Standardizing and optimizing nutrition evaluation frequency of enterally fed patients in an ambulatory pediatric gastroenterology practice: A single-center study

BACKGROUND

Nutrition monitoring is essential in feeding tube-dependent patients receiving home enteral nutrition (HEN). We identified lack of consistency in dietitian evaluations for our pediatric patients receiving HEN. Consequently, after establishing an institutional standard for nutrition reassessment intervals, we underwent a quality improvement (QI) initiative to improve rates of adherence to standard frequency of dietitian consults and referrals among patients receiving HEN.

METHODS

A prospective QI initiative from April 2021 to December 2021 was performed using multiple plan-do-study-act (PDSA) cycles. Interventions included (1) a reminder placard, (2) the display of feeding tube status and date of the last dietitian note in the electronic health record (EHR) clinic schedule dashboard, and (3) an autotext smart element to the EHR default clinic note template. The goal was to enable clinicians to quickly identify the need for nutrition evaluation with either a same-day dietitian consult or a referral to nutrition clinic.

RESULTS

Among 111 HEN patients with >6 months since last nutrition encounter, the dietitian referral/consult rate prior to any interventions was 58%. The placard (PDSA 1) was abandoned before obtaining reportable data because of sampling bias and clinic workflow inefficiencies. The clinic schedule dashboard modification (PDSA 2) improved the dietitian referral/consult rate to 66%. Subsequently, the clinic note smart element (PDSA 3) increased the rate to 77%. An 8-week postintervention check revealed a compliance rate of 78%.

CONCLUSION

Implementation of minimally interruptive EHR enhancements showed a sustained increase in dietitian referrals and consults for patients receiving HEN, which may improve nutrition outcomes.

Attitudes and Perceptions of Blenderized Tube Feed Use Among Physicians and Advanced Practice Providers

BACKGROUND

Blenderized tube feeds (BTFs) have increased in popularity among enteral patients and their caregivers as an alternative to commercial formula. Motivations include ingredient flexibility, increased tolerance, and inclusion in family meals. Research has explored the attitudes and perceptions of patients, caregivers, and registered dietitian nutritionists but not those of physicians and advanced practice providers (APPs). The purpose of this study was to evaluate their attitudes and perceptions of BTFs.

METHODS

A survey created via Research Electronic Data Capture tools was distributed to physicians and APPs to evaluate clinical practice characteristics, experience, knowledge, and perceptions of BTFs.

RESULTS

Survey response rate was 17.3% (n = 206). Half of respondents reported familiarity with BTFs, but 95% of respondents had received no formal training regarding BTFs. Physicians reported higher levels of confidence in BTF knowledge than APPs. However, the overall level of confidence in BTF knowledge was poor, with a majority of respondents (73.3% [n = 151]) reporting either "not very confident" or "not confident at all." The most perceived benefits included tailoring diet to better fit the patients' needs (70.9% [146]) and psychological benefits (59.2% [122]). Barriers that most concerned respondents included tube occlusions (59.7% [123]) and nutrition inadequacy (47.6% [98]). χ² Analysis revealed no relationship between type of provider and perceived benefits or barriers.

CONCLUSION

A majority of physicians and APPs are willing to support BTF use but lack education or guidance, resulting in poor confidence. Increased familiarity with BTF use and awareness of available education materials are required to help physicians and APPs support patients utilizing BTFs.

Prognostic significance of peritumoral vessel invasion in clinical trials of adjuvant therapy for breast cancer with axillary lymph node metastasis

To assess the prognostic significance of peritumoral vessel invasion, data were examined for 1,510 women entered into the Ludwig Breast Cancer Group Trials I to IV evaluating adjuvant therapy for operable breast cancer with axillary nodal metastasis. Vessel invasion by tumor cells was identified by routine light microscopy in 59 per cent (889 of 1,510) of the patients and was equally distributed between premenopausal/perimenopausal (60 per cent, 468 of 778) and postmenopausal (58 per cent, 421 of 732) women. In logrank analyses stratified by nodal status (one to three or four or more positive nodes), the four-year disease-free survival (DFS) rate was significantly lower in patients with vessel invasion than in women without vessel invasion (50 per cent versus 65 per cent, P less than 0.0001). This DFS difference was seen for both premenopausal/perimenopausal (P = 0.0004) and postmenopausal (P = 0.0002) patients. The four-year overall survival rate was also lower in patients with vessel invasion (71 per cent versus 82 per cent, P = 0.0006), both for premenopausal/perimenopausal (P = 0.002) and postmenopausal (P = 0.04) women. The presence of vessel invasion was significantly associated with increasing numbers of positive axillary lymph nodes, rising tumor grade, nonstellate tumor border growth pattern, and higher steroid hormone receptor content of the primary tumor. The assessment of peritumoral vessel invasion continued to have prognostic significance for DFS (P less than 0.0001) and overall survival (P = 0.003) when evaluated in multivariate models controlling for treatment assigned, nodal status, tumor size, estrogen receptor status, menopausal status, and age. Depending on the subpopulation, patients with vessel invasion had a 41 per cent to 54 per cent greater risk of treatment failure than those without vessel invasion and a 29 per cent to 64 per cent greater risk of death. The percentage of treatment failures at distant sites was higher for women with than for those without vessel invasion (27 per cent versus 18 per cent, P = 0.003). In patients with axillary lymph node metastases, peritumoral vessel invasion may be a sign of increased systemic disease burden.