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Strengthening Understanding of the Changing Healthcare Landscape:
A Focus on Malnutrition
Laura L. Frank, PhD, MPH, RD, CDClinical Assistant Professor,,Director of Clinical Sites,
Coordinated Program in Dietetics (CPD), Washington State University,
College of Pharmacy, Nutrition and Exercise Physiology Program
Disclosure
• This educational presentation has been sponsored by Abbott Nutrition Health Institute.
h h h i i• The content has met the continuing education criteria of being evidence‐based, fair and balanced, and non‐promotional.
Objectives
• Discuss malnutrition as a large, hidden component of quality and cost challenges.
• Increase awareness about the importance of lean body mass and relationship to malnutrition and patient outcomespatient outcomes.
• Discuss the new A.N.D/A.S.P.E.N criteria in diagnosing malnutrition.
• Highlight the need for multidisciplinary collaboration in evidenced‐based nutrition intervention.
The Changing Healthcare Landscape
ECONOMIC DRIVER WITH INCENTIVE FOR QUALITY IMPROVEMENT
New Legislation
• On March 23, 2010, President Obama signed into law comprehensive health care reform
legislation, the Patient Protection and Affordable Care Act (PPACA; P L 111 148) asAffordable Care Act (PPACA; P.L. 111‐148), as amended by the Health Care and Education Reconciliation Act (HCERA; P.L. 111‐152).
Objectives of New Legislation
• $AVING MONEY• How?
•Quality Improvement
• Improved Efficiency
•Changes in Reimbursement
•Reductions in Hospital Readmissions
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Reasons for Hospital Readmissions
1. An inadequate relay of information by hospital discharge planners to patients, caregivers, and post‐acute care providers
2. Poor patient compliance with care instructions 3 Inadequate follow up care from post acute and3. Inadequate follow‐up care from post‐acute and
long‐term care providers 4. Variation in hospital bed supply 5. Insufficient reliance on family caregivers 6. The deterioration of a patient’s clinical condition 7. Medical errors
Stone J, Hoffman GJ. Congressional Research Service. Medicare Hospital Readmissions: Issues,Policy Options and PPACA, Sept. 2010.
High Cost Beneficiaries
• Older
• Have chronic conditions, such as diabetes and coronary artery disease
d i i f i i h d• Readmission rates for patients with end‐stage renal disease are twice as high as readmission rates for patients without end‐stage renal disease
CBO, High‐Cost Medicare Beneficiaries, May 2005, http://www.cbo.gov/ftpdocs/63xx/doc6332/05‐03‐MediSpending.pdf.Medicare Payment Advisory Commission (MedPAC), Report to Congress: Promoting Greater Efficiency in Medicare, June 2007, Chapter 5. See http://www.medpac.gov/documents/Jun07_EntireReport.pdf
Disease‐Associated Readmissions
30‐day Readmission Rates:
Heart Failure (26.9%)
Pneumonia (20.1%)
COPD (22 6%)COPD (22.6%)
Psychoses (24.6%)
Gastrointestinal conditions (19.2%)
Cardiac Stent Placement (14.5%)
Major Hip or Knee Surgery (9.9%)
Stephen F. Jencks, M.D., Mark V. Williams, M.D., and Eric A. Coleman, M.D., M.P.H., “Rehospitalizations amongPatients in the Medicare Fee‐for‐Service Program,” New England Journal of Medicine, vol. 360 (April 2, 2009), pp.1418‐1428.
Predictors of Readmission
• A total of 55 participants (38.7%) had a further unplanned hospital admission within 6 months.
• In multivariate analysis, chronic disease (OR: 3.4; 95% CI: 1.3‐9.3, P = 0.002), depressive symptoms95% CI: 1.3 9.3, P 0.002), depressive symptoms (OR: 3.0; 95% CI, 1.3‐6.8, P = 0.01), and underweight (OR: 12.7; 95% CI, 2.3‐70.7, P = 0.004) were significant predictors of readmission after adjusting for age, length of stay and functional status.
