Efficacy and Efficiency of Nutritional Support Teams

Nutritional support team intervention in surgical ICUs and its effect on nutrition delivery and quality in critically ill patients

RATIONAL

Critically ill surgical patients pose one of the greatest challenges in achieving nutritional goals. Several published papers have demonstrated clear benefits when nutrition support (NS) is managed by a multidisciplinary nutrition support team (NST). We hypothesized that implementing a NST in a surgical intensive care unit (ICU) would increase the number of patients achieving their nutritional goals.

MATERIAL AND METHOD

Multicenter "BEFORE & AFTER" study. In the BEFORE phase, an audit of the previous state of NS was conducted in three ICUs without a NST.

INTERVENTION

Implementation of a NST and protocol. In the AFTER phase, a new audit of NS was conducted. Continuous variables (presented as mean ± SD or median Q1-Q3) were tested using the t-test and Mann-Whitney U test. Categorical variables (presented as frequencies and percentages) were assessed using the chi-square test. A binomial logistic regression model was performed, with independent variables introduced using a stepwise forward method. A difference was considered to be significant with a two-sided P-value <0.05. Statistical analysis was conducted using IBM-SPSS 26.

RESULTS

A total of 83 patients were included in the BEFORE phase, and 85 in the AFTER phase. The latter group showed a higher frequency of nutritional risk and malnutrition (SGA B+C odds ratio 2.314, 95% CI 1.164-4.600). Laparoscopy was more frequently utilized as a surgical technique in the AFTER phase. No differences were observed in ICU and hospital LOS or 90 days' survival rates. Two variables remained independent factors to predict NS achievement: NST implementation (odds ratio 3.582, 95% CI 1.733-7.404), and surgical technique (odds ratio 3.231, 95% CI 1.312-7.959).

CONCLUSION

NST positively impacts the chance of achieving NS goals in critically ill surgical patients.

Enteral nutrition: An underappreciated source of patient safety events

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.

Nutrition's Role in Quality Healthcare in the United States: Opportunities and Education for Pharmacists to Take a Bite of the Apple and Strengthen Their Skills

With global chronic disease rates on the rise, diet and nutrition remain pivotal yet under-appreciated aspects of healthcare, including in pharmacy practice. This perspective paper delves into how current United States health policies support nutrition's role in healthcare and its integration into pharmacy practice. The paper also reviews the landscape of nutrition education and training for pharmacists, pharmacy roles in multidisciplinary teams and interprofessional nutrition care, and the opportunities for post-graduate nutrition-focused certification, training, and continuing education. It advocates for a paradigm shift towards greater emphasis on nutrition within pharmacy practice, to improve skills and benefit quality patient nutrition care.

Factors affecting target caloric achievement and calorie intake improvement: the nutrition support team's role

Background

The nutrition support team (NST) works to improve malnutrition in hospitalized patients, and its role is expanding as more hospitals adopt NST. This study aimed to identify the clinical characteristics of NST-referred patients admitted to a tertiary hospital. The study focused on two groups: those who achieved the target calories, approximately 75% or more of their caloric needs relative to their body weight regardless of the period after the first NST referral, and those who improved their calorie intake 1 week after NST therapy. This study also analyzed the important factors affecting the achievement of target calorie intake and improvement in calorie intake to discover the focus of future NST therapy.

Methods

This study examined 1,171 adult patients (aged ≥18 years) who were referred to the NST from all the departments within a tertiary hospital at least twice, with a minimum one-week interval between referrals, between January 1, 2019, and December 31, 2020. The study participants consisted of patients receiving <75% of their required caloric intake at the time of their first NST referral. Patients were categorized and compared according to whether they achieved their target calorie intake regardless of the period after the first NST referral and whether they improved their calorie intake 1 week after the NST therapy. We then identified factors affecting target caloric achievement and improvement in calorie intake.

