Training and monitoring patients on home parenteral nutrition (HPN) • Learning objectives – Understand the importance of training and monitoring patients on home parenetral nutrtion – Learn about common practice on training and monitoring • Summary Home parenteral nutrition is a lifesaving treatment for patients with chronic intestinal failure. It is a complex, expensive treatment with risk of serious complications, that can be prevented if the patients are given the relevant knowledge and technical skills (1). When discharged from hospital with HPN, patients will need to be monitored in order to cope with the problems arising. Most often, monitoring of anthropometry and biochemistry is carried out by the specialised teams in hospital at intervals of about 3 months for the stable patient (2). Studies of training and monitoring practice are needed. Refrences, links • Slide from course • Santarpia et al, Clin Nutr (PDF file) • Slide from course 1. Santarpia et al, Clin Nutr 2. Slides from course
25
Embed
Training and monitoring patients on home parenteral nutrition (HPN) Learning objectives –Understand the importance of training and monitoring patients.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Training and monitoring patients on home parenteral nutrition (HPN)
• Learning objectives– Understand the importance of training and monitoring
patients on home parenetral nutrtion– Learn about common practice on training and
monitoring• Summary Home parenteral nutrition is a lifesaving treatment for patients
with chronic intestinal failure. It is a complex, expensive treatment with risk of serious complications, that can be prevented if the patients are given the relevant knowledge and technical skills (1). When discharged from hospital with HPN, patients will need to be monitored in order to cope with the problems arising. Most often, monitoring of anthropometry and biochemistry is carried out by the specialised teams in hospital at intervals of about 3 months for the stable patient (2). Studies of training and monitoring practice are needed.
Refrences, links• Slide from
course• Santarpia et
al, Clin Nutr (PDF file)
• Slide from course
1. Santarpia et al, Clin Nutr
2. Slides from course
Training patients for HPN
• Training objectives• The European practice• Selection of patients for HPN• The teaching program• How to teach the patients ?• Where are patients trained for HPN?• Monitoring the skills• Guidelines• Conclusions
Training objectives
• Patients or relatives able to manage procedures safely
• Learn about complications and how to handle
• Low rate of complications
• To obtain the best quality of life
Teaching practice in Europe
• Questionnaire based study
• 51 centres in 7 countries
• Range 0-95 patients on HPN, 63 % of centres < 10 patients
• Contraindication criteria
• Teaching
• GuidelinesHome parenteral nutrition (HPN) teaching practice in EuropeA. Micklewright. A.A. Prins, F. Bozzett!2, X. Hebuterne, J.M. Moreno Villares, M. Pertkiewicz, L. Pironi, M. Staun, P. Thul A. Van Gossum and the HAN-W group, Clin Nutr 2002; 21, 42, abstract.
Selection of patients for HPN
• Criteria to exclude patients in 62 % of centres– Intellect (33%)– Physical disability (24 %)– Social situation, education (25%)– Underlying disease (18%)– Age (16%)
Home parenteral nutrition (HPN) teaching practice in EuropeA. Micklewright. A.A. Prins, F. Bozzett!2, X. Hebuterne, J.M. Moreno Villares, M. Pertkiewicz, L. Pironi, M. Staun, P. Thul A. Van Gossum and the HAN-W group, Clin Nutr 2002; 21, 42, abstract.
The teaching program
The European survey reported the following:• Catheter care (100%)• Preventing and recognising complications (98%)• Most common mistakes (92%)• Pump care (92%)• Managing complications (90%)• Adding vitamins (55%)• Bag preparation (50%)• Intravenous medication (50%)
Home parenteral nutrition (HPN) teaching practice in EuropeA. Micklewright. A.A. Prins, F. Bozzett!2, X. Hebuterne, J.M. Moreno Villares, M. Pertkiewicz, L. Pironi, M. Staun, P. Thul A. Van Gossum and the HAN-W group, Clin Nutr 2002; 21, 42, abstract.
The impact of HPN training
• Group A – Oral instruction, two sessions ’hands on’– 91 port-a-cath, 26 tunnelled cath.
• Group B– Detailed instruction theoretical and
practical, written material etc– 68 port-a-cath, 45 tunnelled cath
• Interactive programs– ‘HPN-school’ with demonstrations, hands
on and exercises by patients/relatives and community nurses
– PC-based ?
Teaching the patient in the ward
Where are the patients trained for HPN?
