Provision Of Nutritional Support Research Articles

Invited Review: Nutritional Management of Hyperemesis Gravidarum

Hyperemesis gravidarum (HG) was once a major cause of maternal mortality. The impact of prolonged and severe nausea and vomiting on the fetus and mother can be devastating. Disturbances in fluid, electrolyte, and acid‐base balances are common. The reduction in maternal deaths associated with HG is a result of improved understanding and more aggressive treatment of these metabolic alterations. HG is the most common reason for nutrition support intervention during pregnancy. However, little information is available regarding the nutritional issues associated with HG or the effects of providing nutrition support on pregnancy outcome. This review discusses the nutritional implications of HG and strategies for clinical management, including hydration, pharmacologic therapies, and the provision of enteral and parenteral nutrition. Implications for home care and future research are also presented.

Nutrition support in the critically ill patient.

Despite an absence of well-controlled studies demonstrating a clear mortality benefit, providing nutrition support in the critically ill patient has become routine in most ICU settings. Unless clearly contraindicated, patients should be fed enterally, using conventional isotonic feedings employing gastric or postpyloric access. When to begin nutrition support varies, depending on baseline nutritional status, anticipated time until oral feedings are resumed, and the degree of stress. Energy and protein requirements should be assessed routinely with minimum goals of avoiding overfeeding and minimizing any net negative nitrogen balance. All patients receiving feedings require close surveillance to identify predictable complications and to tailor therapy to achieve nutritional goals. Adjunctive therapies should be employed as needed to help achieve nutritional goals, eg, insulin infusions to control serum glucose and prokinetic agents to improve gastric emptying. When feasible and safe, parenterally fed patients should be transitioned to enteral or oral feedings when appropriate.

A critical evaluation of the use of nutrition screening tools by nurses.

Malnutrition remains a problem in hospital and community patients, the consequences of which have deleterious effects on the sick individual and cost implications for healthcare providers. Provision of nutritional support has been shown to improve patient outcome in those at risk of malnutrition; therefore, the detection and treatment of malnutrition is paramount. Nurses have been identified as being in an ideal position to carry out routine nutritional screening to detect patients at risk of malnutrition and hence refer to the dietitian for detailed nutritional assessment and provision of nutritional support. Therefore, many nutritional screening tools have been developed to guide nurses in basic nutritional screening. However, for a tool to be effective certain criteria must be met including ease of use, cost-effectiveness, the presence of an action plan and prior testing for validity, reliability, sensitivity and specificity. Six such tools are critically evaluated in this article to establish whether they meet these criteria. Surprisingly, none of the screening tools demonstrated a beneficial effect on clinical outcome or met all of the above criteria. It is therefore essential that these tools are refined and retested before becoming part of established nursing practice.

Dietitians Expanded Role Providing Nutrition Support By Utilizing Performance Improvement Plan

Dietitians at a Minnesota community hospital successfully initiated the development and implementation of nutrition support protocols and order forms by using the hospital-wide Performance Improvement (PI) process. The PI plan, called “S.T.E.P.,” defines the following objectives: S eeing the opportunity to improve; T eaming up to develop a plan; E valuating a plan; and P roceeding to adopt the plan. Dietitians began by s eeing the opportunity to improve physicians’ responsiveness to nutrition support recommendations. An “Opportunity Statement” was submitted to the PI committee and a multi-disciplinary t eam was created to develop a plan. The team then e valuated and modified these algorithms and guidelines for administering and monitoring nutrition support. Physicians requested that the enteral nutrition order form include an option indicating that the dietitian should write the order. The team then p roceeded to adopt these newly-developed nutrition support protocols and order forms. They were subsequently presented to the medical staff and PI committee, which accepted them for immediate use. Results indicate that: (1) an increasing number of patients are appropriately placed on nutrition support; (2) dietitian's role as an active team member is validated; and (3) physicians now request dietitians to write enteral orders, which expedites initiation of nutrition therapy. Using the PI process is one method dietitians can proactively expand nutrition practice, take a leadership role in providing nutrition support and ultimately impact patient outcome.

Nutrition support for patients in long-term acute care and subacute care facilities.

