A Positive Approach to

Nutrition as Treatment

Report of a working party chaired byProfessor JE Lennard-Jones

onthe role of enteral and parenteral feeding

in hospital and at home

January 1992

Foreword

In the sophistication of late twentieth-century health care we sometimes miss theobvious. The importance of patients being well-nourished is an example. This workingparty report sets out in straightforward terms why nutrition is an issue in the NHStoday, the benefits to patients and to the NHS as a whole of ensuring patients are well-nourished, and the systems and procedures needed to ensure artificial nutrition is donewell. It covers artificial nutrition both in hospital and in the home, the latter becomingincreasingly important with the growth of home care.

I hope that the report will bring artificial nutrition to the attention of healthprofessionals as well as providing clear guidance on what needs to be done.

I am grateful to John Lennard-Jones, David Silk and Marinos Elia who suggested theneed for a Working Party in the first place, and to all the Working Party for putting somuch effort into making it a success.

The Working Party was itself a good model of multidisciplinary working and ofpartnership with patients.

Barbara StockingDirector,

King's Fund Centre

Contents

FOREWORD

SUMMARY 1

AIMS AND RECOMMENDATIONS 3

INTRODUCTION 5Malnutrition in our MidstThe Extent of Malnutrition in HospitalWhy Change is NeededWhat has Retarded Progress?Financial Provision

WHY DO PATIENTS BECOME MALNOURISHED? 7

THE EFFECTS OF STARVATION OR UNDER-NOURISHMENT 8When does Death Occur?The Effects of Starvation in Normal SubjectsHow does Malnutrition Complicate Illness?

HOW CAN MALNUTRITION BE DETECTED? 10Creating a New Thought PatternInitial AssessmentDevelopment of Malnutrition while under Observation

METHODS AVAILABLE FOR NUTRITIONAL SUPPORT 12From the Simple to the ComplexDefining the Aim, a Plan and a Method of MonitoringSpecially Formulated Liquid Enteral FeedsEnteral Tube FeedsParenteral Nutrition

BENEFITS OF NUTRITIONAL SUPPORT 14Consequences to the Patient of MalnutritionFinancial Cost of MalnutritionBenefits to the Patient of Extra NourishmentCost Saving of Nutritional Treatment

ARTIFICIAL NUTRITION IN HOSPITAL 17How Many Need Treatment?Current Lack of OrganisationThe Advantages of Special Knowledge and a Team ApproachProposed Organisation in HospitalBudgetary Control and Audit

ARTIFICIAL NUTRITION AT HOME 20Why and Who?When is Home Treatment Appropriate?TrainingHow Many Patients are Involved?Quality of Life AchievedA Patient's View of Home Parenteral NutritionPresent Organisation is Unstructured

Proposed Organisation for Home Enteral Tube FeedsProposed Organisation for Home Parenteral Nutrition

SPECIAL PROBLEMS OF BABIES AND CHILDREN 26Growth, Intellectual Development and High Energy NeedsImmaturity of Metabolic ProcessesPsychosocial Factors

ARTIFICIAL NUTRITION IN INTENSIVE CARE 27Frequent Need for Nutritional SupportSpecial ProblemsOrganisationFuture Needs

EDUCATION AND TRAINING 29DoctorsNursesDietitiansPharmacistsThe Public

RESEARCH 31Development and Extent of ResearchFundingCurrent Problems

THE WAY FORWARD 32Development of Clinical Nutrition as a DisciplineRecognition of Training as a DisciplineRationalisationThe Role of Industry

APPENDIX A 39Standards for Artificial Nutritional Support in Hospital

APPENDIX B 41Standards for Artificial Nutritional Support at Home

APPENDIX C 42Specimen Standards for a Purchasing AuthorityPlacing a Contract for Artificial Nutritional Support

APPENDIX D 43Artificial Nutrition in the Cambridge Health District During One Year

APPENDIX E 44Workload of Nutrition Team at Oldchurch Hospital Over Four Years

APPENDIX F 45Potential Cost Saving to a Hospital by a Nutrition Team from a Reductionin Catheter Infection Rate in Patients Receiving Parenteral Nutrition

APPENDIX G 46Potential National Saving from Nutritional Support of Under-nourishedPatients in Hospital

APPENDIX H 47Membership of the Working Party

Summary

Many people with severe illness are at risk froman often unrecognised complication —malnutrition. They starve either because they cannot eat orcannot absorb the nutrients from a normal diet.The resulting malnutrition seriously delaysrecovery from medical and surgical disorders, andat worst is life threatening. Doctors and nursesfrequently fail to recognise under-nourishmentbecause they are not trained to look for it.

Evidence in this report shows the clinicaland financial benefits which can resultfrom better diagnosis and treatment ofmalnutrition. It also explains why, despitethe existence of methods forsupplementing or replacing normal food to aidrecovery, arrangements for copingwith clinical malnutrition in the UK areunsatisfactory.

To some extent the problem arises becausethe patients affected are not a unifiedgroup all suffering from the same illnessor a disorder of one bodily system.Patients range from the very young to thevery old. They comprise temporary orpermanent sufferers from malnutritionlinked to illness involving any system.Some patients most obviously at risk havehad surgery for gut removal, but there aremany other disorders which hinderabsorption of nutrients such as bowelinflammations or cystic fibrosis. Poorappetite, difficulty in swallowing, orhandicaps such as arthritis, motor neuronedisease or multiple sclerosis, may limit aperson's capacity to prepare, swallow orenjoy meals.

Nutritional support depends on giving abalanced formulation of energy, protein,minerals and vitamins as a drink, as a tubefeed directly into the stomach or intestine,or as an infusion into a vein.

The recommendations for improved care inthis report concern the recognition ofmalnutrition at an early stage and theorganisation of nutritional treatment in themost cost effective manner. Theirsuccessful introduction depends on a newattitude to malnutrition by the caring

professions and a new approach to thedivision of responsibilities betweendoctors, nurses, dietitians, pharmacists andother staff. Each has a particularcontribution to make; a team approach isparamount.

Patients who are already malnourished areat a disadvantage if admitted for hospitaltreatment. Ideally, malnutrition should berecognised and treated before admission.However, this ideal is impossible toachieve because many patients are firstseen as an emergency. However, it isimportant for GPs and nurses in thecommunity to watch for signs of under-nourishment so that nutritionalsupplements can be given at homewhenever possible. At least 30,000patients are currently given temporarynutritional support after admission tohospital. One estimate of the potentialsavings to the NHS of improved recoveryrates and shorter stays through nutritionalsupport puts the figure at £266 million peryear.

Over 1,000 potential sufferers frommalnutrition are currently treated at homeafter discharge from hospital. Thesepatients free a hospital bed and enjoy thefreedom of home after careful training inhow to give themselves the nutritionalsupport needed. Their treatment involvesclose collaboration between carers inhospital and the community.

This report suggests that only a proportionof those who need nutritional support receive it.Published data show that asmany as half of certain patient groups aremalnourished on admission to hospital.During prolonged hospital staymalnutrition often becomes worse ordevelops for the first time. Only when theassessment of every patient's nutritionalstatus has become a routine will the fullbenefits of nutritional treatment berealised.

Aims and Recommendations

To improve the treatment of clinicalmalnutrition in hospital and at homethrough adoption of the followingrecommendations.

1. Education

Improve awareness and understanding bydoctors and nurses of under-nutrition andits consequences.

2. Nutritional Assessment

Growth and development are monitored inpaediatric practice. These records shouldbe continued if children or adolescents arecared for by other departments. Everyadult patient's height should be recordedonce in general practice and hospital.Patients should be weighed regularly sothat appropriate weight-for-height valuescan be assessed and changes of weightnoted. A note about each patient'snutritional status should be mandatory inmedical and nursing admission records.

3. Care Plan

Whenever malnutrition is detected, thecause should be established, a plan oftreatment made and its effects monitored.

4. Organisation in Hospital

(a) Every hospital should organise itsnutritional services to link management,catering and all the clinical disciplinesinvolved. Quality of nutritional support inacute medical (including the elderly) andsurgical wards should be the responsibilityof a nutrition team comprising seniorclinician, clinical nurse specialist, dietitianand pharmacist. Quality of nutritional sup-port in paediatric departments and intensive care units should be the responsibilityof one or more members of their staff.

(b) Records should be kept of the clinicalindication for each course of nutritionaltreatment, its type, duration and clinicaloutcome, including any complication(s).A budget should be allocated to nutritionsupport teams based on this audit of theirwork-load, outcomes and costs. Managersshould take account of the potential cost

of complications and increased hospitalstay due to malnutrition when assessingthe cost of nutritional support.

5. Organisation in the Community

(a) Enteral tube feeds at home should beprescribed by the general practitioner andthe present regulations should be amendedso that the necessary disposable equipment can also be prescribed in the community.The hospital nutrition team should offer the same service to the community health team as it does to ward staff in hospital. It will shareresponsibility for care by recommending aregimen, visiting the patient at home as necessary, givinginstruction to the patient and all carers onprocedures and possible complications, providing a telephoneenquiry service for all members of the communityteam and the patient, and giving hospital care asneeded either in a clinic or the ward.

(b) The care of' patients who givethemselves intravenous infusions at homeshould be limited to hospitals which havea well organised nutrition team withextensive experience of inpatientparenteral nutrition and which havesufficient staff and facilities to trainpatients, supervise their treatment at homeand provide a 24-hour advisory service.This complex, uncommon and expensivetreatment will necessarily be largelyinitiated and organised by the hospitalteam. However, as with enteral nutrition,care should as far as possible be sharedwith the general practitioner and thecommunity team.

Identification of the source of fundingshould not inhibit the prompt provision ofthis treatment at home when needed. Atpresent, financial arrangements vary indifferent places but there is likely to beincreased emphasis on funding in the community.

The general practitioner may be asked toprescribe the nutrients and arrange for thesupply of equipment. At present, theequipment is not available on prescriptionand we recommend that this situationshould be altered. Alternatively, a districthealth authority may purchase the treatment which will then be prescribed by the hospital clinician. The nutrients and equipment should

be delivered to thepatient's home either by the hospital or bya commercial delivery service.

6. National Organisation

(a) Clinical nutrition should be recognisedas a discipline by medical schools, royalcolleges and professional associations.

(b) An academic forum for nutritionshould be established in every medicalschool to foster education and research.Dietitians, nutritionists and nurses shouldbe involved in the teaching of medicalundergraduates and postgraduates.Questions on clinical nutrition should beasked in undergraduate and postgraduateexaminations.

(c) An organisation should be createdwhich draws together and represents thecommon interests of patients, academicnutritionists, dietitians, nurses, pharmacists, doctors and the pharmaceutical industry.his body should set standards for nutritional care,promote professional training and research, provide authoritative advice and foster publicawareness of nutritional treatment in illness.

Introduction

Malnutrition prolongs recovery fromillness and can lead to death from anunnecessary complication. Hospitaladmission of a malnourished patient costsmore than for one who is well-nourishedbecause length of stay is prolonged andcost per day is increased. Doctors andnurses often fail to recognise malnutritionbecause they are not trained to look for it.Methods now available for supplementingor replacing normal food speed recovery,reduce the risk of complication and lowercosts.

Malnutrition in our Midst

While starvation elsewhere in the worldhaunts us, healthy people in affluentcountries take food and drink for granted.

Yet in the West there are also those whoare weak and wasted through lack offood, not because they cannot afford orobtain it, but because they cannot or donot eat or absorb it. These babies, childrenand adults who starve in the midst ofplenty are the subject of this report.

The Extent of Malnutrition in Hospital

A recent survey of nutrition among amulti-racial group of children admitted tothe Children's Hospital, Birmingham (1),showed that stunting of growth affectedone in six and almost as many wereseverely wasted. A quarter of childrenwith chronic respiratory or cardiacdisorders, and even more with digestivedisorders were shorter than most childrenof their age. Similar surveys have shown asurprisingly high incidence ofmalnutrition among adults in surgicalwards in this country (2), Australia (3) andAmerica (4). Medical wards (5) and wardsfor the elderly (6) are not exempt. Manypatients become malnourished as aconsequence of illness and its treatment ifadmission to hospital is prolonged (2,6,7).

Why Change is Needed

It is 15 years since attention was firstdrawn to the high prevalence ofmalnutrition in hospital and yet theproblem remains.

The methods exist for effective treatmentbut are often not used, or usedinappropriately or badly.

