Clinical Nutrition ESPEN 50 (2022) 289e306

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Clinical Nutrition ESPEN

journal homepage: http://www.clinicalnutritionespen.com

Original article

A comparison of a home parenteral nutrition service with the current

European (ESPEN) guidelines on chronic intestinal failure in adults
Karen Slye a, Mary McKiernan a, Anne Griffin b, c, Alexandra Cremona b, *
a
Department of Clinical Nutrition and Dietetics, Mater Misericordiae University Hospital, Dublin, Ireland
b
School of Allied Health, Faculty of Education & Health Sciences, University of Limerick, Limerick, Ireland
c
Health Research Institute, University of Limerick, Limerick, Ireland

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: Comprehensive evidenced based guidelines on appropriate and safe provision of
Received 24 November 2021 home parenteral nutrition (HPN) have been developed by the European Society for Clinical Nutrition and
Accepted 28 April 2022 Metabolism (ESPEN) in 2016 and 2020. These guidelines provide clinical standards of care against which
the current practice of HPN services can be audited. The aim of this study was to audit a single center's
Keywords: current practice against 183 recommendations on supporting patients on HPN. The objective was to
Home parenteral nutrition
measure compliance and identify areas for quality improvement.
Intestinal failure
Methods: A retrospective audit of the HPN service received by patients from January 2019eMay 2021
Parenteral nutrition
Clinical guidelines
was conducted. The ESPEN guidelines were used as a benchmark to measure compliance of healthcare
practice. Compliance was evaluated for the 13 subject areas included in the 2016 guideline and the 6
subject areas included in the 2020 guideline. Compliance was calculated as the percentage of criteria
fully met for each subject area and an overall compliance rate with each guideline.
Results: Overall, compliance with the recommendations from 2016 was 80% and compliance with the
recommendations from 2020 was 65%. Within the 2020 guideline there were 24 recommendations
where noncompliance was found, 15 of these were due to the absence of a nutrition support team and
dedicated intestinal failure unit.
Conclusion: This audit and evaluation of current practice has identified areas of good evidence-based
healthcare practice providing HPN. However, the absence of funding of a nutrition support team to
provide a service to patients on HPN was identified as a major barrier to compliance with ESPEN rec-
ommendations in this study.
© 2022 The Author(s). Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and
Metabolism. This is an open access article under the CC BY license (http://creativecommons.org/licenses/
by/4.0/).

1. Background (c) As part of a program of palliative care for incurable malignant

Home Parenteral Nutrition (HPN) is the intravenous adminis-
tration of nutrition, which can include amino acids, glucose, lipids,
electrolytes, vitamins, and trace elements, outside of the hospital
setting. Four key areas of clinical care where HPN can be considered
are [1];
(a) As life-saving therapy for a patient with chronic intestinal
failure (CIF) due to benign disease;
(b) For CIF due to malignant disease;
disease, to avoid death from malnutrition;
(d) To prevent or treat malnutrition in patients with a func-
tioning intestine, who decline other types of medical
nutrition.
The British Intestinal Failure Alliance (BIFA) advocate for pa-
tients receiving HPN to be cared for by an Intestinal Failure (IF) or
HPN designated unit with a multidisciplinary nutrition support
team (NST) [2]. They also advocate for a unit to ideally have at least
20 adult patients receiving HPN of which more than 5 adults have

* Corresponding author. Human Nutrition and Dietetics, Department of Human Nutrition and Dietetics, School of Allied Health, Faculty of Education and Health Science,
University of Limerick, Limerick, V94 T9PX, Ireland.
E-mail addresses: kslye@mater.ie (K. Slye), mmckiernan@mater.ie (M. McKiernan), anne.griffin@ul.ie (A. Griffin), alexandra.cremona@ul.ie (A. Cremona).

https://doi.org/10.1016/j.clnesp.2022.04.029
2405-4577/© 2022 The Author(s). Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/).
K. Slye, M. McKiernan, A. Griffin et al.
Abbreviations
AIO All-in-one
ASPEN American Society for Parenteral and Enteral Nutrition
AuSPEN Australasian Society of Parenteral and Enteral
Nutrition
BIFA British Intestinal Failure Alliance
BMD Bone mineral density
CHMP Committee for Medicinal Products for Human use
CIF Chronic intestinal failure
CIPO Chronic intestinal pseudo-obstruction
CRBSI Catheter related bloodstream infection
CVAD Central venous access device
CVC Central venous catheter
CRVT Catheter-related vein thrombosis
DEXA Dual-energy X-ray absorptiometry, European
Medicines Agency
HSE Health Service Executive
ESPEN European Society for Clinical Nutrition and
Metabolism
EFA Essential fatty acid
EMA European Medicines Agency
GH Growth hormone
GLP-2 Glucagon-like peptid-2
been receiving it for more than 5 years, representing an established
unit [2]. There is currently no specialist intestinal failure centre for
adult patients requiring HPN in Ireland. In 2013, the Irish Society for
Clinical Nutrition and Metabolism (IrSPEN) highlighted the need to
establish a national framework and model of care for adult patients
following a review of HPN delivery across Ireland [3]. Although it is
eight years since this report was published Ireland is still lacking a
model of care for adult patients. In the absence of a framework
patients with complex nutritional needs are managed across a large
number of hospitals throughout Ireland. A review of outcome
measures of patients on HPN for benign intestinal failure (IF) in
2012 found that the risk of death among both adults and children is
increased by the absence of a specialist team [4].
The Mater Miscericordiae University Hospital (MMUH) is a level
4 teaching hospital with acute medical and surgical units, emer-
gency department, tertiary referrals, and a higher-level intensive
care with strong academic partnerships. It is the national centre for
the treatment of patients with peritoneal surface malignancy in
Ireland since 2013. MMUH is typical of Irish hospitals as it lacks a
NST or dedicated funding for any member of the multidisciplinary
team to manage patients requiring HPN. On discharge the medical
management of patients requiring HPN is under the care of the
discharging consultant. During 2020, nine different consultants
within MMUH cared for patients requiring HPN. In the absence of a
NST or an IF unit to refer to, a dietitian acts as the discharge coor-
dinator and monitors the patient post discharge on HPN.
Indications for HPN within the cohort of patients managed by
MMUH include CIF due to benign disease, CIF due to malignant
disease and patients under palliative care for incurable malignant
disease.
The number of patients requiring HPN has increased from one in
2013 to fifteen in 2020, mainly through increasing numbers in
those with incurable malignant disease. The increasing demand to
provide care to patients requiring HPN alongside the acknowl-
edgement that the hospital lacks a NST gave cause to complete an
audit of the current healthcare practice as a quality improvement
activity. Clinical audit is a clinically led quality improvement
290
Clinical Nutrition ESPEN 50 (2022) 289e306
HPN Home Parenteral Nutrition
HSE Health Service Executive
IF Intestinal failure
IFALD Intestinal failure-associated liver disease
IR Interventional radiology
IrSPEN Irish Society for Clinical Nutrition & Metabolism
ITx Intestinal transplantation
MDT Multidisciplinary team
MMUH Mater Miscericordiae University Hospital
N/A Not applicable
NST Nutrition support team
PACIFHAN International Alliance of Patient Organisations for
Chronic Intestinal Failure and Home Artificial
Nutrition
PCRS Primary Care Reimbursement Scheme
PICC Peripherally inserted central venous catheter
PINNT Patients on Intravenous and Nasogastric Nutrition
Therapy
PN Parenteral nutrition
PS Parenteral solution
QoL Quality of life
SBS Short bowel syndrome
SIGN Scottish Intercollegiate Guidelines Network
UK United Kingdom
process that seeks to improve patient care and outcomes through
systematic review of care against explicit criteria and acting to
improve care when standards are not met [5].
Clinical practice guidelines are “statements that include rec-
ommendations intended to optimize patient care that are informed
by a systematic review of evidence and an assessment of the ben-
efits and harms of alternative care options” [6]. European Society
for Clinical Nutrition and Metabolism (ESPEN) guidelines are
developed by expert groups from multiple European countries
working in the field of parenteral nutrition. The first ESPEN
guideline on the provision of HPN care was developed in 2009
included 26 recommendations across 10 subject areas (Table 1) [7].
The guideline developed in 2016 included 112 recommendations
across 13 subject areas (Table 1) [8]. Despite the initial publication
of the ESPEN guidelines on HPN in 2009 and an update in 2016,
mainly geared towards benign disease, a survey of 65 HPN centres
within 22 countries highlighted that HPN provision differs greatly
between countries and among HPN centres [9].
The 2020 guideline was developed to encourage equity of pa-
tient access to an appropriate and safe HPN service [1]. It includes
71 recommendations across 6 subject areas. The increasing demand
to provide care to patients requiring HPN alongside the acknowl-
edgement that the hospital lacks an NST prompted the need to
complete an audit of our current practice against both the newest
2020 ESPEN guidelines as well as the 2016 guideline [1,8]. It was felt
that collectively auditing the 183 recommendations with these two
guidelines represented an extensive review of current practice.
These guidelines are the most recently published guidelines avail-
able on the management of HPN using the GRADE system devel-
oped by the Scottish Intercollegiate Guidelines Network (SIGN) to
grade the literature [10]. Including the 2016 guideline, with a focus
mainly on benign disease, and the 2020 guideline which covers
HPN as a whole, enabled an audit that covered both for our patient
cohort with and without malignant disease. The aim of this study
was to evaluate a single center's current practice against 183 rec-
ommendations found within the two guidelines. The objective was
to audit compliance against European recommendations [1,8], to
K. Slye, M. McKiernan, A. Griffin et al. Clinical Nutrition ESPEN 50 (2022) 289e306

Table 1
List of subject areas included in the 2009, 2016 and 2020 guidelines [1,7,8].

