Nutrition Support Team Research Articles

Nutritional Improvement and Energy Intake Are Associated with Functional Recovery in Patients after Cerebrovascular Disorders

Malnutrition affects the activities of daily living (ADLs) in convalescent patients with cerebrovascular disorders. We investigated the relationship between nutritional improvement, energy intake at admission, and recovery of ADLs. We evaluated 67 patients with cerebrovascular disorders admitted to our rehabilitation hospital between April 2013 and April 2015. These patients received interventions from the rehabilitation nutritional support team according to the following criteria: weight loss of 2 kg or more and body mass index of 19 kg/m(2) or lower. Exclusion criteria included a body mass index of 25 kg/m(2) or higher, duration of intervention of less than 14 days, or transfer to an acute care hospital because of clinical deterioration. We assessed nutritional status using the Geriatric Nutritional Risk Index (GNRI) and ADL using the Functional Independence Measure (FIM) score, FIM gain, and FIM efficiency. The mean age of the patients was 78.7 ± 8.0 years. The numbers of patients in each category of cerebrovascular disorder were 39 with cerebral infarction, 16 with intracerebral hemorrhage, 8 with subarachnoid hemorrhage, and 4 others. Compared with the counterpart group, the group with an improvement in GNRI had a greater gain in FIM (median 17 and 20, respectively; P = .036) and a higher FIM efficiency (.14 and .22, respectively; P = .020). Multivariate stepwise regression analysis showed that an improvement in GNRI, increasing energy intake at admission, and intracerebral hemorrhage were associated independently with greater FIM efficiency. This study suggested that nutritional improvement and energy intake at admission are associated with recovery of ADL after cerebrovascular disorders.

SUN-LB015: Effects of NST (nutrition Support Team) on Nutrition Therapy in Critically Ill Surgical Patients

SUN-LB015: Effects of NST (nutrition Support Team) on Nutrition Therapy in Critically Ill Surgical Patients

Introduction of a complete nutrition support team increases appropriate parenteral nutrition use and reduces its complications

Introduction of a complete nutrition support team increases appropriate parenteral nutrition use and reduces its complications

Outcomes of Systematic Nutritional Assessment and Medical Nutrition Therapy in Pancreatic Cancer

We investigated the nutritional and survival outcomes of medical nutrition therapy by a registered dietitian, along with support from a dedicated nutrition and metabolic support team in pancreatic cancer patients requiring enteral or parenteral nutrition. Subjective global assessment (SGA) was used to assess nutritional status in 304 pancreatic cancer patients. Using baseline and last SGA, patients were categorized into 3 groups: improved SGA, deteriorated SGA, and unchanged SGA. Kaplan-Meier and Cox regression were used to calculate survival after controlling for relevant confounders. One-hundred twenty-five (41.1%) patients had their SGA unchanged, 87 (28.6%) patients had "improved SGA," whereas 92 (30.3%) patients had "deteriorated SGA." On univariate survival analysis, the median survival was 7.8, 11.2, and 12.6 months for deteriorated, unchanged, and improved SGA groups, respectively. On multivariate analysis, change in SGA was independently predictive of survival. Patients with deteriorated SGA had 1.5 times (95% confidence interval, 1.1-2.1) greater risk of mortality compared to those with improved SGA. The majority of pancreatic cancer patients (70%) in our study either maintained or improved their nutritional status during cancer treatment. Improvement in SGA correlated with a significantly decreased risk of mortality independent of sex, previous treatment history, and evidence of biological anticancer activity.

PTH-210 Using quality improvement methodology can easily achieve savings in parenteral nutrition wastage