The situation is illustrated by a NationalSurvey in 1988 which has shown greatdiversity of nutritional support practices indifferent health districts (8). Only about aquarter of hospitals had a multi-disciplinary team or group to advise onclinical practice. Among patientsreceiving least nutritional support werethose in orthopaedic wards even thoughpatients with fractured neck of femur havebeen shown by controlled trial to benefitgreatly by supplementary feeding, asjudged by rate of mobilisation andreduction in hospital stay (9,10).

An average of one in eight patients treatedon general wards by intravenous nutritiondeveloped a catheter infection and themaximum incidence was recorded as ninepatients out of ten. Such infections aredangerous, and can be fatal; they aredifficult and expensive to treat. Manysurveys have shown that the incidence canbe reduced to about 3 per cent by stafftraining, preferably by a specialist nursingsister, and by the creation of a nutritionteam (Appendix F). There is an increasingtrend to provide nutritional support forpatients in the community and a report( 11 ) has shown defects in the organisationof the treatment, and problems with the supply ofnutrients and equipment.

What has Retarded Progress?

A principal reason for lack of progress hasbeen slow acquisition and application ofknowledge.

Clinical nutrition was not taught to thepresent generation of doctors and it is stilla cinderella subject in undergraduatemedical schools ( 12,13). Teaching haslagged behind nutritional research whichhas forged ahead, so increasing the gapbetween knowledge and practice.

Two surveys, one in Scotland (14) and theother in England (15), showed that seniormedical students were only able to answercorrectly half of a number of factualquestions on nutrition topics. Juniordoctors were not much better. In bothsurveys the majority of doctors rated their

own knowledge as poor and felt that moreshould be taught about the practicalapplication of nutritional support.Slow progress has also been due todiffusion of responsibility and lack of co-ordination between the disciplinesinvolved in the recognition and treatmentof malnutrition.

Financial Provision

At present the financial provision fornutritional support is unstructured.Inappropriate or badly organised treatmentleads to waste of nutrients and furtherincreased cost due to expensivecomplications of treatment. Conversely,failure to give treatment when it would bebeneficial leads to increased costs due toincreased length of stay in hospital andgreater costs per day.

We seek to convince purchasers thatnutritional support is an essential need forsome patients and that it is well worth thecost provided that its indications, aims andresults are defined and documented. Wealso aim to show that by better trainingand organisation the money spent will bebest used. Budgets need to be identifiedfor provision of the nutrients andequipment in hospital and provision madefor both to be available on prescription inthe community.

Malnutrition results when a patient's nutrient intake falls short of metabolic requirements. Intake may be reduced because a patient will not, or cannot, eat orbecause food is poorly absorbed.Metabolic requirements in health dependon physical activity and growth.

During illness, tissue damage activatesmechanisms which increase energy needsand lead to further breakdown of tissue.

Social circumstances or handicaps such asarthritis, motor neurone disease ormultiple sclerosis may limit a person'sability to prepare or eat meals. Poverty ora chaotic home may limit meals. Foodmay be unpalatable for a person with lossof taste or poor appetite, or unsuitable fora patient with a painful mouth or difficultyin chewing or swallowing.

Chronic pain, depression or apathy all leadto loss of interest in food. Many patients

are already malnourished when they areadmitted to hospital because of thesefactors and other effects of their illness. Inhospital, food intake is often insufficientbecause meals are missed due to multipleprocedures requiring temporary starvation,or because meals are served in a waywhich takes no account of a physicalhandicap or feeding difficulty.

Lack of nursing supervision at meal timescan mean that a patient's poor intake isunnoticed and corrective action is nottaken. 'Healthy eating' guidelines shouldbe applied with caution when patients are ill.

Specific causes of poor intake includecoma, an inability to swallow, repeatedvomiting and any condition which leads topain, diarrhoea or other symptoms oneating. Reduced absorption of food followssurgical procedures in which a major proportionof the small intestine is removed and may also bea consequence of disorders of the intestinalmuscle or mucosa.

The Effects of Starvation or Under-nourishment

When does Death Occur?

Starvation in a previously healthy personleads to death in about two months. Theeffects of such uncomplicated starvationare seen in prisoners who starvethemselves to death. Whereas a normaladult may survive for about 60 dayswithout food, pre-term infants weighingI kg and 2kg can survive for only 4 and 12days respectively; a normal full-term babyfor about 30 days and a one year old childfor about 40 days ( 16). The effects ofstarvation depend on a person's age andprevious state of nutrition. Clearly~ if aperson who is already malnourished stopseating, death will follow in a shorterperiod.

When a person starves after severetrauma, major surgery and/or duringinfection, weight loss is accelerated andsurvival without food for a previouslyhealthy adult may be reduced to about amonth.

In adults, an acute weight loss of morethan one-third of the original bodyweightis often associated with impending death.In premature babies, with little reserve,survival without food is reduced to a fewdays, and in small children to a period oftwo to three weeks if there is at the sametime infection or injury.

The Effects of Malnutrition inNormal Subjects

A classic experimental study of semi-starvation in healthy adults reduced bodyweight by one quarter. Besides obviousloss of body tissue and muscle strength,the subjects became depressed, anxious,irritable, apathetic, introverted and lostmental concentration (17). Similar observations have been made in prisoncamps and during famine ( 18). In children,under-feeding adversely impairs growth,intellectual development, mother-childinteraction, and emotional and socialbehaviour ( 18).

Recent research has highlighted howseverely muscle function is impaired byunder-nourishment( 19). If a normalsubject limits daily food intake to 400KCal there is demonstrable impairment ofmuscle function with increasedfatiguability in as short a time as twoweeks. The normal respiratory drivecaused by lack of oxygen is reduced (20)and cardiac function is decreased (21). Allthese effects can be rapidly reversed by re-feeding. Low body weight impairs bodyheat protection leading to risk of low bodytemperature in winter, particularly in theelderly. This may be a risk factor forincapacity, falls and injury (22).

How does MalnutritionComplicate Illness?

The mental changes seen in normalsubjects after semi-starvation are of greatclinical importance in the sick patient.Apathy and depression lead to loss ofmorale and loss of will for recovery.Inability to concentrate means that thepatient cannot benefit from instructionabout techniques needed for self-care. Ageneral sense of weakness and illnessimpair appetite and the ability to eat.

Loss of power precedes loss of muscletissue and return of power is more rapidthan replacement of tissue ( 19,23).Weakness affects the respiratory muscles(24) so that it is difficult for a patient tocough and expectorate effectively with aconsequent liability to chest infection (25); thisweakness and loss of sensitivityto oxygen lack may also make it difficultto wean a malnourished patient from aventilator (26). Cardiac muscle function isimpaired with reduced cardiac output anda liability to failure (27). Mobility isreduced delaying recovery (9) and pre-disposing to thrombo-embolism andbedsores (28).

The malnourished patient developsimpaired immune resistance to infection,which in turn worsens the nutritionalstatus (29). Deprivation of nutrients leadsto altered structure and function of the gutwith increased liability to entry and spreadof intestinal bacteria within the body (30).

Starvation is thus an insidious factorwhich prolongs recovery, increases theneed for high dependency nursing careand sometimes intensive care, increasesthe risk of serious complications of illness,and at its worst leads to death either froman unnecessary complication or frominanition. In economic terms, the hospitaladmission of a malnourished patient costsmore than one whose nutrition ismaintained.

How can malnutrition be detected?

Creating a New Thought Pattern

Malnutrition is often unrecognised.Doctors and nurses are not used to lookingfor it. They need to develop a habit ofinstinctively noting under-nourishmentand a sensitivity to situations in which itmight occur. In paediatric practice, growthand development are kept constantlyunder review. Once a person is full-grown,a single measurement of height sufficesand should be recorded in generalpractitioner and hospital notes. Adultsshould be weighed regularly so thatappropriateness of weight for height canbe assessed and changes of weight noted.

Every ward and clinic should haveaccurate weighing scales and a device formeasuring height.

Initial Assessment

A note about each patient's nutritionalstatus should be mandatory in medical and nursing admission records.

A careful study has shown that a simpleclinical assessment of nutritional statusgives results comparable with the mostsophisticated measurements (31). Theassessment should take account not onlyof weight loss but also muscle power andmental state (32).

Questions to be asked are:

• Has recent food intake been normal inamount?

• Have particular foods been avoided?

• Have there been unusual losses fromthe body such as chronic diarrhoea orvomiting?

• Has the patient noticed weight loss,(eg. fit of clothes) and over whatperiod?

• What does he/she regard as theirnormal weight'?

• Do parents think that a baby or youngperson has been growing normally

(records may be available from healthvisitor or clinic)?

• Has the patient had to reduce activitydue to weakness or early fatigue'?

Physical examination should consider:

• Is muscle bulk normal (confirmed bypalpation)?

• Is the amount of sub-cutaneous fatnormal (confirmed by feeling thethickness of folds of skin)'?

• Is there evidence of dehydration; or,conversely, of oedema'?

• Is the patient's muscle power ofexpected strength, eg. grip and abilityto cough vigorously'?

• Is the patient alert or depressed,apathetic and inactive'?

The most important measurements arebody weight and height.

Is weight within the range to be expectedfor a person's height? More use should bemade of the body mass index, which givesa normal range of 19 to 25 when applyingthe formula:

weight in kilograms(height in metres)2

Plotting weight and height of babies andyoung people on standard charts comparesthe actual values with those expected inthe general population.

Development of MalnutritionWhile Under Observation

A patient's nutritional state can slideimperceptibly downwards during illness.Awareness of this possibility is the key torecognition.

Whenever a patient can stand or sit,repeated measurements of body weightshould be made if illness is prolonged.Beware when patients undergo multipleinvestigations or recover slowly fromoperation.

At particular risk is the obese patient whodoes not eat and loses muscle bulk but stillappears fat and overweight.

In appropriate cases, food intake should berecorded and a dietary assessment madefor comparison with estimated normalrequirements .

Methods Available for NutritionalSupport

From the Simple to the Complex

The simplest way of promoting nutritionis to get a patient to eat more. This maymean frequent small meals, or temptingthe patient with appetising dishes offavourite foods, or encouraging nutritiousmeals rather than the patient's usualchoice of low calorie items. Centralisedhospital catering, working on a tightbudget, naturally finds difficulty inproviding frequent snacks orindividualised meals. The disappearanceof the ward kitchen limits the preparationof snacks between meals or thereplacement of meals not taken because ofinvestigation or procedures. The servingof meals in an appetising manner nolonger appears to have high priority in award; it is regarded as a chore, a provisionof the hospital 'hotel services', rather thanas an essential part of treatment for manypatients .

To facilitate the provision of frequentsmall appetising snacks between meals, arange of liquid or semi-solid preparations,conveniently prepared in sterile portions,and with flavours varying from sweet tosavoury is available. These enteralsupplements are a most valuable additionto the hospital diet for selected patientswhose food intake does not maintainnutrition or who require extra nourishmentto replace lost tissue. However, care isneeded that they do not decrease appetitefor food. Such snacks, organised by thedietetic department, should be readilyavailable when needed. Organisation isneeded to make sure that they aredelivered to the patient frequently withencouragement to take them.

Only if these simple measures fail or areinappropriate do the techniques ofartificial nutritional support becomenecessary. These methods range fromprovision of special liquid diets, which aredrunk, to the administration of speciallyformulated liquid nutrients through a tubedirectly into the gut (enteral tubefeeding), to the introduction of nutrientsdirectly into a vein, so by-passing the

intestine (parenteral feeding).

Defining the Aim, a Plan, and aMethod of Monitoring

The aim of providing nutritional supportfor each patient should be clearly stated. Itmay be to maintain current nutritionalstatus or restore lost tissue while a patientcannot eat or cannot eat enough. It may beto provide nutrients of a particularcomposition, or to reduce the amount ortype of food entering the gut because of afistula between the intestine and the skin,acute pancreatitis, or other reason. A planshould be made jointly by the medical,nursing and dietetic staff to achieve theaim which should be reviewed regularlyand modified as necessary. Progressshould be monitored by appropriateclinical observation and measurements.Changes of technique may be needed ascircumstances alter. Treatment should becontinued until the aim is achieved orartificial nutrition i.s no longer appropriate.