Results

The group that achieved the target calorie intake had a lower proportion of neuro department patients (31.3%), a higher proportion of patients receiving intensive care unit (ICU) care (31.9%), and a longer ICU stay (p < 0.001) than the group that did not achieve the target calorie intake. Neuro department admission negatively affected target caloric achievement [adjusted odds ratio (aOR) = 0.305, 95% confidence interval (CI) = 0.150-0.617], whereas the length of ICU stay positively affected target caloric achievement (aOR = 1.025, 95% CI = 1.007-1.043). The proportion of neuro department patients was also low (42.5%) in the group with improved calorie intake 1 week after NST therapy. Neuro department admission was a negative factor (aOR = 0.376, 95% CI = 0.264-0.537) affecting the improvement in calorie intake.

Conclusions

NST therapy significantly improved clinical outcomes for inpatients at nutritional risk. Because achieving target calories and improving calorie intake in neuro department patients is difficult, it is necessary to actively refer them to NST to achieve the target calories and improve calorie intake. Furthermore, because a longer ICU stay positively affects target calorie achievement, the system for ICU nutrition therapy should be expanded and implemented for general-ward patients, including neurological patients.

Impact of a multidisciplinary collaborative nutritional treatment model in patients who are critically ill with neurological disorders: A randomized controlled trial

BACKGROUND

Malnutrition is a widespread problem in critically ill patients with neurological disorders.

OBJECTIVE

The purpose of this study is to investigate the effect of a multidisciplinary collaborative nutritional treatment mode based on a standardized unit for nutritional support on the outcome metrics in patients with neurological disorders who are critically ill.

METHODS

We enrolled 84 participants who were hospitalized in the intensive care unit (ICU) of Yancheng No. 1 People's Hospital for neurological disorders between June 2018 and December 2021. The participants were randomly assigned to the control group and the test group. The control group received traditional nutritional support, while the test group was treated with a multidisciplinary collaborative nutritional treatment mode based on a standardized unit for nutritional support. We collected the general information, feeding tolerance (FT), nutritional risk score, and laboratory indicators before intervention, after intervention for one week, and after intervention for 2 weeks, and other data of the participants.

RESULTS

After the intervention, the test group scored significantly lower than the control group in the incidence of gastroparesis and diarrhea, as well as the NUTRIC score, with statistically significant differences (P< 0.001). The prealbumin levels in the test group increased progressively prior to intervention, after intervention for one week, and after intervention for two weeks. Compared to the control group, the test group had higher prealbumin levels prior to intervention, after intervention for one week, and after intervention for two weeks, with statistically significant differences (P< 0.001).

CONCLUSION

We developed a multidisciplinary collaborative nutritional treatment model based on a standard unit for nutritional support. This model can improve neural function, FT, and pertinent outcome indicators and is generally applicable.

Towards Achieving Nutrition Goal in Critically Ill Patients: Need a Simple Yet Effective Bedside Tool

How to cite this article: Wali S, Gutte SH, Gurjar M. Towards Achieving Nutrition Goal in Critically Ill Patients: Need a Simple Yet Effective Bedside Tool. Indian J Crit Care Med 2023;27(6):379-380.

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.

Nutrition Therapy by Nutrition Support Team: A Comparison of Multi-Chamber Bag and Customized Parenteral Nutrition in Hospitalized Patients

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.

Factors influencing adherence to healthy eating behaviors among adult colorectal cancer survivors: a systematic mixed method review

PURPOSE

Under the umbrella of social cognitive theory, we examined the influences of personal, environmental, and behavioral factors on adherence to healthy eating behaviors among colorectal cancer survivors.

METHODS

Based on Pluye and Hong's framework, a systematic mixed studies review was conducted. An extensive search strategy was applied in PubMed, Web of Science, Embase, CINAHL, and PsycINFO (from date of record to 2022 January 22). The pillar integration process was employed to integrate the extracted data. The Mixed Methods Appraisal Tool was used to appraise the quality of all retained studies.

RESULTS

Twenty-eight studies with a total sample size of 5106 were included in the analysis, with 15 quantitative studies, 12 qualitative studies, and 1 mixed method study. The critical appraisal showed that 22 of the 28 studies (79%) were rated with five stars, while 6 (21%) were rated with four stars. The personal factors influencing adherence to healthy eating behaviors among colorectal cancer survivors included outcome expectancies, self-efficacy, psychological factors, knowledge about healthy eating, demographic and disease characteristics, environmental factors incorporated outside information on healthy eating, power of surrounding people, social activities, cultural milieus, socioeconomic status, and education. The behavioral factors included self-regulation of diet, goals, and other behaviors closely related to healthy eating behaviors.

