National Nurses Nutrition Group Newsletter • Conference Special • 2014

September 2014

www.nnng.org.uk

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Chair’s WelcomeLiz Evans, Chair of the NNNG

The NNNG conferences are always successful and enjoyable and everyyear the committee think “how on earth can we top this next year?” Wehave done it again; this year’s conference was fantastic! We had anextremely high calibre of speakers and this year, for the first time, we wentinternational with a video link from patients in New Zealand and Australiawho spoke of their experiences on home parenteral nutrition.

The venue was wonderful – Chesford Grange Hotel, set in the heart ofWarwickshire countryside, added to the general ambience of the two days.It was wonderful seeing all of you and I do hope you had the chance tonetwork and visit all of the many exhibits. We are extremely lucky to havesuch good attendance from our industry colleagues and I would like tothank them, once again, for coming to support us. I would also like to thankMark Allen, our conference organisers, for doing such a grand job.

The posters were, once again, popular with 10 being exhibited thisyear. It was hard to judge and I would like to thank Hazel Rollins and GilHardy for taking the roles and carrying them out so well.

The AGM was well attended and it was decided that we would continueto have our conferences in the summer. It was reported by all present thatthey preferred the timing to be earlier in the year.

For me, among the many highlights of the conference, was seeing allof my colleagues relax and enjoy themselves – both during the day and inthe evening. Our jobs are hard, we put 110% into them and I do think itis nice to be able to take a step back, learn, reflect and refresh – I hopethat our conference does that for you all.

The evaluations were largely positive with suggestions for next yearand, being member-led, we aim to give you what you want. Suggestionsfrom the previous conference always shape the next one and we alreadyhave some ideas!

I do hope all of you who attended enjoyed yourselves and returnedto work refreshed and ready to put some of what you learnt into practice.Next year’s conference will be in July – date and venue to be confirmed.I hope to see you all then!

NNNG National Conference 2014Compiled by the NNNG Committee

Nutrition Updates: The national pictureLiz Evans, Nutrition Nurse Specialist, Bucks Healthcare NHS Trust/Chairof NNNG

Liz began the proceedings by welcoming delegates and setting thescene by providing an overview of reports and initiatives releasedover the past twelve months and discussed their impact upon the waywe currently provide nutritional care. High profile work streams and

publications include: The Hospital Food Standards Panel; Sign up toSafety (NHS England 2014); Nutritional Care and The Patients Voice –are we being listened to?; DH One Chance to Get it Right: aiming toimprove the patients experience in the last few hours or days of life;EPIC 3, Royal College of Physicians Top Ten Tips for Nutritional Care;and BAPEN’s Malnutrition Matters – A Commitment to Act.

Day 1

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Key Note Address: Eating and Drinking:Making a meaningful impactMarie Batey, Head of Acute & Older People, National QualityImprovement and Care Team, NHS England

Marie in her key note presentation began by reflecting on her feedingexperience as a student nurse back in the 1980s and how, since then,there has been a plethora of policy and resources which, althoughdeveloped to raise awareness and improve practices, can be difficultto implement in practical terms due to a variety of reasons. Varioushigh profile reports, such as the Mid Staffs enquiry, have highlightedtrust and confidence issues; the Care Quality Commission reportshave asked: “Has NHS care lost its way?”

Marie shared details of national strategy and vision, andreferred to Compassion in Practice 2012 where the 6Cs formthe values essential for compassionate care. Marie is leading anational initiative which targets six action areas around the 6Cs.Acknowledging the deleterious effects of malnutrition and underhydration, Marie highlighted that good nutrition and hydration careshould be safe, effective and, ultimately, provide a positiveexperience, promoting dignity, independence and confidence incare. Marie provided an update on the work of the HospitalFoods Standards Panel, NHS England Leadership and Direction,and the 6Cs Live! Communication Hub where individuals cansign-up and stay connected and become involved in a range ofactivities – including making a pledge, becoming a 6C’s Livechampion, submitting a story of the month. Visit the 6Cs Live!Communication Hub: www.6cs.england.nhs.uk; follow on Twitter@6CsLive #6CsLive; email: england.sixcslive@nhs.net. The 6C’s are forEVERYONE.

Patient Best Interest in Nutrition: The use ofrestraint devicesMark Capstone, Nutrition Nurse Specialist, University Hospital ofWales, Cardiff

Mark began by highlighting some of the potential challengeswhen attempting to feed patients with nasogastric tubes whenthere are compliance issues. Mark provided the background to theuse of nasal bridles (retaining) and presented audit data whichdemonstrates the increase in bridle use over the past seven years.Hand mittens (Posey) were introduced in 2009 and have beenused since as a way to restrain patients from removing tubes.Mark shared an example of the care plan used in his Trust; this wasreviewed and refined following audit that demonstrated poorcompliance with legally binding documentation; a third audit isplanned.