Specially Formulated LiquidEnteral Feeds

Certain patients—for example, withpartial oesophageal obstruction—cantake liquids only in small quantities at atime. A sip feed with a balancedcomposition similar to a normal diet, canbe given with an energy level appropriateto the patient's need in a volume whichthe patient can drink. A liquid feed composed ofamino acids or small peptides, glucose oroligosaccharides, and little fat, reduces theintestinal inflammation in some patients withCrohn's disease. Special liquid feeds areavailable for use in renal failure or othermetabolic disorders.

Enteral Tube Feeds

A liquid feed introduced directly through anarrow, flexible tube into the stomach orintestine can be given if oral intake isinadequate. In this event, a tube feedoffers the following advantages:

• it is comfortable and readily acceptedby patients;

• o it can be given independent ofappetite or difficulty in swallowing;

• it requires no muscular effort on thepart of the patient;

• the feed can be given slowly andcontinuously by day or night, orthroughout 24 hours;

• administration of the feed is simpleand can be undertaken withoutdifficulty by a patient or attendant athome;

• the feed and associated equipment arerelatively inexpensive.

Nasogastric enteral tube feeding isrelatively free of complications providedthat the stomach empties normally.Incorrect placement of the tube, severegastroesophageal reflux or delayedpassage of the food onward into theintestine can lead to feed entering thelungs. Damage to the pharynx oroesophagus rarely occurs during passageof a tube or as a consequence of acidreflux.

Diarrhoea can complicate feeding,particularly if large boluses are givenrather than a slow continuous infusion; theoccurrence of diarrhoea is morecommonly due to the coincidental use ofantibiotics than to the feed (33). Infections canoccur from an infected tube orcontaminated feed (34,35). When acatheter is passed through the abdominalwall into the stomach or jejunum, complicationscan occur be associated with introduction of thecatheter, such asperitonitis, bleeding, intestinal ileus, andlocal infection.

Parenteral Nutrition

Infusion of nutrients into a vein shouldonly be undertaken when it is impossibleto maintain nutrition using the intestine.When the indications are correct,parenteral nutrition is an extremelyvaluable technique which can be life-saving. It should be regarded as a potenttreatment only to be undertaken by thoseexperienced in its use.

Nutrients can be infused into a peripheralor central vein. The former is less liable tocomplication but use of a central vein isnecessary for long-term treatment.

One of the greatest hazards of parenteralfeeding is infection of the line or, rarely,the feed giving rise to septicaemia.Thrombophlebitis with venous occlusioncan occur and is a serious complicationwhen the subclavian vein or superior venacava is involved (36). Damage to the largevessels and nerves at the root of the neck,or a pneumothorax, may complicateintroduction of a central venous cannula.Perforation of a large vein, or even theright atrium, occasionally allows escape ofnutritional solution into the pleural orpericardial cavities. Metaboliccomplications include either an excess or adeficit of specific nutrients—forinstance, high blood glucose levels withglycosuria or selenium deficiency in thelong-term with cardiomyopathy.

Benefits of Nutritional Support

Consequences to the Patient ofMalnutrition

Many studies have shown that a patientwho is malnourished when admitted tohospital tends to have a longer hospitalstay, experiences more complications andhas a greater risk of dying than a personwith the same illness whose nutritionalstate is normal. This effect of malnutritionhas been shown among medical(37,38,39), surgical (32,37,40,41) andorthopaedic (9,42) patients, and among theelderly (6,43).

Financial Cost of Malnutrition

The introduction of diagnosis relatedgroups (DRGs) in the United States withincreased payment for co-morbidity,including malnutrition, has led to analysesof the effects of malnutrition on costs oftreatment. In a prospective study of 100admissions to a general medical unit, 40patients were regarded as malnourished bymultiple criteria. The average length ofhospital stay among these patients was 15days as compared with about 10 days inthe remainder and the hospital chargeswere more than double (44). Aretrospective review of 771 patients inthree specified medical and three surgicalcategories found a likelihood ofmalnutrition among just over half thepatients. There was a two-fold increase inminor and a three-fold increase in majorcomplications, associated with an almostfour-fold increase in mortality amongthese patients, which led to an average 50per cent increase in direct variable costdue to increased length of hospital stayand greater cost-per-day. The admission ofa malnourished patient who experienced amajor complication cost four times that ofa normal patient with an uncomplicatedcourse (37).

Benefits to the Patient of ExtraNourishment

No clinician is in doubt that nutritionalsupport often permits survival in acutedisease and allows time for definitivetreatments to take effect or for anoperation to be undertaken as an elective

procedure in a patient whose generalcondition is improved. Mortality from avariety of conditions such as severe sepsis,large area burns, entero-cutaneous fistulaeand severe inflammatory bowel diseasehas decreased over the last two decades,and improved nutritional support is one ofthe factors likely to have contributed tothe improved outcome.

Two controlled trials have shown thebenefit of routine enteral supplements inpatients with fractured neck of femur andanother trial has shown the effect of anutritional supplement in care of theelderly.

In one study of fractured neck of femur(9), three groups of patients weredistinguished, those who were wellnourished on admission, and those whowere thin or very thin. The well nourishedpatients achieved independent mobility ata median time of 10 days after operationand the mortality was about S per cent.The median time to independent mobilityin the very thin patients without a dietarysupplement was 23 days and the mortalitywas 22 per cent. The patients withevidence of malnutrition were randomisedinto two groups: one received anasogastric enteral feed ( 1000 KCal, 28Gof protein) over night in addition to theward diet; the other group took the warddiet only. There was a significant decreasein the time to independent mobility amongthe patients receiving the supplementcompared with the control group. Amongthe very thin patients the medianmobilisation time among the former was16 days and 23 among the latter. A similarstudy (10) used a smaller dietarysupplement (254 KCal, 20G of protein)which was drunk in two portions betweenmeals. The voluntary intake of food wasonly l lOOKCal and this supplementincreased dietary intake of energy by 23per cent and of protein by 62 per cent. Thetotal length of hospital stay wassignificantly shorter among supplementedpatients, with a median of 24 days ascompared with 40 days in the group takingdiet alone. At six months the mortality(24 per cent vs 37 per cent) and theincidence of complications (16 per cent vs37 per cent ) were significantly lower inthe supplemented group.

In a randomised study (6) among 501elderly patients, half received a dietarysupplement of 400 KCal in addition to thehospital diet. The nutritional state of allpatients tended to deteriorate afteradmission but this was less among thesupplemented patients. The mortality inthis group over six months wassignificantly lower (8.6 per cent) thanamong the group taking diet alone (18.6per cent).

More trials are needed in similar situationswhere the patient population ishomogeneous, the injury or illness is welldefined and of uniform severity, andartificial nutritional support can be givenor withheld without ethical difficulty, andwithout many other confoundingvariables. The difficulties involved intesting the effects of nutritional support onclinical outcome are evident in those trialsundertaken to assess its effect on theoutcome of surgery.

Several randomised trials have beenperformed to show whether nutritionalsupport before and after operationdecreases mortality or the frequency ofcomplications. The largest trial conductedin 11 hospitals among 395 patients, allwith some evidence of malnutrition, whounderwent abdominal or thoracic non-vascular surgery, failed to show overallbenefit from parenteral nutrition given forseven to 15 days before operation and atleast three days afterwards. The trialconfirmed previous findings that mortalityand complications tended to be greater -among the most severely malnourishedpatients and suggested that in thesepatients the incidence of non-infectiouscomplications was less among those givennutritional support (45). In six other smalltrials, one has shown a reduction incomplications and mortality (46), one hasshown a reduction in wound infections(47), the others have not shown an effecton outcome (48, 49, 50, 51). Two studies,one of parenteral nutrition and other of anasojejunal tube feed, have shownreductions in mean post-operative stay ofseven and five days respectively in thegroups given extra nutrition (52, 53).Trials of post-operative jejunostomy tubefeeds have failed to show benefit but theresults are confused by complications ofthe procedure (54).

Much has now been learned from thisexperience about the design of such trials.First, it is important to treat an adequatenumber of patients who are seriouslymalnourished rather than an unselectedgroup of all patients. Second, nutritionalsupport should be given for long enoughto have an effect, and in a manner whichminimises complications of the treatment.Third, if possible the treatment should begiven for an adequate time before, as wellas after, surgery.

If patients are identified as malnourishedbefore elective surgery, a good case can bemade for conducting a trial of simpledietary supplementation during thewaiting period so that the patient'smalnutrition is partially or whollycorrected by the time of the operation.

Until more evidence is available, areasonable case can be made for givingnutritional support to a patient who haslost more then 10 per cent of body weightin the three months before operation andwho is unable or unlikely to resume anadequate oral intake without a week ofoperation, and to every patient who isunable to resume an adequate oral intakewithin 10 days of operation.

Cost Saving of NutritionalTreatment

The evidence for cost saving of nutritionaltreatment is based on the controlled trialsdescribed which have demonstrated areduced complication-rate and decreasedhospital stay among surgical andorthopaedic patients. Two analyses of thecost-effectiveness of nutritional support(55,56) have emphasised the importanceof a reduction in complication rate, andthus length of stay and costs per day, as amajor economic benefit. Appendix Gshows an estimate based on a 5-dayreduction in hospital stay for 10 per centof hospital inpatients which illustrates themagnitude of the financial savingpossible. In this example, £266 millionwould be saved annually in Britain, takinginto account the cost of nutrients andincreased nursing time for theiradministration.

Artificial Nutrition in Hospital

How Many Need Treatment?

About I in 50 hospitalised patients inBritain receives artificial nutritionalsupport; the proportion of seriously illpatients receiving it is considerablyhigher. An enteral tube feed appears to begenerally used about three times morecommonly than parenteral nutrition. It isnot known how many patients wouldbenefit from nutritional support but do notreceive it.

The results of a complete survey ofartificial nutrition in one health district(11), which includes hospitals providing afull range of district services and ateaching hospital which also acts as areferral centre for neurosurgery, otherregional services and transplantation, witha population of 340,000, is shown inAppendix D. In total, 811 patients werefed artificially in hospital over 15,549patient days. At any one time 2.8 per centof the inpatient population receivednutritional support, though the proportionwas less than 2 per cent of alladmissions. Enteral tube feeding wasgiven to 570 (11,624 patient days) andparenteral nutrition to 311 patients (3,925patient days); almost 45 per cent of thepatients were in the neonatal period.Excluding neonates, both types of feedingwere given for a wide range of disorders:neurological conditions, malignancy andgastro-intestinal disorders accounted forthe highest proportion of enteral feeds;gastrointestinal tract disorders (includingmalignancy) for the highest proportion ofparenteral feeds.

Figures for the work-load of a nutritionteam in a district general hospital overfour years are shown in Appendix E. Thegreatest number of patients were givensupplements to their diet, but the use ofenteral tube feeds tended to increase overfour years until the number was almost asmany. Enteral tube feeds were given toeight times as many patients as thosegiven parenteral feeding.

A survey among dietitians, only about halfof whom could supply figures, reported13,465 patients who received an enteraltube feed and 5,235 patients who received

parenteral nutrition in hospital during ayear(8). It seems likely that the totalnumbers are at least double these figures.

The prevalence of artificial nutrition, andthe ratio of enteral to parenteral nutrition,vary considerably from ward to ward andfrom hospital to hospital. For example,nutritional support is practiced morecommonly in surgical, medical andintensive care wards than obstetric andorthopaedic wards; also more often inteaching than in non-teaching hospitals.

Current Lack of Organisation

Nutritional care of patients in hospitalsuffers from division of responsibility.

Catering managers do their best on arelatively small budget (£11.00 to 14.50per patient weekly) but tend to have littledirect liaison with the dietetic department.

Doctors tend to regard malnutrition as anursing problem; nurses tend to referresponsibility for malnourishment to adietitian. In many hospitals there is nomember of either the senior medical ornursing staff with a special interest inclinical nutrition.

Dietitians often tend to work in relativeisolation rather than as personal membersof a team.

The pharmacy is increasingly involved inthe preparation and supply of parenteralnutrition solutions, and sometimessupplies enteral feeds.

Medical equipment or suppliesdepartments provide plastic disposables,such as giving sets, and are responsible forthe supply, testing and maintenance ofelectrical pumps.

There is often little contact between thoseresponsible for acute adult medical andsurgical wards, paediatric departmentsand intensive care units.

The financial provision for nutritional carealso tends to be fragmented.

The nutrient solutions and equipment aresupplied by different departments andcharged to various budgets. The cost of

nutritional care is not at present clearlyidentified and in most hospitals there is noaudit of its use.

