Association Between AND-ASPEN Malnutrition Criteria and Hospital Mortality in Critically Ill Trauma Patients: A Prospective Cohort Study.

BACKGROUND: Malnutrition is prevalent in trauma victims because of intense muscle wasting triggered by traumatic events and is a mortality risk. The Academy of Nutrition and Dietetics-American Society for Parenteral and Enteral Nutrition (AND-ASPEN) tool has the potential to diagnose malnutrition in this population. This study aims to evaluate this criterion as a malnutrition diagnostic tool and as a hospital mortality predictor in critically ill trauma patients. METHODS: We performed an observational prospective cohort study from April 2015 to February 2017 in a Brazilian hospital. Patients were >18 years old, remained in the intensive care unit (ICU) >48 hours, and had completed data regarding the recommended clinical characteristics (RCCs) for malnutrition. The main exposure of interest was malnutrition assessed by a specialist dietitian using AND-ASPEN. The primary outcome was all causes of mortality during hospital stay. Secondary outcome was the RCCs assessment, to predict malnutrition and hospital mortality. RESULTS: Included were 414 trauma patients. Malnutrition prevalence was 26.8% at ICU admission. The main analysis showed that malnutrition increases mortality chances 1.96 times (95% CI, 1.13-3.30; P = .015). Secondary analysis showed that all 5 RCCs were significantly associated with malnutrition. The only RCC associated with mortality was energy intake (odds ratio 1.5; 95% CI, 1.1-2.0; P = .008). CONCLUSIONS: AND-ASPEN criterion is a feasible and accurate method to recognize malnutrition and predict hospital mortality when applied by trained dietitians for the critical care trauma population. Further studies are needed considering patient subgroups such as obese and elderly.

Current technologies in body composition assessment: advantages and disadvantages.

The interest in non-invasive methods of body composition assessment is on the rise in health care, especially because of its association with clinical outcomes. Technology has revolutionized our understanding of body composition abnormalities, clinical prognostication, and disease follow-up, but translation to bedside is limited, especially in terms of cost effectiveness. Computed tomography gained increased attention in cancer and sarcopenia studies, for instance. Other methods also have interesting features and applications, including bedside ultrasonography, bioelectrical impedance analysis, and dual x-ray absorptiometry. Compelling evidence indicates these methods can be used to accurately and precisely measure skeletal muscle mass, adipose tissue, and edema; diagnose malnutrition-related diseases; and aid in determining prognoses. To apply this technology properly, it is important to understand the advantages and disadvantages of each technique in specific situations of interest. This review introduces concepts and reference studies published in the scientific literature about these techniques and describes important limitations and considerations necessary to incorporate these methods into clinical practice.

Nutrition support team activities can improve enteral nutrition administration in intensive care units.

OBJECTIVES: The aim of this study was to evaluate the effect of the nutritional support team (NST) activities on the quality of enteral nutrition administration in intensive care units. METHODS: An observational, analytical, and cross-sectional study was performed in nine hospitals in the Brazilian Federal District through the administration of two questionnaires. One questionnaire focused on the activities of the NST and the other on the quality of enteral nutrition administration in intensive care units. RESULTS: There was a strong correlation between the scores of the two questionnaires, which was confirmed by a linear regression model (R2 = 0.623; P = 0.007). The results suggest that high scores in the NST activities questionnaire predict a better performance in enteral nutrition administration. The sections of the NST activity questionnaire that most strongly affected enteral nutrition administration were the protocols (r = 0.895; P < 0.01), quality control (r = 0.779; P < 0.05), and continuing education (r = 0.753; P < 0.05). CONCLUSIONS: The NST has the potential to positively influence enteral nutrition management in intensive care units and investments could be directed to the areas of continuing education, protocols, and quality control to maximize the effect of NST in intensive care units.

