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Ukleja A, Gilbert K, Mogensen KM, Walker R, Ward CT, Ybarra J, Holcombe B. Standards for Nutrition Support: Adult Hospitalized Patients. Nutr Clin Pract 2018; 33:906-920. [DOI: 10.1002/ncp.10204] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Andrew Ukleja
- Beth Israel Deaconess Medical Center; Division of Gastroenterology; Boston Massachusetts USA
| | - Karen Gilbert
- Thomas Jefferson University Hospital; Philadelphia Pennsylvania USA
| | - Kris M. Mogensen
- Department of Nutrition; Brigham and Women's Hospital; Boston Massachusetts USA
| | - Renee Walker
- Michael E. DeBakey Veteran Affairs Medical Center; Houston Texas USA
| | | | - Joe Ybarra
- Medical City McKinney; McKinney Texas USA
| | - Beverly Holcombe
- American Society for Parenteral and Enteral Nutrition; Silver Spring Maryland USA
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Mantegazza C, Landy N, Zuccotti GV, Köglmeier J. Indications and complications of inpatient parenteral nutrition prescribed to children in a large tertiary referral hospital. Ital J Pediatr 2018; 44:66. [PMID: 29880053 PMCID: PMC5992672 DOI: 10.1186/s13052-018-0505-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/25/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Parenteral Nutrition (PN) is prescribed to children with intestinal failure. Although life saving, complications are common. Recommendations for indications and constituents of PN are made in the 2005 guidelines by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). The aim of this study was to establish if the indications for prescribing PN in a tertiary children's hospital were appropriate, and to identify complications encountered. Data were compared to those published by the National Confidential Enquiry into patient outcome and death (NCEPOD) carried out in the United Kingdom in 2010. METHODS Children and newborns receiving inpatient PN over a 6 months period were entered into the study and data was collected prospectively. The appropriate indications for the use of PN were based on the ESPGHAN guidelines. Recorded complications were divided into metabolic, central venous catheter (CVC) related, hepatobiliary and nutritional. RESULTS A total of 303 children (67 newborns) were entered into the study. The main indications for the start of PN were critical illness (66/303), surgery (63/303) and bone marrow transplantation (28/303). The ESPGHAN recommendations were followed in 91.7% (278/303) of cases (95.5% of newborns, 90.7% of children). PN was considered inappropriate in 12/303 patients and equivocal in 13. The mean PN duration was 18 days (1-160) and the incidence of complications correlated to the length of PN prescribed. Metabolic, hepatobiliary and CVC related complications affected 74.6, 24.4, 16.4% of newborns and 76.7, 37.7 and 24.6% of children respectively. In relation to the appropriate indications for the start of PN our results mirrored those reported by the NCEPOD audit (92.4% of newborns and 88.6% children). However, the incidence of metabolic disturbances was higher in our cohort (74.6% vs 30.4% in children, 76.7% vs 14.3% in newborns) but CVC related complications lower amongst our newborns (16,4% vs 25%). CONCLUSIONS Although the indications for inpatient PN in children is mostly justified, there is still a proportion who is receiving PN unnecessarily. PN related complications remain common. There is a need for better education amongst health professionals prescribing PN and access to nutritional support teams to reduce unwanted side effects.
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Affiliation(s)
- C. Mantegazza
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Pediatrics, University of Milan, Ospedale dei Bambini Vittore Buzzi, Milan, Italy
| | - N. Landy
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - G. V. Zuccotti
- Department of Pediatrics, University of Milan, Ospedale dei Bambini Vittore Buzzi, Milan, Italy
| | - J. Köglmeier
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Kochevar M, Guenter P, Holcombe B, Malone A, Mirtallo J. A.S.P.E.N. Statement on Parenteral Nutrition Standardization. JPEN J Parenter Enteral Nutr 2017; 31:441-8. [PMID: 17712154 DOI: 10.1177/0148607107031005441] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In response to questions regarding use of standardized parenteral nutrition (PN) formulations, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) developed a Task Force to address some of these issues. A.S.P.E.N. envisions standardized PN as a broader issue rather than simply using a standardized, commercially available PN product. A standardized process for PN must be explored in order to improve patient safety and clinical appropriateness, and to maximize resource efficiency. A standardized process may include use of standardized PN formulations (including standardized, commercial PN products) but also includes aspects of ordering, labeling, screening, compounding, and administration of PN. A safe PN system must exist which minimizes procedural incidents and maximizes the ability to meet individual patient requirements. Using clinicians with nutrition support therapy expertise will contribute to that safe PN system. The purpose of this statement is to present the published literature associated with standardized PN formulations, to provide recommendations, and to identify areas in need of future research.
