PhilSPEN Online Journal of Parenteral and Enteral Nutrition |
(Article 127 | POJ_0119) January-June 2018 Presentation delivered at the Abbott Nutrition Night, PENSA 2011, Taipei, Taiwan Nutrition care of ICU patients upon discharge from the hospital to the communityTopics | Introduction | Conclusion | References | Back to Total Names Codes Submitted: May 22, 2018 | Posted: May 31, 2018 |
AUTHORS:
NUTRITION SOCIETY AFFILIATION:
TOPICS: | Back
KEYWORDS: ICU, home care INTRODUCTION AND OBJECTIVES OF THE PRESENTATION| Back to Topics The care of the ICU patients discharged from the hospital has not been fully established in the Philippines, thus it is a challenge for the attending physician to ensure that the care of the patient in the home setting will lead to at least maintenance of his/her body composition and functions. The problem is compounded when the patient is on ventilator support, hemodialysis or both. Indeed, all concerned parties from the physicians, support caregivers and logistic resources need to be involved in order to improve patient care in the out-patient setting. This report has the following goals: a) To discuss nutritional issues during ICU and post-ICU discharge, b) To discuss nutrition care plan for post-ICU patients, c) To discuss follow up and monitoring issues for the post-ICU patients and d) To present local experience and suggestions on home nutrition care for ICU patients. NUTRITIONAL ISSUES IN THE ICU AND POST-ICU SETTING: CLINICAL PATHWAY | Back to Topics The nutritional management of ICU patients covers this structured system of care (Figure 1) which is the determination of the nutritional status of the patient and the risk of developing complications which will have a major impact on morbidity or mortality. The nutrition care plan that is developed is in full congruence with the other modalities of treatment which change depending on how the patient responds to the therapy. The implementation of this plan is monitored and will be the basis for the decision changes in management. This structured system will carry over to the post-ICU period until such a time when the patient is ready for discharge from the hospital.
NUTRITION ISSUES: ICU AND POST-ICU | Back to Topics In the critical care setting (ICU) there are now several nutrition strategies available for use in patient care and recovery. These are:
These can be used in combinations that tailor fit the patient’s needs. These are also in either enteral or parenteral formulations which allow achievement of adequate intake in all disease states or when the gastrointestinal tract is inoperative. This same approach is also needed in both the post-ICU and home environment. (Figure 2)
POST-ICU PATIENT PROFILE | Back to Topics Essentially this is the state of the discharged ICU patients: a) Loss of lean body mass due to the following states (sarcopenia [1], cachexia [2], critical care state [3], and malnutrition [4]), b) Multi-organ dysfunction or failure [3] and c) Immune depression or labile immune system [3]. The major difference is the patient is now able to have moderate degree of recovery of both structure and function which has allowed him/her to be discharged. 86% of the problems met covers major organ status and function which have to be addressed nutritionally as well as the overall aspect of disease as reported in a local report (unpublished) by Sioson M (MS), Reyes MC (MCR) and Francisco EM (EMF) [8]. It is to be noted that stroke and cancer patients consist at least 40% of the patient population. (Figure 3)
POST-ICU MANAGEMENT ISSUES | Back to Topics In most of the problem areas focus needs to be done on the following:
An uphill battle in regaining pre-ICU status is seen with the involvement of more issues mentioned above as shown in the report of Herridge et al. on pulmonary problem patients [5], Villet et al. on infection and negative energy balance [6] and Cederholm et al. on worsening malnutrition status in elderly patients while at home care [7]. HOME CARE NUTRITION SURVEYS OF YEARS 2005 AND 2010 | Back to Topics Two surveys were done on the status of home care practice in the Philippines. The first was done in 2005 after the first congress of clinical nutrition was launched in 2004 and questions regarding this issue were raised [8]. The second survey was done in 2010 when one of the principal investigators of the initial survey organized an out-patient home care service in her institution (EMF) [9]. RESULTS OF THE HOME CARE NUTRITION SURVEY IN 2005 (8) | Back to Topics
WHO PROVIDES THE DISCHARGE INSTRUCTIONS AND WHO ARE THE PRIMARY CAREGIVERS? (2005 survey) | Back to Topics
The ultimate care provider of the patient is the relative or “yaya” (home caregiver who has minimal training in this kind of care) and they comprise 60% of the overall care of this “high risk” patient which is far from the ideal or acceptable set up i.e. nurse or special provider who is knowledgeable in this field (25%). STATUS OF DISCHARGE INSTRUCTIONS ON NUTRITION CARE OF THE PATIENTS (2005 survey) | Back to Topics On discharge the proper endorsement and instructions were given to the patient or the family (93%). Then these follow up issues set in: 1) 79% of patients were not seen/available for follow up, 2) 83% of the caregivers were not aware of the previous instructions or even the protocols and guidelines to be followed for the patient’s care. (Figure 4) This would add to the issue of adequate care which is mainly given by untrained personnel.
