Home Enteral Nutrition: Towards a Standard of Care

Adequacy of financing and prescription of home enteral nutrition. Are things being done right?

Introduction

Introduction: this study focuses on Home Enteral Nutrition (HEN), whose use has grown enormously in recent years. Objective: to analyze the prescriptions and, in addition, determine whether National Health System (NHS) funding criteria are met and to explore whether overcosts exist. Methods: a retrospective observational study was conducted on 844 patients (895 episodes) who received HEN, using information obtained from the healthcare database. Demographic, clinical, dietary, and economic data were analyzed. Results: in 9.7 % of the episodes analyzed, the funding criteria were met; in 15.1 %, ≥ 50 % kcal/day required was provided through HEN. During the 3 months of the study an average of 118.1 ± 86.8 units/patient were dispensed, which resulted in an average monthly expenditure of € 69.9 ± 66.3/patient. To go to the hospital to collect HEN, an average of 78.1 ± 69.5 km/patient was traveled, with an associated average monthly fuel cost of € 2.65 ± 2.39/patient. The additional expenditure associated with prescriptions not aligned with the funding criteria was estimated at € 574,259.44/year in the health area analyzed, with a quota of 200,000 inhabitants. Conclusions. the results of this study show a divergence in the use of HEN compared to the conditions established by the NHS for the funding of this treatment. Given the low compliance rate and the current scientific evidence on the use of HEN, it may be necessary to re-evaluate the funding criteria to make them more representative of clinical evidence and actual practice.

Exploring the lived experiences of adults using home enteral nutrition and their caregivers: A meta-aggregation qualitative systematic review

Home enteral nutrition (HEN) provides nutrition through a tube to individuals at home who cannot meet their needs by mouth. Systematic reviews have explored the experiences of HEN subpopulations, such as those with head and neck cancers. Given HEN services care for adults with various underlying conditions, a synthesis of the experiences of all adults using HEN and their caregivers is warranted. The purpose of this study is to summarize the experiences of HEN adult users and their caregivers regardless of underlying condition. Medline, PsychINFO, EmBase and CINAHL were systematically searched in January 2024. Studies with qualitative results and adult participants and focused on HEN were included. Studies with participants in nursing facilities, results using word counts, or not in English were excluded. Study quality was assessed using the Johanna Briggs Institute (JBI) qualitative checklist. Study design and participants' details were extracted. Themes were collated using the JBI meta-aggregative method. Forty studies (n = 732) were included. Three synthesized findings were identified: positive experiences (very low ConQual score), negative experiences (low ConQual score), and facilitators and coping mechanisms (moderate ConQual score). Although more negative than positive experiences were reported, users and caregivers who developed coping mechanisms or accessed supports viewed HEN as a worthwhile experience. Those with few supports or coping mechanisms did not. Based on this review, it is proposed that before starting HEN, users and caregivers should be made aware of the available supports and coping mechanisms. As negative experiences arise, healthcare providers should help users and caregivers access supports to improve their experiences.

A systematic review and quality appraisal of guidelines and recommendations for home enteral tube feeding in adults

Home Enteral Tube Feeding (HETF) is a viable option for people within primary care settings when oral intake is insufficient to meet nutritional needs. As HETF is not a risk-free therapy, guidelines exist to enable its safe provision. This review aims to summarise existing guidelines and their recommendations pertaining to the provision of HETF and appraise their methodological quality. A systematic review was conducted according to the Cochrane Handbook for Systematic Reviews, PRISMA-checklist and a 2019 methodological guide specific to the review of clinical practice guidelines (PROSPERO registration: CRD42023456223). Records were sourced from five bibliographical databases (Medline, Embase, PsychINFO, Scopus, Cinahl) and the grey literature (64 websites, seven guideline repositories). The AGREE-II tool was applied to eligible guidelines. The recommendations of guidelines meeting a predetermined threshold score (domain 3 'rigour of development' score >70%) were extracted, grouped, and assessed using the AGREE-REX tool. A total of 2707 records were screened with 15 guidelines meeting eligibility criteria. The median (IQR) overall AGREE-II score (/7) of all guidelines was 3 (3-5) and only 3/15 guidelines achieved a domain 3 score >70%. The median (IQR) overall AGREE-REX score was 33% (26-37%). No recommendation group achieved a domain score above 70%. No guideline or recommendation group was suggested for use without modification. Key limitations included suboptimal stakeholder involvement and implementability, and lack of methodological transparency. Current HETF guidelines inadequately align with methodological standards. This review highlights key areas HETF guideline developers should consider to create more relevant and implementable guidelines.

Addressing the Need for a Specialized Disconnection Device in Catheter Connection Management: A Case Study of User-Centered Medical Device Innovation

Background/Objectives: Improvements in catheter connection design intended to increase safety have resulted in connections that are difficult to release manually. No medical device exists to safely disconnect catheter connections. Nurses and other users have developed workarounds including use of hemostats, tourniquets, and wrenches. These workarounds are not always successful for performing this task and can break catheters and catheter connections. This study aimed to evaluate a disconnection device to safely disconnect catheter connections. Methods: This is a mixed-methods study using a user-centered design approach with triangulation of quantitative and qualitative data mapped to Valdez's sociotechnical framework. Nurses (N = 139) from units across two academic medical centers encompassing diverse patient populations engaged in usability testing and surveys. Data about users' past catheter disconnection experiences and usability of the specialized disconnection device were collected and analyzed. Triangulation of quantitative data and qualitative themes was mapped using Valdez's socio-technical framework to complement and strengthen the final design generated for nurses' user requirements. Results: Ninety-five percent of nurses reported previous difficulty with disconnecting luer connections; 93% of those reporting difficulty improvised with readily available medical devices or products to better grip the connected parts. Over 85% of nurses reported positive experiences using the specialized disconnection device; others suggested design improvements for better performance. Conclusions: The nurses who tested the developed disconnection device reported high acceptability, accessibility, ease of use, and improved task performance. Moreover, as workarounds develop at points of practice where no systematic solution exists, aiming product development activities at these points help close gaps in achieving and maintaining patient safety. This study was not registered.

Caregiver burden and eating-related guilt during dysphagia rehabilitation: A descriptive cross-sectional time series study

BACKGROUND

Caregivers of patients with chronic dysphasia experience stress and guilt regarding their eating behaviors. Dysphagia rehabilitation, including minimal oral intake with tube feeding, may be vital for caregivers. This study investigated the effects of dysphagia rehabilitation on caregiver well-being and attitudes toward eating assistance.

METHODS

This cross-sectional questionnaire study was conducted at two dental university hospitals on caregivers of homebound patients with dysphagia undergoing rehabilitation. Caregivers' experiences, with an emphasis on guilt and psychological status, were assessed using the Apathy Scale and Patient Health Questionnaire-5 Depression Scale. Patients were evaluated at the time of the survey and rehabilitation commencement using the Barthel Index and Functional Oral Intake Scale (FOIS). Changes in FOIS scores and caregiver guilt were assessed using the Wilcoxon signed rank test and McNemar test, respectively. The impact of oral intake changes on caregiving motivation was assessed using the Fisher exact test.

RESULTS

Between August 2019 and January 2021, 55 of 100 targeted caregivers responded (median age=64.5 years). A significant difference in FOIS scores was found (median rehabilitation duration=9.7 months). Despite 25 pneumonia cases, 65% of the caregivers continued to encourage oral intake. Guilt decreased from 48% during peak dysphagia to 22% at survey time (odds ratio=0.2, 95% CI=0.04-0.70; P < 0.01). No association was found between caregiving motivation and improved oral intake.

CONCLUSION

Severe dysphagia impacted caregiver well-being, indicating preferences for patients' oral intake. To support caregivers, healthcare professionals should explore and integrate new multidisciplinary approaches into dysphagia rehabilitation strategies.

Safety and Effectiveness of Percutaneous Endoscopic Gastrostomy May Be Improved by Proper Pre- and Post-Positioning Management of Elderly Patients with Multimorbidity

INTRODUCTION

The main risk factors for major complications and early mortality after the positioning of percutaneous endoscopic gastrostomy (PEG) reported in the literature are old age, multimorbidity, and the use of inappropriate methods for PEG positioning. A proper PEG positioning technique and adequate post-positioning patient management and surveillance are the main protective factors, but the information on protective factors in the literature is much poorer. The aim of this study was to provide more information on PEG-related complications and mortality in geriatric patients treated with long-term enteral nutrition administered by PEG according to a specific home enteral nutrition (HEN) protocol.