CONCLUSIONS

Adherence to healthy eating behaviors among colorectal cancer survivors was influenced collectively by personal factors, environmental factors and behavioral factors.

Chinese expert consensus on prevention and intervention for the elderly with malnutrition (2022)

Malnutrition is a state of altered body composition and body cell mass due to inadequate intake or utilization of energy or nutrients, leading to physical and mental dysfunction and impaired clinical outcomes. As one of the most common geriatric syndromes, malnutrition in the elderly is a significant risk factor for poor clinical outcomes, causing a massive burden on medical resources and society. The risk factors for malnutrition in the elderly are diverse and include demographics, chronic diseases, and psychosocial factors. Presently, recommendations for the prevention and intervention of malnutrition in the elderly are not clear or consistent in China. This consensus is based on the latest global evidence and multiregional clinical experience in China, which aims to standardize the prevention and intervention of malnutrition in the elderly in China and improve the efficacy of clinical practice and the prognosis of elderly patients.

A prospective epidemiological analysis of controlling nutritional status score with the poor functional outcomes in Chinese patients with haemorrhagic stroke

Nutritional Risk Screening index is a standard tool to assess nutritional risk, but epidemiological data are scarce on controlling nutritional status (CONUT) as a prognostic marker in acute haemorrhagic stroke (AHS). We aimed to explore whether the CONUT may predict a 3-month functional outcome in AHS. In total, 349 Chinese patients with incident AHS were consecutively recruited, and their malnutrition risks were determined using a high CONUT score of ≥ 2. The cohort patients were divided into high-CONUT (≥ 2) and low-CONUT (< 2) groups, and primary outcomes were a poor functional prognosis defined as the modified Rankin Scale (mRS) score of ≥ 3 at post-discharge for 3 months. Odds ratios (OR) with 95 % confidence intervals (CI) for the poor functional prognosis at post-discharge were estimated by using a logistic analysis with additional adjustments for unbalanced variables between the high-CONUT and low-CONUT groups. A total of 328 patients (60·38 ± 12·83 years; 66·77 % male) completed the mRS assessment at post-discharge for 3 months, with 172 patients at malnutrition risk at admission and 104 patients with a poor prognosis. The levels of total cholesterol and total lymphocyte counts were significantly lower in high-CONUT patients than low-CONUT patients (P = 0·012 and < 0·001, respectively). At 3-month post discharge, there was a greater risk for the poor outcome in the high-CONUT compared with the low-CONUT patients at admission (OR: 2·32, 95 % CI: 1·28, 4·17). High-CONUT scores independently predict a 3-month poor prognosis in AHS, which helps to identify those who need additional nutritional managements.

Offering Guidance and Learning to Prescribers to Initiate Parenteral Nutrition using a Validated Electronic Decision TREE (OLIVE TREE)

Parenteral nutrition (PN) is recommended in patients nutritionally at risk and unable to receive oral or enteral nutrition. A standardized electronic PN order format could enhance appropriate PN prescribing. We developed the OLIVE TREE (Offering guidance and Learning to prescribers to Initiate PN using a Validated Electronic decision TREE), embedded in our electronic health record. We aimed to evaluate its validity and impact on physicians' prescribing behavior. A non-randomized before-after study was carried out in a tertiary care center. The OLIVE TREE comprises 120 individual items. A process validation was performed to determine interrater agreement between a pharmacist and the treating physician. To estimate the proportion of patients for whom the OLIVE TREE had an effective and potential impact on physicians' prescribing behavior, a proof of concept study was conducted. The proportion of patients for whom PN was averted and the proportion of decisions not in line with the recommendation were also calculated. The process validation in 20 patients resulted in an interrater agreement of 95.0%. The proof of concept in 73 patients resulted in an effective and potential impact on prescribing behavior in 50.7% and 79.5% of these patients, respectively. Initiation of PN was not averted and recommendations of the OLIVE TREE were overruled in 42.5% of the patients. Our newly developed OLIVE TREE has a good process validity. A substantial impact on prescribing behavior was observed, although initiation of PN was not avoided. In the next phase, the decision tree will be implemented hospital-wide.

