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Using a service improvement technique to improve the care of patients requiring nasogastric feeding tubes
Abstracts / Clinical Nutrition ESPEN 10 (2015) e174ee212
days. This equates to less than half of the prescribed volume of supplement being taken each day. This may have affected the outcomes of the study. This study reinforces that dietary counselling should remain first line treatment for undernourished children. There needs to be further studies done looking at factors (such as prescribed fluid volume and palatability) affecting ONS compliance in children. 1. A report by the University of Ulster, Nutrition screening week survey and audit, UK and Ireland, (2011) 2. Walton J (ED) 2012 National Children’s Nutrition Survey-Summary Report on: Food and Nutrient Intakes, Physical Measurements and Barriers to Healthy Eating OC59. PROPHYLACTIC GASTROSTOMY FOR HEAD & NECK CANCER: 5 YEAR EXPERIENCE FROM A TERTIARY REFERRAL CENTRE S. Fong 1, R. Donnelly 2, P. Lowe 2, H. Al-Hilou 1, K. Patel 1, T. Wong 1, P. Irving 1, J.P. Jeannon 3, R. Simo 3, M. McCarthy 1, J.M. Dunn 1. 1Department of Gastroenterology, Guys and St Thomas' Hospital NHS Trust, UK; 2 3 Department of Dietetics, GSTT, UK; Department of Otorhinolaryngology-Head & Neck Surgery, GSTT, UK Prophylactic gastrostomy placement remains controversial in H&N cancer, with conflicting evidence regarding quality of life (QoL), tube dependency and swallow outcomes. BSG guidance recommends gastropexy over Perctuaneous Endoscopic Gastrostomy (PEG) due to concerns of tumour seeding to PEG site. Guy’s and St Thomas’ Hospital is a tertiary centre for head and neck cancer. We have previously published on formal tumour assessment protocol that eliminated airway obstruction as a complication and reduced the potential for metastases at the gastrostomy site. We present data for prophylactic PEG and Radiologically Inserted Gastrostomy (RIG) insertions prior to chemo-radiotherapy (CRT) for H&N cancer over a 5 year period between 2007 and 2012. Data was obtained from patient records. Analysis was by independent t-tests for continuous variables and chi-squared tests for categorical variables. Gastrostomy insertions were successful in 286/324 (88%) patients. Overall 95% of patients used the tube for feeding. Demographic and outcome data are shown in Table 1. The 30 day mortality post gastrostomy insertion was zero. There were 2 major complications e one peritonitis and one GI bleed, both managed conservatively. Minor complications included mild stoma infections (19%) which all settled on a course of oral antibiotics, and pain (14% mild, 3.5% severe) treated with simple analgesia. No tumour seeding has been reported.
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OC60. INTRODUCTION OF A COMPLETE NUTRITION SUPPORT TEAM INCREASES APPROPRIATE PARENTERAL NUTRITION USE AND REDUCES ITS COMPLICATIONS C.L. Hvas 1, 4, K. Farrer 1, E. Donaldson 2, B. Blackett 3, H. Lloyd 3, C. Forde 3, P. Paine 3, S. Lal 1. 