สถานการณ Nutrition support ในโรงพยาบาลกระทรวงสาธารณสุข
Winai Ungpinitpong, MD. FRCSTDepartment of Surgery, Surin Hospital
25 September [email protected]
SPENT 2008
Malnutrition
• The consequence of– Inadequate intake– Excessive intake– Unbalance nutrient
intake
• In clinical practice “undernutrition” and “malnutrition” are often interchanged
2
3
Malnutrition in Hospital
• Common problems : 15-50%• Under-recognition and Late detection• Complications of malnourished patients are 2-20
times greater than those of well-nourished patients– Increase infection– Delayed wound healing– Prolonged hospital stay– Higher hospital costs– Increase mortality
Buzby GP et al, Am J Surg 1980
Hickman DM, et al, 1980
Klidjian AM, et al, 1982
4
Nutrition SupportNutrition Support
“Prevention is better than cure.”
Nutrition Therapy
5
PolicyHealth Authorities
HospitalDirector
StandardGuidelinesSPENT
HA
Nutrition SupportCommittee
Ward NST 1 Members
Ward NST 2 Members
Ward NST 3Members
Ward NST 4Members
Physician Dietitian- Diagnosis - Calories count
- Placement of CVC - Enteral Nutrition- Team Leader - Transitional Feedings
Nurse Pharmacist- Maintenance of CVC - Admixture Preparation- Physical Assessment - Admixture Formulation- Patient Training - Drug-Nutrient Interaction
Nutrition Support TeamWard NST members
8
HA ตอนท่ี 3(4.3) กระบวนการดูแลผูปวย
ผูปวยที่มีปญหาดานโภชนาการไดรับการประเมินภาวะโภชนาการ วางแผนโภชนบําบัด ไดรับอาหารที่มีคุณคาทางโภชนาการเพียงพอ
9
Making Awareness
Dr.Winai Ungpinitpong Surin Hospital
Development of NST:Surin Hospital
• 2002 SPENT Meetings at Surin hospital• 2002 NST setting up:
– Doctors– Pharmacists– Nurses– Dietitians
• 2003 Clean room for TPN• 2003 Nutritional Risk Screening program1
and guideline, manuals2
• 2003 Workshop of nutritional screening
1.University of Hospital Nottingham: A. Mickewright2.Khonkaen University
Dr.Winai Ungpinitpong Surin Hospital
Development of NST:Surin Hospital
• 2003 100% Nutritional Risk Screening
• 2003 Incidence of malnutrition in Surgical patients at Surin hospital
• 2003 Attend nutrition short course, scientific meeting
• 2004 Dietitian award
• 2005 NF care improved by nutritional supporting
• 2006 Wound assessments program
• 2006 Early nutrition support in necrotizing fasciitis
• 2006 Lowering incidence of malnutrition in Surin hospital
• 2007 Computerized assist nutrition screening
• 2007 Role of IED in necrotizing fasciitis
Activity
• NST round weekly• NST joint meeting monthly• Mini lectures• Workshops• Screening of new patients • Pick up of nutrition risk patients• Management of nutrition therapy
14
NST
• Leader team and active members
• Screening tool: Nottingham University Hospital
• SGA
• Guideline of management (Simple)
• Organizational manual
• Report of activities• Nutrition audit
• Computerized assistDepartment of Surgery, Surin Hospital
15•University of Hospital Nottingham: A. Mickewright
Nutrition Risk Screening 1 2 3 4Body mass index (BMI) kg/m2
0=>201=18-202=<18
Loss weight over the last 3 months0=no1=<3kg2=>3kg
Decrease of food intake over last month0=no1=yes
Stress factors0=none1=moderate2=severe
Total
Stress Factors / Severity of illness
0 = none1 = Moderate• Minor surgery• Chronic disease• Minor pressure sore• CVA• Inflammatory bowel
disease, cirrhosis• Renal failure• COPD• DM
2 = Severe• Multiple injuries• Multiple fractures• Deep pressure sore• Severe sepsis• Malignant disease• Severe dysphagia or
pancreatitis• Major surgery• Post op complications
17
Nutritional Risk Score
0-2 = Low risk Assessment every week
3-4 = Moderate risk Consult to NST
5-7 = High risk Consult to NST
