Royal Liverpool Gastroenterology and Liver Services

Nutritional Services

We offer a comprehensive range of nutritional services including full enteral and parenteral (TPN) support services.

There are two nutrition nurses in the trust, Alison Young is the Nurse Consultant in Nutrition and Lisa Leedham, Clinical Nurse Specialist in Nutrition. Both nurses cover the Royal Liverpool & Broadgreen Hospitals. In addition to this they provide a service to the patients requiring enteral nutrition via gastrostomy/jejunostomy tubes at Liverpool Heart & Chest Hospital.

The Nutrition Nurses are part of a larger hospital nutrition team consisting of two Consultants, Senior Dietitian, a team of middle grade doctors (Specialist Registrars in Clinical Chemistry) and a Senior Pharmacist. The trust also has a Nutrition Group and Nutrition Steering Committee.

Table 1: The Nutrition Team

Clinician/Specialist	Job Title	Contact Details
Alison Young	Nurse Consultant in Nutrition	0151 706 3650 (Bleep 4595)
Dr Paul O’Toole	Consultant Gastroenterologist
Dr Eileen Marks	Clinical Director of Clinical Chemistry and metabolic medicine	0151 706 4244
Lisa Leedham	Clinical Nurse Specialist in Nutrition	0151 706 2658 (Bleep 4024)
Peter Turner	Senior Dietitian	0151 706 2121 (Bleep 4134)
Helen Campbell	Senior Pharmacist	0151 706 2135 (Bleep 4530)

Outpatient and Inpatient Services

The role of the nutrition nurses is to assess all patients referred for artificial nutritional support to decide on the most appropriate method and route for feeding. The Nutrition team (including the Nutrition Nurses, TPN Pharmacist, Senior Dietitian and Clinical Chemist) review all patients requiring parenteral nutrition on a daily basis.

The RLBUHT compound all the parenteral nutrition feeds for our inpatients and for the majority of our outpatients. Patients require daily blood monitoring when an in patient in ensure the parenteral nutrition fulfils there nutrition and hydration needs

The infection rate for parenteral nutrition lines in 1998 was between 15-20% (approximate as limited data available). Within 2 years the infection rate for parenteral nutrition was down to 3.5% which has further decreased in the year 2009.

One of the main reasons for this was the development of skills and training in IV access device placement. As a team the Nutrition Nurses assess and place lines in 99% of patient requiring parenteral nutrition with the other 1% of patients’ who go onto have more invasive IV access devices such as skin tunnelled catheters (which Alison is training to do) or an implantable port.

The Nutrition Nurse team place over 300 peripherally inserted central catheters and peripheral midlines for TPN and IV access annually (with or without ultra sound guidance)and have developed extensive skills in the management of these devices.

At the RLBUHT we have a large group of patients requiring Home Parenteral Nutrition whom the Nutrition Nurses manage and support.

The development of the enteral side of the service is ongoing. Not only do the Nutrition Nurses place PEG tubes they have developed skills in placement of all gastrostomy devices including direct PEJ tubes. Nasal Bridle placement has been done by the Nutrition Nurses very successfully for the past 18 months. Practice is currently being audited which on a brief overview indicates an appropriate management of patients requiring nutritional support.

The Nutrition Nurses also have an excellent relationship with the intervention radiology department who support the Nutrition Nurses with the placement of radiologically inserted gastrostomies as required.

The Nutrition Nurse service is available 5 days a week from 7am-4pm Monday to Friday. We see patients at the Royal Liverpool Hospital, Broadgreen Hospital, the Liverpool Heart and Chest Hospital and from the community. We are contactable on our bleeps or via our direct line 0151 706 3650.

We have built strong links with the PCT commissioners and all the community teams providing regular meetings, training and education.

In addition to providing a nutrition nurse service, our roles also include general gastroenterology clinics (Monday pm) and upper endoscopy (Monday am and Friday am).

