Evaluation of a new enteral feeding tube nurse clinic at the Weston Park Hospital Radiotherapy department

The Trust provides cancer services for patients across the region. Approximately 300 patients each year receive radiotherapy for head and neck cancer, approximately 50% of these patients have enteral feeding tubes placed. Historically, Dietitians provided support for all patients with enteral feeding tubes receiving radiotherapy treatment and the local nursing service provided by the enteral tube feeding contract provider provided community clinical support. Due to increasing patient numbers and increased Dietetic workload, a new “enteral feeding tube nurse clinic” was introduced, run by the local enteral tube feeding homecare nurse, with the intention of supporting patients with enteral feeding tubes. This clinic has been running since 2019 and is a “drop-in clinic” which both staff and patients’ can access for support, including troubleshooting advice on feeding tubes, moving patients from bolus feeding to pump feeding or even giving patients reassurance that they are caring for their enteral feeding tube correctly. This is a unique service built in conjunction with the Dietetic team, designed to meet local patient’s needs. In 2020 a review took place to evaluate the level of patient satisfaction of care from the enteral feeding tube nurse clinic, to establish the confidence of patients in caring for their feeding tubes and to explore feedback from patients to develop the service further. The review took the form of a patient questionnaire, given to patients during the last week of their radiotherapy treatment. Survey questionnaire forms assessing: the patient’s satisfaction with the support and service (5-point scale: 1 not at all satisfied -5 very satisfied);how confident they felt after receiving the support (5-point scale: 1 not at all satisfied -5 very satisfied), and;about their experience overall (free text), were handed out to patients in clinic over a 6-week period. The questionnaire was completed by 12 patients. For satisfaction with the support and service 10/12 (83%) of patients scored 5: very satisfied, with the remaining 2 patients scoring 3: neutral. Comments from patients included: “nurses always willing to help”, “excellent nurses, great, quick, professional job-no fuss”, “help available whenever it is needed”, “very happy with the care provided”, “every time I have requested their help, I have had a prompt reply and always each problem has been addressed”. For confidence with enteral tube feeding procedures, 100% of patients scored 5: very confident. Comments from patients included: “I feel much happier with the tube”, “very confident in cleaning and rotation, and excellent instructions from nurses”. When asked about their experience overall, patient comments included “Thank you for all your support”, “expert care, friendly, informative”, “fantastic prompt treatment”, “grateful that I have had the support”, “friendly, professional staff are always willing to help and always have said ‘if you need me, just ask, at any time”. Due to Covid-19 the clinics had to temporarily stop, however the Dietitians and Consultants missed the instant and direct access to the homecare nurse for enteral feeding tube support, suggesting that the clinic was also highly valued by the healthcare professionals working at the clinic. In August 2021 the clinics started again and there are plans to expand the service later this year. In summary, the enteral feeding tube nurse clinic was positively evaluated by the patients attending the radiotherapy clinic. The overwhelming feedback was that having contact with an enteral tube feeding homecare nurse at least weekly throughout their radiotherapy treatment allowed them to have rapid access to support, advice, reassurance, and training if their feeding requirements changed. Due to the success of this clinic, development of similar clinics in other areas should be considered.

The development and use of e-learning modules to support care home staff caring for enterally tube fed patients

Education is increasingly being accessed digitally, as demonstrated by the success of e-Learning for Healthcare or e-LfH, a health education England programme developed in partnership with the NHS and professional bodies1. Within digital learning, e-learning is a popular medium as it offers users an opportunity to learn at one’s own pace, at a convenient time and place, revisiting as often as required, giving flexibility, and freedom to continue a professional development journey. A plan was therefore formed to develop e-learning to provide important support for enteral tube feeding for care home staff in a simple, convenient, and easily accessible format. Before development of the e-learning, qualitative and quantitative research was undertaken with key stakeholders to assess the acceptability of e-learning for care home staff in the field of enteral tube feeding. Following launch of the e-learning, views and feedback were analysed. Qualitative interviews were conducted with six care home managers across the UK to understand the challenges faced in providing education on enteral tube feeding for care home staff. Difficulties identified included: releasing staff from day-to-day activities;high turn-over of staff resulting in frequent training required for new employees;access to workplace digital devices, and;staff unable to complete their full duties until training was completed and documented. An online survey was conducted to gain quantitative information from an enteral tube feed companies’ homecare nurse team to evaluate the concept of online e-learning for care home staff. 13 homecare nurses responded, (approx. 10%) and 80% felt online training would be valuable for care home staff. Using these learnings an enteral tube feeding e-learning course was developed by the company’s homecare nurse team consisting of six, short interactive modules. Six Dietitians across the UK in both acute and community settings were consulted on the content, which they reviewed and refined ensuring a balanced view of practices and procedures were included. COVID-19 accelerated the requirement for online learning as face-to-face activity and care home access was restricted and the modules were launched earlier than planned in March 2020. A simple registration process granted access to the modules through a variety of electronic devices such as tablets and laptops. Between March 2020 to July 2021, 5,152 individuals registered and completed at least one module, with 3,661 (71%) completing the introductory course and the first 3 modules. Several NHS Trusts have added the e-learning link to their intranet sites as mandatory training for new starters. Feedback has been positive: “E-learning is going down a treat at the moment”;“11 of my staff completed the training. We found it really useful, the system was easy to navigate, gave us information that we didn’t know and helped us to understand the different types of feeding systems available. I would recommend this training as we all felt it gave us more confidence in supporting a person using a feeding system”. The high uptake of the e-learning and positive feedback demonstrate that these e-learning modules are a popular and acceptable form of education for care home staff and are suitable to be used across a variety of settings. The initial research helped to ensure that the e-learning modules which were developed, fully met the needs of care home staff and therefore provide important support in a simple, convenient, and easily accessible format. References 1. e-Learning for Healthcare.