1Intestinal Failure Unit, Manchester M6 8HD, UK; 2Quality Improvement Directorate, Manchester M6 8HD, UK; 3Nutrition Support Team, Salford Royal NHS Foundation Trust, Manchester M6 8HD, UK; 4 Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, 8000 Aarhus C, Denmark Parenteral nutrition (PN) should be provided to malnourished hospitalised patients who cannot be safely fed using the oral or enteral route. A nutrition support team (NST) may improve the efficacy and safety of the PN service provided1-3. We compared the use and complications of hospital PN before and after implementation of a complete NST. From 2009-12, all hospitalised patients outside of intensive care who were referred for PN were consecutively registered in a clinical database. A complete NST was introduced in early 2010. Before introduction of the NST, a mean of 16 patients (limits of normal variation 4-28) were referred for PN each month. After introduction of the NST, this rose to a mean of 26 referrals per month (10-41). The percentage of referrals where PN was not started rose from 5.3% in 2009 to 10.1% in 2012 (p¼0.03). In 82% of these patients, oral or enteral nutrition could replace PN. The increase in referrals where PN was not started was only observed among specialty teams who infrequently referred for PN and in specialties other than gastrointestinal surgery and gastroenterology. Line sepsis rate dropped from 8% to 1% after NST implementation and remained low throughout the follow-up period (p<0.001). The 30-day mortality was unaffected by introduction of the NST (30- day mortality pre NST: 15%; 30day mortality post NST: 14%, p¼0.63) In this study, the introduction of a NST increased both the number of commenced PN courses and the percentage of referrals where enteral nutrition could replace PN. Appropriateness of referral for PN was associated with medical and surgical specialty. The line sepsis rate dropped, but overall 30-day mortality was unaffected after introduction of the NST. 1. Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total parenteral nutrition team improve patient outcomes? A systematic review. JPEN J Parenter Enteral Nutr 2004; 28: 251-8. 2. Kennedy JF, Nightingale JM. Cost savings of an adult hospital nutrition support team. Nutrition 2005; 21: 1127-33. 27. 3. Sriram K, Cyriac T, Fogg LF. Effect of nutritional support team restructuring on the use of parenteral nutrition. Nutrition 2010; 26: 735-9.
Table 1 Study outcomes (OC59).
Age (+/- SEM) Sex (Male) Stage IVA-C Mean BMI (+/- SEM) Median weight change (+/- IQR) Mean length tube in situ (+/- SEM) 30 day mortality (treatmentend date) 1 year mortality (treatment end date)
Total (n¼ 286)
PEG (n¼ 182)
RIG (n¼ 104)
P value
58.6 (+/- 0.64) 75% (214) 75% (286) 24.6 (+/- 0.56) -6.6% (-10.6% -2.7%) 11.8 months (+/- 0.77) 6.6% (19) 23% (66)
58.6(+/- 0.64) 75% (136) 75% (136) 25.2 (+/- 0.50) -6.9% (-11.2% -3.6%) 13.4 months (+/- 1.6) 6% (11) 19% (34)
58.2 (+/- 0.79) 75% (78) 74% (77) 23.6 (+/- 0.56) -6.2% (-10.4% -1.32%) 6.5 months (+/- 0.76) 8% (8) 30% (32)
ns ns ns ns ns 0.006 ns 0.028
This large cohort study supports gastrostomy insertion as a feasible and safe procedure for nutritional supplementation in patients with H&N cancer undergoing CRT. These data demonstrate a statistically significant improvement in 1 year mortality, and a statistically longer duration of tube in situ for PEG versus RIG. Our major and minor complications rates are lower than previous series. These data are limited to a single tertiary centre, with a dedicated team of dietitians, MDT approach to tumour assessment, and consultant led service for PEG or RIG placement.