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Worthington P, Balint J, Bechtold M, Bingham A, Chan LN, Durfee S, Jevenn AK, Malone A, Mascarenhas M, Robinson DT, Holcombe B. When Is Parenteral Nutrition Appropriate? JPEN J Parenter Enteral Nutr 2017; 41:324-377. [PMID: 28333597 DOI: 10.1177/0148607117695251] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.
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Affiliation(s)
| | - Jane Balint
- 2 Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | - Angela Bingham
- 4 University of the Sciences, Philadelphia, Pennsylvania, USA
| | | | - Sharon Durfee
- 6 Central Admixture Pharmacy Services, Inc, Denver, Colorado, USA
| | | | | | - Maria Mascarenhas
- 9 The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel T Robinson
- 10 Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Beverly Holcombe
- 11 American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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DeLegge MH, Basel MD, Bannister C, Budak AR. Parenteral Nutrition (PN) Use for Adult Hospitalized Patients: A Study of Usage in a Tertiary Medical Center. Nutr Clin Pract 2017; 22:246-9. [PMID: 17374799 DOI: 10.1177/0115426507022002246] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The use of parenteral nutrition (PN) is essential for patients who are unable to meet their nutrition requirements through oral or enteral nutrition. Many earlier studies have noted that PN is often inappropriately used in the hospital setting, thereby increasing the risk of associated complications and costs. A prospective study was performed at the Medical University of South Carolina (MUSC), using a nutrition support database to determine the appropriateness of PN use and the associated hospital costs for patients on 3 surgical services over a 6-month period. Appropriateness of PN therapy was determined according to the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines. A total of 139 new PN therapies were initiated in the 6-month period. Forty percent of the cases were deemed inappropriate. A total of 573 PN days ($80,000 hospital PN costs) could have been saved if inappropriate PN therapy had not been ordered. The avoidable costs only reflect the PN solution and not the additional costs associated with laboratory monitoring, central line placement and maintenance care, nursing administration, and ongoing pharmacy and dietitian clinical management. This study illustrated that PN was not always being provided according to A.S.P.E.N. guidelines. In addition, cost savings could be achieved if PN was provided only to MUSC patients who meet these guidelines.
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Affiliation(s)
- Mark H DeLegge
- Nutrition Services, Digestive Disease Center, Medical University of South Carolina, Charleston, SC 29425, USA
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Sacks GS, Aguilar-Nascimento JE, Kudsk KA. Use of Parenteral Nutrition in Patients Receiving Isolated Kidney or Simultaneous Pancreas/Kidney Transplantation. JPEN J Parenter Enteral Nutr 2017; 31:8-11. [PMID: 17202434 DOI: 10.1177/014860710703100108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is little information available on the use of parenteral nutrition (PN) in patients after a kidney (KID) or simultaneous pancreas-kidney (SPK) transplantation. This study examined the indications and use of PN in these patients. METHODS Retrospective study of 25 patients (12M/13F; mean age: 51 +/- 11 years old) receiving PN after KID or SPK transplantation. Patients were divided in 2 groups according to the number of PN days (group A = <7 days and group B = >7 days). RESULTS Overall mortality was 16% (group A: 0/7; group B: 4/18). Postoperative ileus (n = 7), intestinal fistula (n = 5), and nausea/vomiting (n = 4) were the most common indications for PN. Functional disorders accounted for 56% (14/25) of the indications for PN. Factors differentiating group A (7/25; median = 5 [4-6] days) from group B (18/25; median =9 [7-31] days) included a significantly higher preoperative serum albumin, SPK transplantation for the first time, and diagnosis of ileus as the indication for PN initiation. CONCLUSIONS Functional disorders of the digestive tract are the primary reason for initiation of PN in isolated KID and SPK transplantation patients. Well-nourished patients undergoing their first SPK transplantation who develop postoperative ileus usually do not need nutrition intervention.
