Nutrition Support Team Research Articles

Understanding Nutritional Support in Digestive Diseases

The prevalence of hospital malnutrition is still high in patients with digestive diseases, especially for those suffering from cancer and bowel diseases which cause malabsorption. It is well known that malnutrition is associated with delayed wound healing, impaired immunity, infection, increased complication, and poor convalenscence. Recently, nutrition screening and assessment by nutrition support team has become essential for nutrition management, and gastroenterologists comprise a dominant member of the nutrition support team. In critically ill patients and older people with chronic disease, nutritional support with enteral feeding and early feeding contributes to recovery and rehabilitation of patients. Securing enteral feeding routes, such as feeding tube insertion and placement of percutaneous endoscopic gastrostomy/jejunostomy, is an essential part of nutrition care that should be accomplished by gastroenterologists without much difficulty. It will also be necessary to recommend nutrition care as one of the clinical routines in gastrointestinal clinical practices. Therefore, education on nutrition care is strongly required as a part of gastroenterologist's training.

Nutrition Therapy in Critically Ill Patients

Nutrition therapy is challenging in critically ill patients. Critical illness is associated with a state of catabolic stress, in which stress hormones and inflammatory mediators are activated, resulting in proteolysis. Critically ill patients in intensive care units commonly have anorexia or may be unable to feed volitionally by mouth. Therefore, taking care to provide appropriate macronutrients and micronutrients in the form of enteral or parenteral nutrition is necessary. The energy deficit in acutely ill patients contributes to lean-tissue wasting associated with adverse outcomes. In contrast, excessive supply can cause not only metabolic complications but also adverse outcomes. Recently, nutrition therapy has been incorporated into critical care to improve clinical outcome during the acute phase of critical illness. Implementation of a feeding protocol and the involvement of a nutrition support team could lead to more systematic decisions regarding nutrition therapy and greater clinical benefits.

Current situation and issues related to claiming of charges for the operations of nutrition support teams

Current situation and issues related to claiming of charges for the operations of nutrition support teams

The oncologist as coordinator of the nutritional approach

Although the nutritional approach, especially when delivered through a gastric or jejunal tube or in a central vein, is handled by the nutritional support team or a specialist in nutrition, it is the responsibility of the oncologist, who knows the natural history of the disease and the impact of the oncologic therapy, to identify the potential candidates for the nutritional support, to recommend the nutritional strategy and to integrate it within the oncologic program. If gastrointestinal function is preserved, the initial nutritional approach should be through oral supplementation, followed by tube feeding if previous attempts are unsuccessful or upper gastrointestinal tract is not accessible. Parenteral nutrition is the obligatory resort when patients are (sub)obstructed but it may also be a practical way to integrate an insufficient oral nutrient intake (so called “supplemental” parenteral nutrition). Depending on the patient's condition and the disease's stage, artificial nutrition may have a “permissive” role in patients receiving aggressive oncologic therapy or represent just a supportive treatment in patients likely to succumb from starvation sooner than from tumor progression.

Evaluation of nutrition support pharmacist interventions.

The purpose of this study was to determine the number and types of interventions performed by our nutrition support service (NSS) pharmacists that were not directly related to the nutrition formula prescription. This was an institutional review board-approved retrospective study of all adult pharmacy NSS consultations from January 1, 2011 to December 31, 2011. All interventions assessed were categorized as the following: fluids and electrolytes, glucose management, alternate therapy, diagnostics, general laboratory result monitoring, vitamin and trace element monitoring, discontinuing medication, adding medication, dose adjustment, and other. The primary endpoint was to determine the total number of interventions and their acceptance rates. The secondary endpoint was to determine which categories had the most accepted and most denied interventions. There were 132 adult consults evaluated with a total of 383 interventions performed. The overall acceptance rate was 84%, and the top 3 accepted intervention categories were general laboratory result monitoring (96%), fluids and electrolytes (96%), and other (100%). The top 3 denied intervention categories were dose adjustment (60%), diagnostics (50%), and adding medication (22%). The interventions performed by the pharmacists demonstrate the unique perspective, knowledge, and importance of a pharmacist on nutrition support teams.