Introduction Parenteral nutrition (PN) cost ∼£80 per day to provide. Wastage of PN is high due to sudden changes in the clinical condition of the patient, loss of venous access or for organisational reasons. In healthcare settings improvement in patient quality of care at low cost yet that also achieves savings in provision of patient care is imperative to increase the quality of care available to other patients. We undertook a quality improvement project to reduce PN wastage by 10% in 9 months. Method Quality Improvement (QI) project was carried out at a national Intestinal Failure Unit (IFU) to reduce waste in provision of in-patient PN. Using QI methodology we developed a SMART objective of reducing PN wastage by 10% in 9months. We drew up an appropriate driver diagram of primary and secondary drivers for PN wastage. We recorded reason for wastage and using a pareto chart determined the most likely cause of waste to target change. Using Plan, Do, Study, Act (PDSA) cycles we activated a number of different strategies to reduce wastage. We mapped changes in the main 7 categories for waste using i-charts and g-charts. Balancing charts were also used to ensure that any intervention did not have a negative impact on quality provision of care on the IFU. We compared waste between IFU to Nutrition Support Teams in Salford and in Oxford. Results Baseline wastage over 12 weeks suggested 1000 bags per annum (p.a.) wastage. Using the following PDSA cycles we achieved a 39% reduction in PN wastage in 9 months, exceeding the proposed 10% and saving the unit ∼£35000. PDSA cycles used: Team awareness, regular highlighting of the problem, introducing it as a handover question, relabelling bags if not used whilst still within expiry date, stock rotation of stock bags, following a bag from fridge to patient, better coordination of discharge planning to prevent patients being at home when feed bags still available for them, splitting the fridge storage into days of the week so bags could be placed in correct day for each patient and if bags relabelled moved to the next available day, changing to standard bags during weaning process, taking patients off pre-ordering and changed to daily ordering to allow for altered discharge dates. Conclusion PN wastage is common and costly – in a high use unit ∼£90000 p.a. Using appropriate driver diagram, concurrent PDSA cycles and a motivated team high levels of cost savings are possible with resulting quality improvement in patient care. Disclosure of interest None Declared.

PWE-227 A nutrition nurse-delivered nasojejunal tube insertion service promotes appropriate use of nasojejunal nutrition support and is associated with low rates of tube complications

<h3>Introduction</h3> Nasojejunal tube (NJT) feeding provides a less costly and possibly safer alternative to parenteral nutrition (PN) in many settings including acute pancreatitis. However it is frequently underused due to reliance of NJT placement on radiological or endoscopic guidance, attendant delays and frequent mechanical complications including tube displacements and blockages. The Cortrak® electromagnetic imaging system allows bedside placement of NJT, is minimally invasive and avoids the need for radiological or endoscopic guidance. We introduced a Nutrition Clinical Nurse Specialist (CNS)-delivered Cortrak® service at our hospital, as part of a Nutrition Support Service in which which all patients referred for PN or NJT feeding were reviewed by a member of the Nutrition Support Team and suitable patients identified proactively. Bedside NJT placement by the Nutrition CNS was followed by immediate verbal and written communication of tube aftercare instructions to ward staff after placement. An electronic referral system for Cortrak® NJT placement was implemented. <h3>Method</h3> Prospective data were collected on indications, placement success, procedure time and complications over a 10 month period between April 2014 and February 2015. Patients with surgically altered upper gastrointestinal tract anatomy were excluded. Successful placement was determined by inspection of Cortrak® NJT insertion traces, supplemented by abdominal x-ray in a minority of cases (n = 4) where jejunal tip position on Cortrak tracing was considered equivocal. <h3>Results</h3> 66 referrals for bedside NJ tube placement in adult patients were received, of which 16 (24%) were deemed unsuitable on clinical grounds. The most common reason for rejecting referrals was suitability for provision of adequate nutrition via oral or nasogastric routes (7/16, 44%). Of 35 patients suitable for NJT feeding, 20 (57%) had previously been receiving PN or had been referred for PN. 50 insertions were attempted on 35 patients, with successful NJT placement in 42 out of 50 (84%). The median procedure time was 15 min (range 3 to 60). There were no procedure related complications. Involuntary extubation occurred for 5 tubes (12%), and tube blockage in 1 (2.4%). <h3>Conclusion</h3> A Nutrition CNS-delivered bedside NJT insertion service has several benefits. Our data demonstrate high rates of conversion of nutrition support from PN to enteral and avoidance of inappropriate NJT insertion in 24% of cases. Cortrak ® NJT placement was successful in 84% of cases, similar to other series. The incidence of NJT blockage was low (2.4%) and may reflect better communication of tube aftercare instructions to ward staff made possible by a CNS placing tubes on the ward. <h3>Disclosure of interest</h3> None Declared.