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Affiliation(s)
- Gordon S Sacks
- Division of Pharmacy Practice, School of Pharmacy, University of Wisconsin-Madison, 53705, USA.
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Dy SM. Enteral and Parenteral Nutrition in Terminally Ill Cancer Patients: A Review of the Literature. Am J Hosp Palliat Care 2016; 23:369-77. [PMID: 17060304 DOI: 10.1177/1049909106292167] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Many terminally ill patients who are able to eat appear to be eating less than they should, losing weight, and becoming malnourished, and many others develop difficulties with eating. These symptoms and signs are usually a marker of advanced cancer, rather than the cause of decreasing functional status, and providing supplemental nutrition rarely changes the course of the disease. This article reviews evidence on issues relevant to enteral and parenteral nutrition in patients with advanced cancer, including benefits, risks, and discomforts; how these types of nutrition are used and perceived, and how decisions are made; and how decision-making might be improved.
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Affiliation(s)
- Sydney Morss Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, USA.
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Ochoa JB, Magnuson B, Swintowsky M, Loan T, Boulanger B, McClain C, Kearney P. Long-Term Reduction in the Cost of Nutritional Intervention Achieved by a Nutrition Support Service. Nutr Clin Pract 2016. [DOI: 10.1177/088453360001500404] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Dodds ES, Murray JD, Trexler KM, Grant JP. Metabolic Occurrences in Total Parenteral Nutrition Patients Managed by a Nutrition Support Team. Nutr Clin Pract 2016. [DOI: 10.1177/088453360101600204] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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10
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Feng YL, Lee CS, Chiu CC, Chao CM, Lai CC. Appropriateness of Parenteral Nutrition in Elderly Adults. J Am Geriatr Soc 2015; 63:1478-9. [PMID: 26189856 DOI: 10.1111/jgs.13546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yu-Lin Feng
- Department of Nutrition, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Chun-Sung Lee
- Department of Nutrition, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Chien-Ming Chao
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
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Feng YL, Lee CS, Chiu CC, Chao CM, Lai CC. Appropriateness of Parenteral Nutrition Usage in Cancer Patients. Nutr Cancer 2015; 67:1014-7. [PMID: 26134214 DOI: 10.1080/01635581.2015.1053501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This study is to investigate the indication appropriateness of parenteral nutrition (PN) administration in cancer patients. Between December 2013 and August 2014, all cancer patients who received PN (including total PN and Kabiven) in a regional hospital of Southern Taiwan were included in this retrospective study. A total of 107 cancer patients received PN. Among them, colorectal cancer was the most common type of cancer (n = 45, 42.1%), followed by gastric cancer, head and neck cancer, and esophageal cancer. After evaluation of the appropriateness of PN administration, 88 (82.2%) PN episodes were considered appropriate and unavoidable, 4 (3.7%) as appropriate and avoidable but 15 (14.1%) as inappropriate. In conclusion, PN could be inappropriately used by some oncologic physicians. Physicians and nutrition support team specialists should carefully evaluate the indication of PN administration for cancer patients to obey the generally acknowledged usage rule.
