Association between indication for therapy by nutrition support team and nutritional status

Multidisciplinary nutritional support team and mortality in critically ill patients with acute respiratory distress syndrome

BACKGROUND

A careful approach is required when providing nutritional support to patients with acute respiratory distress syndrome (ARDS). This study investigated whether implementing a multidisciplinary nutritional support team (NST) is associated with improved survival outcomes in patients with ARDS.

METHODS

In a nationwide population-based cohort study, all adult patients admitted to the intensive care unit (ICU) in South Korea with a primary diagnosis of ARDS from January 1, 2017, to December 31, 2021, were included. The NST comprised four professionals (physicians, full-time nurses, full-time pharmacists, and full-time clinical dietitians). Patients admitted to ICUs with and without the NST system were allocated to the NST and non-NST groups, respectively.

RESULTS

The analysis comprised a total of 15,555 patients with ARDS. Among them, 6615 (42.5%) were in the NST group, and 8940 (57.5%) were in the non-NST group. After adjusting for covariates in the multivariable logistic regression, the NST group showed a 19% lower 30-day mortality than the non-NST group (odds ratio: 0.81, 95% confidence interval: 0.75-0.87, p < .001). Furthermore, after adjusting for covariates in multivariable Cox regression, the NST group showed a 12% lower 1-year all-cause mortality than the non-NST group (hazard ratio: 0.88, 95% confidence interval: 0.85-0.92, p < .001).

CONCLUSIONS

NST implementation was associated with enhanced 30-day and 1-year survival rates in patients with ARDS. These findings indicate that nutritional support provided by the NST may influence the survival outcomes of patients with ARDS in the ICU.

Multidisciplinary nutritional support team and survival outcomes in patients with sepsis: a nationwide population-based cohort study in South Korea

BACKGROUND

The South Korean government implemented a multidisciplinary nutritional support team (NST) system to focus on the proper evaluation and supply of nutritional status in hospitalized patients who are at a higher risk of malnutrition.

METHODS

This nationwide population-based cohort study included patients diagnosed with sepsis who were admitted to hospitals from 2016 to 2020. The NST should consist of four professional personnel (physicians, full-time nurses, full-time pharmacists, and full-time clinical dietitians). The NST group included patients with sepsis admitted to a hospital with an NST system, whereas the non-NST group included patients with sepsis admitted to a hospital without an NST system.

RESULTS

A total of 323,841 patients with sepsis were included in the final analysis, and 120,274 (37.1%) admitted to a hospital with an NST system were included in the NST group. In the multivariable Cox regression analysis, the NST group showed a 15% lower 90-day mortality than the non-NST group (hazard ratio [HR]:0.85, 95% confidence interval [CI]:0.83, 0.86; P < 0.001). The NST group shows 11% lower 1-year all-cause mortality than the non-NST group (HR:0.89, 95% CI:0.87, 0.90; P < 0.001). In subgroup analyses, a more evident association of the NST group with lower 90-day mortality was shown in the intensive care unit admission group and age ≥65 years old group.

CONCLUSIONS

Multidisciplinary NST intervention is associated with improved survival outcomes in patients with sepsis. Moreover, this association was more evident in patients with sepsis aged ≥65 years old who were admitted to the ICU.

Enhanced hypoglycemic effects of konjac glucomannan combined with Polygonatum cyrtonema Hua polysaccharide in complete nutritional liquid diet fed type 2 diabetes mice

