Last week the Irish Society for Parenteral and Enteral Nutrition (ISPEN) held their annual, well-attended study day for SpRs to educate and update on all areas of clinical nutrition, a specialty that in the past has not been as well developed in Ireland as abroad.
The event attracted over 30 SpRs from specialties including gastroenterology, gerontology, intensive care, oncology, neurology and cardiology. The meeting was also a forum to discuss the whole area of clinical nutrition in Ireland.
“There have been relatively few studies of malnutrition in Ireland, and none to date in free-living people over 65 years of age,” Dr Declan Byrne, consultant geriatrician with a special interest in nutrition at Tralee General Hospital, told the meeting. “In contrast, our European counterparts have already identified malnutrition as a significant issue in the general population and many have accumulated data stretching back almost a decade.
“We know that more than one in four patients tend to already be malnourished on admission to hospital, and these malnourished patients are three times more likely to die within six months of discharge.”
Studies show that older patients with malnutrition on average have 65 per cent more GP visits and are about 80 per cent more likely to be admitted to hospital and stay longer once there.
Estimates based on comparing what Irish data there is Irish studies with larger scale UK surveys suggest that some 140,000 Irish people, half of whom are over 65 years of age, may be affected by malnutrition, at an estimated cost to the health service of €1.5 billion annually, or 10 per cent of the entire healthcare budget, the meeting heard.
“It is vital to raise awareness of malnutrition because it costs relatively little to treat. The experience of other countries suggests that implementing screening and nutrition support programmes can deliver significant savings,” Dr Byrne said. “Delivering high quality nutritional care to all patients is not something that can be achieved without effort and political will.
“A well coordinated national strategy to improve standards of nutritional care and practice throughout the healthcare system should be developed and implemented. ISPEN is fully prepared to lead this,” he added.
In the current economic climate, it can be difficult to justify new initiatives, the meeting heard; however, on the basis that even a one per cent reduction might be expected to deliver a saving of approximately €15million, ISPEN believe now is the time to take action.
An update on tube feeding
Consultant gastroenterologist at Cork University Hospital and RCPI National Specialty Director for Gastroenterology Dr Orla Cosbie told IMN that it is often assumed “malnutrition” simply refers to those underweight.
Malnutrition is both a cause and a consequence of ill-health, she said, and is more common than people realise.
“Many older people and those with any long-term medical or psychosocial problems are chronically underweight and so are vulnerable to acute illness, for example,” said Dr Crosbie. “Even people who are well-nourished eat and drink less if they are ill or injured and although this may only be short-lived as part of an acute problem, if it persists the person can become undernourished to an extent that may impair recovery.”
The consequences of malnutrition include vulnerability to infection, delayed wound-healing, impaired function of heart and lungs, decreased muscle strength, and depression. Studies show that people with malnutrition consult their GP more frequently, go to hospital more often and for longer, and have higher complication and mortality rates.
Surgical patients with malnutrition, for example, have around three times as many post-operative complications and four times greater risk of death than well nourished patients having similar operations.
“Patients should all be assessed nutritionally, either a quick assessment by a nurse on admission, or by a doctor, where possible, and then referred to a dietitian. Every patient entering hospital should have their height and weight recorded, for example, looking in particular for weight loss, which can be a sign of a problem,” Dr Crosbie told IMN. “Even in emergency departments nutrition needs to be assessed – for example, if an elderly patient comes in following a hip fracture, we need to assess why she fell and whether she has osteoporosis. Or an overweight middle-aged gentlemen who might have an underlying cancer. The consequences of malnutrition are huge.”
In the UK each hospital has a nutrition team, Dr Crosbie said, referencing the recent guidelines published by the British Society of Gastroenterology (BSG).
“Those teams are usually run by a consultant gastroenterologist with an interest in nutrition. It also includes specialist nurses, speech and language therapists, dietitians, and so on. This would be best practice. But we don’t currently have the structure or staff for that level of care in Ireland.”
Enteral feeding
According to the BSG guidelines, there is “overwhelming evidence” that the maintenance of enteral feeding is beneficial in patients in whom oral access has been diminished or lost.
Short-term enteral access is usually achieved via naso-enteral tube placement, said Dr Crosbie, and for longer term tube feeding enteral feeding tubes are usually placed percutaneously.
Loss of enteral access is a common occurrence in many severe acute illnesses, and the resulting gut disuse is recognised as a cause of reduced immune integrity with an associated risk of complications, the meeting heard.
The guidelines state that the provision of a percutaneous enteral tube feeding service should be “within the remit of the hospital nutrition support team (NST)”.
“This designated team should provide a framework for patient selection, pre-assessment and post-procedural care,” the UK guidelines state. “Every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service. This should include provision for fitting a PEG jejunal extension (PEGJ) if required. Good understanding of the indications for percutaneous enteral tube feeding will prevent inappropriate procedures and ensure that the correct feeding route is selected at the appropriate time. Each unit should adopt and become familiar with a limited range of PEG tube equipment.”
The study day is an annual event that has become mandatory for SpRs to continously update them on nutrition, Dr Crosbie said.
