Department of Oncological Radiotherapy Xiangya Hospital Central South university, China Senior Nurse Qiaomiao Zeng

Transcription

1 Effect of applying multidisciplinary nutrition management mode on nutritional status and clinical outcomes of patients with head and neck cancer undergoing radiotherapy Department of Oncological Radiotherapy Xiangya Hospital Central South university, China Senior Nurse Qiaomiao Zeng

2 1 Background 2 Purpose 3 Method 4 Results 5 Discussion

3 01 Background cc

4 Background The incidence of malnutrition in patients with head and neck cancer was 3-52% before the start of radiotherapy or chemoradiotherapy, while the incidence of malnutrition increased to 44-88% during the process of treatment [1-2] [1] Langius JAE, Doornaert P, Spreeuwenberg MD, Langendijk JA, Leemans CR, Schueren MA. Radiotherapy on the neck nodes predicts severe weight loss in patients with early stage laryngeal cancer. Radiother Oncol 2010;97:80 5. [2] Unsal D, Mentes B, Akmansu M, Uner A, Oguz M, Pak Y. Evaluation of nutritional status in cancer patients receiving radiotherapy: a prospective study. Am J Clin Oncol 2006;29:183 8.

5 Background A series of side effects... Weight Loss Interruption of Treatments Poor treatment tolerance prolonged Length of Stay Increased medical expenses

6 Background Nutrition Management:Screening Assessment Intervention Monitoring With a series of interventions of malnutrition management, the radiotherapy disruption can be reduced, patients clinical outcomes,survival and quality of life could be improved [1] Prevost V, Joubert C, Heutte N, et al. Assessment of nutritional status and quality of life in patients treated for head and neck cancer[j]. European Annals of Otorhinolaryngology Head & Neck Diseases, 2014, 131(2): [2]Langius J A, Zandbergen M C, Eerenstein S E, et al. Effect of nutritional interventions on nutritional status, quality of life and mortality in patients with head and neck cancer receiving (chemo)radiotherapy: a systematic review.[j]. Clinical Nutrition, 2013, 32(5):671. [3] 彭粤铭, 葛茜, 罗伟香. 住院患者营养筛查及管理模式的研究进展 [J]. 中华现代护理杂志, 2017, 23(11):6-10. Peng YM, Ge Q, Luo WX, Research progress of nutritional screening and management model in hospitalized patients [J]. Chinese Journal of Modern Nursing, 2017, 23 (11): [4] Müllerrichter U, Betz C, Hartmann S, et al. Nutrition management for head and neck cancer patients improves clinical outcome and survival.[j]. Nutrition Research, 2017, 48:1.

7 Background Quality Improvement Investigation on the screening rate of nutritional risk in patients with head and neck cancer(n=97) Wards Cases in total Screening Cases Percentage (%) No.65 69W Tabulator:Xiaofeng Zhen Date of tabulation: Investigation Date: Respondents: Head and Neck Cancer Patients Aim: to investigate the situation of nutrition screening Investigation Location: Oncology 65, 69 Ward Investigation method:checklist Investigators:Qin Man, Qiaomiao Zeng

8 Background Investigation on the incidence of malnutrition among head and neck cancer patients NRS 2002 (Nutrition Risk Screening) PG-SGA (Nutrition Assessment) Investigation Date: Respondents: 95 Head and Neck Cancer Patients(Patients who were admitted to hospital on the investigation date will be excluded ) Aim: to investigate the incidence of malnutrition among head and neck cancer patients Investigation Location: Oncology 65, 69 Ward Investigation method:nrs2002 screening and PG-SGA assessment Investigators:Qin Man, Qiaomiao Zeng

9 Background Investigation on the incidence of malnutrition among head and neck cancer patients Assessment Results Cases Percentage(%) PG-SGA scored PG-SGA scored Malnutrition cases in total Nutrition Nurse was doing PG-SGA for patients Tabulator:Qiaomiao Zeng Date of tabulation: The incidence of malnutrition was 50.53% Investigation Date: Respondents: 95 Head and Neck Cancer Patients(Patients who were admitted to hospital on the investigation date will be excluded ) Aim: to investigate the incidence of malnutrition among head and neck cancer patients Investigation Location: Oncology 65, 69 Ward Investigation method:nrs2002 screening and PG-SGA assessment Investigators:Qin Man, Qiaomiao Zeng

