Author: Rodolfo Dimaano Jr, MD (1) and Luisito O. Llido, MD (2)

Transcription

1 1 Title: The First Philippine Hospital Nutrition Summit Report on the presence of nutrition Author: Rodolfo Dimaano Jr, MD (1) and Luisito O. Llido, MD (2) Institution: 1. Abbott Nutrition Philippines 2. Philippine Society of Parenteral and Enteral Nutrition Keywords: NST, nutrition team, Philippines INTRODUCTION: The status of patient nutrition in the hospital has become a global concern for the past two decades since the first article on hospital malnutrition was published in (1) Today this concern has become multidisciplinary in scope and national societies were organized to address hospital malnutrition, critical care, post- operative, oncologic, geriatric care management and the list is growing. The Philippines is one of the countries in the Asia Pacific region, which has an active nutrition society, the Philippine Society for Parenteral and Enteral Nutrition or PhilSPEN. (2) The primary aim of the society since its foundation in 1994 was to promote the development of clinical nutrition practice in every major hospital in the country through the strategy of installing nutrition teams in these institutions. A key factor in making this a reality was the setting up of a clinical nutrition fellowship training program, started in 2000, which trains physicians in the art and science of clinical nutrition and encourage these specialists to ultimately organize and head these nutrition teams in their specific institutions. The participation of industry in this program was and still is a major catalyst in sustaining this movement which was done through sharing of their vast resources for clinical nutrition education and providing logistics for holding yearly PhilSPEN clinical nutrition congresses and nutrition seminars throughout the country. Abbott Nutrition is right in the thick of the crusade for pushing for the success of the clinical nutrition program through its support of symposia and sharing its own educational instruments like the Total Nutrition Therapy or TNT (1999)(3) and similar activities for different sub- specialties which are going on up to the present. In 2010 it launched the first Hospital Nutrition State of the Art Summit in Manila, which reported on the practice of clinical nutrition in selected hospitals in the U.S. and Asia Pacific region. (4) Subsequent symposia on hospital nutrition state of the art practice in clinical nutrition followed. In 2014 Abbott Philippines organized its First Philippine Hospital Nutrition Summit whose primary goals were: 1) To create awareness among hospital policy makers and key health care providers on the state of nutrition in Philippine hospitals and 2) To present strategies that identify hospital malnutrition and design steps to help improve patient outcomes. The was done

2 2 through a survey which investigated the status of clinical nutrition practice in selected hospitals in the country. This is the report on the results of the survey. METHODOLOGY A two- level structured survey was conducted on selected hospitals in the country. (Table 1) The first level survey was focused on determining the presence of clinical nutrition practice in the institution and the presence of an organized nutrition team. Table 1: Hospital participants in the first Philippine hospital nutrition summit Hospital (N=26) Location Region Government/ Private 1 Capitol Medical Center Quezon City NCR Private 2 Fatima Hospital Quezon City NCR Private 3 Manila Doctors Hospital Manila City NCR Private 4 MCU- FDTMF Caloocan City NCR Private 5 National Kidney Transplant Institute Quezon City NCR Gov t 6 Our Lady of Lourdes Hospital Manila City NCR Private 7 Ospital Ng Makati Makati City NCR Gov t 8 St. Luke s Medical Center Global City Makati City NCR Private 9 The Medical City Pasig City NCR Private 10 UST Hospital Manila City NCR Private 11 Calamba Doctors Hospital Calamba Luzon Private 12 Daniel Mercado Hospital Batangas Luzon Private 13 De La Salle University Medical Center Dasmarinas Luzon Private 14 Jecson Hospital Tarlac Luzon Private 15 Mary Mediatrix Medical Center Lipa City Luzon Private 16 Mt. Carmel Hospital Pampanga Luzon Private 17 Pampanga Medical Specialist Hospital Pampanga Luzon Private 18 Good Samaritan Hospital Nueva Ecija Luzon Private 19 Premiere Medical Center Cabanatuan City Luzon Private 20 St. Louie University Hospital Baguio City Luzon Private 21 Villaflor Hospital Dagupan City Luzon Private 22 Chong Hua Hospital Cebu City Visayas Private 23 Iloilo Doctors Hospital Iloilo City Visayas Private 24 Iloilo Mission Hospital Iloilo City Visayas Private 25 Davao Doctors Hospital Davao City Mindanao Private 26 San Pedro Hospital Davao City Mindanao Private The survey questions (Table 2) were distributed six months before the actual reporting (June 18, 2014). The distribution of surveys and collection of data were done by representatives of Abbott Nutrition and the data synthesis by a team representing both PhilSPEN and Abbott Nutrition.