American society for parenteral and enteral nutrition (a.s.p.e.N.) standards of practice for nutrition support pharmacists.

American society for parenteral and enteral nutrition (a.s.p.e.N.) standards of practice for nutrition support pharmacists.

Assessing the Impact of Registered Dietitian Recommendations on the Appropriate Use of Parenteral Nutrition in a Community Hospital Setting

Introduction: Parenteral Nutrition (PN) can be a beneficial supplementation option when used in the appropriate clinical setting. A nutrition support team (NST) has been demonstrated to reduce the inappropriate use of PN, however less than half of community hospitals in the United States have adopted this model. Our study aimed to evaluate PN usage in a community hospital setting in the absence of a NST. The implementation of a hospital policy requiring a registered dietician consultation prior to the initiation of PN allowed us to assess the impact of this method on PN usage patterns. Methods: A retrospective chart review was conducted at Riverside medical center Kankakee comparing 2 different 9 month time periods. The first time period, February 1, 2012 to October 31, 2012, was preceding the implementation of a hospital policy requiring a registered dietician consultation prior to the initiation of parenteral nutrition. The second time period, December 1, 2012 to August 31, 2013, was after this policy was implemented. One month (November 2012) between these two time periods was excluded from data collection and acted as a wash out period to allow for implementation of this policy. Data was collected on the indication and duration of PN. PN indications were assessed as appropriate or inappropriate based on current ASPEN guidelines. Results: A total of 196 patients were included in this study: 109 prior to policy implementation and 87 after. After policy implementation a decline in the proportion of hospitalized patients receiving PN was observed, however this was not statistically significant (1.52% vs. 1.31%; z=1.04; p-value=0.298, Fisher’s exact test: p-value=0.314). A reduction in inappropriate PN usage was observed after policy implementation, however this reduction was not statistically significant (67% vs. 65.5%, z=0.21 and p-value=0.831). However, a significant reduction in PN duration was observed after policy implementation (8.33 vs. 6.47 (days), t-value=2.40 and p-value=0.017). Conclusion: In a community hospital setting, a policy requiring a registered dietician consultation prior to initiation of PN did not result in a significant decline in the percentage of patients receiving PN or the inappropriate use of PN. This requirement however did result in a significant reduction in the duration for which patients received PN. Additional methods or policies are needed to reduce the inappropriate usage of PN in our community hospital.

Quality and safety impact on the provision of parenteral nutrition through introduction of a nutrition support team.

Parenteral nutrition (PN) should be provided to the malnourished patient if enteral feeding is insufficient or unsafe. A nutrition support team (NST) may improve PN services. We compared the use and complications of hospital PN before and after the implementation of an NST. All inpatients referred for PN outside of the intensive care unit and the intestinal failure unit were prospectively included from 2009 to 2012. The NST was introduced in 2010. Quality improvement methodology was applied. In 2009, a mean of 16 (limits of normal variation 4-28) patients were referred for PN each month. After introduction of the NST, this rose to 26 (10-42) referrals per month. The percentage of referrals where PN was not initiated increased from 5.3% in 2009 to 10.1% in 2012 (P=0.03). This increase was restricted to teams that infrequently referred for PN, and enteral nutrition could replace PN in 31 of 51 patients (61%) as compared with 8 of 32 (25%) patients referred from teams that frequently referred for PN (P=0.001). The frequency of PN started owing to an insufficient oral or enteral intake decreased from 11% to 3% (P=0.01). The catheter-related bloodstream infection rate dropped from 6.7 to 0.7 episodes per 1000 catheter days (P<0.001). Introduction of an NST increased both the total PN use and the percentage of referrals where enteral nutrition could replace PN. Medical specialty influenced the referral pattern and the likelihood that a referral resulted in PN being initiated. Safety of PN catheters improved significantly following NST introduction.

