Exploration of home nutrition support in children with intestinal failure and clinical experience with 10 cases / 中华临床营养杂志

Objective:To explore the application of home nutrition support in children with intestinal failure.Methods:Children with intestinal failure admitted to Division of Pediatric Gastroenterology and Nutrition and Department of Pediatric Surgery in Xinhua Hospital were retrospectively enrolled since January 2009. The details of home nutrition support, nutritional status and home parenteral nutrition (HPN) associated complications were collected.Results:A total of 10 children received HPN support, 7 of whom were with short bowel syndrome (SBS) and the other 3 with pediatric intestinal pseudo-obstruction. The average length of remnant small bowel in 7 SBS children was (36.7±32.4) cm. The average age at HPN onset was (5.4±4.7) years. The average duration of follow-up was (3.1±2.1) years. The average duration of HPN was (619.5±669.1) days after (391.8±340.1) days of parenteral nutrition support in our hospital. All 10 cases started home enteral nutrition (HEN) with tube feeding (3 cases transited to oral feeding during treatment). The average duration of HEN was (536.1±429.6) days. Daily calorie intake was 104.0%±39.0% of the recommended intake according to the guideline, with 46.5%±21.3% via HPN and 57.5%±29.2% via HEN. During follow-up, 3 cases were found with severe malnutrition, 5 with moderate malnutrition and 2 with mild malnutrition. Four children suffered from catheter-related thrombosis and five children were identified with catheter-related blood stream infection. No intestinal failure associated liver disease was observed.Conclusions:HPN is feasible but needs the support of national medical insurance policy. At present, there are still frequent nutritional deficiencies and complications in HPN. Nutrition support team (NST) should provide guidance for more scientific nutrition screening and nutrition management.

Investigation on the utilization of parenteral nutrition preparations in 12 Hospitals of Jiangsu / 中华临床营养杂志

Objective To investigate the use of parenteral nutrition preparations in Jiangsu Province,and to provide reference for the standardized management of parenteral nutrition preparations.Methods 720 cases using parenteral nutrition preparations from January 2017 to June 2017 in the department of general surgery of 12 hospitals in Jiangsu province were selected.The rate of nutritional risk screening,the indications of parenteral nutrition,the way of infusion,the rationality and economy of the prescriptions were retrospectively evaluated.The calorie,amino acid content,non-protein calorie/nitrogen ratio,glycolipid ratio and cation concentration of the patients received total parenteral nutrition were calculated.Results The total costs of parenteral nutrition preparations of 720 cases were 1.614 1 millions,and 346 cases did not have the indications for parenteral nutrition.The results of prescription comment showed that only 16 patients were screened for nutritional risk by Nutritional Risk Screening 2002 tool at admission.544 cases were intravenous dripped with amino acid and fat emulsion from peripheral vein.In the 176 total parenteral nutrition prescriptions,there were 39 non-protein calorie/nitrogen ratio cases,15 glycolipid ratio cases,69 cation concentration cases,61 calorie cases and 32 amino acid content cases failing to comply with the recommendation of the guidelines.Only 31 total parenteral nutrition prescriptions were completely reasonable.Conclusion The costs of parenteral nutrition preparations used in hospitals of Jiangsu are high but the rate of rationality is low.Nutrition support team should be established to regulate the use of parenteral nutrition preparations and save medical resources.

A comparison of nutritional status by intensive nutritional support in enteral nutrition patients / 한국영양학회지

PURPOSE: The aim of this study was to determine the effects of nutritional intervention focused on a Nutrition Support Team (NST) in patients receiving enteral nutrition (EN) in general hospital wards. METHODS: The electronic medical records of 95 adult patients admitted in C university hospital and received EN supply for more than 3 days at a general ward were analyzed retrospectively. The subjects were classified into the intervention group (n = 40) and non-intervention group (n = 55). RESULTS: The calorie support rate (%) and protein support rate (%) increased significantly only in the intervention group after 2 weeks compared to the rate upon admission. The serum albumin levels increased in the intervention group after 2 weeks compared to the levels at admission, but decreased in the non-intervention group. The glucose levels decreased only in the intervention group compared to that at admission. CONCLUSION: The nutritional status of the patients was improved by the proper planning of nutrition management from the beginning of hospitalization and systematically managing the nutrition intervention of the NST.