Mudge, AM. Recurrent readmissions in medical patients: a prospective study. Journal ofHospital Medicine 2011;6:61–67.
Predictors of Readmission
• A total of 370, 983 heart failure admittances were analyzed, with 41, 127 (11.1%) diagnosed with obesity and 4105 (1.1%) with malnutrition.
• Malnourished patients had a much higher risk ofMalnourished patients had a much higher risk of dying while in hospital (OR: 1.83 95%CI: 1.69‐1.97) or of being readmitted within 30 days after discharge (OR: 1.39, 95%CI: 1.29‐1.51), even after adjusting for possible confounding factors.
Zapatero, A. Influence of obesity and malnutrition on acute heart failure. Rev Esp Cardiol. 2011http://www.revespcardiol.org/sites/default/files/elsevier/eop/S1885‐5857%2811%2900581‐0.pdf
Malnutrition
Increased Length of Hospital Stay
Increased Treatment Costs Increased Rates of
Re‐admissions
Stratton RJ, King CL, Stroud MA, Jackson AA, Elia M. ‘Malnutrition Universal Screening Tool’ predictsmortality and length of hospital stay in acutely ill elderly. Br J Nutr 2006;95:325–330.
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What is Lean Body Mass (LBM)?
• Body Composition is comprised of fat mass, LBM and water
• LBM is comprised of skin
• Skeletal muscle is the most abundant tissue in the human body, and the maintenance of its mass is essential to ensure basic function as locomotionLBM is comprised of skin,
bone, tendons and organs
• LBM is 50% to 60% muscle mass by weight
function as locomotion, strength and respiration.
Heymsfield S, Wang Z. Human body composition: advances in models and methods. Ann Rev Nutr. 1997;17:527‐558.
What is Lean Body Mass (LBM)?
• Enzymes
• Antibodies
• T and B cells
• Viscera• Viscera
• Red Blood Cells
• Connective Tissue
Roubenoff R, Kehajias J. The meaning and measurement of lean body mass. Nutr Rev. 1991;49:163‐175.
Etiology of Loss of LBM
Inadequate nutrient intakeIncreased
nutrient requirements
Increased nutrient losses
Poor nutrient absorption
Elia M. Screening for malnutrition: a multidisciplinary responsibility. Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults. Redditch: BAPEN; 2003.
p
Cachexia
Increased Protein Losses, Loss of LBM, Malnutrition
Sarcopenia
Physical Inactivity
Complications Relative to Loss of LBM*
80%
100%
120%
Mortality
Relationships between % loss of LBM and Mortality
Increased PressureUlcers & PNA risk Inability to Sit
Infection‐induced Death
0%
20%
40%
60%
10% 20% 30% 40%
Associated
M
Percent loss of lean body mass
Impaired immunity, Increased infection
Decreased healing, Increased weakness
Ulcers & PNA risk, Inability to Sit, Inability to perform ADLs
*In the absence of pre‐existing LBM loss
Demling RH. Nutrition, anabolism, and the wound healing process: An Overview Eplasty. 2009;9:65‐94.
The Co$t of Malnutrition is Great
• In a retrospective cohort study of 709 hospitalized adults, mortality was 12.4% among malnourished patients (assessed by SGA) and 4 7% among wellnourished patientsSGA) and 4.7% among wellnourished patients (relative risk: 2.63).
• Using multivariate analysis, researchers determined that malnutrition was an independent risk factor for mortality.
CorreiaMITD, Waitzberg DL: The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22(3):235–239.
Nutritional Risk Identified:Compromised Nutrition orLoss of Lean Body Mass
No InflammationYes,
Inflammation ismild to moderate
Yes, Inflammation is acute and severe
INFLAMMATION?