Long-term acute care and subacute care facilities (also transitional care facilities) have evolved from the need to decrease costs associated with acute care in the hospital. As the length of stay in many medical centers has been reduced, patients are admitted to transitional care facilities to continue recovery and rehabilitation. Rehabilitation and recovery can be enhanced with the provision of optimal medical nutrition therapy. Nutrition screening is essential in identifying patients who are at risk of malnutrition or are malnourished. Nutrition assessment verifies the risk or presence of malnutrition followed by the development, implementation, and monitoring of nutrition intervention. Nutrition screening and intervention promote recovery from illness, minimize morbidity and mortality, and enhance quality of life. The goals of nutrition support are to prevent starvation-associated malnutrition, preserve lean tissue mass, support metabolic functions, and improve clinical outcomes. Oral nutrition is the preferred method of nourishment; however, specialized nutrition support is considered for patients unable to meet their nutrient requirements adequately. Enteral nutrition support is recommended when providing nutrition support however, parenteral nutrition support is used when the gastrointestinal tract can not be safely used. With appropriate intention, administration, and monitoring, nutrition support can be safely administered.

Enteral feeding: an overview of indications and techniques.

Most patients requiring nutritional support can be successfully managed using enteral feeding, i.e. the provision of nutritional support via the gastrointestinal tract. Various routes of access are available and patients should be assessed on an individual basis by the multidisciplinary team to select the most appropriate method and decide on a suitable regimen. Careful management and regular monitoring of enteral feeding are required in order to ensure safe and cost-effective nutritional support; the use of standard protocols and guidelines is recommended. With appropriate training, monitoring and support, enteral feeding is best provided in the community for many patients, and the use of home enteral feeding is rapidly increasing.

Grains or Veins: Is Enteral Nutrition Really Better Than Parenteral Nutrition? A Look at the Evidence

Enteral nutrition is said to be better than parenteral nutrition for providing nutrition support to humans. To assess the literature documenting the assertions that enteral nutrition is superior to parenteral nutrition with respect to cost, safety, physiology, intestinal structure and function, bacterial translocation, and outcome. Sources included MEDLINE search, personal files, and references from human comparative studies of enteral vs parenteral nutrition. The goal was to include all human studies directly addressing questions of comparative efficacy of enteral and parenteral nutrition. Emphasis was given to prospective randomized controlled studies where available. Retrospective comparisons were not included. An attempt was made to briefly summarize methodology and findings of relevant studies. No general attempt was made to assess quality of individual studies. Enteral nutrition appears to be less expensive than parenteral nutrition, but new economic analyses are needed given the newer aggressive access techniques for enteral nutrition. Enteral nutrition is associated with meaningful morbidity and mortality. The little comparative data existent suggest no differences in safety. Comparative studies of physiology and metabolism as well as comparative and noncomparative studies of intestinal function and structure do not support putative advantages of enteral nutrition. There is no evidence that enteral nutrition prevents bacterial translocation in humans. Enteral nutrition probably reduces septic morbidity compared with parenteral nutrition in abdominal trauma. Otherwise, there is no evidence that enteral nutrition consistently improves patient outcome compared with parenteral nutrition. With the exception of decreased cost and probable reduced septic morbidity in acute abdominal trauma, the available literature does not support the thesis that enteral nutrition is better than parenteral nutrition in humans.

The challenge of providing nutritional support to the dying

Dying patients are often unable to take food or drink; caregivers must then decide whether to provide nutrition/hydration by artificial means. Providing sustenance to such patients is an area of ongoing controversy not least because of the difficulties associated with determining life expectancy but also because of the need to promote patient comfort and well-being. Decisions relating to the provision of nutritional support must be based on the needs, wishes and expectations of both patients and their families. They must also take into account the legal and ethical dimensions of care provision and the need to ensure that the care provided is based on a true examination of the risks, benefits and burdens to the individual. This paper considers these issues concluding that any therapeutic measures considered must be both individualised and realistic recognising that the prime goal must be the patient’s comfort; prolonging his life is of secondary concern.

Nutritional support of the pediatric oncology patient.

