• Malnutrition, enteral nutrition and the use of the percutaneous endoscopic gastrostomy

      Fallows, Stephen; Wolfendale, Christine; Eckersley, Deborah (University of Chester, 2014)
      The number of adult patients in the community receiving enteral feeding via a percutaneous endoscopic gastrostomy (PEG) is increasing. Identified problems in relation to PEG were highlighted by a community multidisciplinary team including delayed referrals and discharges. The study aimed to explore retrospectively outcomes in relation to PEG insertion following the implementation of a pilot community PEG placement care pathway. The number of adult patients in the community receiving enteral feeding via a percutaneous endoscopic gastrostomy (PEG) is increasing. Identified problems in relation to PEG were highlighted by a community multidisciplinary team including delayed referrals and discharges. The study aimed to explore retrospectively outcomes in relation to PEG insertion following the implementation of a pilot community PEG placement care pathway.The number of adult patients in the community receiving enteral feeding via a percutaneous endoscopic gastrostomy (PEG) is increasing. Identified problems in relation to PEG were highlighted by a community multidisciplinary team including delayed referrals and discharges. The study aimed to explore retrospectively outcomes in relation to PEG insertion following the implementation of a pilot community PEG placement care pathway. Data were analysed for a sample of participants over 18 years of age in three communities, served by a district general hospital in the North West of England. Group 1; ten participants managed on the community PEG placement care pathway and Group 2; ten participants who were not managed on community PEG placement care pathway with a similar primary diagnosis to Group 1. PEG insertion required to maintain nutritional status, hydration and/or medication administration for greater than fourteen days. Group 1 data for referral to treatment (RTT) waiting time was compared with the National Health Service (NHS) RTT waiting times for gastroenterology. Group 1 data for length of stay (LOS) following PEG insertion was compared to Group 2 data by conducting an Independent t‐test to analyse LOS between the two groups. A measure of central tendency obtained for LOS for Group 1 and Group 2 data was used in the calculation to estimate treatment cost. Group 1 data to estimate treatment cost was compared to Group 2 data by conducting an Independent t‐test to analyse treatment cost between the two groups. Data collection was obtained to establish if the hospital’s PEG information booklet was provided prior to PEG insertion. 6/10 participants in Group 1 had a RTT waiting time of 1 to 58 days. Median LOS for Group 1 was 4 days; Median LOS for Group 2 was 10 days. Group 1 had an estimated treatment cost of £1114.15 per patient; Group 2 had an estimated treatment cost of £2314.15 per patient. 7/10 Group 1 participants were provided with the hospital’s PEG information booklet at least one week prior to PEG insertion. A reduction in LOS, a RTT waiting time within 18 weeks and a lower estimated mean treatment cost were noted for Group 1 participants. Expansion of the exploratory study is required so the objectives generated can be challenged further.
    • Malnutrition; Can the Leeds screening tool identify haemodialysis patients at risk?

      Woodall, Alison; Morris, Mike; Bowra, Kim (University of ChesterLeeds Teaching Hospitals, 2014-11)
      There is global recognition of the need for early identification of those at risk of malnutrition. Nutritional screening has been advocated for systematically detecting and managing those at nutritional risk, triggering a dietetic referral where indicated. Dietetic assessment aims to minimise progression to overt malnutrition and ultimately, curtail the associated clinical and financial consequences. Patients receiving haemodialysis treatment are at increased risk of malnutrition. Generic nutritional screening tools are inherently limited in this population due to the observed variances in fluid status. There is currently no validated nutritional screening tool that is effective in this population. The present study aimed to test the effectiveness of the Leeds Nutritional Screening Tool (developed through pilot studies) in 140 representative haemodialysis patients. By means of a clinical audit, the clinical support worker tested the Leeds tool and the dietitian provided the criterion measure. A distinct feature was the inclusion of patients that were unable to fully complete answers, due to dementia, learning difficulties and a language barrier. Risk of malnutrition was evident in 49% of the Leeds sample. The Leeds tool showed good diagnostic accuracy (95%) with sensitivity and specificity comparable with other National Health Service tests. In turn, these results suggest that patients would be appropriately signposted for dietetic assessment, without wasting finite resources. Component analysis showed that the tool was well-balanced with a combination of objective and subjective measures and that it could be simplified by removal of a question on appetite, without affecting performance. Reliability testing was achieved by patient self-completion and by a nurse, both of whom produced consistent results with the clinical support worker. The tool was evaluated to have good practical acceptability amongst users. This research suggests that the Leeds tool can identify patients at risk of malnutrition, fulfilling the requirements needed to consider local implementation, alongside appropriate staff education. This research provide a sound framework for the development and testing of nutritional screening tools, in a field of variable study quality. It is hoped that the results will contribute to the wider audience, with further research needed to assess tool transferability amongst dialysis units.
    • Nutritional education for doctors and nurses: What is the impact?