METHODS

This was a retrospective study based on data from 136 elderly patients in whom PEG was positioned from 2017 to 2023 at the geriatric hospital IRCCS INRCA, Ancona (Italy), 88 of whom were treated with HEN. Data on PEG-related complications, duration of HEN, hospitalizations, and mortality were analyzed.

RESULTS

No complications were registered during or immediately after the PEG positioning. The prevalence of a major complication-buried bumper-was in the lower limit of the range reported in the literature (4.32%). The prevalence of minor complications such as peristomal leakage, inadvertent tube removal, and granulation tissue was higher than that reported in the literature (14.71%, 23.53%, 29.41%), while tube blockage and peristomal site infection were less frequent (8.82%, 38.23%). Three hospitalizations for PEG-related complications occurred. Both the all-cause 30-day mortality and within-two-months mortality were lower than those in the literature (1.92% and 3.84%).

CONCLUSIONS

The impact of the risk factors recognized by the literature on complications and mortality could be probably mitigated by improving the PEG placement techniques and pre- and post-PEG placement patient management practices. Data on the prevalence of complications and mortality must be interpreted in correlation to this information.

Enteral Nutrition Therapy: Historical Perspective, Utilization, and Complications

PURPOSE OF REVIEW

Enteral nutrition (EN) therapy can provide vital nutrition support for patients with various medical conditions as long as it is indicated and supported by ethical reasoning. This review seeks to offer a detailed account of the history of EN development, highlighting key milestones and recent advances in the field. Additionally, it covers common complications associated with EN and their management.

RECENT FINDINGS

After years of research and development, we have reached newer generations of enteral feeding formulations, more options for enteral tubes and connectors, and a better understanding of EN therapy challenges. Given the availability of many different formulas, selecting a feeding formula with the best evidence for specific indications for enteral feeding is recommended. Initiation of enteral feeding with standard polymeric formula remains the standard of care. Transition to small-bore connectors remains suboptimal. Evidence-based practices should be followed to recognize and reduce possible enteral feeding complications early.

Aspiration pneumonia in nursing literature-a mapping review

Introduction

Aspiration pneumonia (AP) is an infection of the lungs caused by inhalation of material. The reported incidences vary across literature and clinical populations and is associated with high morbidity and mortality. Management of AP is best carried out by a multidisciplinary team.

Methods

This aim of this review was to collate and describe the available evidence on AP to develop a greater understanding of the concept of AP as it is represented in the nursing literature. As a collaborative team, we undertook the six stages of a systematic mapping review. We searched for the term aspiration pneumonia in 200 peer reviewed nursing journals across 10 databases, over a ten-year period (2013-2023).

Results

In this review, 293 papers were coded. Dysphagia, oral health and tube feeding emerged as the most frequent risk factors for AP, and the most reported factors for preventing this condition. Mortality was the most commonly described consequence of AP, followed by hospitalisations and morbidity. Multiple management approaches were reported including dysphagia assessment, risk evaluation, oral care and texture modification of food and fluids. The role of nurses and interprofessional collaborations were described.

Discussion

Despite limited evidence related to the topic of AP in the nursing literature, the complexity of the causes, prevention, management and consequences of AP emerged. Certain factors, such as dysphagia, oral health, and tube feeding, were described under prevention, cause and management of AP. The importance of multidisciplinary approach in the management and prevention of AP was presented.

Frontier and hot topics in home enteral nutrition based on CiteSpace bibliometric analysis

Background

The benefits of home enteral nutrition (HEN) are increasingly recognized, with more scholars focusing on this field. This study aimed to comprehensively identify collaborative networks, analyze, and track research trends, focus on current hotspots, and accurately predict the forefront and focus of home enteral nutrition.

Methods

A computer search of the Web of Science Core Collection (WoSCC) was conducted for studies related to home enteral nutrition published from January 1, 2004, to December 31, 2023, and select them in compliance with the PRISMA guidelines. The CiteSpace software was used for bibliometric visualization and comparative analysis of countries, institutions, journals, references, and keywords.

Results

A total of 1,113 documents were included, showing a steady annual increase in publication volume. The United States and the Mayo Clinic were the top publishing country and institution, with 302 and 41 papers, respectively. "CLIN NUTR" had the highest number of publications, totaling 221, while "ESPEN guideline on home enteral nutrition" was the most cited reference, with 43 citations. The most prolific author was Manpreet S with 29 papers.

Conclusion

The management of HEN is a current research hotspot. The safety of HEN and how to improve patient compliance are critical areas for researchers to consider. Future research could focus on these aspects. The blurring of boundaries between hospital and home care and how to utilize telemedicine technologies to serve more patients deserve in-depth exploration. Researchers worldwide should combine their unique characteristics and advantages to strengthen international cooperation.

Patients' and caregivers' perspective on challenges and outcomes with tube feeding: Analysis of home enteral nutrition survey data

BACKGROUND

Given the growing use of home enteral nutrition (HEN), assessing the experience of consumers and caregivers is crucial to understanding the real-world subjective and objective challenges of administering HEN.

METHODS

After obtaining institutional review board approval, a survey was distributed to HEN consumers and caregivers between January 16, 2020, and July 16, 2021. Data collected included information regarding demographics, primary diagnosis, tube and connectors, HEN regimen, and overall HEN experience.

RESULTS

A total of 884 individuals responded to the survey: 673 (76.1%) responses by caregivers and 211 (23.9%) responses by patients. The study cohort included 566 (64%) children and 318 (36%) adults. The leading primary diagnosis of participants was developmental delay and motility disorder for children and adults, respectively. Low-profile gastric tubes were the most used (75.7% of children and 30.3% of adults). Notably, legacy connectors were utilized for more patients (46.7% children, 52.6% adults) compared to ISO-80369-3 connectors (38.9% children, 29.7% adults). HEN complications were prevalent, including enteral tube site infections and other tube-related complications, including clogging and kinking.

CONCLUSION

This real-world data reveals that HEN complications remain prevalent. Additionally, despite introducing ISO-80369-3 connectors many years ago, most patients continue to use legacy tubes with a significant lack of knowledge about ISO-80369-3 connectors. The survey results guide HEN providers to focus on several areas to reduce complications.

Estrategias de enseñanza y aprendizaje en Terapia Enteral domiciliaria: adquisición de conocimiento percibida por los cuidadores

Resumen Objetivo: evaluar cómo las diferentes estrategias educativas contribuyen a la adquisición de conocimiento percibida por los cuidadores de personas que utilizan Terapia Nutricional Enteral. Método: estudio cuasiexperimental realizado en dos etapas; la primera incluyó una clase expositiva dialogada (CE) y la segunda se desarrolló en dos grupos: entrenamiento de habilidades (EH) simuladas in situ y lectura del folleto educativo (FE). Los cuidadores respondieron un cuestionario autoadministrado para evaluar el conocimiento pre-posintervenciones; para el análisis se propuso un modelo lineal generalizado con distribución de Poisson y las comparaciones se realizaron mediante contrastes ortogonales. Resultados: participaron 30 cuidadores, había evidencias de la diferencia de conocimiento entre los tiempos t1 y t0. El análisis de la comparación final sobre el aumento de conocimientos entre los grupos FE y EH, mediante la prueba t de Student, mostró una diferencia estimada de -1,33, con un IC del 95% (-4,98; 2,31) y un valor de p de 0,46. Conclusión: hubo un mayor aumento del conocimiento entre los tiempos t1 y t0, que entre los tiempos t2 y t1 en ambos grupos. Al compararlos, no podemos concluir que uno de los grupos cambió más que el otro entre t0 y t2; por lo tanto, el estudio demostró que hubo adquisición de conocimiento después de todas las estrategias educativas en ambos grupos.

