An evaluation of current home enteral nutrition services at principal referral hospitals in New South Wales, Australia
Sahrish Sonia Faruquie A , Elizabeth Kumiko Parker B C and Peter Talbot BA The University of Sydney, NSW 2006, Australia. Email: sfaruquie@gmail.com
B Department of Dietetics and Nutrition, Westmead Hospital, PO Box 533, Wentworthville, NSW 2145, Australia. Email: peter.talbot@health.nsw.gov.au
C Corresponding author. Email: elizabeth.parker@health.nsw.gov.au
Australian Health Review 40(1) 106-113 https://doi.org/10.1071/AH15029
Submitted: 10 February 2015 Accepted: 5 May 2015 Published: 3 August 2015
Abstract
Objective This cross-sectional study investigates the home enteral nutrition (HEN) services of public principal referral hospitals in NSW, Australia, comparing their services to best practice guidelines for HEN.
Methods HEN service processes were investigated using an online questionnaire and telephone interview with the dietitian primarily working with HEN at each hospital.
Results Participating hospitals reported a total of approximately 3200 HEN patients, 76% required oral nutrition support. Only 69% of hospitals had a dietitian allocated to their HEN service and no hospitals had established multidisciplinary teams to manage HEN patients. Post-discharge follow-up, as recommended for tube fed and oral patients, was achieved by 8% and 15% of hospitals respectively. Forty-six per cent of dietitians were satisfied and 46% of dietitians were dissatisfied with current HEN services provided, and reported the following improvements were required: increased clinical resources allocated to HEN dietitian/coordinator; increased outpatient services (home visits, outpatient clinic, multidisciplinary clinic); and an efficient registration process and database.
Conclusions HEN services among participating hospitals are inconsistent, demonstrating gaps in service provision. Baseline assessment scores varied, with an average of 61% of recommendations currently in use. Best practice guidelines are not firmly adhered to due to limited funding and allocated resources for HEN.
What is known about the topic? HEN is recognised as a cost-effective and reliable way of treating patients requiring nutrition support post hospital discharge. There are best practice guidelines available to ensure quality care is provided to HEN patients in the community or home setting. As there is no national framework in place for HEN in Australia, currently total patient numbers are unknown and each state and territory provides different levels of service delivery and funding for HEN. It is unknown how guidelines in Australia have been implemented and practiced, as no studies were found that have audited HEN services in Australia.
What does this paper add? From the participating hospitals we were able to obtain updated data on HEN patient numbers (~3200). This paper reports on baseline scores in meeting best practice HEN guidelines for tertiary referral hospitals in NSW, Australia and identifies gaps in service provision. It is essential to identify reasons that limit adherence to HEN guidelines, as consequences may include unnecessary re-admissions to emergency departments or hospitals, increasing healthcare costs. Our study found notable differences in service provision ranging from 29% to 86% of recommendations of HEN guidelines achieved, and identified a lack of multidisciplinary teams to manage HEN patients.
What are the implications for practitioners? We found HEN services among principal referral hospitals are inconsistent and best practice guidelines are currently not adhered to. National guidelines together with local health policies assist in defining the required standard of care, enhance service delivery and promote clinical excellence. We found the NSW Health Agency for Clinical Innovation HEN Implementation Checklist to be a practical tool for obtaining baseline scores for adherence to best practice guidelines. Regulation of HEN will be positive for HEN users by ensuring a more equitable service is available by introducing consistent funding for HEN nationally. However, it is the responsibility of states and local health districts to implement guidelines, contributing to better health and quality of care provided to patients.
Additional keywords: dietitians, nutritional support.
References
[1] NSW Agency for Clinical Innovation. ACI nutrition network: guidelines for home enteral nutrition (HEN) services 2nd edition. Chatswood: ACI Home Enteral Nutrition Network, 2012.[2] Chen HL, Shih SC, Bair MJ, Lin IT, Wu CH. Percutaneous endoscopic gastrostomy in the enteral feeding of the elderly. Int J Gerontol 2011; 5 135–8.
| Percutaneous endoscopic gastrostomy in the enteral feeding of the elderly.Crossref | GoogleScholarGoogle Scholar |
[3] Winter J, Streeton C, Kenwood A. Home enteral nutrition practices in Victoria. Aust J Nutr Diet 1999; 56 10–4.