Prevention and management of minor complications in percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) was developed by Ponsky-Gauderer in the early 1980s. These tubes are placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition but can also be used for drainage or decompression. The tubes consist of an internal and external retention device. It is a generally safe technique but major or minor complications may arise during and after tube placement.

METHOD

A narrative review of the literature investigating minor complications after PEG placement.

RESULTS

This review was written from a clinical viewpoint focusing on prevention and management of minor complications and documented with real cases from more than 21 years of clinical practice.

CONCLUSIONS

Depending on the literature the incidence of minor complications after gastrostomy placement can be high. To decrease associated morbidity, prevention, early recognition and popper management of these complications are important.

Management of Malnutrition Based on Multidisciplinary Team Decision-Making in Chinese Older Adults (3M Study): A Prospective, Multicenter, Randomized, Controlled Study Protocol

Background

In hospital settings, malnutrition affects 30-50% of aged inpatients and is related to a higher risk of hospital complications and death. This study aims to demonstrate the effectiveness of a tailored optimum nutritional therapy in malnourished, elderly inpatients based on multidisciplinary team recommendations in hopes of decreasing the incidence of deleterious clinical outcomes.

Methods and Design

This trial will be a multicenter, open-label, randomized control trial conducted in the geriatric wards of at least five hospitals in five different regions. We aim to include 500 inpatients over the age of 60 with or at risk of malnutrition based on a Mini Nutritional Assessment Short-Form (MNA-SF) score of ≤ 11 points and the Global Leadership Initiative on Malnutrition with an expected length of stay of ≥ 7 days. Eligible inpatients will be randomized into a 1:1 ratio, with one receiving a multidisciplinary team intervention and the other receiving standard medical treatment or care alone. A structured comprehensive assessment of anthropometry, nutritional status, cognition, mood, functional performance, and quality of life will be conducted twice. These assessments will take place on the day of group allocation and 1 year after discharge, and a structured screening assessment for elderly malnutrition will be conducted at 3 and 6 months after discharge using the MNA-SF. The primary outcome will be nutritional status based on changes in MNA-SF scores at 3, 6 months, and 1 year. The secondary outcome will be changes in cognition, mood, functional status, length of hospital stay, and all-cause mortality 1 year after discharge.

Discussion

Guided by the concept of interdisciplinary cooperation, this study will establish a multidisciplinary nutrition support team that will develop an innovative intervention strategy that integrates nutritional screenings, evaluations, education, consultation, support, and monitoring. Moreover, nutritional intervention and dietary fortification will be provided to hospitalized elderly patients with or at risk of malnutrition. The nutrition support team will formulate a clinical map for malnutrition in elderly patients with standardized diagnosis and treatment for malnutrition in this population.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [ChiCTR2200055331].

Systematic review with meta-analysis: effects of implementing a nutrition support team for in-hospital parenteral nutrition

BACKGROUND

Nutrition support teams (NST) may improve parenteral nutrition (PN) outcomes. No previous systematic review has provided conclusive data on catheter-related infection (CRI) occurrence after NST introduction, nor have previous studies performed meta-analysis or graded the evidence.

AIMS

To systematically evaluate the effects of implementing an NST for hospitalised adults on PN and compare these with standard care.

METHODS

This was a systematic review and meta-analysis, pre-registered in PROSPERO (CRD42020218094). On November 24, 2020, PubMed, Web of science, Scopus, Embase, Cochrane Library, and Clinical Key were searched. Clinical trials and observational studies with a standard care comparator were included. Primary outcome was relative reduction in CRI rate. A random-effects meta-analysis was used to estimate effects, and evidence was rated using Cochrane and GRADE methodologies.

