes we need to feed early but we still do not know whether early PN should be used and why not?

SPEAKER 2 Emma Graham-Clarke

PN Prescribing

Emma started her session by stating‘give a standard PN regimen to all patients’. The aim of this session was todiscuss the practicalities of prescribingPN in critical care from the views of the Pharmacist.

She discussed each important element of PN, for example, potassium content. The ideal would be to give a standard amount in the bag and if the blood levels run low, then liaise with ITU medical staff and allow them to supplement the difference separately. The impact of drugs on the ITU can also have effect on what should be prescribed in parenteral nutrition and an awareness of these were highlighted in the session.

SPEAKER 3 K Whelan

OC12

Dr Whelan gave the audience an overview of the original contribution submitted on the work of the impact of additional fructo-oligosaccharides in patients receiving enteral nutrition in critical care. He stated that the occurrence of diarrhoea in patients receiving enteral nutrition varies from 2-95% with varying contributory factors, such as antibioticsand infections. The study aim was to determine whether adding additional fructo-oligosaccharides would make a difference in faecal microbiology, faecal SCFA and stool output. It is perceived that this addition could promote the production of bifidobacteria. The results of the study after 1st and 2nd analysis showed that the presence of the additionshad no difference on stool output or faecal SCFA however it was found that the levels of bifidobacteria actually reduced. It was concluded that there is no evidence in supplementing feed with fructo-oligosaccharides – no beneficial changes were seen.

Speakers 4 & 5EN – Dr Tim BowlingPN – Dr Trevor Smith

PN versus EN debate

Dr Sheldon presented a case history to the audience to set the scene. The patient was a male suffering from a 6 week history of RIF pain, diarrhoea and weight loss. Known colonic cancer, cachectic, MUST >2, BMI 17, acidotic, self ventilating,reasonable PU. CT showed no evidenceof perforation, air in the colon and rectum. It was stated that the surgeons wanted to optimise the patient for surgery which was planned for 2 weeks time. The question was put out – would you feed this patient enterally or parenterally?

The large majority of the audience voted enterally.

Dr Tim Bowling took to the stand to plead his case for enteral feeding. He clearly stated that the cancer in the patients colon was not obstructed therefore why not feed enterally? He does have a functioning gut, no h/o vomiting, distension. If he can eat then oral diet +/- ONS should be implemented. Could that be supplemented with overnight NG feeding?

Dr Trevor Smith disagrees with this. He stated that the patient has a short history of very significant GI symptoms, MUST score of 6 therefore he is a very sick patient! He is severely malnourished, at risk of refeeding syndrome.

He asked does he really have a functioning GI tract? No was his answer. History of weight loss and diarrhoea. He was not convinced that safe and effective enteral nutrition could be provided. He also wanted a second opinion on the CT.

Another vote in the audience was cast and there was some movement to people feeling parenteral more appropriate but the majority still voted for enteral.

Dr Cooper informed us that the patient was started on NG feeding with replacement of electrolytes. Day 4 of feeding, the patient obstructs, has a grossly distended small bowel and caecum. He underwent an emergency extended right hemicolectomy with ileostomy. Post operatively, self ventilating,NG feed continued with aspirates of 280ml, absent BS.

A further vote taken and now the majorityof the audience has voted that the patient should be fed parenterally.

Each side pleaded their case, Dr Smith stating now that the patient has not had proper nutrition for days. Dr Bowling however suggested the option of post pyloric feeding, prokinetics, even trying oral intake.

It was agreed that probably the inclusion of both routes would have been viable, supplementing enteral nutrition with parenteral, monitoring condition closely.

11

On March 1st 2012, subscriptions to Practice-based Evidence in Nutrition became available to all BDA members as a complimentary membership benefit.

PEN provides the tools for evidence-based practice through making available the answers to thousands of nutrition and dietetic related practice questions. Each answer has each been formulated by carrying out an extensive, expert led systematic review of the best available international research and guidelines.These questions are supported by background documents, evidence summaries and related client and practitioner facing tools and resources.

The BDA has made available links to hundreds of these tools since launch and have now in addition to the existing resources, begun to develop PEN UK handouts which are available for subscribers to customise, download and print for use with clients.

The resource undergoes constant updates and responds to the requirements of the profession. Should the resource not answer your research question subscribers are provided with the facility to submit their question to the resource. The PEN team will assess the need for a question to be answered based on the frequency of it being asked.