Survey on the State of Nutrition Support Team (NST) Activity: Comparison of the Questionnaire Survey 2016 vs. 2005 and the State of NST Activity since the Introduction of the Medical Insurance Fee

The Korean Society of Health-System Pharmacists (KSHP) and Korean Society for Parenteral and Enteral Nutrition (KSPEN) jointly performed a nation-wide questionnaire survey on the current state of Nutrition Support Team (NST) activity from March to May of 2016. The aim of the survey was to suggest ways to develop NST as well as to improve the relationship between the KSHP and KSPEN. Compared to the results of the 2005 survey, some progress was made in the activity of NST over the last decade. Not only was the activity of NST settled, but quantitative and qualitative growth was also achieved by activating rounds and regular meeting. On the other hand, the ratio of hospitals providing home care services has decreased. Therefore, further effort is needed for their revitalization.

Effects of Compliance with the Nutrition Support Team in Critically Ill Pediatric Patients

PURPOSE: This study performed a comparative evaluation of nutritional condition's improvement and clinical effects in accordance with the Nutrition Support Team (NST) consultation compliance of critically ill pediatric patients. METHODS: The medical records of 64 critically ill pediatric patients (2 to 18 years old), who were officially referred to a NST consultant in pediatric intensive care unit from January to August 2015, were reviewed. The patients were divided into 2 groups according to the compliance of NST consultation answers. The total delivered/required caloric and protein ratio, weight, serum total protein, serum albumin, hemoglobin, and hematocrit were compared. RESULTS: According to the NST consultation answer, 'nutrition support increase' occupied the largest proportion at 38.5%; 'maintenance' and 'decrease' accounted for 35.7% and 18.2% respectively. The NST compliance group and non-compliance group were 20 and 14 patients, respectively. Although total delivered/required caloric ratio was significantly increased in the NST compliance group (19.7%, P=0.036), there was no significant difference in the NST non-compliance group (5.1%, P=0.692). The total delivered/required protein ratio was increased (15.1%, P=0.163) in the NST compliance group and decreased (-4.7%, P=0.774) in the NST non-compliance group. The NST non-compliance group (-8.6%, P=0.219) was further reduced weight than the NST compliance group (-1.0%, P=0.820). The serum albumin was significantly increased in the NST compliance group (13.1%, P=0.003), but there was no difference in the NST non-compliance group (7.1%, P=0.433). CONCLUSION: Although 56.7% of NST consultations were needed for nutritional interventions, a lower NST compliance (53.8%) is the limit of nutritional support. The NST compliance group was supplied adequately with more calories and protein than before consultation and a more improved nutritional status. Therefore, aggressive NST consultation can help increase the therapeutic effect by improving the nutritional status. This study will form the basis to seek ways to further enhance NST compliance.

Characteristics and Clinical Course of Patients Who Received Enteral or Parenteral Nutrition in Tertiary Referral Hospitals in Korea

PURPOSE: The purposes of this study are to evaluate clinical characteristics of malnourished patients who received nutritional therapy and to compare their clinical courses according to nutritional support team (NST) consultation in tertiary referral hospital in Korea. METHODS: From June 2014 to May 2015, 43,954 admitted patients who were more than 18 years old were retrospectively investigated. Characteristics of patients who received enteral nutrition (EN) or parenteral nutrition (PN) for more than 3 days (nutritional therapy group) were compared to the patients without nutritional therapy (control group). In addition, clinical courses according to NST consultation (NST group and non-NST group) were compared through propensity score matching (PSM). RESULTS: EN or PN was applied in 4,599 patients for more than 3 days (nutritional therapy group: 10.5%). For characteristics, there were significant differences between two groups (nutritional therapy group vs. control group) with age, male proportion, body weight, body mass index. All laboratory data at admission were significantly worse in nutritional therapy group. And for clinical courses, there were significant differences in length of stay (LOS), rate of intensive care unit (ICU) admission, LOS in ICU, Acute Physiology and Chronic Health Enquiry (APACHE II) score, days of nutritional therapy, mortality rate. NST consultation was made in 39% of nutritional therapy group. Among departments, Thoracic Surgery showed the highest rate of NST consultation (68.5%) otherwise Neurosurgery showed the lowest rate (18.7%). When PSM between NST group vs. non-NST group were made, significant differences was shown only in the rate of ICU admission, EN or PN support days, cholesterol at discharge. CONCLUSION: In tertiary referral hospital in Korea, more than 10% of patients still needed active nutritional therapy. NST consultation rate varies among departments. We failed to find significant differences between NST group and non-NST group.

