St Mark's: the Intestinal Failure and Home Parenteral Nutrition Service
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This document summarizes the Intestinal Failure (IF) service at St Mark's Hospital, including: - The multidisciplinary team of over 50 staff from various specialties who provide care. - Facilities like a dedicated 20-bed IF unit and services for nutrition, surgery, psychology and more. - Clinical activities including over 8,000 inpatient days, 100+ new patient admissions annually, and care for 323 long-term HPN patients. - Research, teaching and quality initiatives to advance IF care and outcomes for patients.
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St Mark's: the Intestinal Failure and Home Parenteral Nutrition Service
- 1. St Mark’s: the IF & HPN service Dr Simon Gabe Consultant Gastroenterologist St Mark’s Hospital
- 2. 24 severe IF inpatients & 323 HPN patients 2 consultant GI surgeons 2 consultant GI physicians 1 nurse consultant 3 specialist nutrition nurses 2 IF nurse practitioners 1 pharmacy manager 3 specialist pharmacists 5 dietitians 1 psychiatrist 2 psychologists 1 IF coordinator 3 medical juniors 2 surgical juniors Microbiology service Interventional radiology 2 pharmacy technicians Pharmacy aseptics manager IF Service 1 staff grade surgeon
- 3. The IF Service • 20 beds IF Unit • Additional beds for perioperative patients and emergency admissions Frederick Salmon ward (colorectal surgery) • IF Unit • 1 modern matron • 1 nurse manager • 3 sisters • 17 trained nurses • 5 healthcare assistants • 1 physiotherapy assistant (shared) • 1 occupational therapist (shared) • 1 ward clerk Staff • Nutrition team • 2 consultant physicians, 2 consultant surgeons • 1 consultant nurse • 3 CNS (1 seconded from homecare company) • 2 IF nurse practitioners • 5 dietitians • 4 pharmacists • 3 junior medical doctors, 2 junior surgical doctors • 1 IF coordinator
- 4. A dedicated IF unit For intestinal rehabilitation!
- 5. Extended services • Dr Yoram Inspector (IF & eating disorders specialist) • 2 Psychologists (Esther Serranos-Ikkos and Megan Virtue) • Further plans to develop this unit Psychological medicine unit • Drainage of abdominal sepsis • Venoplasty, stenting & recannalisation Interventional radiology • Close working relationship Microbiology • Visiting plastic surgeons from St Thomas’ hospital (David Ross & Joannis Constantinitis) Plastic surgery
- 6. Integration with transplant services • Simon Gabe & Steve Middleton (Cambridge) • Jeremy Nightingale & Peter Friend (Oxford) Joint transplant clinics • St Mark’s – Addenbrooke’s Senior clinical IF & transplant fellow Shared aftercare for transplanted patients • Meetings every 2 months • St Mark’s, Hope, Addenbrooke’s, Oxford NASIT (National Adult Small Intestinal) Forum
- 7. HIFNET Aim to improve quality & access to services Core list of 30 services which Trusts needed to demonstrate they met 30 Trusts submitted June 2012 Peer reviews completed Jan 2014 Current tender process (34 Trusts applied) Next stage commissioner & clinician allocation Approved Trusts will be reimbursed from NHS England BUT currency still not been established! Launch April 2016 (but no tariff) DoH (2008)
- 8. Specialised IF services: referral criteria
- 10. 2010-2015: new IF referrals
- 11. 2014/15: new patient referrals Crohn's disease Mesenteric vascular disease Surgical complication s Motility disorders Radiation enteritis Scleroderma Familial polyposis Malignancy Other Salford 12 8 34 7 1 2 0 10 2 St Mark's 28 17 28 13 5 0 3 7 17 0 5 10 15 20 25 30 35 Patientnumbers
- 12. Crohn's disease Mesenteric vascular disease Surgical complication s Motility disorders Radiation enteritis Scleroderma Familial polyposis Malignancy Other Salford 50 18 73 25 3 6 0 14 6 St Mark's 84 49 74 49 9 1 4 15 37 0 10 20 30 40 50 60 70 80 Patientnumbers 2014/15: all admitted patients
- 13. 2014/15: IF inpatient activity IF Activity St Mark’s Occupied bed days 8455 ICU days 79 HDU 98 Total 8632
- 14. 2014/15: surgery on IF patients Hospital Surgery type No Operation type No St Mark’s IF surgery 58 Fistula repair 12 Restoration of continuity 36 Other 10
- 15. CVC infection rates 2006 2007 2008 2009 2010 2011 2012 2013 2014 Inpatients 3.8 5.1 7.9 5 2.4 1 1.8 1.9 0.23 Outpatients 1.3 1.7 1.5 1.6 1.1 0.8 1.3 0.7 0.26 0 1 2 3 4 5 6 7 8 9 CVCInfectionrate/1000days
- 16. 2014/15: new patient outcomes New patients St Mark’s Discharged home HPN 81 (76%) S/c fluids 1 (1%) Enteral (incl distal) feeding 2 (2%) Oral alone 8 (7%) Died 5 (5%) Hospital Transfer 10 (9%) Total 108 (100%)
- 17. HPN patient numbers 1990 1995 2000 2005 2010 2013 2015 No. Patients 30 60 80 140 206 277 323 0 50 100 150 200 250 300 350 No.Patients
- 18. 2014/15: IF activity Admissions New patient admissions 109 Known patient admissions 193 Outpatients Total new patients 26 Total follow-ups 893 Inpatients Occupied bed days 8455 ICU & HDU days 177
- 19. In house training • All disciplines • Advanced surgical training and medical IF training in place • Refresher course for HPN patients • Observers • National & international • Doctors, nurses, dietitians, pharmacists National teaching courses • 15th National IF & Rehabilitation course • Standard & advanced training for homecare nurses • Baxter National Intestinal Failure Forum • CVC & EN tube masterclasses • EC fistula masterclass • Members of IF team regularly invited speakers nationally & internationally Training & teaching
- 20. Research & audit Research themes • Mesenteric infarction • HPN & transplant prognostic risk factors • Development of a novel ORS • Growth factors: GLP-2 • Tissue engineering • Immunological profiling • PROM development Audit themes • CVC complications • Fractures, infection • Occlusion, thrombosis • Management of PN • Refeeding • Lipids • Reducing dependency • Nutritional status • Micronutrient status • HPN training • PN CVC pressures
- 23. Holiday locations of HPN patients
- 24. Future plans & service developments • Patient-controlled electronic medical records (PKB) • Development of a PROM (St Marks & Salford) Improving the patient experience • Pharmacy & nursing staff monitoring contracts HPN contracts with healthcare provider • Plan to expand posts and develop PICC service IF nurse practitioner post • Awaiting the start of HIFNET • Many established patients will be wary of being transferred Shared & devolved care • Development of enteral and parenteral tubes and devices Collaboration with industry
- 25. 5 year plan