10 [1] Langius JAE, Doornaert P, Spreeuwenberg MD, Langendijk JA, Leemans CR, Schueren MA. Radiotherapy on the neck nodes predicts severe weight loss in patients with early stage laryngeal cancer. Radiother Oncol 2010;97:80 5. [2] Unsal D, Mentes B, Akmansu M, Uner A, Oguz M, Pak Y. Evaluation of nutritional status in cancer patients receiving radiotherapy: a prospective study. Am J Clin Oncol 2006;29: [3] Mueller C; Compher C; Ellen DM; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: Nutrition screening, assessment, and intervention in adults.[j]. Jpen Journal of Parenteral & Enteral Nutrition, 2011, 35(1): [4] 高凤莉, 陈伟, 鲁重美, 等. 头颈部肿瘤患者放疗期间营养状况的变化及其对放疗不良反应的影响 [J]. 中华现代护理杂志,2009,15(33): Gaofengli, Chen Wei, Lu Tongmi, et. Changes of nutritional status in patients with head and neck tumors during radiotherapy and their effects on adverse reactions to radiotherapy [J]. Chinese Journal of Modern Nursing, 2009,15 (33): [5] 彭粤铭, 葛茜, 罗伟香. 住院患者营养筛查及管理模式的研究进展 [J]. 中华现代护理杂志,2017,23(11):6-10. Peng YM, Ge Q, Luo WX, Research progress of nutritional screening and management model in hospitalized patients [J]. Chinese Journal of Modern Nursing, 2017, 23 (11): Background Abroad The incidence of malnutrition in head and neck cancer during the therapy was 44-88% [1-2] The ASPEN and National Cancer Center of the American Society suggest that the nutritional screening rate for hospitalized patients should be 100% [3] China The proportion of patients with moderate to severe malnutrition reached to 90% at the end of radiotherapy [4] According to the statistics from China Nutrition Society, there were nearly one million inpatients each year in our country, however, their nutritional diagnosis rate is less than 1/10,000 [5] Xiangya Hospital The nutrition risk screening rate was 24.74% The incidence of malnutrition among head and neck cancer patients was 50.53% To discuss and construct a standardized and effective nutritional management mode for patients with head and neck cancer is imperative!

11 02 Research Purpose

12 Research Purpose To investigate the effect of multidisciplinary nutrition management mode on nutritional status and clinical outcomes of HNC patients undergoing radiotherapy.

13 03 Research Method

14 Research Method A convenience sampling method Between September 2017 to January 2018, 88 patients with HNC undergoing radiotherapy were recruited from the Radiotherapy Department of Xiangya Hospital in China Included criteria:patients who were assessed as none or mild to moderate malnutrition (PG-SGA scored 2-8) through the Ottery s Patient- Generated Subjective Global Assessment (PG-SGA);Pathological diagnosis was head and neck cancer, patient can withstand radiotherapy, normal liver and kidney function Excluded criteria:combined with other malignant tumors of the system, organ failure, autoimmune disease, active infectious disease, severe cognitive impairment and speech deficiency; refusal to participate in the researcher; the score of PG-SGA 9 Intervention group (N=46) or Control group (N=42)

15 Research Method Respondents Table 1 Baseline characteristics of intervention group and control group(n=88)

16 Research Method Tools PG-SGA(Patient-Generated Subjective Global Assessment) including: Patients self assessment part and clinicians assessment part guided by the PG-SGA operation manual issued by Chinese Anti-cancer Association Patients self assessment part Clinicians assessment part

17 Research Method Method Patients received the multidisciplinary nutrition management mode started from one week before radiotherapy, and last until the end of radiotherapy Intervention Group VS patients in control group were given the routine nutritional guidance Control Group

18 Research Method

19 Research Method Step one Establish a multidisciplinary nutrition management team This management mode is included by a series of nutrition management initiatives led by Decision-making in nutrition Nutrition Consultation Guiding Intervention implementation nurses and participated by both management clinicians, nutritionists and family members Clinicians Nutrition Screening Nutrition assessment Nutritionis t Nurses provider of feedback multidisciplinary nutrition management mode

20 Research Method Step one Establish a multidisciplinary nutrition management team Nutritionists take in charge of training of the team members Content:NRS 2002 PG-SGA Making Diet plan and Diet log Standard:standard operating manual and operating CD issued by the China Anti-Cancer Association Ways of learning:lecture Operation training Lecture Operation Online learning

21 Research Method Step one Establish a multidisciplinary nutrition management team Establishment of Nutrition management team WeChat Group 1 Learning new knowledge 2 Confusion clearing 3 Dynamic monitoring the nutritional status of consultation patients in ward 4 Receive nutritionist advice in time Improves work efficiency Facilitates communication between clinicians, nutritionists and nurses

22 Research Method Step Two Clinicians,nurses and nutritionists formulated the nutrition management standard and procedures nutrition management standard

23 Research Method Step Two Clinicians,nurses and nutritionists formulated the nutrition management standard and procedures nutrition management procedures

24 Research Method Step Three Individualized implementing management scheme Weight measurement Height measurement NRS 2002 PG-SGA Strengthening nutrition education Create nutrition profile Diet plan Diet log

25 Research Method Step Three Individualized implementing management scheme Face-to-face nutrition consultation and lecture

26 Research Method Create nutrition profile for each patient Including: 1 Nutrition File record table 2 NRS2002 record 3 PG-SGA record 4 Diet plan chart 5 Diet log Step Three Individualized implementing management scheme