OC61. USING A SERVICE IMPROVEMENT TECHNIQUE TO IMPROVE THE CARE OF PATIENTS REQUIRING NASOGASTRIC FEEDING TUBES R. Patel 1, A. Rochford 2. 1Department of Nutrition and Dietetics Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK; 2 Department of Gastroenterology, Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK
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Abstracts / Clinical Nutrition ESPEN 10 (2015) e174ee212
Reports have been made to the National Patient Safety Agency (NPSA)(1,2) of cases of serious harm and death as a result of feeding into the lung through misplaced nasogastric feeding tubes (NGT). In 2005, the NPSA provided guidance on the methods that should be used for confirming NGT position; pH testing gastric aspirates is recommended as the first line method followed by radiography(1). Since the alert was issued, further deaths and cases of serious harm due to feeding through misplaced NGT have been reported with the main causal factor being misinterpretation of x-rays(2). A local service improvement project was established using a Plan Do Study Act (PDSA) cycle to investigate current practice; assess compliance with NPSA guidance; make recommendations to improve practice and investigate the cost of radiography for checking the position of NGTs. The project’s benefits link closely to the current need to deliver safe, high value and cost-effective patient care. A bedside documentation chart, including an NPSA compliant algorithm, was co-designed by a multi-professional team and nursing staff were trained to complete the chart using ward based training sessions. An audit tool was developed to assess compliance with NPSA recommendations and NGT insertion across the hospital was audited over a three month period. The results were collated and analysed by one individual. Patients in intensive care were excluded from the study. The study showed a >90% compliance with: Documentation of the rationale for NGT placement X-ray interpretation with instructions for action Use of NPSA compliant pH indicator paper, and Documentation of pH results on the bedside chart. However, there continue to be areas of concern in particular with NGT feeding being initiated without confirmation of position by either method. Aspirate checks were not carried out pre-feeding in 40% of patients and pre-medication administration in 83% of patients. 58% of x-rays were inappropriately requested. The combination of introducing a new bedside documentation chart and training staff about using pH testing appropriately demonstrated an 8 fold reduction in the number of radiological assessments requested post NGT insertion. The study demonstrated a reduction in radiology costs equivalent to almost £1,000 per month. Our study demonstrates the on-going challenge of correct placement of NGT and risks to patient safety. However, we have demonstrated that by using a simple service improvement technique you can improve clinical practice, reduce costs and deliver safer patient care. 1. National Patient Safety Agency (NPSA), 2005. (Accessed October 20, 2012 at http://www.nrls.npsa.nhs.uk/ resources/type/alerts/? entryid45¼59794&q¼0%c2%acfeeding+tubes%c2%ac.) 2. National Patient Safety Agency (NPSA) National Reporting and Learning Service (NRLS), 2011. (Accessed October 20, 2012 at http://www.nrls.npsa. nhs.uk/alerts/?entryid45¼129640.) OC62. A DIETETIC PRESCRIBING SUPPORT INITIATIVE LEADS TO SIGNIFICANT COST SAVING EFFICIENCIES, BY IMPROVING THE CLINICAL MANAGEMENT OF ORAL NUTRITIONAL SUPPLEMENT PRESCRIBING IN PRIMARY CARE P. Cummins, M. Thomson. Department of Nutrition and Dietetics, Lynebank Hospital, NHS Fife, Dunfermline, KY11 4UW, UK In 2010/11, NHS Fife had the highest cost per 1000 patients for oral nutritional supplements of all Scottish health boards (£0.65). Furthermore the % growth cost was significantly higher (12%), compared to the Scottish average (5%). The reasons for this exponential financial spend stemmed from inappropriate clinical and cost effective prescribing. A prescribing support dietitian (PSD) was seconded to review current ONS prescribing in the highest spending general practitioner (GP) practices. The essential remit of this role was to: (i) ensure ONS prescribing practices complied with NHS Fife Prescribing ONS Guidelines1 and Formulary1 respectively, thus (ii) reducing ONS expenditure in NHS Fife. The top 10 GP practices with the highest cost per patient for ONS, were identified under Prescribing Information Systems Management (PRISM) data. The PSD carried out prescribing searches on EMIS or Vision to identify patients who picked up an ONS prescription within the previous 6 months.
Each patient’s medical notes were reviewed to establish whether the prescription was in line with the ONS guidelines1 and formulary1. Data was collated to evaluate this, and a recommendation was made based on this data. Dedicated dietetic clinics were carried out by the PSD for patients where it was unclear whether (i) the prescription met the ONS guideline criteria1 and/or (ii) prescribed a non-formulary1 product. A prescribing change was subsequently recommended as clinically appropriate. There were 328 patients identified that had received an ONS prescription within the last 6 months of the selected GP practices. From the ONS guideline criteria, 52% were identified as clinically malnourished2, 36% unknown and 12% not malnourished. Of the ONS prescriptions issued, 71±17% complied with the formulary. The PSD recommended 148/328 (45%) ONS prescriptions receive a dietetic review and update the current ONS prescription. An outcome summary of the ONS prescribing changes following dietetic review is illustrated in Figure 1.0.