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Affiliation(s)
- Yu-Lin Feng
- a Department of Nutrition, Chi Mei Medical Center , Liouying , Tainan , Taiwan
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12
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Quality control of parenteral nutrition in hospitalized patients. Nutrition 2014; 30:165-8. [DOI: 10.1016/j.nut.2013.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 07/08/2013] [Accepted: 07/08/2013] [Indexed: 11/21/2022]
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Chuah SW, Ng DHL, Liu P, Liu H, Ng JL, Ling KL. The Use of Parenteral Nutrition in an Acute Care Hospital. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2013. [DOI: 10.47102/annals-acadmedsg.v42n8p395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction: Parenteral nutrition (PN) is an important supportive therapy. However, it is expensive and associated with significant complications. Our aim is to describe the patients given PN in 2006, to compare with the 2001 cohort and determine if PN had been prescribed for the appropriate indications. Materials and Methods: A retrospective cohort study of adult patients receiving PN between January and December 2006 was undertaken in a single institution. Appropriateness of indications for PN was based on the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines 2002. Results: One hundred and eighty-two patients received 194 courses (102 males, 92 females) of PN. Median age was 62 years (range, 16 to 100). Eighty-two percent were surgical patients and 18% were medical patients. Median PN duration was 9 days (range, 2 to 115). Common indications were surgeons’ anticipation of non-functioning gut postoperatively [47 (24.2%) courses], postoperative complications [33 (17.0%) courses] and postoperative ileus [31 (16.1%) courses]. Indications for PN met A.S.P.E.N. guidelines in 93.3% of cases compared to 78.3% in 2001. In 1.5% of cases, we were unable to determine if the indications met the guidelines. Ten courses did not meet the guidelines; 3 had PN for <7 days preoperatively, 6 had PN because the managing team thought the patients were critically ill and 1 was given PN for refusal to eat because of depression. Conclusion: Since 2001, there has been an increase in the proportion of PN given for appropriate indications. However, physician education with respect to the benefit of PN for preoperative and critically ill patients with functioning guts needs reinforcing.
Key words: American Society for Parenteral and Enteral Nutrition (A.S.P.E.N) guidelines, Indications of Parenteral Nutrition, Inappropriate use of Parenteral Nutrition
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Affiliation(s)
| | | | - Peiyun Liu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Huimin Liu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jia Lin Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Smyth ND, Neary E, Power S, Feehan S, Duggan SN. Assessing Appropriateness of Parenteral Nutrition Usage in an Acute Hospital. Nutr Clin Pract 2012; 28:232-6. [DOI: 10.1177/0884533612469988] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
| | | | | | | | - Sinead N. Duggan
- Trinity Centre for Health Sciences, Trinity College, Dublin, Ireland
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15
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Ukleja A, Freeman KL, Gilbert K, Kochevar M, Kraft MD, Russell MK, Shuster MH. Standards for nutrition support: adult hospitalized patients. Nutr Clin Pract 2011; 25:403-14. [PMID: 20702847 DOI: 10.1177/0884533610374200] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Boitano M, Bojak S, McCloskey S, McCaul DS, McDonough M. Improving the Safety and Effectiveness of Parenteral Nutrition. Nutr Clin Pract 2010; 25:663-71. [DOI: 10.1177/0884533610385349] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
| | | | | | - David S McCaul
- Critical Care, Scripps Memorial Hospital La Jolla, La Jolla, California
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Martin K, DeLegge M, Nichols M, Chapman E, Sollid R, Grych C. Assessing Appropriate Parenteral Nutrition Ordering Practices in Tertiary Care Medical Centers. JPEN J Parenter Enteral Nutr 2010; 35:122-30. [DOI: 10.1177/0148607110362992] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kelley Martin
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
| | - Mark DeLegge
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
| | - Michele Nichols
- Center for Research in Nutrition and Health Disparities, University of South Carolina, Columbia, South Carolina
| | - Emily Chapman
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
| | - Ronald Sollid
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
| | - Catherine Grych
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
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Kohli-Seth R, Sinha R, Wilson S, Bassily-Marcus A, Benjamin E. Adult parenteral nutrition utilization at a tertiary care hospital. Nutr Clin Pract 2010; 24:728-32. [PMID: 19955551 DOI: 10.1177/0884533609351529] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Guidelines from the American Society for Parenteral and Enteral Nutrition promote appropriate use of parenteral nutrition (PN). In addition, involvement of multidisciplinary nutrition support teams (NSTs) has led to a reduction of inappropriate PN administration. This study evaluated the effect of introducing hospital-wide PN guidelines and a PN review committee on PN prescription behavior of NSTs in the authors' hospital. METHODS A PN guidelines form with established indications was developed and made available to the NSTs. A PN review committee was formed to assess the appropriateness of PN prescriptions and educate the NSTs if an inappropriate PN prescription was noted. The initial-phase PN prescriptions were compared with those in a later (established) phase. RESULTS Of a total of 614 PN prescriptions, 8.1% did not meet the established indications. The initial phase recorded 312 PN prescriptions, and the established phase had 302 prescriptions. The number of inappropriate PN prescriptions decreased significantly from 11.9% in the initial phase to 4.3% in the established phase (P = .001). CONCLUSION The incidence of inappropriate PN prescription was low when NSTs were closely involved in patient care. Availability of written guidelines and continuous oversight of NSTs promoted appropriate PN usage.