18
Nutritional screening and Assessment
• Nutrition screening : All Patients
• Nutritional assessments– SGA– History (medical, dietary, social)– Physical examinations– Anthropometry (weight, height, BMI, muscle
strength)– Biochemical test (CBC, Albumin, etc)
•Consult to Nutritional Support Team : Mod to High Risk
Subjective global assessment (SGA)A B C
นํ้าหนัก ไมเปล่ียนแปลง นํ้าหนักลด < 5% ใน 1 เดือน หรือ < 10% ใน 6 เดือน
นํ้าหนักลง > 5% ใน 1 เดือน หรือ > 10% ใน 6 เดือน หรือลดลงเรื่อยๆ
การกินอาหาร ปกติ ลดลง กินอาหารไดนอยมากๆ
อาการ ไมมีอาการท่ีมีผลตอการกินหรืออาการดีขึ้น
มีอาการมีผลตอการกิน เชน ปวดทอง อาเจียน ทองเสีย เบื่ออาหาร
มีอาการตามขอ B > 2 สัปดาห
ความสามารถในการทํางาน
ปกติ ทํางานไดลดลง ทํางานไดลดลงมาก ทํางานไมไหว
การตรวจรางกาย ปกติ มีลักษณะของการขาดอาหาร เชน ขมับบุม แกมตอบ ผอมลง
มีลักษณะการขาดอาหารชัดเจน เชน ผอมมาก บวมนํ้า
Nutrition Screening in Ramathibodi Hospital. Roongpisuthipong C .
Subjective global assessment (SGA)A B C
นํ้าหนัก ไมเปล่ียนแปลง นํ้าหนักลด < 5% ใน 1 เดือน หรือ < 10% ใน 6 เดือน
นํ้าหนักลง > 5% ใน 1 เดือน หรือ > 10% ใน 6 เดือน หรือลดลงเรื่อยๆ
การกินอาหาร ปกติ ลดลง กินอาหารไดนอยมากๆ
อาการ ไมมีอาการท่ีมีผลตอการกินหรืออาการดีขึ้น
มีอาการมีผลตอการกิน เชน ปวดทอง อาเจียน ทองเสีย เบื่ออาหาร
มีอาการตามขอ B > 2 สัปดาห
ความสามารถในการทํางาน
ปกติ ทํางานไดลดลง ทํางานไดลดลงมาก ทํางานไมไหว
การตรวจรางกาย ปกติ มีลักษณะของการขาดอาหาร เชน ขมับบุม แกมตอบ ผอมลง
มีลักษณะการขาดอาหารชัดเจน เชน ผอมมาก บวมนํ้า
XX
XX
X
Nutrition Screening in Ramathibodi Hospital. Roongpisuthipong C .
Nutritional Risk Score
0-2 = Low risk
85%Assessment every week
3-4 = Moderate risk
10% Consult to NST
5-7 = High risk
5% Consult to NST
“Computerization helps to improve nutrition support delivery in Surin hospital, and seem to identify the patient at risk at the early phase”
26
Incidence of malnutrition on admission to hospital
Study Year Number %Malnourished
Willard et al 1980 200 31.5
Bastow et al 1983 744 52.8
Lasson et al 1990 501 28.5
Mc Whirter and Pennington 1994 500 40.0
Kelly 2000 337 13.0
Eddington et al 2000 1611 20.0
Surin Hospital 2004 672 10.8
27
Nutrition Depletion in Hospital
StudyPatients
assessed on admission
In Hospital > 7 days
Nutrition Depletion in
Hospital
Mc Whirter and Pennington, 1994 500 112 64%
Cornish et al, 1998 569 189 62%
Surin Hospital, 2004 322 174 54%
2002 2003 2004 2005 2006 2007
Moderate 42 561 1080 1097 1683 2617Severe 10 136 450 576 713 963All 711 6844 11251 13715 14263 21809
0
5000
10000
15000
20000
25000In
pat
ient
s
NRS on admission
Everything should be made assimple as possible but not simpler.l
Nutrition Management
30 Department of Surgery, Surin Hospital
Make it EZ
1. EZ Calculate requirement2. EZ Appropriate route of
administration3. Monitor the effect : objective
parameters ~ BW, CBC, Electrolyte, albumin, etc
4. Manage complications5. Modified the regimens if
necessary
• Energy– Harris-Benedict– “Rule of thumb”: 25 – 30 kcal/kg BW– Indirect calorimetry
• Protein– Stable patients: 0.8 – 1.0 g/kg BW– Stressed patients: 1.2 – 2.0 g/kg BW
Nutritional Requirements
32
"If the gut works, use it”
33
Which Route/Access?• Oral : 75% of TEE, calculate by Dietician (1800)• Enteral feeding
– BD– Commercial products
• Parenteral nutrition: all in one/separation– PPN– TPN
• Combination of EN and PN
Monitoring
Every week Every 2 week
NRS /
CBC /
BS /
BUN/Cr /
Electrolyte /
Ca, Mg, Phosphate /
LFT /
Cholesterol /
Triglyceride /
Possible GI complications
• Regurgitation
• Aspiration
• Diarrhea
• Constipation
• Dehydration
• Abdominal discomfort
• Drug interaction• Contamination
Possible Tube-related complications
