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How did the Irish Food Allergy Network (IFAN) come about?
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Paul Manson. Liason/Clinical Librarian, NHS Grampian, Scotland.
Kate Maslin, Allergy Research Dietitian, The David Hide Asthma and…
Niamh Maher, Senior Community Dietitian (Home Enteral Nutrition), HSE Dublin/ North East
Enteral feeding in primary care continues to increase, with patients discharged to home or residential care. Percutaneous endoscopic gastrostomy (PEG) is the commonest method of long term enteral nutrition (Sanders et al., 2001).
Dysphagia associated with head and neck cancer and CVA remain the most common indications for home enteral nutrition (HEN) in adults while the number of dementia patients on HEN is declining (BANS Report, 2010). HEN can allow patients to return to a familiar environment where relationships with family and friends can be resumed and independence restored. However, the rationale for HEN should always be weighed against the patient’s quality of life (CREST Guidelines, 2004).
Successful management of HEN can only be achieved by providing adequate support and follow-up for the patient, their family and health professionals involved in their care (Madigan, 2003). Monitoring of HEN is vital in ensuring that nutritional requirements are met, treatment plans are effective and complications are detected early. Patients on enteral feeding in a primary care setting should be monitored by health professionals with relevant skills and training in nutritional monitoring, who are familiar with the procedures and complications of HEN (NICE Guidelines, 2006).
Community follow-up is often inadequate for patients discharged from hospital on HEN (Lowry & Johnston, 2007). Post-gastrostomy complications range from 8 to 30%. These complications often occur following discharge into the community and may result in hospital readmission (Kurien et al., 2012).
General practitioners and public health nurses feel inadequately trained to manage HEN (Heaney & Tham, 2001) and patients with gastrostomies do not consider that their general practitioners have an adequate knowledge of enteral feeding (McNamara et al., 2000). When community supports are inadequate, dietitians in acute hospitals must continue to monitor and support the patient after discharge, primarily on an outpatient basis.
However, many HEN patients are not mobile or well enough to attend a hospital based clinic (McNamara, 1999), and only limited advice and reinforcement can be provided within the confines of a clinic appointment (Sanders et al., 2001).
Community dietitians trained in HEN can provide home visits to monitor and support patients, troubleshoot feeding tube problems and act as a liaison between community and hospital services (White 2011).
Monitoring Home Enteral Nutrition
Although a patient or carer may be competent to manage their HEN independently, they will require regular monitoring. Many patients find the initial weeks post discharge to be the most difficult, and the greatest numbers of problems are reported during this time (Mensforth, 1999).
The role of the dietitian is changing to include management of non-nutrition related issues associated with HEN such as tube maintenance and stoma care (Madigan 2003). The CREST guidelines (2004) for the management of enteral tube feeding in adults provide standards for monitoring HEN, which include recommendations on frequency of review and parameters to be monitored (Table 2 and Table 3).
All HEN patients and carers should be provided with a contact number for use in the event that any problems arise between scheduled reviews (Madigan 2002).
Monitoring changes in nutritional status can be achieved by weighing patients and calculating BMI at each review. However, this is not always possible in primary care if the patient is unable to stand. Height can be estimated using ulna length, but accessing accurate weights can prove more difficult in bedbound domiciliary patients. An accurate weight can be requested if the patient is scheduled to attend a day centre with hoist facilities or during a hospital or respite admission. Otherwise, alternative measurements such as mid-upper arm circumference must be used to estimate BMI (Malnutrition Universal Screening Tool, BAPEN).
Regular review and revision of feeding regimen is essential where there are changes in clinical condition, tolerance issues or changes in oral intake. The INDI Home Enteral Feeding Resource Pack (2007) provides guidelines on managing feed intolerance in HEN e.g. diarrhoea, nausea & vomiting, abdominal distension and constipation. The nutritional requirements of stable HEN patients, particularly those in residential care can be low, and the volume of feed may be reduced to meet requirements. It is essential to ensure that the feeding regimen remains nutritionally complete in the volume prescribed and that hydration requirements are met with additional water flushes. Where any changes are made to the feeding regimen, a letter to the GP will be necessary to update the prescription.
Dietitians trained in HEN can reduce hospital admissions. This is achieved by unblocking, repairing and replacing tubes in the community, and underpinning the service by training other health professionals, patients and carers to do the same (White et al., 2011). The main causes of feeding tubes blocking are inadequate flushing and build-up of feed/medications. The blocked tube should be irrigated using a 50ml syringe of tepid water, avoiding excessive pressure which may split the tube. If unsuccessful, an enzyme compound (e.g. clog zapper) may be used. The use of pineapple juice or carbonated drinks should be avoided as the pH is too low and may cause the feed to clot. Tubes can be repaired in a primary care setting by replacing clamps, external fixators and Y connectors to maximise the life of the tube.
Regular monitoring of feeding tubes and balloon volume can identify when the tube is perishing and facilitate elective replacement. Dietitians and nursing staff trained to replace G tubes in a community settings can significantly reduce the costs associated with tube displacement. In 2011, 93% of gastrostomy tube replacements in North Dublin were replaced in the patients’ residence, avoiding hospital transfer. For elective replacements, the patient should fast for 12 hours prior to the procedure. Once the new gastrostomy is insitu, feeding should not commence until correct position is confirmed with a gastric aspirate pH<5.5. A spare gastrostomy tube should always be ordered for the patient on discharge to facilitate elective or emergency tube replacement.
The INDI Home Enteral Feeding Resource Pack (2007) provides guidelines on stoma care. The patient and carers should be educated on daily stoma care prior to discharge. The most common stoma related problems are overgranulation, leaking and infection, all of which can be addressed in a primary care setting (Table 4).
Discontinuing Home Enteral Nutrition
The decision to discontinue enteral feeding must be considered in conjunction with the patient and hospital consultant or GP. HEN may be discontinued where oral intake is adequate, where the risk of continuing outweighs the benefits or where further HEN is undesirable to the patient. If the patient is changing over to oral diet, they should be achieving adequate oral intake before HEN is stopped. If the ability to sustain adequate oral intake is in doubt, the tube should remain insitu for an agreed period of time, or until the doubt is removed (CREST guidelines 2004). Tubes with rigid fixation devices must be removed endoscopically but balloon devices can be removed in the community setting once the consultant has given approval.
Enteral tube feeding in the primary care setting can be a challenging task for the patient, their carers and the multidisciplinary team. Standards of care and practice, as well as support, can vary considerably. The management of HEN in the community requires specialist resources, which are rarely provided, resulting in frequent and sometimes inappropriate hospital admissions (Sanders et al., 2001). Successful management of HEN can only be achieved by providing adequate support and follow-up for the patient, their family and health professionals involved in their care (Madigan, 2003). Community dietitians trained in HEN can provide home visits to monitor and support patients, troubleshoot feeding tube problems and act as a liaison between community and hospital services (White et al., 2011).
References available on request