Mary Bird, RGN.
Intravenous and Nutrition Nurse Specialist, Peterborough and Stamford Hospitals NHS TrustNUTRITION
Parenteral nutrition provides nutritional support to patients with a non-functioning or inaccessible gastrointestinal tract (Henry, 1997).
A non-functioning gut can be caused by disease, such as Crohn's or colitis, when treatment would be to rest the gut to prevent further inflammation. An inaccessible gut usually arises due to major excisional surgery or fistulae, thus preventing insertion of an enteral feeding tube (Dewar, 2000). Parenteral nutrition delivers essential nutrients directly into a patient's circulatory system (Power, 2000).
A nutrition support team was formed in our trust in 1997, originally in an advisory capacity, to manage parenteral nutrition. The team's creation followed a rise in the incidence of catheter-related infections. Following approaches to the trust's clinical management board in September 2001, the team took official control of initiating parenteral nutrition from January 2002.
The most common risk of this feeding method is catheter-related infection (Fletcher and Bodenham, 1999), a significant growth of micro-organisms either endoluminally or on the external catheter surface beneath the skin, in the absence of systemic infection (Pratt et al, 2001).
Other risks include metabolic disturbances such as hyperglycaemia/glucose intolerance (Burnham, 1999), liver damage (Reilly, 1998) and re-feeding syndrome (Solomon and Kirby, 1989). Before initiating parenteral nutrition, the risks to each patient should be balanced against the benefits (Henry, 1997).
Before the nutritional support team took control of this area, the most common use of parenteral nutrition (about 28%) locally was for colorectal patients, following resections of the small and large bowel. After the team took over, the largest use was in intensive therapy unit (ITU) patients (39% of those prescribed parenteral nutrition).
An original audit of parenteral nutrition management issues was conducted in 1993-1994 - before my appointment. This revealed that the Peterborough and Stamford Hospitals NHS Trust was administering parenteral nutrition to an average 140 patients a year, higher than the average for the rest of the Norfolk, Suffolk and Cambridgeshire region. Over a one-year period, it was found that parenteral nutrition lines had an annual catheter-related infection incidence of 41%.
This prompted the trust to ask if the feeding method was being administered appropriately in all cases. As a rule, it is indicated in patients with a non-functioning or inaccessible gastrointestinal tract that is not likely to regain function within seven days (Henry, 1997; Reilly, 1998; Dewar, 2000).
Yet much of the parenteral nutrition was being prescribed for less than seven days. This was seen as being of no clinical benefit to the patient - benefits must always outweigh the risks caused by inserting a central venous catheter (Dewar, 2000), which exposes the patient to the possibility of infection, malposition, electrolyte disturbances and fluid overload (Pennington, 1996).
Although many patients were receiving parenteral nutrition for less than the recommended time, this was not reflected in the mean calculated duration for its delivery (the range of days for receiving parenteral nutrition was from 2 to 72 days).
In a study by Maurer et al (1996), in 49.7% of cases parenteral nutrition was avoidable. The researchers found that transfer of the control for prescribing the therapy from the patient's consultant to a nutrition support team reduced the mean number of days it was administered from 500 to less than 100 a month.
Not only does the inappropriate use of this feeding method place patients at risk, it also has financial implications. In our trust, the daily cost is about £93 per patient, taking into account the average feed regimen, ancillary equipment, biochemical tests and daily nursing time.
Trujillo et al (1999) found that delegating the management of parenteral nutrition to a dedicated team brought cost savings and a reduction in metabolic complications in preventable parenteral nutrition days (20%) to parenteral days (74%). These included hyperglycaemia, hypomagnesemia and hypernatraemia.
The decision to initiate parenteral nutrition at our trust used to be made solely by the consultant responsible for a patient's care. But the increase in incidents surrounding potential inappropriate use led to concerns. Ten adverse incidents were reported in 2001, before nutrition support team control. These included:
- Parenteral nutrition wrongly prescribed
- Incorrect programming of the volumetric pump
- Hang time exceeding 24 hours
- Central venous catheter leaking.
In 2002 there was only one incident of inappropriate use - a decision to start parenteral nutrition was overruled by the nutrition support team because it was deemed inappropriate for the patient, who was in the terminal stage of disease.
The incidence of catheter-related infection before and after the initiative is detailed in Table 1. The number of lines exceeds the number of patients because the duration of parenteral nutrition therapy would have necessitated more than one line per patient.
Lennard-Jones (1992) suggested that, in an organisation with an average of 69 patients requiring parenteral nutrition a year, the presence of a nutrition support team would reduce by 16 the number of episodes of catheter-related infection. In addition to Maurer et al's work (1996), other evidence to support the management of parenteral nutrition by a nutrition support team includes research by Dalton et al (1984) and Pennington (1996).