The child with a malignancy frequently will have associated cachexia with significant weight loss and malnutrition. The reasons for this are multifactorial and may be related directly to the tumor, such as increased metabolic rate, circulating peptides leading to anorexia, and decreased intake due to poor appetite or gut involvement. There appears to be other reasons involved, including increased whole body protein breakdown, increased lipolysis, and increased gluconeogenesis. Release of certain cytokines, such as tumor necrosis factor, interleukin-1, interleukin-6, and others may increase the cancer cachexia. Malnutrition in these children leads to intolerance of chemotherapy and radiotherapy as well as increased local and systemic infections. For many years, oncologists were hesitant to provide nutrition support to cancer patients for fear that tumor growth would be enhanced. Pediatric oncologists learned early that starvation plays no positive role in cancer therapy. Adjunctive nutritional support, either enterally or parenterally, supports the patient during therapy with surgery, chemotherapy, or radiation. Many studies have now shown that the nutritionally replete patient tolerates therapy better and in some pediatric malignancies may enhance survival.

The Role of Nutrition Support Dietitians as Viewed by Chief Clinical and Nutrition Support Dietitians: Implications for Training

Objectives To determine current and ideal frequencies with which nutrition support dietitians perform each item on a list of 15 tasks and evaluate dietitian preparation for the practice of nutrition support. Design Data were collected using two questionnaires, one completed by the chief clinical dietitian and the other completed by the nutrition support dietitian at each hospital surveyed. Both versions of the questionnaires contained a list of 15 tasks that had been validated as being related to advanced nutrition support by a panel of 20 nutrition support experts using a modified Delphi method. Follow-up telephone calls were made to increase the number of responses. Sample Questionnaires were mailed to the chief clinical dietitian at 300 randomly selected, general medical/surgical hospitals with 300 or more beds in the United States and Puerto Rico. A total of 134 chief clinical dietitians (45%) and 129 nutrition support dietitians (43%) responded to the surveys; 124 (41%) and 120 (40%) questionnaires, respectively, were usable for statistical analyses. Statistical analyses The Wilcoxon matched-pairs signed-ranks test was used to determine differences between nutrition support dietitian actual and ideal frequencies and between chief clinical dietitian actual and ideal frequencies for each of the 15 tasks. The Mann-Whitney U-Wilcoxon rank sum W test was used to determine differences between nutrition support dietitian and chief clinical dietitian actual frequencies and between nutrition support dietitian and chief clinical dietitian ideal frequencies for each of the 15 tasks. Descriptive statistics were used to analyze the questions regarding educational preparation for nutrition support practice and demographic data. Results The ideal frequency for each of the 15 tasks was significantly greater ( P<.0001) than the actual frequency reported by nutrition support dietitians and chief clinical dietitians. Whereas chief clinical dietitians and nutrition support dietitians agreed on the ideal frequency for most tasks, the nutrition support dietitian ideal frequency indicated for the tasks “determines macronutrient composition of parenteral nutrition” and “performs physical examinations related to nutritional status, fluid status, and gastrointestinal function” was significantly greater ( P<.001, P<.05), respectively) than the ideal frequency indicated by chief clinical dietitians. Of the nutrition support dietitians, 79% agreed and 16% somewhat agreed that experiences beyond those required for becoming a registered dietitian are needed to provide nutrition support dietitians with specialized clinical skills. Applications/conclusions Nutrition support dietitians desire increased responsibility for delivering nutrition support to their patients and this desire is largely supported by chief clinical dietitians. Nutrition support dietitians appear to have a strong interest in postregistration qualifying experiences that would provide a foundation for expanding their roles. According to the results of this study, programs designed to provide practical, clinical experience in nutrition support are needed. J Am Diet Assoc. 1997;97:1255-1260,1263.