RESULTS

Twenty-seven studies with 8166 patients were included. Across 10 studies, NST introduction reduced the CRI rate (IRR = 0.32, 95% CI: 0.19-0.53) with -8 (95% CI: -12 to -5) episodes per 1000 catheter days compared with standard care. Hypophosphataemia occurred less frequently (IRD = -12%, 95% CI: -24% to -1%) and 30-day mortality decreased (IRD = -6%, 95% CI: -11% to -1%). Inappropriate PN use decreased, both judged by indication (IRD = -18%, 95% CI: -28% to -9%) and duration (IRD = -21%, 95% CI: -33% to -9%). Evidence was rated very low to moderate.

CONCLUSIONS

This study documents the clinical impact of introducing an NST, with moderate-grade evidence for the reduction of CRI occurrence compared with standard care. Further, NST introduction significantly reduced metabolic complications, mortality, and inappropriate PN use.

Impact of Refeeding Syndrome on Short- and Medium-Term All-Cause Mortality: A Systematic Review and Meta-Analysis

BACKGROUND

The refeeding syndrome has been described as a potentially life-threatening complication of renutrition. However, moving from single reports to larger population studies, the real impact of refeeding syndrome on all-cause mortality is still unknown.

METHODS

PubMed/Medline, EMBASE, Cochrane library, and CINAHL databases were systematically searched until September 2020 for studies reporting mortality rates in patients who developed the syndrome at renutrition compared with those who did not develop it. Effect sizes were pooled through a random-effect model.

RESULTS

Thirteen studies were finally considered in the meta-analysis, for a total of 3846 patients (mean age 64.5 years; 58% males). Pooled data showed a nonsignificant trend toward an increased short-term (≤1 month) mortality in patients developing the refeeding syndrome (odds ratio = 1.27, 95% confidence interval 0.93-1.72), mostly driven by studies in which renutrition was not prescribed and supervised by a nutritional support team (P = .01 at subgroup analysis) and by studies published in previous years (P = .04 at meta-regression). When examining medium-term (≤6 month) mortality, an overall statistical significance toward higher risk was observed (odds ratio = 1.54, 95% confidence interval 1.04-2.28).

CONCLUSION

This was the first meta-analysis that specifically assessed the impact of refeeding syndrome on mortality. Our results suggested a nonsignificant trend toward increased mortality in the short term but a significantly increased mortality in the medium term. The supervision/management of the refeeding process by a nutrition specialist might be a key factor for the limitation of this mortality excess.

Prognostic Value of Combined Preoperative Carcinoembryonic Antigen and Prognostic Nutritional Index in Patients With Stage II-III Colon Cancer

Background: Tumor status can affect patient prognosis. Prognostic nutritional index (PNI), as a nutritional indicator, is closely related to the prognosis of cancer. However, few studies have examined the combined prognostic value of CEA and PNI in patients. This study investigated the relationship between CEA/PNI and prognosis of colon cancer patients.

Methods: A total of 513 patients with stage II–III colon cancer who underwent curative resection at two medical centers from 2009 to 2019 were included. Clinicopathological factors were assessed and overall survival (OS) was assessed in a cohort of 413 patients. Multivariate analysis was used to identify independent prognostic variables to construct histograms predicting 1-year and 3-year OS. Data from 100 independent patients in the validation group was used to validate the prognostic model.

Results: The median OS time was 33.6 months, and mortality was observed in 54 patients. Multivariate analysis revealed that preoperative CEA/PNI, lymph node metastasis, peripheral nerve invasion, operation mode, and postoperative chemotherapy were independent factors for prognosis evaluation and thus were utilized to develop the nomogram. The C-index was 0.788 in the learning set and 0.836 in the validation set. The calibration curves reached favorable consensus among the 1-, 3-year OS prediction and actual observation.

Conclusion: The combined use of CEA and PNI is an independent prognostic factor and thus can serve as a basis for a model to predict the prognosis of patients with stage II–III colon cancer.

