Audit of nutritional management of surgical patients

1. Nutritional management of
emergency and elective
surgical patients – are we
doing enough?
Chaitya Desai (CT1)
Daniel Hern (Med student)
Mr Vittal Rao

2. Background
• Malnourished patients make poor surgical candidates.
• A proportion of surgical patients will have a degree of
malnutrition owing to their underlying disease process
thus reducing their nutritional reserves in the post-operative
period.
• Malnourished patients are at increased risk of post-operative
complications, such as reduced wound healing, increased
infection rates, and skin breakdown.

3. Aim
• To audit the post-operative nutritional status of elective and
emergency patients under general surgery at UHNM by
assessing completion of dietician referrals and implementation
of nutritional care plans.

4. Methods
• Data collected between 1st September – 1st November 2021
• Total patients = 100
• 50 emergency admissions
• 50 elective admissions
• All patients underwent surgery for GI pathology
• LOS > 5 days
• All emergency patients were deemed to be acutely ill AND no nutritional intake or likelihood of no
intake for more than 5 days – as per the MUST tool
https://www.bapen.org.uk/pdfs/must/must_full.pdf

6. Emergency admissions – Results
• Median LOS = 16 days
30.5 23.7
146
105.5
Pre-op Post-op
Albumin CRP
Oral
supplements
54%
NG feeding
33%
PICC line
and TPN
13%
• 48% had a dietician referral made with
the following plans:

7. Emergency admissions – Referral breakdown
Dietician
referral
made
(n
Total
=24)
• Hartmann's (n=7)
• SB resection + anastomosis (n=5)
• Right hemi (n=4)
• Adhesiolysis (n=2)
• Whipple's (n=2)
• Caecal resection + ileostomy (n=1)
• Sigmoid resection + anastamosis (n=1)
• Lap subtotal colectomy (n=1)
• Subtotal gastrectomy (n=1)
No
dietician
referral
made
(n
Total
=26)
• SB resection + anastomosis (n=9)
• Hartmann's (n=5)
• Right hemi (n=5)
• Transverse colectomy (n=2)
• Anterior resection (n=1)
• Adhesiolysis (n=1)
• Gastropexy with PEG (n=1)
• End sigmoid colostomy (n=1)
• End ileostomy (n=1)

8. Emergency admissions – Complications
4
3
1 1
Wound Infection Death Delirium Pneumonia
2
1 1 1
Death Anastomotic leak Sepsis AKI
In patients with a dietician referral … In patients without a dietician referral …

9. Elective admissions – Results
• Median LOS = 8.5 days
34.9
25.8
13.6
74.5
Pre-op Post-op
Albumin CRP
Oral
supplements
70%
NG feeding
10%
PICC line
and TPN
20%
• 40% had a dietician referral made with
the following plans:

10. Elective admissions – Referral breakdown
Dietician
referral
made
(n
Total
=20)
• Whipple’s (n=5)
• Right hemi (n=4)
• Anterior resection (n=2)
• Subtotal gastrectomy (n=2)
• Subtotal oesophagectomy (n=2)
• Oesophagogastrectomy (n=1)
• Hartmann’s (n=1)
• SB resection + anastomosis (n=1)
• Defunctioning loop colostomy (n=1)
• Duodenal lesion excision (n=1)
No
dietician
referral
made
(n
Total
=30)
• Anterior resection (n=15)
• Right hemi (n=10)
• AP resection (n=2)
• Subtotal colectomy (n=2)
• GIST excision (n=1)

11. Elective admissions – Complications
3
2
1
AKI Wound infection Anastomotic leak
2
1
Death Pneumonia
In patients with a dietician referral … In patients without a dietician referral …

12. Discussion
2021 survey by Matthews et al found that nationally (121 surgical centres):
 57.9% reported using the Malnutrition Universal Screening Tool to screen patients; however, only 50.4%
referred patients at nutritional risk onto a dietitian.
 49.6% lacked confidence in local ability to identify and manage malnutrition perioperatively, with 23.1%
reporting having a structured pathway for managing malnourished patients.
 91.7% agreed that malnutrition impacts on quality of life after surgery and 86.8% felt adopting a standard
protocol would improve outcomes for patients.
 Those reporting a lack of confidence in dealing with malnutrition perioperatively cited:
 Lack of organisational support
 Patients being seen too close to surgery
 Lack of clarity around responsibility
Matthews, L. S., et al. "Screening, assessment and management of perioperative malnutrition: a survey of UK practice." Perioperative Medicine 10.1 (2021): 1-8.

13. Key points
In total, 56% high risk patients with no dietician referral in place.
• Ideally, the need for a dietician referral for nutritional support should be discussed as soon as patient is
seen on post-take WR, and re-evaluated post-surgery.
• Ensure our patients are on ENSURE! - simple interventions such as oral supplementation can be
commenced by the surgical team without dietician input – especially when high-risk as per MUST tool.
Suggested interventions:
- Teaching session for doctors and nurses based across the surgical specialties.
- Educational poster distributed across surgical wards.
Re-audit to evaluate improvement.