PTH-211 Improving standards of care for patients receiving total parental nutrition (tpn) at a district general hospital. a completed audit cycle: Abstract PTH-211 Table 1

<h3>Introduction</h3> Total parenteral nutrition (TPN) is an invasive feeding method, with stringent indications due to higher associated cost and morbidity. The National Confidentiality Enquiry into Patient Outcome and Death (NCEPOD) review – A Mixed Bag,¹identified good clinical practice in only 19% of patients receiving TPN as recently as 2010. We present improvements in standards of care for patients receiving TPN, which were found on completion of an audit cycle at our institution. <h3>Method</h3> Retrospective data collection was undertaken on all patients receiving TPN from December 2013–January 2014 at The Countess of Chester Hospital (Audit 2). This was compared to the same dataset extracted from November 2010–February 2011 (Audit 1). NCEPOD¹and NICE²guidance recommendations were used as gold standards. <h3>Results</h3> Over the 13 month period, 64 patients received TPN. The median age was 68 (range 23–89); male:female ratio 1.5:1. Median duration of TPN was 8 days (range 1–144 days). TPN was commenced in level 1 care in 59.4% of cases; level 2/3 40.6%. 36 patients (56%) received TPN via a dedicated PICC line and 28 (44%) through a central line. Data comparison between audit 1 and 2 is tabulated below. <h3>Conclusion</h3> Early involvement and supervision by the nutrition support team remained at a high standard. Following earlier recommendation, major improvements were seen in the monitoring of daily bloods, obtaining central venous access, and documentation of weekly weight measurements. A multi-disciplinary electronic referral and assessment proforma is now being developed to enable NCEPOD targets to continue to be met. <h3>Disclosure of interest</h3> None Declared.

Management of clinical nutrition

Proper management of Clinical Nutrition requires careful planning of the resources required to delineate the activities to be performed by each of the participants and consider the need for continued evaluation of the results to improve. Units of Nutrition and Nutritional Support Teams must have a multidisciplinary composition, incorporating professionals with training and experience in Clinical Nutrition. Whenever conditions permit and activity of each center indicates, the staff's dedication to nutrition must be complete. The organization of processes and use of clinical practice protocols facilitates the monitoring of the activities carried out by teams of Nutrition. Each stage of a process has quality criteria based on scientific knowledge, and some key objectives whose degree of achievement can be measured by monitoring quality indicators and their comparison with standards. Successive cycles of measurement indicators, evaluation and corrective interventions lead to continuous process improvement.

Applying standards of pharmaceutical practice in nutritional therapy cancer patient

Malnutrition in cancer patients is associated with a poor prognosis, weight loss being an important predictor of mortality. The cancer and its treatment have a great impact on nutritional status, so by applying nutritional therapy can improve quality of life, prognosis and functional status. The application of standards of practice this therapy in cancer patients can reduce variability of interventions and promote efficient, safe and quality use. Being the hospital pharmacist as part of the nutritional support team a key in optimizing nutrition therapy through four strategic partner roles: clinical, technical, operational and manager.

Reimbursement of Nutritional Support Team, What Is the Problem and How Can We Manage It?

Korea Ministry of Health and Welfare launched legislation for reimbursement for Nutrition Support Team (NST) activities from August 1st, 2014, which can be applied as a flat rate fee per day once a week. The indicated patients are those with hypoalbuminemia, on parenteral nutrition or enteral nutrition, critically ill patients in intensive care unit’s, and any patient on suspicion of malnutrition by the physician in charge. NST should be comprised of a professional physician, an educated nurse, an educated pharmacist, and a professional and experienced dietitian. The maximum number of patients that can be treated by one NST is 30 per day. Such a reimbursement system has resulted in some complex problems with NSTs. The low price does not provide adequate reward for the team’s workload because the output of NST belongs to the department in charge and there is no ensured incentive. The Department of Health Insurance Review and Assessment Service cannot detect the quality problem of NST, non-compliance of physicians in charge. There are no stratified codes according to severity of disease and no difference between the first visit and the repeated visit. Every NST should be certified with accreditation and should participate in a qualified education program. Korea Health Insurance does not cover the fees for feeding tubes, formulas, and pumps. Evidence that NST activities can reduce medical cost of hospital-admitted in-patients is needed. Cost-effectiveness can be achieved by quality improvement of NST.

Parenteral Nutrition Utilization After Implementation of Multidisciplinary Nutrition Support Team Oversight: A Prospective Cohort Study.