Estratégias de ensino e aprendizagem na Terapia Enteral domiciliar: ganhos de conhecimentos percebidos por cuidadores

Resumo Objetivo: avaliar como diferentes estratégias educativas contribuem para ganhos de conhecimento percebidos por cuidadores de pessoas em uso da Terapia Nutricional Enteral. Método: estudo quase-experimental realizado em duas etapas; a primeira contemplou uma aula expositiva dialogada (AE) e a segunda aconteceu em dois grupos: treino de habilidades (TH) simulado in situ e leitura da cartilha educativa (CE). Os cuidadores responderam um questionário autoaplicável para avaliação de conhecimentos em pré e pós-intervenções; para a análise foi proposto um modelo linear generalizado com distribuição Poisson e as comparações foram realizadas por contrastes ortogonais. Resultados: participaram 30 cuidadores, observou-se evidência de diferença de conhecimento entre os tempos t1 e t0. A análise da comparação final sobre o aumento do conhecimento entre os grupos CE e TH, por teste t-Student, evidenciou uma diferença estimada de -1,33, com IC 95% (-4,98; 2,31) e valor de p de 0,46. Conclusão: ocorreu uma maior elevação de conhecimento entre os tempos t1 e t0, quando comparada os tempos t2 e t1 em ambos os grupos. Quando comparados, não podemos concluir que um dos grupos mudou mais que o outro em relação aos tempos t0 e t2; assim, o estudo evidenciou o ganho de conhecimento após todas as estratégias educativas nos dois grupos.

Experience with the management of patients requiring home enteral nutrition in routine clinical practice in Spain: the ECONES study

Introduction

Introduction: enteral nutrition is an effective method for restoring the nutritional status in patients unable to eat or fulfil nutritional requirements orally. Objectives: the ECONES study aimed to describe the treatment of patients requiring home enteral nutrition (HEN) in routine practice and the experience of specialists with the high-protein hypercaloric formula 2.0 with fiber IS50 (HP/HC 2.0). Methods: Spanish specialists answered a 38-questions survey about their last six patients with HEN and their treatment with HP/HC 2.0 formula. Results: the formulas were chosen based on the patients' requirements. HP/HC 2.0 was administered in a mean of 31.5 % of patients, and for a mean of 42.2 % of those, it was selected since the beginning of treatment. According to 92.4 % of specialists, the HP/HC 2.0 was considered as adequate based on nutritional requirements. Among adverse reactions, specialists reported diarrhea, bloating and constipation. Specialists reported that caregivers (90.6 %) stated that HP/HC 2.0 was well tolerated by patients (90.6 %) and expressed comfort with the frequency (75.3 %) and administration time (82.9 %). Conclusions: according to the specialists, formulas are chosen based on patients' characteristics. Patients with high nutritional needs benefit from the HP/HC 2.0 formula as it allows volume restriction, presents few adverse events, and improves the quality of life of the patients.

[Innovation in clinical nutrition: single dose in intermittent enteral tube feeding]

Introduction

The home enteral nutrition practical guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN) published in 2020 includes 61 recommendations. A significant number of them are related to safety parameters, prevention of complications, control strategies and quality of life of patients and family members. These are the same reasons why single-dose units are usually used on all medicines. Enteral feeding is one of the few treatments that has not yet reached the single dose and most patients with intermittent enteral nutrition by gastric tube have a dose which differs from pharmaceutical presentation. This leads to the risk of complications arising from errors in the administration that should not be forgotten and that affect mostly elderly and highly dependent populations. The innovation that consists in the creation of 375 ml single-dose containers for enteral feeding following the physiological schedules of the takes can solve most of them and meets the energy protein requirements and recommendations on dosage developed by scientific societies for patients at higher risk.

A quality control circle process to improve enteral nutrition feeding support in discharged patients with colorectal cancer

Correct usage and maintenance of the enteral nutrition feeding pump system is always a challenge in nutrition support for patients with colorectal cancer (CRC). However, there are few studies on the sustained accuracy improvement of the enteral nutrition feeding system in discharged CRC patients. Here, we established a seven-month quality control circle (QCC) activity with the theme of improving the performance of home enteral feeding pumps (EFP) and examined the effect of QCC activity on the nutritional state and quality of life in discharged CRC patients. We enrolled 100 discharged CRC patients treated with home enteral nutrition from Zhejiang Cancer Hospital between March 2020 and December 2021. The patients were randomly split into two research groups: one participated in the QCC activity (n = 50) and the other did not (n = 50). QCC analysis indicated that the top 3 causes of EFP inaccurate usage are the simple and boring contents of training, various types of pumps, no examination rules, and lack of management. Furthermore, both intra- and inter-group comparisons showed that QCC significantly improved the patients' pass rate of nutrition pump operation from 52 to 70% after 1-month of activity, which gradually improved and got the highest (90%) after 3 months (p < 0.05). Interestingly, the established QCC activity significantly increased the patient-generated subjective global assessment (PG-SGA) and Barthel index (BI) scores, body fat mass (BFM) and superior longitudinal muscle (SLM) by intra- and inter-group comparisons. In this study, we clarified the main causes of inaccurate EFP usage and established a QCC process to improve the pass rate of EFP usage. It finally leads to the improvement of nutritional state and quality of life in CRC patients.

Development of Quality Indicators for Geriatric Home Enteral Nutrition (HEN) Services

The evidence on the safety, efficacy and patient centeredness of Home Enteral Nutrition (HEN) services is scarce. In 2015, we carried out a search of the literature to identify specific indicators for HEN services as tools to be used to assess the quality of INRCA HEN services. No specific indicators for HEN services were found. Through a subsequent search of the literature, we have identified the appropriate methodology to define quality indicators and developed eight (8) specific indicators to track the quality of our HEN service for geriatric patients. Following Donabiedan's classification, we have defined two structure indicators, two process indicators and four outcome indicators that are presented in this manuscript. Though they may be used to make a comparison of HEN services for geriatric patients and to monitor the quality of therapy provided at patients' homes, the definition of quality system indicators for HEN services requires the additional joint efforts of experts in the field of nutrition and the scientific community for their validation.

Understanding the use and tolerance of a pediatric and an adult commercial blenderized enteral formula through real-world data

BACKGROUND

Home enteral nutrition (HEN) is frequently prescribed to individuals who cannot consume adequate food orally. Commercial blenderized enteral formulas (CBEF) containing real-food ingredients are becoming more popular and more widely available; however, the demographics of patients receiving these formulas have rarely been evaluated, and little data are available on patient tolerance in the community.

METHODS

US claims data were obtained for children and adolescents/adults who used the CBEF of interest as the sole source of nutrition via enteral feeding tube in the community setting following discharge from acute care. Demographics, concomitant medications, clinical diagnoses, and Charlson Comorbidity Index scores were tabulated using descriptive statistics. Gastrointestinal (GI) symptoms before and after hospital discharge were compared using significance tests.

RESULTS

The study included 231 participants (180 children, 51 adolescents/adults). CBEFs were prescribed to patients with a variety of diagnoses, of which the most common were digestive and respiratory disorders. Children experienced significantly lower rates of diarrhea, nausea, vomiting, constipation, and abdominal distension in the weeks following hospital discharge compared with the baseline (all P < 0.001). Adolescents/adults experienced significantly lower rates of constipation, nausea, and vomiting (all P < 0.05). Neither group increased their usage of GI medications following hospital discharge.

CONCLUSION

These CBEFs, based on real-food ingredients, were prescribed to diverse patients in the community and were well tolerated. These formulas offer an alternative to standard polymeric formulas and an alternative or adjunct to homemade blenderized formulas.

The Impact of Blenderized Tube Feeding on Gastrointestinal Symptoms, a Scoping Review

Severe gastrointestinal symptoms are one of the main reasons for switching from conventional artificial tube feeding to blenderized tube feeding (BTF). This study aimed to describe and quantify the impact of BTF on gastrointestinal symptoms in children and adults. We analyzed four databases (PubMed, Scopus, Cochrane Library, and Google Scholar). The review was performed following the PRISMA extension for Scoping Reviews checklist. The methodological quality of articles was assessed following the NIH quality assessment tools. The initial search yielded 535 articles and, after removing duplicates and off-topic articles, 12 met the inclusion criteria. All included papers unanimously converged in defining an improvement of gastrointestinal symptoms during blenderized feeding: the eight studies involving pediatric cohorts report a decrease from 30 to over 50% in gagging and retching after commencing BTF. Similar rates are reported for constipation and diarrhea improvement in most critically ill adults. Experimental studies and particularly randomized controlled trials are needed to develop robust evidence on the effectiveness of BTF in gastrointestinal symptom improvement with prolonged follow-up and adequate medical monitoring.