Starvation‐related Malnutrition:
chronic starvation(Pure, Chronic Starvation,
Anorexia Nervosa)
Chronic disease– related Malnutrition:
inflammation is chronic(Organ Failure, pancreatic
cancer, rheumatoid arthritis, sarcopenic obesity)
Acute disease or injury–related:
(Major infections, burns, tauma, closed
head injury)
Jensen GL, Mirtallo J, Compher C, et al. Adult starvation and disease‐related malnutrition: a proposal for etiology‐based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. JPEN 2010;34:156‐159.
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A.N.D./A.S.P.E.N. Malnutrition Diagnosis*
• Inadequate Nutrient Intake
• Unintentional Weight Loss
• Loss of Fat Mass LBMLoss of Fat Mass, LBM
• Fluid Accumulation
• Changes in Functional Status
*Any 2 or more characteristics can identify Malnutrition
ADA/ASPEN Clinical Characteristics to support diagnosis of Malnutrition, ADA Workgroup, ASPEN Taskforce.Malnutrition_ClinicalCharacteristics_Diagnosis.pdf.
INADEQUATE NUTRIENT INTAKE
Acute Illness or InjuryChronic Illness or Disease
Environmental or Social Circumstances
Meets < 75% energy needs for
> 7 day
Meets ≤ 50% energy needs for
≥ 5 day
Meets <75% energy needs for
≥ 1 mo.
Meets ≤75% energy needs for
≥ 1 mo.
Meets <75% energy needs for
≥ 3 mo.
Meets ≤ 50% energy needs for
≥ 1 mo.
Avoid contributing to iatrogenic malnutrition in these patients
Moderate or Non‐Severe Malnutrition
SevereMalnutrition
Unintentional Weight LossInterpretation of Weight Loss*
Acute Illness or InjuryChronic Illness or Disease
5% in 1 mo
Environmental or Social Circumstances
>5% in 1 mo1‐2% in 1 wk
5% in 1 mo
7.5% in 3 mo
>1‐2% in 1 wk
>5% in 1 mo
>7.5% in 3 mo
5% in 1 mo
7.5% in 3 mo
10% in 6 mo
20% in 1 yr
>5% in 1 mo
>7.5% in 3 mo
>10% in 6 mo
>20% in 1 yr
>5% in 1 mo
>7.5% in 3 mo
>10% in 6 mo
>20% in 1 yr
>5% in 1 mo
>7.5% in 3 mo
>10% in 6 mo
>20% in 1 yr
Moderate or Non‐Severe Malnutrition
SevereMalnutrition
**Height, weight and usual weight need to be obtained in order to determine the percentage and interpret the significance of weight loss
Changes in Subcutaneous Body Fat*
Acute Illness or InjuryChronic Illness or Disease
Environmental or Social Circumstances
Fat Loss:
MILD
Fat Loss:
MODERATE
Fat Loss:
MILD
Fat Loss:
SEVERE
Fat Loss:
MILD
Fat Loss:
SEVERE
Moderate or Non‐Severe Malnutrition
SevereMalnutrition
*orbital, triceps, fat overlying the rib
Changes in Muscle Mass*
Acute Illness or InjuryChronic Illness or Disease
Environmental or Social Circumstances
Muscle Loss:
MILD
Muscle Loss:
MODERATE
Muscle Loss:
MILD
Muscle Loss:
SEVERE
Muscle Loss:
MILD
Muscle Loss:
SEVERE
Moderate or Non‐Severe Malnutrition
SevereMalnutrition
*temporalis, pectoralis, deltoids, interosseous, latissimus dorsi, trapezious, quadriceps, gastrocnemius
Changes in Fluid Accumulation*
Acute Illness or InjuryChronic Illness or Disease
Environmental or Social Circumstances
Edema:
MILD
Edema:
MODERATE
Edema:
MILD
Edema:
SEVERE
Edema:
MILD
Edema:
SEVERE
Moderate or Non‐Severe Malnutrition
SevereMalnutrition
*Evaluation of generalized or localized edema or ascites, weight loss may be masked by fluid accumulation
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Changes in Functional Status:
Non‐Severe Malnutrition
Hand Grip Strength
(Hand
4 meter/Other walk tests,
Short Performance (Hand
Dynamometer)*
Mild to Moderately
Below Standards
Chair raising,
Stair Climbing
Mild to Moderately
Below Standards
Physical Battery (SPPB)
Mild to Moderately
Below Standards
*Strongest correlation to date with muscle mass and nutritional statusKallman, et al. The role of muscle loss in the age‐related decline of grip strength: cross‐sectional and longitudinal perspectives.J Gerontology; 1990 May;45(3):M82‐8.