      Almiron-Roig, Eva; Ellahi, Basma; Johnson, Vicky (University of Chester, 2010-07)
      The under-recognition and under-treatment of malnutrition in the UK, which costs the NHS an estimated £13 billion each year, has been linked to poor provision of nutritional education in medical and nursing academic programmes. The present study aimed to investigate whether the introduction of a mandatory nutritional education programme for doctors and nurses at a district general hospital would influence knowledge and attitudes related to the recognition and treatment of malnutrition and whether subsequent changes in clinical practice would be observed. It was hypothesised that knowledge, attitudes and clinical practice would all improve following training. A repeated measures design was used to assess knowledge and attitudes among junior doctors and registered nurses before and after an educational intervention using a quantitative questionnaire. A clinical audit of compliance with national clinical standards, in the form of the inpatient nutritional screening policy, was used to assess clinical practice and was a repeat of an audit conducted 12 months before. Both audits were compared for analysis. Baseline knowledge scores were below 55% for both doctors and nurses. Baseline attitude scores reflected an overall positive attitude towards nutritional screening for both groups. The results showed that both knowledge and attitudes improved significantly following training for both occupational groups. The audit identified that national clinical standards were not complied with. However, following training, statistically significant improvements were observed in compliance with the nutritional screening policy between 2008 and 2009. Specifically, the audit found that an additional 8.2% of patients were screened on admission to hospital and an additional 50.1% of patients were screened weekly during admission. Figures of prevalence of malnutrition also increased from 15.79% in 2008 to 19.21% in 2009 but were still lower than national statistics. It is recommended that all NHS Trusts implement mandatory nutritional education programmes for doctors and nurses to support clinical governance. Limitations and considerations for future research are discussed.
    • Subjective global assessment, physical function and anthropometrics: What should we be measuring in maintenance dialysis patients?

      Fallows, Stephen; Stansfield, Jennifer L. (University of Chester, 2008-03)
      Purpose - Malnutrition is common in maintenance dialysis patients; subjective global assessment is a recommended tool to identify nutritional status. The aim of the study was to establish whether a 7 point SGA tool would provide an adequate degree of accuracy in identifying malnutrition when compared to other validated subjective and objective measures of nutritional status. Previous studies have only looked at the total SGA score, this study looked at the total SGA score and also the separate sections of the SGA scoring. Methods - The study population consisted of 67 maintenance dialysis patients receiving either peritoneal dialysis (PD) or Haemodialysis (HD). Patients were assessed using a 7 point SGA tool; anthropometric measures - height, weight, triceps skin-fold, sub-scapular skin-fold, mid arm circumference, mid"arm muscle circumference, calf circumference, mid thigh circumference; dietary measures - 24 hour diet recall and Functional measures - handgrip strength and International physical activity questionnaire (IPAQ) Results Correlations were assessed using Spearman's Rank or Pearson's correlation; and conducted between the total SGA score and separate sections of the SGA tool. Only 3 results indicated a high correlation co-efficient: mid thigh Circumference (cm) with muscle mass section of the SGA score r = 0.778 (p=0.0005), mid calf circumference (cm) with muscle mass section of the SGA score r = 0.727 (p=0.0005) and mid thigh circumference (cm) with the total SGA score r = 0.707 (p= 0.0005) Conclusions - The results suggest that the 7 point SGA tool although it addresses a number of areas to consider when addressing nutrition status does not appear to have a high correlation with a number of validated measures of nutritional status, suggesting that the SGA tool needs further adaptation to prove its worth as a standalone measure.