Teaching and learning strategies in Home Enteral Nutritional Therapy: Knowledge gains perceived by caregivers

OBJECTIVE

to evaluate how different educational strategies contribute to knowledge gains perceived by caregivers of people using Enteral Nutritional Therapy.

METHOD

a quasi-experimental study conducted in two stages: the first one included an interactive lecture class (LC) and the second was carried out in two groups: in-situ simulated skills training (ST) and reading of an educational booklet (EB). The caregivers answered a self-administered questionnaire to assess knowledge before and after the interventions; for the analysis, a generalized linear model with Poisson distribution was proposed and the comparisons were carried out using orthogonal contrasts.

RESULTS

the participants were 30 caregivers; evidence of a difference in knowledge between the t1and t0 moments is evidenced. The analysis of the final comparison about the knowledge gain between the EB and ST groups, according to Student's t, evidenced an estimated difference of -1,33, with 95% CI (-4.98; 2.31) and p-value=0.46.

CONCLUSION

knowledge was further increased between the t1 and t0 moments, when compared to the t2 and t1 moments in both groups. When compared, we cannot conclude that one of the groups changed more than the other in relation to moment t0 and t2; thus, the study evidenced the knowledge gain after all the educational strategies in both groups.

Application of hospital-community-family health education to family caregivers of nasal fed patients under the background of a regional medical association

BACKGROUND

Patients with nasogastric tube (NTG) nutrition after discharge still need to be transferred to community hospitals for continued care. Effective health education is conducive to raising the level of knowledge of caregivers to promote the rehabilitation of patients.

METHODS

Clinical data of 65 caregivers of stroke patients in Putuo Hospital affiliated to Shanghai University of Traditional Chinese Medicine from June 2020 to December 2020 were retrospectively analyzed. These caregivers were divided into an observation group (33 cases, hospital-community-family education model) and a control group (32 cases, routine nursing health education). We used questionnaires to assess the knowledge, attitudes, and practice levels of caregivers before and after education, and recorded the occurrence of complications in patients within 12 weeks.

RESULTS

The scores of the knowledge questionnaire and practice questionnaire of caregivers in the observation group were higher than those in the control group at 2, 4 and 12 weeks after intervention (P<0.05). The scores of caregivers' attitudes questionnaire were higher in the observation group than in the control group at 4 and 12 weeks after intervention (P<0.05). But 2 weeks after intervention, there was no significant difference between the two groups (P>0.05). Within 12 weeks after intervention, the probability of complications in observation group was lower than that in the control group (P<0.05). Logistic regression analysis showed that the hospital-community-family health education helped the outcome.

CONCLUSION

For the main caregivers of NTG nutrition patients, the implementation of a hospital-community-family health education model based on regional medical consortium can improve the level of knowledge, attitude and practice of caregivers' NTG nutrition skills and reduce complications in patients.

A scoping review of best practices in home enteral tube feeding

AIMS

To review the experiences of healthcare professionals (HCPs) and service users on the provision and receipt of home enteral nutrition (HEN) in primary care settings, respectively.

BACKGROUNDS

HEN supports the nutritional needs of service users in primary care settings who are unable to meet their nutritional requirements through oral intake alone. While HEN supports service users to remain in their home, the provision of HEN services can be variable. The prevalence of HEN is increasing as health systems shift delivery of care from acute to primary care settings, and therefore the evolving needs of HCPs and service users in relation to HEN deserve exploration.

METHODS

Quantitative and qualitative studies were included if they described (1) practices that support best outcomes in adults on HEN and residing in their own homes and/or (2) service user and HCP experiences of HEN. Studies on the economics of HEN were included. Databases searched included MEDLINE/PubMed, EMBASE, Web of Science, and CINAHL. Publications up to March 2021 were included. A descriptive analytical approach was used to summarise the findings.

FINDINGS

Key themes included the importance of initial education to enable service users to adapt to HEN and the need for support from knowledgeable HCPs. Access to support from HCPs in primary care was limited, and some HCPs felt their knowledge of HEN was inadequate. Service users highlighted the significant impact of HEN on daily living and emphasised the need for support from a HEN team. HEN services were also associated with reduced hospital admissions, lengths of stay in hospital, and costs of hospitalisation.

CONCLUSIONS

A specialist HEN service can manage enteral nutrition-related complications, reduce unnecessary hospital admissions, and improve quality of care and patient satisfaction. Further education of HCPs is needed on the provision of HEN.

Blenderised Tube Feeds vs. Commercial Formula: Which Is Better for Gastrostomy-Fed Children?

Blenderised tube feeds (BTF) have become a popular alternative to commercial formula (CF) for enterally fed children. This study sought to compare gastrointestinal (GI) symptoms, GI inflammation, and stool microbiome composition between children receiving BTF or CF. This prospective cohort study involved 41 gastrostomy-fed children, aged 2–18 years, receiving either BTF (n = 21) or CF (n = 20). The Paediatric Quality of Life Inventory Gastrointestinal Symptoms Scale (GI-PedsQL) was used to compare GI symptoms between the groups. Anthropometric data, nutritional intake, nutritional blood markers, faecal calprotectin levels, stool microbiota, and parental satisfaction with feeding regimen were also assessed. Caregivers of children on BTF reported greater GI-PedsQL scores indicating significantly fewer GI symptoms (74.7 vs. 50.125, p = 0.004). Faecal calprotectin levels were significantly lower for children receiving BTF compared to children on CF (33.3 mg/kg vs. 72.3 mg/kg, p = 0.043) and the BTF group had healthier, more diverse gut microbiota. Subgroup analysis found that 25% of caloric intake from BTF was sufficient to improve GI symptoms. The CF group had better body mass index (BMI) z-scores (−0.7 vs. 0.5, p = 0.040). Although growth was poorer in children receiving only BTF in comparison to the CF group, this was not seen in children receiving partial BTF. A combination of BTF and CF use may minimise symptoms of tube feeding whilst supporting growth.

[Nutritional status and use of health resources following the implementation of a PEG tube nutrition program for neurological patients in home hospitalization]

Objective: the objective of this study was to demonstrate that implementation of enteral nutrition by gastrostomy tube by the Home Hospitalization Unit (HHU) in patients suffering from neurological diseases, significantly improves their nutritional status, both in terms of anthropometric and analytical parameters. Methods: data on admissions, days of hospital stay, emergency room visits and nutritional parameters were collected during the 6 months before and 6 months after placement of a percutaneous endoscopic gastrostomy (PEG) tube in 100 patients from the UHD at General University Hospital in Elda (Alicante). Results: a total of 100 neurological patients were included in the study; 58 % of them were women and with a mean age (standard deviation, SD) of 78.3 (13.3) years, with 60 % of the patients being > 80 years. The monitoring and home treatment of these patients by the HHU of General University Hospital in Elda led to improvement in quality of life and nutritional parameters (weight, body mass index, proteins, albumin, prealbumin, creatinine, and hemoglobin), as well as a decrease in the number of complications derived from the nutritional management of patients at their home, and a significant reduction in number of admissions (90.27 %) and days of hospital stay (94.05 %), as well as of visits to emergency services (79.47 %), with a consequent reduction in healthcare costs. Conclusions: the implementation of a home-based monitoring program for patients with PEG by a HHU improves their nutritional status and reduces healthcare costs.

Home Parenteral and Enteral Nutrition

While the history of nutrition support dates to the ancient world, modern home parenteral and enteral nutrition (HPEN) has been available since the 1960s. Home enteral nutrition is primarily for patients in whom there is a reduction in oral intake below the amount needed to maintain nutrition or hydration (i.e., oral failure), whereas home parenteral nutrition is used for patients when oral-enteral nutrition is temporarily or permanently impossible or absorption insufficient to maintain nutrition or hydration (i.e., intestinal failure). The development of home delivery of these therapies has revolutionized the field of clinical nutrition. The use of HPEN appears to be increasing on a global scale, and because of this, it is important for healthcare providers to understand all that HPEN entails to provide safe, efficacious, and cost-effective support to the HPEN patient. In this article, we provide a comprehensive review of the indications, patient requirements, monitoring, complications, and overall process of managing these therapies at home. Whereas some of the information in this article may be applicable to the pediatric patient, the focus is on the adult population.