Campanha "Diga não à desnutrição": 11 passos importantes para combater a desnutrição hospitalar / Campaign "Say no to malnutrition": 11 important steps to fight hospital malnutrition

A desnutrição é frequentemente encontrada no ambiente hospitalar. Muitas vezes negligenciada, apesar de afetar desfavoravelmente a saúde da população, a desnutrição apresenta como principais complicações: pior resposta imunológica, atraso no processo de cicatrização, risco elevado de complicações cirúrgicas e infecciosas, maior probabilidade de desenvolvimento de lesões por pressão, aumento no tempo de internação e do risco de mortalidade. Fora isso, acarreta considerável aumento dos custos hospitalares. A taxa de desnutrição varia entre 20 e 50% em adultos hospitalizados e durante a hospitalização esta condição piora progressivamente principalmente em idosos e pacientes críticos. Em 1998, o inquérito brasileiro, conhecido como IBRANUTRI, avaliou 4 mil pacientes internados na rede pública hospitalar de vários estados brasileiros, confirmando a prevalência da desnutrição em 48,1% dos pacientes. Há 20 anos, estes dados foram publicados e o cenário permanece imutável até os dias atuais, pois, em 2016, outro estudo (com aproximadamente 30.000 pacientes) corroborou a manutenção da alta prevalência de desnutrição em pacientes hospitalizados. A identificação precoce da desnutrição, bem como o manejo, por meio de ferramentas recomendadas, possibilita estabelecer a conduta nutricional mais apropriada e melhora do desfecho nestes pacientes.O objetivo desta campanha é reduzir as taxas de desnutrição por meio de uma série de ações que incluem a triagem, o diagnóstico, o manejo e o tratamento da desnutrição. Para facilitar a maneira de difundir este conhecimento, foi desenvolvido um método mnemônico com a palavra "DESNUTRIÇÃO", abordando cada letra inicial de forma simples, desde o conceito até o tratamento da desnutrição. Desta forma, o método garante uma integração interdisciplinar, além de averiguar os principais aspectos do cuidado geral do paciente desnutrido.

Classificação de indicadores de qualidade em ouro e prata por cenário clínico do serviço público de acordo com especialistas em terapia nutricional / Classification of gold and silver quality indicators by clinical setting of the public service according to specialists in nutrition therapy

Introdução: A introdução de práticas de qualidade padronizadas é emergente na terapia nutricional hospitalar. O investimento no controle de qualidade promove redução de custos e melhoria no tratamento, impactando positivamente no processo de recuperação. Poucos são os relatos de estudos que visam apresentar indicadores de qualidade da terapia nutricional (IQTN) confiáveis para o ambiente hospitalar. O objetivo deste trabalho foi selecionar, por meio de um painel de especialistas, IQTN aplicáveis à realidade do setor público brasileiro divididos por cenário clínico. Método: Pela técnica Delphi foi feito um painel de especialistas em duas etapas com questionários eletrônicos. Cada uma dessas etapas foi precedida de um estudo piloto que as simulou identicamente. Entre a primeira e a segunda etapa foi fornecido um feedback de resultados aos participantes, a fim de promover consenso entre os especialistas. Completaram a pesquisa 35 especialistas, que selecionaram indicadores com aceitação entre 80% e 100% divididos em Ouro (≥ 90%), Prata (89% - 80%). Resultados: Foram selecionados 8 indicadores ouro para unidade de terapia intensiva (UTI) e 10 para enfermaria, 8 indicadores prata para UTI e 10 para enfermaria, e nenhum para pronto-socorro. Conclusão: A lista produzida nesse painel forneceI QTN para cenários clínicos específicos, podendo ser utilizada para compor o leque de possibilidades de escolha dessas ferramentas no serviço público hospitalar brasileiro.(AU)

