ESPEN Congress Istanbul 2006

Transcription

1 ESPEN Congress Istanbul 2006 Guidelines in clinical nutrition practice Implementing guidelines nutrition support team S. Bischoff (Germany)

2 28th ESPEN Congress, Oct 2006, Istanbul Implementing guidelines nutrition support team (NST) Stephan C. Bischoff, MD Professor of Medicine Chair of Nutritional Medicine & Prevention University of Hohenheim Stuttgart, Germany ernährungsmedizin & prävention

3 Definition of Clinical GUIDELINES in the Web Clinical guidelines are systematically developed statements for practitioners and patients about appropriate health care for specific clinical circumstances. Statements developed through a specific process that are designed to assist health practitioners and patients in making appropriate health care decisions about a specific condition or treatment. Clinical guidelines are usually developed under the auspices of a medical association or government agency by a panel of experts, and are based on a thorough review of scientific studies on the topic being addressed.

4 What is a Nutrion Support Team (NST)?

5 Definition of a Nutritional support team (NST) A multidisciplinary team/unit with expertise in nutrition, which is involved in nutritional support, whose remits varies according to local circumstances, interest and resource allocations. Usually takes active part in nutritional support, and serves in a quality control capacity, standardising practice, gathering new information and educating other health care professionals. Council of Europe. Committee of Ministers. Resolution ResAP(2003) on Food and Nutritional Care in Hospitals

6 The Link Knowledge Standards Recommendations Instructions Manual Executive Guidelines NST A set of general procedures/principles Experience Enhanced Knowledge

7 Nutrition Guidlines in Germany ESPEN guidelines for Enteral Nutritiıon Clın Nutr German guidelines for Parenteral Nutrition Akt Ernaehrungsmed 2006 ın press

8 Guidelines for management of HPN in adult chronic intestinal failure patients Outcome improvement for intestinal failure patients needs intestinal failure teams having expertise in all medical and surgical aspects of this field. Messing B, Joly F. Gastroenterology 130:S43-51, 2006

9 Consequences 1. NST should perform EBM 2. NST need guidelines 3. NST need to participate in developing guidlines 4. Outcome studies on NST using guidelines are needed

10 Tasks of a NST Nutritional assessement Nutritional recommendations for patients and professionals Check of the indication of a particular nutrition support (enteral/parenteral nutrition etc.) Realization and/or supervision of nutrition support Surveillance for complications Act following up-to-date literature and guidelines Provide instruments for quality ensurance and prove of efficacy

11 Particular task: Home enteral and parenteral nutrition (1) Prepare the patients and the logistics for artificial nutrition at home before demission (2) Registration of the disease/disease state, the prognosis, the expectations/wishes of the patient and his family ( informed consent ) (3) Definition of the type of intervention (enteral or parenteral, individual or general dispensing) (4) Contact of the family doctor, the insurance, the pharmacy, the provider and the nursing service) (5) Monitoring of the nutrition administration and the follow-up status (if possible) (6) Teaching and advicing the family, the doctor, and the nursing service in case of complications

12 NST international comparison UK 37 % USA 30 % Germany 2-5% Turkey??? Elia et al. J R Coll Physicans Lond 27, 8-15, 1993 Senkal et el. Clin Nutr 21, , 2002 Shang E et al. Clin Nutr. 24: , 2005

13 Results I: Responsibilites of the NST/ other personnel Time of consultation of the NST Decision-making on nutrition therapy % at admittance in case of problems % NST unclear other personnel

14 Results II: Quality control % Quality control in NST Guidelines No guidlines Guidelines include internal guidelines as well as EBM guidelines of national and international societies

15 Organigramm Krankenhausleitung Kliniken Abteilungen Beteiligung an Entscheidungsprozessen Stationen Ambulanzen Ernährungsteam Apotheke Endoskopie Zuweisung von Patienten Konsultation und Beratung Zubereitung bzw. Lieferung von TPE nach Maßgaben des Team Zusammenarbeit bei der Anlage von PEG s

16 Conclusion of these studies Low prevalence of NST in Germany Need for nutritional standards and guidelines Improve of financial support of NST required

17 Medical and cost efficacy of Nutfrition Support Teams (NST)

18 Efficacy of NST Original studies Descriptive studies Reviews/ Metaanalysis USA UK Deutschland sonstige Total: 15 Studies (2005)

19 Nutritional support of the hospitalized patient The team concept A. E. Nehme, JAMA 243:1906-8, 1980 Prospective study over 24 month A: n = 211 managed by a NST B: n = 164 managed by a variety of physicians Complications of catheter insertions A (284) B (391) Pneumothorax 0 12% Malposition 3% 13% Total 3% 33% Catheter sepsis 1.8% 12.5% Metabolic complications A (211) B (164) Electrolyte imbalance 6 59 ph imbalance 6 31 High amonia 2 17 Trace elements 2 8 Hyperglycemia 0 11* Folate defiency 8? Essential FA defiency 0 9 Rebound hypoglycemia 0 17** * 8 died ** 2 died

