BAPEN recently caught up with a team of dietitians from Ashford and St Peters Hospital in Surrey, who are keen to share their success and learnings from establishing a Dietetic Liver Service with the wider nutrition community. Offered to patients in their Trust, this service supports patients with managing their nutritional status and intake alongside liver conditions.

Please can you tell us about the ‘Dietetic Liver Service’ that you offer in your Trust?

We are a team of five WTE gastroenterology dietitians and a dietetic assistant practitioner, covering a 22-bed inpatient gastroenterology ward. Trust data shows that 25-50% of patients we review per month are liver patients.

We decided to introduce weekly face-to-face liver-specific dietetic clinic (7 appointments per week) to allow anthropometric measurements, including hand dynamometry and visual assessment of fluid and muscle wastage. We are also planning to introduce Subjective Global Assessments (SGAs) into this clinic to allow more accurate diagnosis of malnutrition.

We include all liver cirrhosis (compensated and decompensated) and alcoholic hepatitis patients in our referral criteria (inpatient and outpatient), regardless of nutritional status. Furthermore, we attend the weekly hepatology MDT (including hepatology consultants, specialist hepatology nurses and admin staff) to ensure we are capturing all appropriate patients and to allow for liaison with the hepatology team to improve patient care.

We have also introduced a ‘liver disease working group’ within our team, which has enabled us to undertake a range of projects and audits to aim to improve the dietetic service for our liver patients, including:

• A project to promote the provision of 50g CHO snack before bed on inpatient ward with a focus on food-first approach and reducing reliance on ONS. As part of this, we have worked with the pharmacy team to get a 50g CHO snack as a prescribable item on the drug chart. We are currently working on a project to introduce a specific 50g CHO snack trolley for the ward.
• An audit of dietetic documentation across the inpatient wards (gastro as well as general medical and surgical) to ensure dietetic input is meeting national guidance.
• Producing new patient information leaflets including an ‘Easy Read’ pictorial sheet for those with limited literacy and specific resources for patients with liver cirrhosis as well as a metabolic dysfunction e.g. diabetes.
• Regular ward-based training for doctors, nurses and HCAs on the ward regarding nutrition concerns, referrals and advice for liver patients.
• Building improved relationships with inpatient physiotherapists to promote early intervention to prevent muscle wastage. We are currently working on developing this within the outpatient setting as well.
• We have produced a range of resources, including a dietetic help sheet and assessment templates, as well as training to aid our non-gastro specialist dietetic colleagues in managing liver disease patients.
• We are in the process of developing a new pathway for MASLD patients to refer in to a group education session and collect longitudinal data, including Fibroscans, weight and abdominal girth.

What were your team’s motivations for setting up this Service?

We are a passionate team of dietitians, and we noted a number of gaps in the provision of our service. As a team, our shared goal is to improve our data collection to ensure we have objective measures to demonstrate our worth within the gastroenterology service, including improving efficiencies within the service.

We strive to improve patient care and ensure the highest level of nutritional intervention for these vulnerable patients. We’re also fortunate to have a group of engaged hepatology consultants who value and support dietetic input.

Are you able to share any of the results – either quantitative or anecdotal – from offering this service?

• 50g CHO snack audit:
  • Following the provision of ward-based training and resources, we saw an increase in the provision of 50g CHO pre-bed snacks from 76% of patients requiring a snack to 98%.
  • Pre-audit all snacks provided were a juice-based ONS and so far we have increased food-based snack provision to 8% of snacks (and increasing!).
  • Ongoing work in this area includes improving nursing documentation regarding snack provision.
• Dietetic documentation audit:
  • Following dietetic training and additional resources, identification of oedema & ascites (and therefore accurate assessment of dry weight) increased from 67% to 83%
  • Dietetic documentation to request the prescription of micronutrient supplementation (as per ESPEN guidelines 2020) increased from 0% to 79%
• We have provided additional training to our gastro dietetic assistant and she is now able to undertake a full assessment for liver disease patients which has improved team efficiency and allows for more thorough assessments. Our DA also undertakes hand dynamometry assessments for all our liver inpatients, which we are then able to follow up in outpatient clinic.
• We haven’t yet fully analysed our hand dynamometry data; however anecdotally, it does appear to show that patient’s hand dynamometry results are improving with dietetic intervention
• We have been able to present our results at our Trust AHP day, as well as posters at BAPEN’s 2024 Annual Conference – we are keen to keep sharing what we’re doing!

What learnings do you have from running the Service that might be of interest to other dietitians around the country?

The first thing that springs to mind is that team support and accountability are essential to keep projects and service development progressing. We would encourage anyone who’s keen to champion a similar project to set deadlines and check in with team members. Getting your MDT on board is also crucial – having support from our medical and nursing colleagues has been essential for seeing results. Our service improvement projects have really highlighted the importance of dietitians being integrated within hepatology services and pathways to promote improved patient outcomes.

We realised how important it is to set aside allocated time for our working group to meet – this helped to facilitate discussions, spark new ideas and provide accountability to complete tasks.

Education is key! Our main interventions have been focussed on staff education (dietetic and beyond) to improve patient care. On top of this, keep repeating cycles of education and audits to ensure improvements have longevity.

And lastly, even small interventions (such as a patient bed space poster) can be enough to promote improvement in patient care!