Quality of care concepts and nutrition support.

The Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) Agenda for Change has refocused and redefined quality monitoring in health care. The JCAHO has operationalized these new concepts of quality monitoring and evaluation by means of a 10-step process that includes the development of clinical indicators. Theoretical frameworks for the 10-step process were drawn from the work of theorists whose applications of quality-monitoring methods occurred in business and industry. An enhanced understanding of the current JCAHO definitions of quality and processes for quality measurement will help practitioners prepare for future accreditation surveys. A review of quality monitoring and evaluation activities in nutrition support has demonstrated a need for more published accounts to document these important activities.

Psychosocial issues of nutritional support. A multidisciplinary interpretation.

In many cases, initiation of specialized nutritional support is a final attempt at medically managing illness for which other treatments have failed. Patients may have suffered for months or even years with their underlying diseases and are usually aware that poor response to nutritional support and concurrent therapies may lead to surgical intervention or more complex treatment. In some cases, there may be few alternatives left to pursue. For such patients, this paints a very stressful picture. If we as caregivers are empathetic to each patient's situation, we are better able to offer the support that these patients need. Health care professionals must keep patients informed of treatment plans and encourage participation in the planning process--during hospitalization, through the discharge phase, and after hospitalization. We need to pay close attention to those needs, whether nutritional support is short-term during hospitalization, prolonged, or permanent. The health care environment is demanding greater proficiency in cost containment and quality assurance in the delivery of care. Complex patient cases are becoming more difficult to manage as time constraints and resources become more restrictive. The ingenuity and imagination of health care providers trying to find ways to continue providing high-quality and safe care to patients are being tested daily. These worthwhile goals can be met only through cooperation, communication, and support among all levels and disciplines involved with the delivery of care. Feelings of helplessness, dependence, and loss of control can be diminished if health care providers maintain optimistic, confident attitudes, offer positive reinforcement for patients successes, and try to restore hope during this stressful period in patients' lives.

Morbidity and mortality related to home parenteral nutrition in patients with gut failure.

The clinical course of 39 patients on HPN for 5.5 years at The Cleveland Clinic Foundation were reviewed. Rehospitalization and mortality rates were relatively low in this group of patients who had significant disease processes. Rehospitalization and mortality were usually due to the primary underlying disease process rather than to the therapy. HPN is an efficacious, therapeutic modality that helps return patients with gut failure to a near normal life-style.

Home parenteral nutrition.

Home parenteral nutrition is a life-sustaining mode of therapy for patients with short bowel syndrome that is unresponsive to conventional therapy. It requires learning specialized skills through an intensive training program and carefully following this program in a home setting. This training can be best provided by a group of health care specialists including a physician, nurse, dietitian, psychiatrist, social worker, and pharmacist who are knowledgeable about the issues that face the patient requiring home parenteral nutrition. The resources of career medical centers ar most appropriately utilized to provide the support needed to successfully undertake a home parenteral nutrition program. The nutritional requirements of these truly long-term patients have to be more accurately defined to guarantee that macronutrient and micronutrient requirements are being adequately provided for over the many years of required treatment. Fluid delivery systems and techniques for infection-free long-term venous catheterization have to be perfected. Home parenteral nutrition is a valuable life support system for patients with gut failure. Although expensive, it costs substantially less than in-hospital parenteral nutrition and can return the patient to a near normal life at home.

Home parenteral nutrition for the short bowel syndrome. Psychological issues.

Home parenteral nutrition (HPN) for the short bowel syndrome represents a treatment modality that raises issues about prolonged machine dependency for living. Psychological reactions are described for patients with inflammatory bowel disorders and anatomical loss of small bowel. Liaison psychiatry involvement with 50 patients in the HPN program has identified such problems as grief reactions, depression, organic brain syndromes, drug dependency, and body image changes as they influence the initial adjustment to the in-hospital phase of HPN learning for patient and family. The importance of family and mental status examination are emphasized in the evaluation of the patient before and during the institution of an PHN program. Outlined are psychological parameters that need to be considered when assessing what factors might impede or enhance the acquisition and use of HPN information.