Reimbursement of Nutritional Support Team, What Is the Problem and How Can We Manage It?

Korea Ministry of Health and Welfare launched legislation for reimbursement for Nutrition Support Team (NST) activities from August 1st, 2014, which can be applied as a flat rate fee per day once a week. The indicated patients are those with hypoalbuminemia, on parenteral nutrition or enteral nutrition, critically ill patients in intensive care unit's, and any patient on suspicion of malnutrition by the physician in charge. NST should be comprised of a professional physician, an educated nurse, an educated pharmacist, and a professional and experienced dietitian. The maximum number of patients that can be treated by one NST is 30 per day. Such a reimbursement system has resulted in some complex problems with NSTs. The low price does not provide adequate reward for the team's workload because the output of NST belongs to the department in charge and there is no ensured incentive. The Department of Health Insurance Review and Assessment Service cannot detect the quality problem of NST, non-compliance of physicians in charge. There are no stratified codes according to severity of disease and no difference between the first visit and the repeated visit. Every NST should be certified with accreditation and should participate in a qualified education program. Korea Health Insurance does not cover the fees for feeding tubes, formulas, and pumps. Evidence that NST activities can reduce medical cost of hospital-admitted in-patients is needed. Cost-effectiveness can be achieved by quality improvement of NST.

Effects of a Nutrition Support Team with Parenteral Nutrition on Gastrointestinal Cancer Patients Who Underwent Surgery

PURPOSE: Cancer patients are frequently malnourished, and malnutrition can increase morbidity and mortality. Postoperative malnutrition can cause poor wound healing and failure of the immune response. Administration of parenteral nutrition (PN) after surgery may decrease complication and hospital length of stay. Intervention of a Nutrition Support Team (NST) improves patient outcomes through nutritional assessment and proper nutrition support. In this study we investigated effects of NST intervention with PN on gastrointestinal cancer patients who underwent surgery. METHODS: This retrospective study was conducted at Kyung Hee University Hospital at Gangdong from 2012 January to 2013 December. This study reviewed gastrointestinal cancer patients who were administered PN for more than seven days. The patients were divided into two groups: NST group versus non-NST group. RESULTS: In this study, 53 patients with malnutrition were administered PN for more than seven days. Nutrition support between the NST group and non-NST group was not statistically significant, except multivitamin and trace element. Changes in nutritional index were not statistically significant. No difference in incidence of complication, monitoring performance rate was observed between the two groups. CONCLUSION: Due to a small number of patients and lack of severity of disease in this study, no significant difference in improvement of nutritional index was observed between the NST group and non-NST group. For safe and effective PN, conduct of additional study is necessary in order to determine the effects of NST.

Roles of nutrition support team for esophageal carcinoma patients treated with concurrent chemoradiotherapy / 中国肿瘤临床

Objective:To investigate whether the nutrition support team (NST) benefits esophageal carcinoma (EC) patients who are concurrently undergoing chemoradiotherapy. Methods: Between June 2012 and December 2013, 40 EC patients undergoing chemoradiotherapy were divided into the NST group and routine treatment (RT) group, with 20 patients in each group. At the end of chemoradiotherapy, the nutritional status, incidence of complications, and completion rates of radiotherapy were evaluated. The length of hospital stay (LOS) and cost were also compared between the two groups. Results:The nutrition and blood parameter values of the NST group were better (P0.05) for the patients of the NST group. Conclusion: NST could maintain the nutritional status and improve the treatment compliance and tolerance of EC patients undergoing chemoradiotherapy, thereby shortening the LOS time and reducing the costs.