• Malposition of tube• Knotting of tube
• Accidental removal perforation of GI tract
• Obstruction, breakage
• Leakage, infection & bleeding from insertion site
• Erosion, ulceration & necrosis of skin
Possible metabolic complications
• Electrolyte disturbance
• Hyper/hypoglycemia
• Tube feeding syndrome• Vitamin/ trace element deficiency
complications
• Route related– Catheter sepsis
– Thrombophlebitis
– Catheter occlusion
– Pneumothorax
• Metabolic– Hyperglycemia
– Abnormal LFTs
– Fluid retension
– Excessive CO2production
40
Parenteral Nutrition
41
Combination of EN and PN
TPNTPN PPNPPN
>14 d <14 d
Restrict fluid
NA
No Sepsis NA
>900 mOsm/L
<900mOsm/L
Putting evidence into practice
Classification DefinitionRecommended for practice Interventions for which effectiveness has been
demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systematic reviews, and for which expectation of harms is small compared with the benefits
Likely to be effective Interventions for which the evidence is less well established than for those listed under “recommended for practice”
Benefits balance with harms
Interventions for which clinicians and patients should weigh the beneficial and harmful effects according to individual circumstances and priorities
Effectiveness not established
interventions for which data currently are insufficient of inadequate quality
Effectiveness unlikely Interventions for which lack of effectiveness is less well established than for those listed under “not recommended for practice”
Not recommended for practice
Interventions for which ineffectiveness or harmfulness has been demonstrated by clear evidence, or the cost or burden that is necessary for the intervention exceeds anticipated benefit
Necrotizing Fasciitis(NF)
• Life-threatening infection affecting the superficial fascia and subcutaneous tissue
• Mortality rate 10% to 50%.
1.Norton KS, Johnson LW, Am Surg. Aug 2002;68(8):709-713.
2.Mokoena T, Br J Surg. May 1994;81(5):772.
3.Mohammedi I, Intensive Care Med. Aug 1999;25(8):829-834.
4.Mittermair RP, Surg Endosc. Apr 2002;16(4):716.
Management
• Early diagnosis
• Resuscitation
• Broad-spectrum antibiotics
• Immediate and extended surgical debridement
• Intensive care support
• Appropriate nutritional support
• Reconstruction1. Ward RG. Bmj. Jul 30 1994;309(6950):341.2. Wall DB, de Virgilio C, Am J Surg. Jan 2000;179(1):17-21.
NF Day0
Day 14
Day40
Appropriate nutritional support
• NF
• Increased requirements for nutrients
• Reduced food intake.
• Nutritional status is carefully considered.
1. Ord H. Br J Nurs. Nov 22-Dec 5 2007;16(21):1346-13522. Singh, G., S. K. Sinha, et al. (2002). Eur J Surg 168(6): 366-71.
50
Early nutrition support in necrotizing fasciitis
• Aims: To compare the duration before split thickness skin graft of necrotizing fasciitis between the early nutritional support patients and conventional support.
• Setting: Surin Hospital• January – December 2005
Lower Extremities
NF
N= 55
Resuscitation
Empiric Antibiotics
Extensive Debridement
NRS and Assessment
Early Nutrition Support within 4
days
N=28
Conventional Support
N=27
Wound Assessment
Duration before STSG
Random
52
Route/Access
• "If the gut works, use it”• Oral : 75% of TEE, calculate by Dietician (1800)• Enteral feeding
– BD– IED 200 ml x 4 feedings
• Combination of EN and PN
Assessment by well training nurses
AWM assessment chart
54
Results
• 61 patients entered the study
• 6 patients refused to join the trial as unstable condition
• 55 patients (35 males, 20 females) were randomized,
• 28 to the Early nutritional support
• 27 to the Conventional support.