Critically ill patients with and without SARS-CoV-2 better achieve energy and protein targets with a high-energy, high-protein peptide-based enteral tube feed;insights from a multicentre clinical audit performed during the COVID-19 pandemic

Meeting energy and protein requirements in critically ill patients is important for prognosis, yet difficult to achieve as a consequence of disease, management and/or altered nutritional intake[1]. Improvements in achieving energy and protein requirements with a high-energy, high-protein peptide-based tube feed were observed in community patients with impaired gastrointestinal function[2]. To establish whether this remained true in the critical care setting, where feeding intolerance is observed frequently in patients with[3] and without SARS-CoV-2[4], a retrospective multicentre audit was performed. Adults (> 18years) with or without SARS-CoV-2, admitted to critical care across 6 UK hospitals between May 2020 and December 2020, were retrospectively included if they received a peptide-based enteral tube feed (Nutrison Peptisorb Plus HEHP®, Nutricia Ltd), containing 1.5kcal/ml and 7.5g protein/100ml (herein referred to as HEHP). Data were collected from 15 critically ill patients (52±12y;87% male), with mean length of hospital stay being 26days (range: 7-49days). Of these, 10 were SARS-CoV-2 positive, with the remainder having pancreatitis (n=3), delayed gastric emptying (n=1) or unconfirmed diagnosis (n=1). HEHP was used second line (after whole protein) and indications (multiple were cited for some) for use included tolerance issues (n=10), elevated energy and protein requirements (n=5) or due to primary diagnosis (n=2). Estimated energy and protein intakes (% of requirements achieved) were recorded before and during use of HEHP. In addition, Dietitians were asked whether HEHP allowed patients to better meet their nutrient target Mean intake of HEHP was 2008±461kcal/day and 100±23g protein/day provided over a mean of 12days (range: 3-29days). The percentage of estimated energy and protein targets achieved increased albeit non significantly with the use of HEHP (from 76% before vs 87% during use of HEHP for both) and the direction of effect remained true regardless of SARS-CoV-2 status. Two thirds (67%, n=10 of 15) of Dietitians reported HEHP helped patients better meet their nutrient targets and 87% (n=13 of 15) of Dietitians perceived the high protein content of HEHP as beneficial for this patient group. Gastrointestinal tolerance (anecdotal reports) remained largely unchanged in approximately half of SARS-CoV-2 positive patients when using HEHP yet improved for others including non-SARS-CoV-2 patients. Enteral tube feeding in critically ill patients poses numerous difficulties, especially in SARS-CoV-2 positive patients. This audit in critically ill patients demonstrates that a high-energy, high-protein, peptide-based enteral tube feed can help complex patients better achieve energy and protein targets in patients with and without SARS-CoV-2. References 1.Pullen K, Colins R, Stone T et al. Are energy and protein requirements met in hospital? Clin Nutr 2017;31(2): 178-187. 2.Green B, Sorensen K, Phillips M et al. Complex Enterally Tube-Fed Community Patients Display Stable Tolerance, Improved Compliance and Better Achieve Energy and Protein Targets with a High-Energy, High-Protein Peptide-Based Enteral Tube Feed: Results from a Multi-Centre Pilot Study. Nutrients. 2020, 12, 3538. 3.Liu R, Paz M, Siraj L et al. Feeding intolerance in critically ill patients with COVID-19. Clin Nutr 2021. 4.Gungabissoon U, Hacquoil K, Bains C et al. Prevalence, Risk Factors, Clinical Consequences, and Treatment of Enteral Feed Intolerance During Critical Illness. J. Parenter. Enteral. Nutr. 2015, 39, 441–448.