Nutritional support teams: the cooperation among physicians and pharmacists helps improve cost-effectiveness of home parenteral nutrition (HPN).

Modern home parenteral nutrition (HPN) requires the preparation of tailored admixtures. The physicians' demands for their composition are often at the variance with pharmaceutical principles, which causes the necessity of either the preparation of ex tempore admixtures or stability testing ensuring long shelf life. Both approaches are not cost-effective. The aim of the study was to use the cooperation among physicians and pharmacists to assure both: cost-effectiveness and patient-tailored HPN admixtures. The first part of the study consisted of the thorough analysis of prescriptions for the most demanding 47 HPN patients (27 females and 20 males, mean age 53.1 year) treated at one HPN center to create few as possible long-shelf life admixtures. The second part of the study consisted of stability testing and modifications. The analysis showed over 137 variations needed to cover all macro- and micronutrients requirements. Their cost as ex-tempore solutions was extremely high (over 110 000 EURO/month) due to logistics and similarly high if stability test for variation were to be performed (68 500 EURO). Therefore prescription was prepared de novo within team of physicians and pharmacists and four base models were designed. Water and electrolytes, particularly magnesium and calcium showed to be the major issues. Stability tests failed in one admixture due to high electrolytes concentration. It was corrected, and the new formula passes the test. Five basic models were then used for creation of new bags. Cost of such an activity were 3 700 EURO (p<0.01) CONCLUSIONS: The cooperation within the members of nutritional support team could improve the cost-effectiveness and quality of HPN.

PP278-SUN: Outstanding abstract: Vitamin D Deficiency Reduces Fasted Muscle Protein Synthesis Rate in Old Rats Through Ectopic Fat Deposition and Increased EIF2α Phosphorylation

Rationale: Critically ill children are at high risk of developing nutritional deficiencies, and hospital undernutrition is known to be a risk factor for morbidity and mortality in children. Clinical guidelines are used to standardize and provide better care in the pediatric intensive care unit (PICU). The study aims were to examine nutrition support practices before and after implementation of nutrition support guidelines in the PICU. Methods: Chart review of dietary intake for first 8 days of PICU admission prior to (Oct-Dec 2012) and after (Oct-Dec 2013) educational interventions and training completed during August 2013 by the nutrition support team to all nursing and clinical staff. IRB approved. Results: 191 patients: age 1.4 (0.3 7.5) yrs (median (25 75th percentile) and PICU length of stay (LOS) 6 (4 10) days; and 193 patients, 1.8 (0.5 8.2) yrs and PICU LOS 6 (4 10) days preand post-implementation, respectively, were included.

OP029: Quality and Safety Impact on the Provision of Parenteral Nutrition through Introduction of a Nutrition Support Team

OP029: Quality and Safety Impact on the Provision of Parenteral Nutrition through Introduction of a Nutrition Support Team

PP026-MON: Nutritional Support Team Performance is Related to Exclusive Dedication to the Team

Rationale: Our aim was to determine the national variation in assessment and provision of nutrition and its resource implications within the Welsh critical care community. Methods: All critical care units in Wales were contacted via email. At each unit a Dietitian and a Consultant in ICM were invited to complete an online survey. The units that failed to respond received follow up emails and telephone calls to ensure best response rate. Results: Of the 16 units contacted, 12 Dietitians and 12 Consultants responded sampling district general and university hospitals. Only 15% of units met the minimum dietetic requirement per bed, with 23% of centres having no dedicated dietetic time. None of the units reached optimum dietetic staffing levels of 0.1 WTE per bed. Only 50% patients receive a daily weekday review with 55% Dietitians never attending ICU rounds or MDT’s. 90% units initiate EN within 24 48 hours. 90% units utilize NJ feeding to achieve nutritional goals; via mainly endoscopically placed NJT. 80% units use <10 NJ tubes per annum. All units monitor gastric residual volumes; however there is considerable variation in threshold values for altering feeding rates or initiation of prokinetic agents. The majority of units calculate nutritional requirements using predictive equations. Only one unit documents nutritional requirements at the bedside. Less than 50% units calculate nutritional deficits, a third of which are highlighted via MDT meetings and two thirds via the medical notes. Conclusion: Nutrition support in critical care is staggeringly under-resourced with only two units meeting the minimum standard of dietetic staffing; in addition Dietitians appear inadequately integrated into the care of this patient group. Highlighting patients developing or having established nutritional deficits is problematic. A bedside traffic light system under evaluation may improve awareness by MDT members.