20 Dalton MJ, et al. Consultative total parenteral nutrition teams: the effect on the incidence of total parenteral nutrition-related complications JPEN J Parenter Enteral Nutr , Study design: Group A: 28 pts on TPN Group B: 29 pts on TPN, supported by a NST that took care for the indication for TPN, katheter issues, and control of laboratory parameters

21 Results I Mechanical complications Group A Group B No. of catheters No. of pts Overal complications 7 2* Air embolism 3 0* Catheter dislocation 1 0 Catheter disconnection 1 0 *Significant difference between A and B! Dalton MJ, et al. JPEN 8; , 1984

22 Results II Metabolic complications No significant difference between A and B with regard to blood electrolyte and glucose levels Total numbers of metabolic complications reduced in group B (p < 0.01) Dalton MJ, et al. JPEN 8; , 1984

23 Outcomes in a pediatric intensive care unit before and after the implementation of a NST Analysis of a historical cohort study of infants hospitalized for >72 hours at the PICU Five periods were selected (P1 to P5), considering the modifications incorporated into the program: P1, without intervention; P2, basic themes and original articles discussion; P3, clinical and nursing staff participation; P4, clinical visits; P5, NST. RESULTS: Increase in EN use from 25% in P1 to 67% in P5 (p =.0001) Reduction in PN use, from 69-73% in P1 to 0% in P5 (p =.0001) Reduction in mortality rate during P4 and P5 among medical patients (p <.001) The risk of death was 83% lower in patients that received EN for >50% of LOS (OR = 0.17; CI ; p =.000) Gurgueira GL, et al. JPEN 29:176-85, 2005

24 Implementation of dietitian recommendations for enteral nutrition results in improved outcomes Registered dietitian recommendations lead to shorter length of stay (28.5 ± 1.8 vs 30.5 ± 4.8 days, P < 0.05) improved albumin (0.13 ± 0.17 vs ± 0.21 g/dl, P < 0.05) weight gains (0.51 ± 0.10 vs ± 0.20 %, P < 0.05) Braga JM, J Am Diet Assoc. 106:281-4, 2006

25 Metaanalysis: Gales BJ, Gales MJ. Nutritional support teams: a review of comparative trials. Ann Pharmacother 28: , 1994 Improve in catheter sepsis rate Reduction of metabolic complications Improved documentation Redction of costs

26 Reduction of costs by Applying EBM guided criteria for the indication of artificial nutrition Early detection of malnutrition avoidance of complications Quick start of an appropriate enteral or parenteral nutrition Reduction of the complication rates Careful selection of products and of laboratory means for follow-up controls Critical questioning the start and end of nutritional intervention

27 Decrease of inappropriate PN by the work of a NST Indications were checked by the NST based on the ASPEN standards The number of inappropriate TPN orders declined from 62/194 (32.0%) in the 1st year to 22/168 (13.1%) in the 2nd year (P < ), and to 17/215 (7.9%) in the final year of data collection Surgery Department, University of Virginia, Charlottesville Saalwachter AR, et al. Am Surg. 70: , 2004

28 Costs of avoidable PN With NST Without NST TPN necessary - - TPN necessary and GI tract functional $ $ EN/PN not necessary 903 $ $ Total $ $ Trujillo EB, et al. JPEN 1999, 23:109-13

29 Cost savings of an adult hospital nutrition support team I The Leicester Royal Infirmary experience, UK NST founded in 1999 Data collected about all patients given PN for 2 consecutive years (a retrospective pre-nst year and a prospective NST year). Aim of the study (1) Cost savings (equipment, investigations, and medication costs for PN) (2) Quality issues (placement of PN catheters, catheterrelated sepsis (CRS), duration of PN, and mortality) Kennedy JF, Nightingale JM. Nutrition 21: , 2005

30 Cost savings of an adult hospital nutrition support team II pre-nst year NST year: 82 PN episodes 78 PN episodes (54 patients) (75 patients) 71% CRS rate 29% CRS rate P < 0.05 (7/100 PN days) (3/100 PN days) 7% (0.6/100 PN days) in the final 3 mo Tangible cost savings for the NST year were derived from 55 avoided PN episodes ( pounds sterlings) and 35 avoided CRS episodes (7.974 pounds sterlings) In-hospital mortality for patients who had PN 23 of 54 (43%) in the pre-nst year compared with 18 of 75 (24%) in the NST year (P < 0.05) Kennedy JF, Nightingale JM. Nutrition 21: , 2005

31 Conclusion: NST are most efficient if they work following EBM guidelines! Acting according to most recent data and guidelines Reduction of mechanical and metabolic complications of artificial nutritions and associated costs NST required not only in hospitals but also for out-patients!