Multidisciplinary nutrition teams can help guide the use of parenteral nutrition (PN), thereby reducing infectious risk, morbidity, and associated costs. Starting in 2007 at Harborview Medical Center, weekly multidisciplinary meetings were established to review all patients receiving PN. This study reports on observed changes in utilization from 2005-2010. All patients who received PN from 2005-2010 were followed prospectively. Clinical data and PN utilization data were recorded. Patients were grouped into cohorts based on exposure to weekly multidisciplinary nutrition team meetings (from 2005-2007 and from 2008-2010). Patients were also stratified by location, primary service, and ultimate disposition. In total, 794 patients were included. After initiation of multidisciplinary nutrition meetings, the rate of patients who started PN decreased by 27% (relative risk [RR], 0.73; 95% confidence interval [CI], 0.63-0.84). A reduction in the number of patients receiving PN was observed in both the intensive care unit (ICU) and on the acute care floor (RR, 0.64; 95% CI, 0.53-0.77 and RR, 0.80; 95% CI, 0.64-0.99, respectively). The rate of patients with short-duration PN use (PN duration of <5 days) declined by 30% in the ICU (RR, 0.70; 95% CI, 0.51-0.97) and by 27% on acute care floors (RR, 0.73; 95% CI, 0.51-1.03). Weekly multidisciplinary review of patients receiving PN was associated with reductions in the number of patients started on PN, total days that patients received PN, and number of patients who had short-duration (<5 days) PN use.

Experiences of health professionals with nutritional support of critically ill patients in tertiary hospitals in Malawi.

Nutritional support is a recognized determinant of outcome in critically ill patients. Development of critical care services in low-income countries has not been accompanied by certain appropriate ancillary services and interventions, such as adequate nutritional support. This study was designed to investigate the experiences of health professionals who have provided nutritional supportive care to critically ill patients admitted to two major central hospitals in Malawi, with the aim of identifying the common practices in nutritional support in these settings. A cross-sectional study in which 50 health professionals working in intensive care and high dependency units, admitting both adult and pediatric patients, were interviewed using a semi-structured questionnaire. Data were coded and then analyzed using SPSS version 16.0. Responses between the two hospitals were compared using Fisher's exact test. There was no difference in the composition of respondents from the two hospitals. About 60% of respondents had had experience with nutritional supplementation in their patients-mainly enteral. The most commonly used formulations were the "ready-to-use therapeutic feeds," followed by modified milk. A high percentage of respondents (40%) reported having used dextrose solution as the sole nutritional supplement. Lack of in-service training, nonexistent nutrition protocols pertaining to acutely and critically ill patients, and a lack of clinical nutritionists were the major challenges identified. Knowledge of nutrient supplementation was poor among the respondents. The use of ready-to-use therapeutic feeds was quite common, although there is no evidence of its effectiveness in care of acutely critically ill patients. There is a need to establish nutritional support teams in these tertiary hospitals. Clinical nutritionists would ideally help train and play leadership roles in such teams, who would be responsible for assessing patients for their nutritional needs, and ensuring that the feeds provided to patients are appropriate and adequate for their needs.

An American Clinical Training Program for Spanish Nutrition Support Pharmacists: A Three-Year Experience

A clinical nutrition support pharmacist training program, in collaboration with the Spanish Foundation of Hospital Pharmacy, Spanish Society of Clinical Nutrition, Abbott Nutrition International, University of Tennessee, College of Pharmacy and Regional One Health, is described. Nutrition support pharmacists from Spain were selected to participate in a one-month training program with an experienced board-certified nutrition support pharmacist faculty member within an interdisciplinary nutrition support team environment in the U.S. Participants were expected to actively engage in an advanced clinical practice role with supervision. Clinical activities included daily intensive patient monitoring, physical assessment, critical evaluation of the patient and development of an appropriate treatment plan for patients receiving either enteral or parenteral nutrition therapy. Upon successful completion of the training program, participants were anticipated to incorporate these techniques into their current practice in Spain and to train other pharmacists to function in an advanced clinical role independently or within an interdisciplinary nutrition support team environment.

Nutrition quality control in the prescription and administration of parenteral nutrition therapy for hospitalized patients.

Nutrition quality control in parenteral nutrition therapy (PNT) allows the identification of inadequate processes in parenteral nutrition (PN). The objective of this study was to assess the quality of PNT at a hospital with an established nutrition support team (NST). This observational, longitudinal, analytical, and prospective study examined 100 hospitalized PNT adult patients under the care of an NST for 21 days or until death/hospital discharge. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) 2007 guidelines for PNT prescription were followed. PNT indications were not in accordance with the A.S.P.E.N. 2007 guidelines in 15 patients. Among the remaining 85 patients, 48 (56.5%) did not receive adequate PNT (≥80% of the total volume prescribed). Non-NST medical orders, progression to and from enteral nutrition, changes in the central venous catheter, unknown causes, and operational errors (eg, medical prescription loss, PN nondelivery, pharmacy delays, inadequate PN bag temperature) were associated with PNT inadequacy (P < .005). Compared with patients who died, the discharged patients received PN volumes ≥80% on most days (P = .047). The quality indicators for nutrition therapy related to estimated energy expenditure and protein requirements and glycemia levels reached the expected targets; however, the central venous catheter infection rate was higher than 6 per 1000 catheters/d and did not meet the expected targets. Despite an established NST, there was a moderate level of PNT inadequacy in indications, administration, and monitoring. It is important to establish periodic meetings among different health professionals who prescribe and deliver PNT to define responsibilities and protocols.