Table 2. Summary Of Services Provided by the Nutrition Nurses

Service provided	Description	Lead	Contact Details
Nasogastric Tube Placement	This service is for situations where staff have been unable to place a NG tube. The Nutrition Nurses can be contacted for advise and support	Alison Young Lisa Leedham	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Nasal Bridle Placement	For patients who have self removed 3 or more nasogastric tubes	Alison Young Lisa Leedham	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Nasojejunal tube placement	For patients who are unable to tolerate nasogastric feeding. Self propelling device placed on the ward. Requires abdominal x-ray post procedure to assess tip position.	Alison Young Lisa Leedham	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Endoscopic placement of Nasojejunal Tubes	For patients who are unable to tolerate nasogastric feeding in whom blind placement is deemed not appropriate. Place available on the endoscopy list daily (Monday-Friday). Naso-jejunal tubes come in a range of types, single, dual and triple lumen depending on the patient’s need.	Alison Young Lisa Leedham Dr O’Toole Dr Smart	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Percutaneous Endoscopic Gastrostomy Tube assessment	Long term device for patients requiring enteral nutrition for more than 4 weeks. Place available on the endoscopy list daily (Monday-Friday)	Alison Young Lisa Leedham	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Gastrostomy tube assessment and placement	Regular review of gastrostomy tubes as inpatient/outpatient. Appointments available Mon/Fri 8-4pm	Alison Young Lisa Leedham	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Low Profile gastrostomy device placement	An alternative device for patients requiring long term nutritional support via the enteral route. Inpatient/outpatient appointments available Mon/Fri 8-4pm	Alison Young Lisa Leedham	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Gastrojejunostomy Placement	Placement of a gastrostomy device with integral jejunal extension. Placed using endoscopy or in intervention radiology.	Alison Young Lisa Leedham	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Percutaneous Endoscopic Gastrostomy Tube with jejunal extension	For patients intolerant of gastric feeding or having issues with aspiration pneumonia. Place available on the endoscopy list daily (Monday-Friday)	Alison Young Lisa Leedham	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Direct Percutaneous Endoscopic Jejunostomy (PEJ)	Placement of a feeding device directly into the small bowel. Place available on the endoscopy list once a week Dr O’Toole or Dr Smart’s list.	Alison Young Dr Paul O’Toole Dr Howard Smart	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Radiologically Placed Gastrostomy	For patients who are unable to have a PEG, a radiologically placed device is indicated. Referrals should be sent on ICE to intervention radiology and also to the nutrition nurses for assessment pre procedure.	Dr Jonathan Evans	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Parenteral Nutrition Assessment and management	Patients with a non functioning gut should be referred to the nutrition team for assessment for parenteral nutrition. These patients are reviewed daily by the nutrition team.	Alison Young Lisa Leedham Helen Campbell Peter Turner Dr Eileen Marks	Refer via ICE 0151 706 2000 Bleep 4595, 4024, 4530 or 4134
Peripheral Midline insertion	The decision regarding which IV access device is appropriate for the proposed therapy is decided by the nutrition nurses. A peripheral midline is ideal for patients requiring short term IV therapy, up to 6 weeks.	Alison Young Lisa Leedham	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Peripherally Inserted Central Catheters (PICC)	The decision regarding which IV access device is appropriate for the proposed therapy is decided by the nutrition nurse. A PICC line provides IV access for weeks/months. PICC lines are single, dual or triple lumen depending on the clients needs.	Alison Young	Refer via ICE 0151 706 2000 Bleep 4595 or 4024
Skin tunnelled Catheter insertion	The decision regarding which IV access device is appropriate for the proposed therapy is decided by the nutrition nurse. A skin tunnelled catheter provides IV access for weeks/months. Skin tunnelled catheters are single or dual lumen depending on the clients needs. These devices are ideal for patients with long term conditions for self management at home.	Sue Benton Intervention radiology department	Refer via ICE 0151 706 2748
Nutrition Clinic	Every alternate Friday morning. Outpatients clinic for patients requiring home nutritional support. Based on ward 2C	Alison Young Eileen Marks Pete Turner	0151 706 4304
Education & Training	Education and Training in all areas of nutritional support/IV access management is provided by the nutrition nurses. The nutrition nurses deliver regular training at the education centre (RLBUHT), John Moores University, Edge Hill University, and Liverpool University.	Alison Young	0151 706 3650