Hot TopicsNeil Wilson, Senior Lecturer and Academic Lead for AdmissionsPre-Registration Adult Nursing, Manchester Metropolitan University

Once again, this session proved to be very popular and generatedmuch discussion and debate around a range of topics. Neil hadchosen the topics for discussion from issues that were raised bymembers on the NNNG google groups forum.Topics included:• Subcutaneous ports and their use in those requiring parenteral nutrition >5 times per week: practices and appropriateness

• Gastrostomy extension sets: how should they be cleaned and howoften should they be replaced?

• Routine replacement of balloon gastrostomies used as jejunostomyfeeding tubes: where should they be placed (community or hospital), by whom and the procedure for checking tube position

• The Hydrant drink vessel: what is the experience?The one common theme throughout all the these discussions wasit was clear that there are differences of opinion and practicethroughout the UK, and more rigorous research and accuratepresentation of results is required to provide clarity for nurses andto drive down variance in practice.

Dementia SymposiumDementia: The disease, its management and nutritional perspectivesDaryl Leung, Clinical Director of Elderly Care, and Sue Merrick TeamLeader, Nutrition Support, New Cross Hospital, Wolverhampton

Daryl and Sue presented how dementia affects a person’s ability toeat and drink and the nutritional perspectives to be consideredwhen caring for them. They are endeavouring to educate hospitalstaff to provide a homely environment and involving relatives in thenutritional support of their patients.

Strategies of Managing Nutrition in DementiaSheena Wylie, Director of Dementia Services, Barchester Healthcare

Sheena outlined how Barchester manage nutritional support in theircare home Memory Lane communities. Sue discussed the importanceof person-centred approaches to nutritional support and findingout a person’s likes, dislikes and what their abilities are. Sheena thenwent on to introduced the initiatives that Barchester are using toensure that food and fluid intakes are met, whilst caring for peoplein a residential setting.

Caring for a Relative with DementiaAnn Marie Harmer, Dementia Care Specialist, Barchester Healthcare

Ann Marie discussed her experiences of caring for a close relativewho was living with dementia. She delivered the personal versus theprofessional perspective with poignancy and humour but stressedthe importance of remaining the relative alongside understandingindividual needs and wishes and not imposing our professionalbeliefs and knowledge upon the person.

Breakfast SymposiumAn introduction to the Baxter Education Centre (BEC): A uniqueeducation support for patientsLynda Hedgecock, Lead Nurse Regional Manager, and Janet Wild,Head of Therapy & Clinical Development, Baxter Healthcare Ltd.

Lynda and Janet presented an overview of the history of BEC, theethos and training model, evidence of success. The centre wasestablished in 1991 and was originally set up to train Baxter Renalpatients on continuous ambulatory peritoneal dialysis. However itproved so successful that the service was expanded in 2012 toaccommodate patients on home parenteral nutrition. Previous BECpatient, Lisa Blewitt and her husband Jon were also interviewed ontheir experience of BEC. They spoke glowingly of the service, thecare and empathy of the staff and how it really had transformed theirlives as a family. Lisa described BEC as being like a hotel only with alot of hard work. They said that they found the support and traininggiven, along with the follow up and after care second to none. Therewas good discussion amongst all regarding the need to standardisepractices around HPN and the need for a national protocol; a workstream is being developed to address this.

PN SymposiumIntestinal Failure and the Liver (kindly reported by Lynne Colagiovanni)Dr JeremyNightingale, Consultant Gastroenterologist, St Mark’s Hospital,London

The first half of Jeremy’s talk, which was on intestinal failure (IF), wasa succinct and useful review of the subject, including an overview ofthe different classifications of IF helpful to those new to the area.

Day 2

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However, it was probably the second half of his presentationdiscussing the relationships between PN and the liver that manynutrition nurses would have found interesting and helpful in theireveryday practice. A rise in liver function tests (LFTs) oftenaccompanies those acutely ill patients receiving PN and Jeremyclearly outlined which individual LFTs may be involved and what thecauses of these increases might be. Although some of our colleaguesmay be quick to blame PN for increased LFTs, Jeremy reminded usthat the key culprits in the acutely ill are more likely to be infectionor medication and these should be excluded before consideringany changes to the PN regimen. The talk concluded with Jeremyreviewing the various types of lipid solutions available and how thesemight be used in those patients for whom other causes of raised LFTshave been excluded and PN may be a contributing factor.