• Early NS had a shorter mean duration before split thickness skin graft (STSG) than the conventional support. (mean±SD 17.2±4.5, 21.89±5, P=0.01)
55
Characteristic Early NS28
Control27
P
Sex – M/F 16/12 19/8 0.403
Age - year 53±21.2 57±17.7 0.271
Comorbidiy - % 0.365
1. No comorbid 32.1 29.6
2. Diabetes 21.4 7.4
3. CRF 7.1 14.8
4. Streroid use 7.1 14.8
5. Cirrhosis 25.0 37.0
Albumin 2.7±0.9 2.9±0.8 0.811
BUN 27.5±11.6 25.48±14.05 0.582
Creatinine 1.89±1.65 2.07±1.61 0.883
Duration STSG 17.2±4.5 21.8±5.1 0.010
Day0 Day0 Day0
Day3 Day10 Day13
DRGs system
58
Unit Cost IPD (2006)
รายงานประจําป ของสํานักพัฒนาระบบบริการสุขภาพ ประจําป งบประมาณ 2549
14,019.37 Baht
LOS=4.2days
59
Version Refined Diagnosis code Procedure code
Groups Implement
1 No ICD-10 (WHO) 1992
ICD-9-CM 2000 511 พย.2541
2 No ICD-10 (WHO) 1992
ICD-9-CM 2000 511 กพ.2544
3
3.0 5 levels ICD-10 (WHO) 1992
ICD-9-CM 2000 1,283 ตค.2546
3.1 5 levels ICD-10 (WHO) 1992
ICD-9-CM 2000 1,283 เมย.2548
3.3 5 levels ICD-10 (WHO) 2005
ICD-9-CM 2005 1,283 กพ.2549
3.55 levels ICD-10 (WHO)
2005ICD-9-CM 2005 1,467 -
45 levels ICD-10 (WHO)
2007 + ICD-10-TM*
ICD-9-CM 2007 with extension
1,920 มค.2551
Thai DRGsThai DRGs
* For data entry only (not for new classification)
60
โครงสรางของ DRG
0 7 0 5 2
MDC=โรคตับและทอทางเดินนํ้าดี
DC (Disease Cluster)
เลขซึ่งสัมพันธกับ CC ไดแก 0, 1, 2, 3, 4 และ 9
opened cholecystectomy, w mild to mod CC
61
Possible ICD-10 codesMalnutrition
E40-E46 MalnutritionE43 Severe degree malnutritionE44.0 Moderate degree malnutritionE44.1 Mild degree malnutritionE46 Not specified PEME64.0 Consequences of PEME77.8 HypoproteinemiaE88.0 HypoalbuminemiaR63.3 Nutrition problems and improper nutritionR64 Cachexy
62
ICD-10 codesMetabolic disorders
E87.5, E87.6 Hyper-, Hypo-kalemiaE87.0, E87.1 Hyper-, Hypo-natremiaE83.4 HypomagnesemiaE83.5 HypocalcemiaE68 Sequelae of hyper-alimentationE87.2, E87.3 Acidosis, AlkalosisE87.8 Other Electrolyte imbalanceE61 Deficiency of other nutrient elements
DRG & Nutrition issues
• Provide financial incentive to provider• Encourage efficiency & cost effectiveness
summary1 summary2
Pricipal diagnosis Acute Cholecystitis (K810)
Acute Cholecystitis (K810)
SDx1 Moderatemalnutrition (E44.0)
SDx2
SDx3
Procedure Opened Cholecystetomy (5122)
Opened Cholecystetomy (5122)
DRG 07050No CC
07052Moderate CC
RW 2.2817 3.0947
Acute Cholecystitis
summary1 summary2 summary4
Pricipal diagnosis NF (L088) NF (L088) Pancreatitis (K859)
SDx1 Mild malnutrition (E44.1)
Moderatemalnutrition (E44.0)
SDx2
SDx3
Procedure Debridement (8660)
Debridement (8660)
Debridement (8660)
DRG 09060No CC
09060No CC
09063Severe CC
RW 1.5044 1.5044 3.2367
Cellulitis > 17 yr
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis
Pancreatitis (K859)
Pancreatitis (K859)
Pancreatitis (K859)
Pancreatitis (K859)
Pancreatitis (K859)
SDx1 Mild malnutrition (E44.1)
Moderatemalnutrition (E44.0)
Severe malnutrition (E43)
Severe malnutrition (E43)
SDx2 Hypokalemia (E87.6)
SDx3
Procedure PPN (9915) PPN (9915) PPN (9915)
DRG 07530No CC
07530No CC
07532Moderate CC
07532Moderate CC
07533Severe CC