PP277-SUN: Implementation of Nutrition Support Guidelines for the Critically Ill Child: A Quality Improvement Program

Rationale: Critically ill children are at high risk of developing nutritional deficiencies, and hospital undernutrition is known to be a risk factor for morbidity and mortality in children. Clinical guidelines are used to standardize and provide better care in the pediatric intensive care unit (PICU). The study aims were to examine nutrition support practices before and after implementation of nutrition support guidelines in the PICU. Methods: Chart review of dietary intake for first 8 days of PICU admission prior to (Oct-Dec 2012) and after (Oct-Dec 2013) educational interventions and training completed during August 2013 by the nutrition support team to all nursing and clinical staff. IRB approved. Results: 191 patients: age 1.4 (0.3 7.5) yrs (median (25 75th percentile) and PICU length of stay (LOS) 6 (4 10) days; and 193 patients, 1.8 (0.5 8.2) yrs and PICU LOS 6 (4 10) days preand post-implementation, respectively, were included.

Effects of a Nutrition Support Team with Parenteral Nutrition on Gastrointestinal Cancer Patients Who Underwent Surgery

Effects of a Nutrition Support Team with Parenteral Nutrition on Gastrointestinal Cancer Patients Who Underwent Surgery

국내 상급종합병원과 전국 분포 종합병원의 임상영양서비스 실태 조사 연구: 전국 규모 설문조사를 통하여

The purpose of this study was to investigate the status of clinical nutrition services provided at tertiary hospitals and general hospitals in Korea. In total, 157 questionnaires were distributed to the departments of nutrition at hospitals on September 2013. The results of this study are as follows. The median number of beds was 607 and average length of stay was 8 days. 63.1% of dietitians had over 5 years of career experience. Nutritional screening rate was 97% in tertiary hospitals but only 67.2% in general hospitals (P<0.001). The rate of equipment with computerized nutritional screening system was 100% in tertiary hospitals but 71.9% in general hospitals (P<0.001). Hospitals with the best regarding nutritional care were hospitals accredited by JCI (Joint Commission International). On the other hand, hospitals not accredited by the JCI but KOIHA (Korea Institute for Healthcare Accreditation) showed the lowest performance rate of nutritional care. Nutrition support teams (NSTs) were established in all tertiary hospitals but in only 73% of general hospitals (P<0.001). The rate of actively operating NSTs was 89% in tertiary hospitals but only 62% in general hospitals (P<0.001). There is a need to provide proper standardized clinical nutrition services as a primary treatment and we observed large variations in the quality of nutritional service between hospitals. Therefore, local solutions are needed to implement nutritional programs and policies for improved service and care.

Home enteral nutrition reduces complications, length of stay, and health care costs: results from a multicenter study

