Home Enteral Nutrition Research Articles

Exploring the advanced practice role of the Home Enteral Feeding Dietitian

Introduction: Home Enteral Nutrition (HEN) can improve quality of life and reduce healthcare costs through reduced hospital admissions. In North Dublin, Community Dietitians (CDs) trained in HEN, provide structured follow-up for adults on HEN and in an advanced practice role, monitor gastrostomy stoma care and feeding tube maintenance (including performing elective tube replacement). However, only a third of HEN patients nationally have access to a comparable service.

Prevalence of diabetes mellitus in patients with home enteral nutrition

BackgroundThere are few data available in the literature on the prevalence of diabetes mellitus (DM) in patients with home enteral nutrition (HEN) via tube feeding. The objective was to analyze the prevalence of DM in patients receiving HEN, as well as evaluating the complications, the prescribed antidiabetic treatments and the nutrition regimen selected. DesignThis was a retrospective, single-center, observational study reviewing clinical histories. The population consisted of patients over 18 years of age who started HEN by tube between January 2016 and January 2018. Sociodemographic variables were recorded, as well as variables related to HEN. Additional variables were recorded in patients with DM. ResultsIn the 198 study patients, followed up for a median of 104 days, the prevalence of DM was 31.8%, and patients with DM were older (71.3±11.5 vs. 64.2±15.8; p=0.002) than those without DM. There were no differences between patients with and without DM as regards the prescription of HEN, its route and form of administration, and its complications. One hundred and thirty-two patients (66.7%) died during follow-up. The presence of DM did not increase the risk of death during follow-up (after adjusting for age, gender, and diagnosis). More than 85% of patients with DM received a specific formula for diabetes, and 84.1% of these patients received drug treatment. ConclusionThe prevalence of DM was high in patients receiving HEN, most of whom were prescribed specific enteral nutrition formulas. The presence of DM was not associated with greater morbidity and mortality or with differences in HEN regimens or indications.

The use of calorically dense enteral formulas in adult home enteral nutrition population in a tertiary care center: A retrospective analysis

Introduction: The prevalence of home enteral nutrition (HEN) has increased dramatically as studies showing clinical benefit have emerged. During this time, the practice of HEN has evolved as well including the availability of diverse formulas ranging in macronutrient distribution and concentration. Despite this availability, there continues to be a paucity of data regarding the efficacy of 2.0 kcal/ml density formulas in the HEN population. Materials and Methods: A retrospective review of HEN database was conducted for the use of concentrated formula (2.0 kcal/ml). Baseline variables as well as efficacy of formula were assessed. Results: In the time period evaluated, 32 HEN patients with a mean age of 58 ± 13.4 years met inclusion criteria. A total of 25 (78.1%) patients were male, the most common indication for HEN was dysphagia (53.1%), and the most common diagnosis was head-and-neck cancer (65.7%). The vast majority (87.4%) received concentrated formula through percutaneous gastrostomy (PEG) and were able to receive 93.1% ±19.7% of their goal calories needs as well as 98.5% ±21.7% of their goal protein needs. A total of 9 (28%) patients were initially started on concentrated formula, whereas 23 (72%) were switched from their initial formula with most common indication being the need for additional calories. Twenty-nine patients (90.6%) were able to utilize the formula as their primary source of nutrition with 22 patients (69%) reported no adverse effects. Conclusions: Our study found that the use of concentrated formula was well tolerated in a diverse cohort of patients, meeting their calorie and protein needs. The following core competencies are addressed in this article: Medical knowledge, Practice-based learning, Systems-based practice.