Nutrition support in clinical practice: review of published data and recommendations for future research directions. Summary of a conference sponsored by the National Institutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition

In the last 30 years, marked advances in enteral feeding techniques, venous access, and enteral and parenteral nutrient formulations have made it possible to provide nutrition support to almost all patients. Despite the abundant medical literature and widespread use of nutritional therapy, many areas of nutrition support remain controversial. Therefore, the leadership at the National Institutes of Health, The American Society for Parenteral and Enteral Nutrition, and The American Society for Clinical Nutrition convened an advisory committee to perform a critical review of the current medical literature evaluating the clinical use of nutrition support; the goal was to assess our current body of knowledge and to identify the issues that deserve further investigation. The panel was divided into five groups to evaluate the following areas: nutrition assessment, nutrition support in patients with gastrointestinal diseases, nutrition support in wasting diseases, nutrition support in critically ill patients, and perioperative nutrition support. The findings from each group are summarized in this report. This document is not meant to establish practice guidelines for nutrition support. The use of nutritional therapy requires a careful integration of data from pertinent clinical trials, clinical expertise in the illness or injury being treated, clinical expertise in nutritional therapy, and input from the patient and his/her family. (Journal of Parenteral and Enteral Nutrition 21:133-156, 1997).

Nutrition support in clinical practice: review of published data and recommendations for future research directions

In the last 30 years, marked advances in enteral feeding techniques, venous access, and enteral and parenteral nutrient formulations have made it possible to provide nutrition support to almost all patients. Despite the abundant medical literature and widespread use of nutritional therapy, many areas of nutrition support remain controversial. Therefore, the leadership at the National Institutes of Health, The American Society for Parenteral and Enteral Nutrition, and The American Society for Clinical Nutrition convened an advisory committee to perform a critical review of the current medical literature evaluating the clinical use of nutrition support; the goal was to assess our current body of knowledge and to identify the issues that deserve further investigation. The panel was divided into five groups to evaluate the following areas: nutrition assessment, nutrition support in patients with gastrointestinal diseases, nutrition support in wasting diseases, nutrition support in critically ill patients, and perioperative nutrition support. The findings from each group are summarized in this report. This document is not meant to establish practice guidelines for nutrition support. The use of nutritionaltherapy requires a careful integration of data from pertinent clinical trials, clinical expertise in the illness or injury being treated, clinical expertise in nutritional therapy, and input from the patient and his/her family.

Functions of Dietitians Providing Nutrition Support to Patients with Inherited Metabolic Disorders

This article examines functions of dietitians who provide nutrition services to patients with inherited metabolic disorders. A survey questionnaire was developed and pilot-tested in a sample of dietitians, revised, and mailed to all dietitians in the United States who treat patients with inherited metabolic disorders. One hundred forty-two usable questionnaires were returned. Descriptive statistics were used to calculate response frequency. The highest academic degree attained by 37% of the dietitians was a bachelor's degree; 58% had earned a master's degree and 5% a doctorate. Dietitians provided nutrition services during diagnosis, critical illness, and long-term care. More than 90% of the dietitians performed these functions: evaluated nutrition status; prepared, implemented, and evaluated the nutritional support plan; revised the nutrition support plan as needed; monitored dietary compliance; coordinated care with other agencies; developed materials and educated parents, caregivers, and patients about the nutrition support plan; and recorded information in the medical record. Without nutrition support, patients with inherited metabolic disorders may become mentally retarded, experience neurologic or metabolic crises, or die.

Nutrition support in clinical practice: review of published data and recommendations for future research directions. National Institutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition.

In the last 30 years, marked advances in enteral feeding techniques, venous access, and enteral and parenteral nutrient formulations have made it possible to provide nutrition support to almost all patients. Despite the abundant medical literature and widespread use of nutritional therapy, many areas of nutrition support remain controversial. Therefore, the leadership at the National Institutes of Health, The American Society for Parenteral and Enteral Nutrition, and The American Society for Clinical Nutrition convened an advisory committee to perform a critical review of the current medical literature evaluating the clinical use of nutrition support; the goal was to assess our current body of knowledge and to identify the issues that deserve further investigation. The panel was divided into five groups to evaluate the following areas: nutrition assessment, nutrition support in patients with gastrointestinal diseases, nutrition support in wasting diseases, nutrition support in critically ill patients, and perioperative nutrition support. The findings from each group are summarized in this report. This document is not meant to establish practice guidelines for nutrition support. The use of nutritional therapy requires a careful integration of data from pertinent clinical trials, clinical expertise in the illness or injury being treated, clinical expertise in nutritional therapy, and input from the patient and his/her family.