Introduction: The introduction of standardized quality practices is emerging in nutritional therapy. Organized investment in quality, promotes cost reduction and treatment improvement what impact positively in the recovery process. There are few reports of studies that provides reliable quality indicators for Nutritional Therapy (QINT). The aim of this study is to promote a specialist panel to select applicable IQTN to the public health system according to clinical scenario. Methods: It was performed a two stages panel of experts with Delphitechnic utilizing electronic questionnaires. Each of these steps was preceded by a pilot study that simulated identically the first and the second stages. The total of 35 experts completed the study, they selected indicators between 80% and 100% acceptance to compose the final list of IQTN. The indicators were divided into Gold (≥ 90%) and Silver (89% - 80%). Results: A total of 8 gold indicators were selected to Intensive Care Unit (ICU) and 10 to the ward, 8 silver indicators were selected for the ICU and 10 to the ward, not being selected any for emergency room. Conclusion: This panel provided a list of QINT for specific clinical scenarios what can be useful to compose the range of QINT of choice in the Brazilian public hospital reality.(AU)

Development of a tool for quality control audits in hospital enteral nutrition / Desarrollo de una herramienta de auditorías de control de calidad en nutrición enteral hospitalaria

Background and aims: Malnutrition is very prevalent in hospitals, causing physical capacity deterioration, increasing complications and raising mortality. This scenario overloads public health costs enormously. Enteral nutrition (EN) is the first option to fight against malnutrition. Nutrition support teams (NST) work combating such conditions, promoting humanization, but also analyzing the cost benefit of EN therapy. Brazil is one of the first Latin American countries to develop EN laws. Quality control it is in the core of this legal instrument, playing an essential role in NST`s task of providing care. Nowadays, tools to access quality control represent a gapin the area. The aim of this study was to develop a quality control tool, according to Brazilian law for EN Therapy regarding multidisciplinary approach, good practices, standard operating procedures, protocol implementation, proper registration and electronic health record. Methods: A content validation method was utilized in this four stages development process: bibliographic research, expert opinion (subjective), semantic evaluation and expert opinion (objective). In the latter stage ten specialists, expressed their opinion, evaluating the tools by four different attributes: utility, simplicity, objective and low cost on a 5-point Likert scale (1-5).Results: We elaborate three independent tools that together, represent the whole evaluation process, named: NST Activities, EN Preparation and EN Administration. Content Validation Index to the four different attributes ranged from 0,9 to 1.Conclusion: This tool had positive approval from experts and is of great value guiding hospital audits, or even serving as checklist to implement a plan on ENtherapy (AU)

Introducción: La desnutrición es muy frecuente en hospitales provocando degradación de capacidad física, complicaciones y elevando la mortalidad. Este escenario sobrecarga enormemente los costos de salud pública. Nutrición enteral (NE) es la primera opción para luchar contra la desnutrición. Equipos de soporte nutricional(ESN) trabajan combatiendo tales condiciones, humanizando el tratamiento sino también analizando su costo beneficio. Brasil fue uno de los primeros países latinoamericanos en desarrollar legislación específica para NE. El control de calidad es el centro de este instrumento legal, ejerciendo rol esencial para proporcionar atención nutricional de calidad. Actualmente, herramientas de acceso al control de calidad representan un vacío en este nicho. Objetivo: Desarrollar una herramienta de control de calidad para NE, conforme la legislación brasileña, con respecto a ESN, buenas prácticas, implementación de protocolos y registros electrónicos. Métodos: Se utilizó una validación de contenido desarrollada en cuatro etapas: investigación bibliográfica, opinión de expertos (subjetiva), evaluación semántica y opinión de expertos (objetivo). En la última etapa diez especialistas, evaluaran los instrumentos utilizando cuatro atributos diferentes: utilidad, simplicidad, objetividad y bajo costo en una escala Likert de 5 puntos (1-5).Resultados: Elaboramos tres herramientas independientes que juntas, representan todo proceso de la NE: Actividades de ESN, Preparación de NE y Administración de NE. Indicies de validación de contenido calculados para los 4 atributos variaran entre 0,9 y 1,0.Conclusión: Estas herramientas tienen aprobación positiva de los expertos y son de gran valor en auditorias hospitalarias, además de servir como una lista de verificación para implementar un plan de terapia nutricional (AU)