3 3 Table 2: Survey Questions For patients admitted to the Ward Yes No 1. Do you have nutrition screening on admission? 2. Do you know the prevalence of malnutrition in your hospital? 3. Do you have nutrition protocols/specific nutrition policies 4. Do you policies on pre/post surgical nutrition? 5. Do you have a formal process for communicating a post- discharge nutrition care plan? For patients admitted to the ICU 1. Do you assess nutritional status of ICU patients? 2. Do you know the prevalence of malnutrition in the ICU? 3. Do you have nutrition protocols/specific policies for advanced nutrition care? 4. Do you have policies on ICU feeding? 5. Do you have in- hospital tracking and post- discharge nutrition planning? The second level survey was done in the actual workshop, where all participants were asked to discuss their felt- needs in either organizing a clinical nutrition program or setting up a clinical nutrition team. (Table 3) The patient populations, which were covered in the survey were the adult and elderly population. In essence the features of the clinical nutrition process that will determine the level of development of the institution are the following: 1. Level 1 or Basic Level: presence of a system of nutrition screening and/or presence of a nutrition assessment process. This means the hospital has complied the minimum requirement for an active clinical nutrition program a diagnostic and/or preventive tool for malnutrition detection. Hospitals must have these processes in place a. Step 1: Nutrition screening = entry level diagnostic process for malnutrition detection; indicator used: presence of a nutrition screening tool or physicians entry of height and weight in the patient s chart b. Step 2: Nutrition assessment = higher level process of qualifying the degree the malnutrition of the initially detected at risk of developing malnutrition patient; indicator used: presence of a nutrition assessment tool (e.g. the PhilSPEN nutrition assessment tool) (5) 2. Level 2 or Intermediate Level: presence of an interventional clinical nutrition process like nutrition care plan, food intake monitoring or feeding protocols. These steps should be in place: a. Step 3: Nutrition care plan development and implementation = the initial interventional aspect of patient care where the nutritional requirements are determined and the manner of delivery of nutrients designed

4 4 b. Step 4: Nutrition care delivery and monitoring; the indicators used here are the presence of feeding protocols which includes gastric residual volume monitoring 3. Level 3 or Advanced Level: presence of a clinical nutrition team with both Level 1 and Level 2 processes in place a. Steps 1 to 4 are in place b. Step 5: The monitoring process includes documentation of the nutrition delivery process and analysis on improving the nutrition care process Then the hospitals with the same levels were grouped together and their specific felt- needs discussed. Then practical approaches were brainstormed and solutions recommended to solve/handle these needs/issues. Table 3: Felt- needs for organizing a clinical nutrition program and nutrition team Felt Need Question 1. Nutrition screening and Do you need one and how can PhilSPEN and Abbott assessment help? Where will you get the funding? 2. Nutrition intervention Do you need the forms for nutrition care plan? Do you need workshops on how to conduct nutrition care plan and computation for requirements? 3. Clinical nutrition Do you need clinical nutrition guidelines? Resources? guidelines 4. Nutrition team Do you need help in organizing for a nutrition team? development Are you ready to have one? How can you obtain funds 5. Clinical nutrition personnel for sustaining a team and a program? Do you need a clinical nutrition dietitian or physician? Do you need resources and funding? How can PhilSPEN and Abbott help? RESULTS Level 1 Hospitals: Table 4 shows the hospitals placed in the Basic category. Table 4: Hospitals with nutrition screening and assessment (=Level 1) Nutrition screening and assessment NCR Luzon Visayas Mindanao Total Participating hospitals (+) screening system 4/10 4/11 2/3 2/2 12/26 (40%) (36%) (66%) (100%) (46%) (+) tool for screening 9/10 9/11 1/3 1/2 21/26 (90%) (82%) (33%) (50%) (80%) (+) nutrition assessment 7/10 9/11 2/3 1/2 26 (70%) (82%) (66%) (50%) (77%)

