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Citty SW, Chew M, Hiller LD, Maria LA. Enteral nutrition: An underappreciated source of patient safety events. Nutr Clin Pract 2024; 39:784-799. [PMID: 38667904 DOI: 10.1002/ncp.11153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/08/2024] [Accepted: 03/30/2024] [Indexed: 07/04/2024] Open
Abstract
Enteral nutrition (EN) therapies are prescribed for patients not able to maintain adequate nutrition through the oral route. Medical errors and close calls associated with the provision of EN therapy leading to actual and potential patient harm have been reported. The purpose of this study was to determine the number, type, and severity of safety events related to the provision of EN therapies reported to a national database and provide workable recommendations from the literature to improve safety. An interdisciplinary team queried the National Center for Patient Safety (NCPS) Joint Patient Safety Reporting (JPSR) system using keywords related to EN therapy use. The team reviewed the number, type, and severity of reported events and safety codes as categorized by the NCPS and then thematically classified the narratives using the Medication Use Process (MUP). Our query revealed 1227 safety events related to the EN keywords. Thematic analysis of the top five event subtypes (n = 1030) revealed that there were 691 EN safety reports directly related to an MUP step, and the majority fell into the steps of administering (31%), followed by monitoring (28%), dispensing (26%), prescribing (11%), and transcription (4%), with many events involving more than one MUP step. Safety events associated with the provision of EN therapies leading to patient harm have been reported to the JPSR system. To improve safety related to EN use, modifications to prescribing, transcribing/documenting, dispensing, administering, and monitoring of prescribed EN therapies are needed.
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Affiliation(s)
- Sandra Wolfe Citty
- Geriatric Research, Education, and Clinical Center, Department of Family and Community Health Systems, North Florida South Georgia Veteran's Health System, University of Florida, College of Nursing, Gainesville, Florida, USA
| | - Mary Chew
- Nutrition and Food Services, Phoenix VA Health Care System, Phoenix, Arizona, USA
| | - Lynn D Hiller
- Nutrtion and Food Services, James A Haley Veteran's Hospital, Tampa, Florida, USA
| | - Lisa A Maria
- Bruce W. Carter VA Medical Center, Miami VA Healthcare System, Miami, Florida, USA
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Yalçın N, Kaşıkcı M, Kelleci-Çakır B, Allegaert K, Güner-Oytun M, Ceylan S, Balcı C, Demirkan K, Halil M, Abbasoğlu O. A Novel Machine-Learning Algorithm to Predict the Early Termination of Nutrition Support Team Follow-Up in Hospitalized Adults: A Retrospective Cohort Study. Nutrients 2024; 16:2492. [PMID: 39125373 PMCID: PMC11314116 DOI: 10.3390/nu16152492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/26/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND For hospitalized adults, it is important to initiate the early reintroduction of oral food in accordance with nutrition support team guidelines. The aim of this study was to develop and validate a machine learning-based algorithm that predicts the early termination of medical nutritional therapy (the transition to oral feeding). METHODS This retrospective cohort study included consecutive adult patients admitted to the Hacettepe hospital (from 1 January 2018 to 31 December 2022). The outcome of the study was the prediction of an early transition to adequate oral feeding before discharge. The dataset was randomly (70/30) divided into training and test datasets. We used six ML algorithms with multiple features to construct prediction models. ML model performance was measured according to the accuracy, area under the receiver operating characteristic curve, and F1 score. We used the Boruta Method to determine the important features and interpret the selected features. RESULTS A total of 2298 adult inpatients who were followed by a nutrition support team for medical nutritional therapy were included. Patients received parenteral nutrition (1471/2298, 64.01%), enteral nutrition (717/2298, 31.2%), or supplemental parenteral nutrition (110/2298, 4.79%). The median (interquartile range) Nutritional Risk Screening (NRS-2002) score was 5 (1). Six prediction algorithms were used, and the artificial neural network and elastic net models achieved the greatest area under the ROC in all outcomes (AUC = 0.770). Ranked by z-value, the 10 most important features in predicting an early transition to oral feeding in the artificial neural network and elastic net algorithms were parenteral nutrition, surgical wards, surgical outcomes, enteral nutrition, age, supplemental parenteral nutrition, digestive system diseases, gastrointestinal complications, NRS-2002, and impaired consciousness. CONCLUSIONS We developed machine learning models for the prediction of an early transition to oral feeding before discharge. Overall, there was no discernible superiority among the models. Nevertheless, the artificial neural network and elastic net methods provided the highest AUC values. Since the machine learning model is interpretable, it can enable clinicians to better comprehend the features underlying the outcomes. Our study could support personalized treatment and nutritional follow-up strategies in clinical decision making for the prediction of an early transition to oral feeding in hospitalized adult patients.
