bsna parenteral nutrition survey presentation of results

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.

http://www.bsna.co.uk/categories/parenteral_nutrition/

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


• 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.


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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).


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


Teaching Hospital

Total


• 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%).


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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).


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


• 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.


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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


TeachingHospital

Total


• 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


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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%).


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


Teaching Hospital

Total


• 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.


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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.


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


Teaching Hospital

Total


• The majority of HCPs (89%) agreed that it is appropriate for patients receiving PN to have enteral/oral nutritional intake.


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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.


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


TeachingHospital

Total


• 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.


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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.


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


TeachingHospital

Total


• 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).


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


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.


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


Teaching Hospital

Total


• 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.


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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.


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


Teaching Hospital

Total


• 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


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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.


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


Teaching Hospital

Total


• Only 2% HCPs disagreed that PN should be withdrawn in a planned and stepwise manner.


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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).


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


Teaching Hospital

Total


• 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%).


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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.


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


• 97% HCPs strongly agreed that catheter care is essential when administering PN to a patient to avoid infection (81% strongly agreed and 16% agreed).


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


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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.


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


TeachingHospital

Total


• 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.


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%


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%


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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%).


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%


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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).


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%


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


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%


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


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%


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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).


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%


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• 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%).


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%


Gastroenterologist

Nurse

Pharmacist

Dietitian

Total


• Only 32% HCPs reported being confident at discharge planning for patients being discharged home on PN.


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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bsna parenteral nutrition survey presentation of results

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