Changes in Functional Status:
Severe Malnutrition
Hand Grip Strength
(Hand
4 meter/Other walk test,
Short Performance (Hand
Dynamometer)*
Severely Below
Standards
Chair raising,
Stair Climbing
Severely Below
Standards
Physical Battery (SPPB)
Severely Below
Standards
*Strongest correlation to date with muscle mass and nutritional statusNorman K, et al. Hand Grip: Outcome predictor & marker of nutritional status. Clin Nutr 2011; 30: 135‐142
EARLY, MULTIDISCIPLINARYEARLY, MULTIDISCIPLINARY IDENTIFICATION OF AT‐RISK PATIENTS IS MANDATORY
The Economic Impact of Nutrition Screening
Studies show that for every $1.00 spent on
Nutrition Screening Initiative: Malnutrition in the Elderly. www.aafp.org
nutrition screeningand intervention, at least $3.25 are saved.
Specific Validated Screening Tools
• Malnutrition Universal Screening Tool (MUST)
• Nutritional Risk Screening 2002
• Mini Nutritional Assessment®
• Short Nutritional Assessment Questionnaire©
• Malnutrition Screening Tool (MST)
• Subjective Global Assessment (SGA)
Anthony PS. Nutrition Screening Tools for Hospitalized Patients. NCP. Aug 2008, 23: 373‐382.
The Bottom Line
• Identify inadequate nutrition intake
• Identify loss of appetite
• Identify unintentional weight lossIdentify unintentional weight loss
• Identify impaired functional status
• Identify neuro‐pyscho‐social barriers
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Screening Tools can Identify Nutritional Risk
• By the widely used Mini Nutritional Assessment, the reported prevalence of nutritional risk in older subjects is approximately 45% in the community, with higher values in hospitals and 84%‐100% in residential care facilities.
VisvanathanR, and Chapman IM. Undernutrition and anorexiain the older person. Gastroenterol Clin North Am. 2009;38:393‐409.
Nutrition Care Algorithm
Ukleja A, Freeman KL, Gilbert K, et al. Standards for nutrition support: adult hospitalized patients. Nutr Clin Pract. 2010;25:403‐414.
Collaborative EffortsRole Nurse Dietitian
Screening Utilize Nursing Admit Screen,
Utilize Nutrition Screen
Utilize Nutrition Screen
Anthropometrics Obtain Admit Weights, Daily Weights
Depend on RN to weight pt?
Other options: Weigh p gpatient, obtain knee‐
height, arm‐span, ask pt
Physical Assessment Head‐to‐Toe Eyes, Skin, Lips, Tongue, Fingernails, Muscle
Wasting
Nutrition Intake Assist with Calorie Count, 1:1 assist,
Assist with 24 hr UUN
Order Calorie Count, 24 hr UUN
Kcal, Protein Analysis
Functional Status Toilet transfers, ADLs Promotion of Physical Movement, Other
Oral Intake Intervention Strategies
Importance of Dietary Protein
• During stress state or catabolic illness, dietary protein may contribute up to 30% of total energy needs.
• Most of your patients don’t get the nutrition they need to maintain and rebuild LBMthey need to maintain and rebuild LBM.
