PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article 133 | POJ_0125)

Original Clinical Investigation

Patients receiving High Risk Nutrition Package at St. Luke's Medical Quezon City during the period from September 2016 to September 2017

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | Back to Total Name and Codes page2

Submitted: | Posted:

Authors:

    1. Precious Gem Calamba, MD; Clinical Nutrition Service, St. Luke's Medical Center, Quezon City, Philippines
    2. Luisito O. Llido, MD; Clinical Nutrition Service, St. Luke’s Medical Center, Quezon City, Philippines
    Corresponding Author: Dr. Precious Gem Calamba

Institution where research was conducted

Clinical Nutrition Sevice, St. Luke’s Medical Center, E. Rodriguez Avenue, Quezon City, Metro-Manila, Philippines

 

ABSTRACT: | Back

Background:

The SLMC clinical nutrition team created and implemented High Risk Critical Care Nutrition Package last March 2016 in the adult critical care units in response to the lack of full implementation of feeding protocols and monitoring. This pilot study assessed if the existing nutrition team High Risk Critical Care Nutrition Package achieved the delivery of adequate caloric and protein intake.

Objective:

To determine the demographic and clinical profile of critical care patients receiving High Risk Nutrition Package; establish adequacy of caloric and protein intake among adult patients receiving High Risk Critical Care Nutrition Package intervention

Methodology:

Single center, descriptive study on patients admitted at critical care units at St. Lukes Medical Center, Quezon City who have received 3-day High risk nutrition packages.

Results:

A total of 210 patients were included. Male and female ratio is 1:1; mean age  67.6 years old; mean weight 62.365 Kg; mean BMI 23.89 kg; majority (68%) were malnourished, majority were “high risk” (95%), SGA score “C” (95%) and NR score Level 3 (95%); mean ICU stay 6.5 days; mean total protein requirements 75.9 g/day; mean protein intake 54.25 g/day. Majority received adequate protein and caloric intake - 86% and 79%, respectively. The mean total caloric requirements and mean caloric intake at 1,596.83 kcal/day and 1,255.14 kcal/day, respectively.

Conclusion:

The study showed that the 3-day critical care nutrition package at St. Luke Medical Center-Quezon City critical care unit patients significantly achieved adequacy of the caloric and protein requirements among these patients.

KEYWORDS: High risk nutrition package, SLMC based

 

INTRODUCTION | Back

Adequate intake is associated with improved mortality and morbidity outcomes in critical care patients and the presence of nutrition support teams sustains this result. The Clinical Nutrition Service of SLMC was organized for this purpose with the team working to achieve adequate nutrient intake, calories and protein. The nutrition committee of St. Lukes Medical Center (SLMC), Quezon City, Philippines, started its Clinical Nutrition Program in 1999. This program encompasses the following core functions: a) nutrition screening of all admitted patients, b) nutritional assessment of identified patients at risk of developing malnutrition, c) nutrition care plans development for these high risk patients, d) monitoring and reevaluation of nutrition management, and re designing nutrition care plan if needed (1). Nutrition Team composed of clinical nutrition physicians and fellows in training, clinical dietitians, clinical pharmacists and nurses. Its main task is to follow up the “need to be seen” patient population including patients in the critical care units (2). 

A report of ten-year experience of SLMC Clinical Nutrition Team on the supervision of nutrient intake among critical care patients showed that the presence of a team can sustain the adequacy of intake of both calorie and protein in the long term (3).  However, Manuales, et.al elucidated that there is a lack of full implementation of feeding protocols and monitoring particularly among critical care patients not referred to nutrition teams (1). Feeding protocols, once fully implemented, improved delivery of macro and micro nutrients leading to improved survival of patients in critical care units. It is within this light that the SLMC clinical nutrition team created and implemented High Risk Critical Care Nutrition Package in March 2016 in the adult critical care units.

As studied, malnutrition is associated with higher morbidity and mortality in hospitalized patients and the group with highest risk of developing these complications is in the intensive care units (ICU). In the recent consensus data, it has been recommended that appropriate calorie intake should be provided to critically ill patients as a major component of therapy (4-5).  The SLMC follows the 3-day intensive critical care nutrition protocol at the adult critical care units (coronary care unit, Jonathan-Dy ICU, neuro-critical care units, and Acute Stroke Units). All patients in these areas are tagged once admitted and receive nutrition interventions based on “short method” of caloric computation. This is done by multiplying the patients weight in kilograms by 20-30 kcal/kg per day (factoring the patients’ disease state) and patient’s Body mass index (BMI) (4,7). Total protein requirement is computed by multiplying patient’s actual body weight in kilograms by a factor that depends on the disease state (0.8 to 1.5 g of actual body weight). However, among patients who are obese (BMI greater than 30 kg/m2), caloric requirement computation is based on their ideal body weight (4). These data can be seen on the daily nutrient monitoring sheet (Appendix C). Intake is deemed adequate if 75% of the computed calorie and protein requirement of the patient is met (8).