The Advantages of SpecialKnowledge and a Team Approach

The aim of treatment for any patient mustbe to provide the simplest, safest, cheapestmethod of nutritional support whichachieves the desired goal.

Advice on the most appropriate treatmentcan be given by a doctor with specialexperience in nutrition, a clinical nursespecialist or a dietitian. Each has a particularcontribution. The doctor is trained toassess the clinical situation, with particularreference to the likely course of theillness, and to understand any metabolicdisorder which may be present. The nurseunderstands the particular problems ofday-to-day care in the ward, and thepatient's reaction to the illness. The dietitian isinterested particularly in dietaryquantity and composition and the range ofnutrient support which can be provided.

A team of different disciplines with goodcommunication enables nutritional supportto be given in the best manner for eachpatient. Such a team improves the qualityof treatment and reduces costs by:

avoiding unnecessary treatments andsimplifying the treatments used(57,58,59,60); reducing complications(61-68 and Appendix F);

monitoring use of nutrients and outcomeof treatment (60,68,69,70);

reducing waste (for example, solutionsprepared but not given or only partiallyused) (58);

standardising nutrients and equipment toenable bulk purchase and negotiation ofcompetitive rates (57,59,60,68).

Appendix F shows that the cost-saving toan average hospital from a reduction incatheter-related infection afterintroduction of a nutrition team is likely tobe of the order £26 - 80,000 each year. Asaving of £80,000 per annum was alsocalculated after action by a clinicalnutrition team to reduce the catheter

infection rate at a children's hospital (68).

Proposed Organisation in Hospital

A flexible organisation needs to be createdwhich optimises nutritional care in eachdepartment, monitors outcome and the useof resources, and has the confidence ofmanagement. A nutritional steering groupcan be linked to a therapeutics andsupplies committee.

A team approach should be built up inadult and paediatric wards, and intensivecare. In some hospitals, one team mightserve all these departments, in others ateam will evolve in each department. Suchteams may act in an advisory capacity totheir colleagues, but even so tend to haveauthority because they control the suppliesof nutrients and equipment. There isevidence that a team which controls andsupervises enteral tube and parenteralfeeds leads to better quality of care than ateam which advises only (70,71).

A typical team consists of four memberswith overlapping responsibilities, asfollows:

Dietitian —To assess nutritional statusand intake of patients who are referredbecause of malnourishment. To calculatenutritional requirements and designenteral, and sometimes parenteral, feedswith knowledge of the products available.To work with other members in thesupervision of enteral, and sometimesparenteral, nutrition and in the training ofstaff, patients and carers.

Nurse —To prepare, teach and superviseprotocols for the care of intravenous linesand other aspects of enteral and parenteralnutrition. To place fine bore nasogastrictubes and assist with the placement ofgastrostomy and intravenous lines. To actjointly with the clinician and dietitian inthe practical aspects of artificial nutritionin the wards. To train and prepare patientswho will continue the treatment at home;to liaise with relatives and the community teacare team who will help the patient afterdischarge.

Clinician —To liaise with the patient'smedical or surgical team. To beresponsible for arranging the placement of

gastrostomy or intravenous cathetersunder sterile conditions by experiencedpersonnel. To prescribe parenteral nutritionsolutions. To accept overall responsibilityfor the nutritional aspects of care forpatients referred to the team and to auditthe outcome.

Pharmacist —To be responsible forproviding enteral feeds and sterileparenteral nutrition solutions, to optimisetheir composition based on knowledge ofthe products available, to advise on thecompatibility of mixtures of nutrients andon any reactions with drugs.

Each team needs to have close liaison witha member of the departments of chemicalpathology and microbiology for advice onthe prevention and management ofmetabolic and infective complications.The primary members of the team maydelegate day-to-day duties to colleagues asnecessary while maintaining their ownareas of responsibility. The team(s) willmeet regularly and frequently, and willreview together the management ofpatients with difficult problems. Themembers will maintain a continuous auditof the efficacy, complications and cost ofartificial nutrition in the hospital.

The team will be responsible for theeducation of medical and nursing staff intheir departments in the principles and thedetails of nutritional support and for thepreparation of protocols, guidelines andstandards.

Budgetary Control and Audit

There are many advantages to be gainedby allocating a budget to each nutritionteam which will:

• provide a focus on artificial nutrition;

• reduce unnecessary cost;

• encourage regular monitoring and soensure that protocols lead to the mostcost efficient use of resources.

This regular audit should be discussedwith management and form the basis ofbudgetary allocation.

Artificial Nutrition at Home

Why and Who?

Artificial nutritional support usuallybegins in hospital and for some patientscontinues at home. Return home allowsthe patient to escape from an institution toindependence, a familiar environment,increased activity, and more normalrelationships. Domiciliary treatment freesa hospital bed which would oftenotherwise be occupied for many weeks ormonths. Some children are at present keptin hospital for long periods solely becausetheir nutritional treatment is difficult toorganise at home. This situation isunacceptable and very different from thatfound in America.

A national register of patients receivingenteral nutrition at home (72), and asurvey of all patients in one health district(Appendix D) has shown that theindications are very varied and includeneurological conditions which interferewith swallowing, cardiac or respiratorydisorders which impair food intake,patients with intestinal failure and a fewwith slowly progressive malignancies(11). Among children, indications includechronic renal failure, cardiac disease,chronic liver disease, malignancy, Crohn'sdisease, fibrocystic disease and otherreasons for failure to thrive due to aninadequate intake (73).

Parenteral nutrition is required only forintestinal failure. A short gut occurs aftermajor resection(s) of small intestine forCrohn's disease, irradiation enteritis, orvascular occlusion, including volvulus inyoung people. A diseased gut includesdisorders of the mucosa, muscle or entericplexus.

When is Home TreatmentAppropriate?

Treatment at home is limited by a patient'sor carer's manual dexterity and ability tounderstand the technique, its potentialcomplications and what to do if things gowrong. The aim of home treatment is toachieve the greatest possible rehabilitationor to maintain nutrition despite a disabilityor during treatment such as chemotherapy.These treatments are not therefore given to

patients whose underlying illness is likelyto progress rapidly with deterioratingquality of life unless they relievesymptoms as in carcinoma of theoesophagus. For this reason, patients withsuch conditions as widespread progressiveneoplasia, advanced systemic sclerosis, orelderly patients with generalised vasculardisease, are not often regarded as suitablefor home tube feeds or parenteralnutrition.

Training

Training begins in hospital and mustsometimes wait until the patient isphysically and mentally well enough tolearn and understand the procedures (74).Staff have to remember that the equipmentused, and concepts such as maintenance ofsterility, are strange to a lay person.Teaching has to be gradual, repetitive andprogressive. It may therefore take two tofour weeks for a patient or carer with noprevious experience to learn the technique.Children need psychological preparationas play therapy including a specialcolouring book, or for the older childexplanation and meeting other childrenwho are receiving the treatment (73,75).Explanatory leaflets and audio-visual aidsshould be available.How Many Patients are Involved?

A national register of patients receivinghome enteral tube feeds has provided datafor 144 of 218 health districts (72). Bythe end of 1990, 1274 patients had beenregistered, one-third of whom werechildren and two-thirds adults. The meanlength of feeding was 188 days forchildren and 156 days for adults. Thenumber of patients starting treatmentduring 1990 was 698, including 258children and 440 adults. A survey in onehealth district over a period of two yearsshowed that 33 patients received anenteral tube feed at home (76).

During one year patients treated at homecontributed about one third of the totalpatient days of treatment for bothinpatients and outpatients in two series(Appendix D and E). These figuressuggest that over 1,000 patients arereceiving home enteral tube feeding inEngland and Wales and this figure islikely to increase. Although the total

numbers are small relative to hospitaltreatment, the financial consequences arelarge because of the long duration oftreatment for each patient.

A national register of patients receivingparenteral feeding at home has beenmaintained since the treatment wasintroduced (77). Between 1977 and 1986,200 patients were discharged home andthe number of new patients starting eachyear plateaued in later years to about 40each year. About half of these patients areable to stop treatment and the numberreceiving treatment over the country isestimated as 100 to 150 at any one time.The proportion of children treated in thiscountry is smaller than in America andsome other countries. It seems likely thatthe number of children treated willincrease (75).

Quality of Life Achieved

Many adults who receive enteral tubefeeds at home are in older age groups andhave severe illnesses, often withdifficulties in swallowing, which limitphysical capacity, and length of life.Overall about one-fifth undertake fullactivity, three-quarters are restricted tosome degree, for example some areconfined to a wheel chair, and theremainder (6 per cent) are confined to bedand even semi-conscious (72). Themortality is high and at least one in four ofthese patients dies each year (72,76).

In contrast, 40 per cent of children treatedwith an enteral tube feed at home lead anormal active life and the mortality is low,though again a few (5 per cent) are bed-fast or semi-conscious. A survey has beenconducted among parents of 70 childrenwith experience of home enteral nutritionover a total of about 11,000 patient days(73). Many said that their child appearedmore happy and active than before, andthey experienced a sense of freedombecause they no longer had to devote timetrying to get their child to eat. Sleepdisturbance both for children and parentsis a problem and most parents get upduring the night to check on their childand the accuracy of the pump. Olderchildren tend to be self-conscious about anasogastric tube when leaving the houseand may overcome this difficulty by

learning to pass the tube themselves eachnight and take it up in the morning, or byaccepting a gastrostomy.

Those patients who infuse nutrients into avein mostly do so overnight and close offthe venous cannula by day; most of themcan eat small meals during the day tomaintain social life and contribute to theirnutrition. If they eat larger quantitiesdiarrhoea, or an excessive output from anabdominal stoma, becomes a socialproblem (74). Almost half the patients (43per cent) are at work full time or able tolook after a home and family unaided(77,78). Only a small proportion (7 percent) are housebound and need majorassistance with their parenteral nutrition;the remainder are able to work part time orunable to work but able to cope with theirparenteral nutrition unaided.

A Patient's View of HomeParenteral Nutrition

Support should include the psychologicalaspects of the treatment as well as thepractical issues. Until the patient acceptsthe treatment it is very difficult for him orher to deal with the practical issues, and tocope with the magnitude of change toeveryday life. Consideration should begiven to training in counselling skills forall nutrition nurses and to the involvementof medical social workers. Good rapportwhich enables doctor and patient todiscuss therapeutic options, and thepatient to participate in decisions increasesthe latter's confidence, sense ofindependence and self-esteem.

Once discharged from hospital a greatresponsibility is placed on the patient andon the family. Firstly they have toremember all the procedures and how todeal with serious complications shouldthey arise. There are also problems witheveryday life and income. A handbookproves very valuable and all units shouldideally provide one. Most generalpractitioners, district nurses and healthvisitors express ignorance when askedquestions regarding parenteral nutrition,thus emphasising the need for furthereducation in the community on artificialnutrition and the importance of extendingthe role of the specialised units outside thehospital.

The need for a member of the unit to bealways available by telephone and for anemergency admission procedure is

especially important if the patient livesseveral miles away.

A great deal of improvement is needed inthe equipment given to patients for use inthe home. With one or two exceptions theequipment is specifically designed forhospital use, where there are flat vinylfloors, lifts and high levels of noise. Putthe same equipment into the home and itbecomes impossible to get up and downstairs, difficult to push over carpets andoften noisy.

For many years individual units indifferent parts of the country have offeredvarying levels of support and useddifferent procedures. As a patient, it wouldbe encouraging to see the units uniting tofight for improved standards of patientcare, funding and equipment, and alsotrying to establish uniformity in protocols.We could then have standard packs,avoiding waste and making the procedureseasier and quicker to carry out. As oneorganisation of carers and patients wewould carry more weight than acting asindividuals or as separate hospital units.

Present Organisation isUnstructured

Since artificial nutrition is usually startedin hospital, patients naturally turn to theexpertise of the hospital nutrition team inany difficulty. As a result there can betension between the roles of the hospitalstaff and that of the general practitioner.The relative rarity of this type of treatmentin the community means that thecommunity care team is unfamiliar with itand therefore lacks confidence inprescribing nutrients or dealing withproblems. The situation is particularlyunsatisfactory because, with presentbudgeting arrangements, the hospital teamhas to rely on the general practitioner toprescribe the nutrients, though by anadministrative anomaly the GP is unable to order the equipment needed.Administrative responsibility between thehospital and community health teams isthus ill-defined to the detriment of the patient.

