This document summarizes an audit of postoperative nutritional management of 100 emergency and elective surgical patients at UHNM. For emergency patients, 48% received a dietician referral but 56% of high-risk patients did not. Elective patients had a lower referral rate of 40%. Patients without referrals had more complications. The discussion notes most UK hospitals struggle with identifying and managing malnutrition perioperatively due to various organizational challenges. The key points recommend discussing nutritional needs earlier, ensuring oral supplementation, and staff education to improve postoperative nutritional care.

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.