In our aging society, dysphagia and malnutrition are growing concerns, necessitating intervention. Liquid nutrition support offers a practical solution for traditional dietary issues, but it raises a key issue: the potential for post-meal glucose spikes impacting efficacy. This study examined the effects of supplementation of Polygonatum cyrtonema Hua polysaccharide (PCP), konjac glucomannan (KGM) and their combination on acute phase postprandial glycemic response and long-term glucose metabolism in T2DM mice on a complete nutritional liquid diet. KGM was more effective in reducing postprandial glucose response, while PCP was more prominent in ameliorating long-term glucose metabolism. The KGM-PCP combination demonstrated superior outcomes in fasting blood glucose, insulin, and glucose homeostasis. PCP and KGM also influenced the composition and abundance of the gut microbiome, with the H-PCP group showing optimal performance. Moreover, the KGM-PCP combination improved body weight, lipid homeostasis, and liver health the most. PCP potentially regulates glycemia through metabolic pathways, while KGM improves glycemic metabolism by reducing postprandial glucose levels in response to viscous intestinal contents. This research identifies the structure, viscosity properties, and hypoglycemic effects of KGM and PCP in complete nutritional liquid diet fed T2DM mice, enabling their strategic utilization as hypoglycemic components in nutritional administration and glycemic regulation.

Role of family medicine physicians in providing nutrition support to older patients admitted to orthopedics departments: a grounded theory approach

BACKGROUND

Care of older adults requires comprehensive management and control of systemic diseases, which can be effectively managed by family physicians. Complicated medical conditions in older patients admitted to orthopedic departments (orthopedic patients) necessitate interprofessional collaboration. Nutrition is one of the essential components of management involved in improving the systemic condition of older patients. Nutrition support teams play an important role in nutrition management and can be supported by family physicians. However, the role of family physicians in nutrition support teams is not well documented. This study aimed to investigate the role of family physicians in supporting nutrition management in orthopedic patients.

METHODS

This qualitative study was conducted between January and June 2023 using constructivist grounded theory methodology. Eight family medicine physicians, three orthopedic surgeons, two nurses, two pharmacists, four rehabilitation therapists, four nutritionists, and one laboratory technician working in Japanese rural hospitals participated in the research. Data collection was performed through ethnography and semi-structured interviews. The analysis was performed iteratively during the study.

RESULTS

Using a grounded theory approach, four theories were developed regarding family physicians' role in providing nutrition support to orthopedic patients: hierarchical and relational limitation, delay of onset and detection of the need for geriatric care in orthopedic patients, providing effective family medicine in hospitals, and comprehensive management through the nutrition support team.

CONCLUSIONS

The inclusion of family physicians in nutrition support teams can help with early detection of the rapid deterioration of orthopedic patients' conditions, and comprehensive management can be provided by nutrition support teams. In rural primary care settings, family physicians play a vital role in providing geriatric care in community hospitals in collaboration with specialists. Family medicine in hospitals should be investigated in other settings for better geriatric care and to drive mutual learning among healthcare professionals.

Implementation of a multidisciplinary nutritional support team and clinical outcomes in critically ill patients with COVID-19

BACKGROUND & AIMS

The South Korean government established the multidisciplinary nutritional support teams (NST) system for enhancing the evaluation and adequate supply of nutritional support to patients at high risk of malnutrition. However, the impact of the NST on clinical outcomes in critically ill patients with coronavirus disease 2019 (COVID-19) remains unclear. We aimed to investigate whether NST implementation affects survival outcomes in patients with COVID-19 requiring intensive care unit (ICU) admission.

METHODS

Using data from the National Health Insurance Service and Korea Disease Control and Prevention Agency in South Korea, adult patients with COVID-19 admitted to the ICU between October 8, 2020, and December 31, 2021, were included. The NST comprised four professional personnel (physicians, full-time nurses, full-time pharmacists, and full-time clinical dietitians). Patients admitted to ICUs with and without the NST system were assigned to the NST and non-NST groups, respectively.

RESULTS

A total of 13,103 critically ill adult patients were included in the final analysis; among them, 10,103 (77.1 %) and 3,000 (22.9 %) patients were included in the NST and non-NST groups, respectively. In the NST group, 2,803 (27.7 %) critically ill patients with COVID-19 were prescribed enteral or parenteral nutrition by the NST. In a covariate-adjusted multivariable model, the NST group showed a 40 % lower in-hospital mortality rate than the non-NST group (odds ratio: 0.60, 95 % confidence interval: 0.51, 0.71; P < 0.001). In subgroup analyses, compared with the non-NST group, the NST group showed significantly lower in-hospital mortality rates at 2, 3, 4, and 5 points on the World Health Organization clinical progression scale among patients with acute respiratory distress and mechanical ventilatory support.