Proposed Organisation for HomeEnteral Tube Feeds

In hospital, the nutrition team has specialexperience and advises clinicians indifferent disciplines on this aspect oftreatment; in the community, the hospitalnutrition team can have a similarrelationship with local health care.

The team can share responsibility for careby recommending a regimen, givinginstruction to the patient and all carers onprocedures and possible complications,providing a telephone enquiry service forall members of the community team andthe patient, and by giving hospital care asneeded either in a clinic or the ward. Thegeneral practitioner can acceptresponsibility for treatment at home,prescribe the nutrients and, we hope in thefuture, the equipment required. It isconvenient for the patient to have thenutrients and supplies delivered to thehome and prescriptions may be sent to acommercial delivery service.

The hospital and community teams shouldliaise as closely as possible. When thepatient is discharged from hospital, amember of the hospital nutrition teamshould visit the home to meet the generalpractitioner or other representative of thecommunity team and explain details of thetreatment. A member of the hospital team,often the clinical nurse specialist, may beinvited to make further home visits. It islikely that the patient will continue to visita clinic at the hospital for follow-up, whensuggestions about altering the feedingregimen may be made.

The simple infusion pumps and dripstands used should be bought from anidentified hospital or community budgetand loaned to patients. A reserve stock isneeded so that new patients can besupplied quickly, with an allowance forsome pumps to be out of use for servicing.Alternatively, commercial firms leasethese items of equipment as part of theirhome supply service.

Proposed Organisation for HomeParenteral Nutrition

The cost of home parenteral nutrition ishigh for each patient (around £25,000 pafor nutrients and disposable equipment)but the number is small (100 to 150).Some health districts will therefore nothave one of these patients and the most islikely to be two or three. Parenteralnutrition is much more complex thanenteral nutrition and a scrupulous protocolto avoid line infection is required twicedaily when the feed is connected and theempty container is disconnected from thecatheter. To avoid metaboliccomplications a strictly controlled rate ofinfusion is required, and since infusionoccurs during sleep the pump must alsoincorporate a system of alarms to wake thepatient if the line becomes blocked orother malfunction occurs. The pump istherefore expensive and requires regularmaintenance.

It is not acceptable to discharge a patientinto the community to assumeresponsibility for this complex techniquewithout first-class training and the mostefficient and comprehensive back-upservice possible.

Education of patients for self-administeredhome care is best undertaken in a hospitalwhich already has a well-developedorganisation for inpatient parenteralnutrition. Training requires a skilled andexperienced teacher and teaching aids.Patients who are giving themselves treatment can also help one another bymutual support and exchange ofinformation. The organisation of treatmentat home needs considerable knowledge ofthe equipment and supplies required, ofthe facilities needed within the home, andof potential difficulties and complications.A member of the hospital staff who knowsthe patient and is familiar with thetechnique should be available forconsultation by the patient 24 hours a day.If a complication develops, such as ablocked cannula or line infection, thepatient needs admission without delay to aunit which understands the problem.

For all these reasons, the care of patientsgiving themselves parenteral nutrition athome should be concentrated in relatively

few hospitals, each serving more than onehealth district, but with appropriate back-up in the local district in case ofemergency.

As with home enteral nutrition, thehospital nutrition team should, as far aspossible, share responsibility for treatmentwith the general practitioner andcommunity health team. The generalpractitioner should receive a bookletwhich describes the treatment, its benefitsand complications. The indications for thetreatment for his/her patient and anyspecial problems in management shouldbe made clear. Personal contact betweenthe hospital staff and the generalpractitioner should be maintained.

Present financial arrangements for thisexpensive and uncommon treatment areoften unsatisfactory, and vary from placeto place. A clear funding structure isneeded either through the community orthe hospital.

Supra-regional funding through a limitednumber of specialised hospital units hasnot been accepted by the Department ofHealth. However, for the reasons outlined,many patients are trained for home

Treatment at home entails capital andrevenue payments for electrical equipmentand its maintenance (unless it is leased),and payment for daily nutrient andassociated supplies. The electricalequipment includes the sophisticatedpump, its stand and sometimes arefrigerator for storing nutrient solutions.The nutrients for each day are mixedaccording to the individual prescriptionfor the patient's needs and usuallysupplied in a plastic bag containing two tothree litres of fluid.

The cost of care in the community can bemet from one of three sources, the districtpurchasing authority, the family healthservices authority, or from the budget of afundholding general practitioner.

The general practitioner often agrees toprescribe the nutrient solutions advised bythe hospital, usually through a commercialpharmacy which provides a sterilecompounding service and home delivery.This arrangement has three disadvantages.

First, the general practitioner takes legalresponsibility for a prescription usingunfamiliar products. Secondly, the generalpractitioner is at present unable toprescribe the disposable items ofequipment which the patient needs everyday, though we recommend that thisrestriction should be removed. Third, asource of funding has to be found for theelectrical equipment.

parenteral nutrition at hospitals outsidetheir own health district. The cost of carefor the patient while in hospital will bearranged with the patients' districtpurchasing authority, either as part of anexisting contract or as an extra-contractualreferral. The hospital has no budget formeeting the cost of care for the patientwho returns home, although staff in thehospital are likely to share care with thecommunity services and to provideoutpatient and inpatient facilities as necessary.

At present, the disposable and electricalequipment has to be provided from thecommunity budget of the districtpurchasing authority. A non-fund-holdingGP needs to inform the family healthservices authority about this essential butexpensive treatment for a patient so thatvariation from the indicative drug amount(IDA) is understood. A fund-holdinggeneral practitioner may have to negotiatea special arrangement for payment withthe regional health authority.

An alternative, and more satisfactoryarrangement is that the district purchasingauthority, through its purchasing orcontract monitoring officer, agrees topurchase the nutrient solutions anddisposable items of equipment for thepatient either directly from a commercialhome-supply firm or from a hospital, ineither case on the prescription of thehospital clinician.

The pump, drip stand and, if need be therefrigerator, should be bought from anidentified community or hospital budgetand loaned to the patient, with provisionfor immediate replacement if the pumpfails or requires servicing. Alternatively,the electrical equipment can be leasedfrom a home-supply firm.

The nutrients and equipment should be delivereddirectly to the patient's home either by thehospital or by a commercial firm.

Special Problems of Babies andChildren

Growth, Intellectual Developmentand High Energy Needs

Children are not miniature adults and havespecial problems. Their nutritionalreserves are smaller and thus treatment isrelatively more urgent and must be startedat an earlier stage of illness. This isparticularly so for premature infants whohave nutritional stores sufficient for only afew days. Furthermore, their energy needsrelative to their size are greater, theyrequire nutrition not only to maintain lifebut also to grow.

These nutritional requirements areincreased during stress due to infection orinflammation and, as a consequence,disease may prevent growth and result inmalnutrition sooner than in adults. Growthis fastest during early childhood,especially the first year of life, and duringadolescence. A special aspect of growth isthat during infancy prolonged malnutritionis associated with delayed psychosocialdevelopment which may subsequentlyresult in impaired intellectual attainment.

Immaturity of MetabolicProcesses

The nutrient requirements of children varyconsiderably from those of adults both inquantity and composition of nutrients; forexample, certain amino acids are not fullymetabolised by neonates and an excess ofamino acids in the new born can lead tocoma, sometimes with irreversible braindamage. Up to the age of six to ninemonths the infant kidney is unable toexcrete sodium and hydrogen ionsefficiently: thus inappropriately highsodium loads may lead to an obligatoryhigh urine volume and dehydration, andsmall children are liable to metabolic

acidosis. Lastly, infective complications oftreatment such as catheter sepsis may bemore common than in adults due to theimmunodeficiency of malnourishedinfants and may present with non-specificillness.

Psychosocial Factors

Psychosocial considerations are speciallyimportant in young children. Those whoreceive long-term parenteral nutrition inhospital frequently suffer impairment oftheir social and intellectual development.Facilities for parents to live at the hospitalare important so that the bond betweenparent and child is not broken. Playtherapists and nurses have specific rolesand regular developmental checks areneeded to identify those who need specialhelp. It is also important that oralstimulation is not completely removed;games are devised using the mouth andwherever possible small amounts of foodare allowed.

Compared with adults, children areespecially mobile and inquisitiveregarding their treatment. Equipment andcatheters must be 'tamper proof' yet mustalso be light, portable wherever possibleand easy to use. In older children specialsteps are needed to reduce fear and gaincollaboration.

Artificial Nutrition in Intensive Care

Frequent Need for NutritionalSupport

Intensive care units admit patients of allages and with a wide variety of life-threatening conditions. Most patients havefailure of one or more vital systems and alarge number require mechanicalventilation. Many are either unconsciousor heavily sedated, some haveneurological conditions which impairswallowing and, in some, malnutritionmay be a major cause of their criticalillness.

A high proportion therefore requireartificial nutrition. Little data is available,but figures for individual units suggestthat between 10 and 20 per cent of patientsreceive parenteral nutrition. Enteralfeeding is used more frequently, but isprecluded by an ileus in many patients.This may be due to sedative drugs givento facilitate mechanical ventilation, or itmay be the result of hypoxia or abdominalsepsis or trauma. This greater use ofnutritional support compared with otherhospital areas is reflected in the fact thattotal parenteral nutrition consistentlyfeatures among the most expensivepharmaceutical products when intensivecare drug costs are analysed.

Special Problems

Additional factors enter the risk-benefitanalysis in the intensive care setting.Vascular access can be difficult in patientswith numerous other invasive lines andmay be particularly hazardous in thepresence of a coagulopathy or heparinadministration. Line-related infections aremore likely in patients who are alreadysepticaemic, have numerous otherintravascular lines or poor immunefunction .

Respiratory, circulatory, renal or hepaticfailure must be taken into account whenprescribing nutrition and there may be a-greater need than in other hospital wardsto tailor prescriptions to individual patientrequirements. Energy and nitrogenrequirements may, however, be difficult toestimate in the critically ill and there is noclear idea of their vitamin or trace element

needs. Also, because of changes in bodycomposition, body weight ceases to giveany useful guide to body cell mass, andother methods for monitoring nutritionalstate may be equally unsatisfactory.

Unfortunately, hard evidence of anyclinical benefit from nutritional support islacking in these patients and muchpractice is based on data from the lessseriously ill or on considerations oftheoretical benefit. What is certain,however, is that if nutritional support isbadly provided, recovery may be delayedor threatened.

Organisation

The concept of intensive care as amultidisciplinary specialty applies asmuch to nutritional support as it does tothe support of other failing vital systems.While those working in this area musthave a clear understanding of theprinciples of nutritional support,appropriate use should also be made ofother expertise that may be available; a'nutrition team' for example. Suchdialogue will ensure optimal managementof these complex cases, and also facilitatecontinuity of care if the patient still needsnutritional support when transferred to ageneral ward.

Future needs

Clearly, more information is requiredabout the provision of artificial nutritionin intensive care units with particularregard to the extent of and reasons for itsuse. Research is also needed to definewhich patients actually benefit fromnutritional support and to improve theways in which it is given. Work is neededinto ways of maintaining or restoring leanbody mass in the seriously ill and theplace, if any, of specially formulated feedsneeds to be defined (79). To study aspectsof nutritional support in particular types ofpatient, much of this research will have tobe organised on a multi-centre basis.

Education and Training

Doctors

Clinical nutrition is not a clearly definedsubject in the undergraduate curriculum,neither is it a separate discipline in thehealth service. There are no consultantsworking exclusively in the field.Knowledge of nutrition, however, isrequired in many branches of medicine. In1983, the British Nutrition Foundation setup a task force to study and report on theeducation of undergraduates ( 12). It wasclear that very little nutrition was taught tomedical students and it was rarely presented in a systematic way. It was often notacknowledged as relevant and no attemptwas made to co-ordinate basic .scienceteaching, usually from biochemistrydepartments, with clinical experience laterin the curriculum. The report proposedthat an academic unit or department with aspecial interest in nutrition should begiven the responsibility to integrate theteaching of nutrition throughout the curriculum.It further recommended that

teaching and training in clinical nutrition.should be essentially practical and coverpreventive as well as therapeutic aspectsof nutritional care.

