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BANS Survey Report

Sean White, BANS Committee Member

The British Artificial Nutrition Survey (BANS), now a web-based system, has been collecting data about patients on home enteral tube feeding (HETF) for two decades. BANS reports provide evidence of trends with regards the use of artificial nutrition support (ANS). It continues to evolve in response to the needs of health professionals supporting patients on ANS and to the changes to how NHS services are commissioned. A multi-disciplinary committee, including nursing, dietetics, pharmacy and medical representation from all 4 home countries, oversee BANS initiatives and seek to disseminate meaningful data about current practice. It is the largest register of patients on ANS in the world and is regularly cited in research studies, guidance and other publications focusing on patients receiving ANS. The BANS Committee wish to further develop the e-BANS HETF database, focusing on the data collected and the ease of reporting both locally and nationally. To help inform this process, the BANs Committee recently conducted a survey amongst healthcare professionals and here we share the responses.

Methods

A survey was conducted using the Bristol Online Survey tool, asking respondents for their opinion on using HEFT e-BANS and also exploring why professionals may not be entering any data onto the e-BANS system. The survey used closed questions, likert scales and opportunities for people to expand using free text. Using convenience sampling, a link to the survey was e-mailed to PENG Virtual Home Enteral Feeding (HEF) Group, NNNG forum and PENG members.

Results

70 health professionals replied to the survey. 24 (35%) currently register their HETF patients on e-BANS and 45 (65%) do not.

Feedback from respondents not currently registering HETF patients on e-BANS Respondents who answered that they did not register their patients with e-BANS were asked a series of questions about why this was and what would encourage them to start. Figure 1 describes reasons why respondents do not enter data onto e-BANS.

 

Figure 1: Reasons why respondents do not enter data onto HETF e-BANS

Other reasons why respondents gave for not using e-BANS include:

  • Confusion over who registers patients who are shared with other departments
  • The feed company registers the patient
  • Reports found not to be useful.

The range of feedback to encourage respondents to start registering their HETF patient caseload with e-BANS is summarised below:

  • Improve the ease of use of the system
  • Provide instructions on shared care patients
  • Allow registration through enteral feed company
  • Production of meaningful reports, including ability to run reports using local data
  • Improved understanding of the value of e-BANS data collection and reporting
  • Ability to identify patients on the system
  • Email reminders, possibly in the form of a periodic newsletter II
  • Encouragement/requirement from manager
  • Feedback on data reports
  • Can it be linked to electronic records such as Systm One
  • Reassurance about confidentiality
  • Time to enter the data
  • Not aware e-BANS still exists.

The BANS Committee wished to receive feedback on whether the incentive of an annual award would encourage respondents to register HETF patients onto e-BANS and/or update their data. Only 36% of respondents felt that possibility of winning an award would encourage them to enter data onto e-BANS.

Feedback on the practice of respondents currently registering HETF patients on e-BANS

Respondents who reported entering data onto e-BANS were asked a series of questions about how they use the system and feedback on possible improvements.

The dietitian was most often the person entering data onto e-BANS, followed by the dietetic assistant and clerical staff, as shown in Figure 2.

 

Figure 2: Role of person entering their team’s data onto e-BANS

Figure 3 describes how often respondents update HETF e-BANS data. The majority of respondents using e-BANS do not update any of the demographic data during an episode of HETF (69%). 13% update when the route of enteral feeding changes; 9% update when the patients location changes; 7% update when the level of independence changes; and 2% update if the patients activity level changes.

 

Figure 3: How respondents engage with HETF e-BANS

Recommendations for improvements to e-BANS

Respondents were asked for their feedback on possible changes that may be made to HETF e-BANS with regards specific indications for HETF. The responses are summarised below.

  • Head and neck cancer:
    • Time between tube placement and removal
    • Whether tube was used
    • How many patients have multiple tubes placed i.e. due to recurrence
    • Include reason for placement: ‘inserted before treatment’.
  • Stroke:
    • Time between date of tube placement and date of death
    • Method of feeding at discharge and at death
    • The type of stroke the patient has had.
  • Cerebral palsy/learning disabilities:
    • Age at transition from children's to adult service.
  • Cystic fibrosis:
    • Cystic fibrosis related diabetes.
  • Diseases of gastrointestinal tract, e.g. Crohn’s and ulcerative colitis:
    • Use of elemental feeds.
  • Upper GI cancer:
    • Active treatment v palliative reason for placement
    • Method of feeding.
  • Long-term neurological conditions:
    • Taking oral diet at time of tube placement?
  • Relevant to all patients on HETF:
    • Anthropometric changes during episode of HETF
    • Meeting dietetic outcomes?
    • Use of blended diet
    • Complications, e.g. buried bumper
    • Demonstrate the benefit of HETF service
    • Proportion of patients with each indication
    • Feed tolerance
    • Length of consultation
    • Method of feed administration, i.e. bolus (gravity/pump/plunger) v pump feeding
    • Is biochemistry being monitored
    • What anthropometry is being used?
    • Frequency of follow up.
  • A summary of respondents suggestions about how to make it easier to enter data onto e-BANS are described below:
    • Include Patient identifiable data (PID) or easier to identify identifier, e.g. initials/which CCG
    • Ability to run local reports
    • Ability to choose time period for report
    • Ability to compare with national picture
    • Ability to collect standalone collections
    • Develop an app to update information
    • Update format of BANS database
    • Email reminders when updates are required with link and allow instant update
    • Proactively send reporters their end of year report (local and national)
    • Joint access with other trusts for shared patients
    • Clear instructions for each question (help button for each question)
    • More promotion (by BANS committee)
    • Update training
    • More meaningful reporting capability
    • Less time consuming
    • Link with enteral feed company registration
    • Increased use of tick boxes.