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Affiliation(s)
- Nadir Yalçın
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, 06100 Ankara, Türkiye; (B.K.-Ç.); (K.D.)
| | - Merve Kaşıkcı
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, 06100 Ankara, Türkiye;
| | - Burcu Kelleci-Çakır
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, 06100 Ankara, Türkiye; (B.K.-Ç.); (K.D.)
| | - Karel Allegaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium;
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Child and Youth Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, 3015 GD Rotterdam, The Netherlands
| | - Merve Güner-Oytun
- Department of Internal Medicine, Division of Geriatrics, Faculty of Medicine, Hacettepe University, 06100 Ankara, Türkiye; (M.G.-O.); (S.C.); (C.B.); (M.H.)
| | - Serdar Ceylan
- Department of Internal Medicine, Division of Geriatrics, Faculty of Medicine, Hacettepe University, 06100 Ankara, Türkiye; (M.G.-O.); (S.C.); (C.B.); (M.H.)
| | - Cafer Balcı
- Department of Internal Medicine, Division of Geriatrics, Faculty of Medicine, Hacettepe University, 06100 Ankara, Türkiye; (M.G.-O.); (S.C.); (C.B.); (M.H.)
| | - Kutay Demirkan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, 06100 Ankara, Türkiye; (B.K.-Ç.); (K.D.)
| | - Meltem Halil
- Department of Internal Medicine, Division of Geriatrics, Faculty of Medicine, Hacettepe University, 06100 Ankara, Türkiye; (M.G.-O.); (S.C.); (C.B.); (M.H.)
| | - Osman Abbasoğlu
- Clinical Nutrition Master’s Program, Hacettepe University, 06100 Ankara, Türkiye;
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Kawano B, Grisel B, Wischmeyer P, Holsman M, Agarwal S, Fernandez-Moure J, Haines KL. Racial and ethnic demographics in malnutrition related deaths. Clin Nutr ESPEN 2024; 60:135-138. [PMID: 38479901 DOI: 10.1016/j.clnesp.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND AND AIMS Currently, 40 million Americans are food insecure. They are forced to skip meals and buy non-nutritious food, leading to health disparities for those of low socioeconomic status. This study aims to investigate relationships between malnutrition deaths and sociodemographic groups. METHODS This cross-sectional study from 2009 to 2018 used aggregate data from the CDC Wide-ranging Online Data for Epidemiologic Research (CDC Wonder). Patients with known race, gender, and Hispanic origin age ≥18 who died from malnutrition (E40-E46) were included. Place of death was grouped into home, inpatient medical facility, hospice facility, nursing facility/long-term care, other (including outpatient, ED, and DOA), and unknown. Crude rates of malnutrition deaths per 100,000 persons for race, gender, and Hispanic origin were calculated using US census estimates. Gross proportions of total deaths were calculated for each place of death. RESULTS Between 2009 and 2018, there were 46,517 malnutrition deaths in the US. Death rates for Black (1.8) and White Americans (2) were twice as high compared to Native Americans (1.1) and Asians or Pacific Islanders (0.7). Death rates among females (2.3) were higher than males (1.5). Death rates among non-Hispanics (2.1) were twice as high compared to Hispanics (0.7). Most people who died of malnutrition died in hospitals (37 %). CONCLUSION Malnutrition deaths occur at greater rates among White, Black, non-Hispanic Americans, and females. Despite reported disparities in food access, Black and White Americans have similar malnutrition mortality rates, raising concerns that malnutrition is under-diagnosed among Black patients. Given the existing nutrition literature, this finding requires further investigation.