A meeting was held at the Royal Societyof Medicine in 1989 to review the resultsof the Nutrition Foundation's initiative( 1~). It was clear that relatively littleprogress had been made when the information on nutritional teaching in the 25medical schools which responded wasstudied. For example, questions on nutritionaltopics were rarely .set in final examinations.Many schools reported no change of emphasisbut in a few schools there were signs of increasedactivity in clinical nutrition. The creation of twonew Chairs in human nutrition and one Lecturerpost was a welcome development.

The role of the dietitian in medicaleducation has clearly been neglected. Only16 per cent of a large number of dietitiansworking in teaching hospitals took part inundergraduate education. More nutrition isnow being taught but it is difficult toquantify and more integration and co-ordination is clearly required.

The undergraduate course in clinical nutritionprovided at the University of Cam-bridge as an elective option is a modelwhich other schools should investigate.Some medical students are able to takeintercalated science degrees in nutritionbut the overall emphasis remains limiting.

Questions on clinical nutrition are notoften included by the royal colleges intheir postgraduate examinations.Multidisciplinary courses have beenorganised but these tend not to be wellattended because they are often consideredirrelevant to individual specialties.

Nurses

Emphasis in basic training at present tendsto be placed on the importance of healthyeating rather than on the problems ofunder-nutrition, it’s assessment, methods ofnursing intervention and monitoring.Some continuing education courses,particularly on intensive care nursing,provide comprehensive teaching inclinical nutrition. There are currently twoEnglish National Board courses in clinicalnutrition. Those hospitals with a nutritionnurse .specialist frequently have structurednurse teaching programmes with frequentupdating of information. A system of 'linknurses' in which a ward nurse acceptsparticular responsibility for nutritionalcare in that ward and meets the nutritionteam for regular teaching and briefing canbe very successful.

Dietitians

Dietitians qualify with a degree innutrition and dietetics. a training whichincludes teaching in both the theory andpractical application of nutritional support.While all dietitians have this basictraining, few specialise in this subject. TheParenteral and Enteral Nutrition Group(PEN Group) of the British DieteticAssociation was established in 1982 andcurrently has a membership of 250. Itorganises a postgraduate course in clinicalnutrition each year attended by about 45dietitians, and similar courses are held forstudents. The Group has also producedguidelines on nutritional support forcollege tutors and students to improve thestandard and uniformity of undergraduatetraining.

The Group organises meetings andworkshops for its members to shareinformation and skills.

While many dietitians are experienced inenteral nutrition, both in hospital and thecommunity, few are experienced inparenteral nutrition, a technique in whichmore training is needed.

Dietitians need encouragement to initiateresearch into nutritional support, publishtheir work and study for higher degrees.

Pharmacists

Little formal training in clinical nutritionis given at undergraduate or postgraduatelevels, though some undergraduatecourses in clinical pharmacy do include amodule on clinical nutrition. Practicaltraining in aseptic preparation andcompatibility should be provided inundergraduate courses and in all pharmacyproduction units which prepare fluids forparenteral nutrition. Postgraduate trainingin clinical nutrition for pharmacists isuneven through the country but some

regions have well structured courses. It ishoped to establish a 'certificate innutrition' through the National TotalParenteral Nutrition Group this year, andeventually a diploma. The National TotalParenteral Nutrition Group and the 'All inOne Society' cater particularly forpharmacists with an interest in nutrition,and they also develop expertise throughmultidisciplinary meetings.

The Public

Through a spate of articles in the press,books, and media programmes, thegeneral public is acutely aware of dietaryfactors which promote health. The benefitsof a low calorie diet and an increased fibreintake are widely known. However, thepublic is not generally aware thatmalnutrition with weight loss is a majorcomplicating factor in many illnesses.Contrary to current teaching in health,many people who are ill need guidanceabout how to increase their energy intakeby reducing the proportion of low energyfoods in what they eat.

The positive role of nutrition as atreatment in illness needs publicity.Increased awareness of this need will inturn bring consumer pressure to bear onhospital catering and the provision ofnutritional support when an adequate dietcannot be taken.

Research

Development and Extent ofResearch

Good teaching and training are fostered bystrong research programmes. Advances inpatient care and rationalisation of clinicalpractice depend on research in the basicsciences, the development of new productsand equipment by industry, and the criticalapplication of measurement andexperimental design to clinical problems.

There is steady growth in nutrition-relatedresearch in many universities. Surgerydepartments have made majorcontributions to new understanding of theenergy demands of the critically ill and theprovision of long-term nutritional support.Medical departments have contributedparticularly to knowledge of enteralfeeding and the management of intestinalfailure. The high quality of the scientificpapers at the meetings of the ClinicalMetabolism and Nutrition Support Groupof the Nutrition Society and of the SmallBowel and Nutrition Group within theBritish Society of Gastroenterology bearwitness to this success.

Funding

Research in clinical nutrition is supportedmainly by the universities, charitablefoundations and industry; increasedawareness of the practical importance ofthe subject would attract further funds. InAmerica, artificial nutritional support iswell organised and widely employed.Industrial support for research iscorrespondingly greater there than in thiscountry. The improved organisation ofnutritional support recommended in thisreport would encourage contribution toresearch from industry, though it is to behoped that this would not only be product-oriented but also help basic understanding.Industry is in a good position to undertakemulticentre controlled trials to answerquestions about possible benefits ofnutritional support.

Current Problems

Further basic scientific investigation isneeded into the response to injury andinfection. Provision of nutrients does not

reverse the body's catabolic response tostress so that it is difficult, and oftenimpossible, to improve a patient'snutritional state while these factors persist.Endocrine therapy, or selective preventionof cytokine release or antagonism to oneor more of their effects, may alter theresponse to injury in such a way thatnutrients given can be utilised for proteinsynthesis. Similarly, new nutritionalsubstrates may be found which have thesame effect.

Patients who are ill have a poor appetite.Stimulation of appetite so that they eatmore would avoid the need for artificialnutritional support in some cases.

Continued research is needed into theeffects of nutritional deprivation andreplacement on the outcome of illness.Such research would benefit patient careand improve the efficient use of resources.To this end, measurements of bodycomposition and metabolic function, cleardefinition of patient groups, and thedevelopment of both clinical andeconomic indicators of outcome needfurther critical study.

The Way Forward

Development of Clinical Nutritionas a Discipline

Clinical nutrition should be recognised asan important part of health care. For thisto occur it needs:

• integration of professional groups.There is at present no Britishorganisation which draws together thecommon interests and expertise ofacademic nutritionists, dietitians,nurses, pharmacists, doctors and thepharmaceutical industry. Such anorganisation could set standards fornutritional care, promote professionaltraining, provide an expert forum formanagement, government andindustry, and co-ordinate research;

• recognition of clinical nutrition in thebasic and post-basic training of therelevant professions;

• the creation of more academicdepartments with staff drawn from thebasic sciences and all clinicaldisciplines to promote teaching andresearch.

Recognition of Training

The training of dietitians is registered, butthere is no mechanism by which specialistpostgraduate training in nutrition ofnurses, doctors or pharmacists isrecognised.

Rationalisation

The wider application of research willshow when artificial nutritional supportfavourably affects clinical outcome andwhen it does not. Operational researchwill show which procedures are essentialand which are inessential for effective safeadministration of nutrition. Uniformprotocols and equipment will result whichsimplify clinical care. Research will showwhen nutritional solutions can bestandardised without detriment to care sothat prescription becomes easier and costsare reduced.

The Role of Industry

The pharmaceutical industry is responsiveto clinical need and provides a wide rangeof specialised nutrients. The domiciliaryservice for enteral and parenteral nutritionwhich delivers all the nutrients andequipment needed to the patient's home,and integrates the cost of the various itemsinto one account, meets a real need.Purchasers will enter into contracts withindustry for provision of these services forwhich standards will need to be prepared.

References

1. Moy RJD, Smallman S, Booth IW. Malnutritionin a UK children's hospital. J Hum Nutr Dietet1990;3:93-100.

2. Hill GL, Pickford I, Young GA, Schorah CJ,Blackett RL, Burkinshaw L, Warren JV,Morgan DB. Malnutrition in surgical patients: an unrecognised problem. Lancet 1977;i:689-692.

3. Zador DA, Truswell AS. Nutritional status onadmission to a general surgical ward in a Sydneyhospital. Aust NZ .J Med 1987;17:234-240.

Bistrian BR, Blackburn GI, Hallowell E,Heddle R. Protein status of general surgicalpatients.JAMA 1974;230:858-860.

5. Bistrian BR, Blackburn GL, Vitale J, Cochran D,Naylor J. Prevalence of malnutrition in generalmedical patients. JAMA 1976;253: 1567-1570.

6. Larsson J, Unosson M, Ek A-C, Nilsson L,Thorslund S, Bjurulf P. Effect of dietarysupplement on nutritional status and clinicaloutcome in 501 geriatric patients - arandomised study. Clin Nutr 1990;9: 179-184.

7. Pinchcofsky GD, Kaminski MV. Increasingmalnutrition during hospitalisation:documentation by a nutritional screening program.J Am Coll Nutr 1985: 4: 471-479.

8. Payne-James J, de Gara C. Grimble G, ReesR, Bray J, Rana S, Cribb R, Frost P, Silk D.Nutritional support in hospitals in the UnitedKingdom: national survey 1988.Health Trends 1990;22:9-13.

9. Bastow MD, Rawlings J, Allison SP. Benefits of supplementary tube feeding afterfractured neck of femur: a randomised controlledtrial. Br Med. J 1983;287: 1589-1592.

10. Delmi M, Rapin C-H, Bengoa J-M, DelmasPD, Vasey H, Bonjour J-P. Dietarysupplementation in elderly patients with fracturedneck of the femur. Lancet 1990;335: 1013-1016.

11. Wilcock H, Armstrong J, Cottee S, Neale G,Elia M. Artificial nutrition in theCambridge health district with particular referenceto tube feeding. Health Trends 1991;(in press).

12. Nutrition in Medical Education. Report of theBritish nutrition task force on human nutrition.London: British Nutrition Foundation, 1983.

13. Judd PA. Teaching nutrition to medical and dental students J Hum Nutr Dietet1988; 1: 145-50.

14. Brett A, Godden DJ, Keenan R. Nutritionalknowledge of medical staff and studentsis present education adequate. Hum Nutr1986;40A:217-224.

15. Heywood P, Wootton SA. Nutritionalknowledge and attitudes towards nutritioneducation in medical students at SouthamptonUniversity Medical School. Proc NutrSoc 1991; (in press).

16. Heird WC, Driscoll JM, Schullinger JN, GrebinB, Winters RW. Intravenous alimentation inpediatric patients. J Pediatrics 1972;80:351-372.

17. Keys A, Brozek J, Henschel A, Michelsen O,Taylor HL. In: The biology of humanstarvation. Minneapolis MN: University ofMinnesota Press: 1950. Vol 1 703-748, vol 2 819-918.

18. Brozek J. Effects of generalised malnutritionon personality. Nutrition 1990;6:389-395

19. Jeejeebhoy KN. Bulk or bounce - the object of nutritional support. J Parent Ent Nutr1988;12:539-549.

20. Doekel RC, Zwillich CW, Scoggin CH, KrygerM, Weil JV. Clinical semi-starvation: depression of hypoxic ventilatory response. N Engl J Med1976;295:358-361

21. Gottdiener JS, Gross HA, Henry WL, BorerJS, Ebert MH. Effects of self-inducedstarvation on cardiac size and function in anorexianervosa. Circulation 1978;58:425-433.

22. Fellows IW, MacDonald IA, Bennett T, AllisonSP. The effect of undernutrition onthermoregulation in the elderly. Clin Sci 1985; 69: 525-532.

23. Christie PM, Hill GL. Effect of intravenousnutrition on nutrition and function inacute attacks of inflammatory bowel disease.Gastroenterology 1990;99:730-736.

24. Arora NS, Rochester DF. Respiratory musclestrength and maximal voluntaryventilation in undernourished patients. Am RevRespir Dis 1982; 126:5-8.

25. Windsor JA, Hill GL. Risk factors for post-operative pneumonia: the importance ofprotein depletion. Ann Surg 1988;208:209-214.

26. Benotti P, Bistrian B. Metabolic and nutritional aspects of weaning from mechanicalventilation. Critical Care Medicine 1989;17:181-185.

27. Heymsfield SB, Bethel RA, Ansley JD, GibbsDM, Felner JM, Nutter DO. Cardiacabnormalities in cachectic patients before andduring nutritional repletion. Am Heart J1978;95:584-594.

