Appropriate Use of Enteral Nutrition: Part 1 A Team-Based Approach to. Presented at A.S.P.E.N. s Clinical Nutrition Week January 24, 2012 Orlando, FL

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1 Appropriate Use of Enteral Nutrition: Part 1 A Team-Based Approach to Overcoming Clinical Barriers Presented at A.S.P.E.N. s Clinical Nutrition Week January 24, 2012 Orlando, FL According to the Commission on Dietetic Registration (CDR) guidance for CPE activity types, recordings of approved presentations viewed in a Study Group can be no older than one year past the date of the presentation. To comply with this guidance, this program will not be valid for Dietitian CPEU if viewed after January 31,

2 Gail Cresci, PhD, RD, CNSD, LD Staff Researcher The Cleveland Clinic Cleveland, OH 2012 Abbott Laboratories Disclosure This educational event is supported by Abbott Nutrition Health Institute, Abbott Laboratories. No relevant financial relationships to disclose. 2

3 Malnutrition Occurs in 30-55% hospitalized patients 50% not identified 69% hospitalized patients have nutritional decline during stay Somanchi M, et al. JPEN 2011;35: Kruizenga H, et al. Am J Clin Nutr 2005;82: Isabel M, et al. Clin Nutr 2003;22: Giner M, et al. Nutrition 1996;12:23-29 Malnutrition During Hospitalization WHY?? Metabolic stress and consequences Hypermetabolism, hypercatabolism No nutrition intervention procedures, overlooked Pain (general, abdominal) Incontinence Nausea, vomiting Depression Feeding difficulties Unpalatable foods, altered feeding schedules Inadequate diets 3

4 Clinical Consequences of Malnutrition Protein alterations Muscle wasting Muscle function / Weakness Coagulation capacity Altered gut function Impaired immune response / Infection rate Impaired wound healing / Wound formation Financial Consequences of Malnutrition Increased Hospital and ICU length of stay Resource utilization Hospital charges and costs Hospital and ICU readmissions Early recognition and intervention Improves health outcomes, morbidity, mortality, reduces hospital LOS Diagnosis-related group (DRG) coding for malnutrition Positively impacts hospital reimbursements & decreases hospital costs Somanchi M, et al. JPEN. 2011;35:

5 Practice Guidelines: Indications for Nutrition Support Therapy Nutrition support therapy should be initiated in the patient who is unable to maintain volitional intake Enteral nutrition (EN) preferred over parenteral feeding EN should be started early within the first hours following admission The feedings should be advanced toward goal over the next hours ASPEN/SCCM. JPEN 2009;33: ESPEN, Clin Nutr 2006;25: Canadian, 2009, AND Evidence Analysis Library, Putting It Into Practice Not so easy.is it?? 5

6 Reduction of Inappropriate Parenteral Nutrition Use: Outcomes with Team Collaboration Susan Lessar MS, RD, CNSC Corporate Director, Nutrition Therapy Valley Health System 2012 Abbott Laboratories Disclosure This educational event is supported by Abbott Nutrition Health Institute, Abbott Laboratories. No relevant financial relationships to disclose. 6

7 Objectives Review typical cost associated with providing parenteral nutrition (PN) Explain the development of the Winchester Medical Center s (WMC) Nutrition Support Team 12/29/2011 7

8 10/09/2011 WMC Clinical Dietitians 8 Registered Dietitians February 2011, Dietary to Nutrition Therapy Direct report to Vice President of Ancillary Services 8

9 Parenteral Nutrition History at WMC More reactive than proactive RD recommendations for calories and protein Physicians view of PN Case Study 76 yo male, had a central line placed for PN on hospital lday 2 Dx Acute Pancreatitis Amylase 157, Lipase 98 Diet order clear liquids No recent weight changes, at 115% IBW. 9

10 National Drug Shortages American Hospital Association 89% of hospitals experienced nutrition titi product shortages 19 parenteral nutrition components on the American Society of Health System Pharmacists (ASHP) drug shortages list A.S.P.E.N. Drug Shortages Update. Accessed January 7, 2012 What Was Available? 10

11 National IV Amino Acid Shortage December 2010 Nutrition Committee and P&T Committee Recommendations All new starts would be reviewed and approved for appropriateness ICU reviewed by Jeff Spray Pharm.D., BCPS, and RDonthe weekends Medical floors reviewed by Susan Lessar MS, RD, CNSC If the Gut Works Use it! Conditions precluding use of the GI tract expecting to last >7 10 days Perioperative support of moderate to severely malnourished patients GI fistula Short Bowel Syndrome Severe Acute Necrotizing Pancreatitis Mesenteric Ischemia Paralytic Ileus 11