CONCLUSIONS

NST implementation was associated with improved survival outcomes in critically ill patients with COVID-19; accordingly, it may be recommended for improving adequate nutritional support and evaluation in critically ill patients.

Impact of Visual Nutritional Indicator on the Nutritional Therapy in Intensive Care Unit

Background

We wanted to evaluate if a visual nutritional indicator (VNI), which shows the total amount of calories and protein, can improve the quality of nutritional therapy (NT) and result in better clinical outcomes prospectively.

Materials and methods

We randomly assigned patients to VNI or non-VNI (NVNI) groups. In the VNI group, VNI was attached to the patient's bed for the attending physician. The primary goal was a higher supply of calories and proteins. The secondary goals were the shorter length of intensive care unit (ICU) stay, mechanical ventilation, and renal replacement therapy.

Results

The total calorie supply was 18.6 kcal/kg and 15.6 kcal/kg in the VNI and NVNI groups, respectively (p = 0.04). The total protein supply was 0.92 g/kg and 0.71 g/kg, respectively (p = 0.05). The length of ICU stay was 5.6 days and 5.3 days in the VNI and NVNI groups, respectively (p = 0.09). The length of mechanical ventilation was 3.6 days and 3.8 days, respectively (p = 0.07). The length of renal replacement therapy was 5.7 days and 6.3 days, respectively (p = 0.13). The mortality on the seventh day was 14.6% and 16.1% in the VNI and NVNI groups, respectively (p = 0.08). The mortality on the thirtieth day was 20 and 20.8%, respectively (p = 0.87).

Conclusion

Visual nutritional indicator, indicating the total amount of calories and protein provided, can improve the quality of NT but fail to obtain a better clinical outcome.

How to cite this article

Mun S. Impact of Visual Nutritional Indicator on the Nutritional Therapy in Intensive Care Unit. Indian J Crit Care Med 2023;27(6):392-396.

Characteristics and clinical course of patients referred to the NST

Background and aims

The nutrition support team (NST) comprises doctors, nutritionists, pharmacists, and nurses who provide intensive nutritional treatment designed for each patient by evaluating their nutritional status of hospitalized patients. This study aimed to identify the clinical characteristics of patients referred to the NST among those admitted to a tertiary hospital and to understand the factors affecting their clinical course and changes in pressure sore grades.

Methods

This study included 1,171 adult patients aged 18 years or older referred to the NST at a tertiary hospital in a metropolitan city between 1 January 2019 and 31 December 2020. Patients were divided into five age groups, neuro department and non-neuro department, those treated in the intensive care unit (ICU), and those not treated in the ICU. Patients were also compared based on the presence of pressure sores at the time of NST referral and changes in pressure sore grades at the first time of NST referral and discharge (improved pressure sores, no change in pressure sores, and aggravated pressure sores). In addition, this study examined the factors affecting changes in pressure sore grades.

Results

As age increased, the proportion of both low albumin levels and pressure sores significantly increased (p < 0.001), and the neuro department showed a significantly lower proportion of low albumin levels and pressure sores (p < 0.001). The proportion of patients with pressure sores was higher (64.9%), and this patient group showed significantly higher rates of low albumin levels (p < 0.001) and treatment in the ICU (p < 0.001). The group with aggravated pressure sore grades had a significantly higher proportion of patients in the surgery department (p = 0.009) and those treated in the ICU (p < 0.001). Admission to the surgery department was a factor that aggravated the grade of pressure sores [adjusted odds ratio (aOR) = 1.985, 95% confidence interval (CI) = 1.168-3.371]. When patients were not treated in the ICU, the grade of the pressure sores was less likely to worsen (aOR = 0.364, 95% CI = 0.217-0.609).