These studies, and the recognised risks to patients, prompted our trust's decision in September 2001 to transfer the initiation of parenteral nutrition to the nutrition support team from January 2002.
Locally, the team includes: three consultants - chemical pathologist, physician and surgeon; a clinical nurse specialist, a senior pharmacist and a senior dietitian.
The exercise started by targeting the prescribing of parenteral nutrition for adult patients in secondary care. Critical care areas were excluded, as the therapy is prescribed by expert intensivists in these areas, and there was evidence of nutrition-focused care. Paediatric parenteral nutrition was rarely used, as most children were managed by a tertiary centre.
Nine months was allowed for the change, to provide time to collate data and persuade stakeholders that the outcome would benefit both patients and staff.
A multidisciplinary approach was crucial to gain the co-operation of all the professionals and ensure a smooth transition. Target personnel included the medical staff responsible for each patient's overall care, nurses delivering care and the pharmacy department.
The nutrition nurse specialist managed a database on patients who had parenteral nutrition in the previous three years - information used to support the case for change.
A meeting was held with the trust's clinical management board, the highest local forum for decision-making, to present the data and argue for the nutrition support team to take over initiation of all adult parenteral nutrition within the organisation.
The board is headed by the directors of nursing and medicine and meetings are attended by the lead clinicians from all specialties and allied health professional department heads.
An appropriate management style is vital to gain the co-operation of stakeholders for proposals that involve making changes to accepted modes of working. The nutrition support team decided to adopt the systems approach.
Mullins (2002) defines this as an approach that looks at the organisation both as an entity and as part of a wider environment. It focuses on problems as the result of system failure rather than as the consequence of the actions of an individual. The systems approach promotes a no-blame culture - endorsed by the Department of Health - that should be supported at local level through a system of adverse incident reporting.
The SMART formula (see box, page 24) (Upton and Brooks, 1995) was used to demonstrate that all aspects of the process had been addressed and clear objectives had been set.
The nutrition support team decided a face-to-face approach at clinical management board level would enable the proposals to be presented as part of wider picture, as well outlining the likely impact on ward staff (Upton and Brooks, 1995).
The terms developmental, transitional and transformational are used to highlight the processes needed to achieve change. Transitional change is the desire to achieve a state that differs from the existing one (Iles and Sutherland, 2001).
This method of change is planned and can be due to a fault in the system that needs to be rectified - in this case, the financial implications and the rise in infection rate that was likely to occur without the change. To facilitate the change process and to achieve behaviour modification our organisation needed to go through three stages (Mullins, 2002):
Unfreezing: This is defined as justifying the need for change (Iles and Sutherland, 2001). To gain stakeholder co-operation it was necessary to outline the rationale for change. A force-field analysis was used to consider the variables involved and to determine whether the change was likely to occur (Iles and Sutherland, 2001; Lewin, 1997). It involves balancing the driving forces against the restraining forces - in our case, it demonstrated strength in the driving forces, supporting the need for change. The restraining forces highlighted foreseeable obstacles, which were overcome through use of appropriate leadership skills.
Movement: The next step was to implement the plan. The nutrition support team assumed control of parenteral nutrition prescribing from January 1, a date that would make it easier to compare data from previous years.
The nutrition link nurses - a network of nurses from all clinical areas responsible for disseminating and acting on nutrition policies - were contacted and given the task of ensuring compliance.
The lead clinicians for each specialty reported on the change at their clinical management team meetings over a period of three months following our initial meeting with the clinical management board. We circulated a laminated flow chart detailing how to initiate parenteral nutrition to ward areas.
Refreezing: This term describes when the new point of view is integrated (Iles and Sutherland, 2001). Once the change occurs, the focus switches to maintaining momentum.
The nutrition support team decided clinical audit would be the most suitable method of achieving this. The figures on the previous three years' use of parenteral nutrition and incidence of catheter-related infection allowed comparison with post-change data to be made. To ensure staff were aware of the changes in patient care, the nutrition support team drew up guidance containing all the relevant evidence-based policies on initiating, managing and discontinuing parenteral nutrition.
Since the nutrition support team assumed control of initiating parenteral nutrition, its use has decreased significantly (by 35% between 2001 and 2003) and, as predicted, the reduction has brought marked financial benefits, with average annual savings of about £60,000.
Before the change, the incidence of catheter-related infection had become a major concern. More appropriate provision of nutrition, and meticulous nursing care, led to a decrease of infections in 2003, after a marked increase in 2002. Table 1 shows that even though the percentage figures rose in 2002, fewer lines were actually used - there were 12 episodes of catheter-related infection out of 74 lines (16.2%) compared to 12 episodes in 111 lines in 2001 (10.8%).