[4] De Luis DA, Izaola O, Cuellar LA, Terroba MC, Cabezas G, De La Fuente B. Experience over 12 years with home enteral nutrition in a healthcare area of Spain. J Hum Nutr Diet 2013; 26 39–44.
| Experience over 12 years with home enteral nutrition in a healthcare area of Spain.Crossref | GoogleScholarGoogle Scholar | 23651049PubMed |
[5] Hebuterne X, Bozzetti F, Moreno Villares JM, Pertkiewicz M, Shaffer J, Staun M, Thul P, Van Gossum A. Home enteral nutrition in adults: a European multicentre survey. Clin Nutr 2003; 22 261–6.
| Home enteral nutrition in adults: a European multicentre survey.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3s3ktlGntA%3D%3D&md5=59548b2b4aaa500b3e26d9d87e2e5351CAS | 12765665PubMed |
[6] Klein GL, Rogers JZ, Friedmann J, Jensen GL. A multidisciplinary approach to home enteral nutrition. Nutr Clin Pract 1998; 13 157–62.
| A multidisciplinary approach to home enteral nutrition.Crossref | GoogleScholarGoogle Scholar |
[7] Dietitians Association of Australia. Towards a national home enteral nutrition service for patients requiring nutrition support at home. Canberra: Dietitians Association of Australia; 2009.
[8] Ojo O. Home enteral nutrition NICE guidelines and nutrition support in primary care. Br J Community Nurs 2010; 15 116–20.
| Home enteral nutrition NICE guidelines and nutrition support in primary care.Crossref | GoogleScholarGoogle Scholar | 20220626PubMed |
[9] Stewart JAD, Mason DG, Smith N, Protopapa K, Mason M. A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition. London: National Confidential Enquiry into Patient Outcome and Death; 2010.
[10] Health NSW. NSW Peer Hospital Groups 2011/2012. Available at: http://www.health.nsw.gov.au/hospitals/peer_groups.asp [verified 1 November 2013].
[11] Greater Metropolitan Clinical Taskforce Home Enteral Nutrition Network. Home enteral nutrition report: nourishing lives at home. Sydney: GMCT; 2007.
[12] NSW Agency for Clinical Innovation. Home enteral nutrition meeting. Sydney: Concord Hospital; 2013.
[13] Smith T, Micklewright A, Hirst A, Stratton R, Baxter J. The British Association for Parenteral and Enteral Nutrition (BAPEN). Annual British Artificial Nutrition Support (BANS) Report; Artificial Nutrition Support in the UK 2000–2010. BAPEN UK; 2011.
[14] Health NSW Agency for Clinical Innovation (ACI). NSW home enteral nutrition service business case: collaborative project of NSW Agency for Clinical Innovation and EnableNSW. Sydney: ACI Home Enteral Nutrition Network; 2010.
[15] Government of Western Australia Department of Health. Home enteral nutrition model of care. Perth: Health Networks Branch; 2010.
[16] NSW Agency for Clinical Innovation (ACI). ACI Nutrition Network: NSW Model of Care for Home Enteral Nutrition, Draft. Sydney: ACI Home Enteral Nutrition Network; 2012.
[17] Van Gossum A. Home Enteral Nutrition Epidemiology and Legislation in Europe. Nestle Nutr Workshop Ser Clin Perform Programme 2005; 10 59–71.
| 1:STN:280:DC%2BD2M7osFSqsw%3D%3D&md5=bb023546ed182aa6955f4746401d28acCAS | 15818022PubMed |
[18] Moreno JM, Shaffer J, Staun M, Hebuterne X, Bozzetti F, Pertkiewicz M, Thul P, Van Gossum A. Survey on legislation and funding of home artificial nutrition in different European countries. Clin Nutr 2001; 20 117–23.
| Survey on legislation and funding of home artificial nutrition in different European countries.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3MzgvFClug%3D%3D&md5=c14205583daef5161ee549b270ff603cCAS | 11327738PubMed |
[19] Stratton RJ, Elia M, British Artificial Nutrition Survey (BANS) A cost-utility analysis in patients receiving enteral tube feeding at home and in nursing homes. BMJ 2006; 332 1266–8.
[20] Davis J, Marvi V. Trends in the use parenteral nutrition over 10 years: re-audit of referrals to the nutrition support team (NST). Proceedings of the Nutrition Society Conference; Malnutrition Matters, Joint BAPEN and Nutrition Society Meeting; 27–28 November 2007; The Royal Surrey Country Hospital, Guildford, UK.