Effect of nutrition support team on clinical outcomes in surgically treated children with congenital heart disease / 中华临床营养杂志

Objective To investigate the effect of nutrition support team (NST) on the clinical outcomes in surgically treated children with congenital heart disease (CHD).Methods Totally 60 surgically treated CHD children from January 2010 to June 2010.In March 2010,they were divided into two groups based on the interventions:before the intervention (BET group) and after the intervention (AET group).Nutritional risk screening rate,enteral nutrition (EN) application rate,all-in-one parenteral nutrition (PN) application rate,postoperative mechanical ventilation time,length of ICU stay,average hospitalization days,expenses directly related to nutrition,and hospitalization expenses were compared between these two groups.Results The nutritional risk screening rate,EN application rate,and all-in-one PN application rates before and after intervention of NST were 13.3％ (4/30) vs 100％ (30/30),43.3％ (4/30) vs 63.3％ (19/30),and 35.3％ (6/17) vs 100％ (11/11),respectively,in AET group and BET group (x2 =132.11,19.65,and 24.73,respectively,all P ＜ 0.05).Mechanical ventilation time [(7.03 ± 1.76) h vs (8.09 ±2.56) h],length of ICU stay [(24.81 ±2.52) h vs (37.01 ±3.47) h],average hospitalization days [(17.96 ±4.03) d vs (19.60 ±4.53) d],nutritionrelated expenses [(4 132.27 ±416.27) yuan vs (2 754.03 ±323.47) yuan],and hospitalization expenses [(25 725.11 ±515.68) yuan vs (31 975.53 ±600.56) yuan] were also significantly favorable in AET group (t =5.76,3.04,2.05,32.07,and 43.30,respectively; all P ＜ 0.05).Conclusion NSP is an effective approach to promoting the standard efficacious nutrition support therapy in clinical settings and can improve the therapeutic effectiveness and clinical outcomes in surgically treated CHD children.

Validating a Nutrition Support Team's (NST) Effect in Convalescent Stroke Rehabilitation using the Functional Independence Measure / The Japanese Journal of Rehabilitation Medicine

The aim of this study is to validate the effect of a nutrition support team's (NST) interventions in convalescent stroke rehabilitation using the Functional Independence Measure (FIM). Three hundred and four patients were retrospectively divided into an NST-nourishment group, an NST-losing-weight group and a non-NST group. We then compared the FIM gain, the FIM efficiency and the change of body mass index during admission among these three groups. The FIM gain was 17.3±15.9 in the NST-nourishment group and 16.7±12.5 in the non-NST group and there was no significant difference. The FIM efficiency in the NST-nourishment group (0.20±0.19) was significantly lower than the one in the non-NST group (0.27±0.19). Patients with an FIM of 53 or less showed no significant difference in FIM gain and FIM efficiency between the two groups. Since those patients who received NST intervention would tend to have a poor prognosis in general, we assumed that our “no difference” results indicated the effectiveness of the NST intervention. There was no evident relationship between FIM gains and changes in the body mass index.

A study on the provision of TPN for hospitalized patients

In Korea, implementation of nutrition support guidelines has been limited due to strict health insurance reimbursement policies as well as the lack of consensus on the best approach to TPN management. We examined the impact of TPN provision to hospitalized patients where NST (nutrition support team ) consultations were not requested by their primary physicians. The study showed the followings : 1. The median dutation of TPN provision was 8 days, but many patients were on TPN for less than 1 week. 2. The intake of energy and protein were less than the patient's requirements 3. Lipid emulsion was not provided to the most TPN patients. In conclusion, the role of NST should be expanded and studies are needed not only on TPN formulations which are suitable to Koreans but also on the cost-effectiveness of NST activities. TPN policies and protocols should be established based on the needs of each hospital.

The Medical Staffs` Perception about Nutrition Care

This study was undertaken to identify medical staffs perception about nutrition care and dietitian's role in hospitals. Questionnaires were sent to 874 medical staffa at 50 general hospials size over 100 beds, located in Seoul and Pusan, A total of 649(74.3%) of medical staffs returned questionnaries from 47 general hospitals. The results of this study can be summarized as follows. 1. 89.6% if educak stffs responded that they required the help of the dietitian when the patients needed the nutrition acre and also most of them(87.0%) held positive perceptions abuot the necessity of the nutrition support team. 2. When the medical staffs prescribed the special diet of the patients' nutrition care, 90.0% of them preferred that diet would be order after consulting with dietitian. 3. Half of the medical staffs(52.1%) responded that they were scarced of the knowledge about the clinical mutrition and then 66.4% of them recognized the need of nutrition education at the medical school. 4. The medical staffs responded that dietitian must have the knowledge abuot food, nutrition and medical science(52.5%) and the competence of discussion with medical staffs about nutrition the patients(30.8%).