Reduced 30-day gastrostomy placement mortality following the introduction of a multidisciplinary nutrition support team: a cohort study.

BACKGROUND: Percutaneous endoscopic gastrostomy feeding allows patients with dysphagia to receive adequate nutritional support, although gastrostomy insertion is associated with mortality. A nutrition support team (NST) may improve a gastrostomy service. The present study aimed to evaluate the introduction of a NST for assessment and follow-up of patients referred for gastrostomy. METHODS: We included adult inpatients referred for gastrostomy insertion consecutively between 1 October 2010 and 31 March 2013. During the first 6 months, a multidisciplinary NST assessment service was implemented. Patient characteristics, clinical condition, referral appropriateness and follow-up were documented prospectively. We compared the frequencies of appropriate referrals, 30-day mortality and mental capacity/consent assessment time spent between the 6 months implementation phase and 2 years following establishment of the assessment service ('established phase'). RESULTS: In total, 309 patients were referred for gastrostomy insertion and 199 (64%) gastrostomies placed. The percentage of appropriate referrals rose from 72% (61/85) during the implementation phase to 87% (194/224) during the established phase (P = 0.002). Thirty-day mortality reduced from 10% (5/52) to 2% (3/147) (P = 0.01), whereas time allocated to assessment of mental capacity and attainment of informed consent rose from mean 3 days (limits of normal variation 0-7) to mean 6 (0-13) days. CONCLUSIONS: The introduction of a NST to assess and select patients referred for gastrostomy placement was associated with a rise in the frequency of appropriate referrals and a decrease in 30-day mortality following gastrostomy insertion. Concomitantly, time spent on patient assessment and attainment of informed consent increased.

Quality and safety impact on the provision of parenteral nutrition through introduction of a nutrition support team.

BACKGROUND/OBJECTIVES: Parenteral nutrition (PN) should be provided to the malnourished patient if enteral feeding is insufficient or unsafe. A nutrition support team (NST) may improve PN services. We compared the use and complications of hospital PN before and after the implementation of an NST. SUBJECTS/METHODS: All inpatients referred for PN outside of the intensive care unit and the intestinal failure unit were prospectively included from 2009 to 2012. The NST was introduced in 2010. Quality improvement methodology was applied. RESULTS: In 2009, a mean of 16 (limits of normal variation 4-28) patients were referred for PN each month. After introduction of the NST, this rose to 26 (10-42) referrals per month. The percentage of referrals where PN was not initiated increased from 5.3% in 2009 to 10.1% in 2012 (P=0.03). This increase was restricted to teams that infrequently referred for PN, and enteral nutrition could replace PN in 31 of 51 patients (61%) as compared with 8 of 32 (25%) patients referred from teams that frequently referred for PN (P=0.001). The frequency of PN started owing to an insufficient oral or enteral intake decreased from 11% to 3% (P=0.01). The catheter-related bloodstream infection rate dropped from 6.7 to 0.7 episodes per 1000 catheter days (P<0.001). CONCLUSIONS: Introduction of an NST increased both the total PN use and the percentage of referrals where enteral nutrition could replace PN. Medical specialty influenced the referral pattern and the likelihood that a referral resulted in PN being initiated. Safety of PN catheters improved significantly following NST introduction.

Nutritional screening of elderly patients: a health improvement approach to practice.

INTRODUCTION: Almost 60% of elderly care in-patients are at risk of malnutrition. Malnourished patients have poorer clinical outcomes and this is a key factor with respect to prolonging the length of stay. Since 2003, the Malnutrition Universal Screening Tool (MUST) has been advocated as a method for identifying these at-risk patients. Screening should take place on admission; however, the Trust has set a stretch target of aiming to document the score accurately within 6 h of admission. METHODS: Three 'care of the elderly' wards participated in the project. Each month, the timeliness (within 6 h of admission) and accuracy (compared to a dietician assessment) of the MUST scores on the wards were reviewed. Plan-Do-Study-Act cycles were used to rapidly test changes in the ward areas. Tests included a study day, one-to-one ward-based nutrition training, a focus on the use of alternative anthropometric measurements, the development of a training pack and the identification of the challenges for undertaking accurate and timely assessments. RESULTS: Baseline data identified that a MUST was documented in <60% of patients within 6 h of admission and that only 70% were accurate. After implementation of the change package, all the wards achieved an improvement and documented MUST within 6 h of admission; one ward achieved 90% accuracy in the scores. CONCLUSIONS: Ward teams receiving training and monthly feedback of their results creates ownership, momentum and maintains enthusiasm for striving to reach stretch targets. The team continues to work on improving accurate nutritional screening across the Trust by using quality improvement methodologies.

The influence of surface charge on the attachment of Neisseria gonorrhoeae to human cells.

Isoelectric focusing showed that Neisseria gonorrhoeae has an overall negative surface charge. Chemical modification of protein amino or carboxyl groups changed the surface charge and thereby altered the ability of the organisms to attach to human amnion cells grown in tissue culture. Attachment of modified and unmodified N. gonorrhoeae was increased by the presence of pili only when the bacteria bore a negative surface charge. Thus an important factor in the pathogenesis of gonorrhoea may be the ability of pili to facilitate attachment of N. gonorrhoeae by overcoming the initial electrostatic repulsive barrier which exists between it and the host cell.