[21] Dietitians Association of Australia. A national program to address equity of access for Australians requiring home enteral nutrition, pre-budget submission 2013–2014. Canberra: Dietitians Asssociation of Australia; 2012.
[22] Dietitians Association of Australia. Towards a National Home Enteral Nutrition Service for patients requiring nutrition support at home. Canberra: Dietitians Association of Australia; 2009.
[23] Schneider SM, Pouget I, Staccini P, Rampal P, Hebuterne X. Quality of life in long-term home enteral nutrition patients. Clin Nutr 2000; 19 23–8.
| Quality of life in long-term home enteral nutrition patients.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c7mslCjsg%3D%3D&md5=e5a31b8a585f9715778dd98a5102310aCAS | 10700530PubMed |
[24] Loeser C, von Herz U, Küchler T, Rzehak P, Müller MJ. Quality of life and nutritional state in patients on home enteral tube feeding. Nutrition 2003; 19 605–11.
| Quality of life and nutritional state in patients on home enteral tube feeding.Crossref | GoogleScholarGoogle Scholar | 12831946PubMed |
[25] National Institute for Health and Care Excellence (NICE). Oral nutrition support, enteral tube feeding and parenteral nutrition. NICE clinical guideline 32. London: NICE; 2006.
[26] Kovacevich D, Frederick A, Darlene K, Nishikawa R, Young L. Standards for Specialised Nutrition Support: Home Care Patients. Standards of Practice 2005; 20 579–90.
[27] American Society for Parenteral and Enteral Nutrition Board of Directors Clinical guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2012; 33 255–9.
[28] National Institute for Health and Care Excellence (NICE). Quality standard for nutrition support in adults. NICE quality standard 24. London: NICE; 2012.
[29] Green S. Home enteral nutrition: organisation of services. Art & Science 2013; 25 14–8.
[30] Braun E, Baidusi A, Alroy G, Azzam ZS. Telephone follow-up improves patients satisfaction following hospital discharge. Eur J Intern Med 2009; 20 221–5.
| Telephone follow-up improves patients satisfaction following hospital discharge.Crossref | GoogleScholarGoogle Scholar | 19327616PubMed |
[31] Kurien M, Simpson SWG, Grant J, Sanders DS, McAlindon ME. Managing patients with gastrostomy tubes in the community: can a dedicated enteral feed dietetic service reduce hospital readmissions? Eur J Clin Nutr 2012; 66 757–60.
| Managing patients with gastrostomy tubes in the community: can a dedicated enteral feed dietetic service reduce hospital readmissions?Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC38vjsl2qtg%3D%3D&md5=c497f93d114ce736b31e4214a452d405CAS | 22353924PubMed |
[32] Klek S, Szybinski P, Sierzega M, Szczepanek K, Sumlet M, Kupiec M. Commercial enteral formulas and nutrition support teams improve the outcome of home enteral tube feeding. JPEN J Parenter Enteral Nutr 2011; 35 380–5.
| Commercial enteral formulas and nutrition support teams improve the outcome of home enteral tube feeding.Crossref | GoogleScholarGoogle Scholar | 21527600PubMed |
[33] Scott F, Beech R, Smedley F, Timmis L, Stokes E, Jones P, Roffe C, Bowling TE. Prospective, randomized, controlled, single-blind trial of the costs and consequences of systematic nutrition team follow-up over 12 months after percutaneous endoscopic gastrostomy. Nutrition 2005; 21 1071–7.
| Prospective, randomized, controlled, single-blind trial of the costs and consequences of systematic nutrition team follow-up over 12 months after percutaneous endoscopic gastrostomy.Crossref | GoogleScholarGoogle Scholar | 16308129PubMed |
[34] NSW Government. NSWBUY Contract 955: Health Support Services State Contract Control Board. Sydney: Enteral Nutrition Support and Services; 2012.
[35] Francke AL, Smit MC, De Veer AJE, Mistiaen P. Factors influencing the implementation of clinical guidelines for health care professionals: A systematic meta-review. BMC Med Inform Decis Mak 2008 8: 38. Available at: http://www.biomedcentral.com/1472-6947/8/38.
[36] Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PAC, Rubin HR. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282 1458–67.
| Why don’t physicians follow clinical practice guidelines? A framework for improvement.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c%2FgsVSqtw%3D%3D&md5=faf428b7fbe6b15327d3b1e098044276CAS | 10535437PubMed |