Fig. 1.0ONS prescribing changes implemented following dietetic review.ĂThis di-
etetic prescribing support initiative has contributed towards reducing ONS expenditure and the cost per 1000 patients is now at the Scottish average (£0.51). The estimated annual spend for 2012/13 based on year to date actual figures is £829,034. This translates as a 22% reduction in spend compared to 2010/11. Primarily this dietetic led intervention has contributed towards implementing appropriate ONS prescribing, which has consequently led to significant cost saving efficiencies. 1. Oral Nutritional Supplements Formulary and Prescribing Guidelines for the appropriate use of Oral Nutritional Supplements (ONS in the Community) http://www.fifeadtc.scot.nhs.uk/, under section 10 of the Formulary. December 2011 2. Elia M (2003) Screening for Malnutrition: A Multidisciplinary Responsibility. Development and use of the Malnutrition Universal Screening Tool (‘MUST’) for Adults. Redditch: BAPEN OC64. REDUCING INAPPROPRIATE ORAL NUTRITIONAL SUPPLEMENT PRESCRIBING TO FUND COMMUNITY DIETETIC SUPPORT A. Gilson 1, A. Rochford 2. 1Department of Nutrition and Dietetics Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK; 2 Department of Gastroenterology Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK Newham University Hospital is a District General Hospital in East London that serves a population of almost 300,000 people. The local population is diverse, with 70% from Black, Asian or minority ethnic groups, and has significant health and social needs; it is the 3rd most deprived area in England. We have the 5th highest childhood obesity rates in England and the highest incidence of type 2 diabetes. In 2009, the community dietetic service had two 0.5 whole time equivalent (WTE) adult nutrition support posts covering home enteral feeding and appropriate prescribing. There were 65 patients on home enteral feed (HEF) and the appropriate prescribing post supported 64 GP practices. Since 2009 the community dietetic service has been increased and now includes 1 WTE HEF / nutrition support, 1 WTE general nutrition support /diabetes / dyslipidaemia and 0.6 WTE intermediate care / obesity / diabetes. The service now more closely reflects the needs of our local population.
days. This equates to less than half of the prescribed volume of supplement being taken each day. This may have affected the outcomes of the study. This study reinforces that dietary counselling should remain first line treatment for undernourished children. There needs to be further studies done looking at factors (such as prescribed fluid volume and palatability) affecting ONS compliance in children. 1. A report by the University of Ulster, Nutrition screening week survey and audit, UK and Ireland, (2011) 2. Walton J (ED) 2012 National Children’s Nutrition Survey-Summary Report on: Food and Nutrient Intakes, Physical Measurements and Barriers to Healthy Eating OC59. PROPHYLACTIC GASTROSTOMY FOR HEAD & NECK CANCER: 5 YEAR EXPERIENCE FROM A TERTIARY REFERRAL CENTRE S. Fong 1, R. Donnelly 2, P. Lowe 2, H. Al-Hilou 1, K. Patel 1, T. Wong 1, P. Irving 1, J.P. Jeannon 3, R. Simo 3, M. McCarthy 1, J.M. Dunn 1. 1Department of Gastroenterology, Guys and St Thomas' Hospital NHS Trust, UK; 2 3 Department of Dietetics, GSTT, UK; Department of Otorhinolaryngology-Head & Neck Surgery, GSTT, UK Prophylactic gastrostomy placement remains controversial in H&N cancer, with conflicting evidence regarding quality of life (QoL), tube dependency and swallow outcomes. BSG guidance recommends gastropexy over Perctuaneous Endoscopic Gastrostomy (PEG) due to concerns of tumour seeding to PEG site. Guy’s and St Thomas’ Hospital is a tertiary centre for head and neck cancer. We have previously published on formal tumour assessment protocol that eliminated airway obstruction as a complication and reduced the potential for metastases at the gastrostomy site. We present data for prophylactic PEG and Radiologically Inserted Gastrostomy (RIG) insertions prior to chemo-radiotherapy (CRT) for H&N cancer over a 5 year period between 2007 and 2012. Data was obtained from patient records. Analysis was by independent t-tests for continuous variables and chi-squared tests for categorical variables. Gastrostomy insertions were successful in 286/324 (88%) patients. Overall 95% of patients used the tube for feeding. Demographic and outcome data are shown in Table 1. The 30 day mortality post gastrostomy insertion was zero. There were 2 major complications e one peritonitis and one GI bleed, both managed conservatively. Minor complications included mild stoma infections (19%) which all settled on a course of oral antibiotics, and pain (14% mild, 3.5% severe) treated with simple analgesia. No tumour seeding has been reported.