28. Holmes R, MacChiano K, Jhangiani SS,Agarwal NR, Savino JA. Combatingpressure sores - nutritionally. Am J Nursing1987;1301-1303.

29. Bistrian BR, Sherman M, Blackburn GL, et al.Cellular immunity in adultmarasmus. Arch lntern Med 1977;137:1408-1411.

30. Deitch EA, Winterton J, Li M, Berg R. The gutas a portal of entry for bacteremia:role of protein malnutrition. Ann Surg1987;205:681-690.

31. Baker JP, Detsky AS, Wesson DE, WolmanSL, Stewart S, Whitewell J, Langer BJeejeebhoy KN. Nutritional assessment: acomparison of clinical judgement andobjective measurements. New Engl J Med1982;306:969-972.

32. Windsor JA, Hill GL. Weight loss withphysiologic impairment: a basic indicator ofsurgical risk. Ann Surg 1988;207:290-296.

33. Keohane PP, Attrill H, Love M, Frost P, SilkD~A. Relation between osmolality ofdiet and gastrointestinal side effects in enteralnutrition. Br Med J 1984;228:678-680.

34. Anderton A, Aidoo KE. The effect of handlingprocedures on microbialcontamination of enteral feeds. J Hosp Infect1988; 11 :364-372.

35. Freedland CP, Roller RD, Wolfe BM, FlynnNM. Microbial contamination of continuous dripfeedings. J Par Ent Nutr 1989; 13: 18-22.

36. Pennington CR. Review article. Towards saferparenteral nutrition. Aliment Pharmacol Therap1990;4:427-441.

37. Reilly JJ, Hull SF, Albert N, Waller A,Bringardener S. Economic impact ofmalnutrition: A Model System for HospitalisedPatients. J Parent Ent Nutr1987; 12:372-376.

38. Anderson MA, Collins G, Davis G, Bivins BA.Malnutrition and length of stay - a relationship?Henry Ford Hosp Med J 1985; 4:19()-193.

39. Weinsier RL, Hunker EM, Krumdieck CL,Butterworth CE,Jr.. A prospectiveevaluation of general medical patients during thecourse of hospitalisation. Am.J ClinNutr 1979;32:418-426.

40. Warnold 1, Lundholm K. Clinical significanceof preoperative nutritional status in215 non-cancer patients. Ann Surg 1984;199:299-305.

41. Meguid MM, Campos ACL, Meguid V,Debonis D, Terz JJ. IONIP, a criterion of

surgical outcome and patient selection forperioperative nutritional support. Br J ClinPract 1988;42Suppl.63:8-14.

42. Jensen JE, Jensen TG, Smith TK, JohnstonDA, Dudrick SJ. Nutrition in orthopaedic surgery.J Bone Jt Surg 1982;64-A: 1263- 1272.

43. Sullivan DH, Patch GA, Walls RC, LipschitzDA. Impact of nutrition status onmorbidity and mortality in a select population of geriatric rehabilitation patients. Am. JClin Nutr I 990;51 :749-758.

44. Robinson G, Goldstein M, Levine GM. Impactof nutritional status on DRG lengthof stay. J Parent Ent Nutr 1987; 11 :49-51.

45. The Veterans Affairs Total Parenteral NutritionCo-operative Study Group.Perioperative total parenteral nutrition in surgicalpatients. N Eng J M 1991 ;325:525-532.

46. Muller JM, Brenner U, Dienst C, Pichlmaier H.Pre-operative parenteral feeding inpatients with gastrointestinal carcinoma. Lancet1982;i:68-71.

47. Heatley RV, Williams RHP, Lewis MH. Pre-operative intravenous feeding - acontrolled trial. Postgrad Med J 1979;55:541-545.

48. Thompson BR, Julian TB, Stremple JF. Peri-operative total parenteral nutrition inpatients with gastrointestinal cancer. J Surg Res1981 ;30:497-500.

49. Holter AR, Fischer JE. Effects of perioperativehyperalimentation on complicationsin patients with carcinoma and weight loss. J Surg Res 1977;23:31 -34.

50. Woolfson AMJ, Smith JAR. Elective nutritionalsupport after major surgery: a prospectiverandomised trial. Clin Nutr 989;8:15-21.

51. Fan ST, Lau WY, Wong KK, Chan YPM. Pre-operative parenteral nutrition inpatients with oesophageal cancer: a prospectiverandomised clinical trial. Clin Nutr1989;8:23-27.

52. Askanazi J, Hensle TW, Starker PM, Lockhart SH, Lasala PA, Olsson C, KinneyJM. Effect of immediate postoperative nutritionalsupport on length of hospitalisation.Ann Surg 1986;203:236-239.

53. Sagar S, Harland P, Shields R. Early post-operative feeding with elemental diet.Br Med J 1979; 1 :293-295.

54. McMahon MJ. The feeding jejunostomy.r J Clin Pract 1988;42 Suppl. 63:85-88.

55. Twomey PL, Patchings SC. Cost-effectivenessof nutritional support. J Parent EntNutr 1985;9:3-10.

56. Jendteg S, Larsson J, Lindgren B. Clinical and economic aspects on nutritionalsupply. Clin Nutr 1987;6: 185- 190.

57. O'Brien DD, Hodges RE, Day AT, WaxmanKS, Rebello T. Recommendations ofnutrition support team promote cost containment.J Parent Ent Nutr 1986; 10:300-302.

58. Macfie J. Towards cheaper intravenousnutrition. Br Med J 1986;292: 107- 110.59. Harper PH, Royle GT, Mitchell A, Greenall MJ,Grant A, Winsley B, Atkins SM,Todd EM, Kettlewell MGW. Total parenteralnutrition: value of a standard feedingregimen. Br Med J 1983;286:1323-1327.

60. Puntis JWL, Booth IW. The place of anutritional care team in paediatric practice.Inten Ther Clin Mon 1990;7: 132- 135.

61. Freeman JB, Lemire A, MacLean LD.Intravenous alimentation and septicaemia.Surg Gynec Obstet 1972;135:708-712.

62. Sanders RA, Sheldon GF. Septic complications of total parenteral nutrition. Amer J rg 1976; 132:214-220.

63. Ryan JA, Abel RM, Abbott WM, et al. Catheter complications in total parenteralnutrition. N Engl J Med 1980;390:757-760.

64. Nehme AE. Nutritional support of thehospitalised patient: the team concept. JAMA1980;243: 1906-1908.

65. Keohane PP, Attrill H, Northover J, JonesBMJ, Silk DBA. Effect of cathetertunnelling and a nutrition nurse on catheter sepsisduring parenteral nutrition. Lancet1983; ii: 1388- 1390.

66. Jacobs DO, Melnik G, Forlaw L, Gebhardt C, Settle RG, DiSipio M, Rombeau JL.Impact of a nutritional support service on VASurgical patients. J Amer Coll Nutr1984;3:311-315.

67. Faubion WC, Wesley JR, Khalidi N, Silva J.Total parenteral nutrition cathetersepsis: impact of the team approach. J ParentEnt Nutr 1986: 10:642-645.

68. Puntis JWL, Holden CE, Smallman S, Finkel Y, George RH, Booth IW. Staff training: a keyfactor in reducing intravascular catheter sepsis.Arch Dis Child1991 ;66:335-337.

69. Traeger SM, Williams GB, Milliren G, YoungDS, Fisher M, Haug MT. Total parenteral nutritionby a nutrition support team: improved quality ofcare. J Parent EntNutr 1986; 10:408-412.

70. Brown RO, Carlson SD, Cowan GSM,Jr.,Powers DA, Luther RW. Enteralnutritional support management in a universityteaching hospital: Team vs nonteam. J Parent Ent Nutr 1 9X7; 11 :52-56.

71. Dalton MJ, Schepers G, Gee JP, Alberts CC,Eckhauser FE, Kirking DM.Consultative total parenteral nutrition teams: theelefffect on the incidence of totalparenteral nutrition-related complications.

J Parent Ent Nutr 1984;8: 146- 152.

72. Micklewright A, Todorovic V. The UK homeenteral feeding register (in press).

73. Holden CE, Puntis JWL, Charlton CPL, BoothIW. Nasogastric feeding at home:acceptability and safety. Arch Dis Child 1991 ;66: 148- 151.

74. Lennard-Jones JE, Wood S. The organisationof intravenous feeding at home.Health Trends 1985; 17:73-75.

75. Bisset WM, Stapleford P, Morten A, Long S, Sokel B, Milla PJ. Home parenteralnutrition (HPN) in childhood. Arch Dis Child 1991;(in press).

76. Weekes E, Cottee S, Elia M. Home artificial nutritional support in the Cambridgehealth district - 1988-90. 1992; (in press.)

77. Mughal M, Irving M. Home parenteral nutrition in the United Kingdom and Ireland.Lancet 1986; 2: 383 -387.

78. Stokes MA, Almond DJ, Pettit SH, et.al. Home parenteral nutrition: A review of100 patient years of treatment in 76 consecutivecases. Br J Surg 1988; 75 :481 -483.

79. Streat SJ, Beddoe AH, Hill GL. Aggressive nutritional support does not preventprotein loss despite fat gain in septic intensivecare pa patients. J Trauma 1987;27:262-266.

Appendix A: Standards for ArtificialNutritional Support in Hospital(Modified from standards prepared by theAmerican Society of Parenteral and EnteralNutrition)

Assessment

Simple criteria will be established for theidentification of the malnourished patientand of any patient who may becomemalnourished. The nutritional status of allpatients admitted will be assessed from thehistory and physical examination,including measured weight and height,and a history of weight change over time.Appropriate laboratory measurements willbe made if indicated. These observationsand measurements will be clearly recordedin the medical record.

Guidelines for Intervention

Normally nourished patients andmalnourished patients who are eatingsufficient to replace lost tissue will not begiven nutritional support. Well nourishedpatients with impaired intake limited toone week will not be given artificialnutritional support. Patients with 10 percent or more loss of usual body weight orthose with other evidence of malnutritionwho cannot eat normally will be givenartificial support, particularly if theanticipated course of the illness. and ofany procedures such as surgical treatment,makes it unlikely that normal feeding willbe resumed within a week.

Therapeutic Plan

The objective of nutritional support willbe defined. The duration of treatment willbe estimated. When appropriate, thepossible need for treatment at home willbe anticipated and the necessaryarrangements and training begun. Thegastrointestinal tract will be used fornutritional support whenever possible.

Parenteral nutrition will only be usedwhen the gastrointestinal tract cannot beused or absorption is inadequate to supplyadequate nutrition. The mode of supportwill be re-assessed frequently in casechange is needed. The nutrition fluid usedwill be appropriate to correct any

metabolic abnormality and to promotetissue replacement. When similarlyeffective formulations are available thecheapest will be chosen.

Implementation

Access

Access for nutritional support will beachieved in a manner which minimisesrisk to the patient. The person who placesany access device will be properly trainedin the technique. Standard techniques andprotocols will be established and followedfor access procedures. Proper placementof each access device will be confirmedbefore use. Any complications during theaccess procedure will be recorded.Protocols will be established for theroutine care of access devices.

Feeding preparation

The feeding solution will be accuratelyprescribed and labelled. The compatibilityand stability of the mixture will beconfirmed. The preparation will bechecked before administration and thisfact, together with the date and time ofadministration, will be entered in thepatient's record. Feeding solutions will besterile. The mode of storage and the expirydate will be specified. Protocols will beprepared controlling additions to the feedon the ward.

Avoidance of infection

Protocols will be established for changingdelivery sets to minimise secondary infection ofconnections and to limit the time for which eachdelivery set is used.

Appendix B: Standards for ArtificialNutritional Support at Home(Modified from standards prepared by theAmerican Society of Parenteral and EnteralNutrition)

Patient Selection and Aims

• The patient who is being consideredfor home artificial nutritional supportshould be unable to achieve adequateoral intake.

• Artificial nutritional support shouldaim to provide benefits to the patient,and these should be defined prior toinitiation of therapy, e.g. to produceremission of a disease process,promote healing of a fistula or wound,improve quality of life or preventdeterioration.

• An assessment should be made of thehome environment and of the patient'sand carer's ability to copesatisfactorily with the treatment.

Organisation

1. Home enteral nutrition will beprescribed and supervised by the generalpractitioner with the assistance of acommunity nurse and/or dietitian. Ahospital nutrition team will be availablefor advice and help.

