Nutrition Support Team Research Articles

Assessment, Intervention, and Monitoring: Stepwise Nutritional Management in Pediatric Intensive Care Units: A Short Review

Context: Previous studies have indicated that 24 - 53 of children admitted to pediatric intensive care units (PICUs) suffer from acute or chronic malnutrition at admission. Furthermore, a large number of them undergo deterioration in nutritional status during hospitalization. Critically ill children are at an increased risk of malnutrition because of altered metabolism, and baseline nutritional assessment helps identify those patients at risk of developing malnutrition or further nutritional deterioration. This leads to an early nutritional intervention, which is the ultimate goal of nutrition support therapy. Principal Findings: This review was conducted to describe three main steps of nutritional management (baseline nutritional assessment, nutritional intervention, and monitoring) in PICU admitted patients and discuss the importance and considerations of each step. According to the fact that early and proper nutritional support is seriously important in intensive care medicine, considering a stepwise approach toward nutrition management in pediatric intensive care units might be so useful. The assessment of nutritional status, identifying patients at risk of further nutritional deterioration, accurate measurement of energy and nutrient need for each patient, initiating nutrition support based on the nutrition support team (NST)-approved protocols, and regular assessment of anthropometry and nutritional parameters during the admission period are the stepwise phases of nutritional management in PICU patients. Conclusions: Following these steps might reduce the number of PICU patients who deteriorate mainly due to the poor or late nutritional support. Copyright © 2018, Journal of Comprehensive Pediatrics.

The usefulness of a hospital nutrition support team, as a separate unit, in diagnosing and treating malnutrition

The usefulness of a hospital nutrition support team, as a separate unit, in diagnosing and treating malnutrition

Catheter related line sepsis rate reduced with establishing nutrition support team

Catheter related line sepsis rate reduced with establishing nutrition support team

Standards for Nutrition Support: Adult Hospitalized Patients.

The American Society for Parenteral and Enteral Nutrition defines standards as benchmarks representing a range of performance of competent care that should be provided to assure safe and efficacious nutrition care in most circumstances. Standards are documents that define the structure needed to provide competent care. These Standards for Nutrition Support for Adult Hospitalized Patients are an update of the 2010 Standards. These practice-based standards are intended for use by healthcare professionals charged with the care of adult hospitalized patients receiving nutrition support therapy in any hospital with or without a formal nutrition support service or team. These Standards address professional responsibilities as they relate to patient assessment, diagnosis, education, care plan development, implementation, clinical monitoring, evaluation, and professional issues around nutrition support.

Effects of cyclic parenteral nutrition on parenteral nutrition-associated cholestasis in newborns.

Parenteral nutrition (PN) is one of the main nutritional methods used in newborns; however, long-term PN may induce PN-associated cholestasis (PNAC). This study aims to evaluate the effect of cyclic PN in the prevention and improvement of PNAC in newborns requiring long-term PN. A retrospective cohort study was conducted on patients admitted at the Seoul National University Children's Hospital neonatal intensive care unit between October 2010 and September 2015 and referred to the nutrition support team with total parenteral nutrition for more than 14 days. The primary outcome was the incidence of PNAC. The incidence of hypoglycemia, changes in direct bilirubin (DB) concentrations, and length of hospital stay were investigated. A total of 124 patients were observed in this study. Among these, 100 patients received continuous PN, whereas 24 patients received both continuous and cyclic PN. PNAC occurred in 31.5% (39/124) of study population. The incidence rates of PNAC were 27.4% during continuous PN period and 20.8% during cyclic PN period. Cyclic PN was an independent factor that significantly decreased PNAC incidence (OR=0.154; 95% CI, 0.045-0.529, p=0.003). DB concentrations significantly decreased (p=0.049) with therapeutic cyclic PN, but remained normal with prophylactic cyclic PN. No significant difference in hypoglycemia incidence and length of hospital stay was observed in both continuous PN and continuous to cyclic PN groups. Cyclic PN could be effective in the prevention and improvement of PNAC and also safe in terms of hypoglycemia in newborns.

Treatment of malnutrition decreases complication rates and shortens the length of hospital stays in aradiation oncology department.