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Nardo P, Dupertuis YM, Jetzer J, Kossovsky MP, Darmon P, Pichard C. Clinical relevance of parenteral nutrition prescription and administration in 200 hospitalized patients: A quality control study. Clin Nutr 2008; 27:858-64. [DOI: 10.1016/j.clnu.2008.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 06/30/2008] [Accepted: 08/01/2008] [Indexed: 10/21/2022]
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21
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Guidelines for colorectal cancer: Effects on nutritional intervention. Clin Nutr 2007; 26:691-7. [DOI: 10.1016/j.clnu.2007.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Revised: 08/23/2007] [Accepted: 08/30/2007] [Indexed: 01/15/2023]
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Hearnshaw SA, Thompson NP. Use of parenteral nutrition in hospitals in the North of England. J Hum Nutr Diet 2007; 20:14-23; quiz 24-6. [PMID: 17241188 DOI: 10.1111/j.1365-277x.2007.00742.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) is a costly technology used widely to provide nutrition to patients who have an inaccessible or nonfunctioning intestine. A prospective survey was designed to collect data on PN for inpatients to study the current use of PN, its complications and outcomes in the north of England. The study objectives were to use the Northern Nutrition Network to collect data from all acute hospital inpatients prospectively receiving PN, for 3 months and to provide evidence for current PN practice, and to establish whether this is in line with recognized published clinical guidelines. METHODS Using a paper-based collection tool information was recorded on aspects of PN including: total inpatient episodes, patient demographics, indications, duration, venous access used, complications, number returning to enteral feeding and mortality. The presence of a nutrition support team was also recorded. RESULTS Data on 193 patient PN episodes were recorded totalling 1708 patient days. The median age of the patients was 67 years. Of these, 158 (82%) were deemed to have a clear indication for PN using the indications cited in the NICE guidelines (http://www.nice.org.uk). The median duration of PN was 7 days (range 1-93). Thirty (16%) patients developed complications due to PN, 23 (12%) had catheter infections which were most common on medical wards. Thirty-nine (20%) patients died within 28 days of PN starting; no deaths were attributable to PN. A total of 118 (61%) patients returned to full enteral feeding. Only three hospitals had nutrition support teams, which had no significant effect on outcomes. CONCLUSIONS Parenteral nutrition practice in the north of England is generally in line with current guidelines, however, only three of 15 hospitals had nutrition support teams. Eighteen per cent of patients did not have a clearly documented indication for PN and 15% developed a complication, most often a catheter-related infection.
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Affiliation(s)
- S A Hearnshaw
- National Blood Service, John Radcliffe Hospital, Oxford, UK.
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Leite HP, Carvalho WBD, Santana e Meneses JF. Atuação da equipe multidisciplinar na terapia nutricional de pacientes sob cuidados intensivos. REV NUTR 2005. [DOI: 10.1590/s1415-52732005000600008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pacientes hospitalizados podem ter necessidades nutricionais especiais em função da desnutrição e dos desequilíbrios metabólicos impostos pelas doenças. A terapia nutricional, principalmente nos estágios críticos das enfermidades, deve ser administrada de modo seguro e eficaz. Vários estudos têm avaliado o papel da equipe multidisciplinar na administração da terapia nutricional. Com o objetivo de identificar os problemas inerentes à administração da terapia nutricional em pacientes hospitalizados e verificar o impacto da atuação de uma equipe multidisciplinar na qualidade dos procedimentos, foi realizada uma revisão que analisou artigos publicados entre 1980 e 2004 sobre o papel da atuação de equipes multidisciplinares no cuidado e na evolução nutricional de pacientes hospitalizados, principalmente os que se encontravam sob cuidados intensivos. Os termos utilizados na pesquisa foram: "multidisciplinary team", "nutritional support", "parente-ral nutrition", "enteral feeding", "critically ill", "intensive care unit","critically ill child". Dos 130 estudos inicialmente identificados, foram selecionados 24, dos quais 14 compararam o padrão de terapia nutricional com e sem a presença da equipe multidisciplinar. Os principais problemas detectados na administração de terapia nutricional em pacientes hospitalizados foram a oferta inadequada de nutrientes, as complicações infecciosas e metabólicas e o uso excessivo de nutrição parenteral. Nos estudos comparativos, a presença da equipe multidisciplinar melhorou o padrão de oferta nutricional, reduziu a incidência de complicações e os custos.