GESTIÓN INTEGRAL DE LA NUTRICIÓN ARTIFICIAL DOMICILIARIA: HUMANIZACIÓN E INNOVACIÓN AL SERVICIO DEL PACIENTE

Disease-related malnutrition is a common pathology in the developed world. It affects 30 million people in Europe and it has an associated cost of one hundred and seventy billion euros per year. In Spain, around 1.7 million adults, 4.4% of total population, are negatively affected. Malnutrition affects one out of four patients on hospital admissions. It is estimated that hospitalized patients who are malnourished throughout their stay range from 23.7% to 37%; sharpening these figures for multi-patients over 70 years old, and almost 10% are disensuaded during their hospital stay. All this implies an increase in hospital stays and associated costs; in particular, the direct costs of hospital malnutrition were estimated at 1.143 million annually in 2009, representing 1.8% of health expenses within the national health system. Advances in technology and infrastructure have facilitated the transfer of complex hospital-to-home services. Nowadays, the international trend points to the increasing development of the domicile as a care center. A meta-analysis of 61 randomized and controlled trials, published in 2012, showed that patients treated at home had a six-month mortality rate between 19% and 38% lower than those who were hospitalized. Home artificial nutrition (HAN) is the nutrients home-administration, among other therapeutic agents, administered through the digestive tract -home enteral nutrition (HEN)- or intravenously -home parenteral nutrition (NPD-), with the objective of improving or maintaining, at home, the patient’s nutritional status. That reports into a benefit for the patient as being able to continue the family, social and work commitments. The environment, in which 21st century health professionals work, is changing significantly. There are multiple innovations in process management, given by the growing potential offered by new technologies in remote care. It supports the patient’s home stay, either in the community or in a more familiar environment, that is, in a more humanized environment. Finally, HAN is shown to be an effective-cost alternative in relation to classical hospital care, resulting in the adoption of the efficiency criterion as an element of prioritization in healthcare.

Older adults undergoing home enteral nutrition therapy: integration of national public policy and municipal programs

Abstract Objective: to verify if national public policies and municipal programs contain elements that contribute to ensure the Human Right to Adequate Food (HRAF) of older adults undergoing home enteral nutrition therapy (HENT) and to propose the integration of these elements. Method: a qualitative study was carried out based on the content analysis of the documents of the National Policy for Older Adults (or PNI), the National Policy for the Health of Older Adults (or PNSPI) and the National Food and Nutrition Policy (or PNAN). Analysis of the relationships (co-occurrences) in programs of the 29 cities of the 2nd regional health region of Paraná to provide care for people with special dietary needs (SDN), such as older adults undergoing HENT, was also carried out. For the analysis of the relationships, the keywords older adult and right were used. Furthermore, the integration of national public policies and municipal programs was proposed. Results: the PNI, PNSPI and PNAN contain converging principles, guidelines and actions, but they are not fully integrated into the programs. Only seven cities with programs that aimed to organize care involving SDN were identified, documented in five protocols and two decrees. A co-occurrence was verified in three of the analyzed documents, but a relationship between the keywords older adult and right was not verified in the protocols and decrees. In the integration proposal, a network was described, based around the goal of reaching the center, which represents the HRAF for older adults undergoing HENT. Conclusion: national public policies contain elements to ensure the HRAF of older adults undergoing HENT, but the municipal programs do not include all these elements. A proposal to integrate the elements was created.

Overhauling Nutrition Assistance Programs to Provide Comprehensive Nutrition Support for Older Adults

Older adults want to “age in place,” but the currently fragmented and inadequate nutrition assistance environment is at odds with this goal. Given the substantial gap between resources needed to make the “Aging in Place” dream a reality and current level of support, investigation into mechanisms of an overhaul to nutrition assistance for older adults is warranted. In this article, we assess the need for comprehensive nutrition support for older adults, review the current federal nutrition support, provide rationales for legislation supporting nutrition support integration and expansion (with an emphasis on home nutrition support for older adults), and introduce operational approaches for an expansion. Older adults face unique challenges to maintaining adequate nutrition. Upwards of 19% of older adults with low incomes (those living in households below 185% of the poverty threshold) were food insecure, and approximately 90% of these individuals did not receive meal services. Fragmentation of federal services across the US Department of Agriculture and Department of Health and Human Services, mobility, technology use, and stigma surrounding assistance programs all but guarantee that older adults do not derive maximal benefit from available services. In light of the complementary nature of different nutrition policies and programs, leading policy experts have called for integrated, multicomponent government strategies that adapt and streamline existing structures and systems. We urge the US Department of Agriculture and the Department of Health and Human Services to conduct pilot studies granting states joint waiver authority for SNAP, Medicaid, Medicare Advantage, and the Older Americans Act Nutrition Program. Leveraging resources and information across parallel programs can allow more older adults to manifest their right to “age in place.”

