PhilSPEN Online Journal of Parenteral and Enteral Nutrition. Issue January- June

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1 Title: Nutrition care of ICU patients upon discharge from hospital to community (Delivered at the Abbott Nutrition Night, PENSA in Taiwan, October 2011) Authors: Eliza Mei Francisco MD and Luisito O. Llido MD Nutrition Society Affiliation: Philippine Society of Parenteral and Enteral Nutrition (PhilSPEN) Introduction and objectives of the presentation: The care of the ICU patients discharged from the hospital has not been fully established in the Philippines, thus it is a challenge for the attending physician to ensure that the care of the patient in the home setting will lead to at least maintenance of his/her body composition and functions. The problem is compounded when the patient is on ventilator support, hemodialysis or both. Indeed, all concerned parties from the physicians, support caregivers and logistic resources need to be involved in order to improve patient care in the out- patient setting. This report has the following goals: a) To discuss nutritional issues during ICU and post- ICU discharge, b) To discuss nutrition care plan for post- ICU patients, c) To discuss follow up and monitoring issues for the post- ICU patients and d) To present local experience and suggestions on home nutrition care for ICU patients. Nutritional issues in the ICU and post- ICU setting: clinical pathway The nutritional management of ICU patients covers this structured system of care (Figure 1) which is the determination of the nutritional status of the patient and the risk of developing complications which will have a major impact on morbidity or mortality. The nutrition care plan that is developed is in full congruence with the other modalities of treatment which change depending on how the patient responds to the therapy. The implementation of this plan is monitored and will be the basis for the decision changes in management. This structured system will carry over to the post- ICU period until such a time when the patient is ready for discharge from the hospital. 1

2 Nutrition issues: ICU and post- ICU In the critical care setting (ICU) there are now several nutrition strategies available for use in patient care and recovery. These are: 1) Different forms of enteral nutritionals which fit the GIT ability to maximize its function from nutrient digestion and absorption to mucosal defense, 2) Disease specific nutritionals that are tailored to fit the disease itself like modifications for pulmonary disease function and status, for diabetes or for better glucose control, for renal problems from macro to micro modifications, and for cancer (either upbuilding or immune modulation), 3) 3)Pharmaconutrients are now developed that further improve status and function through their ability to modify the inflammation status of the cell environment, enhance the energy provision of all cells, and effect the cellular external environment like perfusion and response to the injury process. These can be used in combinations that tailor fit the patient s needs. These are also in either enteral or parenteral formulations which allow achievement of adequate intake in all disease states or when the gastrointestinal tract is inoperative. This same approach is also needed in both the post- ICU and home environment. (Figure 2) Post- ICU patient profile Essentially this is the state of the discharged ICU patients: a) Loss of lean body mass due to the following states (sarcopenia 1], cachexia [2], critical care state [3], and malnutrition [4]), b) Multi- organ dysfunction or failure [3] and c) Immune depression or labile immune system [3]. The major difference is the patient is now able to have moderate degree of recovery of both structure and function which has allowed him/her to be discharged. 2

3 86% of the problems met covers major organ status and function which have to be addressed nutritionally as well as the overall aspect of disease as reported in a local report (unpublished) by Sioson M (MS), Reyes MC (MCR) and Francisco EM (EMF). It is to be noted that stroke and cancer patients consist at least 40% of the patient population. (Figure 3) Post- ICU management issues In most of the problem areas focus needs to be done on the following: Sarcopenia/cachexia Cardio- pulmonary function Metabolic management (glucose control) Immune function optimization Intake of adequate and complete nutrients Weight maintenance or gain Rehabilitation (= exercise) Nursing care (pressure ulcers) An uphill battle in regaining pre- ICU status is seen with the involvement of more issues mentioned above as shown in the report of Herridge et al. on pulmonary problem patients [5], Villet et al. on infection and negative energy balance and Cederholm et al. on worsening malnutrition status in elderly patients while at home care. Home Care Nutrition Surveys of years 2005 and 2010 Two surveys were done on the status of home care practice in the Philippines. The first was done in 2005 after the first congress of clinical nutrition was launched in 2004 and questions regarding this issue were 3