In 2003, catheter-related incidence fell to 2.7% (one episode out of 36 lines). Because fewer patients were on the therapy, the support team was able to allocate more time for each individual. In addition, seminars for nursing and medical staff had been held trustwide on line care, ensuring that full aseptic precautions were taken when inserting lines.
The change in practice has achieved the transformations it aimed for, of reducing catheter-related infection and saving money. The nutrition support team has now suggested that, in addition to initiating parenteral nutrition, it should also take control of cessation of feed.
Ultimately, the decision to switch control of parenteral nutrition to the nutrition support team was worthwhile, because it has achieved the goal of improving patient care.
Guidance on clinical governance, elements of which are applicable to the delivery of parenteral nutrition
- The Healthcare Commission monitors the quality of clinical governance in the NHS. A local CHI review identified that a robust system was in place to monitor adverse incidents, ensuring that a true picture is given on practice. Therefore targets for training could be identified following the number of incidents reported in relation to the management of parenteral nutrition
- Clinical governance is a vital component of health care: it provides clinicians with a framework to improve quality of care and to safeguard standards of care (Harvey, 1998)
- The components of clinical governance - such as clinical audit or input from patients - assist in monitoring standards to highlight good practice or identify a need for change.
Author contact details
Mary Bird, Intravenous and Nutrition Nurse Specialist, Peterborough and Stamford Hospitals NHS Trust, Thorpe Road, Peterborough PE3 6DA. Email: firstname.lastname@example.org
Burnham, P. (1999) Parenteral nutrition. In: Dougherty L, Lamb, J. (eds) Intravenous Therapy in Nursing Practice. Edinburgh: Churchill Livingstone.
Dalton, M.J., Schepers, G., Gee, J.P. et al. (1984)Consultative total parenteral nutrition teams: the effect on the incidence of total parenteral nutrition-related complications. Journal of Parenteral and Enteral Nutrition 8: 146-152.
Dewar, H. (2000)Dietetic aspects of parenteral nutrition. In: Hamilton, H. Total Parenteral Nutrition: A practical guide for nurses. London: Churchill Livingstone.
Fletcher, S.J., Bodenham, A.R. (1999)Catheter-related sepsis: an overview, Part 1. British Journal of Intensive Care 9: 2, 46-53.
Harvey, G. (1998)Improving patient care: getting to grips with clinical governance. RCN Magazine Autumn, 8-9.
Henry, L. (1997)Parenteral nutrition. Professional Nurse 13: 1, 39-42.
Iles, V., Sutherland, K. (2001)Managing Change in the NHS. Organisational change. A review for healthcare managers, professionals and researchers. London: National Co-ordinating Centre for NHS Service Delivery and Organisation. Available at: www.sdo.lshtm.ac.uk/pdf/changemanagement_review.pdf (accessed on August 22, 2004).
Lennard-Jones, J. (1992)A Positive Approach to Nutrition as Treatment. London: King's Fund.
Lewin, K. (1997)Resolving Conflicts and Field Theory in Social Science (reprint edn). Washington: American Psychological Association.
Maurer, J.S., Weinbaum, F., Turner, J. et al. (1996)Reducing the inappropriate use of parenteral nutrition in an acute care teaching hospital. Journal of Parenteral and Enteral Nutrition 20: 4, 272-274.
Mullins, L.J. (2002)Management and Organisational Behaviour (6th edn). London: Pearson Education.
Pennington, C.R. (ed.) (1996)Current Perspectives on Parenteral Nutrition in Adults. A report by a working party of the British Association for Parenteral and Enteral Nutrition. Maidenhead: BAPEN.
Power, J. (2000)Nutritional support. In: Mallet, J., Dougherty, L. (eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (5th edn). Oxford: Blackwell Science.
Pratt, R.J., Pellowe, C.M., Loveday H.P. et al. (2001)The epic project: developing national evidence-based guidelines for preventing healthcare-associated infections. Phase I: Guidelines for preventing hospital-acquired infections. London: Department of Health.
Reilly, H. (1998)Parenteral nutrition: an overview of current practice. British Journal of Nursing 7: 8, 461-467.
Solomon, S.M., Kirby D.F. (1989)The refeeding syndrome: a review. Journal of Parenteral and Enteral Nutrition 14: 1, 90-97.
Trujillo, E.B., Young, L.S., Chertow, G.M. et al. (1999)Metabolic and monetary costs of avoidable parenteral nutrition use. Journal of Parenteral and Enteral Nutrition 23: 2, 109-113.
Upton, T., Brooks, B. (1995)Managing Change in the NHS. Milton Keynes: Open University Press.