• Research has shown that elderly, hospitalized patients who were served a meal containing 40 grams of protein consumed only 10 grams of protein, half of which was from dessert.
Breslow RA, et al. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc. 1993;41:357‐362.Paddon‐Jones D. In: Gussler J (ed): Role of Nutrition in the Accretion, Retention, and Recovery of Lean Body Mass, Report of the 110th Abbott Nutrition Research Conference, 2009.
Challenges to Overcome
• Protein intake and efficiency of use appears to decrease with age.
• Potential etiologies: greater expense, increased satiety, dentition/chewing diffi l i h i di i idifficulties, changes in digestion, gastric emptying, splanchnic uptake and peripheral use, etc.
• Nutrition alone is ineffective in preventing muscle protein loss in inflammation
Walrand S, Boirie Y. Optimizing protein intake in aging. Curr Opin Clin Nutr Metab Care 2005;8:89–94.Symons TB, et al. Aging does not impair the anabolic response to a protein‐rich meal. Am J Clin Nutr 2007;86:451–6.
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Muscle Mass Accretion
• Most optimal practice for increasing muscle protein synthesis (MPS) is through a combination of both diet and exerciseintervention strategies.
Phillips S. Role of Protein Absorption and Nutrient Timing on Muscle Mass Accretion. Johnson C. Nutrition, Muscle Mass and Muscular Performance in Middle Age and Beyond. Paddon‐Jones D. Lean Body Mass Loss with Age.
The 110th Abbott Nutrition Research Conference, Columbus, OH June 23‐25, 2009.
Protein Requirements for Elderly• Currently, there is no standard practice for the amount of dietary protein to either maintain or increase muscle protein in patients at risk for sarcopenia, cachexia or malnutrition.
• Review of studies by de Souza Genaro & Martini yshow a wide range of dietary protein for improved patient outcomes.
• There is reasonable evidence indicating that protein intake levels higher than the RDA (0.8 g∙kg–1∙d–1 ) are required.
de Souza Genaro P, Martini LA. Effect of protein intake on bone and muscle mass in the elderly Nutrition Reviews. 2010; Vol. 68(10):616–623.
Amount Matters
Among the elderly, several studies support the
k 1 d 1 d i
Millward DJ, et al. Aging, protein requirements, and protein turnover. Am J Clin Nutr 1997;66:774–86.Zanni E, Calloway DH, Zezulka AY. Protein requirements of elderly men. J Nutr 1979;109:513–24.
0.8 g∙kg–1∙d–1 recommendation
Amount Matters
• Other studies have suggested that a moderately higher protein intake of 1.0‐1.3 g∙kg–1∙d–1 may be required to maintain g g y qnitrogen balance and offset a potentially lower energy intake, decreased protein synthetic efficiency, and impaired insulin action in elderly individuals.
Cuthbertson D, et al. Anabolic signaling deficits underlie amino acid resistance of wasting, aging muscle. FASEB J 2005;19:422–4.Symons TB, et al. Aging does not impair the anabolic response to a protein‐rich meal. Am J Clin Nutr 2007;86:451–6.Campbell WW, et al. The recommended dietary allowance for protein may not be adequate for older people to maintain skeletal muscle. J Gerontol A Biol Sci Med Sci 2001;56:M373–80.Morais JA, e tal. Protein turnover and requirements in the healthy and frail elderly. J Nutr Health Aging 2006;10:272–83.Bunker VW, et al. Nitrogen balance studies in apparently healthy elderly people and those who are housebound. Br J Nutr 1987;57:211–21.
Amount Matters
• A moderate 113 g (4 oz) serving of an intact protein (ie, lean beef) contains sufficient amino acids (30 g total; 10 g essential amino acids) to increase mixed muscle protein synthesis by ≈50% in both young and elderly men and women .
• Diets containing a moderate amount of protein (20–35% energy) do not appear to be associated with negative health outcomes.