The nutritional status of inpatients influences the therapeutic outcome. Malnutrition is acommon comorbidity in oncological patients. Both radio- and radiochemotherapy may contribute to the additional deterioration of the nutritional status. The aim of this study was to evaluate the impact of specialized treatment of malnutrition as aclinical routine. The nutritional status of inpatients was assessed by the Nutritional risk screening (NRS-2002) on the day of admission to the University Department of Radiation Oncology. In case of significantly elevated NRS-2002 (NRS ≥ 3), aguideline-compliant, individual nutritional treatment was initiated by aspecialized nutrition support team. The influence of the nutritional status and nutritional treatment on length of stay and complication rate was assessed. Of 840 included patients, 344patients (40.95%) were at risk for malnutrition. Malnutrition was asignificant, independent risk factor for both prolonged hospital stay, represented by the deviation between the actual length of stay and the DRG-associated mean length of stay (dLOS at risk: 0.88 days, dLOS not at risk: -0.88 days, p = 0.0047), as well as for the occurrence of complications (OR: 1.758 CI: [1.286-2.402], p = 0.0006). In the group of 337 (40.12%) rehospitalized patients the nutritional management was able to assimilate the values of length of stay as well as the complication rates to standard values. The high risk for malnutrition and the negative consequences for patients and hospitals underline the urgent need for malnutrition screening on admission and treatment of malnutrition. Aspecialized, interdisciplinary nutrition support team positively influences patient outcome and should be established routinely in all oncological disciplines.

Impact of a Standardized Clinical Assessment and Management Plan (SCAMP®) on growth in infants with CHD.

Growth failure is prevalent among infants with CHD. A Standardized Clinical Assessment and Management Plan was introduced at Boston Children's Hospital's cardiac medical ward to identify patients with growth failure, evaluate relevant contributing conditions, and recommend a management plan including collaboration with nutrition physicians. The objective of this study was to determine whether enrolled patients had improved growth compared with historical controls. A total of 29 patients were enrolled in the period July, 2013-June, 2014. In all, 42 historical controls who met eligibility criteria for enrolment were selected for comparison from patients admitted to the same ward in the period June, 2010-June, 2011. Patients with CHD aged <1 year , with growth failure defined as weight-for-age z-score <-2, or failure to sustain adequate weight gain were eligible for participation. Primary outcome was change in weight-for-age z-score from enrolment to most recent weight measurement among patients with at least 6 months of follow-up. Control patients were older at baseline admission weight (118 versus 95 days, p=0.33), and had a higher weight-for-age z-score, -2.9 (-3.1, -2.6) versus -3.7 (-4.3, -3.0) (p=0.02), compared with enrolled patients. Enrolled patients had greater gain in weight-for-age z-score, 2.7 (2.0, 3.4) versus 1.8 (1.5, 2.2) (p=0.03), from baseline to most recent follow-up. Patients enrolled in a nutrition-focused protocol had greater weight improvement than historical controls. Identification of growth failure and collaboration with a nutrition support team was associated with improved weight gain among CHD patients experiencing growth failure. CHD programmes should consider a structural approach, including nutrition expertise to address growth failure.

PRM18 - Total Parenteral Nutrition in Asian Countries – A Systematic Literature Review of Cost-Effectiveness Studies

An ever-growing proportion of critically ill adult patients require parenteral nutrition (PN) as a lifesaving therapy when enteral nutrition is inadequate or impossible. It is estimated that PN utilization will significantly grow in Asia Pacific region in the near future. The objective of this study was to evaluate cost-effectiveness of different PN formulations in Asian countries using systematic literature review. The literature search was conducted in PubMed/Medline and Tufts registry. Cost-effectiveness studies assessing different parenteral formulations in malnourished adults in Asian countries were included. Two independent reviewers screened and evaluated studies using the 24-item Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Four articles satisfied predefined inclusion criteria. The studies evaluated addition of omega-3 fatty acids (n=2) or structured triglycerides (n=1) to standard lipid emulsions and cost-benefit of a nutritional support team for PN (n=1). The studies were performed in Chinese (n=3) and Japanese (n=1) healthcare contexts. All of the studies analyzed healthcare costs from patients’ perspective over a short time horizon, limited to the length of hospital stay. The most commonly employed model type was discrete event simulation model (n=2). All four studies demonstrated cost-effectiveness of the new technologies vs. standard PN treatment. The mean CHEERS score for the studies was 15 (SD=4.30) and studies mostly failed to justify the choice of model and time horizon. No study reported cost per quality-adjusted life year. The present study demonstrated that only few studies assessed cost-effectiveness of PN in Asian countries. All of them showed that novel PN formulations were cost-effective in comparison to standard treatment. However, a longer time horizon and focus on subgroups with homogenous prognoses are required to provide sufficient evidence and direct PN to “all patients who need it, in a cost-effective manner”, as recommended by World Health Organization.