ESPEN 2009 subject headings ESPEN 2016 subject headings ESPEN 2020 subject headings

1. Indications 1. Management of HPN for benign chronic intestinal failure 1. Indications for HPN
2. The nutrition support team in HPN 2. Parenteral Nutrition Formulation 2. CVAD and infusion pump
Prescription of HPN
3. Intravenous catheters and devices 3. Intestinal rehab strategy e medical short bowel syndrome 3. Infusion line and catheter site care
4. Improving prognosis in HPN 4. Chronic intestinal pseudo-obstruction 4. Nutritional admixtures
5. Education and training 5. Radiation enteritis 5. Program monitoring
6. Monitoring 6. Intestinal rehab strategy non transplant surgery 6. Management (NST, training,
emergency, travelling)
7. Liver disease in HPN 7. Intestinal transplantation
8. Management of underlying disease 8. Prevention/treatment of CVC-related infection
9. Optimization of the nutrient admixture 9. CVC-related occlusion/thrombosis
during chronic care
10. Intestinal transplantation in HPN patients 10. Prevention/treatment of IF-associated liver disease
11. Prevention/treatment of gallbladder sludge and stones
12. Prevention/treatment of IF-associated renal failure and stones
13. Prevention/treatment of IF-associated metabolic bone disease

identify any gaps in current service provision and to determine if
the lack of an IF centre in Ireland impacts on the level of care
received.
2. Methods
A retrospective audit of the HPN service provided to patients
under the care of MMUH from January 2019eMay 2021 was con-
ducted. Data was collected by investigator KS, a clinical specialist
dietitian (KS) and the discharge coordinator for patients requiring
HPN. Where the information audited related to an area outside of
the remit of the dietitian, expert opinion was sought from the
appropriate specialist.
Data was collected in an Excel™ spreadsheet designed to cap-
ture the adherence of current HPN practice against the 112 rec-
ommendations from 2016 [8] and the 71 recommendations from
2020 [1]. There were three possible responses to the audit (Table 2).
Compliance was evaluated for the 13 subject areas included in
the 2016 guideline [8] and the 6 subject areas included in the 2020
guideline [1]. These subject areas are listed in Table 1 and were
taken directly from the two guidelines. Within each subject area if
any questions were deemed “N/A” they were not included in the
percentage compliance calculation e.g., if there were 10 questions
within a subject area but 2 were deemed N/A then the percentage
calculation of compliance/non-compliance was worked out of a
total of 8 questions (Table 3). Not applicable responses were also
not included in the overall compliance calculation (Table 3).
A brief explanatory comment was included beside each
recommendation audited.
2.1. Expert opinion provided from the appropriate specialist
Compounding of parenteral nutrition is provided by an
external commercial parenteral nutrition (PN) provider. The PN
manufacturer was contacted to provide information to audit the
relevant recommendations on preparation of admixtures, were
accurately considered. Patients and family are trained on the
administration of parenteral nutrition at home by an external
nursing homecare company. All recommendations contained in
the two guidelines which were relative to nursing care provided
by this company were discussed with the company to ensure audit
accuracy. Within MMUH, consultants in interventional radiology,
colorectal surgeon, nephrology, and the coagulation team lead
provided the audit response to the recommendations relating to
line insertion, bowel surgery, renal function, and central venous
catheter (CVC) related occlusion and thrombosis, respectively.
Two microbiology consultants gave their expert opinion on
questions related to line sepsis. All audit answers were discussed
with another dietitian experienced in providing care to patients
requiring HPN as an additional check to verify information.
Following stakeholder engagement and completion of the cross-
check with another dietitian, a final list of recommendations that
were deemed ‘non-compliant’ were compiled. The list and the brief
accompanying explanations provided through audit were analysed
to identify common themes and gaps in the current service. Those
recommendations deemed not applicable in the current audit were
noted as areas that need to be addressed in the future e.g., if our
patient cohort changes.
2.2. Ethics
An MMUH Clinical Audit Application Form was submitted to the
Research Ethics Committee who provided institutional approval for
application number CA21-061 to meet the requirements of publi-
cation of clinical audit.
3. Results

Table 2 Figs. 1 and 2 demonstrate the distribution of Yes, No, and not
Possible audit response. applicable answers. Not applicable questions only represented 4.5%
of the 2016 answers and 2.8% of the 2020 answers.
Yes Indicating full compliance with the recommendation
Table 4 includes the complete list of 112 recommendations from
No Indicating non- or partial compliance
the ESPEN 2016 [8] guidelines on chronic intestinal failure in adults,
with the recommendation
Not Applicable (N/A) Indicating the scenario associated with a Yes, No or N/A response and an explanatory comment in relation
the recommendation had not arisen at this clinical site to the service in MMUH. Table 5 includes the complete list of 71
A “yes” response was only accepted if it was recognised as usual practice. If partial
recommendations from the ESPEN 2020 [1] guideline on HPN, a
compliance with a recommendation was established, then the response “no” was Yes, No or N/A response and an explanatory comment in relation to
entered to highlight the area as required potential improvement. the service in MMUH.
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K. Slye, M. McKiernan, A. Griffin et al. Clinical Nutrition ESPEN 50 (2022) 289e306

Table 3 together to enable an analysis of impacting factors (Table 6). The

Compliance calculations. corresponding number of the recommendation referred to is listed
Compliance with each (Yes answers within the subject)*100/ to enable the reader to link back to Tables 4 and 5 which includes
subject area (Total number of subject questions e N/A the brief accompanying explanation.
subject questions)
Overall compliance (Total Yes answers)*100/(Total number
of questions e N/A questions) 4. Discussion

Our audit of the current HPN service provision against evi-

3.1. Compliance
Compliance with ESPEN 2016 [8] when grouped by subject area
is shown in Fig. 3. Compliance with ESPEN 2020 [1] when grouped
by the subject areas found within that guideline, is shown in Fig. 4,
with both figures including an overall compliance rate with the
guideline.
3.2. Non-compliance
Those recommendations that were found to have non-
compliance in current MMUH HPN practice were grouped
denced based clinical practice guidelines found that overall
compliance with the recommendations from 2016 was 80% (86/107
yes answers; excluding five N/A recommendations) and overall
compliance with the recommendations from 2020 was 65% (45/69
yes answers; excluding two N/A recommendations).
To the best of our knowledge, this is the first published audit of
the care provided to patients requiring HPN in an Irish hospital
against European guidelines. This evaluation of our current practice
has identified areas of good clinical practice but also areas that
require further service development and a strategy for quality care
improvement. We have identified gaps in the current service pro-
vision relating to NST/IF units, central venous access devices, the

Fig. 1. Distribution of answers from the comparison with the 2016 guideline.

Fig. 2. Distribution of answers from the comparison with the 2020 guideline.

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K. Slye, M. McKiernan, A. Griffin et al.
Table 4
Comparison of practice in the Mater hospital against the complete list of recommendations from the ESPEN 2016 guideline on chronic intestinal failure.
Recommendation
Management of home parenteral nutrition for benign chronic intestinal failure
1 We recommend that the aims of an HPN programme include Yes
provision of evidence-based therapy, prevention of HPN-related
complications such as catheter-related infections and metabolic
complications and ensure quality of life is maximized.
2 We recommend regular audit of therapy and outcomes against No
standards to ensure safety and efficacy of an HPN programme
3 We recommend that patients selected for an HPN programme have Yes
confirmed intestinal failure that despite maximal medical therapy
would lead to deterioration of nutrition and/or fluid status
4 We recommend that prior to discharge, patients are metabolically Yes
stable, able to physically and emotionally cope with the HPN
therapy, and have an adequate home environment
5 We recommend that HPN patients have access to infusion pumps or Yes
devices with specified safety features together with ancillary
products, safe compounding, and delivery systems
6 We recommend that patient/caregiver training for HPN Yes
management be patient-centred with a multidisciplinary approach,
together with written guidelines. HPN training may take place in
hospital or at home.
7 We recommend regular contact by the HPN team with patients, No
scheduled according to patients' clinical characteristics and
requirements
8 We recommend that laboratory testing be done on a regular basis
using appropriate tests and timing relative to PN infusion
9 We recommend that quality of life for HPN patients be regularly
measured using validated tools as part of standard clinical care.
Quality of care should be assessed regularly according to recognized
criteria.
10 We suggest that HPN patients be encouraged to join non-profit
groups that provide HPN education, support, and networking
among members. This may be beneficial to patient consumers of
HPN with respect to quality of life, depression scores, and catheter
infections.
11 We recommend that CIF patients be cared for by a multidisciplinary
team with skills and experience in intestinal failure and HPN
management.
Parenteral Nutrition formulation
12 We recommend that the protein and energy requirements for CIF
patients be based on individual patient characteristics (e.g.,
intestinal absorptive capacity as estimated by gastrointestinal
anatomy and/or underlying disease) and specific needs (e.g. acute
illness, protein malnutrition), and that the adequacy of the regimen
is regularly evaluated through clinical, anthropometric, and
biochemical parameters.
13 We recommend that HPN patients have optimal blood glucose
control, based on blood glucose below (10.0 mmol/L) during HPN
infusion and normal HbA1c levels (if diabetic), through regular
monitoring.
14 We cannot make a recommendation at this time on addition of
insulin to HPN admixtures due to lack of evidence-based data
regarding insulin prescription for HPN patients who have
hyperglycaemia
15 We suggest, in patients totally dependent on HPN, a minimal supply
of 1 g/kg/week of intravenous lipid emulsion containing EFA, to
prevent EFA deficiency.
16 We suggest that most patients on long-term HPN for CIF without
ongoing metabolic complications be safely treated with provision of
no more than 1 g/kg/day of intravenous soybean-based lipid
emulsion.
17 We recommend regular monitoring of signs and symptoms of
dehydration, fluid balance, laboratory tests, and 24-h urine output
as well as timely adjustment of fluid supplementation to prevent
chronic renal failure in patients on HPN.
Clinical Nutrition ESPEN 50 (2022) 289e306
Yes, No or N/A Mater Hospital comparison
This would be the basis of our HPN service. The wording of this
should be included in our HPN policy.
Annual report of nutritional parameters completed but this is not
extensive enough as line sepsis data and QOL data not included
All patients discharged on HPN have confirmed intestinal failure
Patients would meet these requirements for safe discharge.
Discharge plans reflect their level of stability
No concerns in relation to the quality of equipment/ancillaries and
delivery systems
Discharge is coordinated by a dietitian with experience in intestinal
failure and training is provided by a nurse from a company linked to
our PN admixture provider. The remainder of the MDT would differ
depending on the discharging specialty
There is currently no set HPN team. Medical/Surgical review is
dictated by the patients' needs. The dietitian reviews the patient at
their medical/surgical appointments with additional
communication dictated by individual patient needs. HPN care
remains under the responsibility of the discharging team
irrespective of their area of specialty. Apart from the dietitian and
the nursing care in the community the discharging MDT is involved
in the care post discharge
Yes Patients have laboratory testing either weekly or every second
week; dictated by how medically stable the patient is
No Preliminary/preparatory work has only been done in relation to
measuring QoL. Gaps exist in relation to assessing quality of care
e.g., line sepsis rates
No We currently do not direct our patients to join any non-profit
groups. In the UK a charity PINNT (patients on intravenous &
nasogastric nutrition therapy) exists but there isn't an Irish charity
geared towards patients on HPN.
No All our patients are cared for by a dietitian experienced in intestinal
failure and HPN. The PN provider provides nursing care and an out
of hours contact service. Nursing will ring the on-call team if
required. The remainder of the MDT patients receive is from the
discharging specialty. This speciality will be whichever specialty the
patient was under when first discharged on HPN
Yes Fully compliant, nutritional requirements are assessed for each
patient with regular evaluation of the adequacy of the nutrition care
plan.
Yes We work towards an ideal target of <10.0 mmol/L and >4.0 mmol/L
N/A Addition of insulin to PN has never been considered for our patients
Yes All patients fully dependent on HPN receive a minimum of 1 g/kg/
week of lipid emulsion containing EFA
Yes 100% soybean-based lipid emulsion is not received by any of our
patients. All patients receive <1 g/kg/day of lipid emulsion
irrespective of the fact that it isn't fully soybean-based
Yes Regular monitoring of signs and symptoms of dehydration, fluid
balance, laboratory tests and timely adjustment of fluid provision is
completed with 24-h urine output collected when clinically
indicated
(continued on next page)
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Table 4 (continued )