27 Research Method Key points in nutrition management The 24-hour intake of food was accounted by the Mint Net Food library software in China, the actual intake energy (kcal) and protein (g) were obtained. The daily energy intake=30kcal*ideal weight (kg) ; Protein intake=1.5g*ideal weight (kg) [1] Oral Nutritional Supplement was given to supplement the dietary deficiencies [2] [1] 中华人民共和国国家卫生和计划生育委员会. WS/T 恶性肿瘤膳食指导 [S] National Health and Family Planning Commission of the People s Republic of China. WS/T Malignant tumor dietary guidance [S] [2] Starmer, H.M., Dysphagia in head and neck cancer: prevention and treatment. Current opinion in otolaryngology & head and neck surgery, 22(3), pp

28 Research Method Key points in nutrition management The nutrition nurse regularly check the diet log table Only the nutrition nurse implement the PG-SGA assessment and intake accounting for all the respondents Use measuring tools to guide food intakeons the respondents used were from one company Experiment process control

29 Research Method Data collection Guidelines from Clinical Oncology Society of Australia recommend that head and neck cancer patients should be followed up every 2 weeks during radiotherapy. The changes of evaluate indexes were measured and compared between the two groups at four different stages of radiotherapy, including Pre radiotherapy, the 2nd week, the 4th week, and the end of radiotherapy. Hemogram index Mean energy and protein intake in 24 hours PG-SGA Scoring Evaluate indexes Clinical outcomes 1-month weight loss ratio(%) One months weight loss ratio (%) = (weight of one month ago -current weight)/weight of one month ago Hemogram index(fasting venous blood samples):serum albumin, total leukocyte count, neutrophil count, lymphocyte count, hemoglobin and platelet counts Head and Neck Guideline Steering Committee. Evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer. Sydney: Cancer Council Australia[S/OL].( )[ ]. Head and Neck Guideline Steering Committee. Evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer. Sydney: Cancer Council Australia. Available at:< [Accessed at 15 April 2018]

30 Research Method Statistical analysis Statistical analysis was performed using SPSS18.0 software. The measurement data were described by mean ± standard deviation (SD), and the T-test is used to compare between groups, and the repeated measures analysis of variance (ANOVA) is used to analyze data from different time points. Chi-square test was used in enumeration data analysis, the difference of P<0.05 means statistically significant.

31 04 Results

32 The mean calorie and protein intake of the intervention group at 4 time points of radiotherapy were significantly higher than those of the control group (P<0.001 for all) Results

33 The 1-month weight loss ratio(%)of the experimental group at 4 time points of radiotherapy were significantly lower than those of the control group (P<0.001 for all) Results

34 The PG-SGA score of two groups both increased gradually during radiotherapy, and the PG-SGA score of the intervention group were lower than those of the control group at 2-week, 4-week, and the end of radiotherapy (P<0.05) Results

35 The hemoglobin and serum albumin levels in intervention group at the 4th week and the end of radiotherapy were higher than those of the control group (P<0.001), while in the 2nd week of radiotherapy, the difference was not obvious (P>0.05). There was no significant difference of leukocyte, neutrophils, lymphocyte and platelet count between two groups in 4 time points of radiotherapy (P>0.05for all). Results

36 The results have clinical significance Results

37 05 Discussion

38 Discussion calorie 放疗起始放疗 2 周放疗 4 周放疗结束 Pre RT 2th week of RT 4th week of RT End of RT 多学科营养管理组 Intervention Group (IG) 常规营养指导组 Control Group (CG)

39 Discussion protein 放疗起始放疗 2 周放疗 4 周放疗结束 Pre RT 2th week of RT 4th week of RT End of RT 多学科营养管理组 Intervention Group (IG) 常规营养指导组 Control Group (CG)

40 Discussion 放疗起始放疗 2 周放疗 4 周放疗结束 Pre RT 2th week of RT 4th week of RT End of RT 多学科营养管理组 Intervention Group (IG) 常规营养指导组 Control Group (CG)

41 Discussion The multidisciplinary nutrition management mode on HNC patients with mild to 8 moderate malnutrition who were receiving 6.96 radiotherapy preserves body weight, 6 increased calorie and protein intake on a daily basis, achieved better hemogram indexes, which resulted 4in improved nutritional status and clinical outcomes of patients. 2 0 放疗起始放疗 2 周放疗 4 周放疗结束 Pre RT 2th week of RT 4th week of RT End of RT 多学科营养管理组 Intervention Group (IG) 常规营养指导组 Control Group (CG)

42 Discussion Nutrition nurses play an important role in the multidisciplinary team Screening Nutrition risk screening S Education Individualized education for patients E A Assessment Dynamic nutrition status assessment Implementation Implementation of interventions in nutrition management I C Communication Provides feedback about the effect of intervention

43 Reflection No follow-up for discharged patients No one nutrition standard or procedure for all the hospitals No abundant ways for nurses to achieve specialized nutrition management knowledge Workload

44 Thank you