สถานการณ์ nutrition support ในรพ. ก. สาธารณสุข

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


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

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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

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Nutritional Risk Score

0-2 = Low risk Assessment every week

3-4 = Moderate risk Consult to NST

5-7 = High risk Consult to NST

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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”

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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

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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

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"If the gut works, use it”

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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

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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.

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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

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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)

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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


ICD-9-CM 2000 1,283 เมย.2548


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

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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

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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)



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


Pricipal diagnosis

Enterocutaneous Fistula (K632)









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


Pricipal diagnosis

CA Esophagus (C15.9)





SDx1 Moderatemalnutrition (E44.0)




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


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


Pricipal diagnosis

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)




DRG 06030No CC

06034 24100 24103 24104

RW 3.8865 9.8118 6.1573 8.1515 12.0640

Trauma


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

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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


Thank you for your attention

สถานการณ์ nutrition support ในรพ. ก. สาธารณสุข

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