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Affiliation(s)
- Heitor Pons Leite
- Universidade Federal de São Paulo, Brasil; Hospital São Paulo, Brasil
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Gurgueira GL, Leite HP, Taddei JADAC, de Carvalho WB. Outcomes in a pediatric intensive care unit before and after the implementation of a nutrition support team. JPEN J Parenter Enteral Nutr 2005; 29:176-85. [PMID: 15837777 DOI: 10.1177/0148607105029003176] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND We evaluated the effect of parenteral nutrition (PN) and enteral nutrition (EN) on in-pediatric intensive care unit (PICU) mortality before and after a continuous education program in nutrition support that leads to implementation of a nutrition support team (NST). METHODS We used a historical cohort study of infants hospitalized for >72 hours at the PICU from 1992 to 2003. Five periods were selected (P1 to P5), considering the modifications incorporated into the program: P1, without intervention; P2, basic themes and original articles discussion; P3, clinical and nursing staff participation; P4, clinical visits; P5, NST. The samples were compared in terms of sex, age, admitting service (ie, medical vs surgical), prognostic index of mortality, length of stay (LOS), duration of mechanical ventilation, in-PICU mortality rate, and percentage of time receiving EN and PN for each patient. Bi- and multivariate analyses were performed. Statistical significance was set at 0.05 level. RESULTS Progressive increase was observed in EN use (p = .0001), median values for which were 25% in P1 and rose to 67% by P5 in medical patients; there was no significant difference in surgical patients. A reduction was observed in PN use; in P1 medians were 73% and 69% for medical and surgical patients respectively, and decreased to 0% in P5 for both groups (p = .0001). There was significant reduction in-PICU mortality rate during P4 and P5 among medical patients (p < .001). The risk of death was 83% lower in patients that received EN for >50% of LOS (odds ratio, 0.17; confidence interval, 0.066-0.412; p = .000). CONCLUSIONS The program motivated an increase in EN and a decrease in PN use, mainly after implementation of NST and reduced in-PICU mortality rate.
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Affiliation(s)
- Gisele Limongeli Gurgueira
- Pediatric Intensive Care Unit and the Discipline of Nutrition and Metabolism, Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
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Saalwachter A, Evans H, Willcutts K, O'Donnell K, Radigan A, Mcelearney S, Smith R, Chong T, Schirmer B, Pruett T, Sawyer R. A Nutrition Support Team Led by General Surgeons Decreases Inappropriate Use of Total Parenteral Nutrition on a Surgical Service. Am Surg 2004. [DOI: 10.1177/000313480407001216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to decrease the number of inappropriate orders for total parenteral nutrition (TPN) in surgical patients. From February 1999 through November 2000 and between July 2001 and June 2002, the surgeon-guided adult nutrition support team (NST) at a university hospital monitored new TPN orders for appropriateness and specific indication. In April 1999, the NST was given authority to discontinue inappropriate TPN orders. Indications, based on the American Society for Parenteral and Enteral Nutrition (ASPEN) standards, included short gut, severe pancreatitis, severe malnutrition/catabolism with inability to enterally feed ≥5 days, inability to enterally feed ≥50 per cent of nutritional needs ≥9 days, enterocutaneous fistula, intraabdominal leak, bowel obstruction, chylothorax, ischemic bowel, hemodynamic instability, massive gastrointestinal bleed, and lack of abdominal wall integrity. The number of inappropriate TPN orders declined from 62/194 (32.0%) in the first 11 months of the study to 22/168 (13.1%) in the second 11 months ( P < 0.0001). This number further declined to 17/215 (7.9%) in the final 12 months of data collection, but compared to the second 11 months, this decrease was not statistically significant ( P = 0.1347). The involvement of a surgical NST was associated with a reduction in inappropriate TPN orders without a change in overall use.