The impact of a nutrition support team over a 8 year period on the management of parenteral nutrition in type 1 intestinal failure

Rationale: Every hospital should have a nutrition support team (NST) to manage patients on artificial nutrition support. The demand for the input has increased over 8 years because of tertiary services for surgery, gastroenterology and the introduction of a regional trauma centre. In 2009, the NST was introduced in our hospital primarily to address catheter-related blood stream infection (CRBSI) rates in patients with type 1 intestinal failure (IF).

Nutrition support team performance and outcome of hospitalized patients in a tertiary-level hospital in São Paulo

Rationale: Studies indicate that malnutrition has a 40-60% prevalence at hospital admission, increasing accordingly to length of hospital stay, emphasizing the importance of Nutrition Support Teams (NST). We aim to evaluate the impact of a NST on the outcome of hospitalized patients in a tertiary care public university hospital in São Paulo city, Brazil.

Effect of video endoscopic examination of swallowing function early after admission on length of hospital stay for patients with acute cerebral infarction: A retrospective study

Rationale: Since April 2016, our nutrition support team has evaluated patients with acute cerebral infarction using a video endoscopic examination (VE) of the swallowing function as early as possible (within 24 hours from hospitalisation). We have constructed a system for nutritional treatment suitable for each swallowing function. In this study, we evaluated the effect of early swallowing evaluation on length of hospital stay.

Treatment of malnutrition decreases complication rates and shortens the length of hospital stays in a radiation oncology department

The nutritional status of inpatients influences the therapeutic outcome. Malnutrition is a common comorbidity in oncological patients. Both radio- and radiochemotherapy may contribute to the additional deterioration of the nutritional status. The aim of this study was to evaluate the impact of specialized treatment of malnutrition as a clinical routine. The nutritional status of inpatients was assessed by the Nutritional risk screening (NRS-2002) on the day of admission to the University Department of Radiation Oncology. In case of significantly elevated NRS-2002 (NRS ≥ 3), a guideline-compliant, individual nutritional treatment was initiated by a specialized nutrition support team. The influence of the nutritional status and nutritional treatment on length of stay and complication rate was assessed. Of 840 included patients, 344 patients (40.95%) were at risk for malnutrition. Malnutrition was a significant, independent risk factor for both prolonged hospital stay, represented by the deviation between the actual length of stay and the DRG-associated mean length of stay (dLOS at risk: 0.88 days, dLOS not at risk: −0.88 days, p = 0.0047), as well as for the occurrence of complications (OR: 1.758 CI: [1.286–2.402], p = 0.0006). In the group of 337 (40.12%) rehospitalized patients the nutritional management was able to assimilate the values of length of stay as well as the complication rates to standard values. The high risk for malnutrition and the negative consequences for patients and hospitals underline the urgent need for malnutrition screening on admission and treatment of malnutrition. A specialized, interdisciplinary nutrition support team positively influences patient outcome and should be established routinely in all oncological disciplines.

Nutrition support team service in hospitalized patients in Korea

Nutrition support team service in hospitalized patients in Korea

Nutrition and Clinical Outcomes of Nutrition Support in Multidisciplinary Team for Critically Ill Patients

To examine the outcomes of the implementation of a multidisciplinary nutrition support team (NST) that included a pharmacist for critically ill patients in the intensive care unit (ICU). Data were retrospectively collected from electronic medical records and compared between the pre-NST group (n = 73) and post-NST group (n = 75). Patients were included if they received enteral or parenteral nutrition support for at least 72hours in the ICU of an approximately 900-bed, top-tier university medical center. The percentage of goal kcal, the percentage of goal protein, serum albumin level, total lymphocyte count, C-reactive protein, duration of mechanical ventilation use, hospital length of stay (LOS), ICU LOS, and mortality were evaluated. There were significant differences in the percentage of goal kcal (66.9% ± 25.9% vs 86.2% ± 27.5%; P < 0.001) and the percentage of goal protein (67.0% ± 29.9% vs 81.7% ± 30.7%; P < 0.05) between the pre-NST and post-NST groups. A higher percentage of goal kcal was associated with a significant decrease in the ICU LOS (P < 0.05) and hospital LOS (P < 0.05). The percentage of goal kcal was associated with mortality rate (odd ratio, 0.977; 95% confidential interval, 0.959-0.996; P = 0.016). Implementation of a multidisciplinary NST service for critically ill patients was associated with higher percentages of goal kcal and goal protein, as well as a shortened duration of mechanical ventilation use. Higher energy supply was associated with a reduced mortality rate.

