Overview of a Home Enteral Nutrition Service in North Dublin

Abstract

Introduction: Home Enteral Nutrition (HEN) positively impacts on quality of life and reduces healthcare costs through a reduction in hospital readmissions and complications. However, management of HEN in the primary care setting can be a challenging task for the patient, their carers and the multidisciplinary team. Community dietitians (CD) trained in HEN can provide domiciliary visits to monitor and support patients, troubleshoot feeding tube problems and act as a liaison between community and hospital services. Practice change: Previously in North Dublin, clients discharged on HEN were either reviewed in the acute setting or lost to follow-up. Now a specialist HEN Service is established in the area with the CD acting as a liaison between hospital and community services. Aim: The service offers equitable access to a specialist HEN service in a community setting, which aims to optimise nutritional support, reduce hospital attendences/readmissions and provide for the training needs of HEN clients/carers and relevant healthcare professionals. Target population & stakeholders: All adults aged over 18 years discharged into CHO Area 9, resident in both domiciliary and residential care settings. Timeline: Initiated in 2008 solely for older persons on HEN, the service expanded to all adults in 2012. The audit presented was undertaken in 2015. Highlights: A total of 266 HEN clients had been referred by December 2014, with the CD acting as a liaison between community services and 12 different discharging hospitals. A standardised 'transfer of care' form was developed for use by all hospitals referring to the HEN service and a 'shared-care' pathway was developed for clients who also continued to attend a specialist service in hospital. The average intervention time was 16 months. Two-thirds of clients referred were aged over 65 years and the male to female ratio was 1:1.1. Fifty-six percent (n=149) of clients were resident in their own homes, with the remainder in nursing homes. Equity of access was ensured by extending the HEN service to residents in private nursing homes. The most common underlying medical conditions leading to gastrostomy insertion were cancer (33%), neurology (24%) and CVA (22%). Gastrostomy was the predominant feeding route (94%) and in an extended role the CD faciliates elective replacement of feeding tubes to reduce incident of tube dislodgement. Sustainability: This integrated care approach allows the HEN client to have their care optimally managed in a primary care setting. Given the complexity of the caseload, this service requires a dedicated CD experienced in HEN and with an advanced practioner role in tube replacement. Transferability: This model of service delivery is fully transferable to other community areas.