Implementation of an electromagnetic imaging system to facilitate nasogastric and post-pyloric feeding tube placement in patients with and without critical illness.

BACKGROUND: Artificial nutrition support is required to optimise nutritional status in many patients. Traditional methods of placing feeding tubes may incur clinical risk and financial costs. A technique facilitating placement of nasogastric and post-pyloric tubes via electromagnetic visual guidance may reduce the need for X-ray exposure, endoscopy time and the use of parenteral nutrition. The present study aimed to audit use of such a system at initial implementation in patients within an acute NHS Trust. METHODS: A retrospective review was undertaken of dietetic and medical records for the first 14 months of using the Cortrak system. Data were collected on referral origin, preparation of the patient prior to insertion, placement success rates and need for X-ray. Cost analysis was also performed. RESULTS: Referrals were received from primary consultants or consultant intensivists, often on the advice of the dietitian. Fifty-nine percent of patients received prokinetic therapy at the time of placement. Thirty-nine tube placements were attempted. Sixty-nine percent of referrals for post-pyloric tube placement resulted in successful placement. X-ray films were requested for 22% of all attempted post-pyloric placements. Less than half of nasogastric tubes were successfully passed, although none of these required X-ray confirmation. The mean cost per tube insertion attempt was 111 pounds. CONCLUSIONS: This system confers advantages, particularly in terms of post-pyloric tube placement, even at this early stage of implementation. A reduction in clinical risk and cost avoidance related to X-ray exposure, the need for endoscopic tube placement and parenteral nutrition have been achieved. The implementation of this system should be considered in other centres.

Dietetic service provision for burn care in the United Kingdom: are nutrition support standards being met?

BACKGROUND: Catabolism and lean body mass losses in severe burn injury present an extreme challenge to the dietitian. A high level of nutritional intervention is often required, but service levels have not been described in the UK. This study aimed to identify levels of current dietetic services with respect to burns and to assess adequacy against existing nutrition support standards. METHODS: A postal survey of 34 UK dietetic departments known to provide care to burned adult and paediatric admissions was undertaken. Data were collected on burns settings, hospital service characteristics, staffing and caseload issues, and absence cover. Comparison was made between funding and activity to National Health Service standards for the nutritional care of inpatients. RESULTS: The response rate was 71% and data were analysed for 20 departments Clinical settings were either burn units or plastic surgery wards. Dietetic care was provided to critically ill burned patients in 16 hospitals. Most hospitals had no dietetic funding assigned for burn care. The funding deficit for critical care compared to recommendations was 5.9 full-time equivalents and no individual hospital met funding standards. Thirty-seven percent of dietitians were unable to provide daily follow up for critically ill patients. Absence cover was limited in 60% of cases. Approximately one-third of dietitians were members of a nutrition support team. CONCLUSIONS: Compared to national guidelines for nutrition support, deficiencies of dietetic service provision exist within UK burns settings. This is further reinforced when practice is compared with existing multi-professional burns management standards.

Nutrition support in major burn injury: case analysis of dietetic activity, resource use and cost implications.

BACKGROUND: Patients with major burn injury are among the most catabolic and nutritionally vulnerable of all hospital admissions. A considerable amount of dietetic intervention is often required. To date, UK practice has not been described in detail. This study aimed to identify nutritional interventions, resource use and associated costs for a typical patient admitted with major burns. METHODS: A 28-year-old male with 43.5% total body surface area flame injury was selected for study. Dietetic, medical and pharmacy records were reviewed for data regarding nutritional status, interventions and product use. Costs of dietetic staffing, nutrition support products, related ancillary items and hospital food provision were calculated. RESULTS: The patient required 68 days of nutrition support, including 40 days of nasogastric tube feeding. Seventy per cent of bedside reviews resulted in dietetic intervention. Initiation of nutrition support, substrate use, and frequency of biochemical and weight monitoring were largely in compliance with practice guidelines. Overall cost of nutritional care for the inpatient episode was pound 1377. CONCLUSION: Work is now required to assess current nutrition practices across different UK centres and for a range of burn severities, to establish a baseline from which resource and financial requirements can ultimately be developed.

Adequacy of dietetic service provision to adult critical care: a survey of 33 centres in Northern England.

BACKGROUND: Nutrition interventions improve morbidity, mortality and length of stay in the critically ill. Dietitians play a central role in facilitating these interventions. However, data regarding the current level and adequacy of dietetic service provision to critical care in the UK is lacking. This study aimed to clarify current service trends in Northern England for critical care, in relation to dietetic funding, grading and activity characteristics and comparisons with nationally recognized standards of care. METHODS: A work profile questionnaire was sent to 53 dietitians in Northern England. Data was collected on funding, activity patterns, organization of nutrition support, pay banding/grade and arrangements for cover during absence. RESULTS: The response rate was 66% (35/53). Thirty-three hospitals were represented. No critical care centre funding or actual activity achieved national guidance for funded dietetic full-time equivalents (FTE). Total sample deficit for funding against recommendations was 32.9 FTE. Staff pay bands/grades were inconsistent. Routine patient review occurred on a daily basis by 31% dietitians and 23% were members of a nutrition support team. Cover during absence was limited or provided by a dietitian at a lower staff grade in 67% of centres. CONCLUSIONS: Serious deficiencies exist in dietetic services to critical care in the sample studied. Further work is now required to identify inter-regional and national trends and to define appropriate dietetic job profiles for critical care.

Immune modulating nutrition support for a patient with severe toxic epidermal necrolysis.

Toxic epidermal necrolysis (TEN) is a rare but serious condition with a high mortality rate, whose clinical features resemble major thermal injury. Nutritional substrates which can affect the immune response have been shown to benefit burned and critically ill patients but there is a lack of data in the TEN literature. A case study is presented of a 63-year-old female admitted to our burn unit with extensive skin and mucosal involvement. Immune modulating artificial nutrition support was given initially via the parenteral route and then the nasogastric route. Maintenance of the patient's nutritional status and clinical outcome suggest that there may be a role for this type of intervention in TEN.

Audit of successful weight maintenance in adult and paediatric survivors of thermal injury at a UK regional burn centre.

BACKGROUND: Thermal injury is associated with significant weight loss, particularly of lean body mass. Weight loss increases the risk of morbidity and increased length of stay (LOS). Appropriate nutrition support can improve these outcomes. The aim of this audit was to evaluate the success of nutrition intervention in minimizing weight loss in adults and children with thermal injury. METHOD: Patients referred for nutrition support were monitored for weight change during their inpatient care episode. Sixty cases met the study criteria. Admission and discharge weight profiles were identified. The degree of weight loss was calculated. Comparison was made to a recognized standard of acceptable weight loss. RESULTS: On admission five (13.2%) adults were found to be clinically underweight. All children were within the acceptable weight percentile range. Adults demonstrated higher (mean +/- SD) percentage weight loss (8.1 +/- 6.0%) than children (4.7 +/- 4.5%). About 76.7% of all cases met the standard used. More children (95.5%) met the standard than adults (65.8%). CONCLUSIONS: Most subjects maintained weight within an acceptable limit during the inpatient episode. Children appeared particularly successful at weight maintenance. Reasons are multifactorial and warrant further investigation.