Developing a clinical care pathway to reduce and treat enteric feeding tube site skin excoriation: a quality-improvement pilot study

Skin excoriation is a common complication of enteral tube feeding; however, universal guidelines for treatment do not exist. A quality improvement pilot study to inform the development of a local clinical care pathway was conducted. The enteral nutrition team identified products and assessed patient preference, ease of use, availability, and clinical outcomes for inclusion. This pathway includes gentle site cleansing followed by skin protectant application. For mild skin excoriation (<5 mm), acrylate terpolymer barrier film (3M Cavilon No Sting Barrier Film) was applied once every seven days. Moderate skin excoriation (5-20 mm) received acrylate terpolymer barrier film twice a day for seven days. Severe skin excoriation (>20 mm) received advanced elastomeric skin protectant (3M Cavilon Advanced Skin Protectant) applied once every 3-4 days for 2-4 weeks. Ten patients were included, three were selected for discussion. Adoption of this local clinical care pathway resulted in skin healing and improved patient comfort.

Low risk for microbial contamination of syringe and tube feeding bag surfaces after multiple reuses with home blenderized tube feeding

BACKGROUND

Guidelines for the reuse of enteral tube feeding (ETF) equipment guidelines are limited to manufacturer recommendations. ETF equipment reuse studies are needed as the enteral population has increased, along with blenderized tube feeding (BTF).

METHODS

This experiment tested microbial contamination of a reusable gravity feeding bag and syringe after 15 BTF reuses and cleanings. Eight bags and syringes were filled with the BTF, held at room temperature for 20 min, and then emptied, washed, and air dried. After the last air drying, the inner surfaces of the bag and syringe were swabbed, and aerobic microbial counts were performed using serial dilutions and plate counts.

RESULTS

The microbial counts for all syringes and six bags were <1 colony-forming unit (CFU)/cm² ; one bag was <5 CFU/cm² and one bag was 12.5 CFU/cm² . No legal guidelines for surface cleanliness exist for the food sector. Several studies propose a safe microbial level to be <2.5 CFU/cm² , and the European Commission recommended <10 CFU/cm² . Based on these proposed guidelines, microbial counts of all syringes and seven bags were within the proposed guidelines, except for one bag just above 10 CFU/cm² .

CONCLUSION

The feeding bag used in this study may be used multiple times for BTF with a reduced risk of microbial contamination when manufacturer's cleaning guidelines are followed. Although bolus tube feeding is an off-label use for syringes, they are frequently used for BTF, and in this study the cleaning after 15 uses over 5 days was effective to reduce microbial counts.

The Effects of Enteral Nutrition on the Intestinal Environment in Patients in a Persistent Vegetative State

Enteral nutrition (EN) is a rational approach to providing nutritional intake via the intestines in patients who are unable to tolerate parenteral nutrition. We conducted a preliminary study to investigate the effects of EN on the intestinal environment in 10 patients in a persistent vegetative state (PVS) (n = 5 each in the EN and EN with probiotics; Clostridium butyricum MIYAIRI 588) groups compared with 10 healthy controls. The results of 16S amplicon sequencing of the intestinal microbiota showed that EN led to dysbiosis with a decrease in α-diversity and an obvious change in β-diversity. A particularly significant decrease was seen in useful intestinal bacteria such as Bifidobacterium and butyrate-producing bacteria. Analysis of intestinal metabolites also supported these results, showing significant decreases in butyric and pyruvic acid after EN. Although C. butyricumMIYAIRI 588 improved some intestinal metabolites that were decreased after EN, it did not improve the dysbiosis of the intestinal microbiota. These findings indicate that EN causes dysbiosis of the intestinal microbiota and an imbalance in some intestinal metabolites in patients in a PVS. Moreover, although C. butyricumMIYAIRI 588 improved the imbalance of some intestinal metabolites after EN, it did not prevent dysbiosis of the intestinal microbiota.

Blenderized formulations in home enteral nutrition: a narrative review about challenges in nutritional security and food safety

Blenderized formulations (BFs) are prepared by homogenization of food that is normally used in oral nutrition. BFs are mainly used in home enteral nutrition (HEN), although their use has also been reported by hospitals when commercial enteral formulas are not available. HEN is applied when the patient has been discharged from the hospital. This nutritional therapy promotes the patient's reintegration into the family nucleus and promotes humanized care, and decreases treatment costs. However, the patient should continue to receive health and nutritional care, ranging from periodic nutritional re-evaluation to adaptation of the dietary plan. HEN provides the patient a greater contact with the family, whereas BFs promote the adaptation of the diet with food, respecting the food diversity and culture, lower cost, and easier access to food. Disadvantages of BFs include more time spent by the professional to calculate the dietary plan, greater difficulty in adjusting daily needs, and less microbiological and chemical stability. In this review, the nutritional, food security, and safety aspects of BF used in HEN are discussed. Technological quality aspects that are essential knowledge in the preparation of the patient's dietary plan also are presented.

Experiences and needs of home caregivers for enteral nutrition: A systematic review of qualitative research

AIMS

To systematically identify, evaluate and synthesize the qualitative evidence on enteral nutrition of home caregivers.

DESIGN

A qualitative evidence synthesis using the Sandelowski and Barroso methodology.

DATA SOURCES

We reviewed articles from eight databases: CINAHL, Embase, PubMed, Web of Science, Cochrane, CNKI, Wanfang Data and CSTJ. Qualitative, peer-reviewed, original studies published in English or Chinese before April 2020 on home caregivers' experience and needs for enteral nutrition were included. The studies were selected by screening titles, abstracts and full texts, and the quality of each study was assessed by two researchers independently.

REVIEW METHODS

Two researchers independently used qualitative assessment and review tools for quality assessment and thematic synthesis for data analysis.

RESULTS

This review included 10 articles. The themes identified included balance the enteral nutrition, the experiences and feelings in practice and the recommendations to meet challenge.

CONCLUSION

Home caregivers reported that they played an important role and faced greater pressure. Future studies should establish a systematic and standardized follow-up schedule to improve home caregivers' physical and mental health.

IMPACT

The findings established that home caregivers experienced not only changes in their roles and concerns but also spiritual changes. Home caregivers develop different coping strategies to adapt to enteral nutrition without standardized training and support. Although home caregivers make much account of enteral nutrition and feeding issues, they lack of information and support services. Understanding existing problems from a caregiver's perspective can allow interventions to be more clearly developed and well-established training standards established in the future.

A telephone support program for patients with home enteral nutrition contributes to nutrition status and quality of life maintenance and reduces health resource use

BACKGROUND

Appropriate patient/caregiver training and continuity of care after hospital discharge are key factors for the success of home enteral nutrition (HEN). This study aims to assess the effects of a specific patient support program (PSP) on the nutrition status, health-related quality of life (HRQoL), and healthcare resource utilization and associated costs of patients with HEN.

METHODS

Observational study of adult patients with HEN enrolled in a PSP. Sociodemographic variables (baseline), HRQoL (NutriQoL) and nutrition status (Mini Nutritional Assessment [MNA]) (baseline, 6 months after PSP enrollment), and use of unplanned HEN-related healthcare resources (6 months prior to or after PSP enrollment) were recorded. HEN-related resource cost was estimated from total resources used (all patients) and each resource cost. Data were analyzed with Stata program (v. 14), considering P < 0.05 as significant.

RESULTS

Forty-three patients were included in the study (mean age, 72 years [SD = 21]; 54% women; mean HEN duration, 4 years [SD = 5]). A total of 401 calls were recorded in the PSP, 7% made proactively by the patient. HRQoL and nutrition status remained stable during the study period (NutriQoL baseline, 64; 6-months, 66; P = 0.3737; MNA baseline, 10; 6-months, 10; P = 0.0675). Unplanned resources amounted to €6229 (US $5563) and €4711 (US $4207) before and after PSP enrollment, respectively. Cost savings, representing €1518 (US $1356), were related to fewer emergency visits.

CONCLUSIONS

Health advice provided through a PSP and close patient monitoring in the hospital can help to maintain patients' nutrition status and HRQoL and to reduce the use of certain unplanned HEN-related resources, leading to cost savings.