12 Contraindications Functional and accessible GI tract Patient is taking oral diet Prognosis does not warrant aggressive nutrition support (terminally ill) Risk exceeds benefit Patient expected to meet needs within 7 10 days 2009 ASPEN/Society of Critical Care Medicine Guidelines Use of guidelines to determine appropriateness it of PN therapy B1. Malnourished and unable to provide EN PN B3. PN therapy provided for a duration of less than 5 7 days would be expected to have no outcome effect and may result in increased risk to the patient. McClave SA, Martindale RG, Vanek VW, et al:guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) JPEN 2009 May Jun;33(3):

13 WMC Parenteral Nutrition Use Reduction in PN Use 12/20/2010 5/25/ new starts total; 7 per month # Patients 13

14 WMC Cost of Providing PN Central Line Placement Supplies, Procedure, CXR = $ Pharmacy Tech, Pharm D, bag/tubing, macro/micronutrients, additives (i.e. Heparin, Insulin, etc) = $340.00/pt/day RD/Nutrition Therapy Time for assessment, physician contact, writing orders per MD request = $42.00/pt/day IV Therapy Gather tubing, deliver to the floor, verify orders to label on the bag, program pump = $26.00/pt/day Cost of Providing PN cont. Laboratory standard monitoring x 5 days Daily Chem 8, Mg, Phos $ Triglyceride x 2 $73.50 Pre albumin x 2, Q Mon/Thurs $ Finger Sticks q 6 hours $ $

15 Total Savings Per patient, providing PN x 5 days = $ Average reduction of 10 patients/month would annually yield approximately = $677,542 Minus Central line = $396,646 *Per CDM Medicare/Medicaid payer mix is 60 70% Additional Costs Not Included Insulin to cover Hyperglycemia MD time Nursing care Increased length of stay, waiting for po diet to advance and tolerate prior to discharge Possibility of Central Line Associated Blood Stream Infection Venous thrombosis ultrasound, anticoagulation 15

16 Other Outcomes CLABSI* Hospital LOS in days (range) Mortality /239 (<1%) 19 (2-108) 21/239 (9%) /170 (2%) 21 (3-81) 29/170 (17%) 2011 (12/20/10-5/25/11) 1/44 (2%) 19 (3-107) 4/44 (9%) *Central Line Associated Blood Stream Infection Where Do We Go From Here? Formal Nutrition Support Team Comprised of MD, RD, Pharm D, RN Review new cases, assess need for monitoring labs Patient safety and efficacy of care are enhanced when there is a collaborative team 16

17 Performance Improvement and Medical Staff Support Inappropriate p PN use Excess cost Nutrition Support Team Moving Forward Nutrition Committee to report up through Staff Executive Committee (SEC) Nutrition Support Team (NST) will be SEC commissioned and will report its progress and challenges to both SEC and the Performance Improvement Committee. Team of four primary physicians to support the NST. Rotate weekly call schedule. 17

18 Thank You WHO S GOING TO BE THE TEAM DOCTOR? Paul J. Ulich, M.D. Winchester, Virginia 2012 Abbott Laboratories 18

19 DISCLOSURE Synthes Ethicon Endosurgery No relevant financial relationships for this program NUTRITION SUPPORT TEAM RD, MD, PharmD, RN Gold Standard Specialized, standardized care Improvements in safety, outcomes, finances (don t forget coding!) 19

20 STARTING UP Hospital needs Set goals, benefits Standardize protocols Prepare to educate Assemble your team and make a difference! FINDING YOUR MD CHAMPION Background Understands and utilizes EN & PN why/who/when/what/how Specialty surgery, trauma/critical care, GI, Oncology Well respected and collegial Willing to interact, intervene, educate 20

21 THE MD AS CHAMPION Especially relevant in the absence of accepted NST managed care Interactions with Administration Interactions with MDs appropriateness of EN/PN discussion of options support of NST protocols Rounds (multidisciplinary) THE MD AS CHAMPION Nutrition Committee policies, protocols, topics relevant to providers support and advise in studies Use Medical Staff organizations for support Recruitment challenges? 21

22 LAST RESORT?? 22