This study would like to assess the value of the existing nutrition team High Risk Critical Care Nutrition Package in terms of the adequacy of the caloric and protein intake of patients, as well as the patients’ demographic and clinical profile enrolled in the package.

To describe the demographic and clinical profile of critical care patients receiving High Risk Nutrition Package. To establish the adequacy of calories and protein intake among adult patients during the acute phase (3 day ICU period) in the critical units among patients receiving High Risk Critical Care Nutrition Package intervention.

METHODOLOGY | Back

This study determined the demographic profile described as mean age and sex ratio; clinical profile as mean weight, Body Mass Index, Modified Subjective Global Assessment score and length of ICU stay of critical care patients receiving High Risk Critical Care Nutrition Package. The study also established whether our team achieved administration of adequate calories and protein intake among adult patients during the acute phase (3 day ICU period) in the critical units among patients receiving such.

A single center, descriptive study was conducted on the patients admitted on critical care units particularly at Jonathan Dy ICU, Coronary care unit, neurocritical care unit, and acute stroke unit.
All patients admitted at critical care units who received 3-day High risk nutrition package were included in the study.  Patient with incomplete chart data were excluded in the study.

Operational Definition:
Nutrition Risk Level -  We have considered Nutrition Risk Level Score (NRLS)   categorized as 0 - being low risk or level 1; 1-2 moderate risk or level 2; and >3 as high risk or level 3. Also Subjective Global Assessment (9) were considered in the study. Scoring were as follows: A, B and C. These data were available on Nutritional assessment and risk level form (appendix A).

 

DESCRIPTION OF STUDY PROCEDURE

This study entailed chart review of patients admitted at critical care units who have received a 3-day nutritional intervention from the period of September 2016 to September 2017.  Data were gathered from the Medical Records as follows:  Age and sex; nutritional risk score and subjective global assessment grading; 3 day calorie and protein intake (Appendix C); adequacy and calorie and protein balance (positive or negative); and clinical outcome such as length of ICU stay.

Sample Size Estimation
Sample size was calculated using web-based Roasoft sample size calculator based on the following parameters: There were a total of 400 patients who had received 3-day High risk nutrition package during the study period, assuming 95% confidence level, confidence interval of 5, total computed sample siA single center, descriptive study was conducted on the patients admitted on critical care units particularly at Jonathan Dy ICU, Coronary care unit, neurocritical care unit, and acute stroke unit.
All patients admitted at critical care units who received 3-day High risk nutrition package were included in the study.  Patient with incomplete chart data were excluded in the study.

Operational Definition:
Nutrition Risk Level -  We have considered Nutrition Risk Level Score (NRLS)   categorized as 0 - being low risk or level 1; 1-2 moderate risk or level 2; and >3 as high risk or level 3. Also Subjective Global Assessment (9) were considered in the study. Scoring were as follows: A, B and C. These data were available on Nutritional assessment and risk level form (appendix A).

Description of the Study Procedure

This study entailed chart review of patients admitted at critical care units who have received a 3-day nutritional intervention from the period of September 2016 to September 2017.  Data were gathered from the Medical Records as follows:  Age and sex; nutritional risk score and subjective global assessment grading; 3 day calorie and protein intake (Appendix C); adequacy and calorie and protein balance (positive or negative); and clinical outcome such as length of ICU stay.

Sample Size Estimation
Sample size was calculated using web-based Roasoft sample size calculator based on the following parameters: There were a total of 400 patients who had received 3-day High risk nutrition package during the study period, assuming 95% confidence level, confidence interval of 5, total computed sample size is at 204.


RESULTS | Back

Table 1: Demographic and Clinical Profile of Patients Receiving High Risk Nutrition Package at St Luke’s Medical Center Quezon City during the Period September 2016 -  September 2017 (n=210)

Demographic and clinical characteristics
Package

Demographic Characteristics

Age
     Mean, SD
     Range (min – max)
Sex
     Ratio Male:Female

 

67.6 y, 42.6
21-106 y

1:1

Clinical Characteristics

Weight
     Mean    
     Range (min – max)

 

62.365 Kg
29.7 Kg -150 Kg

Body Mass Index Kg/m2 (mean, range min-max)
     Underweight (%,f)
     Normal (%,f)             
     Overweight       
     Obese

23.89%; 10.2-63
29%, 61
31.9%, 67
25%, 53

Modified Subjective Global Assessment score
     A (%,f)                 
     B (%,f)                   
     C (%,f)   
0 % , 0)
5% , 11
95%, 199
Length of ICU stay of critical care patients
   Mean  
   Range