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OC60. INTRODUCTION OF A COMPLETE NUTRITION SUPPORT TEAM INCREASES APPROPRIATE PARENTERAL NUTRITION USE AND REDUCES ITS COMPLICATIONS C.L. Hvas 1, 4, K. Farrer 1, E. Donaldson 2, B. Blackett 3, H. Lloyd 3, C. Forde 3, P. Paine 3, S. Lal 1. 1Intestinal Failure Unit, Manchester M6 8HD, UK; 2Quality Improvement Directorate, Manchester M6 8HD, UK; 3Nutrition Support Team, Salford Royal NHS Foundation Trust, Manchester M6 8HD, UK; 4 Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, 8000 Aarhus C, Denmark Parenteral nutrition (PN) should be provided to malnourished hospitalised patients who cannot be safely fed using the oral or enteral route. A nutrition support team (NST) may improve the efficacy and safety of the PN service provided1-3. We compared the use and complications of hospital PN before and after implementation of a complete NST. From 2009-12, all hospitalised patients outside of intensive care who were referred for PN were consecutively registered in a clinical database. A complete NST was introduced in early 2010. Before introduction of the NST, a mean of 16 patients (limits of normal variation 4-28) were referred for PN each month. After introduction of the NST, this rose to a mean of 26 referrals per month (10-41). The percentage of referrals where PN was not started rose from 5.3% in 2009 to 10.1% in 2012 (p¼0.03). In 82% of these patients, oral or enteral nutrition could replace PN. The increase in referrals where PN was not started was only observed among specialty teams who infrequently referred for PN and in specialties other than gastrointestinal surgery and gastroenterology. Line sepsis rate dropped from 8% to 1% after NST implementation and remained low throughout the follow-up period (p<0.001). The 30-day mortality was unaffected by introduction of the NST (30- day mortality pre NST: 15%; 30day mortality post NST: 14%, p¼0.63) In this study, the introduction of a NST increased both the number of commenced PN courses and the percentage of referrals where enteral nutrition could replace PN. Appropriateness of referral for PN was associated with medical and surgical specialty. The line sepsis rate dropped, but overall 30-day mortality was unaffected after introduction of the NST. 1. Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total parenteral nutrition team improve patient outcomes? A systematic review. JPEN J Parenter Enteral Nutr 2004; 28: 251-8. 2. Kennedy JF, Nightingale JM. Cost savings of an adult hospital nutrition support team. Nutrition 2005; 21: 1127-33. 27. 3. Sriram K, Cyriac T, Fogg LF. Effect of nutritional support team restructuring on the use of parenteral nutrition. Nutrition 2010; 26: 735-9.
Table 1 Study outcomes (OC59).