Comparison of HPN in Australia, New Zealand and the UKProfessor Gil Hardy, Massey University, New Zealand

Gil Hardy presented an interesting and often funny tale of theprogress in the provision of parenteral nutrition to adults and childrenin Australasia. He talked about the increasing number of patientson HPN, describing the difficulties they experience in living in ruralenvironments with differing funding systems and equipment costsand provision. Gil spoke about the differences patients living in NZand Australia experience with compared to patients in the UK, andhighlighted the collaborative work undertaken with PINNT in settingup a patient support group Parenteral Nutrition Down Under (PNDU).Gil then shared details of recent survey exploring patient experiencesof connection procedures and support from healthcare facilities.Concluding his presentation, Gil suggested recommendations toimprove the care of patients on PN in Australasia, includingstandardising techniques and procedures and implementing onenational model of care and, something that we will all recognised,communication

Living with HPN and Caring for a Child on HPN Down UnderKaren Winterbourn (via video), PNDU, and Shirley Davy, HPN Caregiver,New Zealand

Karen Winterbourne, regaled delegates with her experience ofliving with HPN in Australia. Without the support of a national healthservice, Karen discussed issues she had experienced in obtainingfeed and equipment in the Australian summer. She talked about herexperiences of travelling with PN and her role in PNDU to supportother patients.

Shirley discussed the issues that she had to deal with on a dailybasis in caring for her son who required nutrition support. She talkedabout the regular hospital admissions and the impact that caring fora child requiring nutrition support had upon the family unit.

These sessions were very powerful and emotive and remindeddelegates of the importance of treating all patients like individualsand recognising the difficulties they faced. It was interesting to seethe differences in service provision between the UK and Australia –but also the similarities as well. It is to be hoped that as a result ofthis session, there will be some much closer working with both PNDUand PINNT to try and improve patient experience.

Transitional CareHazel Rollins CBE, Clinical Nurse Specialist Gastroenterology andNutrition, Luton and Dunstable University Hospital NHS Trust

Hazel set the scene by providing an overview of some of theunderlying paediatric conditions within the service, clearlyhighlighting the difference compared to adult care. In contrast to apure ‘transfer’, transition is the purposeful, planned movement ofadolescents and young adults to adult services which often takesplace over a complex timeline when the patients gut function isdeteriorating (e.g. in individuals with cerebral palsy). Hazel illustratedthe need for a variety of tools and resources for successful transition,which included a key worker, transition coordinator, planningmeetings, transition pathway documentation, enteral caseload

management, and a range of transition competencies. To avoidnegative experiences where the patient/family may perceive a loss ofrelationships and/or services and may question why the move to adultservices is needed at all, communication across the board, planningand sharing experience is essential to develop effective transitionservices and improve patient and family experience. Transition isrecognised as a quality issue for the NHS and a NICE guideline isin development.

Liquidised Enteral Tube FeedingA Risk Assessment Tool for the Administration of a Blended DietAilsa Kennedy Home Enteral Feed Lead, Community Nutrition SupportDietitian, PENG & BDA

Ailsa gave background information that has led to the developmentof a risk assessment tool for the administration of a blended diet.Although this practice would not be advocated as a routinealternative to prescribed pre-packaged formula, it is now becomingmore prolific and many parents are becoming increasingly aware ofthis practice and choosing this method of feeding. More research isneeded in this area to explore the benefits/risks.

Providing a Blended Diet – The carer’s perspectiveNicole Watson, parent of Lucy Watson

Nicole provided a thought provoking insight into the experience ofproviding a blended diet to her child Lucy. Many present admittedthat it did change their perception of blenderised food and could seethe improvement of the quality of life to patients. It was concludedthat more discussions and recommendations were needed as this wasnot something that was going away.

Practicalities of Blended Food and Enteral Feeding TubesJane Fletcher, Nutrition Nurse Specialist, Queen Elizabeth Hospital,Birmingham, and Neil Wilson, Senior Lecturer and Academic Lead forAdmissions Pre-Registration Adult Nursing, Manchester MetropolitanUniversity

This was a highly entertaining session but did raise an importantpoint of the need for good equipment. Jane used an ordinary handblender and really did have to dilute the food a lot to get it to theright consistency for tube feeding. Nicole said that she had a highperformance blender and, therefore, did not have to add suchamounts of fluid. It was suggested by audience members thatadding such high amounts of fluid to food could prove problematicalas the patient may not be able to cope with that amount of food inthe stomach at once.

Poster presentations Ten posters were received by delegates for display. Of those, nineposters were presented over lunchtime on both days. This gavedelegates the opportunity to discuss a piece of their work to asmall but interested audience (the 10th poster was written byGil Hardy and was discussed within his presentation). The posterspresented were entered into a prize draw to receive fundingtoward an educational event. Judging of posters was undertakenby Hazel Rollins and Gil Hardy.

The winning poster was submitted and presented by FfionJones, Nutrition Nurse Specialist, University Hospital of Wales, whowon £250 for her work which addressed Improving Patient Safetyby Reducing the Number of Chest X-rays Required to ConfirmNasogastric (NG) Position. Trish Parnell, Nutrition Nurse at StMark’s, presenting on behalf of Mia Small, Nurse Consultant,St Mark’s, won £150. Trish presented The Effect of 70% IsopropylAlcohol Port Protection on Central Venous Catheter RelatedInfection in Patients on Home Parenteral Nutrition. Ilva Jones,Enteral Nutrition Technician, won £50 for her poster Dignity andIndependence – A recipe for success.

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