2. Home parenteral nutrition will be basedon a hospital with an experienced nutritionteam comprising a doctor, specialisednurse, dietitian and pharmacist. The doctorwill prescribe the nutrients, or advise thegeneral practitioner about a suitableprescription. The hospital team will acceptresponsibility for training the patient andsupervising the treatment, with the help ofthe general practitioner and communitynurse. Liaison will be maintained not onlybetween the supervising hospital, and thecommunity health team, but also the localhospital if appropriate.

3. Written policies and protocols willcover delivery of feed plus ancillaries,training and education of the patient andcarer, and all techniques involved inpatient care, monitoring and follow-up.

4. Financial arrangements will be definedat the outset. Policies and procedures willbe reviewed and modified as appropriate.

6. Clear written instructions for dealingwith problems including emergenciesshould be established.

Operation

1. All patients and carers will be trained inthe technique to a sufficiently highstandard to ensure efficacy and safety ofthe treatment.

2. The GP will be informed of the plansand arrangements for home artificialnutritional support.

3. The patient and/or carer will receivewritten instructions prior to dischargeincluding instructions about hygienictechniques for changing and administeringfeeds, changing dressings, how to dealwith simple problems, and who to contact(e.g. by telephone) when there are moreserious problems, e.g. tube displacement,tever and malaise, inadequate supply offeeds and ancillaries.

4. The patient's nutritional and clinicalstatus and results of investigations will beclearly documented.

5. Home artificial nutritional support willstop when the patient obtains no furtheradvantage from the therapy (e.g. when theaims have been achieved and the patient isable to achieve adequate oral intake, orwhen the aims are considered to be nolonger achievable).

It may also be stopped temporarily ascomplications demand (e.g.line sepsis).

Patient Monitoring

The patient's clinical status, includingfluid input and output, and weight will bemonitored regularly. Laboratorydeterminations will be undertakenregularly, but not more frequently thaninfluences clinical management.

Stopping Treatment

A patient on enteral tube feeding shouldbe able to take and tolerate adequate oralnutrition before the feed is stopped; aperiod of oral feeding by day and tubefeeding by night may provide anintermediate stage. A patient on parenteralfeeding should be able to tolerate andabsorb oral feeding or enteral tube feedingbefore the parenteral feed is stopped; aperiod of oral/enteral feeding by day andparenteral feeding at night may provide anintermediate phase.

Protocols will be developed to indicatewhen feeding should be stopped due to adefinite or possible complication, and todefine the other actions to be taken.

Organisation

A nutrition support team or group will beestablished consisting of a doctor,registered nurse, registered dietitian andpharmacist, each with special interest inand responsibility for the nutritionalservice. This team will prepare policiesand distribute protocols for local use;these policies and procedures will bereviewed and revised periodically tomaintain optimum standards.

The nutrition team will maintain recordsof treatment given and the outcomethroughout the hospital. The team will beresponsible to management for the properadministration of artificial nutritional

Appendix C: Specimen Standardsfor a Purchasing Authority Placing aContract for Artificial NutritionalSupport(Based on draft standards prepared for SalisburyHealth Authority)

Scope

Artificial nutritional support covers theactivities involved in total parenteralnutrition, peripheral vein nutrition, tubefeeding using artificial diets andsupplemental feeding. The Authorityrecognises that appropriate and timelyartificial nutritional support is beneficialto patient care but that inappropriate andunjustified use may be both expensive andof little patient benefit.

Principle

All patients have a right to anticipateappropriate nutritional support.

Standards

The purchaser wishes to receive evidence that:

1. An assessment of patients' nutritionalstatus and needs is made by medical andnursing staff on admission.

2. There is a published policy for artificialnutritional support which is agreed byprofessional groups involved and whichis reviewed formally at regular intervalsby a group of experts in this field.

3. There is an effective system of referralof patients requiring nutritional supportfor expert opinion, and agreed indicationsfor the use of artificial nutritional support.

4. The policy covers the needs of adultsand children and the range of clinicalconditions encountered regularly in theunit.

5. The policy relates not only to thefeeding preparations, but also to deliverysystems, storage, transport, deliveryprotocols, avoidance of septiccomplications.

6. The policy covers not only acutehospitals but also the needs of patients athome and in other care institutions.

7. Standards are agreed with commercialproviders of all consumables for deliverytimes, shelf life, cost.

8. Funding for community based feedingis agreed and explicit.

9. There are formal links with cateringdepartments.

10.Ward, community, patient and carerinformation is clear and acceptable to theuser.

11.There is appropriate training for allstaff involved in artificial nutritionalsupport and also for patients and carers toallow them to feel secure in the use ofproducts and equipment.

12.There i s a system of review ofprescribing practice, possibly inassociation with the drug and therapeuticscommittee.

13.There is a system of audit ofappropriate use of artificial nutritionalsupport and of complication such assepsis, pulmonary problems, lineblockage, diarrhoea.

Appendix D: Artificial Nutrition in the Cambridge HealthDistrict During One Year (1988/89)

Number of patients Patient DaysEnteral Tube Feeds

Neonatal 279 4654

Non-neonatal:Hospital 291 6970Home 19 4192

Parenteral Feeds

Neonatal 116 1257

Non-neonatal:Hospital 195 2668Home 3 637

Diagnoses of patients (excluding neonates) receiving artificialnutrition in the Cambridge Health District (1988/89)*

Enteral Tube Feeds Parenteral Feeds

Cerebro-vascular accident 57 3

Head injury 55 3

Trauma without head injury 2 6

Malignancy 47 64

Other gastrointestinal disorders 36 75

Other neurological conditions 32 3

Respiratory 24 3

Cardiovascular 5 15

Other and unknown 33 12

* Adapted from Wilcock et al. 1 991 (Ref 11)

Appendix E: Workload of Nutrition Team at Oldchurch Hospital (740 beds) over Four Years

1987 1988* 1989 1990Supplements

Patients 226 334 199 173Patient days 3913 6222 3045 4507

Enteral TubePatients 140 217 161 172Patient days 2344 2507 2188 3748

ParenteralPatients 23 18 23 21Patient days 452 194 471 240

Home Enteral TubePatients 2 6 11 11Patient days 90 613 961 1236

* A nutrition education week was organised in 1988 (data kindly supplied by Dr W R Burnham)

Appendix F: Potential Cost Saving to a Hospital by a Nutrition Teamfrom a Reduction in Catheter Infection Rate in Patients ReceivingParenteral Nutrition

These studies show the proportion of patients receiving parenteral nutrition who developed a catheterrelated infection before and after the introduction of a nutrition team:

Infection rate per centReference Before After61 21 1.362 29 4.763 33 364 25 1.365 33 466 24 067 24 3.5

Mean 27 2.5

Assumptions

1. An average hospital unit will treat 69 patients with parenteral nutrition each year (8).

2. The introduction of a nutrition team will save 16 episodes of catheter-related infection each year from mean figures above.

3. The cost of each episode of sepsis lies between £1650 and £5,000 derived as follows:

a) ‘Best case scenario’ (stay in a general ward increased by seven days, organism sensitive toantibiotic, catheter removed and need not be replaced)

Hospital bed @ £250 per day 1400Bacteriology (cultures, antibiotic sensitivity) 100Antibiotics 50IV fluid disposables 50Repeat bacteriology X2 50

£1650

b) ‘Worst case scenario’ ( stay in high dependency unit increased by 10 days, resistant organismneeding special antibiotics, catheter has to be removed and replaced)

Hospital bed @ £450 per day 4000Bacteriology 100Antibiotics 400Replace intravenous catheter 450Repeat bacteriology X2 50

£5000

(Figures estimates from departments at the Central Middlesex Hospital NHS Trust)

ConclusionPotential cost saving for a reduction of 16 episodes of catheter infection lies between £26,000 and £80, 000.

Appendix G: Potential NationalFinancial Saving from NutritionalSupport of Under-nourished Patientsin Hospital

Evidence in this shows report that feedingmalnourished patients improves recoveryrates, decreases complications, reduceslength of hospital stay and cost per day.

Assumptions

Ten per cent of UK hospital inpatientscould have their hospital stay reduced by 5days (notes 1 and 2).Each of these patients is fed for 14 days afteradmission (note 3)Average increased cost of feeding is£19/day (note 3).Average inpatient cost is £150/day (note4).Number of admissions is 540,000 (note 5).

Cost Savings

5 days at £ 150/day £750

Increased Cost of Feeding

14 days at £19/day £266

Saving per patient £484

National Saving for 10 per cent ofInpatients

(540,000 admissions) £266 million

Note 1. Number of undernourished in-patients. Reports have shown that up to50 per cent of surgical patients admitted(4) and 44 per cent of medical admissions(5) are under-nourished. These two patientgroups represent 70 per cent of totalinpatients. We have assumed 10 per centof all admissions to ensure that the calculation isbased on a conservativeassumption.

Note 2. Potential Reduction in hospitalstay. Published figures (9,10,45,52,53)show a range between 5 and 16 days, the lower limit is taken as the mostconservative number.

Note 3. Average increase in cost of feeding for 14 days. We have assumed that:

65 per cent are sip fed with 1 litre of I .5Kcal/ml enteral feed per day;

25 per cent are tube fed with 2 litres of 1.0Kcal/ml enteral feed per day;

10 per cent are parenterally fed for 14days.

The average cost per day is £19 includingan incremental one hour per day ofnursing time (nutrients alone £7 per day)

Note 4. The cost per day for an inpatientcare. This is usually quoted at between£100-£200 for general wards and between£500-£1000 for critical care units. Weassumed an average cost of £150 per day.

Note 5. The number of inpatients. This isbased on 2.3 million medical admissions(minus 15 per cent for day cases), 4.0million surgical admissions (minus 25 percent for day cases) and 0.5 milliongeriatric admissions.

Appendix H: Membership of the Working Party

Dr S P Allison MD FRCP Consultant Physician EditorUniversity Hospital Nottingham Clinical. Nutrition

Miss P Brown BSc RGN Manager, Primary ServicesRHV NDN Riverside Health Authority

Mr K Cottam Divisional ManagerAbbott Laboratories Ltd

Dr M Elia MD MRCP Head, Adult ClinicalNutrition GroupMedical Research CouncilDunn Clinical Nutrition Centreand Hon. Consultant PhysicianAddenbrooke's Hospital Cambridge

Miss J Field RGN Clinical Nutrition Sister SecretaryUniversity Hospital Nottingham National Nurse

Nutrition GroupRoyal College of Nursing

Miss C Holden RGN RSCN Clinical Nurse Specialistin NutritionBirmingham Children's Hospital

Mrs J P Howard SRD District Dietitian ChairBristol Royal Infirmary Parenteral Enteral British Dietetic Association Nutrition Group

Prof I D A Johnston MCh Professor of Surgery ChairHonFACS FRCS University of Newcastle Clinical Metabolism and

Nutrition Support GroupOf the Nutrition Society

Prof J E Lennard-Jones (Chair)MD FRCP Consultant Gastroenterologist

St Mark's Hospital, London

Mr M J McMahon PhD Consultant Surgeon British Representative ofChM FRCS The General Infirmary Leeds the European Society of

Parenteral and Enteral Nutrition

Dr N Melia MSc MRCP (Observer) Department of Health

Mr M Mughal ChM FRCS Senior LecturerDepartment of SurgeryHope HospitalSalford

Dr P Milla MD FRCP Senior LecturerInstitute of Child Health .Hospital for Sick ChildrenGreat Ormond StreetLondon

Dr M Nielsen FFARCS Consultant in Charge Member of Council,Intensive Care Unit Intensive Care Southampton General Hospital Society

Mrs C A Russell SRD District Dietitian ChairNorthampton General Hospital Parenteral and

Enteral Nutrition Group

Dr D B A Silk MD FRCP Joint DirectorDept of Gastroenterologyand NutritionCentral Middlesex HospitalLondon

Mr T Sizer B Pharm (Hons) Director SectretaryMR Pharm S Pharmaceutical Production National Total

Cheltenham General Hospital ParenteralNutrition Group

Mrs C Wheatley Patient SecretaryPatients on Intravenous and NasogastricNutrition Therapy

Miss S Wood RGN Dip N Clinical Nurse Specialist inNutritionSt Mark’s HospitalLondon

Ms P Wright B Pharm Principal Pharmacist ChairWest Middlesex University National Total Hospital Parenteral NutritionLondon Group

Administrative Support Project OfficerMiss C Davis King’s Fund Centre for Health Services Development