Nutrition Support for Children with HIV/AIDS

Weight loss, malnutrition, and wasting have long been associated with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Not so long ago an estimated 80% of patients with HIV/AIDS died malnourished. Today, the important role that nutrition support plays in preventing malnutrition in persons with HIV/AIDS is well recognized. Combined with new drug therapies, nutrition support allows people with HIV/AIDS to live longer, better-quality lives. Providing proper nutrition support to children with HIV/AIDS is critical for two simple reasons: it provides the greatest opportunity for normal growth and development, and it supports the optimal functioning of the immune system. This article outlines issues dietetics professionals need to consider in providing nutrition support to children with HIV/AIDS.

The Dietitian-case Manager Partnership

LEARNING OUTCOME:To understand the information required by case managers by dietitians for reauthorization of nutrition therapy.The dietitian and the case manager can form a partnership to merge the goals of each party to provide quality patient care that is cost effective. Dietitians establish this relationship by listening to the case manager to discover what information is essential to them. In our experience, case managers require a statement of medical necessity, measurable short and long term goals of therapy, and clinical follow-ups on a consistent basis. This dietitian worked closely with the case manager on a patient with HTV/AIDS that was prescribed TPN for diarrhea and 35 pound weight loss secondary to Microsporidia. The initial nutrition assessment documented the medical necessity of TPN including decreased GI integrity and nutrient malabsorption. The goals of treatment were established to provide 100% of estimated nutrition and hydration needs with TPN, to promote weight gain of 1-2 pounds per week, and taper the TPN with a decrease in stool output. The Microsporidia was treated and diarrhea subsided, however, the patients oral intake remained inadequate. Absorption studies were completed and a gastrostomy tube was considered as a more clinically appropriate and cost effective means of providing nutrition support with a functional GI tract. In the transition phase, specific goals of therapy were provided to the case manager on a weekly basis, including the weight goal and TPN tapering schedule with the specific dates and calories. By providing specific details of the nutrition plan, to the case manager, we were able to maintain authorization of the TPN until adequate enteral nutrition (oral or tube feedings) and weight maintenance were established.

A Proposed Revision of Current ICD-9-CM Malnutrition Code Definitions

Protein-energy malnutrition (PEM) is as common today in adult medical and surgical patients as it was when it was first identified more than 25 years ago. Under the current diagnosis-related group (DRG) payment system, malnutrition is considered a comorbidity or complicating condition. Thus, the identification and coding of malnutrition through the use of the International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM) malnutrition codes can potentially change a patient's DRG and subsequently increase the amount of reimbursement a hospital receives. Unfortunately, the definitions for the current ICD-9-CM malnutrition diagnosis codes were developed principally in relation to clinical syndromes of primary PEM seen in pediatric age groups in less developed countries, rather than in relation to syndromes seen in hospitalized adult patients in industrialized societies. This discrepancy often leads to confusion and inconsistency when institutions attempt to code adult patients for malnutrition. Furthermore, inaccurate coding can result in inadequate reimbursement or rejection of a claim. Clearly, a separate description of the different forms of PEM seen in adults is needed not only for optimal application of nutrition support therapies but also for accurate medical records, quality assurance procedures, and reimbursement purposes. On the basis of 20 years of experience providing nutrition support to hospitalized adult patients, this article presents a schema developed at the Deaconess Hospital (Boston, Mass) that attempts to better define adult PEM using the ICD-9-CM malnutrition codes. The purpose of this article is to foster discussion and ultimately promote general agreement about a definition of adult PEM. J Am Diet Assoc. 1996; 96:370-373.

Case management in home total parenteral nutrition: a cost-identification analysis.

Home parenteral nutrition (HPN) requires intensive medical case management by practitioners with expertise in the provision of nutrition support. There is expenditure of considerable time and resources for management of these patients not covered by any of the traditional reimbursement mechanisms. The costs associated with this unreimbursed input and follow-up are most often borne by the Nutrition Support Team or individual practitioners. Reimbursement by home care agencies to physicians for management of patients after discharge cannot be done because this may be construed as a "kick-back" for referral of patients to particular home care agencies. Time and costs associated with management of HPN patients after discharge from the hospital were assessed using a cost-identification analysis of 24 different factors. Daily activity logs were kept by the Nutrition Support Team members over a 2-week period. Costs of space and furnishings were calculated. On average, a total of 25 h/d was spent by members of the Nutrition Support Team on our HPN patients. Variable activities accounted for 5640.1 hours of time with fixed support at 890.3 hours. This computes to a total annual personnel cost of $168,482 ($1982 per patient). If costs of furnishings and space are also included, the overall cost of all resources was $175,989 per year or $2070 per patient. Significant and currently nonreimbursed costs are involved in HPN patient management. These costs are most often absorbed by the Nutrition Support Team and should be considered when evaluating total costs of HPN.