Role of nutritional care and general guidance for patients with advanced or metastatic gastric cancer

Patients with advanced or metastatic gastric cancer often suffer from malnutrition, which can have an impact on quality of life, increase the toxicity of chemotherapy and reduce overall survival. Options available to the clinician to manage a patient's nutritional status include screening and assessment of malnutrition at diagnosis, monitoring during the 'cancer journey', early detection of precachexia and the ongoing use of a multidisciplinary team (oncologists, other medical specialists and nutritionists). Because malnutrition is frequently overlooked and under treated in patients with advanced or metastatic gastric cancer, this narrative review focuses on the clinical meaning of nutritional status in gastric cancer and provides general guidance regarding nutritional care management for patients with advanced or metastatic gastric cancer.

Value of nutrition support therapy in patients with gastrointestinal malignancies: a narrative review and health economic analysis of impact on clinical outcomes in the United States

Malnutrition, particularly under-nutrition, is highly prevalent among adult patients with a diagnosis of gastrointestinal (GI) cancer and negatively affects patient outcomes. Malnutrition is associated with clinical and surgical complications for patients undergoing therapy for GI cancers and the costs associated with those complications is a high burden for the US health system. Our objective was to identify high-quality evidence for nutrition support interventions associated with cost savings for patient care, followed by a complex economic value analysis to project cost savings for the US health system. A narrative literature search was conducted in which combined keywords in the areas of therapeutic nutrition (nutrition, malnutrition), a specific therapeutic area [GI cancer (esophageal, gastric, gallbladder, pancreatic, liver/hepatic, small and large intestine, colorectal)], and clinical outcomes and healthcare cost, to look for nutrition interventions that could significantly improve clinical outcomes. Medicare claims data were then analyzed using the findings of these identified studies and this modeling exercise supported identifying the cost and healthcare resource utilization implications of specific populations to determine the impact of nutrition support on reducing these costs as reflected in the summary of the evidence. Eight studies were found that provided clinical outcomes and health cost savings data, 2 of those had the strongest level of evidence and were used for Value Analysis calculations. Nutrition interventions such as oral diet modifications, enteral nutrition (EN) supplementation, and parenteral nutrition (PN) have been studied especially in the peri-operative setting. Specifically, peri-operative immunonutrition administration and utilization of enhanced recovery pathways after surgery have been associated with significant improvement in postoperative complications and decreased length of hospital stay (LOS). Utilizing economic modeling of Medicare claims data from GI cancer patients, potential annual cost savings of $242 million were projected by the widespread adoption of these interventions. Clinical outcomes can be improved with the use of nutrition interventions in patients with GI cancers. Healthcare costs can be reduced as a result of fewer in-hospital complications and shorter lengths of hospital stay. The application of nutrition intervention provides a positive clinical and economic value proposition to the healthcare system for patients with GI cancers.

Effect of the Timing of Nutritional Support Team Intervention on Nutritional Status on Patients Receiving Enteral Nutrition

Many hospitalized patients usually have a high risk of malnutrition, which delays the therapy process and can lead to severe complications. Despite of the potential benefits, the effects of timely intervention by nutrition support team (NST) on the nutritional status of admitted patients are not well established. This study aimed to compare the nutritional status between patients with early and delayed NST supports and to assess the effect of the timing of NST support initiation on the nutritional status of enteral nutrition patients. In a simple comparison between the two groups, the early NST intervention group had shorter hospital stays and fewer tube feeding periods than the delayed NST intervention group. The increase in the amount of energy intake from first to last NST intervention was 182.3 kcal in patients in the early NST intervention group, higher than that in patients in the delayed intervention group (p = 0.042). The extent of reduction in serum albumin and hemoglobin levels between the initial and last NST intervention tended to be lower in the early NST intervention group than in the delayed NST intervention group. The mean odds ratio for the patients who were severely malnourished in the early NST intervention group was 0.142 (95% confidence interval, 0.045–0.450) after adjusting for hospital stay and age. The results of this study indicate that early NST intervention can improve patients' overall nutritional status.