UK dietitians have contributed to around 20 knowledge pathways in the last year

and further UK led pathways are under development. To further enhance your EBP skills, the BDA are now offering members the opportunity to enrol in an online evidence-based tutorial subsidised at a rate of 50%. Successful completionof this course will mean you meet the standards required to become a PEN reviewer, for which remuneration is available.

Should you wish to know more about PEN visit http://www.bda.uk.com/pen or contact Sylvia Turner at globalpen@bda.uk.com or Tel: 0121 200 8046

g r o u p

ddfDigestive Disorders Federation (DDF) Conference

2012 BAPEN MEETING

17-20 JUNE 2012 | ACC, LIVERPOOLin association with BSG, AUGIS & BASL combined as theDIGESTIVE

DISORDERSFEDERATION

BRITISH ASSOCIATION FOR PARENTERAL AND ENTERAL NUTRITION

Practice-based Evidence in NutritionSylvia Turner, PEN Project Development Officer/KTP Associate, BDA Office

PEN Group Publications

Pocket Guide to Clinical Nutrition

4th edition updated 2011 editors Vera Todorovic and Ann Micklewright

NEW UPDATED SECTIONS

Buy your very own copy now by contacting: pocketguide.peng@bda.uk.com

or for more information: www.peng.org.uk

ReducedPrice for

PENG members

12

Earlier this year, the NPSA issued another report building on the previousreport of the misplacement of NG tubes “Reducing the harm caused by misplaced feeding tubes in adults, children and infants” (NPSA/2011/PSA002) from March 2011.

The Alert requires all organisations to ensure that “Nasogastric tubes are not flushed, nor any liquid feed introduced through the tube following initial placement, until the tube tip is confirmed by pH testing or x-ray to be in the stomach”

This does not sound different to previousadvice issued over the last several yearshowever what is interesting is the interpretation of this statement by staff working at placing NG tubes.

The reason for the second issue was another reported 2 patient deaths since the release of the report in March 2011. This has since uncovered a common

belief amongst staff that NG tubes with lubricants required a flush to activate the lubricant and therefore the “never flush” rule was not adhered to. The mixing of water and lubricant, gave a pH reading that was acceptable resulting in feed being given through feeding tubes that were in the patient’s lung.

Uncovering such beliefs amongst professions is difficult, as unless the belief is changed, the behaviours, even if instructed by such high profile organisations, do not change.

Response to the NPSA Rapid Response Report 22nd March 2012

To ensure that such “never events “ do not occur, the Nutricia Nurse Governance Team (NNGT) have responded swiftly to implement an internal national program of both theoretical and practical training, learning and competence to ensure all Nutricia Nurses that place Nasogastric

Tubes (NGT’s) in the community adhere to all criteria outlined in the NPSA alert.Some of these include:

• NG tube risk assessment tool for all placements in the community

• National audit of all NG tube placements performed by Nutricia nurses

• A practical and theoretical training programme on adherence to the NPSA alert guidance with a pass rate of 80% required

This is followed by a robust incident reporting procedure where these are fully investigated by a clinical team. To date such “never events” have not been associated with Nutricia Nurse practice

PRODUCT/SERVICE NEWS

News from the NPSA NPSA Rapid Response Report 22nd March 2012

Harm from flushing of nasogastric tubes before confirmation of placement Summarised by Kirsten Harris (Clinical Governance Manager and Practice Lead Nutricia)

Nutricia Advanced Medical Nutrition announced the latest addition to its Low Energy tube feed range at the end of February.

Nutrison 800 Complete Multi Fibre has been specifically developed by Nutricia in response to requests from UK dietitians for an 800 kcal complete feed in 100ml to meet the needs of HETF patients with low energy requirements.

Key features of the product include:• 800 complete - complete in micronutrients in 800 kcals

• 1000ml volume - reduces wastage and the risk of higher calorie delivery

• 55g protein - this is 25% higher than provided in 800ml of a 1000 kcal complete feed

• 15g fibre - a mix of insoluble and soluble fibres with Nutricia’s MF6 fibre blend

• Ready to use - Easy, fast and safe to administer with good compliance

For further information, please contact the Nutricia Resource Centre (resourcecentre@nutricia.com) 01225 751098.

*Nutrison 800 Complete Multi Fibre is a prescribable ACBS approved enteral feed containing 55g of protein in 1 litre and is nutritionally complete in vitamins, minerals and fibre.

Product Update

Nutrison 800 Complete Multi Fibre 800 kcal Complete Nutrition* in 1000ml

13

Welcome to the Elevator Interview for PENlines - could you briefly explain your role?Director of a private not-for-profit company that provides commissioning solutions for health in the criminal justice

sector and for commercial healthcare organisations; I also have a background in NHS commissioning.