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Affiliation(s)
- Bradley Kawano
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Braylee Grisel
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Paul Wischmeyer
- Division of Critical Care Surgery, Department of Anesthesia, Duke University Medical Center, Durham, NC, USA.
| | - Maximilian Holsman
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Joseph Fernandez-Moure
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Krista L Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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Schwarz E, Nass O, Giocondo V, Kozeniecki Schneider ML. Identification of enteral nutrition errors in a single-center quality-improvement audit. Nutr Clin Pract 2024; 39:470-474. [PMID: 37772481 DOI: 10.1002/ncp.11076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Enteral nutrition (EN) therapy is a multistep process including evaluation, prescription, procurement, dispensing, labeling, administration, and monitoring. EN therapy is prone to human errors, but these are poorly defined in the literature. The purpose of this study was to audit EN administration practices to quantify errors of execution and identify which components of the EN order were labeled, administered, or documented incorrectly. METHODS On 2 nonconsecutive days, we identified all hospitalized patients with active EN orders and prospectively collected the following information: EN formula hanging/documented, formula hang time, infusion rate/documented rate (continuous EN), infused volume and documented schedule (intermittent EN), and EN modular documentation. Mismatches to the EN order were considered errors. We reviewed 1 month of hospital EN-related safety events for comparison. RESULTS Of 1045 data points collected from 160 patients, we identified 275 errors of execution: 135 labeling errors and 140 administration errors. The most common were hang time >48 h (85%), wrong number of modulars documented (48%), and wrong infusion rate (19%). We found one reported safety event (wrong formula delivered but not infused). CONCLUSION We identified a 15.9% error rate in EN order execution/documentation and 14% compliance with documentation of 48-h hang time. Errors (safety events) were grossly underreported. This highlighted several areas of opportunity to improve current EN use process, consistent with previous research on EN and oral nutrition supplement administration. Based on our findings, we plan to recommend implementation of EN barcoding at our institution, to model the familiar medication administration record.
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Affiliation(s)
- Elise Schwarz
- Nutrition Services Department, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Olivia Nass
- Nutrition Services Department, Froedtert Hospital, Milwaukee, Wisconsin, USA
- Department of Clinical Nutrition, Tampa General Hospital, Tampa, Florida, USA
| | - Vanessa Giocondo
- Nutrition Services Department, Froedtert Hospital, Milwaukee, Wisconsin, USA
- Clinical Nutrition Services, Medical University of South Carolina, Charleston, South Carolina, USA
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Cheon S, Oh SH, Kim JT, Choi HG, Park H, Chung JE. Nutrition Therapy by Nutrition Support Team: A Comparison of Multi-Chamber Bag and Customized Parenteral Nutrition in Hospitalized Patients. Nutrients 2023; 15:nu15112531. [PMID: 37299494 DOI: 10.3390/nu15112531] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/26/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
This study aimed to investigate the activity of a nutrition support team (NST) and the trends of multi-chamber bag (MCB) and customized parenteral nutrition (PN) with NST consultations in South Korea. Data were obtained from the National Inpatient Sample Cohort between 2015 and 2020. Three datasets were constructed for NST consultation, MCB-PN product prescriptions, and aseptic preparation of total PN. The intersections of the NST consultation and each PN dataset were compiled into MCB-PN with NST or customized PN with a NST sub-dataset, respectively. Using personal identifiers, the patients' characteristics were evaluated in the NST cohort. A total of 91,384 reimbursements and 70,665 patients were included. The NST activity had increased by more than 50% over 6 years. Approximately 70% and 11%, respectively, of the NST cohort were classified into two subgroups: MCB-PN with NST (M-NST) and customized PN with NST (C-NST). M-NST had many elderly patients with cancer and showed a higher in-hospital mortality than C-NST (12.6% vs. 9.5%). C-NST included a larger number of patients under the age of 5 years, and the hospitalization period was more extended than M-NST (26.2 vs. 21.2 days). The present study showed that NST activities and the proportion of PN with NST consultation are gradually increasing in South Korea.