5 5 (+) Physician checks height/weight on admission NCR = National Capital Region 5/10 (50%) 3/11 2/3 (66%) 11/26 (42%) Seventy seven to eighty percent (77% - 80%) of the participating hospitals had a nutrition screening and assessment process, which indicates a high degree of awareness for the need to identify malnutrition among the patients. The majority of hospitals, which had nutrition screening and assessment tools were in the National Capital Regions and Luzon. Level 2 Hospitals: Table 5 shows the hospitals placed in the Intermediate category: Table 5: Hospitals with nutrition intervention procedures (=Level 2) Interventional Procedures NCR Luzon Visayas Mindanao Total Participating hospitals (+) feeding protocol for ICU, surgery 5/10 (50%) 8/11 (73%) 1/3 (33%) 15/26 (58%) (+) monitor nutrition intake 6/10 (60%) 7/11 (64%) 1/3 (33%) 15/26 (58%) GRV < 50ml: hold feed 2/10 (20%) 1/11 (9%) 0/3 3/26 (12%) GRV > 100 ml: hold feed 3/10 (30%) 7/11 (64%) 0/3 2/2 (100%) 13/26 (50%) GRV hold feed: no answer 5/10 (50%) 3/11 3/3 (100%) 11/26 (42%) TF: 100% blender form 0% 0% 0% 0% 0% TF: commercial formula 2/10 (20%) 3/11 1/3 (33%) 7/26 TF: blender/ commercial 8/10 (80%) 7/11 (64%) 2/3 (66%) 2/2 (100%) 19/26 (73%) GRV = Gastric Residual Volume; TF = Tube Feed; NCR = National Capital Region Fifty to fifty eight percent of the participating hospitals (50% - 58%) had Level 2 competencies (=interventional nutrition process like feeding protocols and monitoring e.g. GRV monitoring). Utilization of pure commercial formulas for the hospital diet and enteral nutrition is within the range of 20% - 30% while mixed blendered and commercial formulas comprise 2/3 (73%) of all feeding regimens (range: 64% - 100%).

6 6 Level 3 Hospitals: Table 6 shows the hospitals placed in the Advanced category: Table 6: Hospitals with full clinical nutrition program and nutrition team (=Level 3) Parameters NCR Luzon Visayas Mindanao Total Participating Hospitals (+) screening (+) assessment (+) prevalence malnutrition data (+) identify severe malnutrition (+) assess high risk (+) measure intake / adequate intake 3/10 (30%) 3/11 1/3 (33%) 7/26 There are 7/26 or 27% of participating hospitals which have a fully functioning clinical nutrition program with a nutrition team in place. Most of them are in the urban centers like Manila, Cebu and Davao indicating that the level of quality care is still highest in the urban areas and still to be developed in the provinces. Felt- Needs of the different hospitals: Table 7 shows the felt needs of the different institutions in setting up a clinical nutrition program: Table 7: Felt needs and suggested solutions Felt Needs Background Suggested solutions Nutrition 44% use PhilSPEN forms PhilSPEN has the forms screening and 14% use BMI- based screening assessment (downloadable from website) Abbott can coordinate with the institutions for sustaining these forms Nutrition intervention Clinical nutrition guidelines 70% have some form of patient assessment mainly in the ICU 27% use the PhilSPEN modified SGA form (5) PhilSPEN national or regional conventions and Abbott nutrition sponsored seminars are available 30% do not assess high risk/icu patients 48% do not have feeding protocols for the ICU 22% do not feed ICU patients availability Assessment can be downloaded from website PhilSPEN and Abbott can help in organizing seminars on the clinical nutrition process for the multi- disciplinary team the institution or the team can request for one PhilSPEN and Abbott can provide the clinical nutrition guidelines and/or literature from the international societies and