Relative importance of e-BANS

Respondents were asked to rate the importance of the following functions of e-BANS: Respondents stated how important they felt it was to...

...be able to retrieve reports relating to your local HETF caseload

...contribute to the national e-BANS data collection

...receive more regular reports collated from the e-BANS data set

...have ability to run local reports from e-BANS whenever you need them

Feedback on what other reports they would like e-BANS to be able to run are summarised below:

  • % meeting dietetic goals
  • HETF outcomes, e.g. weight
  • Number of patients on HETF (local and national)
  • Length of time on HETF per indication
  • Reasons for discharge
  • Trusts that have commissioned support teams
  • Ascertain complexity of cases.

Any other feedback

  • Link with enteral feed company registration
  • Concerns about accuracy of data if dietitians not updating database when patients die or stop feeding, or when feeding route ore circumstances changes
  • Receiving reports may inspire to update records more frequently
  • Concerns about completeness of the data set.

17 people agreed to be part of working group to develop the HETF e-BANS data set and reporting capabilities.

Discussion

Patient identifiable data

Many respondents described being unable to identify individual patients on e-BANS as a barrier to using the system. For a period of time during 2008/9 patient consent was required for data to be submitted on BANS. This led to a significant drop in reporting and therefore the data protection authorities agreed that there was no future requirement to obtain consent, on the understanding that BANS developed a pseudonomised code (i.e. not patient identifiable data); this code includes the first 2-4 digits of the patient's postcode, the year of birth and the last 4 digits of the NHS number. However, the inability to recognise the identity of individual patients on e-BANS is likely to be one of the reasons why information relating to the patient is not updated throughout an episode of HETF, with 69% not updating during an episode of HETF. Though many suggested that e-BANS could be used to host HETF outcomes, this would be very difficult without being able to easily identify each individual patient on the system, to allow updates to be made. For this reason, it may be more realistic to concentrate on meaningful data that can be collected at the time of commencing and ending (e.g. death, move out of area or tube removed) an episode of HETF.

The BANS Committee intend to re-visit the possibility of the enteral feeding companies facilitating the registration of patients commencing HETF onto e-BANS.

e-BANS reporting

61% of respondents felt it is ‘very important’ to be able to be able to run reports relating to the local HETF population. Currently e-BANS can only generate reports pertaining to the national HETF population. The ability for BANS users to be able to independently run reports about their own HETF caseload may have a number of benefits, motivating current users to update their data input, and to encourage new users to sign up to BANS. HETF teams in individual NHS Trusts could use these local reports to demonstrate longitudinal changes in their HETF caseload, compare to other similar sized Trusts (particularly useful if the system recorded the number of HCPs supporting HETF in each locality), and also compare with the national picture. 63% of respondents felt it was ‘very important’ to have the ability to run reports from e-BANS whenever they need them. This should involve setting defined date periods for reports to be run over (e.g. monthly, annually, financial years).

In addition to local centres to be able to run their own reports when they like, there may also be benefits associated with the e-BANS system being able to automatically generate periodic reports using both national and each localities data. These reports could be sent to local reporters to provide feedback on the data they are entering onto the e-BANS system. This may improve the motivation to keep data up-to-date and raise the profile of BANS in general.

Ultimately, the ability to generate reports that are meaningful to the people entering data into the e-BANS system is likely to be the main driver to increase the number of e-BANS reporters and improving the quality of the data collected. Using the feedback from this survey, the BANS Committee intend to further explore the options available for data collection and reporting, based on how reporters most commonly engage with the system. Allowing reporters to have the freedom to run reports relating to their local HETF case-load when they want, will hopefully have benefits in terms of health professionals’ perceived value of contributing to the BANS data. This in turn, may lead to an improved picture of national trends in HETF.

Keeping e-BANS data up-to-date

Respondents expressed concern about the quality of the data collected and reported upon by BANS. As demonstrated in this survey, not all reporters update during an episode of HETF. There are a number of reasons why reporters do not always update their data, including lack of time available, doubting the value of e-BANS data, etc. The planned review and update of HETF e-BANS, should include in its aims to:

  • Improve confidence in the reports produced
  • Keep it quick and simple to update at key stages during episodes on HETF
  • Encourage reporters to improve the validity of the data collected.

Suggestions to improve the validity of the data collected include sending reporters email reminders which, if possible, include links to their data sets to update when required. More pro-active communication with reporters about their e-BANS activity may also encourage them to update their data. A greater presence on social media and increased communication with key groups, such as NNNG, BAPEN, PENG and the Virtual HEF Group, may also increase engagement with e-BANS and its core aims.

Perceived value of HETF e-BANS

A number of people suggested that there should be greater awareness of BANS and its value. Previous BANS reports, free to download via the BAPEN website, are frequently cited in academic papers and national guidance relating to trends in HETF. The BANS committee has considered attempting to publish shorter, but more frequent reports, containing headline data. More frequent reporting may have an effect of increasing the profile of BANS, if communicated effectively via the relevant professional groups and social media. The BANS committee will work with Streets Heever, to improve the reporting function of e-BANS, including pro-actively circulating both local and national reports to current reporter and publishing on BAPEN website.

For further information on BANs click here.

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