All Wales nutrition screening audit: nephrology inpatients.

Transcription

1 All Wales nutrition screening audit: nephrology inpatients.

2 Starter Malnutrition- a deficiency of energy, protein & other nutrients that causes adverse effects on the body (shape, size & composition), the way it functions & clinical outcomes(must 2003). Major clinical problem in CKD, and in particular ESRD - Reported prevalence in dialysis: 30-50%(Fouque at al, 2011). - Independent predictor of poor clinical outcomemorbidity, mortality, quality of life length of stay

3 Cost implications of Malnutrition The healthcare cost of managing individuals with malnutrition is more than twice that of managing non- malnourished individuals (Guest et al 2011). Tackling malnutrition improves: - nutritional status, - clinical outcomes, and - reduces health care use. (Elia & Russell 2009).

4 Value for money Disease-related malnutrition costs in excess on 13 billion per annum, based on malnutrition prevalence figures & the associated costs of both health & social care(elia et al 2009).

5 B.O.G.O.F NICE CG32 : substantial cost savings can result from identifying & treating malnutrition CG32 is ranked 3 rd in the top clinical guidelines shown to produce savings (NICE 2006). The cost of managing malnutrition using prescribed nutrition support is low: - just 2.5% of the total expenditure on malnutrition (Stratton 2010).

6 Welsh Recipe - Blas o Gymru The Welsh Government has recognised the importance of nutrition & catering as an essential part of the care patients receive in hospitals All Wales Nutrition care pathway for Hospitals pathway for nutrition screening highlighted All Wales Nutrition & catering standards for food & fluid provision for hospital inpatients. Nutritional screening is also recommended by DoH, RCN, RCP, NICE & NPSA.

7 Who s role is it? Chief Executive & Executive Board Catering manager Dietitians Nursing staff (incl HCSW) Doctors Pharmacists, SALT. Everybody s responsible!!!!

8 Underpinned by recommendations- Francis report (2013) and Andrews report (2014) a small number of fundamental standards focusing on key areas of patient care. Whether patients are getting food and water, and help to eat and drink if they need

9 All Wales Hospital Nutrition care Pathway protocol states: Standards(1)- Within 24 hours of admission to hospital all patients should be weighed & screened for malnutrition or risk of malnutrition using a validated nutritional screening tool (WAASP / MUST).

10 Standards(2)- When a Nutrition Risk Score (NRS) and weight has been established a multi-professional nutrition care plan should be implemented. The care plan developed will depend on the NRS.

11 Nutrition Risk Screening tool - WAASP

12 MUST

13 All Wales Renal Nutrition Screening Audit Audit the nutrition screening process of inpatients in acute nephrology beds across Wales. Collaborative pro-forma designed to look at patients on admission, during admission, their nutritional assessment & on discharge.

14 Methodology 1. Assessment of nutritional screening process, nutritional care and effect on outcome in all patients admitted to nephrology/transplant wards in Wales over same 2 weeks, June All patients admitted during this period were assessed and followed up until discharge, or following 2 weeks after audit end.

15 Demographics 1 CKD vs Acute CKD Acute No. patients Cardiffneph Swansea Wrexham maelor Glan Clwyd Ysbyty Gwynedd

16 60 Demographics 2- DM vs non-dm non DM DM 50 No. patients Cardiffneph Cardiff- Transplant Swansea Wrexham maelor 16 5 Glan Clwyd Ysbyty Gwynedd

17 Demographics 3- malignancy vs non No. patients. malign non-malig Cardiff-neph Cardiff-trans Swansea Wrexham maelor Glan Clwyd Ysbyty Gwynedd

18 Nutritional screening completed within 24 hours %

19 WAASP & MUST Mean & Median WAASP score Interventional Monitor MUST score Low risk 1 0 Cardiff-neph Cardiff-trans Swansea Wrexham maelor Glan Clwyd Ysbyty Gwynedd 0

20 Weight before & after admission: Data completeness Number % completion Cardiff Nephrology 36/48 75% Cardiff Transplant 36/39 92% Swansea 21/38 97% WXham 8/18 75% GC 6/21 42% YG 2/32 6%

21 Weight loss during admission Number Cardiff Nephrology 22/36 61% Cardiff Transplant 21/36 58% Swansea 21/38 55% WXham 18/24 75% GC 9/21 43% % patients losing weight

22 120 Weight loss during admission: mean weight before & after 110 Weight Kg Before After Cardiff Nephrology Cardiff Transplant Swansea Wrexham GCL Before After

23 Weight loss for those admitted with no oedema Kg

24 Referred to dietitian or not Not referred Referred No. patients Cardiffneph Cardiff trans Swansea Wxham GC YG

25 Reason for referral to dietitian Cardiff - Nephrology Nutrition Electrolyte K/P/ DM Fluid Other Support info (K/Po) 23/29 79% 3.5% 1/29 3.5% 1/29 3.5% 1/ % 3/29 Cardiff Transplant - 52% 11/21 9.5% 2/21 1/21 4.5% 0 7/21 34% Transplant Swansea 16/20 80% 15% 3/20 0 5% 1/20 0 WXm WXham 11/16 69% 12.5% 2/16 6% 1/ % 2/16 GC 2/3 67% % 1/3 YG 82% 9% 0 0 9%

26 Length of stay as an outcome. Influence of the presence of sepsis. Biochemical markers. Any surgery received. Bowels. Type of nutrition support used by dietitians.

27 Problems with NRS & audit incl: Not renal focussed - MUST not sensitive enough in renal inpatients(lawson et al 2010) Relies on accurate weight/weight history oedema/nephrotic patients not considered. Renal patients referred for other things (Na/K/Po/fluid). Re-screen logistics.

28 Over 2 weeks audit period was data collection true reflection? Acutely unwell patient group, complex treatments, multi-professional input.

29 Conclusions We are currently not meeting standards, for many reasons. Education central to moving forwards. Continue audit-cycle, & look at auditing other CKD groups. Renal nutrition group (RNG) work into producing a robust, universal renalspecific NST. Renal Registry area to look at.

30 Recommendations All Wales Renal dietitian group to look into most appropriate screening tool, referral criteria at ALL stages of CKD to ensure: Equity of access to service Timely referral & review Risk reduction Continuous monitoring & re-auditing

31 Time for dessert We are all responsible, & have unique roles to play to ensure adequate nutritional care is attained & maintained in our complex patient group.

32 UHW Sally Finlay, Claire Farley, Rachel Long, Fiona Hillen, Helen Long, Andrea Miller, Anne Williams. North Wales Harriet Williams, Elizabeth Wynne, Caroline Fazakerley, Ffion Huges, Sarah Gooda. ABMU Sara Watkins, Jill Skinner, Eleri Wright, Emma Catling. Thanks/Diolch - Dr A Mikhail, Tom Hurley, Chris Brown, Fiona Willingham (RNG)

33 Diolch Thanks Cwestiynau?- Questions?