Hospital Malnutrition, Nutritional Risk Factors, and Elements of Nutritional Care in Europe: Comparison of Polish Results with All European Countries Participating in the nDay Survey

NutritionDay (nDay) is a project established by the Medical University of Vienna and the European Society for Clinical Nutrition and Metabolism (ESPEN) to audit the nutritional status of hospitalized patients and nursing home residents. This study aimed to evaluate nDay data describing the prevalence of hospital malnutrition, nutritional risk factors, and elements of the nutritional care process implemented in hospital wards in 25 European countries and to compare the data derived from Poland with the data collected in all the European countries participating in the study. In total, 10,863 patients (European reference group: 10,863 participants including Poland: 498 participants) were involved in the study. The prevalence of malnutrition was identified on the basis of the ESPEN diagnostic criteria established in 2015, while the prevalence of nutritional risk factors was assessed by analyzing the following parameters: body mass index (BMI), score of Malnutrition Screening Tool (MST), recent weight loss, insufficient food intake, decreased appetite, increased number of drugs intake, reduced mobility, and poor self-reported health status. Malnutrition prevalence was 12.9% in patients from the European reference group and 9.4% in patients from Polish hospital wards (p < 0.05). However, the prevalence of some nutritional risk factors, i.e., recent weight loss, history of decreased food intake, and low actual food intake, were approximately four times more prevalent than diagnosed malnutrition (referring to approximately 40-50% of all participants). In comparison to the European reference group, the significant differences observed in Polish hospital wards concerned mainly dietitian's involvement in the process of treating malnutrition (16% vs. 57.2%; p < 0.001); supply of special diets (8% vs. 16.1%; p < 0.0001); provision of oral nutritional support (ONS) (3.8% vs. 12.2%; p < 0.0001); prescription of enteral/parenteral nutrition therapy to hospitalized patients (8.2% vs. 11.7%; p < 0.001); as well as recording patient weight performed at hospital admission (100% vs. 72.9%; p < 0.0001), weekly (20% vs. 41.4%; p < 0.05), and occasionally (0% vs. 9.2%). These results indicate that the prevalence of malnutrition and malnutrition risk factors in hospitalized patients in Poland was slightly lower than in the European reference group. However, some elements of the nutritional care process in Polish hospitals were found insufficient and demand more attention.

[Pillars for excellence in nutrition support units. Regulation]

Introduction

Nutritional assessment and treatment, necessary for the prevention and treatment of disease-related malnutrition, should be carried out by a multidisciplinary team where each member has well-defined skills and functions, and mechanisms are established to allow adequate coordination, both in the inpatient and outpatient settings. In Spain, the development and implementation of these teams or units dedicated to clinical nutrition has been very important: today they are present in most hospitals. This paper reviews the characteristics of clinical nutrition units, the functions of their team members, and the regulatory framework in our country.

[Perioperative nutritional support for surgical patients]

The article presents an algorithm for perioperative nutritional support of surgical patients operated on as planned. Today, planned surgical care is provided in accordance with the canons of the accelerated rehabilitation Program (ARP). The relevance of the problem of nutritional insufficiency, which is an important component of ARP, is due to the dependence of the results of surgical treatment on the initial nutritional status of the patient. Methods of screening for nutritional deficiency and options for correcting protein-energy disorders are described. The predominant method is the enteral delivery of nutrients and energy. Oral supplemental nutrition by sipping is a convenient way to correct nutritional disorders at all stages of the perioperative period.

Nutrition Support Teams: A Systematic Review

BACKGROUND

The concept of a nutrition support team (NST) was first introduced at the end of the 20th century in the US and Europe. Expected benefits include reduced (inappropriate) prescription of (par)enteral nutrition; however, to the authors' knowledge, no recent review has assessed the effectiveness of NSTs. Therefore, this systematic review evaluated the effectiveness of NSTs with respect to the prevalence of adult patients receiving (par)enteral nutrition.

METHODS

Five literature databases were searched and completed by citing searches. Studies on NSTs that were published between 2000 and 2018 in Western countries, applied a comparative design, and contained at least outcome data on the prevalence of (par)enteral nutrition were included. Analyses were mainly descriptive because of high heterogeneity that prevented meta-analyses.