Recommendation Yes, No or N/A Mater Hospital comparison

18 We recommend that the HPN formula be adjusted with the aim of Yes PN bags are compounded weekly, and changes can be made once an
normalizing laboratory tests related to fluid, electrolytes, and updated prescription is received by the PN provider Normal practice
mineral balance in patients on HPN. would be to make changes prior to a patients usual compounding
day. More immediate responses if required are made using
additional IV fluids ± electrolytes
19 We recommend regular monitoring of acid-base status in patients Yes Serum chloride and bicarbonate included as standard in all bloods
on long-term HPN (serum concentration of chloride and for patients on HPN
bicarbonate), because either metabolic acidosis or metabolic
alkalosis can occur.
20 We suggest that clinical signs and symptoms as well as biochemical Yes Fully compliant with this. Of note the covid pandemic has reduced
indexes of vitamin deficiency or toxicity be regularly evaluated at face to face reviews leading to the use of technology as required
clinical review.
21 We suggest that baseline serum vitamin concentrations be Yes Vitamin concentrations at baseline are completed post-acute
measured, according to laboratory availability, at the onset of HPN episode when CRP has normalized unless a patient has a very poor
and then at least once per year prognosis <2 months with high CRP. Target for micronutrients is 6
monthly but this has increased for some patients during the covid
pandemic with levels available for all patients at least annually
22 We suggest that vitamin doses in HPN are adjusted as needed. Yes Vitamin doses in HPN are adjusted as needed and the enteral route
is utilised if appropriate
23 We suggest that the route of vitamin supplementation be selected Yes The enteral route is the first line if appropriate for micronutrient
according to the characteristics of the individual patient replacement with adjustments made to the IV route as required
24 We suggest that clinical signs and symptoms as well as biochemical Yes Fully compliant with this. Of note the covid pandemic has reduced
indexes of trace element deficiency or toxicity be regularly face to face reviews leading to the use of technology as required
evaluated at clinical review.
25 We suggest that baseline serum trace element concentrations be Yes Trace element concentrations at baseline are completed post-acute
measured, according to laboratory availability, at the onset of HPN episode when CRP has normalized unless a patient has a very poor
and then at least once per year. prognosis <2 months with high CRP. Target for trace elements is 6
monthly but this has increased for some patients during the covid
pandemic with levels available for all patients at least annually
26 We suggest that trace element doses in HPN are adjusted as needed. Yes Trace element doses in HPN are adjusted as required and the enteral
route is utilised if appropriate
27 We suggest that the route of trace element supplementation be Yes The enteral route is the first line if appropriate for micronutrient
selected according to the characteristics of the individual patient. replacement with adjustments made to the IV route as required
28 We do not suggest that routine addition of individual amino acids Yes Individual amino acids are not used
(glutamine, cysteine, taurine) in the parenteral formula to decrease
complications in adults on HPN
Intestinal rehabilitation strategy-medical short bowel syndrome
29 We recommend that SBS patients be advised to consume regular Yes Appropriate patients with SBS receive this advice from a dietitian
whole food diets, and are encouraged to compensate for experienced in this area
malabsorption by hyperphagia.
30 We suggest that dietary counselling be guided by an expert Yes Patients with IF secondary to short bowel receive advice from one of
dietitian, based on the subjective experience of the patient, and two experienced dietitians
ideally supported by objective metabolic balance measurements, in
order to ensure high compliance
31 We recommend that SBS patients with a preserved colon consume a Yes Appropriate patients receive this advice
diet high in complex carbohydrates and low in fat whereas the
fat:carbohydrate ratio seems of less importance in patients without
a colon.
32 We suggest a diet with a high content of medium-chain Yes Appropriate patients receive this advice
triglycerides with confers a marginal benefit on overall energy
absorption compared to a diet containing regular long-chain
triglycerides in SBS patients with a preserved colon.
33 We recommend in SBS patients consuming a low fat diet or where Yes Signs of EFA deficiency assessed and fat soluble vitamin levels
the long-chain triglycerides have been replaced by medium-chain monitored
triglycerides that attention is paid to the potential deficiency in
essential fatty acids and fat-soluble vitamins.
34 We don't recommend the addition of soluble fibre (e.g. pectin) to Yes Patients are not given this advice
the diet to enhance overall intestinal absorption.
35 We suggest that lactose not be excluded from the diet of SBS Yes We do not inappropriately exclude lactose
patients unless intolerance has been documented on a clinical basis,
such as a clear association between lactose ingestion and increase of
diarrhea or of stoma output.
36 We suggest the addition of oral isotonic nutritional supplements in Yes Strategy used when indicated
borderline (i.e. B1 category of clinical classification) SBS intestinal
failure patients at risk of malnutrition.
37 We suggest the use of enteral tube feeding in combination with oral Yes Current patient cohort do not meet this criteria but we are cognizant
feeding in patients with CIF with a low-level of HPN dependence of this option
(i.e. B1 category of clinical classification) and in whom the expected
gain with tube feeding could allow them to wean off HPN.
38 We suggest, in patients with CIF treated with enteral tube feeding, Yes Standard practice to do this
the use of polymeric isotonic enteral diets
39 We don't recommend the addition of glutamine, probiotics, or other Yes Fully compliant with this.
supplemental nutrition to the diet in the aim of promoting the
intestinal rehabilitation process.

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Table 4 (continued )

Recommendation Yes, No or N/A Mater Hospital comparison

40 We suggest that SBS patients use salt liberally and restrict the Yes The additional of salt liberally is encouraged for appropriate
administration of oral fluids in relation to meals. patients
41 We suggest that patients who have borderline dehydration or Yes Our standard practice in this situation is to use double strength
sodium depletion use an isotonic high sodium oral rehydration dioralyte
solution to replace stoma sodium losses.
42 We suggest limiting the oral intake of low sodium, both hypotonic Yes Standard practice to limit hypotonic fluids in this scenario, patients
(e.g. water, tea, coffee, or alcohol) and hypertonic (e.g. fruit juices, are encouraged to use small cups when drinking hypotonic fluids to
colas) solutions in order to reduce output in patients with net- aid compliance
secretion and high output jejunostomy.
43 We recommend the use of H2-receptor antagonists or protein pump Yes We use the hospital “protocol for the management of high output
inhibitors in reducing faecal wet weight and sodium excretion, stoma” which includes advice on the use of H2-receptor antagonists
especially during the first 6 months after surgery, mainly in those and protein pump inhibitors
SBS with a faecal output exceeding 2 L/day.
44 We suggest that in the individual patient, H2-receptor antagonists Yes Patients are on H2-receptor antagonists or protein pump inhibitors
or protein pump inhibitors are also effective in reducing faecal wet in line with our hospital protocol for the management of high
weight and sodium excretion in the long-term. output stoma
45 We suggest, especially in the short-term after intestinal resection, Yes Our octreotide use is covered as part of the hospital protocol for the
the use of octreotide for patients with high output jejunostomy in management of high output stoma
whom fluid and electrolyte management is problematic in spite of
conventional treatments.
46 We recommend careful monitoring of patients treated with Yes Patients on octreotide are monitored closely in line with this
octreotide, to prevent fluid retention in relation to initiation of the recommendation
treatment, as well as potential adverse effects and potential
negative interference with the process of intestinal adaptation
during long-term use.
47 We recommend oral loperamide to reduce wet weight and sodium Yes Loperamide use is first line treatment in SBS as per our protocol for
faecal excretion in SBS patients with an ostomy. the management of high output stoma
48 We recommend oral loperamide be preferred to opiate drugs, such Yes Loperamide is first line in our protocol for the management of high
as codeine phosphate or opium, because it is not addictive or output stoma
sedative.
49 We recommend that in SBS patients with a high ostomy output, the Yes Loperamide use is first line treatment for short bowel guided by
use of loperamide be guided by objective measurements of its effect. stoma output
50 We recommend that SBS patients who have motility disorders, Yes This treatment is utilised if required for appropriate patients
including those with dilated segments of residual small bowel, blind
loop etc., and who suffer from symptoms of bacterial overgrowth,
benefit from occasional antibiotic treatment
51 We do not recommend the routine use of antibiotics in SBS patients Yes The fermentation of carbohydrates is maximized for this patient
with a preserved colon, given the benefit of the energy salvage due cohort
to colonic bacterial fermentation of malabsorbed carbohydrate to
short-chain fatty acids, in spite of a potential reduction in the
production of gases and consequent symptoms relation to this
fermentation.
52 We recommend that patients with CIF due to SBS be carefully No In Ireland teduglutide was only added to the PCRS (Primary Care
informed of the potential benefits and risks associated with growth Reimbursement Service) High Tech arrangement on the 17th of
factor treatments; information should deal with the probability of December 2020. A managed access protocol is in place. Currently
reducing the need for or the weaning from HPN, the probability of prescription of teduglutide is approved for two centres, one adult
quality of life improvement, the expected duration of treatment, the centre and one paediatric, neither of which are MMUH. Access is
expected effects after cessation of the treatment, the potential currently provided to teduglutide based on the inclusion/exclusion
adverse effects and risks of the treatment, the cost-effectiveness of criteria of the Steps trial 1 and 2 (criteria found in Jeppesen et al.,
the treatment, and the need to undergo careful and regular 2012)
monitoring.
53 We suggest that, for those carefully selected SBS patients who are No See explanation for recommendation 52
candidates for growth factor treatment, the GLP2-analog,
teduglutide, be the first choice.
54 We recommend evaluation of the efficacy of growth factor No See explanation for recommendation 52
treatment according to standardized protocols measuring fluids,
electrolytes and, whenever possible, energy balance.
55 We recommend that intestinal growth factors are only prescribed No See explanation for recommendation 52
by experts who are experienced in the diagnosis and management
of SBS patients and who have the ability and the facilities to
objectively evaluate and balance the benefit and clinical
meaningfulness of the interventions versus the inconveniences,
adverse effects, potential risks, and cost-effectiveness.
56 We recommend drugs be prescribed on an individual basis to Yes Hospital protocol for the management of high output stoma
patients with SBS following a careful evaluation of the absorptive available which assists with this but the lack of a specialist IF
capacity of the remnant bowel, knowledge of the physiochemical pharmacist means it can be a challenge outside of these
characteristics of the drug, and an evaluation as to if the drug can be recommendations
titrated according to an objectively measure effect or according to
measurements of plasma concentrations. The use of parenteral and
transdermal routes and the use of suppositories should also be
considered in SBS patients with limited intestinal absorption.
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Table 4 (continued )

