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Update on access to nutritional support

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VOL: 99, ISSUE: 03, PAGE NO: 55

Variations in the provision of nutritional care mean that many patients are being denied the potentially life-saving support of tube feeding and total parenteral nutrition, according to a survey by the British Association for Parenteral and Enteral Nutrition (2002). BAPEN is calling for hospitals to establish multidisciplinary nutritional support teams with agreed procedures, and to improve staff training to ensure that all patients who need nutritional support have access to quality care.

The British Artificial Nutrition Survey (BANS) is based on audit and research data on nutritional care in hospitals and in the community. The 2002 report found wide variations in the care offered by trusts within the same region. For example, in the Trent region, in Scunthorpe, only 151 patients per million of population receive clinical nutritional care at home, whereas in Nottingham the figure is almost three times higher at 430 patients per million.

According to the report's editor, Marinos Elia, this variation cannot be accounted for by differences in the rates of cancer, intestinal failure and other conditions for which patients require clinical nutrition such as stroke, swallowing difficulties and Crohn's disease.

Previous BANS reports have revealed even larger discrepancies in the provision of total parenteral nutrition (TPN). In Scotland, a managed clinical network provides nutritional support, and systematically identifies patients who require TPN. This scheme has resulted in 14 patients per million receiving TPN. The same rate of service delivery is found in the north west of England from one of two national intestinal failure centres. The average rate for England as a whole is eight per million, with a range of 0-36 per million. These variations in TPN delivery rates are thought unlikely to be linked to rates of disease.

Both of England's national intestinal failure centres are unable to cope with the demand for their services, and have lengthening waiting lists. In addition, many of the patients who access support from the centres have to travel long distances to reach them.

'Many patients are travelling hundreds of miles for both routine and emergency care - for instance when a feeding line becomes infected,' says Carolyn Wheatley, chair of Patients on Intravenous and Nasogastric Nutrition Treatment (PINNT). 'If services closer to home are involved, these are often inadequate. Local staff may not be prepared to listen to us, the expert patients.'

Failure to provide TPN to patients with intestinal failure has serious consequences. 'Patients who cannot feed or absorb nutrients properly, urgently require TPN and will die without it,' says Dr Barry Jones, co-editor of the BANS report. For people who may benefit from enteral nutrition, such as those with cancer, failure to provide this support could adversely affect their quality of life and their life expectancy.

Hazel Rollins, nutrition nurse specialist at Luton and Dunstable NHS Trust, believes that trusts need to act urgently to ensure that patients in need of nutritional support have access to it locally. 'Trusts need to study the report and look at how they can improve their approach to patient selection and discharge planning procedures,' she says. 'They also need to look carefully at examples of best practice and find ways of achieving it themselves. That may be by establishing nutritional support teams, and it certainly points to the key role of the nutrition support nurse in safe discharge planning.'


The British Association for Parenteral and Enteral Nutrition (BAPEN) is a multiprofessional association and registered charity committed to improving clinical practice with regard to nutrition, nutritional treatment and outcomes for patients. BAPEN offers members a newsletter, website, regional activities and national meetings. More information can be found on the BAPEN website

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