RESULTS

The 27 included studies mainly originated from the UK and US. Only 1 of the included studies was a randomized trial; the other studies had a pre-post design (n = 17) or compared groups in a nonrandomized way. All but 2 studies were performed in acute care hospitals, and 5 studies focused only on intensive care patients. There was conflicting evidence of whether NSTs lead to reduction or increase in patients starting parenteral nutrition (PN); however, weak evidence suggested that NSTs might lead to an increase in the ratio of enteral nutrition to PN use and might decrease inappropriate PN use.

CONCLUSION

Although almost all studies concluded in favor of NSTs, the evidence base is weak and insufficient because of a lack of well-designed studies and successful outcomes.

When is parenteral nutrition indicated in the hospitalized, acutely ill patient?

PURPOSE OF REVIEW

The current review discusses current practices regarding appropriate indications for parenteral nutrition in acutely ill hospitalized patients. We address-specific indications for parenteral nutrition in the perioperative period, and in inflammatory bowel disease, oncology, hepatobiliary, critical care and end-stage renal disease patients.

RECENT FINDINGS

Acutely ill hospitalized patients can develop intestinal failure requiring parenteral nutrition. Recent studies have provided insight into the main indications. The most common indications for inpatient parenteral nutrition include postsurgical complications, including prolonged ileus, sepsis, fistula and leaks, and bowel obstruction, predominantly malignant. Severe or complicated inflammatory bowel disease and cancer treatment-related mucosal enteropathies (mucositis, enterocolitis, gut graft-versus-host disease) are the next commonest indications. Less frequent indications are primary motility disorders and inability to secure enteral access for enteral nutrition. Gastrointestinal failure of the intensive care patient is a separate entity resulting from multiple mechanisms, including an enteropathy and dysmotility.

SUMMARY

Despite the wider availability of nutrition support teams, use of parenteral nutrition is not without risk. The risks and benefits of parenteral nutrition in the acute setting need to be carefully considered even when it is indicated.

The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients

Parenteral nutrition (PN) is a complex and specialized form of nutrition support that has revolutionized the care for both pediatric and adult patients with acute and chronic intestinal failure (IF). This has led to the development of multidisciplinary teams focused on the management of patients receiving PN: nutrition support teams (NSTs). In this review we aim to discuss the historical aspects of IF management and NST development, and the practice, composition, and effectiveness of multidisciplinary care by NSTs in patients with IF. We also discuss the experience of two IF centers as an example of contemporary NSTs at work. An NST usually consists of at least a physician, nurse, dietitian, and pharmacist. Multidisciplinary care by an NST leads to fewer complications including infection and electrolyte disturbances, and better survival for patients receiving short- and long-term PN. Furthermore, it leads to a decrease in inappropriate prescriptions of short-term PN leading to significant cost reduction. Complex care for patients receiving PN necessitates close collaboration between team members and NSTs from other centers to optimize safety and effectiveness of PN use.

Hospital Malnutrition, a Call for Political Action: A Public Health and NutritionDay Perspective

Disease-related malnutrition (DRM) is prevalent in hospitals and is associated with increased care needs, prolonged hospital stay, delayed rehabilitation and death. Nutrition care process related activities such as screening, assessment and treatment has been advocated by scientific societies and patient organizations but implementation is variable. We analysed the cross-sectional nutritionDay database for prevalence of nutrition risk factors, care processes and outcome for medical, surgical, long-term care and other patients (n = 153,470). In 59,126 medical patients included between 2006 and 2015 the prevalence of recent weight loss (45%), history of decreased eating (48%) and low actual eating (53%) was more prevalent than low BMI (8%). Each of these risk factors was associated with a large increase in 30 days hospital mortality. A similar pattern is found in all four patient groups. Nutrition care processes increase slightly with the presence of risk factors but are never done in more than 50% of the patients. Only a third of patients not eating in hospital receive oral nutritional supplements or artificial nutrition. We suggest that political action should be taken to raise awareness and formal education on all aspects related to DRM for all stakeholders, to create and support responsibilities within hospitals, and to create adequate reimbursement schemes. Collection of routine and benchmarking data is crucial to tackle DRM.