7 7 Nutrition team development Clinical nutrition personnel even after 48 hours 48% do not measure actual intake and percent requirement for the ICU patient 78% do not know what is considered the cut- off for inadequate intake 78% hold feedings even when GRV is below 100 ml 70% still use mixed blenderized and commercial formulas for enteral nutriton 22% are now using commercial formulas for enteral nutrition 0% - no one uses blenderized enteral formulas anymore Do you need help in organizing for a nutrition team? 100% said YES. Only 27% have a fully functioning nutrition team Most of the 73% who have no teams are willing to organize, but expressed need for administration support and funding Only 48% follow up clinical nutrition patients 100% indicated need for more personnel 100% indicated need for more funding to achieve this local recommendations especially for the different disease states Regular reporting on local critical care nutrition is encouraged PhilSPEN and Abbott will conduct contests for researches in clinical nutrition Study grants for research are available PhilSPEN is more than willing to help Abbott can provide resources in education materials and formal visits to hospitals with functioning teams St. Luke s Medical Center presented data on how to have a clinical nutrition team that is self- sufficient the role of oral supplements provision played a key role (6) PhilSPEN and Abbott can help in providing information and guidelines in patient follow- up; they can also organize short term visits for observations on how to run a clinical nutrition program and team ROI (return of investment) data are available from the PhilSPEN website (6)

8 8 DISCUSSION The hospitals, which presented their state of affairs in the practice of clinical nutrition, were mainly private institutions (92%) there were only two participating government hospitals (2/26 or 8%). The presence of a clinical nutrition process in the hospital is the benchmark which qualifies an institution as basic, intermediate, or advanced level in terms of quality of nutrition care. 46% (12/26) of hospitals declared they have some form of nutrition screening process, which place them on the basic level, but it is not clear whether this was done on all admitted patients. However 80% indicated they have a nutrition screening tool, with the PhilSPEN nutrition screening tool as the preferred one (44%). This is encouraging in regard to the efforts of the society (PhilSPEN) in promoting malnutrition detection in the hospitals for the past twenty (20) years. Today it is shown that every institution has placed malnutrition detection (=nutrition screening) in its primary care procedures. (2) 77% (26) of these hospitals are performing nutrition assessment of their high- risk patients. For hospitals on the intermediate level around 58% to 73% (n=15 to 19) already have protocols for feeding critical care patients and monitoring their progress. Some areas still need improvement like establishing adequate energy and nutrient intake levels or gastric residual volume protocols, but they are already on track. It will only be a matter of time before they will reach the advanced level. Hospitals which have reached the advanced level comprise 27% (7/26) of the whole participant population. This may at first appear low, but reviewing the history of the development of nutrition teams in the country, this is good evidence which shows that the drive to establish nutrition teams may be slow, but sure from 22% in 1998 to 27% today (2014). (7) What is notable at this time is the focus and awareness of clinical nutrition practice it is still in the urban centers and not much in the provincial levels. There is a lot of work needed in this area, perhaps the current thrust of doing regional clinical nutrition conferences by PhilSPEN may help. (8) So what factors may help to fast track this development concern? In the felt- needs data, these are the primary concerns and possible solutions: a) Nutrition screening and assessment forms are readily available in the PhilSPEN website. A regular provision for downloading and supporting availability of these forms to the interested institutions can be done both by Abbott Nutrition and PhilSPEN. Seminars and symposia can be organized to familiarize these tools in the hospital b) Nutrition care plan development and formulation the process of teaching all institutions on the formulation of nutrition care and designing each patent s