4 raised. The second survey was done in 2010 when one of the principal investigators of the initial survey organized an out- patient home care service in her institution (EMF). Results of the Home Care Nutrition Survey in 2005 [8] Patient Profile (Table 1) Variables Number/value (n=70) Male 55% Female 45% Age distribution < 40 years old 16% years old 16% years old 19% years old 30% years old 16% >90 years old 3% Type of Feeding (Table 2) Table 2: Type of Feeding Number/value (n=70) Oral 21% Enteral 72% Commercial preparation 59% of all enteral feedings o Polymeric 44% of all commercial preparations o Semi- elemental 6% of all commercial preparations o Modular 20% of all commercial preparation o Disease- specific 30% of all commercial preparations Blendered preparation 13% of all enteral feedings Combined preparation (1 and 2) 28% of all enteral feedings Parenteral 7% Who provides the discharge instructions and who are the primary care givers? (Table 3) Table 3: Discharge Instructions Number/value (n=70) Who provides/provided the discharge instructions? Attending physician 26% Specialist physician 1% Dietitian 20% Nutrition team 17% Nurse 1% Relative 29% Who is the primary care provider? Relative 55% Nurse 25% 4

5 Yaya (=home caregiver) 5% Midwife 1% The ultimate care provider of the patient is the relative or yaya (home caregiver who has minimal training in this kind of care) and they comprise 60% of the overall care of this high risk patient which is far from the ideal or acceptable set up i.e. nurse or special provider who is knowledgeable in this field (25%). Status of discharge instructions on nutrition care of the patients On discharge the proper endorsement and instructions were given to the patient or the family (93%). Then these follow up issues set in: 1) 79% of patients were not seen/available for follow up, 2) 83% of the caregivers were not aware of the previous instructions or even the protocols and guidelines to be followed for the patient s care. (Figure 4) This would add to the issue of adequate care which is mainly given by untrained personnel. Outcomes of the Home Care Survey 2005 (Figure 5) The outcomes show the manner of home care nutrition: 1) The rehospitalization rate was low at 6% and mortality rate was 7% (quite low), 2) There were no complications noted in 28% of patients followed up. These are the different types of complications encountered: 1) Mechanical, like ventilators, enteral and parenteral nutrition delivery (14%), 2) Metabolic problems (14%), 3) Gastrointestinal problems (22%) apparently nutrition care delivery is still to be improved. 5

6 Results of the Home Care Nutrition Survey in 2010 [9] The nutrition team of Asian Hospital Medical Center was formally established in This is the first hospital in the country which established the structured home nutrition care service based on the international standards of the Joint Commission International (JCI) [10]. This was headed by Dr. Eliza Mei Francisco and this is their report. Table 4: Patient profile and outcomes Number/value (n=70) ICU (n=36) 51% ICU patients discharged as palliative care 6% ICU patients who died (8/36) 22% Non- ICU (n=34) 49% Non- ICU patients discharged as palliative care 6% Non- ICU patients who died 0% Organs affected and mortality outcome (Figure 6) This is the relationship of the number of organs affected to outcome: 1) Pulmonary, renal or gut failure - patients on mechanical ventilators with or without central lines or dialysis support died within 21 days, 2) Gut and renal failure - patients on central parenteral nutrition or dialysis had fewer mortalities compared to those with ventilators, 3) Patients on standard care had a 5% mortality within 150 days and if they survive beyond this period no mortality was noted. 6