With the ‘new’ NHS how do you think that the commissioning of services such as dietetic services will change?I think that this is a new and exciting opportunity for commissioning to really come into its own, particularly clinical commissioning and commissioning for health and well being outcomes. Commissioning will still need the programme and project management processes of procurement and contracting,but there will be a new impetus driven by clinical commissioning to get different results. Services which may have been overlooked in the past, such as dietetic services, should hopefully start to see a fresh commissioning approach, as the focus of commissioning moves beyond QIPP to improving health and well being. A number of key drivers will enable this shift, the new health and well being boards, the emphasis on clinically-driven commissioning, and the new Public Health England. The whole issue of malnutrition and dietetics will, albeit gradually, start to become more prominent on the commissioning agenda.

How big is the population in your area? How many different care settings does this cover? eg hospital/care homes/GP centres...I live in a mixed urban and rural district of around quarter of a million people. Much of the population have long-termconditions and there is an ever-increasing health inequalities gap within the district and also compared to other areas. We have a plurality of healthcare providers from the large acute hospital to a well-developed primary care service.

Do you currently commission a dietetic service or what is your involvement in this? What does the service cover?As an NHS commissioner I was not involved in commissioning dietetic provision at all; in fact I don’t know anyone who was. This illustrates how we need to raise the profile of dietetic provision through commissioning to show the difference it can make to people’s lives and to their health.

Will public health service change over the next 12months and how do you think this may affect dietetic services?Public health services will change enormously over the next 12 months with the advent of Public Health England and the new Health and Well Being Boards. This represents a massive opportunity to improve the profile of dietetic services and its role in improving public health.

What should dietitians do to make sure they are continued to be seen as the experts in good nutrition whether it be advising other healthcare professionals or budget holders? How can they get involved? How can dietitians increase their profile?For dietitians to make sure that they continue to be seen as the experts in good nutrition they should strive to get more involved in the development of broader care pathways and to work with their service managers to move further beyond delivering outputs of provision but toward influencing the realisation ofbroader health improvement and health and well being goals and outcomes. I would like to see dietitians become more influential in specifying programme goals for commissioned services and influencing contract and budget holdersat a strategic level, perhaps even at the upstream stage of commissioning programmes and procurement projects helping to specify commissioning or provision requirements. To do this would need really strong leadership from dietitians in terms of their influencing and change management skills and to really exploit their ‘knowledge power’ to get dietetics onto the commissioning agenda. Now is a great opportunity for dietitians because of the advent of

clinical commissioning groups and, perhaps the first time, a new paradigm is coming about where clinicians will start to be listened to when it comes to commissioning services. Dietitians will need to think in a more business-like way and develop commercial acumen so they can make and position their ‘value proposition’ to the business case when tendering for contracts or for when bidding for additional funds. Essentially, dietitians need to start to ‘market’ themselves and their profession as representing expertise in an area of healthcare which can make a real difference to people’s lives and that theycan create, if allowed to do so, a best-value proposition and demonstrate a unique selling point of healthcare provision.

Do you think that the area you work/cover has a population who are being treated effectively for malnutrition if at high risk and have a good system in place for identifying those at risk and providing appropriate dietary advice? If yes - please comment and if no please comment.I really do not know; Barnsley clearly has some real deprivation and health inequality problems and I am pretty sure that many people are likely to be at risk of malnutrition in this area.

Where do you live? Barnsley, Yorkshire.

What place or thing should people go to or do if visiting the area in which you live?Visit the local Worsbrough Country Park, which is very pleasant and a million miles away from down-town Barnsley.

What is the book you are reading at the moment or would like to read?The Chelsea Murders – an old 70s thriller.

What is you favourite meal?Very hot curry!

Thank you

If you have any questions you would like to ask Danny Alba please email: communications.peng@bda.uk.com

Elevator InterviewWe step inside with

Danny Alba MSc PSC (Birm) FCMI CMgr

Director of Commissioning Innovative Solutions Ltd

14

NEW

Supporting patients with low energy needs to fi nd the right balance

Introducing Nutrison 800 Complete Multi Fibre –800 kcal complete nutrition* in 1000mle *Nutrison 800 Complete Multi Fibre is a prescribable ACBS approved enteral feed containing 55g of protein in 1 litre and is nutritionally complete in vitamins, minerals and fi bre.

Nutricia Ltd, White Horse Business Park, Trowbridge, Wilts, BA14 0XQ.For further information call 01225 751098, or visit www.nutricia.co.uk