Age (+/- SEM) Sex (Male) Stage IVA-C Mean BMI (+/- SEM) Median weight change (+/- IQR) Mean length tube in situ (+/- SEM) 30 day mortality (treatmentend date) 1 year mortality (treatment end date)
Total (n¼ 286)
PEG (n¼ 182)
RIG (n¼ 104)
P value
58.6 (+/- 0.64) 75% (214) 75% (286) 24.6 (+/- 0.56) -6.6% (-10.6% -2.7%) 11.8 months (+/- 0.77) 6.6% (19) 23% (66)
58.6(+/- 0.64) 75% (136) 75% (136) 25.2 (+/- 0.50) -6.9% (-11.2% -3.6%) 13.4 months (+/- 1.6) 6% (11) 19% (34)
58.2 (+/- 0.79) 75% (78) 74% (77) 23.6 (+/- 0.56) -6.2% (-10.4% -1.32%) 6.5 months (+/- 0.76) 8% (8) 30% (32)
ns ns ns ns ns 0.006 ns 0.028
This large cohort study supports gastrostomy insertion as a feasible and safe procedure for nutritional supplementation in patients with H&N cancer undergoing CRT. These data demonstrate a statistically significant improvement in 1 year mortality, and a statistically longer duration of tube in situ for PEG versus RIG. Our major and minor complications rates are lower than previous series. These data are limited to a single tertiary centre, with a dedicated team of dietitians, MDT approach to tumour assessment, and consultant led service for PEG or RIG placement.
OC61. USING A SERVICE IMPROVEMENT TECHNIQUE TO IMPROVE THE CARE OF PATIENTS REQUIRING NASOGASTRIC FEEDING TUBES R. Patel 1, A. Rochford 2. 1Department of Nutrition and Dietetics Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK; 2 Department of Gastroenterology, Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK
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Abstracts / Clinical Nutrition ESPEN 10 (2015) e174ee212
Reports have been made to the National Patient Safety Agency (NPSA)(1,2) of cases of serious harm and death as a result of feeding into the lung through misplaced nasogastric feeding tubes (NGT). In 2005, the NPSA provided guidance on the methods that should be used for confirming NGT position; pH testing gastric aspirates is recommended as the first line method followed by radiography(1). Since the alert was issued, further deaths and cases of serious harm due to feeding through misplaced NGT have been reported with the main causal factor being misinterpretation of x-rays(2). A local service improvement project was established using a Plan Do Study Act (PDSA) cycle to investigate current practice; assess compliance with NPSA guidance; make recommendations to improve practice and investigate the cost of radiography for checking the position of NGTs. The project’s benefits link closely to the current need to deliver safe, high value and cost-effective patient care. A bedside documentation chart, including an NPSA compliant algorithm, was co-designed by a multi-professional team and nursing staff were trained to complete the chart using ward based training sessions. An audit tool was developed to assess compliance with NPSA recommendations and NGT insertion across the hospital was audited over a three month period. The results were collated and analysed by one individual. Patients in intensive care were excluded from the study. The study showed a >90% compliance with: Documentation of the rationale for NGT placement X-ray interpretation with instructions for action Use of NPSA compliant pH indicator paper, and Documentation of pH results on the bedside chart. However, there continue to be areas of concern in particular with NGT feeding being initiated without confirmation of position by either method. Aspirate checks were not carried out pre-feeding in 40% of patients and pre-medication administration in 83% of patients. 58% of x-rays were inappropriately requested. The combination of introducing a new bedside documentation chart and training staff about using pH testing appropriately demonstrated an 8 fold reduction in the number of radiological assessments requested post NGT insertion. The study demonstrated a reduction in radiology costs equivalent to almost £1,000 per month. Our study demonstrates the on-going challenge of correct placement of NGT and risks to patient safety. However, we have demonstrated that by using a simple service improvement technique you can improve clinical practice, reduce costs and deliver safer patient care. 1. National Patient Safety Agency (NPSA), 2005. (Accessed October 20, 2012 at http://www.nrls.npsa.nhs.uk/ resources/type/alerts/? entryid45¼59794&q¼0%c2%acfeeding+tubes%c2%ac.) 2. National Patient Safety Agency (NPSA) National Reporting and Learning Service (NRLS), 2011. (Accessed October 20, 2012 at http://www.nrls.npsa. nhs.uk/alerts/?entryid45¼129640.) OC62. A DIETETIC PRESCRIBING SUPPORT INITIATIVE LEADS TO SIGNIFICANT COST SAVING EFFICIENCIES, BY IMPROVING THE CLINICAL MANAGEMENT OF ORAL NUTRITIONAL SUPPLEMENT PRESCRIBING IN PRIMARY CARE P. Cummins, M. Thomson. Department of Nutrition and Dietetics, Lynebank Hospital, NHS Fife, Dunfermline, KY11 4UW, UK In 2010/11, NHS Fife had the highest cost per 1000 patients for oral nutritional supplements of all Scottish health boards (£0.65). Furthermore the % growth cost was significantly higher (12%), compared to the Scottish average (5%). The reasons for this exponential financial spend stemmed from inappropriate clinical and cost effective prescribing. A prescribing support dietitian (PSD) was seconded to review current ONS prescribing in the highest spending general practitioner (GP) practices. The essential remit of this role was to: (i) ensure ONS prescribing practices complied with NHS Fife Prescribing ONS Guidelines1 and Formulary1 respectively, thus (ii) reducing ONS expenditure in NHS Fife. The top 10 GP practices with the highest cost per patient for ONS, were identified under Prescribing Information Systems Management (PRISM) data. The PSD carried out prescribing searches on EMIS or Vision to identify patients who picked up an ONS prescription within the previous 6 months.