1399 Role of total parenteral nutrition in the provision of nutritional support in cancer patients

Total parenteral nutrition (TPN) is a method of providing nutritional support to an individual whose gastrointestinal tract is either inaccessible or not functioning. This study will be a review of the nutritional support provided parenterally to cancer patients at the Clatterbridge Centre for Oncology July 1993–July 1995. The diagnosis, reasons for implementation, method of delivery, duration of nutritional support, percentage weight changes, alteration in body mass index (BMI) and outcome measures will be analysed. Preliminary results indicate 86% (n=12) had head and neck cancer. TPN was implemented in 64% (n=9) of cases due to the difficulty of passing a nasogastric (NG) tube, 14% (n=2) refused an NG tube, 7% (n=1) had bowel obstruction and the remaining 14% (n=2) were referred to the centre with TPN in situ. Feeding via this method was usually short, mean period of 9 days (range 3–29 days) and predominantly via the peripheral route [72% (n=10)] rather than via a central line [28% (n=4)]. Body weight was maintained successfully (range −1.7% to +4.5%). Enteral feeding was resumed in 64% of patients on cessation of TPN. 36% (n=5) were transferred back to the referring hospital on TPN, 7% (n=1) were discharged home with TPN in situ. Body weight can be maintained successfully using TPN. It is predominantly used as an interim feeding method whilst the gastrointestinal tract is inaccessible. The peripheral route is implemented in preference to a central line due to fewer associated complications.

Actual and Ideal Tasks of Nutrition Support Dietitians: A Survey of Nutrition Support and Chief Clinical Dietitians

Two questionnaires were sent to the “Chief Clinical Dietitian” at 300 randomly selected, general medical/surgical hospitals, with 300 or more beds in the United States and Puerto Rico. One questionnaire was to be completed by the chief clinical dietitian (CC); the other was to be given to a nutrition support dietitian (NSD) who spends at least 50% of her/his time managing patients receiving enteral and/or parenteral nutrition. The questionnaires consisted of 3 parts: a list of 15 tasks of nutrition support dietitians, questions regarding preparation for the practice of nutrition support, and demographic data. Twenty experts in nutrition support validated the list of 15 tasks using the Delphi method. The NSDs were asked to indicate how often they perform each task and would ideally perform each task (5 point scale, 5 = always, 1 = never). Likewise, the CCs were asked to indicate their perception of how often each task is currently and would ideally be performed by the NSD at their hospital. The total response rate among the CC group was 42.6% (N=128); 118 of the questionnaires were usable. The total response rate among the NSD group was 40% (N=120); 111 of the questionnaires were usable. The Wilcoxon Matched-Pairs Signed-Ranks Test was used to determine differences between NSD actual and ideal frequencies, between CC actual and ideal frequencies, between NSD and CC actual frequencies, and between NSD and CC ideal frequencies. The differences between NSD actual and ideal frequencies and CC actual and ideal frequencies for all 15 tasks were significant (p < 0.0001). Both the NSDs and CCs wanted increased involvement of NSDs in tasks such as fluid and electrolyte management, parenteral nutrition order writing, and feeding tube placement. No other comparisons between NSD and CC responses reached significance except the ideal frequency for “Determines macronutrient composition of parenteral nutrition.” The difference between CC and NSD ideal was significant (p < 0.0005) with the NSDs wanting to ideally perform this task more often than the CCs wanted die NSDs to perform it. According to 94.6% of the NSDs, post-R.D. qualifying experiences are needed to provide nutrition support dietitians with specialized clinical skills. In summary, NSDs desire increased involvement in patient care and this desire is largely supported by CCs. NSDs also seek post-R.D. qualifying experiences to increase their skills in nutrition support.