7 Critical care patients have the highest mortality rates once discharged. These are the implications: a) Organ system dysfunction or failure has a major role in outcome (most patients on ventilators don t last long beyond 21 days), b) Patients who survive beyond 150 days have low mortality, c) Loss of lean body mass is central to the outcome status Feeding profile of discharged patients: (Table 5) The feeding status of these patients were similar to the 2005 survey: a) 66% were tube fed, b) 32% had oral intake with or without enteral or parenteral nutrition supplementation, c) 1% had full parenteral nutrition. Table 5: Feeding profile Number/value Oral 25% Oral and parenteral nutrition 7% Tube feed 63% Tube feed and parenteral nutrition 3% Parenteral nutrition 1% This is the feeding profile of the patients discharged from the ICU (Figure 7) The intake of the ICU patients show these patterns: a) 45% of feeding were given through the gastrointestinal tract, b) 3% had full parenteral nutrition and c) 15% had supplemental parenteral nutrition. It will be noted here that these modifications were designed to achieve adequate intake of the patients. 7

8 Feeding type of ICU patients and mortality (Table 6) This table shows the relationship between type of feeding and mortality of the patients discharged from the ICU. Once they lose oral intake and become dependent on enteral and parenteral nutrition mortality starts to rise. This is indicative of the contribution of multiorgan failure (e.g. gastrointestinal) to increasing the morbidity or mortality of the patient s status. The role of pharmaco- nutrition in mortality outcomes (Table 7) Table 7: Pharmaco- nutrition given Alive (n=28) Died (n=8) Glutamine alone 4% 23% 8

9 Fish oil alone 32% 13% Fish oil and glutamine 14% - Fish oil, glutamine, antioxidants 4% 13% None 46% 50% For the patients who were discharged alive there is a heavy utilization of pharmaco- nutrition, but this utilization was also seen in the patients who died. There were more patients discharged alive however (28 vs. 8). The role of a specialist in the care of patients discharged from the ICU The role of the private duty nurse in the type of outcome can be seen in this table (Table 8). It shows the relationship between mortality and the quality of service provided to the patient specially with the presence of special interventions. Most of the mortalities were in patients where no private duty nurse (PDN) was provided to give over- all care. Conclusion In conclusion: 1) There is a need for a full multidisciplinary trained home care nutrition team to follow up discharged ICU patients, 2) Lean body mass loss and inflammation still need to be addressed through all means (e.g. type of feeding and addition of pharmaconutrients, exercise), 3) Identified problem areas leading to mortality are: a) Mortality is associated with 2 or more organ failures (e.g. cardiopulmonary and gastrointestinal failure) and b) Quality of care delivered by the caregiver needs more improvement Proposed work flow The proposed workflow of the hospital nutrition care service set up on discharge is shown in Figure 8 and followed by the following: a) Caregiver education and monitoring of outcome, b) Documentation of outcome data and c) Scheduled discussion/conference with both hospital clinical nutrition team and attending physician or other specialists 9

10 References 1. Vandewoude M. Sarcopenia. Abbot symposium on sarcopenia, ESPEN 2011; Goteborg, Sweden. 2. Bozzetti F et al. ESPEN guidelines in parenteral nutrition: non- surgical oncology. Clin Nutr 2009; 28(4): Rosenthal MD, Moore FA. Review: Persistent inflammatory, immunosuppressed, catabolic syndrome (PICS): A new phenotype of multiple organ failure. J Adv Nutr Hum Metab 2015; 2: e784. doi: /janhm Hegazi R et al. Malnutrition syndrome. TNT or Total Nutrition Therapy version 3; Herridge MS et al. One- year outcome in survivors of the Acute Respiratory Distress Syndrome. NEJM 2003; 348(8): Villet S, Chiolero R, Bollmann M et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 2005; 24: Cederholm T, Jagren C, Hellstrom K. Outcome of protein- energy malnutrition in elderly medical patients. Am J Med 1995; 98: Francisco E, Sioson M, Reyes T. Profile of home care nutrition practice in the Philippines, (unpublished) 9. Francisco EM. Home Care Nutrition Survey (unpublished) 10. JCI accreditation is considered the gold standard in global health care. 10