Health-Related Quality of Life and Home Enteral Nutrition in Children with Neurological Impairment: Report from a Multicenter Survey.

We aimed to measure the health-related quality of life (HRQoL) of children with neurological impairment (NI) on home enteral nutrition (HEN). An original survey among the caregivers of NI children on HEN for ≥ 12 months followed in three Italian centers (Messina, Como and Varese) was carried out between January 2013 and September 2018. The questionnaire was made up of 12 issues focused on the frequency with which certain situations associated with HEN are perceived, and grouped into physical and psychological/social dimensions. The results were analyzed statistically according to the age of the children, underlying disease, and the HEN programs’ duration. In total, 80 caregivers were approached, and 75 surveys were completed (an overall response rate of 93.7%). Nearly all the caregivers reported a satisfying HRQoL, ranging from acceptable (n = 6, 8%), to good (n = 22, 29.3%), to excellent (n = 47, 62.7%). A significant correlation was found between HRQoL and underlying NI-associated disease (p = 0.001). Our data showed that HEN positively affects the QoL of NI children and their caregivers. This should encourage healthcare providers to consider this nutritional intervention early in the approach to this group of patients, in order to prevent or reduce QoL impairment.

Patients Discharged with Home Enteral Nutrition from a Third-Level Hospital in 2018.

Patients who, during admission, begin to use enteral nutrition (EN) and do not recover adequate oral intake need proper planning prior to discharge. The present study is a descriptive analysis of patients discharged with EN from our hospital in 2018. In all, the study included 141 patients (50.3% male) with an average age of 76.18 ± 14 years with the most frequent reasons for enteral support being neurological disease (71.3%) and ear, nose, and throat (ENT) and maxillofacial surgery (17.02%) (others accounted for 11.68%). In these two groups, differences were observed in both the average age (77 vs. 70.5 years) and sex of patients—mostly women (58%) in the first group and men (70%) in the second. Overall, the access routes used were nasogastric tube (76.4%), and percutaneous endoscopic gastrostomy (18.4%); 67.1% of the episodes ended by 30 June, 60.6% of patients died (47% of neurological patients), and 39.3% patients recovered function of the oral passage (85% of surgical/head and neck tumor). The duration of support was as follows: 1–3 months, 32%; 6–12 months, 26.9%; more than 12 months, 18.5%. This indicated some frequent and clearly differentiated profiles in the patients studied, which may contribute to better care and support in order to maintain long-term treatment.

COMPARAÇÃO ENTRE TRÊS SOFTWARES DE CÁLCULO DE DIETAS: UMA ANÁLISE DO VALOR ENERGÉTICO DE UMA DIETA ENTERAL SEMIARTESANAL

O objetivo do presente estudo foi recalcular as dietas enterais semiartesanais padrões apresentados em uma Cartilha de Terapia Nutricional Enteral Domiciliar. Foram selecionadas as dietas 1.500, 1.800 e 2.100 kcal. Utilizaram-se três softwares de cálculo de dietas, Programa A, B, C, e cálculo manual com o auxílio de três referências bibliográficas. A dieta de 1.500 kcal pelo Programa A apresentou percentual de inadequação de -22,62%, Programa B -13,9%, Programa C +15,73% e pelo cálculo manual -1,1%. A dieta de 1.800 kcal apresentou no Programa A -26,6%, Programa B -15,6%, Programa C +11,17% e no cálculo manual -1,8%. A dieta de 2.100 kcal pelo Programa A -25,5%, Programa B -15,8%, Programa C +7,2% e no cálculo manual -4,8%. No estudo foi inviável reproduzir as dietas com auxílio do Programa A, B e C. O cálculo manual foi o método que mais se aproximou dos valores de oferta calórica apresentados pela cartilha.