6.5 days
3 -12 days

Mean Total Protein Requirements (grams/day)
75.9 grams/day
Mean Protein Intake (grams/day)
Adequacy of Protein Intake (%)
   Adequate               
   Inadequate

54.25 grams/day

86%
14%

Mean Total Caloric Requirements (kcal/day)
1,596.83 kcal/day
Mean Caloric Intake (kcal/day)
Adequacy of Caloric Intake (%)
   Adequate               
   Inadequate

1,255.14 kcal/day

79%
21% 

 

DISCUSSION: | Back

A total of 210 included charts of patients admitted at critical care units who have received a 3-day nutritional intervention from the period of September 2016 to September 2017 were reviewed. There was equal distribution of males and females, age mean was at 67.6 years old with range of 21 to 106 years old.

As to patients’ clinical characteristics, mean weight was 62.365 Kg with range of 29.7 to 150 Kg. Body Mass Index (BMI) mean was at 23.89 kg with a little more than a quarter (31% or 67) having normal BMI and the rest were malnourished having abnormal BMI with 29% (61) severely underweight to underweight, 25% (53) overweight and 13.8% (29) obese 1 to obese 2. These patients Modified Subjective Global Assessment (SGA) score were nearly all at “C” (95%) and a fraction is at “B” (5%, 11). The Nutrition Risk Score is generally at Level 3 (more than 3) or high risk at 95% (199) with a fraction categorized at moderate risk (5% or 11). This is consistent with the SGA score. The range of ICU stay of these critical care patients is at 3 to 12 days, with mean of 6.5 days prior to trans-out to regular room. The mean total protein requirements in grams per day is at 75.9 g/day with mean protein intake (g/day) at 54.25 g/day. Majority of these patients received adequate protein intake (86%) with only few (14%) inadequate protein intake. Moreover, these patients’ mean total caloric requirements and mean caloric intake in kcal/day were 1,596.83 kcal/day and 1,255.14 kcal/day respectively. Similarly, the patients’ caloric intake was largely adequate (79%) with just a fifth having inadequate caloric intake (21%).

 

CONCLUSION: | Back

There is similar distribution of included patients in terms of sex with wide variation in their ages and weight. Most of the included patients were malnourished as reflected in their Body Mass Index (BMI). Nearly all included patients were “high risk” as reflected by the Modified Subjective Global Assessment (SGA) Score and Nutrition Risk Score. The length of ICU stay is usually brief and all received the 3-day high risk nutrition package.

This study also showed that the 3-day critical care nutrition package at St. Luke Medical Center-Quezon City critical care unit patients significantly achieved adequacy of the caloric and protein requirements among these patients.
 

REFERENCES: | Back

  1. Manuales,G; De Ramos, M; Sinamban,R;  Llido,L; Critical Care Nutrition: the effect of adequate calorie and protein intake in mortality, ventilator days, ICU and hospital stay;  http//dpsys120991.com
  2. Llido,L The impact of computerization of nutrition support process on the nutrition support program in a tertiary care hospital in the Philippines; Clinical Nutrition 2006; 25:91-101
  3. Llido,L; Sioson ,M; Inciong, J; Manuales, G; Nutrition Team Supervision on nutrient intake in critical carepatients : a report of ten year experience 2000-2011; http//dpsys120991.com
  4. Umali,N; Llido, L; Francisco,E; Recommended and actual calorie intake of intensive care unit patients in a private tertiary hospital in the Philippines; Clinical Nutrition 22: 345-34
  5. Heyland DK; Mcdonald K; Keefe L; Total parenteral nutrition in the critically ill patients; JAMA 1998; 280:2013-9
  6. JCAHO board of directors; comprehensive accreditation manual for hospitals , oakbrook , Il. 1994
  7. McClave,S MD; Taylor,B; Martindale,R; Guidelines  for  the Provision and Assessment of Nutrition Support Therapy in Adult Critically Ill patients: SCCM, ASPEN guidelines; January 15, 2016
  8. Llido,L; Sioson ,M; Inciong, J; Manuales, G; Nutrition Team Supervision on nutrient intake in critical care
    patients : a report of ten year experience 2000-2011; http//dpsys120991.com
  9. Rahman A, Hasan RM, Agarwala R, Martin C, Day AG, Heyland DK. Identifying critically-ill patients who will benefit most from nutritional therapy: Further validation of the "modified NUTRIC" nutritional risk assessment tool. Clin Nutr. 2015. 
  10. Del Rosario,D; Inciong, F; The effect of adequate energy and protein intake on morbidity and mortality in surgical patients nutritionally assessed as high or low risk,  2011

 

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Total Name and Codes page2