• At the ward of the discharging hospital– Involving the nutrition team– By far the most common procedure
according to survey data
• At home– By the team as an outgoing service– By a home care agency
Monitoring skills
• Aim– Quality of life – Reduce rate of complications
• Monitoring skills– When readmitted– Periodic surveys– Following the occurrence of complications
Guidelines training
• The survey showed– 96% of centres had guidelines for training– 26 % had local guidelines– Guidelines based on national standards in
some centres
Home parenteral nutrition (HPN) teaching practice in EuropeA. Micklewright. A.A. Prins, F. Bozzett!2, X. Hebuterne, J.M. Moreno Villares, M. Pertkiewicz, L. Pironi, M. Staun, P. Thul A. Van Gossum and the HAN-W group, Clin Nutr 2002; 21, 42, abstract.
Training conclusions
• Practice varies between centres– Training at hospital / home
• Current practice based on local experience and guidelines
• Prospective studies of different training regimens are warranted
Monitoring patients on HPN
• Monitoring goals
• Monitoring practice of HPN patients in Europe
• Guidelines
• Conclusions
Why monitoring HPN patients ?
• Quality of life
• Manage complications– Line infections– Mechanical problems– Thrombosis– Metabolic problems– Depression, social life
Monitoring practice in Europe
• Questionnaire based study in 2002
• 42 centres in 8 countries
• Experience 2-30 years, 0-125 patients
• 934 patients, 90% non-malignant disease, 54% on HPN > 1 year
Wengler, A. Micklewright, X. Hebuterne, F. Bozzetti, M. Pertkiewicz, J. Moreno, L. Pironi, P. Thul, A. Van Gossum and M. Staun and The ESPEN HAN Working Group. Clin Nutr 2003;22:s87
Where HPN patients are monitored
• The specialised unit monitored 73%
• Local hospital 12%
• GP 11%• Home care
agency 4%
0
5
10
15
20
25
30
35
40
Ward ofspec unit
Out ptclinic
Localhosp.
GP HomeCare
Agency
Where the HPN-pt is monitored.
no. c
entr
es
all patients
most of the pt
few pt
no pt
Which personnel are responsible for the monitoring process ?
• Responsibility was assigned to one person in 90 % of centres
• Physician 60%• Nurse 33%
Physician Nurse Others
Intervals between monitoring visits
• 60% of centres at 3 months intervals
• 25% at 0-1 month interval
• 15% at longer intervals
Intervals between monitoring visits of the stable HPN-patient.
0-1 month
2-3month
4-6 month
6-12 month
others
Clinical parameters monitored
01020304050
Body w
eight
Body t
emp.
Blood
pres
s
Pulse
Hydra
tion
Oral in
take
Moo
d
Parameters evaluated at monitoring visits.
No
. cen
tres
Every visit
Not at every visit
Only in case of problems
No inform
Biochemical parameters monitored
01020304050
Haem
atolo
gy
Liver
funct
s-cr
ea/K
/Na
s-Ca/
Mg/P
h
s-glu
cose
s-ch
ol/trig
s-al
b.
Trace
ele
men
ts
Vit AED,B
12
BMD
No
. c
en
tre
s
Every visit
Not at every visit
Only in case of problems
No inform
Who will the patients get in touch with in case of problems ?
05
101520253035
HPN-team
Outpa
tient
clin
ic
Loca
l Hos
pital
Traini
ng H
ospit
al
Comm
unity
Nur
seGP
Pharm
aceu
tical
com
pany
Home
Care
Agenc
y
No
. ce
ntr
es Always
Usually
Occasionally
Never
Guidelines monitoring HPN
• No official European guidelines available
• The 2002 survey on monitoring:– 66% of centres had some kind of guidelines– Centres had used input from National health board
or clinical nutrition society– Locally developed guidelines most common
Wengler, A. Micklewright, X. Hebuterne, F. Bozzetti, M. Pertkiewicz, J. Moreno, L. Pironi, P. Thul,
A. Van Gossum and M. Staun and The ESPEN HAN Working Group. Clin Nutr 2003;22:s87
Summary and conclusion for monitoring HPN
• Monitoring usually at discharging hospital – Access to specialised team
• Intervals between visits vary, being on average 3 months– The unstable patient needs more attention
• Biochemistry, anthropometry at all visits– Trace elements, vitamins and BMD occasionally
• Official guidelines for monitoring not available– Prospective studies warranted