Nutrition support team activities can improve enteral nutrition administration in intensive care units

The aim of this study was to evaluate the effect of the nutritional support team (NST) activities on the quality of enteral nutrition administration in intensive care units. An observational, analytical, and cross-sectional study was performed in nine hospitals in the Brazilian Federal District through the administration of two questionnaires. One questionnaire focused on the activities of the NST and the other on the quality of enteral nutrition administration in intensive care units. There was a strong correlation between the scores of the two questionnaires, which was confirmed by a linear regression model (R2 = 0.623; P = 0.007). The results suggest that high scores in the NST activities questionnaire predict a better performance in enteral nutrition administration. The sections of the NST activity questionnaire that most strongly affected enteral nutrition administration were the protocols (r = 0.895; P < 0.01), quality control (r = 0.779; P < 0.05), and continuing education (r = 0.753; P < 0.05). The NST has the potential to positively influence enteral nutrition management in intensive care units and investments could be directed to the areas of continuing education, protocols, and quality control to maximize the effect of NST in intensive care units.

Advanced practice nursing: Nutrition Nurse Specialist role and function

Different disciplines should be represented in Nutritional Support Teams, e.g. a physician, dietician, pharmacist and a nurse. The latter one can function as an Advanced Practice Nurse, which implicates that he or she must have sufficiently thorough knowledge, attitudes and competences to fulfill the profile of a nutritional expert in the field of clinical nutrition. Description of the scope of practice, education and added value related to a Nutrition Support Nurse, based on detailed published competency profiles. The described competencies reflect the advanced role and clinical expertise of a Nutrition Support Nurse. She can make a significant contribution to the overall quality of nutritional care, uncover the multidimensional aspects of nutrition, monitor effectiveness/ appropriateness of nutrition therapy and improve clinical outcomes. A Nutrition Support Nurse can incorporate nutrition nursing in the overall nutrition support, acting as an important player for users, carers and the healthcare organization in general.

A survey on pediatric nutrition and nutritional support in 45 hospitals

Objective To investigate, through a survey on hospitals, the disciplinary development of pediatric nutrition and the present situation of clinical nutritional support in China, in an effort to inform and promote development of pediatric clinical nutrition. Methods A questionnaire was designed by the group of clinical nutrition, Chinese Pediatric Society, Chinese Medical Association. Respondents were 45 hospitals where members of the group work. The survey included 8 aspects in clinical work. Results Of all the 45 hospitals, 40 were grade-A tertiary hospitals; 4 were grade-B tertiary hospitals; and one was a secondary hospital. 25 (55.6%) of the surveyed hospitals were children's hospitals, and 20 (44.4%) were general hospitals. All the hospitals were divided into 8 groups according to their geographical distribution in China, and East China hosted the most while Northeast China had the least. Nutritional support team (NST) was set up in 32 (71.1%) hospitals, with head of the team majoring in the specialty/subspecialty of pediatric gastroenterology or clinical nutrition. In 39 (86.7%) hospitals, physicians working in the nutrition department were attending or above, and in 38 (84.4%) tertiary hospitals, chief of the nutrition department held an academic title of associate chief or above. 39 (86.7%) hospitals had nutrition clinics, 42 (93.3%) provided nutritional counseling, 40 (88.9%) involved nutritionists in consultations, 25 (55.6%) had independent nutritional rounds. Screening tools for nutritional risk and dysplasia in children(STRONGkids) and screening tool for the assessment of malnutrition in pediatrics (STAMP) were the most widely used tools for malnutrition screening, and the same with self-rating depression scale(SDS) and percentile for nutritional status evaluation. In the most surveyed hospitals, key institutional requirement and procedural protocol were put in place for the nutritional department. Conclusions Pediatric clinical nutrition was developing well in tertiary hospitals in China. NST was established in most institutions. There was strong toolkit for clinical nutritional support and sound administrative institutions. There is room, though, for further improvement. Key words: Pediatrics; Nutritional support; Survey

