SUSTENANCE: Development of a toolkit to improve poSt-operative feeding practices and nUritional intake in patientS wiTh hEad and Neck cANCer undergoing surgEry with flap tissue reconstruction.

Background Surgery is a widely accepted treatment for head and neck cancer (HNC).

After surgery, patients are made 'nil-by-mouth' for approximately 6-12 days to enable wound healing and nutrition is provided via a feeding tube placed through the nose (naso-gastric tube) or directly into the stomach (gastrostomy).

Variation exists for time to first oral intake, type of feeding tube placed and when these are removed, with limited evidence to determine optimal practice. Many patients experience delays in recommencing oral intake which deconditions swallowing musculature.

During the transition from tube to oral intake, 40-72% of patients have inadequate nutrition due to premature removal of feeding tubes.

Optimising nutrition is critical in supporting post-operative recovery and improves wound healing, survival, and quality-of-life.

Research question Development of a toolkit to improve post-operative feeding practices and nutritional intake in patients with HNC undergoing surgery with flap tissue reconstruction.

Aims and objectives This research aims to investigate post-operative feeding practices for patients with HNC undergoing surgery when transitioning from tube to oral intake and to develop a staff toolkit to improve timing/adequacy of intake. The nature of the toolkit will be determined by conducting exploratory work as part of evidence synthesis.

This will be achieved by examining the literature, describing current practice, investigating nutritional outcome data, exploring patient experiences, staff perceptions and practices.

Methods A mixed-methods convergent-parallel approach over three years, across five workstreams: Scoping review of existing literature to map current post-operative feeding practices and identify knowledge gaps necessitating further inquiry.

Cross-sectional web-based survey of healthcare professionals working in UK HNC centres (n=65) to map variation in practices and describe current reality including typical time to first oral intake, type of tube placed and home tube-feeding status.

Prospective observational cohort study (n=90) to investigate nutritional status and intakes during the transition from tube to oral intake, time/type of first oral intake and associated factors. Multiple regression analysis to identify predictors of nutritional adequacy.

Qualitative approaches using semi-structured interviews and observation exploring patient experiences (n=10) and healthcare professionals (n=16-18) perceptions and practices of transitioning from tube-feeding to optimal oral intake. Framework Analysis of transcripts and fieldnotes. Development of a post-operative feeding toolkit with stakeholder consultation.

Impact Patients: Improved nutritional outcomes by identifying facilitators and barriers for achieving nutritional adequacy and optimal timing for removing feeding tubes to avoid nutritional deficits. Improved return to swallowing function by identifying optimal timing for re-commencing oral feeding.

Healthcare professionals: Potential to change perioperative HNC feeding management by developing a toolkit that optimises decision-making when transitioning patients from tube to oral intake, accounting for variation in local resources and infrastructure.

NHS/service: It is anticipated that streamlining oral feeding commencement and avoiding post-operative nutritional deficits will reduce hospital stays, readmissions and associated costs.

Dissemination Results will be disseminated in peer-reviewed journals targeted to the HNC readership and through conferences, professional networks and websites including the NIHR and charities.

To reach the wider audience, an animation will be shared via social-media, blogs and support groups according to patient and public involvement advice.