Macronutrients and energy in home-prepared enteral tube feeding: Comparison between food composition table estimates, nutrition labels, and laboratory analysis

BACKGROUND

The effectiveness of home enteral nutrition depends on the supply and delivery of the prescribed nutrients. This study compared the macronutrient and energy values of home-prepared enteral tube feeding analyzed in the laboratory with the same information calculated from labels and food composition tables.

METHODS

A total of 107 enteral formulations were analyzed: 66 commercial enteral formulas (CEFs), 19 homemade enteral preparations, and 22 blended enteral preparations (BEPs). The values of macronutrients and energy and the ratio between the values found in the laboratory and the calculated values were all evaluated. The tolerance limit of acceptable variation was 20%. The results were subjected to chemometric methods using principal component analysis (PCA) and hierarchical cluster analysis (HCA).

RESULTS

In the three categories of the enteral formulations, the calculated values for protein and fat were higher than those obtained in the laboratory. The calculated values for energy were higher than those obtained in the laboratory for the BEPs and CEFs. The CEFs had the highest percentage within the limit of acceptable variation for carbohydrate and protein, whereas the BEPs presented the lowest values for fat and energy. In the exploratory analysis of data using PCA and HCA, it was possible to verify similarities and discrepancies between the enteral formulations analyzed in the laboratory with those calculated from the labels and food composition tables.

CONCLUSION

The enteral formulations showed differences between the values of macronutrients and energy analyzed in the laboratory and those calculated from labels and/or food composition tables.

Nurses' perceptions regarding barriers to implementing the Internet Plus Nursing Service programme: A qualitative study

AIM

The aim of this work is to investigate nurses' perceptions of barriers constraining the implementation of the Internet Plus Nursing Service program.

BACKGROUND

The Internet Plus Nursing Service programme helps meet the demands of an ageing population, people with chronic diseases, the disabled, and home convalescents, and affirms the value of nurses. However, this programme has failed to elicit nurses' active participation, and there is limited knowledge regarding nurses' perceptions of the barriers to the programme's implementation.

METHODS

A qualitative study was conducted. Thematic analysis of the data was performed.

RESULTS

The analysis yielded three main themes: a sense of insecurity, role conflict, and a lack of support.

CONCLUSION

This study explores nurses' perspectives on the factors impeding the implementation of the programme, which are identified as being insufficient protection and support on nurses at personal, sociocultural, infrastructural, and organizationallevels.

IMPLICATIONS FOR NURSING MANAGEMENT

The study results will guide the department of nursing management to foster supportive work and social environment for nurses, which will decrease their feeling of insecurity and role conflicts and provides them enough infrastructural and organizational supports through proposing emergency code system and improving training system and team collaboration.

Clinician and carer moral concerns when caring for children who tube-feed

Child healthcare can be vexed by moral concerns - this extends to the care of children who tube-feed. Children who tube-feed often receive care from family members and clinicians of various disciplines. Each brings expertise, experiences, values, and views to a situation, prioritising the child's needs while attending to those they deem important in potentially disparate ways. Their understanding of a situation is shaped by beliefs, feelings, and perceptions. How then are key decisions made about the care of a child who tube-feeds? This article explores clinicians' and carers' moral concerns when caring for children who tube-feed. Interviews with clinicians (n = 9) and carers (n = 9) clarified three findings: first, there are often disparate beliefs about the need for tube-feeding; second, tube-feeding can evoke strong emotions; and third, it can be difficult to normalise tube-feeding. This article demonstrates how challenges can emerge when relationships between clinicians and carers diverge. Furthermore, it establishes how an ethic of care can bring different interests together to bolster the relationships required to optimise feeding care and promote health outcomes among children who tube-feed and their carers. This requires improved dialogue between and among clinicians and carers to create shared understandings of what is, what should be, and how to benefit children who tube-feed.

Growing use of home enteral nutrition: a great tool in nutrition practice toolbox

PURPOSE OF REVIEW

Home enteral nutrition (HEN) is a well-established practical nutrition therapy tool that is typically managed by an interdisciplinary team. Prevalence of HEN is increasing across the globe given significant evidence for utility, feasibility, efficacy, safety, and reliability of HEN in helping patients meeting their nutrition needs. The current review highlights the growing use of HEN in the context of what is novel in the field including trends in HEN practice with regards to tubes and connectors, feeding formula and real food blends, and common complications. The review also highlights that the use of HEN is expected to expand further over coming years emphasizing the need for national consensus recommendations and guidelines for HEN management.

RECENT FINDINGS

The growing use of HEN has always been parallel to adoption of holistic definitions and concept of malnutrition in clinical nutrition practice and more understanding of the need for malnutrition risk stratification, meeting unmet needs in practice and addressing challenges that lead to suboptimal enteral nutrition.

SUMMARY

Research and advancements in technology as well as in tube feeding formula industry have led to the development of more solutions and have helped identify and implement best HEN practices.

[The NADYA-SENPE Home Enteral Nutrition Registry in Spain: years 2018 and 2019]

AIM

to present the results of the Spanish home enteral nutrition (HEN) registry of the NADYA-SENPE group for the years 2018 and 2019.

MATERIAL AND METHODS

from January 1, 2018 to December 31, 2019 the home enteral nutrition registry was recorded, and afterwards a further descriptive and analytical analysis was done.

RESULTS

in 2018, 4756 active patients were registered and the prevalence was 101.79 patients per one million inhabitants; in 2019 there were 4633 patients with a prevalence of 98.51 patients per one million inhabitants. They originated in 46 hospitals: 51.3 % were male, and median age was 71.0 years in both periods. The most frequent diagnosis was a neurological disorder that presents with aphagia or severe dysphagia - 58.7 % and 58.2 %, respectively. The main cause of episode termination was death. A total of 116 pediatric patients were registered in 2018 and 115 in 2019. Females represented 57.8 % and 59.1 %, respectively, in each of the periods. Median age at the beginning of HEN was 5 and 7 months. The most commonly recordered diagnostic group (42.2 % and 42.6 %) was included within the other pathologies group, followed by neurological disorders that present with aphagia or severe dysphagia in 41.4 % and 41.7 % of children. The route of administration was gastrostomy in 46.6 % and 46.1 %, respectively, in each of the periods.

CONCLUSIONS

the NED registry of the NADYA-SENPE group continues to operate uninterruptedly since its inception. The number of registered patients and the number of participating hospitals remained stable in the last biennium analyzed.

Reducing outpatient gastrostomy tube complications

OBJECTIVE

To monitor the effectiveness of a multidisciplinary education protocol for gastrostomy tube (GT) use and care for patients to reduce complications postplacement.

METHODS

Baseline assessment included a preintervention/intervention design through quantitative measures to determine reduction in the number of GT complications postprocedure following implementation of a patient education protocol for 16 patients in the study.

INTERVENTION

A multidisciplinary approach was used in protocol development for standardizing patient education. Verbal, written, and hands-on demonstration methods for GT care were used to provide multiple education pathways to increase patient knowledge. Over the progression of 8 months (July 2019 to March 2020), patients with a new GT were followed postprocedure (1-2 weeks prior to starting radiation treatments) and throughout their course of radiation treatments (typically 6-7 weeks).

RESULTS

All 16 patients (100%) in the intervention group were included in the final analysis. GT complications were reduced from 91% in the preintervention group (n = 11) to 37% in the intervention group (n = 16). The most significant reduction occurred in technique issues, which decreased from 36% (n = 4) to 0%.

CONCLUSIONS

Implementation of a multidisciplinary approach with multiple educational sessions prior to GT placement and use led to increased patient knowledge and reduced GT complications.