Assessing the appropriateness of parenteral nutrition use in hospitalized patients. A comparison on parenteral nutrition bag prescription in different wards and nutritional outcomes

Our aim is to assess parenteral nutrition (PN) bag prescription in hospitalized patients and evaluate clinical outcomes linked to PN therapy. We performed an observational longitudinal retrospective study on PN prescription in a General Public Hospital in Turin, Italy, on ninety-five patients receiving PN prescribed by the Nutrition Support Team (NST). We described patients' demography and assessed nutritional outcomes, as well as PN bag prescription in different wards. Medians were calculated for several clinical parameters before and after PN therapy. A z-test for proportions has been performed to better understand the impact of various conditions on clinical outcomes and to compare differences between administered nutrients and required amounts. The NST resulted responsible for only 18% of bags prescribed in the geriatrics ward and for 48% in the surgery wards. PN was not able to fulfill nutritional requirements resulting in a median lack of 3.1 calories and 0.23g of proteins per kilogram of reference body weight per day. Despite this, PN therapy was able to improve total blood proteins and calcium blood levels in our cohort. The NST changed the prescription in 55.8% of the pre-existing PN regimens. More strict adherence to guidelines is needed in order to maximize effectiveness of PN and observe a positive impact on clinical parameters.

Effects of home enteral nutrition for post-operative patients of esophageal cancer

Objective To explore the method and efficacy of home enteral nutrition for patients undergoing radical resection of esophagus cancer. Methods A total of 85 patients who underwent radical surgery for esophageal cancer and jejunum fistula from January 2016 to March 2017 were enrolled and were divided into observation group (n=44) and control group (n=41) by random number table method. Patients of control group took normal family diet orally after nutrition assessment and jejunum fistula clipped while patients of observation group received extra special immune enteral nutrition preparations for tumor through fistula of jejunostomy under the guidance of a nutrition support team. After one month treatment, plasma nutrition indicators and European Screening for Nutrition Risk (NRS 2002) assessment were performed to analyze the difference of two groups to compare the nutrition status. Results All indicators did not differ when discharged for two groups (P>0.05) . After one month intervation, level of hemoglobin, total serum protein, albumin, prealbumin and transferrin of the observation group were statistically higher than those of control group [ (12.90±1.33) vs. (10.83±1.35) g/dl, (72.22±4.83) vs. (63.90±5.44) g/L, (41.63±2.67) vs. (36.98±3.69) g/L, (217.70±56.72) vs. (166.27±39.97) mg/L, (2.41±0.38) vs. (1.76±0.47) g/L; P<0.01]. Percentage of patients with high nutritional risk (NRS 2002 ≥3) in the observation group was lower than that of the control group (45.5% vs. 68.3%; P<0.05) . Conclusions Nutritional support at home after discharge could improve the nutritional status and reduce the risk of malnutrition for patients who underwent radical surgery for esophageal cancer. Key words: Esophageal neoplasms; Continued nursing; Home enteral nutrition; Nutritional risk

Nutrition Support Team Guide to Maternal Diet for the Human-Milk-Fed Infant.

Human milk feeding is encouraged for all infants; however, the mammary gland depends on maternal dietary intake of vitamins A, B1, B2, B6, B12, D, docosahexaenoic acid (DHA), choline, and iodine. Nutrition support team knowledge of maternal feeding guidelines for these nutrient sources can therefore impact infant intake. We hypothesized that these key nutrients for lactation in the mother's diet would be less than the dietary guidelines in the United States. This was a secondary analysis of nutrition data collected during a randomized, controlled trial. Dietary records were analyzed from 16 mothers (13 with singleton and 3 with multiple births) completing the study. Mean dietary intakes of selected nutrients were calculated and compared with the current dietary reference intakes. Mean maternal dietary intake for singletons was significantly (P < .05) lower than the dietary reference intakes for (vitamin A (58%), vitamin D (44%), and choline (58%);) DHA comprised only 5% of the current expert recommendation. Based on singleton recommendations, mothers to twins consumed an adequate intake except for DHA. Women providing breast milk for singleton preterm infants did not consume dietary reference intakes for key nutrients. Twin mothers' diets were adequate except for DHA, but these guidelines are based on singleton pregnancies and remain poorly understood for twin needs. The nutrition support team can have a unique role in maternal dietary education to impact human milk nutrient delivery to the infant.