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Affiliation(s)
- Seunghyun Cheon
- College of Pharmacy and Institute of Pharmaceutical Science and Technology, Hanyang University, Ansan-si 15588, Gyeonggi-do, Republic of Korea
| | - Sang-Hyeon Oh
- College of Pharmacy and Institute of Pharmaceutical Science and Technology, Hanyang University, Ansan-si 15588, Gyeonggi-do, Republic of Korea
| | - Jung-Tae Kim
- Department of Pharmacy, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
| | - Han-Gon Choi
- College of Pharmacy and Institute of Pharmaceutical Science and Technology, Hanyang University, Ansan-si 15588, Gyeonggi-do, Republic of Korea
| | - Hyojung Park
- Department of Pharmaceutical Services, Samsung Medical Center, Seoul 06351, Republic of Korea
- School of Pharmacy, Sungkyunkwan University, Suwon-si 16419, Gyeonggi-do, Republic of Korea
| | - Jee-Eun Chung
- College of Pharmacy and Institute of Pharmaceutical Science and Technology, Hanyang University, Ansan-si 15588, Gyeonggi-do, Republic of Korea
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Improving Administration and Documentation of Enteral Nutrition Support Therapy in a Veteran Affairs Health Care System: Use of Medication Administration Record and Bar Code Scanning Technology. J Patient Saf 2023; 19:23-28. [PMID: 36538338 DOI: 10.1097/pts.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The goal of this project was to evaluate and improve the ordering, administration, documentation, and monitoring of enteral nutrition therapies within the inpatient setting in a Veteran's Health Administration system. METHODS An interdisciplinary team of clinicians reviewed the literature for best practices and revised the process for enteral nutrition support for hospitalized veterans. Interventions included training staff, revising workflows to include scanning patients and products, including enteral nutrition orders within the medication administration record (MAR), and using the existing bar code medication administration system for administration, documentation, and monitoring. Baseline and postprocess improvement outcomes over a year period were collected and analyzed for quality improvement opportunities. RESULTS Before process change, only 60% (33/55) of reviewed enteral nutrition orders were documented and 40% (22/55) were not documented in the intake flowsheet of the electronic health record. In the year after adding enteral nutrition therapies to the MAR and using bar code scanning, a total of 3807 enteral nutrition products were evaluated. One hundred percent of patients were bar code scanned, 3106/3807 (82%) products were documented as given, 447/3807 (12%) were documented as held (with comments), 12/3807 (<1%) were documented as missing/unavailable, and 242/3807 (6%) were documented as refused. CONCLUSIONS Inclusion of enteral nutrition order sets on the MAR and using bar code scanning technology resulted in sustained improvements in safety, administration, and documentation of enteral therapies for hospitalized veterans.
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Bellanti F, lo Buglio A, Quiete S, Vendemiale G. Malnutrition in Hospitalized Old Patients: Screening and Diagnosis, Clinical Outcomes, and Management. Nutrients 2022; 14:nu14040910. [PMID: 35215559 PMCID: PMC8880030 DOI: 10.3390/nu14040910] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/18/2022] [Accepted: 02/19/2022] [Indexed: 02/05/2023] Open
Abstract
Malnutrition in hospitalized patients heavily affects several clinical outcomes. The prevalence of malnutrition increases with age, comorbidities, and intensity of care in up to 90% of old populations. However, malnutrition frequently remains underdiagnosed and undertreated in the hospital. Thus, an accurate screening to identify patients at risk of malnutrition or malnourishment is determinant to elaborate a personal nutritional intervention. Several definitions of malnutrition were proposed in the last years, affecting the real frequency of nutritional disorders and the timing of intervention. Diagnosis of malnutrition needs a complete nutritional assessment, which is often challenging to perform during a hospital stay. For this purpose, various screening tools were proposed, allowing patients to be stratified according to the risk of malnutrition. The present review aims to summarize the actual evidence in terms of diagnosis, association with clinical outcomes, and management of malnutrition in a hospital setting.
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