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Affiliation(s)
- A.R. Saalwachter
- From the University of Virginia Health System, Charlottesville, Virginia
| | - H.L. Evans
- From the University of Virginia Health System, Charlottesville, Virginia
| | - K.F. Willcutts
- From the University of Virginia Health System, Charlottesville, Virginia
| | - K.B. O'Donnell
- From the University of Virginia Health System, Charlottesville, Virginia
| | - A.E. Radigan
- From the University of Virginia Health System, Charlottesville, Virginia
| | - S.T. Mcelearney
- From the University of Virginia Health System, Charlottesville, Virginia
| | - R.L. Smith
- From the University of Virginia Health System, Charlottesville, Virginia
| | - T.W. Chong
- From the University of Virginia Health System, Charlottesville, Virginia
| | - B.D. Schirmer
- From the University of Virginia Health System, Charlottesville, Virginia
| | - T.L. Pruett
- From the University of Virginia Health System, Charlottesville, Virginia
| | - R.G. Sawyer
- From the University of Virginia Health System, Charlottesville, Virginia
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Kesek DR, Akerlind L, Karlsson T. Early enteral nutrition in the cardiothoracic intensive care unit. Clin Nutr 2002; 21:303-7. [PMID: 12135590 DOI: 10.1054/clnu.2002.0542] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS Early enteral nutrition (EN) improves intestinal integrity, motility and immunocompetence. However, technical problems such as diarrhoea and gastric residual volumes are said to be associated with the method and have prevented its implementation. We have prospectively assessed clinical problems connected to early EN. PATIENTS AND METHODS Seventy-three consecutive patients eligible for EN were assessed and observed until discharge from the intensive care unit (ICU) or until they resumed oral nutrition. They had surgery for coronary artery bypass grafting and/or valvular disease, thoracic or thoracoabdominal aortic aneurysms or other combined procedures. Two cardiac patients were not subjected to surgery. RESULTS In 59/73 patients, EN was started within 3 days. EN was discontinued in half of the patients when they were able to feed themselves. Twelve patients vomited, one of them severely. Dislocation of the nasogastric tube occurred in 28 patients. The 15 patients with diarrhoea were treated with 2-6 broad-spectrum antibiotics during their ICU-stay. Out of 73, 40 patients did not show any gastric residual volume (GRV). GRV decreased during EN in 50% of the patients with fairly large or large residual volumes. The incidence of aspiration pneumonia was 10%. CONCLUSION In the cardiothoracic ICU, individually adjusted early EN is feasible with few problems.
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Affiliation(s)
- D R Kesek
- Department of Cardiothoracic Anesthesiology, Uppsala University Hospital, Uppsala, Sweden
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Howard P. Organizational aspects of starting and running an effective nutritional support service. Clin Nutr 2001; 20:367-74. [PMID: 11478836 DOI: 10.1054/clnu.2000.0381] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Setting up and running a Clinical Nutritional Support Team can be challenging and is time consuming. Team members have to be motivated, committed and persistent. High quality working relationships are fundamentally important within the team, between teams and with other healthcare professionals. Good communication, careful planning, sensitive implementation and robust monitoring are the cornerstones of a successful service. Looking forward as well as back will help the team to maintain and improve its position in an ever-changing environment. While nutritional support is everyone's business, an effective multiprofessional Clinical Nutritional Support Team is the best way to ensure that patients receive appropriate and timely treatment. It is also wise to remember that a successful Clinical Nutritional Support Team will be as committed to its own development as it is to the care of the patients referred to it.
