Home parenteral nutrition in South Wales

Abstract

The adult multidisciplinary nutrition support team (NST) at the University Hospital of Wales (UHW) was funded in 1998 for inpatients requiring short-term parenteral nutrition (PN). Patients requiring home PN (HPN) were transferred to Intestinal Failure centres (IFC) for HPN training and/or specialised surgery. Development of the specialist expertise within the UHW NST led to a minority of patients being trained locally, a service that was subsequently commissioned by Health Commission Wales (HCW) in 2003. This is a summary of the activity of the adult HPN service at UHW to date.Since 2000, 49 patients (25 female, 24 male) have been referred to the UHW adult NST for HPN assessment and training (41 new patients) or ongoing care (8 established HPN). Of the 41 new referrals, 25 were inpatients (9 UHW; 13 local hospital; 3 IFC) and 16 were outpatients. The 8 established HPN patients were also outpatients. Thirty nine out of 41 patients were discharged on HPN. Two patients were not discharged home (1 died and 1 refused HPN). The main indication for HPN (70 %) is a result of multiple bowel resections (55 % of which Crohn's disease), bowel infarction (19 %) and altered GI motility (11 %).Overall, the mean age of patients at the start of HPN was 50.55 years, range 18-76 years. On discharge or transfer of care, 35 patients were self-caring, 7 dependent upon nursing support by home care company and 5 supported by their spouse/partner. The majority (45) patients were discharged to their own home, 1 to sheltered accommodation and 1 to residential care. Forty four patients were relatively independent and 3 housebound. Patients have received HPN for a mean of 4.1 years (range 1 week to 26 years).Since discharge or transfer of care, 7 patients have died (not HPN related) and 7 have stopped HPN (4 following reconstructive surgery, 1 patient request, 2 repeated infection) resulting in the current cohort of 33 patients. Three patients have gone from self-caring to needing nursing support. Mean age of current patients is 52.6 years, range 18-78 years.Referrals for HPN have dramatically increased in more recent years. During 2001-5, 1 to 2 patients were discharged annually, 6-7 per year 2006-7 and in excess of 10 per year, 2008-9. A further 3 patients are currently being trained for HPN. This is likely a combination of improved critical care medicine, surgical expertise, wound and stoma care in addition to PN and line care and an increased knowledge/ confidence in the local specialist service and an agreed commissioning model of service.