The care of home tube fed patients varies throughout the country. Follow up may be by means of home visits, telephone calls or hospital appointments at a specialist clinic or other clinic. The feeding may be managed by dietitians alone or there may be a specialist community nutrition team. Services are fragmented and some patients may not be followed up at all. At the Royal London Hospital we have a wealth of experience with home tube feeding. The Trust Nutritional Support Folder details the policy for discharge. Patients are reviewed at the weekly nutrition clinic. The clinic comprises of the Nutrition Team Consultant, a Senior Dietitian, and the Nutrition Nurse. A lay counsellor is also available. There are also close links with those working in the community. Twice yearly nutrition study days are run for district nurses and a community nutrition care program has been produced. Unfortunately funds are not available for a community dietitian or nutrition nurse to make home visits. This is also the case in Newham, an area where many of our patients are discharged home.

Methods

Patients sent home on tube feeding between 1.1.96 and 31.12.97 were identified by means of dietetic and endoscopy records. Data on age, diagnosis, ethnic groups, accommodation, area of residence and feeding details was collected, this was compared with national figures where possible. Method of follow up was also looked at and length of time to follow up if the patient attended the clinic.

Eighty-two patients were discharged during the audit period. Of these, 28 were known to be still feeding by 31.12.97, of the remainder, 20 had resumed full oral intake, 25 had died, 1 person had to discontinue due to not tolerating the feed and 8 were lost to follow up. Our home feed patients tended to be younger than the national figures, 45% of our population were above 65 years old compared to 57%. The vast majority of our patients needed artificial nutrition due to impaired swallow  of  either  mechanical  origin  (41%)  or neurological origin (44%). This reflects the diagnosis of our patients (see figure 1). When compared to national figures, we feed a similar percentage of stroke patients (37% nationally). However, the percentage of our patients with oral/oesophageal carcinomas is double that of the national figure, whether this reflects the type of patients we have at the London or the prevalence of tube feeding in maxillofacial surgery patients is not known.

The nutritional status could be assessed by means of the body mass index (BMI) in 57 cases. 22 had a BMI within the normal range (20-24.9 Kg/m2), 17 were moderately malnourished (BMI 17-19.9 Kg/m2), 9 were severely malnourished (BMI <17 kg/m2) and 9 were overweight (BMI >25 Kg/m2). In 44 cases there was sufficient data to look at nutritional outcomes. A goal was assigned to the nutritional treatment of weight gain, weight loss or weight maintenance which was determined by the BMI, for some patients whose treatment was palliative it was not appropriate to assign a goal. Twenty six patients (59%) achieved their goal, more importantly this figure was higher in those who needed to gain weight, 19 out of 26 (73%).

It is intended that all patients will be followed up in the nutrition clinic and the first appointment will be made within 4 weeks of discharge. However, only 55 patients (67%) had an appointment made and only 41 of these people actually attended the clinic, hence only half of our patients were seen in the clinic. The reasons for no appointment  being made or non attendance of appointment are shown in Figure 2.

At the Royal London Hospital we have already gone a long way towards meeting the BAPEN and PENG standards. There are polices and procedures in place for the discharge of home tube fed patients and we contribute to the national register of home artificially fed patients (BANS) as well as keeping our own data. The ward nurses, nutrition nurse and dietitians work together to ensure a smooth transition from hospital to home and the multidisciplinary nutrition clinic allows a coordinated approach to follow up. However it is evident from the audit that we are unable to provide 100% cover by means of the clinic. Only half of our patients were seen, and the target of an appointment within 4 weeks of discharge was only met in 39% of cases. When the reasons for non-attendance of the clinic are looked at it is seen that approximately 1/3 of the patients receive appropriate follow up locally or at other hospital clinics. This leaves the remaining 2/3 (26 patients) where it is not clear whether follow up was adequate. We do not know what happened to 11 patients and local services did not provide follow up for one person who lived too far away. Of the 12 patients who were too ill or died it was not appropriate for them to attend the clinic. It needs to be established whether a home visit, or a telephone follow up would have been beneficial.

This audit revealed interesting data about the type of patients we are feeding and their nutritional treatment. It is hoped that now the data base is in place we will be able to continue collecting some of this information. This will make follow up of these patients and further audits easier and identification of certain patient types for study possible.

The audit of follow up revealed that follow up is not always adequate. The data base of patients discharged on tube feeding will help to stop patients slipping through the net. Meetings every 8 weeks between the nutrition nurse and the dietitian to discuss all new and established home tube feeding patients are to be started. These meetings will serve as an additional measure to adequate follow up.

Many areas have community services for tube fed patients. A community service may complement the clinic and provide cover where the clinic is unable for example in the very ill or as an interim follow up before the first clinic appointment.  This needs to  be investigated and funding identified.

A repeat audit should be carried out next year to see if the measures suggested improve the care of home tube fed patients.

I would like to thank the Kings Fund who provided a bursary to help make this project possible, the medical audit department, especially Joanne Robinson, who provided help with the planning, data collection and analyses and Dr Powell-Tuck for his valuable comments on the project.

1. Elia M. et al.  The 1997 Annual Report of the British Artificial Nutrition Survey.

2. Elia M. Enteral and Parenteral nutrition in the community. A report by a working party of the British Association for Parental and Enteral Nutrition. 1994.

3. McAtear CA, Wright C. PEN Group Standards. 1996.