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.

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Malnutrition is both a common and concerning problem with almost 60 % of elderly care in-patients being at risk (1) . It is well established that malnourished patients will have poorer clinical outcomes (2) and that malnutrition is a key factor in prolonging length of stay in elderly patients (1) . The Malnutrition Universal Screening Tool (MUST) has been developed as a method of identifying these at-risk patients and has been advocated across the NHS since 2003 (3) . The nutrition team at SRFT were keen to understand local current practice and then take action to improve the situation. In order to achieve this the team designed a quality improvement project based on the Model for Improvement (4) . 3 elderly care wards were invited to participate in the first phase of this project as these wards have many patients at high risk of malnutrition. Each developed a multidisciplinary improvement team of ward staff to work on improving MUST screening.The nutrition team designed a driver diagram which articulated the aim of the project and the key workstreams that would be necessary to achieve it. This was used as a clear visual method of communicating the project to the ward teams. Each month the timeliness (within 6 hours of admission) and accuracy (compared to a dietician assessment) of MUST scores on the three wards was reviewed. Ward teams received monthly feedback of their results to create ownership, maintain enthusiasm and generate momentum for improvement. Baseline data identified that a MUST screen was performed in < 60 % of patients and in those with an assessment only 65 % were accurate.Plan-Do-Study-Act (PDSA) cycles were used to rapidly test changes in the ward areas. Tests included a nutrition study day, one-to-one ward based nutrition training, focus on the use of alternative anthropometric measurements, development of a training pack and identification of the challenges to undertaking accurate and timely assessments.During the project all the wards achieved an improvement in the proportion of patients screened with one ward achieving 100%. It was identified that strong ward leadership was a key factor in this ward's success. There was also some evidence that the drive to screen within 6 hours resulted in less accurate assessments and that assessments within 24 hours might be more accurate. We also identified that only 60-70% patients screened had a nutrition care plan and thus that screening does not necessarily result in action to improve nutritional state.The nutrition team is now working with wards to evaluate the link between timeliness and accuracy of assessment in more detail. We are also looking at the role of Health Care Assistants in MUST screening. The team continues to work on improving nutritional screening but is now focussed on developing reliable processes, using quality improvement methodologies and the application of reliability science, to ensure the delivery of appropriate interventions to patients identified as high risk.

Background The use of home parenteral nutrition (HPN) for palliative indications is increasing internationally and is the leading indication in some countries. Discharge on HPN can be complex in metabolically unstable patients and requires intestinal failure expertise. Methods Between 2012 and 2018, we performed a retrospective analysis aiming to assess the impact of a novel remote discharge pathway for palliative HPN patients. This was evaluated using a quality improvement approach. Results One hundred and twenty‐five patients with active malignancy [mean (range) age 58 (25–80) years] were referred to the intestinal failure unit (IFU) for remote discharge. Of 82 patients were discharged from the oncology Centre on HPN using the pathway. The remaining 43 patients either declined HPN or the Oncology team felt that the patient became too unwell for HPN or died prior to discharge. There was an increase in patients referred for remote discharge from 13 in 2012 to 43 in 2017. The mean number of days between receipt of referral by the IFU to discharge on HPN from the oncology centre reduced from 29.4 days to 10.1 days. Following remote discharge, the mean number of days on HPN was 215.9 days. Catheter‐related blood stream infection rates in this cohort were very low at 0.169 per 1000 catheter days. Conclusions This is the first study to demonstrate the remote safe, effective and rapid discharge of patients requiring palliative HPN between two hospital sites. This allows patients with a short prognosis more time in their desired location.

Refeeding syndrome can result in a wide variety of complications and may be life threatening. Although well described in hospital practice, refeeding syndrome is often under-recognized and inadequately treated.

Patients with intestinal failure (IF) and home parenteral nutrition commonly develop abnormal liver function tests. The presentations of IF-associated liver disease (IFALD) range from mild cholestasis or steatosis to cirrhosis and decompensated liver disease. We describe the reversal of IFALD in an adult patient with IF secondary to severe Crohn's disease and multiple small bowel resections. The patient developed liver dysfunction and pathology consistent with IFALD. Multiple causal factors were implicated, including nutrition-related factors, catheter sepsis and the use of hepatotoxic medications. Multidisciplinary treatment in a tertiary IF referral centre included aggressive sepsis management, discontinuation of hepatotoxic medications and a reduction of parenteral nutrition dependency through optimisation of enteral nutrition via distal enteral tube feeding. Upon this, liver function tests normalised.

RationaleOur intestinal failure unit provides care for patients from a wide geographical area. Patients dependent on home parenteral nutrition (HPN) are routinely reviewed in the clinic at 3–6 monthly intervals. Between March 2008 and 2015, we noted a significant rise in the number of patients under our care, with an associated 51% increase in clinic appointments offered. We evaluated whether telemedicine would provide a strategy to reduce patients’ need to travel while maintaining safe clinical standards.MethodsImplementation began in December 2015 via patient consultation and small tests of change. Clinical data were obtained from a prospectively maintained database. Remote video consultation discussions were carried out via internet video call service (Skype). An anonymous satisfaction questionnaire was offered to patients for completion following consultation. The number of miles saved by obviating the need to attend hospital was calculated for each patient.ResultsDuring the study period, patients receiving HPN rose by 18% to 288. Twenty-five patients used telemedicine for HPN follow-up, three of these for follow-up with the psychologist. By avoiding hospital attendance, this saved a mean travel distance of 56.7 miles with a total of 18 346.6 cumulative miles saved. Sixty-three per cent of patients rated their satisfaction with the system at ≥90%, with a mean satisfaction of 85%. Eight per cent of the telemedicine cohort was admitted with an HPN complication, compared with an admission rate of 24% for the whole HPN cohort. One emergency admission was avoided.ConclusionTelemedicine can obviate the need for clinic attendance in HPN-dependent patients, so reducing the need of individuals with chronic illness to travel while maintaining standards for follow-up.

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