Home Enteral Nutrition in Singapore's Long-Term Care Homes-Incidence, Prevalence, Cost, and Staffing.

Introduction: Data on home enteral nutrition (HEN) in long-term care facilities (LTCF) in Singapore is scarce. This study aims to determine the prevalence and incidence of chewing/swallowing impairment and HEN, and the manpower and costs related. Methods: A validated cross-sectional survey was sent to all 69 LTCFs in Singapore in May 2019. Local costs (S$) for manpower and feeds were used to tabulate the cost of HEN. Results: Nine LTCFs (13.0%) responded, with a combined 1879 beds and 240 residents on HEN. An incidence rate (IR) of 15.7 per 1000 people-years (PY) and a point prevalence (PP) of 136.6 per 1000 residents were determined for HEN, and an IR of 433.0 per 1000 PY, with PP of 385.6 per 1000 residents for chewing/swallowing impairment. Only 2.5% of residents had a percutaneous endoscopic gastrostomy (PEG). The mean length of residence in LTCF was 45.9 ± 12.3 months. More than half of the residents received nasogastric tube feeding (NGT) for ≥36 months. Median monthly HEN cost per resident was S$799.47 (interquartile range (IQR): 692.11, 940.30). Nursing costs for feeding contributed to 63% of total HEN costs. Conclusions: The high usage and length of time on NGT feeding warrants exploration and education of PEG usage. A national HEN database may improve the care of LTCF residents.

Effective Tube Weaning and Predictive Clinical Characteristics of NICU Patients With Feeding Dysfunction.

The present study evaluated the effectiveness of a multidisciplinary earlier discharge model for neonates receiving home enteral nutrition (HEN). A retrospective data review and analysis was performed on 183 patients discharged out of the neonatal intensive care unit (NICU) receiving partial oral feeds (PO) and partial HEN from September 2016 to March 2018. These patients were followed in a multidisciplinary clinic led by a pediatric gastroenterologist, a neonatal feeding therapist, and a pediatric dietitian. Demographics and data were recorded for patients at discharge, and then chart reviews were performed for additional data. Of 182 patients, 121 (67%) weaned off HEN with a median time to full PO at 79 days (interquartile range [IQR] 15, 247) and had median PO intake of 20% (0, 43) at time of discharge. When comparing patients who gained 100% PO vs patients who did not wean off HEN, the weaned group consisted of 88% nasogastric tubes, with median time off feeds at 27 days (IQR 8, 79) and median PO intake of 29% (11, 50) at discharge. Only 13% of the cohort had an emergency room or hospital admission, which corresponds to 1.6 and 0.8 events, respectively, per 500 tube days specifically due to HEN complications. Our study supports that NICU patients with feeding dysfunction can effectively and safely discharge home earlier while receiving HEN. Our data suggest that a dedicated outpatient clinic can facilitate effective tube weaning in a majority of neonates with complex medical diseases with low rates of adverse events.

Creation of a Standard Model for Tube Feeding at Neonatal Intensive Care Unit Discharge.

Feeding dysfunction is a common consequence of prematurity and illness in neonates, often requiring supplemental nasogastric (NG) or gastrostomy (GT) feeding tubes. A standardized approach to the discharge of infants receiving home enteral nutrition (HEN) is currently lacking. The Home Enteral Feeding Transitions (HEFT) program was developed to identify patients eligible for HEN and create a standard discharge process. A structured tool helped determine discharge timing and route, and a dedicated outpatient clinic was created for infants discharged on HEN. Demographic, inpatient, and outpatient data were prospectively collected and compared with a historical cohort. A total of 232 infants discharged from our neonatal intensive care unit (NICU) over 9 months met inclusion criteria. Ninety-eight (42%) were discharged with HEN, 68 NG and 30 GT, compared with 134 (58%) receiving full oral feeds. This represented a 10% increase in HEN utilization (P=0.003) compared with our historical control group. Median HEN length of stay was 31.5 days compared with our historical average of 41 days (P=0.23). Frequency of emergency department visits and admissions because of HEN was unchanged postintervention. Parents were satisfied (8.6/10), and 98% said they would choose HEN again. The median time to NG discontinuation after discharge was 13.5 days, with an estimated cost savings of $2163 per NICU day. Our program is the first of which we know to use a standard care-process model to guide the decision-making and utilization of HEN at NICU discharge. HEFT shows that HEN at NICU discharge can be safe and effective, with high parental satisfaction.