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Affiliation(s)
- P Howard
- Nutrition and Dietetic Services, Bristol Royal Infirmary, Bristol, BS2 8HW, UK
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Abstracts of Original Communications. Proc Nutr Soc 2001. [DOI: 10.1017/s0029665101000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Waterbury JT. Refuting patients' obligations to clinical training: a critical analysis of the arguments for an obligation of patients to participate in the clinical education of medical students. MEDICAL EDUCATION 2001; 35:286-294. [PMID: 11260453 DOI: 10.1046/j.1365-2923.2001.00865.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
CONTEXT The clinical teaching of medical students is essential to the continuation of medicine, but it has a major impact on the patient's health care and autonomy. Some people believe that there is a moral obligation for patients to participate in this training. Such an obligation, real or perceived, may endanger patients' autonomy. OBJECTIVES The author makes a critical analysis of the main arguments he encounters supporting such an obligation. These arguments are: (1) the furthering of medical education; (2) compensation when uninsured or unable to pay; (3) an equitable return for the care received in a teaching hospital, and (4) fulfilment of a student's need for (and some say right to) clinical training. METHODS Related literature is reviewed in search of evidence and/or support for such arguments. CONCLUSIONS The review reveals that these arguments either cannot be verified or do not necessarily place any obligations on the patient. It is argued that, while a medical student may have a right to clinical education, the obligation to fulfil this right rests with the medical university and not on the patients of its teaching hospitals. SOLUTIONS Several proposals are made about how to satisfy this need without infringing on the patient's right to refuse participation, explaining the patient's rights and role in clinical teaching, and the use of standardized patients where necessary.
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Affiliation(s)
- J T Waterbury
- Pécs University Medical School, Pécs Science University, Pécs, Hungary
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Trujillo EB, Young LS, Chertow GM, Randall S, Clemons T, Jacobs DO, Robinson MK. Metabolic and monetary costs of avoidable parenteral nutrition use. JPEN J Parenter Enteral Nutr 1999; 23:109-13. [PMID: 10082002 DOI: 10.1177/0148607199023002109] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We prospectively collected data on in patients receiving parenteral nutrition to determine the magnitude of potentially preventable metabolic and monetary costs associated with parenteral nutrition. METHODS Parenteral nutrition was prescribed by the treating physicians with optional consultation from a multidisciplinary metabolic support service. Days on parenteral nutrition, appropriateness of parenteral nutrition, metabolic complications, and avoidable parenteral nutrition charges were determined. Parenteral nutrition use was considered "indicated" or "not indicated" based on the American Society for Parenteral and Enteral Nutrition guidelines and "preventable" if the gastrointestinal tract was functional but not accessed when possible. RESULTS Of the 209 parenteral nutrition starts, 62% were indicated, 23% were preventable, and 15% were not indicated. Parenteral nutrition starts were deemed indicated in 82% of instances in which a metabolic support service consult was obtained, compared with 56% in which a consultation was not obtained (p = .004). Hyperglycemia was the most common metabolic complication, with an overall incidence of 20%. Metabolic complications occurred less frequently in patients who received a metabolic support service consultation compared with patients who did not (34% vs 66% of parenteral nutrition days, respectively; p = .004). Parenteral nutrition use of < or =5 days duration was significantly less frequent among patients who received metabolic support service consultation (16% vs 35%; p = .002). Parenteral nutrition that was not indicated or preventable resulted in excess annualized patient charges of more than one half million dollars not accounting for charges related to treatment of potentially avoidable parenteral nutrition complications. CONCLUSIONS This study illustrates that not-indicated and preventable parenteral nutrition initiation, short-term parenteral nutrition use, and metabolic complications are less likely when patients receive consultation by a multidisciplinary team with expertise in nutrition and metabolic support. Furthermore, the avoidance of inappropriate parenteral nutrition use translates into substantial cost savings.
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Affiliation(s)
- E B Trujillo
- Metabolic Support Service, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
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Évaluation de l'indication et de la qualité de la prise en charge nutritionnelle en cancérologie médicale. NUTR CLIN METAB 1998. [DOI: 10.1016/s0985-0562(98)80089-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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