9 9 requirement can be done through different symposia either through a regional or individual hospital context. (8) Again the partnership between PhilSPEN and industry will be able to address this area of development. c) The current need for references as to what or how to implement nutrition therapy is one of the priorities in clinical nutrition practice development. Here provision of clinical nutrition guidelines as well as literature or study/research materials will help every institution update or revise their current diet practice and patient care. The vast resources of industry will help in providing these requirements with guidance or through proposals from either PhilSPEN or medical/surgical societies. Large international societies like ASPEN (American Society of Parenteral and Enteral Nutrition) (9), ESPEN (European Society for Clinical Nutrition and Metabolism) (10) have created consensus guidelines in clinical nutrition practice in major specialty areas with updates done on a regular basis. By having these information within reach through postings or actual sharing of articles PhilSPEN and Abbott Nutrition can do much in filling up this need. At this time there are now attempts to make simplified clinical nutrition on the local level. Changes in practice in clinical nutrition are now seen. In this conference no participant has indicated using full blenderized tube feeding formula for enteral nutrition (26/26 or 100%). This is an important development specially in the area of patient safety since two local studies have both raised the issue of bacterial contamination in all hospital blenderized diets. (11,12). Improvements in practice still need to be seen in the following areas: calculation of energy and protein intake, monitoring of actual nutrient intake, need to measure gastric residuals and when to stop feeding. Industry and PhilSPEN can help through sponsoring studies in these areas and organizing competitions for researches done in the same areas. The establishment of clinical nutrition teams in every institution may still be far- off, but with the partnership of PhilSPEN, the different medical societies and industry this goal may be fast- tracked. A key factor is sustainability of the nutrition team and others call this the ROI (=Return of Investment) factor. The seven (7) participant hospitals, which have the full clinical nutrition program and nutrition team, have shown the way. They had different approaches and manner of reaching this goal, but the common factor is - the team is headed or coordinated by a graduate or graduates of the clinical nutrition fellowship training program at St. Luke s Medical Center Quezon City. (13) Industry can help in this goal by providing resources that will help develop and/or sustain the practice and team in clinical nutrition in the hospital setting.

10 10 REFERENCES: 1. Butterworth CE Jr. The skeleton in the hospital closet. Nutrition1994; 10(5): History of clinical nutrition in the Philippines. Philippine Society of Parenteral and Enteral Nutrition (PhilSPEN) website. Available at: Accessed July 16, Waitzberg DL et al. Total nutritional therapy: a nutrition education program for physicians. Nutr Hosp 2004; 19(1): First hospital nutrition state of the art summit: Abbott Nutrition. Available at hospital- nutrition- state- of- the- art- summit- manila- philippines. Accessed July 18, Lacuesta- Corro L et al. The results of the validation process of a Modified SGA (Subjective Global Assessment) Nutrition Assessment and Risk Level Tool designed by the Clinical Nutrition Service of St. Luke s Medical Center, a tertiary care hospital in the Philippines. PhilSPEN Online Journal of Parenteral and Enteral Nutrition; Article 12 (Issue February December 2014): 1-7. Available at: Accessed July 17, First Philippine Hospital Nutrition Summit: St. Luke s Medical Center Quezon City best practice presentation (Financial viability, Slides 7-10). Available at: Accessed July 18, Hospital Malnutrition and Clinical Nutrition Program Task Force, Philippines. The role of the PHILSPEN and clinical nutrition fellowship training program. PhilSPEN Online Journal of Parenteral and Enteral Nutrition; Article 5 POJ_0017.html) Issue January January 2012: Available at: Accessed July 20, The PhilSPEN regional clinical nutrition congress. Available in Accessed July 21, American Society of Parenteral and Enteral Nutrition (ASPEN). Available at: Accessed July 21, European Society for Clinical Nutrition and Metabolsim (ESPEN). Available at: Accessed July 21, Tanchoco CC et al. Enteral feeding in stable chronic obstructive pulmonary disease patients. Respirology 2001; 6(1): Sullivan MM et al. Bacterial contamination of blenderized whole food and commercial enteral tube feedings in the Philippines. J Hosp Inf 2001; 49(4): The clinical nutrition fellowship training program. PhilSPEN website. Available at

11 11 Accessed July 21, 2015.