Recommendation Yes, No or N/A Mater Hospital comparison

Chronic intestinal pseudo-obstruction

57 We recommend that a specific diet not be prescribed but that Yes Individualized advice providing based on patient symptoms/
patients with CIPO be encouraged to eat according to individual tolerance/history and preferences
tolerance.
58 We suggest trying enteral tube feeding as a first step in patients Yes This is current practice when appropriate
with chronic gastrointestinal motility dysfunctions who are not able
to meet their energy needs with oral nutrition alone and continue to
lose weight, before using HPN
59 We recommend that HPN not be delayed in malnourished CIPO Yes The nutritional status of a patient is acknowledged as a factor when
patients with chronic gastrointestinal motility dysfunctions when considering moving from the enteral to the parenteral route
oral/enteral nutrition is obviously inadequate.
60 We recommend attempting a trial with prokinetics in patients with Yes This is standard practice
chronic gastrointestinal motility dysfunctions.
61 We recommend using antibiotic therapy to treat intestinal bacterial Yes This is standard practice
overgrowth and to reduce malabsorption in patients with chronic
gastrointestinal motility dysfunction.
62 We suggest periodic antibiotic therapy to prevent intestinal Yes This is standard practice, although required infrequently with
bacterial overgrowth in patients with chronic intestinal motility current patient cohort
dysfunction who have frequent relapsing episodes.
Radiation enteritis
63 We recommend that nutritional regime in chronic radiation Yes Patients on HPN due to radiation enteritis are managed in line with
enteritis patients follows the same criteria adopted for the HPN of other patients with CIF
patients with other causes of CIF
64 We suggest trying enteral tube feeding in patients with radiation Yes This is standard practice
enteritis if oral nutrition including use of oral nutritional
supplements is inadequate.
65 We recommend HPN not be delayed in malnourished radiation Yes The nutritional status of a patient is acknowledged as a factor when
enteritis patients, if oral nutrition/enteral tube feeding is obviously considering moving from the enteral to the parenteral route
inadequate.
Intestinal rehabilitation strategy-non-transplant surgery
66 We recommend that, in patients with SBS, during intestinal Yes This is standard practice, confirmed by a colorectal surgeon
resection, bowel length be conserved to the fullest extent possible
to avoid dependence on HPN.
67 We recommend that, in patients with SBS, restoration of intestinal Yes If appropriate this is usually considered 6 months post initial
continuity, be realized whenever possible, to decrease HPN surgery. Confirmed by a colorectal surgeon
dependence.
68 We recommend that, when considering non-transplant surgery in No This treatment option is not currently carried out in the Mater
patients with SBS, bowel lengthening procedures be considered in Hospital
selected patients.
69 We recommend that, in patients with SBS, management is Yes Management of patients with SBS initially post operatively is
performed through a multidisciplinary approach to optimize completed by the colorectal MDT and the protocol for the
intestinal rehabilitation and overall patient outcome. management of high output stoma if appropriate is utilized.
70 We suggest to avoid surgery in CIPO patients, whenever possible, Yes Current practice would be in line with this recommendation,
due to the risk of postoperative worsening of intestinal function and confirmed by a colorectal surgeon
need for subsequent reoperation; venting ostomy (either
endoscopically or surgical), however, can diminish symptoms in
selected patients.
Intestinal transplantation
71 We recommend HPN as the primary treatment for patients with CIF No Intestinal transplant is not available in Ireland. Traditionally
and the early referral of patients to intestinal rehabilitation canters patients from Ireland have been referred to Oxford or Cambridge
with expertise in both medical and surgical treatment for CIF, to transplant centres. As there is not one consultant over the care of
maximize the opportunity of weaning off HPN, to prevent HPN our patients on HPN knowledge of referral routes and referral
failure, and to ensure timely assessment of candidacy for intestinal criteria may vary depending on the specialty managing each
transplantation. patient, although this was not assessed as part of this audit. It was
difficult to choose between no and n/a for this section as our patient
cohort has traditionally not met the referral criteria for transplant.
As one patient currently may meet the criteria of high morbidity No
was chosen
72 We recommend assessment for candidacy for intestinal No See explanation for recommendation 71
transplantation, when one of the following indications exists. 1.
Failure of HPN * Impending (total bilirubin above 3e6 mg/dl (54
e108 umol/L), progressive thrombocytopenia, and progressive
splenomegaly) or overt liver failure (portal hypertension,
hepatosplenomegaly, hepatic fibrosis, or cirrhosis) because of
intestinal failure-associated liver disease (IFALD). *Central venous
catheter-related thrombosis of two or more central veins (internal
jugular, subclavian, or femoral). * Frequent central line sepsis: two
or more episodes per year of systemic sepsis secondary to line
infections requiring hospitalization: a single episode of line-related
fungemia; septic shock and/or acute respiratory distress syndrome.
*Frequent episodes of severe dehydration despite intravenous fluid
in addition to HPN. 2. High risk of death attributable to the
underlying disease *Invasive intra-abdominal desmoid tumors
*Congenital mucosal disorders (i.e. microvillus inclusion disease,
tufting enteropathy). *Ultra short bowel syndrome (gastrostomy,

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Table 4 (continued )

Recommendation Yes, No or N/A Mater Hospital comparison

duodenostomy, residual small bowel <10 cm in infants and <20 cm

in adults). 3. Intestinal failure with high morbidity or low
acceptance of HPN * Need for frequent hospitalization, narcotic
dependency, or inability to function (i.e. pseudo-obstruction, high
output stoma). *Patients unwillingness to accept long-term HPN
(i.e. young patients)
73 We recommend that patients with impending or overt liver failure N/A Current patient cohort do not meet this criteria
due to IFALD and those with an invasive intra-abdominal desmoid
tumour be listed for a life-saving intestinal transplantation (with or
without liver transplantation).
74 We suggest that patients with central venous catheter related N/A Current patient cohort do not meet this criteria
thrombosis of two or more central veins (internal jugular,
subclavian or femoral) be listed for a life-saving intestinal
transplantation on a case-by case-basis
75 We do not recommend listing for a life-saving intestinal N/A Current patient cohort do not meet this criteria
transplantation of patients with CIF having any of the indications for
assessment of candidacy other than IFALD-related liver failure,
intra-abdominal desmoids or CVC-related multiple vein thrombosis.
76 We suggest that patients with CIF with high morbidity or low No See explanation for recommendation 71
acceptance of HPN might be listed for rehabilitative intestinal
transplantation on a careful case-by-case basis
77 We recommend that, whenever possible, patients listed for No See explanation for recommendation 71
intestinal transplantation undergo the procedure while they are in
stable clinical condition, as represented by being able to stay at
home and not requiring hospitalization while waiting for
transplant. For patients listed for a combined intestinal and liver
transplantation, mechanisms to prioritize patients on the waiting
list for liver transplantation should be adopted in order to minimize
the risk of mortality while on waiting list and after transplantation.
Prevention/treatment of CVC-related complications CVC-related infection
78 We recommend that the choice of central venous catheter type and No There is no multidisciplinary HPN team within the Mater hospital.
location of exit site be made by a multidisciplinary HPN team, along
with an experienced specialist as well as the patient.
79 We recommend that access to the upper vena cava is the first choice Yes Standard practice confirmed by IR Consultant
for CVC placement, via internal jugular vein or subclavian vein.
80 We suggest that right-sided access is preferable to a left-sided Yes Standard practice confirmed by IR Consultant
approach with respect to risk of thrombotic complications.
81 We recommend that the tip of the catheter be placed at the level of Yes Standard practice confirmed by IR Consultant
the right atrial-superior vena cava junction.
82 We recommend that the exit site of the catheter should be easily No Patients wishing to be independent with the administration of HPN
visualized and accessible for patients doing self-care and that the have received a standard PICC line in IR when this has not been
preferred site be marked by clinicians experienced with HPN. communicated accurately requiring the patient to go through an
additional line insertion procedure. The preferred site is not marked
prior to attending IR.
83 We recommend that tunnelled central venous catheters or totally No If IR are aware that a patient requires a line for HPN then a tunnelled
implanted devices are used for long-term HPN. line is inserted. Non tunnelled lines have been inserted when this
was not communicated accurately.
84 We do not recommend the use of PICC lines for expected long-term No PICC lines have been used for patients on HPN for <6 months due to
HPN, because of the higher risk of thrombosis and issues related to a palliative diagnosis.
self-administration of HPN.
85 We recommend that central venous catheter-related infections are Yes There is a 24/7 clinical microbiology service on management of
diagnosed according to current guidelines on catheter-related sepsis including line infections and catheter related sepsis is
infections. managed as per national guidelines
86 We recommend that central venous catheter-related infections be Yes There is a 24/7 clinical microbiology service on management of
managed according to current guidelines on long-term sepsis including line infections and catheter related sepsis is
intravascular catheters and as described in the comments section. A managed as per national guidelines
conservative approach with systematic and local (locks) use of
antibiotics is advocated for simple infections. Catheter removal
should be the first choice in case of tunnel infections or blood
cultures positive for virulent bacteria; catheter removal is
mandatory for port abscesses, complicated infections, persistent
hemodynamic instability, or blood cultures that are positive for
fungi.
87 We recommend, for prevention of central venous catheter-related Yes Confirmed by nurse manager of the company that trains patients þ/
infections: *education of staff and patients/caregivers or carers on administration of HPN
*implementation of an adequate policy of hand washing and
disinfection by patients and staff
*handwashing and disinfection by patient and caregivers before
touching central venous catheter as well as after catheter care
*disinfection of the hub connector every time it is accessed
*use of tunnelled single-lumen catheters whenever possible
*use of chlorhexidine 2% for antisepsis of hands, catheter exit site,
stopcocks, catheter hubs and other sampling ports
*regular change of i.v. administration sets
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Table 4 (continued )