OUTCOMES OF THE HOME CARE NUTRITION SURVEY OF 2005 (Figure 5) | Back to Topics The outcomes show the manner of home care nutrition: 1) The rehospitalization rate was low at 6% and mortality rate was 7% (quite low), 2) There were no complications noted in 28% of patients followed up. These are the different types of complications encountered: 1) Mechanical, like ventilators, enteral and parenteral nutrition delivery (14%), 2) Metabolic problems (14%), 3) Gastrointestinal problems (22%) – apparently nutrition care delivery is still to be improved.
RESULTS OF THE HOME CARE NUTRITION SURVEY OF 2010 (9) | Back to Topics The nutrition team of Asian Hospital Medical Center was formally established in 2010. This is the first hospital in the country which established the structured home nutrition care service based on the international standards of the Joint Commission International (JCI) [10]. This was headed by Dr. Eliza Mei Francisco and this is their report.
ORGANS AFFECTED AND MORTALITY OUTCOME (2010 survey) (Figure 6) | Back to Topics This is the relationship of the number of organs affected and outcome: 1) Pulmonary, renal or gut failure - patients on mechanical ventilators with or without central lines or dialysis support died within 21 days, 2) Gut and renal failure - patients on central parenteral nutrition or dialysis had fewer mortalities compared to those with ventilators, 3) Patients on standard care had a 5% mortality within 150 days and if they survive beyond this period no mortality was noted.
Critical care patients have the highest mortality rates once discharged. These are the implications: a) Organ system dysfunction or failure has a major role in outcome (most patients on ventilators don’t last long beyond 21 days), b) Patients who survive beyond 150 days have low mortality, c) Loss of lean body mass is central to the outcome status. FEEDING PROFILE OF DISCHARGED PATIENTS (2010 survey) (Table 5) | Back to Topics The feeding status of these patients were similar to the 2005 survey: a) 66% were tube fed, b) 32% had oral intake with or without enteral or parenteral nutrition supplementation, c) 1% had full parenteral nutrition.
This is the feeding profile of the patients discharged from the ICU (Figure 7). The intake of the ICU patients show these patterns: a) 45% of feeding were given through the gastrointestinal tract, b) 3% had full parenteral nutrition and c) 15% had supplemental parenteral nutrition. It will be noted here that these modifications were designed to achieve adequate intake of the patients.
FEEDING TYPE OF ICU PATIENTS AND MORTALITY (2010 survey) | Back to Topic Table 6 shows the relationship between type of feeding and mortality of the patients discharged from the ICU. Once they lose oral intake and become dependent on enteral and parenteral nutrition mortality starts to rise. This is indicative of the contribution of multiorgan failure (e.g. gastrointestinal) to increasing the morbidity or mortality of the patient’s status.
THE ROLE OF PHARMACO-NUTRITION IN MORTALITY OUTCOMES (2010 survey) (Table 7) | Back to Topics
For the patients who were discharged alive there is a heavy utilization of pharmaco-nutrition, but this utilization was also seen in the patients who died. There were more patients discharged alive however (28 vs. 8). THE ROLE OF A SPECIALIST IN THE CARE OF PATIENTS DISCHARGED FROM THE ICU (2010 survey) | Back to Topics The role of the private duty nurse in the type of outcome can be seen in this table (Table 8). It shows the relationship between mortality and the quality of service provided to the patient specially with the presence of special interventions. Most of the mortalities were in patients where no private duty nurse (PDN) was provided to give over-all care.
CONCLUSION: | Back In conclusion: 1) There is a need for a full multidisciplinary trained home care nutrition team to follow up discharged ICU patients, 2) Lean body mass loss and inflammation still need to be addressed through all means (e.g. type of feeding and addition of pharmaconutrients, exercise), 3) Identified problem areas leading to mortality are: a) Mortality is associated with 2 or more organ failures (e.g. cardiopulmonary and gastrointestinal failure) and b) Quality of care delivered by the caregiver – needs more improvement PROPOSED WORK FLOW | Back to Topics The proposed workflow of the hospital nutrition care service set up on discharge is shown in Figure 8 and followed by the following: a) Caregiver education and monitoring of outcome, b) Documentation of outcome data and c) Scheduled discussion/conference with both hospital clinical nutrition team and attending physician or other specialists
REFERENCES: | Back
Topic | Introduction | Conclusion | References | Back to Total Names Codes
|
