Ensure safe and effective care when using enteral and parenteral nutrition
Rollins S (2011) Nutritional support: how to reduce the risk of harm. Nursing Times; Early online publication.
Approximately 30% of adults and up to 14% of children are malnourished on admission to hospital.While most patients in hospital are fed orally, enteral and parenteral nutrition (PN) are used to support patients where oral feeding is impossible or inadequate. However, invasive nutritional support can be problematic and is best managed by a multiprofessional nutrition support team. Over the last 18 months three areas of nutrition support practice have come under scrutiny.
First, an alert from the National Patient Safety Agency (NPSA, 2011) has reported harm (including death) to patients from failure to detect misplaced nasogastric tubes. Trusts need to ensure they are using evidence-based guidelines; that staff are trained and assessed as competent in a nasogastric tube insertion; and that practice is regularly audited.
Second, the NPSA (2010) reported 11 deaths and 11 cases of serious harm relating to complications after gastrostomy tube insertion. It identified the need for frequent observation of vital signs, pain scores, the tube and the stoma site. Key issues appear to be a lack of awareness of danger signs and lack of access to an urgent senior review in case of complications. Staff who are contacted by a patient post gastrostomy need to be acutely aware of the risks.
Third, a National Confidential Enquiry into Patient Outcome and Death demonstrated poor quality of care and organisation of PN (NCEPOD, 2010). There were delays in recognising the need for PN, getting started, gaining and managing venous access and recognising and managing complications.
The risks, benefits and alternatives to nutritional support should be discussed with patients. Written information should be provided with the opportunity to ask questions, to ensure informed consent.
5 key points
- Patients should be screened for malnutrition risk using a validated, age-appropriate screenng tool on admission to hospital and then at least weekly
- The position of nasogastric tubes should be checked by testing the pH of gastric aspirate (pH1-5.5), and if this is inconclusive, by X-ray
- It is essential to identify enteral feeding tubes correctly so that it is clear whether the tip of the tube is in the stomach or small bowel
- Gastrostomy tube insertion carries the risk of life-threatening complications. Patients require careful monitoring in the first 72 hours after insertion
- Parenteral nutrition should be considered only when enteral nutrition is contraindicated or has failed
When to contact the nurse specialist
- If you need help to implement or use a nutritional screening tool such as Paediatric Yorkhill Malnutrition Score in children or Malnutrition Universal Screening Tool in adults
- If you have ethical or clinical concerns about a patient’s nutritional care
- If you need training and support in enteral and parenteral nutrition practice
- If there is difficulty passing a nasogastric tube or your patient needs a nasal bridle to keep it in-situ
- If your patient is considered for a gastrostomy, post-pyloric feeding or discharge on home enteral tube feeding
- If your patient needs parenteral nutrition
Guidance and resources
The British Association for Parenteral and Enteral Nutrition brings together health professionals, patient groups and industry. www.bapen.org.uk
The National Nurses Nutrition Group aims to improve nutritional care by providing education and networking opportunities for nurses, and promoting the role of the specialist nurse. www.nnng.org
The National Patient Safety Agency publishes safety alerts and never events. www.nrls.npsa.nhs.uk
PINNT is a support group set up and run by patients on nutritional support, to promote best practice and campaign for improved care and products. www.pinnt.com
Hazel Rollins is clinical nurse specialist, Gastroenterology and Nutrition, Paediatric Unit, Luton and Dunstable Hospital Foundation Trust