Recommendation Yes, No or N/A Mater Hospital comparison

88 We do not recommend, for prevention of central venous catheter- Yes Standard practice; confirmed by nurse manager
related infections; *use of in-line filters *routine replacement of
catheters *antibiotic prophylaxis *use of heparin lock
89 We suggest, for prevention of central venous catheter-related Yes Standard practice; confirmed by nurse manager
infections: *performing site care, including catheter hub cleaning on
at least a weekly basis *changing catheter dressings at least once
weekly * avoiding catheter care immediately after changing or
emptying ostomy appliances *disinfecting hands after ostomy care
90 We suggest that catheter locking with taurolidine may be used to Yes Taurolidine is currently used for all patients on their second line
prevent central venous catheter-related infection in carefully sepsis episode and considered after the first episode.
selected patients.
91 We suggest the creation of arterio-venous fistulae to prevent central N/A No suitable patients in current patient cohort
venous catheter-related infections in carefully selected patients.
92 We do not recommend catheter locking with 70% ethanol to prevent Yes Compliance confirmed on all patients prescriptions and by nurse
central venous catheter-related infections, because its use is manager
associated with systemic toxicity, catheter occlusion and catheter
damage.
93 We recommend in patients who repeatedly present with central Yes Taurolidine is currently used for all patients on their second line
venous catheter-related infections, re-education of the patient and/ sepsis episode and considered after the first episode. Patients
or caregiver and/or use of an antimicrobial catheter lock. receive re-education in the community by the nurses linked to PN
provider
CVC-related occlusion/thrombosis
94 We recommend: *treating HPN patients with central venous Yes Standard practice
catheter-related venous thrombosis with anticoagulation; *the
duration of this treatment be chosen on an individual basis *the
decision to maintain the catheter be dependent on individual
factors (e.g. necessity of a central line, lack of infection, clinical
outcome)
95 We recommend, for the primary prevention of central venous Yes Standard practice confirmed by IR Consultant
catheter-related venous thrombosis, insertion of the catheter using
ultrasound guidance and placement of the tip at the superior vena
cava-right atrium junction.
96 We do not recommend routine thromboprophylaxis with drugs Yes None of our patients on HPN are on routine thromboprophylaxis
(heparin, warfarin) as primary prevention of central venous
catheter-related venous thrombosis for all adults on HPN based on
the risk/benefit balance.
97 We suggest flushing catheters with saline to prevent central venous Yes Standard practice, confirmed by nursing manager
catheter occlusion.
98 We suggest irrigation of the catheter with saline as the first attempt Yes Standard advice, confirmed by nursing manager
to restore catheter patency in intra-lumen catheter occlusion.
99 We suggest using fibrinolytic drugs for the treatment of acute Yes Standard advice if this occurs but there is no standard policy
catheter occlusion likely caused by blood clotting. Patients have when required attended colorectal outpatient clinic
for administration
Prevention/treatment of intestinal failure-associated liver disease
100 We recommend for prevention of intestinal failure-associated liver Yes All of these parameters are standard practice in the Mater hospital
disease that: *sepsis is prevented and/or managed, if present
*attempts are made to preserve small intestinal length and retain
the colon in continuity with small bowel; *oral/enteral intake is
maintained; *PN is cycled; *PN overfeeding is avoided; *the dose of
soybean-oil based lipid is limited to less than 1 g/kg/day
101 We suggest for treatment of intestinal failure-associated liver Yes All of these parameters are standard practice in the Mater hospital
disease: *to re-consider all the measures to prevent intestinal
failure-associated liver disease; *to revise the lipid component of
the PN admixture, in order to decrease the total amount and/or to
decrease the w6/w3 PUFA ratio; *to revise any potential
inflammatory/infective foci
Prevention/treatment of gallbladder sludge and stones
102 We suggest for the prevention/treatment of gallbladder sludge to Yes This is a standard practice, when safe to do so, irrespective of bowel
maintain/resume oral feeding length
103 We recommend for the treatment of gallbladder sludge and stones Yes When required patients are referred to the hospital hepatobiliary
to perform cholecystectomy and/or endoscopic procedures in case team for appropriate management in line with this
of biliary complications as for the general population. recommendation
Prevention/treatment of intestinal failure-associated renal failure and stones
104 We recommend for the primary prevention of renal failure and of Yes All patients have their renal function and fluid balance closely
renal stones, regular monitoring of renal function and fluid balance monitored. Fluid volume needs of the PN bag are regularly
as well as a timely adjustment of fluid supplementation in order to reassessed and the use of addition of IV fluids in case of any
avoid episodes of dehydration in patients with CIF emergency
105 We recommend for the primary prevention of renal failure, that Yes This is standard practice in the Mater hospital and is likely aided by
acute and chronic infections as well as acute and chronic the well established renal service whose expertise is called on when
dehydration are addressed by the relevant clinical intervention. required
106 We suggest for the primary prevention of renal stones a low oxalate Yes Two dietitians experienced in the provision of HPN and
and low fat diet, in addition to an increase or oral calcium, to reduce interventions in IF provide this advice, when appropriate
the risk of oxalate stone formation in patients with SBS with a colon
in continuity.