Understanding the Need for Tools and Resources to Manage Enteral Nutrition Intolerance: An On-line Survey

Purpose: Enteral nutrition intolerance (ENI) is a common complication among tube-fed patients, associated with reduced volumes of nutrition delivered, and may contribute to malnutrition risk. This research aimed to obtain insights about dietitians' needs and preferences related to tools and resources to help identify and manage ENI.Methods: An online survey was administered to registered dietitians (RD) engaged in enteral nutrition (EN) management, recruited from a list of attendees at a national webinar. The 16-question survey asked about participant's experience with ENI and interest in resources to manage ENI.Results: Of the 219 surveys completed (25% response rate), 86% identified ENI as an issue/concern that interferes with adequate nutrition or hydration for their patients. Ninety-seven percent reported being interested in having tools/resources to manage ENI. The symptoms identified as most pressing to manage were diarrhea (73%), bloating/abdominal discomfort (42%), and nausea (32%). Preferred types of tools were hard-copy resources (70%), algorithms (67%), and web-based instruments (62%).Conclusions: ENI remains an issue for clinicians working with tube-fed patients and RDs are interested in management tools. These results have implications for the development of evidence-based resources to help improve EN delivery and ultimately may contribute to clinician's efforts at reducing malnutrition.

High costs and limited dietitian services for home enteral nutrition users: A Canadian study

BACKGROUND

Home enteral nutrition (HEN) is the provision of nutrition through a tube outside the hospital. The Canadian prevalence of HEN is not previously well understood. This study aimed to (1) describe the demographics and healthcare usage of HEN in adults in a Canadian health authority, (2) compare the proportion of HEN-related hospital visits between patients who did and did not receive a community registered dietitian (RD) follow-up, and (3) determine associations between demographic and healthcare usage of HEN adults .

METHODS

A retrospective chart review was conducted on the records of HEN patients with a tube placed between April 1, 2012, and March 31, 2015. Descriptive and comparative statistics were applied.

RESULTS

A total of 390 adults were discharged receiving HEN. The majority (74.9%, n = 271) of the sample did not have any record of visiting a community RD up to 6 years after tube placement. Fifty-three percent of the sample visited the hospital for HEN-related complications, costing CAD $14,324,465.00 (USD $10,677,946.00) to the healthcare system. Multiple regression analysis revealed that females ( P < .05), jejunostomy tubes ( P < .05), and older age ( P < .05) were associated with more hospital or emergency room visits.

CONCLUSION

This study found a higher prevalence of HEN patients and more varied demographic and clinical characteristics than previously reported. The healthcare costs per patient per year exceed previous reports. Further research is needed to explore the population's experiences and develop interventions that improve gaps in the healthcare system.

Real-World Evidence of Treatment, Tolerance, Healthcare Utilization, and Costs Among Postacute Care Adult Patients Receiving Enteral Peptide-Based Diets in the United States

Objective

Peptide ‐based (PB) enteral tube feeding (ETF) formulas have been shown to reduce gastrointestinal (GI) intolerance in patients receiving enteral nutrition. However, limited data exist in relation to their use in the postacute/home care setting. We sought to assess the real‐world GI tolerance, healthcare utilization, and resource use costs of 100% whey‐protein PB ETF in adults in a postacute care setting and describe their demographic, clinical, and treatment characteristics.

Method

Using medical claims data from the United States, we analyzed GI intolerance events occurring in adults receiving 100% whey‐protein PB ETF (Peptamen^® adult formulas) for one year before and after initiation of ETF. Resource use costs were subsequently estimated using a multivariate general linearized model and adjusted for age, gender, and Charlson Comorbidity Index score.

Results

The proportion of adults experiencing no GI intolerance events increased from 41% (418/1022) to 59% (601/1022) in the one‐year period after initiation of 100% whey PB ETF (P < .001). The proportion of patients with at least one hospital inpatient visit also decreased from 100% (1022/1022) to 72% (737/1022) over the same period, and the mean number of inpatient visits per patient decreased from 15.6 to 13.0. Cost modeling revealed that outpatient visits accounted for 42% ($1174/$2820) of total estimated healthcare resource costs in the first 30 days after 100% whey PB ETF initiation, with only 9% ($255/$2820) due to emergency room visits.

Conclusion

These 100% whey‐protein PB ETF formulas are a valuable nutrition treatment option for patients with or at risk of malnutrition who show intolerance to standard ETF formulas and may reduce hospital inpatient visits and associated costs.

Exploring Clinical Outcomes and Feasibility of Blended Tube Feeds in Children

Commercially produced complete nutritional formulas (CFs) are commonly delivered to children requiring enteral nutrition via gastrostomy. However, a cultural shift toward consuming a more natural diet consisting of whole foods has caused the use of blenderized tube feeds (BTFs) to grow in popularity among parents and carers in recent years. There are advantages and disadvantages of both BTF and CF use. There is evidence that suggests that BTFs can significantly improve tube-feeding tolerance and reduce gastrointestinal symptoms associated with tube feeding, such as gagging, retching, and constipation, thereby resulting in an improved quality of life (QoL) for enterally fed children and their caregivers. BTFs have also been implicated in increasing the diversity of the gut microbiota in enterally fed children. However, concerns have been raised that BTFs may be inferior to CFs in energy and nutrition sufficiency. Issues such as microbial contamination, tube blockages, and difficulties in preparation and administration may also complicate the use of BTFs. Additionally, like CFs, BTFs can vary significantly in nutrition composition, and dietitian involvement with BTF use is crucial. The current literature on the clinical outcomes of BTF use is limited, and further research is needed before recommendations can be made on BTF use in children. A literature review was conducted to compare clinical outcomes between BTFs and CFs and evaluate the feasibility of BTF use in children.

Translation and cross-cultural adaptation of the NutriQoL® questionnaire to the Portuguese language: Brazilian version

ABSTRACT Objective The objective of this study was to translate and cross-culturally adapt the NutriQoL® into Brazilian Portuguese. Methods The NutriQoL® comprises 17 questions that evaluate the quality of life of patients receiving home enteral nutrition therapy. The methodological procedures included the translation from the Spanish version into Portuguese by two translators, synthesis of the translations, back translation, evaluation by a committee of judges composed of 24 individuals in which a content validity index > 0.78 was considered acceptable, and generation of the pre-final version. A pre-test to analyze its semantic equivalence was administered to 12 patients receiving home enteral nutrition therapy. The final version of the questionnaire was then prepared. Results A summary version of the questionnaire was obtained using two versions of the translation. Both back translations were identical for 73.6% of sentences (n=25). Twenty-four volunteers were included in the committee of judges. The content validity index was 0.88±0.11, and 14.7% (n=5) of questions had a low content validity index and were thus reformulated. In the pre-test, 35.3% (n=12) of items obtained low levels of understanding and required adjustment. In the preparation of the final version, the inconsistencies of the items mentioned were corrected and/or adjusted. Conclusion After completing the methodological procedures, a Brazilian Portuguese version of the NutriQoL® questionnaire was obtained. Following the validation process, it can be used by dieticians and other health professionals to assess the quality of life of patients receiving home enteral nutrition therapy to contribute to improvements in care practices.

The use of Lactobacillus plantarum 299v (DSM 9843) in cancer patients receiving home enteral nutrition - study protocol for a randomized, double-blind, and placebo-controlled trial

BACKGROUND

Nutritional treatment is one of the most important components of multidisciplinary anti-cancer therapy. Home enteral nutrition is considered as a safe procedure, however, it may be associated with the risk of side effects, such as nausea, vomiting, abdominal pain, and diarrhoea. It is uncertain whether diarrhoea is the result of the enteral formula administration or gut dysbiosis. One of the methods which may be used to alter the composition of gut microbiota is the administration of a probiotic strain. Lactobacillus plantarum 299v ingestion was found to diminish the adverse events of irritable bowel syndrome and Clostridium difficile infection - entities that share the symptoms with enteral nutrition side effects. Therefore, the primary aim of this study is to determine the effect of Lactobacillus plantarum 299v on prevention of weight loss of cancer patients receiving home enteral nutrition. The secondary aims are to evaluate the role of this probiotic strain in the improvement of nutritional status, enteral nutrition tolerance, and patients' quality of life.

METHODS

Forty patients with cancer receiving home enteral nutrition will be enrolled in this clinical trial and randomized to receive one capsule of Lactobacillus plantarum 299v (Sanprobi IBS®) twice a day or placebo for 12 weeks in a double-blind manner. Laboratory tests (the level of albumin, total protein, transferrin, and total lymphocyte count), anthropometric parameters (body mass, the content of fat mass, muscle mass, and total body water), Nutritional Risk Screening (NRS 2002), enteral nutrition tolerance as well as quality of life will be measured. Measurements will be obtained at the baseline and after 4 and 12 weeks of treatment.