Each patient’s medical notes were reviewed to establish whether the prescription was in line with the ONS guidelines1 and formulary1. Data was collated to evaluate this, and a recommendation was made based on this data. Dedicated dietetic clinics were carried out by the PSD for patients where it was unclear whether (i) the prescription met the ONS guideline criteria1 and/or (ii) prescribed a non-formulary1 product. A prescribing change was subsequently recommended as clinically appropriate. There were 328 patients identified that had received an ONS prescription within the last 6 months of the selected GP practices. From the ONS guideline criteria, 52% were identified as clinically malnourished2, 36% unknown and 12% not malnourished. Of the ONS prescriptions issued, 71±17% complied with the formulary. The PSD recommended 148/328 (45%) ONS prescriptions receive a dietetic review and update the current ONS prescription. An outcome summary of the ONS prescribing changes following dietetic review is illustrated in Figure 1.0.
Fig. 1.0ONS prescribing changes implemented following dietetic review.ĂThis di-
etetic prescribing support initiative has contributed towards reducing ONS expenditure and the cost per 1000 patients is now at the Scottish average (£0.51). The estimated annual spend for 2012/13 based on year to date actual figures is £829,034. This translates as a 22% reduction in spend compared to 2010/11. Primarily this dietetic led intervention has contributed towards implementing appropriate ONS prescribing, which has consequently led to significant cost saving efficiencies. 1. Oral Nutritional Supplements Formulary and Prescribing Guidelines for the appropriate use of Oral Nutritional Supplements (ONS in the Community) http://www.fifeadtc.scot.nhs.uk/, under section 10 of the Formulary. December 2011 2. Elia M (2003) Screening for Malnutrition: A Multidisciplinary Responsibility. Development and use of the Malnutrition Universal Screening Tool (‘MUST’) for Adults. Redditch: BAPEN OC64. REDUCING INAPPROPRIATE ORAL NUTRITIONAL SUPPLEMENT PRESCRIBING TO FUND COMMUNITY DIETETIC SUPPORT A. Gilson 1, A. Rochford 2. 1Department of Nutrition and Dietetics Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK; 2 Department of Gastroenterology Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK Newham University Hospital is a District General Hospital in East London that serves a population of almost 300,000 people. The local population is diverse, with 70% from Black, Asian or minority ethnic groups, and has significant health and social needs; it is the 3rd most deprived area in England. We have the 5th highest childhood obesity rates in England and the highest incidence of type 2 diabetes. In 2009, the community dietetic service had two 0.5 whole time equivalent (WTE) adult nutrition support posts covering home enteral feeding and appropriate prescribing. There were 65 patients on home enteral feed (HEF) and the appropriate prescribing post supported 64 GP practices. Since 2009 the community dietetic service has been increased and now includes 1 WTE HEF / nutrition support, 1 WTE general nutrition support /diabetes / dyslipidaemia and 0.6 WTE intermediate care / obesity / diabetes. The service now more closely reflects the needs of our local population.