Editorial introductions

Editorial introductions

AVERAGE LIFE OF BALLOON GASTROSTOMY TUBES (BGT): ANALYSIS OF 239 DEVICES

Considering the limited technical data provided by the manufacturing companies, the aim of this study was to evaluate the average life of different silicon BGT. All patients in home enteral nutrition treatment through BGT from 01/05/2015 to 06/09/2018 were evaluated. All patients were trained and assessed over time by the same staff using the same instruction set and operating methods. Patients’ data (age, sex) and BGT's data (date of placement/removal, reason for removal, company, size, number of BGTs placed for each patient) were recorded. Statistical processing was performed with IBM SPSS software. 239 BGT placed in 44 patients (14 males, 30 females; average age 72: min 23 – max 95) were assessed. Of these, 132 BGT were produced by Bard, 51 by Kimberly-Clark, 55 by Nutricia. BGT sizes are shown in graph 1, whereas the number of BGT placed per patient is shown in graph 2. The average life of BGT was 169 days (134 Bard, 166 Kimberly-Clark, 208 Nutricia). The difference among companies in terms of duration is statistically significant (Log Rank Mantel-Cox p=0.000, see figure 3). A multivariate analysis by diameter, age, sex, and number of BGT per person was also performed. The diameter was the only variable proved to be statistically significant of BGT life. BGT lifespan were found different and variable with the manufacturer, in particular the Nutricia company's tubes lasted longer. Besides the diameter of the device was found to have a significant impact on BGT life.

SUN-LB658: Home Enteral Nutrition After Minimally Invasive Esophagectomy can Improve Quality of Life and Reduce the Risk of Malnutrition

SUN-LB658: Home Enteral Nutrition After Minimally Invasive Esophagectomy can Improve Quality of Life and Reduce the Risk of Malnutrition

MON-PO390: Home Enteral Nutrition in Cancer Patients with Jejunal Access

MON-PO390: Home Enteral Nutrition in Cancer Patients with Jejunal Access

PT03.04: An Enhanced Nutritional Support Pathway Including Extended Preoperative and Home Enteral Nutrition is Safe, Feasible and May Benefit Patients Undergoing Enhanced Recovery After Esophagectomy: A Pilot Randomized Clinical Trial

PT03.04: An Enhanced Nutritional Support Pathway Including Extended Preoperative and Home Enteral Nutrition is Safe, Feasible and May Benefit Patients Undergoing Enhanced Recovery After Esophagectomy: A Pilot Randomized Clinical Trial

SUN-PO268: How to Administrate Home Enteral Nutrition (HEN) More Precisely Among Adult Patients: A Systematic Review and Meta-Analysis

SUN-PO268: How to Administrate Home Enteral Nutrition (HEN) More Precisely Among Adult Patients: A Systematic Review and Meta-Analysis

MON-PO469: Effect of Home Enteral Nutrition in Malnourished Patients with Intestinal Failure/Intestinal Insufficiency

MON-PO469: Effect of Home Enteral Nutrition in Malnourished Patients with Intestinal Failure/Intestinal Insufficiency

MON-PO562: Reduction in Health Care Utilization with Transition to Peptide Based Diet in Intolerant Home Enteral Nutrition Patients

MON-PO562: Reduction in Health Care Utilization with Transition to Peptide Based Diet in Intolerant Home Enteral Nutrition Patients