Symons TB, et al. Aging does not impair the anabolic response to a protein‐rich meal. Am J Clin Nutr 2007;86:451–6.Hayashi Y. Application of the concepts of risk assessment to the study of amino acid supplements. J Nutr 2003;133:2021S–2024S.Cordain L, et al. Plant‐animal subsistence ratios and macronutrient energy estimations in worldwide hunter‐gatherer diets. Am J Clin Nutr 2000;71:682–92.
Distribution Matters
Figure 1A pictorial example of the proposed relationship between the amount of protein ingested per meal and the resultant anabolic response. (a) Ingestion of 90 g of protein, distributed evenly over 3 meals. (b) Ingestion of 90 g of proteins unevenly distributed throughout the day. Stimulating muscle protein synthesis to a maximal extent during the meals shown in Figure 1A is more likely to provide a greater 24 h protein anabolic response than an unequal protein distribution.
Paddon‐Jones D, Rasmussen BB. Dietary protein recommendations and the prevention of sarcopenia. Curr Opin Clin Nutr Metab Care. 2009. 12(1): 86‐90
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Quality Matters
• Essential Amino Acid (Indispensible AA) content, in particular leucine, serves as the primary determinant of protein’s anabolic potential.
• Leucine is a Branched‐Chain Amino Acid (BCAA) along with valine and isoleucine.
Paddon‐Jones D, et al. Differential stimulation of muscle protein synthesis in elderly humans following isocaloric ingestion of aminoacids or whey protein. Exp Gerontol 2006;41:215–9.Volpi E, et al. Essential amino acids are primarily responsible for the amino acid stimulation of muscle protein anabolism in healthy elderly adults. Am J Clin Nutr 2003;78:250–8.Tipton KD, et al.Nonessential amino acids are not necessary to stimulate net muscle protein synthesis in healthy volunteers. J Nutr Biochem 1999;10:89–95.
Quality Matters
• In a randomized trial involving 41 subjects with sarcopenia aged 66 to 84 years, intake of the BCAA‐rich supplements increased muscle mass, reduced tumor necrosis factor‐α and improved insulin sensitivityα, and improved insulin sensitivity .
• As a result, leucine enriched balanced amino acid supplements are now considered as part of the nutritional recommendations for the management of sarcopenia.
Solerte SB, et al. Nutritional supplements with oral amino acid mixtures increases whole‐body lean mass and insulin sensitivity in elderly subjects with sarcopenia. Am J Cardiol. 2008;101:69E‐77E. Morley JE, et al. Nutritional recommendations for the management of sarcopenia. J Am Med Dir Assoc. 2010;11:391‐396.
Leucine and BCAA content of foods1
Food Leucine BCAA
Whey protein isolate 14 26
Milk protein 10 21
Muscle protein 8 18
Soy protein isolate 8 18
Wheat protein 7 15
1 Values reflect grams of amino acids/100 g of protein. Source: USDA Food Composition Tables.
Layman D K J. Nutr. 2003;133:261S‐267S
.
Layman D K J. Nutr. 2003;133:261S‐267S
©2003 by American Society for Nutrition
Oral Nutrition Supplements (ONS)
• ONS have been shown to supply necessary protein to help treat malnutrition and support protein needs, even among patients with several malnutrition‐relatedwith several malnutrition related complications such as pressure ulcers, open wounds, catabolic and/or chronic illness.
Dorner B, PosthauerME, Thomas D; National Pressure Ulcer Advisory Panel. Adv Skin Wound Care. 2009;22(5):212‐221. Ratliff C, Tomaselli N. WOCN Guidelines for Prevention and Treatment of Pressure Ulcers, 2010. Pritchard C, Duffy S, Edington J, Pang F. Enteral nutrition and oral nutrition supplements: a review of the economics literature. JPEN Journal of Parenteral and Enteral Nutrition.2006;30:52‐59.