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Table 4 (continued )
Recommendation
107 We suggest avoiding metabolic acidosis and giving citrate
supplementation, to reduce the risk of uric acid stones
108 We recommend treating renal failure and renal stones in patients
with CIF according to the standards for these conditions.
Prevention/treatment of intestinal failure-associated metabolic bone disease
109 We recommend that for routine purposes diagnosis of metabolic
bone disease is based on a combination of bone densitometry
scanning and biochemistry
110 We recommend that the HPN population is routinely monitored for
metabolic bone disease by bone densitometry scanning and
biochemistry.
111 We recommend that general risk factors for developing
osteoporosis be promptly addressed, as well as factors with a
possible negative impact on bone health, i.e. chronic inflammation,
infections, drugs and other relevant factors related to the
underlying disease, in all patients on long-term HPN
112 We recommend as the primary step for treatment of metabolic bone
disease to optimize the program for parenteral nutrition with the
required supplements of vitamin D, calcium and phosphate. Further,
medical treatment may be useful to increase bone mineral density
and lower fracture risk.
use of teduglutide, transplant awareness, monitoring and audit,
including CRBSI, bone monitoring, bowel lengthening surgery,
venous blood gas analysis, the use of citrate to reduce the risk of
uric acid stones, documentation of PN infusion rate on the bag,
antiseptic barrier caps, portable pumps and non-profit groups.
Identifying gaps in current service provision provides an opportu-
nity to initiate change which can then be recognised in future re-
audits. The gaps identified are discussed including identifying
those that can be improved on in the short-term and within current
resources and those requiring the investment of resources and a
medium-long term approach, some with external influences e.g.
Teduglutide.
4.1. Nutrition support team/intestinal failure unit
Non-compliance was found with all recommendations related
to NST or intestinal failure centres. There were 18 recommenda-
tions between the two guidelines; three recommendations from
the 2016 guideline (2.7%) and fifteen (21%) of the 2020 guideline.
Within the 2020 guideline there were 24 recommendations where
noncompliance was found, 15 of these were due to the absence of a
nutrition support team and a dedicated intestinal failure unit. A
further three recommendations where noncompliance was found
from the 2016 guideline (2.7%) were related to the absence of an
NST. Although the 2016 guidelines only concern patients with CIF
-therefore excluding some of the patient cohort with malignant
disease-compliance with the 2016 guideline was higher than the
2020 guideline. The greater emphasis on questions related to a NST
within the 2020 guideline had a major impact on the overall
compliance rate achievable. Using percentage compliance across
the two guidelines with each recommendation given the same level
of importance has its limitations. Despite this, compliance with the
2016 guidelines is higher.
It is acknowledged that the management of patients on HPN by
NST in IF units is best practice and recommended not only by ESPEN
but also by AuSPEN and ASPEN [1,4,7,8,12,13]. A comprehensive
paper on the benefits of a NST was published from a Dutch
perspective in 2020 [14]. This review supported the view that
multidisciplinary care by an NST leads to fewer complications
including infection and electrolyte disturbances, and better survival
for patients receiving both short and long-term PN [14]. Another
review of the efficacy and efficiency of nutrition support teams
Clinical Nutrition ESPEN 50 (2022) 289e306
Yes, No or N/A Mater Hospital comparison
No It is standard practice in the mater hospital to use bicarbonate over
citrate.
Yes Patients with renal failure and renal stones are consulted to our well
established renal service
No DEXA scans not completed for all patients
No DEXA scans not completed for all patients
Yes No standard policy re bone health
Yes This is standard practice for all patients
from a Swiss group includes a list of potentials roles for the indi-
vidual members of the NST [15].
4.2. Central venous access devices
Patients in MMUH have CVADs inserted in interventional radi-
ology. When it is highlighted to interventional radiology that a line
insertion is for HPN an appropriate line is inserted. This audit has
highlighted that interventional radiology is often not aware that a
line is for access for HPN and at times an appropriate line is not
requested by the primary team. For example, a patient may have a
PICC line inserted which is subsequently changed to a tunnelled
line prior to discharge. The process for ordering lines for patients
requiring access for HPN represents an area that needs to be
addressed. The 2016 guideline did not recommend the use of PICC
lines for expected long-term HPN, because of the higher risk of
thrombosis and issues related to self-administration of HPN
(recommendation 84). A recent Italian study reported significantly
better outcomes with PICC lines over tunnelled-cuffed centrally
inserted central catheters with no increased risk of thrombosis [16].
The 2020 guideline acknowledges that PICCs can be used if the
duration of HPN is estimated to be less than 6 months. Typically,
PICC lines have been utilised for our patient cohort requiring PN for
less than 6 months and where independent administration was not
a possibility.
4.3. Catheter related blood stream infections (CRBSI)
CRBSI rates of our patients on HPN is not currently recorded. A
target CRBSI rate for a NST has been suggested to be less than 1 per
1000 [18]. CRBSI rates are put forward by ESPEN as an indicator of
the quality of the care provided and noted within the recommen-
dations on monitoring and auditing. Practices to promote good line
care are in place but without an up-to-date CRBSI rate it is not clear
if there are any improvements to service provision required.
4.4. Intestinal transplant
Intestinal transplantation is a treatment available for patients
typically with a high risk of mortality, with HPN viewed as the
primary treatment option [19]. Patients from the Republic of
Ireland requiring a small intestinal transplant have been referred
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K. Slye, M. McKiernan, A. Griffin et al.
Table 5
Comparison of practice in the Mater hospital against the complete list of recommendations from the ESPEN 2020 guideline on home parenteral nutrition.
Recommendation
Indications for HPN
1 HPN should be administered to those patients unable to meet their
nutritional requirements via the oral and/or enteral route and who can
be safely managed outside of the hospital
2 HPN should be prescribed as the primary and life-saving therapy for
patients with transient-reversible or permanent irreversible CIF due to
non-malignant disease
3 HPN can be considered for patients with CIF due to malignant disease
4 HPN should be prescribed to prevent an earlier death from malnutrition
in advanced cancer patients with CIF, if their life expectancy related to
cancer is expected to be longer than one to three months, even in those
not undergoing active oncological treatment
5 HPN can be considered for patients without intestinal failure who are
not able or do not want to meet their nutritional requirements via the
oral/enteral route. The patient should be clearly informed about HPN
benefits and risks.
6 The patient and/or caregiver should be trained by a NST to safely infuse
the PN with appropriate monitoring and prompt recognition of any
complications
7 The prescribed nutritional admixture and ancillaries required for safe
and effective therapy should be delivered by an experience/certified
health care provider
8 The NST should provide appropriate monitoring and treatment for
routine and/or emergency care, with appropriate contact details
provided to the patient 24 h per day, seven days per week.
CVAD and infusion pump
9 The choice of CVAD and the location of the exit site shall be made by an
experienced HPN NST, as well as the patient
10 The exit site of the CVAD should be easily visualized and accessible for
self-caring patients.
11 Tunnelled CVAD or totally implanted CVADs shall be used for long-term
HPN
12 Access to the upper vena cava should be the first choice for CVAD
placement, via the internal jugular vein or subclavian vein
13 Right-sided access should be preferred to the left-sided approach to
reduce the risk of thrombosis
14 The tip of the CVAD should be placed at the level of the right atrial-
superior vena cava junction
15 Peripherally inserted central venous catheters (PICCs) can be used if the
duration of HPN is estimated to be less than 6 months
16 HPN should be administered using an infusion pump for safety and
efficacy reasons
17 In exceptional circumstances a flow regulator can be temporarily used
for HPN; administration sets with only a roller clamp should not be
used.
18 A portable pump can improve patient's QOL when compared to
stationary pumps
Infusion line and catheter site care
19 Either a sterile gauze or sterile, transparent, semipermeable dressing
should be used to cover the CVAD exit site.
20 When transparent dressings are used on tunnelled or implanted CVAD
exit sits, they can be replaced no more than once per week (unless the
dressing is soiled or loose)
21 A tunnelled and cuffed CVAD with a well healed exit site might not
require dressing to prevent dislodgement
22 Tubing to administer HPN should be replaced within 24 h of initiating
the infusion
23 Strict aseptic technique for the care of home CVAD shall be maintained
300
Clinical Nutrition ESPEN 50 (2022) 289e306
Yes, No or N/A Mater Hospital comparison
Yes Standard practice in the Mater Hospital
Yes Patients discharged on HPN from the Mater hospital
have met this criteria
Yes Patients under the care of the oncology service with
CIF who are deemed safe to receive PN outside of
the hospital setting are discharged on HPN
Yes Patients under the care of the oncology service with
CIF who meet this criteria are considered for HPN.
N/A This scenario has not arisen in the Mater hospital.
Obtaining funding from the health service executive
(HSE) may be challenging if this scenario arises.
No Training is completed by external nursing service as
there is no NST within the Mater hospital
Yes The nutritional admixture is compounded by a
commercial provider and delivered alongside
required ancillaries
No No NST team available. For out of hours contact
patients contact on out of hours nurse service. If
required, they can then ring switch and the registrar
either from the speciality looking after the patient
or the medical registrar on call.
No No NST team available in the Mater hospital
No Patients wishing to be independent with the
administration of HPN have received a standard
PICC line in IR when this has not been
communicated accurately requiring the patient to
go through an additional line insertion procedure.
The preferred site is not marked prior to attending
IR.
No If IR are aware that a patient requires a line for HPN
then a tunnelled line is inserted. Non tunnelled lines
have been inserted when this was not
communicated accurately.
Yes Standard practice confirmed by IR Consultant
Yes Standard practice confirmed by IR Consultant
Yes Standard practice confirmed by IR Consultant
Yes PICC lines have been used for patients that have
required HPN for less than 6 months. This decision
has been made when a PICC line was in place prior
to a decision to proceed with HPN
Yes Infusion pump is supplied to all patients on HPN by
the commercial provider
N/A This situation has never occurred
No Currently only 30% of our patients have a portable
pump. The default traditionally has been for
stationary pumps to be used with portable pumps
only provided when specifically requested
Yes Confirmed by company providing training on
administration of PN
Yes Confirmed by company providing training on
administration of PN
Yes Confirmed by company providing training on
administration of PN
Yes Confirmed by company providing training on
administration of PN
Yes Confirmed by company providing training on
administration of PN
K. Slye, M. McKiernan, A. Griffin et al. Clinical Nutrition ESPEN 50 (2022) 289e306

Table 5 (continued )

Recommendation Yes, No or N/A Mater Hospital comparison

24 Hand antisepsis and aseptic non-touch technique should be used when Yes Confirmed by company providing training on
changing the dressing on CVADs administration of PN
25 0.5e2% alcohol chlorhexidine solution shall be used during dressing Yes Confirmed by company providing training on
changes and skin antisepsis; it there is a contraindication to administration of PN
chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol shall be
used as an alternative
26 Hand decontamination, either by washing hands with soup and water Yes Confirmed by company providing training on
but preferably with alcohol-based hand rubs, should be performed administration of PN
immediately before and after accessing or dressing a CVAD
27 A needle-free connector should be used to access intravenous tubing Yes Confirmed by company providing training on
administration of PN
28 Needle-free systems with a split septum valve may be preferred over Yes Confirmed by company providing training on
some mechanical valves due to increased risk of infection with administration of PN
mechanical valves
29 Contamination risk shall be minimized by scrubbing the hub connectors Yes Confirmed by company providing training on
(needleless connectors) with an appropriate antiseptic (alcoholic administration of PN
chlorhexidine preparation or alcohol 70%) and access it only with sterile
devices
30 For passive disinfection of hub connectors (needleless devices) No Antiseptic barrier caps are not currently used
antiseptic barrier caps should be used
31 If HPN is delivered via an intravenous port, needles to access ports Yes Confirmed by company providing training on
should be replaced at least once per week administration of PN
32 The CVAD or CVAD site should not be submerged unprotected in water Yes Confirmed by company providing training on
administration of PN
33 Sodium chloride 0.9% instead of heparin should be used to lock long- Yes This is standard practice
term CVAD
34 As an additional strategy to prevent CRBSIs, taurolidine locking should Yes Taurolidine is currently used for all patients on their
be used because of its favourable safety and cost profile second line sepsis episode and considered after the
first episode. Patients receive re-education in the
community by the nurses linked to PN provider
35 If a PICC is used for HPN, a sutureless device should be used to reduce Yes Confirmed by company providing training on
the risk of infection administration of PN
36 For the securement of medium to long term PICCs (>1 month) a Yes Confirmed by company providing training on
subcutaneously anchored stabilization device can be used to prevent administration of PN
migration and save time during dressing change
37 In multilumen catheters, a dedicated lumen should be used for PN Yes This is standard practice
infusion
38 Routine drawing of blood samples from CVAD should be avoided if Yes Confirmed by company providing training on
possible due to an increased risk of complications administration of PN
Nutritional admixtures
39 Either commercially available ready-to-use admixtures or customized Yes All patients on HPN discharged from the Mater
and tailored to the individual patient's requirements admixtures can be hospital receive admixtures tailored to their needs
used for HPN
40 Customized and tailored HPN admixtures can be prepared either by Yes All patients on HPN discharged from the Mater
individual compounding or by ready-to-use prepared and adapted hospital receive admixtures tailored to their needs
commercial multi-chamber bags, according to the manufacturer
instructions and using aseptic admixture technique preferably in a
laminar flow cabinet
41 Customized AIO admixture stability should be documented for the Yes Confirmed by the commercial PN provider
individual admixture based on checks by appropriate lab methods
42 Customized AIO admixture stability shall not be extrapolated from the Yes Confirmed by the commercial PN provider
literature
43 AIO admixture shall be completed immediately before infusion by Yes Confirmed by the commercial PN provider
adding trace elements and vitamins according to stability and
compatibility data
44 Drug admixing into AIO admixture shall be avoided, unless specific Yes Not current practice
pharmaceutical data are available to document compatibility and
stability of the AIO
45 AIO admixtures shall be labelled for the individual patient indicating the No The rate of PN administration is not currently
composition (dose) of the individual components according to written on the PN bag it is written in the paperwork
standards, the date, the patient's name and indication for handling such provided.
as storage, admixes to be made, infusion rate
46 For customized AIO admixtures, the cold chain should be guaranteed Yes Confirmed by the commercial PN provider
during transport and at the patient's house
47 The hanging time for a HPN admixture should be no longer than 24 h Yes HPN patients are typically discharged on a 12 h
infusion. On a rare occasion where a nurse is funded
to administer the PN at home a 14 h infusion has
been used to aid nurse visiting times to meet staff
availability
48 At the end of cyclic PN administration, the infusion rate can be reduced
to avoid rebound hypoglycaemia (e.g. half of the infusion rate over the
last half an hour)
Yes Commercial provider
confirmed that the
(continued on next page)