Conclusion

Pressure sores and low albumin levels are closely related, and the risk of developing and aggravating pressure sores is particularly high in patients in the surgery department and those receiving ICU treatment. Therefore, it is necessary to actively implement NST referral to ensure that overall nutrition, including albumin, is well supplied, especially for patients in the surgery department and treated in the ICU, as they are at high risk of pressure sore development and aggravation. Moreover, since low albumin levels frequently occur in elderly patients, it is necessary to consider including the elderly in the indications for referral to the NST.

[Nutritional status and use of health resources following the implementation of a PEG tube nutrition program for neurological patients in home hospitalization]

Objective: the objective of this study was to demonstrate that implementation of enteral nutrition by gastrostomy tube by the Home Hospitalization Unit (HHU) in patients suffering from neurological diseases, significantly improves their nutritional status, both in terms of anthropometric and analytical parameters. Methods: data on admissions, days of hospital stay, emergency room visits and nutritional parameters were collected during the 6 months before and 6 months after placement of a percutaneous endoscopic gastrostomy (PEG) tube in 100 patients from the UHD at General University Hospital in Elda (Alicante). Results: a total of 100 neurological patients were included in the study; 58 % of them were women and with a mean age (standard deviation, SD) of 78.3 (13.3) years, with 60 % of the patients being > 80 years. The monitoring and home treatment of these patients by the HHU of General University Hospital in Elda led to improvement in quality of life and nutritional parameters (weight, body mass index, proteins, albumin, prealbumin, creatinine, and hemoglobin), as well as a decrease in the number of complications derived from the nutritional management of patients at their home, and a significant reduction in number of admissions (90.27 %) and days of hospital stay (94.05 %), as well as of visits to emergency services (79.47 %), with a consequent reduction in healthcare costs. Conclusions: the implementation of a home-based monitoring program for patients with PEG by a HHU improves their nutritional status and reduces healthcare costs.

Bridging Policy and Service Performance of Hospital-Based Nutrition Support by Healthcare Information Technology

Although the healthcare policy was implemented to incentivize the multidisciplinary services of hospital-based nutrition support team (NST) in South Korea, timely completion of the services has been challenging in the hospitals. We enhanced NST healthcare information technology (NST-HIT) to bridge the gap between policy implementation and seamless execution of the policy in the hospital system. A 48 month pre-test-post-test study was performed, including a 12 month pre-intervention period, a six month intervention period, and a 30 month post-intervention period. The enhanced NST-HIT provided sufficient patient data and streamlined communication processes among end-users. A Student's t-test showed that the timely completion rate of NST consultations, the reimbursement rate of NST consultations, average response times of NST physicians and nurses, and length of hospital stay significantly improved during the post-intervention period. A segmented regression analysis of interrupted time series showed that the average response times of NST physicians had sustained after the interventions. We believe that well-structured, multi-pronged initiatives with leadership support from the hospital improved service performance of hospital NST in response to national-level healthcare policy changes.

Tutorial on Diarrhea and Enteral Nutrition: A Comprehensive Step-By-Step Approach

This tutorial suggests a current strategy toward a multiprofessional therapy based upon a comprehensive step-by-step approach to the course of intensive care unit diarrhea episodes. Evidence published in the last 10 years, obtained through a database search (PubMed), shows that its prevalence is quite variable. Although multicausal, it is often erroneously associated with the supply of enteral nutrition. Several complications affect not only nutrition status but also the development of skin lesions, which can become the focus of infections, and the length of hospital stay. Here, we propose an early, objective, directed, and multimodal approach, aiming at optimizing care for these patients. In a dynamic walkthrough, the reader will find a guide for the general diagnosis and for colitis resulting from Clostridium difficile infections, as well as current instructions and recommendations for drug treatment and supportive therapy for these 2 modalities. We also bring together ways to prevent and treat associated skin lesions in this setting. Because it is neglected in the critical environment, diarrhea is still a poorly addressed disease, and its complications bring about a significant worsening in quality of life and hospital stay.