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Enteral feeding delivers nutritionally complete feed directly into a patient’s stomach,

duodenum or jejunum and can transform the lives of seriously ill people who cannot take

food, fluid or medications by mouth. However, having the expertise, the time to train and

review enterally fed patients and their carers, as well as the time to address issues, poses

a problem for pressurised NHS services.

In response, Nutricia established an Enteral Nurse Specialist (ENS) service in 2000 to

work alongside the NHS team to help deliver the best possible care to people who need

enteral feeding. This series of case studies will highlight the numerous ways

in which the Nutricia Homeward ENS services benefits patients, carers and

the NHS by minimising tube-related readmissions into hospital, helping to

keep as many patients as possible safely managed at home.

We begin with Richard Thornton, a Nutricia ENS who covers about

5000 km2 of Wales, often caring for people living in very rural locations.

“Our local trusts do not have an in-house enteral nurse specialist. So,

the local NHS sees the Nutricia Homeward ENSs as core members of

the multidisciplinary team and we’re treated as such,” he says.

The Role of theNutricia HomewardEnteral Nurse Specialistas part of the MDTCase Study

The Nutricia Homeward Nursing Service Case Study SeriesKeeping you up-to-date on the benefits of the Nutricia Homeward Nursing Service to patients, carers and the NHS byminimising tube-related readmissions into hospital, helping to keep as many patients as possible safely managed at home.

Richard Thornton

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Nutricia Homeward Nursing Service | Case Study

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For further information visit: www.nutricia.co.uk

A core member of themultidisciplinary teamAs a core member of the local

multidisciplinary team, Richard attends

complex nutritional care meetings to

provide feedback and raise issues to

consultants and dietitians, who will then

develop individual care plans.“We arefully involved in these meetings,” he says.

“They see us as the specialists in themanagement of enteral tubes and valueour input.”

The local NHS team also values the

healthcare professional training Richard

offers, which he ensures is based around

best-practice guidance from NICE and

the National Patient Safety Agency (NPSA).

“Nutricia has robust evidence-basedpolicies. Broadly, practice in Glasgow is thesame as in London as it is here,” he says.

“However, the NHS operates here in aslightly different way to England anddistrict nurses have a slightly differentrole. So, I adapt the training to the Welshcircumstances.”

Usually, Richard trains nurses and

carers – although, a clinical skills manager

from the trust attended a recent teaching

day to update her knowledge and

understanding. He also teaches student

dietitians, nursing home staff and care

teams. “The training doesn’t aim to makethe healthcare professionals into specialists.Depending on the audience, we can teachcertain skills, such as the role of theenteral nurse specialist, tube identificationand daily care of the patient with anenteral feeding tube, and common issueswith the different tubes. We aim toempower nursing teams to understandthe issues and the escalation process,should they require it. They may not havethe expertise to deal with issues, butthey then know where to go to get help.After training, healthcare professionals tellme that they are much less anxious aboutcaring for a person who is enterally fed.”

An innovative clinicAs an ‘integral part’ of the multidisciplinaryteam Richard was closely involved indeveloping, and currently helps run, anelective gastrostomy assessment clinic.

“By working seamlessly with our NHScolleagues, the clinic allows us to improvethe quality of care for patients and theirfamilies, ensuring a smooth transitionbetween the hospital and the community,as well as providing continuity of care,”he says.

The clinic covers a wide-range ofpatients, including those with motorneurone disease, multiple sclerosis andprogressive supranuclear palsy.“Thesepatients often experience swallowingdifficulties. They may develop aspirationpneumonia and may well have presentedwith previous lower respiratory tractinfections. They struggle to maintain theirnutrition, hydration and ability to takemedicines,” Richard explains.

At the assessment clinic the patient isseen by the different members of themultidisciplinary team, a dietitian, a speechand language therapist and the HomewardENS. This enables a holistic assessmentat one appointment, including the patient’snutritional status, dysphagia risk, medicalhistory, current medications and socialcircumstances.

“For example, we look at the socialcircumstances and discuss who will managethe tube once inserted. In some cases,I liaise with the district nurse and careagency teams. A patient or family may haveproblems flushing the tube so we canapproach the care agency team to dothis having had appropriate training fromourselves,” Richard says.

Richard then went on to explain theimportance of the mobility of the clinic,as well as the response to the needs ofpatients: “Most of the assessments aremade in conventional healthcare settings,but some patients need to be seen in theirhomes because they are either too unwell,face logistical difficulties or need expeditedreview,” he explained.

Being a valued member of themultidisciplinary team, Richard and JudithGethin, another Nutricia Homeward ENS,presented results from a review of thisinnovative elective gastrostomy assessmentclinic alongside their NHS colleagues atthe prestigious 2016 British Association forParenteral and Enteral Nutrition (BAPEN)Annual Conference in Brighton. The studypresented at BAPEN retrospectivelyreviewed 68 patients managed by theelective gastrostomy assessment clinic.

Of these, 53% agreed to have a PEG tube,22% underwent RIG placement and 19%declined tube feeding.

The study also compared the 68patients managed by the electivegastrostomy assessment clinic with 34controls managed by the gastroenterologyoutpatient clinic. Waiting time forgastrostomy tube placement fell from amean of 116 days with the outpatientclinic to 30 days in those managed by theelective gastrostomy assessment clinic.Mean hospital stay declined from 63 to 11days respectively.“Although this was asmall study, the review showed that theelective gastrostomy assessment clinicbenefits patients and the NHS,” Richardadds.“Our NHS colleagues acknowledgedin the poster that the involvement of theNutricia Homeward ENS was a key to theclinic’s success. It’s an amazing feeling todeliver a gold-standard service.”

Training and follow upRichard notes that the clinic helps patientsand carers understand the benefits ofplacement and the associated issues.“For instance, I explain that in our area,having a PEG tube usually entails a four-dayhospital stay. Patients have to remain inhospital for at least 72 hours after the tubeis inserted to watch for red flags, such aspain, bleeding and inflammation.”

Before discharge, Richard explainsfeeding and tube management includingthe care of their enteral tubes and usingthe pumps. “I also see patients in theirhome within 10 days following dischargeto deal with any issues,” he says. “After thatI see them for their regular reviews andas and when they need additional support.The training and the support has to beindividualised to each patient. Over time,you develop a strong bond with patientsand their families. They trust you to offerthe best possible care to the patient.”

Being able to make a difference – bydeveloping a bond with his patientsand working in collaboration with hisNHS colleagues – offers Richard “real jobsatisfaction”. “You see patients who lookso ill before feeding, but after they receivethe required nutrition they show vastimprovement and can get on with theirlives,” he concludes.“It really does happenand it’s immensely rewarding.”

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