DISCUSSION

The adverse events observed during administration of enteral nutrition have an negative impact on enteral formula tolerance and as a consequence patients' quality of life. The previous studies have demonstrated that probiotics may reduce the gastrointestinal symptoms related to enteral nutrition. Thus, administration of Lactobacillus plantarum 299v may be effective in improvement of nutritional status, enteral nutrition tolerance, and quality of life of cancer patients receiving home enteral nutrition.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03940768 .

An Evaluation of the Nutritional Value and Physical Properties of Blenderised Enteral Nutrition Formula: A Systematic Review and Meta-Analysis

Background: Although there are merits in using commercial “enteral nutrition formula” (ENF) compared with blended ENF, there is a growing preference for the use of blended ENF in many countries globally. However, the nutritional value and physical properties of blended ENF compared with commercial ENF may be limiting its use. We have not found any evidence of a meta-analysis on the nutritional value of blended diets in the adult population. Aim: The aim of this review was to compare the nutritional value, physical properties, and clinical outcomes of blended ENF with commercial ENF. Methods: The preferred reporting items for systematic reviews and meta-analyses were used for this review. The search strategy was based on a Population, Intervention, Comparator, Outcome framework. The following databases; Pubmed, EMBASE, PSYCInfo, and Google scholar were searched for articles of interest using keywords, Medical Subject Heading (MeSH) and Boolean operators (AND/OR) from the inception of each database until 23 February 2020. The articles were evaluated for quality. Results: Based on the systematic review and meta-analysis, four distinct themes were identified; Nutritional value, Physical properties, Clinical outcomes; and Adverse events. The findings of this review showed inconsistencies in the macronutrient and micronutrient values of the blenderised ENF compared with the commercial ENF. The results of the meta-analysis demonstrated that there were no significant differences (p > 0.05) between the blenderised ENF and the commercial ENF in relation to the fat and protein contents of the diets. However, the blenderised ENF was significantly lower (p < 0.05) than the commercial ENF regarding the energy content of the diets, with an overall mean difference of −29.17 Kcal/100 mL (95% CI, −51.12, −7.22) and carbohydrate content with an overall mean difference of -5.32 g/100 mL (95% CI, −7.64, −3.00). In terms of sodium, potassium, and vitamin A, there were no significant differences (p > 0.05) between the blenderised and commercial ENF, although significant differences (p < 0.05) were observed between the two diets with respect to calcium, phosphorus, magnesium, zinc, iron, and vitamin C contents. Furthermore, the blenderised ENF showed significantly higher levels (p < 0.05) of viscosity and osmolality than the commercial ENF. The significantly lower levels of some of the macro-nutrients and micro-nutrients in the blenderised ENF compared with the commercial ENF and the difference in the expected nutritional values may be due to the fact blenderised ENF is produced from common foods. Thus, the type of foodstuffs, cooking, and processing methods may lead to loss of nutrients and energy density. The deficits in the energy content and some of the macro- and micro-nutrients in the blenderised ENF compared with commercial ENF may have implications for patients’ health and clinical outcomes. The clinical implications of the underdelivering of nutrients may include increased risk of undernutrition, including energy malnutrition, which could have a negative effect on body composition and anthropometric parameters, morbidity, mortality, length of hospital stay, and costs. For outpatient care, this could increase the risk of hospital re-admission and homecare costs. Additionally, the higher viscosity and osmolality of the blenderised ENF compared with the commercial ENF can increase the risk of complications, including tube blockage, and impaired delivery of feed, water, and medications, with significant implications for patients’ nutritional status and health outcomes. Conclusion: The results of this systematic review and meta-analysis identified significant variability in the nutritional value of blenderised ENF compared with commercial ENF. Furthermore, the nutritional values of the blenderised ENF do not meet the expected recommended levels compared with commercial ENF and these may have implications for patients’ nutritional status and health outcomes, including the effect on body composition, morbidity, mortality, hospital re-admission, and costs. Further studies are needed to elucidate the nutritional value of blenderised ENF on patients’ clinical outcomes.

Perceived needs of patients and family caregivers regarding home-based enteral nutritional therapy in South Africa: A qualitative study

INTRODUCTION

The need for specialized care, particularly enteral nutritional therapy in community settings is now increasing with implications for both patients and primary care providers. More research is needed to identify the needs of patients and primary caregivers. The study aimed to explore the perceived support needs regarding the provision of home-based enteral nutritional therapy among critically ill adult patients and family caregivers in the KwaZulu-Natal Province of South Africa.

METHODS

A qualitative study of purposely selected adult patients on homebased enteral nutritional therapy and family caregivers was conducted in a district hospital, a community health centre, two primary health care clinics and selected households in the KwaZulu-Natal Province, South Africa. Semi-structured individual interviews were conducted between June and September 2018 and the content analysis approach was used to analyse data.

RESULTS

Two major themes and five subthemes emerged from the results of the interviews. The major themes concerned socioeconomic and psychosocial support needs related to the provision of home-based enteral nutritional therapy. Subthemes included the need for financial assistance, need for enteral nutrition products and supplementary supplies, need for infrastructure for continuity of care, and psychological support needs.

CONCLUSION

Results of this study confirm the need for developing strategies adapted to a South African context and yonder to meet patients' and family caregivers' needs with regard to nutritional services. More research on the identification of needs through monitoring and evaluation of the implementation of nutritional guidelines is needed, particularly in the district hospital and primary health care (PHC) setting.

Survival Analysis of Enterally Fed Patients: Prognosis and Mortality Risk According to Baseline Characteristics

BACKGROUND

Enteral nutrition is widely used. However, its benefits remain unclear in specific conditions like dementia. This study assesses the survival of enterally fed patients and the baseline characteristics associated with higher mortality.

METHODS

A retrospective analysis of biochemical and clinical data from 377 patients (age 77.5 ± 13.8) who received enteral tube feeding (ETF) at a tertiary hospital in Spain was performed. Kaplan-Meier and Cox regressions were used to analyze survival expectancy and mortality risk (MR). Risk was evaluated for 30/180 days and up to 5 years.

RESULTS

The most common individual diagnoses leading to ETF prescription were dementia (37.9%) and head/neck/upper-gastrointestinal-tract cancer (17.5%). Comorbidities (high blood pressure [HBP] and/or diabetes) were present in 72.4% of patients. The first 30 days after tube placement showed the highest mortality rate, corresponding to 85.4% of patients that did not continue being tube-fed. Multivariate Cox analysis (P < .05, 95% CI) showed HBP and glycemia to be predictive of overall (hazard ratio [HR] = 1.600; HR = 1.756) and long-term (HR = 3.092; HR = 4.539) death. In the short-term, only glycemia showed an increased MR (HR = 1.572).

CONCLUSION

This enterally fed population showed a noticeably high initial mortality rate. Despite official recommendations against it, ETF is very common in advanced dementia. Baseline characteristics are useful for identifying patients that would be less benefited by the intervention. Accordingly, families should be informed about realistic outcomes and risks derived from this procedure.

Nutritional status and clinical evolution of the elderly in home enteral nutritional therapy: a retrospective cohort study

OBJECTIVE

to evaluate the clinical and nutritional evolution of elderly patients receiving home enteral nutritional therapy.

METHOD

retrospective cohort observational study. Data collection was performed through the analysis of clinical and nutritional records. The demographic, nutritional and clinical variables were analyzed. The sample consisted of elderly patients using home enteral nutritional therapy via the probe or the stomach. For the statistical analysis, the Statistical Package for the Social Sciences program was used, adopting the level of significance of 5%.

RESULTS

the sample was 218 participants, with a mean age of 76 ± 10.12 years, of which 54.1% were female. The main morbidity was the stroke sequelae. Malnutrition was the nutritional diagnosis and the overall subjective assessment, the main instrument of nutritional evaluation. The route of administration of the most prevalent diet was the nasoenteric/nasogastric tube, however, after one year of follow-up, gastrostomy became the main route. It was observed the predominance of general condition maintenance and the most prevalent clinical outcome was death.

CONCLUSION

the majority of patients in home enteral nutrition therapy presented maintenance and / or improvement of clinical and nutritional status. Therefore, this therapy may contribute to a better clinical and nutritional evolution.