RW 1.0068 1.0068 1.4107 1.4107 2.3798
Acute Pancreatitis
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis
Enterocutaneous Fistula (K632)
Enterocutaneous Fistula (K632)
Enterocutaneous Fistula (K632)
Enterocutaneous Fistula (K632)
Enterocutaneous Fistula (K632)
SDx1 Mild malnutrition (E44.1)
Moderatemalnutrition (E44.0)
Severe malnutrition (E43)
Severe malnutrition (E43)
SDx2 Hypokalemia (E87.6)
SDx3
Procedure PPN (9915) PPN (9915) TPN (9915)
DRG 06600No CC
06600No CC
06603Moderate CC
06603Moderate CC
06604Severe CC
RW 1.7043 1.7043 2.1178 2.1178 2.3798
Enterocutaneous Fistula
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis
CA Esophagus (C15.9)
CA Esophagus (C15.9)
CA Esophagus (C15.9)
CA Esophagus (C15.9)
CA Esophagus (C15.9)
SDx1 Moderatemalnutrition (E44.0)
Severe malnutrition (E43)
Severe malnutrition (E43)
Severe malnutrition (E43)
SDx2 Hypo K (E87.6)
Hypo K (E87.6)
Hypo K (E87.6)
SDx3
Procedure PPN (9915) PPN (9915) SEMS Stent (4281)
Gastrostomy (43.19)
DRG 06550No CC
06503 Severe CC
06504CatastrophicCC
06164 06014
RW 1.5334 2.5773 3.7863 6.8600 9.0348
CA Esophagus
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis
CA Stomach (C16.9)
CA Stomach (C16.9)
CA Stomach (C16.9)
CA Stomach (C16.9)
CA Stomach (C16.9)
SDx1 malnutrition (E44.0)
malnutrition (E43)
malnutrition (E43)
malnutrition (E43)
SDx2 Hypo K (E87.6)
Hypo K (E87.6)
Hypo K (E87.6)
SDx3
Procedure TPN (9915) Gastrostomy (43.19)
Gastrectomy (43.89)
DRG 06500No CC
06503 Severe CC
06504CatastrophicCC
06014 06304
RW 1.5334 2.5773 3.7863 9.0348 12.6030
CA Stomach
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis
Injury to large bowel (S36.5)
Injury to large bowel (S36.5)
Injury to large bowel (S36.5)
Injury to large bowel (S36.5)
Injury to large bowel (S36.5)
SDx1 malnutrition (E43)
Fx Femur (S72.9)
Fx Femur (S72.9)
Fx Femur (S72.9)
SDx2 Hypo K (E87.6)
malnutrition (E43)
Malnutrition (E43) + Hypo K (87.6)
Procedure ORIF (79.35)
ORIF (79.35)
ORIF (79.35)
Procedure Repair large bowel (46.75)
Repair large bowel (46.75)
Repair large bowel (46.75)
Repair large bowel (46.75)
Repair large bowel (46.75)
DRG 06030No CC
06034 24100 24103 24104
RW 3.8865 9.8118 6.1573 8.1515 12.0640
Trauma
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis
Burns (T300)
Burns (T300)
Burns (T300)
Burns (T300)
Burns (T300)
SDx1 malnutrition (E43)
malnutrition (E43)
malnutrition (E43)
malnutrition (E43)
SDx2 Hypo K (E87.6)
Hypo K (E87.6)
Hypo K (E87.6)
SDx3 Anemia (D649)
Septicemia (A419)
Procedure PPN (9915) PPN (9915) Debridement (8622)
DRG 22520No CC
22522 22523 22523 22524
RW 0.8565 1.5278 3.5348 3.5348 4.8587
Burns
72
Conclusion• Policy of Nutrition support
• Standard of care
• Appropriate reimbursement • Alliance
• Support each other
• Encourage a team with success
• Continuous development• Sharing experience
• Smile = Thank youDepartment of Surgery, Surin Hospital
“ To be born as a Human
Is to serve Humanity
TO CARE FOR THE ONES FOLLOWING YOU
The Underprivileged and the Weak
The Poor and the Sick “
T. Uttaravichien 1977
Dr.Winai Ungpinitpong Surin Hospital
Thank you for your attention