Zinc: physiology, deficiency, and parenteral nutrition.

The essential trace element zinc (Zn) has a large number of physiologic roles, in particular being required for growth and functioning of the immune system. Adaptive mechanisms enable the body to maintain normal total body Zn status over a wide range of intakes, but deficiency can occur because of reduced absorption or increased gastrointestinal losses. Deficiency impairs physiologic processes, leading to clinical consequences that include failure to thrive, skin rash, and impaired wound healing. Mild deficiency that is not clinically overt may still cause nonspecific consequences, such as susceptibility to infection and poor growth. The plasma Zn concentration has poor sensitivity and specificity as a test of deficiency. Consequently, diagnosis of deficiency requires a combination of clinical assessment and biochemical tests. Patients receiving parenteral nutrition (PN) are susceptible to Zn deficiency and its consequences. Nutrition support teams should have a strategy for assessing Zn status and optimizing this by appropriate supplementation. Nutrition guidelines recommend generous Zn provision from the start of PN. This review covers the physiology of Zn, the consequences of its deficiency, and the assessment of its status, before discussing its role in PN.

Pumps, feed and sets: is procurement limiting outcomes?

This article aims to review the unique ways in which enteral feed, ancillary items and pumps are procured in the UK and to evaluate whether these are inhibiting innovation and reducing the choices of patients. There are a number of models that have been developed across the UK for the procurement of enteral feed, feeding accessories and pump. The two most common are the hospital-based nutrition support team, which may have an overarching role in the community, and the home enteral nutrition (HEN) team, a multidisciplinary community-based team with skilled health professionals dedicated to the delivery of the enteral nutrition service. While the HEN service has its advantages over other models in the community, it is primarily driven by its clinical role. The lack of significant opportunity for clinical audits and research within the service limits the prospects for service improvement, innovation and patients' choices.

Implementation of a computerized system in pediatric wards to improve nutritional care: a cluster randomized trial.

Malnutrition occurs frequently in hospitalized children. We aimed to assess whether a computerized system could lead to improved clinical practices in malnourished children. Healthcare workers (242) from six departments in a pediatric university hospital participated in a cluster randomized trial, studying 1457 malnourished children hospitalized from September 2009 to August 2011. Following a baseline observational pre-intervention period, all departments were randomized into either intervention or control arms. A computerized malnutrition-screening system was implemented in the intervention group to automatically trigger a dietetic referral in real time. Furthermore, the nutrition support team conducted an awareness campaign with healthcare workers and a leadership-based strategy to reinforce the message during the entire study period. Adherence to practice guidelines (daily weights, investigation of etiology for malnutrition, management by a dietitian and application of refeeding protocols) was compared between pre- and post-intervention periods in both the intervention and trial arms. When compared with the pre-intervention period, the clinical practices were significantly improved within the intervention arm for every outcome (P<0.01), whereas remained unchanged in the control arm. In addition, during the post-intervention period, malnutrition etiology investigation by physicians (adjusted odds ratio (OR) of 4.4, 95% confidence interval (CI) 1.7-11.8, P=0.003) and management by a dietitian (OR 2.7, 95% CI 1.0-6.9, P=0.046) occurred more frequently in the intervention clusters. Implementation of an electronic system to detect malnutrition in real time was associated with a rapid improvement in clinical practices for better care of hospitalized children.

Give 'em 3 liters of hyperal.

Give 'em 3 liters of hyperal.

Organization and the Role of Nutirition Support Team

With the development of specialized nutrition therapy and the need for interdisciplinary approach, nutrition support teams (NSTs) were created to optimize effectiveness and safety of nutritional therapy. NSTs are interdisciplinary support teams with specialty training in nutrition that are typically comprised of physicians, dietitians, nurses, pharmacists, and others. Their role includes nutrition screening, assessment, determination of nutrition needs, recommendations for appropriate nutrition therapy, management of nutrition support therapy, and monitoring. Studies have demonstrated significant improvements in patient nutrition status and improved clinical outcomes as well as reductions in costs when patients were appropriately managed by NSTs. Organization and the role of NSTs are discussed in this review.

Outcome and problem in nutrition support team in university hospital

Outcome and problem in nutrition support team in university hospital