Home enteral nutrition (HEN) has always been recognized as a life-saving procedure, but with the ongoing economic crisis influencing health care, its cost-effectiveness has been questioned recently. The unique reimbursement situation in Poland enabled the otherwise ethically unacceptable, hence unavailable, comparison of the period of no-feeding and long-term feeding and the subsequent analyses of the clinical value of the latter and its cost-effectiveness. The observational multicenter study in the group of 456 HEN patients [142 children: 55 girls and 87 boys, mean (±SD) age 8.7 ± 5.9 y; 314 adults: 151 women and 163 men, mean age 59.3 ± 19.8 y] was performed between January 2007 and July 2013. Two 12-mo periods were compared. During the first period, patients were tube fed a homemade diet and were not monitored; during the other period, patients received HEN. HEN included tube feeding and complex monitoring by a nutrition support team. The number of complications, hospital admissions, length of hospital stay, biochemical and anthropometric variables, and costs of hospitalization were compared. Implementation of HEN enabled weight gain and stabilized liver function in both age groups, but it hardly influenced the other tests. HEN implementation reduced the incidence of infectious complications (37.4% compared with 14.9%; P < 0.001, McNemar test), the number of hospital admissions [1.98 ± 2.42 (mean ± SD) before and 1.26 ± 2.18 after EN; P < 0.001, Wilcoxon's signed-rank test], and length of hospital stay (39.7 ± 71.9 compared with 11.9 ± 28.5 d; P < 0.001, Wilcoxon's signed-rank test). The mean annual costs ($) of hospitalization were reduced from 6500.20 ± 10,402.69 to 2072.58 ± 5497.00. The study showed that HEN improves clinical outcomes and decreases health care costs. It was impossible, however, to determine precisely which factor mattered more: the artificial diet itself or the introduction of complex care.

Support and practical advice for the use of nutrition support teams.

There are many guidelines recommending that provision of parenteral nutrition (PN) should be supervised by nutrition support teams (NSTs). There is some evidence that these teams make economic sense, decrease complications and result in greater delivery of target nutritional requirements. Moreover, a recent report on the quality of PN care in the UK found only 19% was considered to be consistent with current good practice. Recommendations exist on how to set up teams, but advice on the practical aspects of doing the job is lacking. In this article, the authors outline the NST method of practice at North Shore Hospital in Auckland, New Zealand, including its assessment sheet and a description of its working acronym LIFEWRAP, which is used to ensure consistent assessment and care.

Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study

Good nutritional practice (GNP) includes screening, nutrition plan and monitoring, and is mandatory for targeted treatment of malnourished patients in hospital. To optimize energy- and protein-intake in patients at nutritional risk and to improve GNP in a hospital setting. A 12-months observational multi-modal intervention study was done, using the top-down and bottom-up principle. All hospitalized patients (>3 days) were included. A university hospital with 758 beds and all specialities. Record audit of GNP, energy- and protein-intake by 24-h recall, patient interviews and staff questionnaire before and after the intervention. Based on pre-measurements, nutrition support teams in each department made targeted action plans, supervised by an expert team. Education, diagnose-specific nutrition plans, improved menus and eating environment, and awareness were initiated. Mann-Whitney and Kruskal-Wallis test was used for ordinal data, and Pearson Chi square test for nominative data. Overall 545 patients participated (287 before/258 after) from 26/22 departments. There were no significant differences regarding sex, age, BMI or previous weight loss before and after the intervention. Result-indicators: Energy intake improved from 52% to 68% (p < 0.007), and protein intake from 33% to 52% (p < 0.001) (>75% of requirements). Intake of less than 50% of requirements decreased with 50%. Process-indicators: Screening improved from 56% to 77% (p < 0.001), nutrition plans from 21% to 56% (p < 0.0001), and monitoring food intake from 29% to 58% (p < 0.0001). Intake of energy and protein as well as GNP improved using a multi-modal top-down and bottom-up approach.

Corrigendum.

DeLegge MH, Kelly AT. State of nutrition support teams. Nutr Clin Pract. 2013;28:691-697. (Original DOI: 10.1177/0884533613507455 ).

Parenteral Nutrition Utilization in Bone Marrow Transplant Recipients

Bone marrow transplant (BMT) recipients often require parenteral nutrition (PN) to meet their nutrient needs. While general guidelines for the provision of PN support by nutrition support teams (NSTs) have been shown to decrease inappropriate PN use, recommendations for nutrition in BMT recipients are lacking.