301
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Table 5 (continued )

Recommendation Yes, No or N/A Mater Hospital comparison

pump is programmed
to do this.
Program monitoring
49 Patients receiving HPN shall be monitored at regular intervals to review Yes Currently there is no set criteria for frequency of
the indication, the efficacy and the risks of treatment review, and it is decided by the discharging team
and typically based on the medical needs of the
patient
50 The time between reviews should be adapted to the patient, care setting Yes The time between reviews are based on the medical
and duration of nutrition support; intervals can increase as the patient is needs of the patient rather than the PN needs unless
stabilized on nutrition support earlier review is requested by the dietitian
51 HPN monitoring should be carried out by the hospital NST in No No NST available Patients are monitored by a
collaboration with experienced home care specialists, home care Dietitian and the discharging medical team. This has
agencies and/or general practitioners resulted in at times 9 different Consultants caring
for patients on HPN
52 Patients and/or caregivers can be trained to monitor nutritional status, Yes Part of HPN training by the commercial provider
fluid balance and the infusion catheter
53 Monitoring should comprise of nutritional efficacy, tolerance of PN, No QOL currently not assessed and CRBSI not audited
patient/caregiver management of infusion catheter, Qol and quality of
care (e.g. CRBSI rate, readmission rate etc)
54 In clinically stable patients on long-term HPN, body weight, body No Non-compliant with blood gas recommendation
composition and hydration status, energy and fluid balance and
biochemistry (haemoglobin, ferritin, albumin, CRP, electrolytes, venous
blood gas analysis, kidney function, liver function and glucose should be
measured at all the scheduled (e.g. every three to six months)
55 In patients on long-term HPN, clinical signs and symptoms as well as Yes Micronutrient levels every 6 months are targeted.
biochemical indexes of vitamin and trace metal deficiency or toxicity This was longer during the pandemic, but
should be evaluated at least once per year. appropriate patients met the criteria of having
levels done at least annually
56 In patients on long-term HPN, bone metabolism and bone mineral No No bone metabolism policy also poor compliance
density should be evaluated annually or in accordance with accepted with DEXA scan recommendation
standards (e.g. DXA at max. every 18 months)
Management (nutrition support team, training, emergency, travelling)
57 The suitability of the home care environment should be assessed and Yes Home visits prior to discharge are not standard
approved by the HPN nursing team before starting HPN, wherever practice but can be arranged if required
possible
58 A formal individualised HPN training program for the patient and/or Yes Confirmed by commercial provider that this is part
caregiver and/or home care nurses shall be performed, including of the training
catheter care, pump use and preventing, recognizing and managing
complications; training can be done in an in-patient setting or at the
patient's home
59 Patients on HPN should be cared for by specialised, dedicated and a No No NST available
clearly identifiable hospital unit, normally termed “HPN center or IF
center or intestinal rehabilitation center”
60 The HPN unit should have offices for outpatient visits and dedicated No No dedicated offices for HPN outpatient visits and
beds for patients who need hospitalization no dedicated inpatient beds
61 All HPN patients should be cared for by a NST with experience in HPN No No NST team available, the main discharging team
management, independent from the underlying disease leading to becomes the team on discharge to monitor HPN
intestinal failure
62 The NST consists of experts in HPN provision. This can include a No There is no NST in the Mater hospital Patients have
physician, specialist nurses (including in catheter, wound and stoma access to all of the listed healthcare workers, but
care), dietitians, pharmacists, social worker, psychologist, as well as an they are not necessarily an expert in PN
appropriate practitioner with expertise in CVC placement. Surgeons
with expertise in Intestinal failure should also be available for
structured consultation
63 The NST for HPN/CIF shall have clear written pathways and protocols in No There is no NST in the Mater Hospital There could be
place for the management of patients with complications relating to more protocols developed to ensure consistency
HPN with managing complications, but a HPN policy
does exist but further development of this is needed
64 The NST for HPN/CIF shall provide patients and caregivers with written No No NST team available for out of hours contact
information relating to the recognition and subsequent management of patients contact on out of hours nurse service. If
HPN-related complications including details (e.g. telephone number) of required, they can then ring switch and the registrar
an appropriate NST member to contact in the case of an emergency, either from the speciality looking after the patient
available 24 h a day or the medical registrar on call.
65 The NST or HPN/CIF shall disseminate clear protocols related to the No A HPN review document is provided to patients
recognition, investigation and initial management of HPN-related when appropriate, but more work needs to be done
complications to hospital emergency departments where patients are in this area.
likely to be present; where appropriate and available, written protocols
an also be carried by the patient or accessed electronically via a secure
web-portal.
66 When patients are admitted to hospital with HPN-related complications No No NST and also no national IF centre
their care shall be delivered by the NST for HPN/CIF If patients are
admitted to a hospital where such expertise does not exit, then clinical
guidance should be provided by the NST/CIF, until the time when the
patient can be transferred to the HPN/CIF centre, as required

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K. Slye, M. McKiernan, A. Griffin et al.
Table 5 (continued )
Recommendation
67 Written protocols for the management of HPN-related complications
shall be developed and shared with the patient's local hospital, if it is
likely that the patient will be admitted first to that hospital rather than
to an HPN/CIF center in the event of an emergency; these should include
contact details for the NST for HPN/CIF to advise on treatment and/or
possible transfer to the HPN/CIF center. Where appropriate and
available, written protocols can also be carried by the patient or
accessed electronically via a secure web-portal
68 Patients shall carry details relevant to their condition, and/or have
access to a secure web-portal containing relevant clinical information,
when travelling away from home, in order to aid clinical teams and
other hospitals should emergency treatment be required
69 The NST for HPN/CIF shall ensure that patients, caregivers and general
practitioners are aware of the roles and responsibilities of the health
care professionals involved in aspects of the patient's condition that are
unrelated to HPN, including any complications relating to the patients
underlying disease and other non-IF related conditions.
70 For a patient to travel safely, he/she shall receive a sufficient supply of
PN and relevant ancillaries during the journey and at the destination
and the NST responsible for the patient's care shall endeavour to
establish contact with a skilled NST at the patient's destination, in case
medical support is required
71 Incidence of catheter-related infection, incidence of hospital
readmission and Qol, should be used as criteria to assess the quality of
care of HPN programs
to one of two centres in the UK: Cambridge and Oxford. The Na-
tional Health Service Annual Report on Intestinal Transplantation
in 2020 reports survival rates [20]. They reported survival 90 days,
one- and five-years post-transplant, without a liver to be 95%, 88%
and 73% respectively and with a liver as 89%, 74% and 39% [20].
Based on these findings’ early referral of high-risk patients is
advocated [19]. The care of patients on HPN within MMUH staying
under the care of the discharging consultant has a potential to be a
negative factor in relation to prompt referral. For example,
knowledge of referral pathways for intestinal transplant assess-
ment is unlikely to be equal across all specialties managing these
patients which include nephrology, gastroenterology, gynaecol-
ogy and colorectal.
4.5. Pharmacotherapy
Teduglutide, a glucagon-like peptide 2 analogue, is used to
facilitate intestinal adaptation in IF secondary to short bowel syn-
drome via reductions in requirements for parenteral support (PN or
IV fluids) [21]. Teduglutide was first approved for use in Europe in
2012 after the Committee for Medicinal Products for Human Use
(CHMP) of the European Medicines Agency (EMA) recommended
its approval [22]. In Ireland, teduglutide was only added to the PCRS
(Primary Care Reimbursement Service) of the Health Service Ex-
ecutive (HSE) High Tech arrangement on the 17th of December
2020 [23]. Currently, prescription of teduglutide is approved for
one adult centre in Ireland; not MMUH. The inclusion/exclusion
criteria set out in the managed access protocol is the criteria set out
in the Steps 1 and 2 trials [24,25]. Parenteral support volume re-
ductions were seen in 65% of patients and 20% of study completers
achieved independence from parenteral support [21]. Further
studies have tried to identify within the patients on PN with SBS,
more specific cohorts of patients more likely to respond to tedu-
glutide [21,26e28]. A review of recent literature available on its use
is available [29]. Teduglutide currently represents a potential
treatment option to reduce PN dependence for some patients on
HPN and access to this going forward will need to be addressed.
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Clinical Nutrition ESPEN 50 (2022) 289e306
Yes, No or N/A Mater Hospital comparison
No A HPN review document is provided to patients
when appropriate, but more work needs to be done
in this area.
Yes A HPN review document is provided to patients
when travelling
No The link between hospital and GP is not strong as
GPs do not take a key role in management of
patients on HPN. This could be easily improved by
sending on HPN review documents to the GP
No Partial compliance as travel is safely organised but
not organised by a NST and the nearest hospital if
travel within Ireland also does not have an NST
No Not QoL and catheter-related infection are not
audited at present
4.6. Bone health
Metabolic bone diseases are a group of diseases that cause
disorders of bone and are commonly found in patients on long term
parenteral nutrition, with osteoporosis reported in 57e88% [30].
Out of the five recommendations related to bone health across the
two guidelines compliance was only 40%. Although bloods related
to bone health are included as standard practice, patients requiring
HPN under the care of MMUH have not consistently had a dual-
energy x-ray absorptiometry (DEXA) scan to assess their bone
density. Factors impacting the numbers of patients to have received
a DEXA scan include failure to attend a DEXA appointment and for a
period from March 2020, the COVID-19 pandemic imposed limi-
tations on high-risk patients entering the hospital environment.
Compliance with recommendations for bone health would be
improved by ensuring patients receive regular DEXA scans [1,8].
4.7. Bowel lengthening
Bowel lengthening includes longitudinal intestinal lengthening
and tailoring or Bianchi procedure, serial transverse enteroplasty
and spiral intestinal lengthening [31]. These procedures are only
preformed in highly specialist centres, and it does not represent an
area of non-compliance that needs to be addressed.
4.8. Venous blood gas analysis
Recommendation 54 of the 2020 guideline includes a list of
parameters to complete at all scheduled appointments in stable
patients on long-term HPN and includes venous blood gas analysis
[1]. This is the only parameter listed audited as non-compliant and
reasoning for inclusion is not discussed. Serum bicarbonate and
chloride levels are included as standard as part of our renal profile,
but we do not complete blood gas analysis. Apart from the logistical
issue of completing blood gas analysis in an outpatient setting
(analysers are not available in the outpatient department), the
evidence base for its use in stable HPN patients is lacking.
K. Slye, M. McKiernan, A. Griffin et al. Clinical Nutrition ESPEN 50 (2022) 289e306