Oral Nutrition Supplements (ONS)
• National Institute for Health and Clinical Excellence (NICE) Study
• A meta‐analysis using ONS (+/‐ counseling) versus standard care in older people showed a significant reduction in complications in patients in hospital or hshort‐term care. – It also showed a reduction in mortality in patients in acute settings and in patients transferred from hospital to the community
• Economic analysis has found that cost savings can be achieved using ONS in selected patient groups.
National Institute for Health and Clinical Excellence (NICE). Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (clinical guideline 32). London: National Institute for Health and Clinical Excellence (NICE); 2006.Stratton RJ and Elia M. A review of reviews: A new look at the evidence for oral nutritional supplements in clinical practice. Clin Nutr 2007;2(Suppl 1):5‐23. Elia M, Stratton RJ, Russell C, Green C, Pang F. The cost of disease‐related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. Redditch: BAPEN; 2005.
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Nutrition Support for those Who Cannot Have p.o. intake
• Nutrition support intervention is recommended for patients identified by screening and assessment as at risk for malnutrition or malnourished. (Grade C)(Grade C)
• Enteral Nutrition (EN) is the preferred route of feeding over parenteral nutrition (PN) for the critically ill patient who requires nutrition support therapy(Grade B)
Mueller C, Compher C, DruyanME. and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults. Journal of Parenteral and Enteral Nutrition (JPEN). Jan 2010; 35(1): 16‐24. McClave SA, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J PEN J Parenter Enteral Nutr. 2009;33(3):277–316.
Enteral Nutrition (EN)
• Associated with decreased mortality rates if provided within 24 hours upon admit.
• Associated with decreased complications & infection rates compared to ParenteralNutritionNutrition.
• Associated with improved glycemic control
• Associated with decreased length of stay.
• EN is a cost‐effective treatment that yields improved outcomes.
Statton RJ, Elia M. A cost‐utility analysis in patients receiving enteral tube feeding at home and in nursing homes. Proceedings of the Nutrition Society (2008), 67 (OCE), E111. http://www.nutritioncare.org/Index.aspx?id=5696Webster, N. & Galley, H. Nutrition in the critically ill patient. J.R. Coll. Surg. Edinb. 2000. (45)373‐379.
Collaborative EffortsRole Nurse Dietitian
Nutrition Intervention Place Feeding Tubes, Initiates & Complies with Nursing‐Initiated Orders (NIOs): HOB 30‐45 °,
Operational in Providing Nutrition Support
Provides Nutrition & Fluid Recommendations based on patient’s Nutrition
Diagnosis* and Metabolic Milieu and Medical
Condition, l di bPlace Feeding Tubes
Monitoring & Evaluation On‐going NIOs: Flushes, Monitoring Gastric
Residual Volume, Stooling, Body Weight,
Maintain Feeding Tubes, Integrates care with
Nutrition, Pharmacy & Physical Therapy
Monitors & Evaluates EN or PN tolerance &
Adequacy (Body Weight, Stooling, CO2 output,
Hyperglycemia, Hypertriglyceridemia, CRP + visceral protein status,
other laboratory measures)
*The International Dietetics & Nutritional Terminology (IDNT) Reference Manual, 3rd Ed., Academy of Nutrition & Dietetics, formerly known as the American Dietetic Association
Muscling our way through the changes in the Healthcare Landscape
• Identify malnutrition or patients at risk for malnutrition
• Use Nutrition Screening Tools
l idi i li h• Use Multidisciplinary Approaches to Screening, Assessment, and Intervention
• Stress importance of Nutrition in the interplay of patient outcomes
• Rescreen and Reassess through various Healthcare settings (Continuum of Care)
The Changing Healthcare Landscape
By using collaborative efforts to identify patients at risk of malnutrition and treating or preventing factors related to malnutrition we can meet new CMSto malnutrition, we can meet new CMS mandates, improve patient outcomes across healthcare settings, reduce readmissions, and save healthcare
dollars.
Screen
Assess
Intervene
Questions?
Intervene
Follow‐up