Table 6
Summary of non-compliance.

Subject area Number of Recommendation from Recommendation from Guideline

No answers Guideline 2016 2020 (Number 1e71)
(Number 1-112)

Nutrition Support Team/Intestinal failure unit 18 7, 11, 78 6, 8, 9, 51, 59, 60 61,62,63,64,65,66,67, 69, 70
Central venous access device (CVAD) insertion 5 82, 83, 84 10, 11
Teduglutide 4 52, 53, 54, 55 e
Transplant awareness 4 71, 72, 76, 77 e
Monitoring/Audit including CRBSI 4 2, 9 53, 71
Bone monitoring (use of DEXA) 3 109, 110 56
Bowel Lengthening surgery 1 68
Venous blood gas analysisa 1 e 54
Use of Citrate to reduce the risk of uric acid stonesa 1 107 e
PN infusion rate on the bag 1 e 45
Antiseptic barrier caps 1 e 30
Portable pump 1 e 18
Non-profit groups 1 10 e
Total No answers 45

- Indicates that guideline did not have any No answers for that subject area.
a
Indicates areas not in line with the recommendations but where poor evidence exists of the need to change current practice.

Fig. 3. Percentage compliance of MMUH provision of HPN care audited against ESPEN (2016) guideline on chronic intestinal failure [8]. A line for overall compliance is
included. Compliance calculations exclude recommendations that were deemed N/A. HPN, home parenteral nutrition; CVC, central venous catheter; IF, intestinal failure.

4.9. Use of citrate to reduce the risk of uric acid stones 4.10. PN infusion rates

MMUH complies with 80% of the recommendations related to
renal failure and renal stone formation. The only barrier to reaching
100% is the absence of the use of citrate to reduce the risk of uric
acid stones. The evidence for the use of citrate is acknowledged by
ESPEN to be very low. It is standard practice in MMUH, where we
have an established nephrology service to use bicarbonate over
citrate. Citrate is converted to bicarbonate in the body and both
sodium bicarbonate and citrate are recognised treatment options
[32,33]. Acetate use in the admixture can also play a role in the
management of metabolic acidosis as acetate is converted to bi-
carbonate in the liver [34].
PN infusion rates are present on all inpatient parenteral nutri-
tion bag labels used within MMUH. Despite the same PN provider
supplying our patients on HPN this review has highlighted that the
infusion rate is not present on the bags they receive at home.
Consultation with all providers of PN to the Republic of Ireland has
confirmed that no provider currently includes the infusion rate on
bags provided for use in the home. Infusion rates are present on
additional paperwork, but the lack of awareness of its absence on
the front label of the bag received at home could represent a safety
risk. It is our recommendation the PN providers introduce this in
line with the ESPEN 2020 guideline [1].

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K. Slye, M. McKiernan, A. Griffin et al.
Fig. 4. Percentage compliance of MMUH provision of HPN care audited against ESPEN (2020) guideline on home parenteral nutrition [1] A line for overall compliance is included.
Compliance calculations exclude recommendations that were deemed N/A. HPN, Home Parenteral Nutrition; CVAD, Central Venous Access Device; NST, Nutrition Support Team.
4.11. Antiseptic barrier caps
Antiseptic barrier caps are not currently used by our patients for
passive disinfection of hub connectors which is recommend in the
2020 guideline (recommendation 30) [1]. The evidence base quoted
by ESPEN for this recommendation is a small study from 2006 and a
systematic review with meta-analysis from 2017 [35,36]. Both were
not specific to the HPN population and highlighted the need for
further research on the effectiveness of the cap in the HPN setting
but the potential to reduce CRBSI rates with associated cost savings
is accepted to be a simple safety measure and a change in practice
should be considered within the short term.
4.12. Portable pumps
Portable pumps are currently only used by 30% of our patients.
The default traditionally has been for stationary pumps with an
intravenous stand to be used, portable pumps have been used
when requested for a specific indication. A Canadian study of 20
patients on HPN used a 2-month prospective crossover open study
to assess quality of life of patients during a transition from a sta-
tionary to a portable pump [37]. They used a 36-item short form
health survey (SF-36) and a pump specific questionnaire. The SF-36
is a set of generic, easily administered quality of life measures so not
specific to HPN. Patients were significantly happier with the
portable pump, and this represents a potential simple change that
should be incorporated into our future practice. We should engage
with our PN provider and consider changing our default pump to a
portable pump.
4.13. Patient support
PACIFHAN is the International Alliance of Patient Organisations
for Chronic Intestinal Failure and Home Artificial Nutrition, and
they list nine different non-profit organisations throughout the
world suitable for patients on HPN to join. Geographically the
nearest member to Ireland is the UK charity PINNT (patients on
intravenous & nasogastric nutrition therapy). Going forward we
should direct our patients towards PINNT and inform them of any
meetings planned for Ireland.
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Clinical Nutrition ESPEN 50 (2022) 289e306
4.14. Quality of life
Assessment of quality of life of patients requiring HPN via the
use of a treatment specific Qol questionnaire is advocated as part
of routine clinical management of HPN, something ESPEN
acknowledged in 2009 [8,38]. We are currently only compliant
with one of the seven recommendations related to quality of life
(recommendation number 1, 9, 10 and 52 of the 2016 guideline
and 18, 53 and 72 of the 2020 guideline) which equates to a
compliance rate of 14%. The Home parenteral nutrition-quality of
life (HPN-QOL©), is a validated self-assessment tool for the mea-
surement of QoL in patients on HPN developed by the Home
Artificial Nutrition and Chronic Intestinal Failure (HAN&CIF)
special interest group of ESPEN [11,39e41]. Access to this tool has
been obtained but data has not been collected to date and it
represents an area that needs to be addressed.
5. Conclusion
This audit represents a thorough overview of the current prac-
tice of providing HPN at a single site, level 4 teaching hospital. It has
identified areas of good evidence-based practice, but also areas that
require further development, enabling the consolidation of a
strategy for improvement. This review has highlighted elements of
our practice that could be improved with the use of very little re-
sources e.g., portable pump use, antiseptic barrier caps, directing
patients to non-profit groups. It is also clear that we are unlikely to
ever be 100% compliant as elements like bowel lengthening surgery
are unlikely to be a part of our practice going forward.
The lack of funding of any MDT member to manage patients
requiring HPN is a major barrier to initiating changes to current
practice, especially where engagement with multiple stakeholders
is required. There is currently no formal medical governance
structure over the HPN service and the establishment of a formal
HPN governance committee is a potential forum to address change
going forward. Identifying gaps in current service provision pro-
vides an opportunity to initiate change which should be re-
evaluated periodically to ensure high quality of clinical care for
patients. The absence of funding of a nutrition support team to
provide a service to patients on HPN was highlighted as a major
barrier to compliance with ESPEN recommendations in this study.
K. Slye, M. McKiernan, A. Griffin et al.
As the first published audit of the care provided to patients
requiring HPN in an Irish hospital against European guidelines this
study gives an overview of the service received by patients
attending MMUH. In the absence of nutrition support teams or an IF
unit within the Republic of Ireland, repeating this study across
multiple hospitals could provide a detailed evaluation of the quality
of services received by patients requiring HPN.
CRediT author statement
Karen Slye: Conceptualization, Methodology, Investigation,
Visualization, Writing e original draft Mary McKiernan: Supervi-
sion Anne Griffin: Conceptualization, Supervision, Writing e re-
view & editing Alexandra Cremona: Conceptualization,
Supervision, Writing e review & editing.
Funding
No funding was received for this research study.
Declaration of competing interest
All authors declare no conflict of interest.
Acknowledgements
We thank Christina Molloy (MMUH, Senior Colorectal Dietitian),
Mr Jurgen Mulsow (MMUH, Consultant Colorectal Surgeon), Pro-
fessor Leo Lawler (MMUH, Consultant Interventional Radiologist),
Professor Denise Sadlier (MMUH, Consultant Nephrologist),
Maureen Lynch and Deirdre Brady (MMUH, Consultant Microbiol-
ogist), Professor Fionnuala Ní Ainle (MMUH, Consultant Haema-
tologist), our parenteral nutrition commercial provider and the
nurse manager from the homecare company that provides nursing
care to our patients on HPN all of which provided clarity on their
own specialist areas.
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