สถานการณ์ nutrition support ในรพ. ก. สาธารณสุข by โครงการวัคซีนป้องกันเด็กจมน้ำ จังหวัดสุรินทร์

สถานการณ Nutrition support ในโรงพยาบาลกระทรวงสาธารณสุข Winai Ungpinitpong, MD. FRCST Department of Surgery, Surin Hospital 25 September 2008 winai_ung@golfchannelclub.com

SPENT 2008

Malnutrition • The consequence of – Inadequate intake – Excessive intake – Unbalance nutrient intake

• In clinical practice “undernutrition” and “malnutrition” are often interchanged 2

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 3

Nutrition Support Nutrition Support

“Prevention is better than cure.”

Nutrition Therapy

Policy Health Authorities

Standard Guidelines

SPENT

Hospital Director

Nutrition Support Committee

Ward NST 1 Members

Ward NST 2 Members

Ward NST 3 Members

Ward NST 4 Members

Nutrition Support Team Ward NST members Physician - Diagnosis

Dietitian

- Placement of CVC - Team Leader

- Calories count - Enteral Nutrition - Transitional Feedings

Nurse

Pharmacist

- Maintenance of CVC - Physical Assessment - Patient Training

- Admixture Preparation - Admixture Formulation - Drug-Nutrient Interaction

HA ตอนที่ 3(4.3) กระบวนการดูแลผูปวย ผูปวยที่มีปญหาดานโภชนาการไดรับ การประเมินภาวะโภชนาการ วางแผนโภชนบําบัด ไดรับอาหาร ที่มีคุณคาทางโภชนาการเพียงพอ

Making Awareness

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. Mickewright 2.Khonkaen University

Dr.Winai Ungpinitpong

Surin Hospital

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 Dr.Winai Ungpinitpong

Surin Hospital

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

NST • Leader team and active members • Screening tool: Nottingham University Hospital • SGA • Guideline of management (Simple) • Organizational manual • Report of activities • Nutrition audit • Computerized assist Department of Surgery, Surin Hospital

Nutrition Risk Screening

Body mass index (BMI) kg/m2 0=>20 1=18-20 2=<18

Loss weight over the last 3 months 0=no 1=<3kg 2=>3kg

Decrease of food intake over last month 0=no 1=yes

Stress factors 0=none 1=moderate 2=severe

Total

•University of Hospital Nottingham: A. Mickewright

Stress Factors / Severity of illness 0 = none 1 = 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 • • • • • •

Nutritional Risk Score

0-2 = Low risk

Assessment every week

3-4 = Moderate risk

Consult to NST

5-7 = High risk

Consult to NST

Nutritional screening and Assessment • Nutrition screening : All Patients •Consult to Nutritional Support Team : Mod to High Risk

• Nutritional assessments SGA History (medical, dietary, social) Physical examinations Anthropometry (weight, height, BMI, muscle strength) – Biochemical test (CBC, Albumin, etc) – – – –

Subjective global assessment (SGA) A

น้ําหนัก

ไมเปลี่ยนแปลง

น้ําหนักลด < 5% ใน 1 เดือน หรือ < 10% ใน 6 เดือน

น้ําหนักลง > 5% ใน 1 เดือน หรือ > 10% ใน 6 เดือน หรือลดลงเรื่อยๆ

การกินอาหาร

ปกติ

ลดลง

กินอาหารไดนอยมากๆ

อาการ

ไมมีอาการที่มีผลตอการ มีอาการมีผลตอการกิน เชน ปวดทอง อาเจียน กินหรืออาการดีขึ้น ทองเสีย เบื่ออาหาร

มีอาการตามขอ B > 2 สัปดาห

ความสามารถใน การทํางาน

ปกติ

ทํางานไดลดลงมาก ทํางานไมไหว

การตรวจรางกาย

ปกติ

ทํางานไดลดลง

มีลักษณะของการขาด มีลักษณะการขาดอาหาร อาหาร เชน ขมับบุม แกม ชัดเจน เชน ผอมมาก ตอบ ผอมลง บวมน้ํา Nutrition Screening in Ramathibodi Hospital. Roongpisuthipong C .

Subjective global assessment (SGA) A

น้ําหนัก

ไมเปลี่ยนแปลง

น้ําหนักลด < 5% ใน 1 เดือน หรือ < 10% ใน 6 เดือน

น้ําหนักลง > 5% ใน 1 เดือน หรือ > 10% ใน 6 เดือน หรือลดลงเรื่อยๆ

การกินอาหาร

ปกติ

ลดลง

กินอาหารไดนอยมากๆ

อาการ

มีอาการตามขอ B > 2 สัปดาห

ความสามารถใน การทํางาน

ปกติ

ทํางานไดลดลงมาก ทํางานไมไหว

การตรวจรางกาย

ปกติ

X X X X

ทํางานไดลดลง

Nutritional Risk Score

0-2 = Low risk

85%

Assessment every week

3-4 = Moderate risk

10%

Consult to NST

5-7 = High risk

â&#x20AC;&#x153;

Computerization helps to improve

nutrition support delivery in Surin hospital, and seem to identify the patient at risk at the early phaseâ&#x20AC;?

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 26

Nutrition Depletion in Hospital

Study

Patients assessed on admission

Nutrition In Hospital > Depletion in 7 days Hospital

Mc Whirter and Pennington, 1994

500

112

64%

Cornish et al, 1998

569

189

62%

Surin Hospital, 2004

322

174

54%

NRS on admission 25000

In patients

20000 15000 10000 5000 0 Moderate Severe All

2002

2003

2004

2005

2006

2007

42 10 711

561 136 6844

1080 450 11251

1097 576 13715

1683 713 14263

2617 963 21809

Nutrition Management

Everything should be made simple as possible but not simpler.

Make it EZ 1. EZ Calculate requirement 2. EZ Appropriate route of administration 3. Monitor the effect : objective parameters ~ BW, CBC, Electrolyte, albumin, etc 4. Manage complications 5. Modified the regimens if necessary 30

Department of Surgery, Surin Hospital

Nutritional Requirements • 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

"If the gut works, use itâ&#x20AC;?

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 NRS

CBC

BUN/Cr

Electrolyte

Every 2 week

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 CO2 production

Parenteral Nutrition

Combination of EN and PN

TPN

PPN

>14 d

<14 d

Restrict fluid

No Sepsis

>900 mOsm/L

<900mOsm /L

Putting evidence into practice

Classification

Definition

Recommended 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) â&#x20AC;˘ Life-threatening infection affecting the superficial fascia and subcutaneous tissue â&#x20AC;˘ 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 • Reconstruction 1. 2.

Ward RG. Bmj. Jul 30 1994;309(6950):341. 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. 2.

Ord H. Br J Nurs. Nov 22-Dec 5 2007;16(21):1346-1352 Singh, G., S. K. Sinha, et al. (2002). Eur J Surg 168(6): 366-71.

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 50

Early Nutrition Support within 4 days N=28

Resuscitation

Lower Extremities NF N= 55

Extensive Debridement NRS and Assessment

Wound Assessment

Random

Empiric Antibiotics

Duration before STSG

Conventional Support N=27

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

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) 54

Characteristic

Early NS 28

Control 27

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

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

Albumin

Day0

Day3

Day10

Day13

DRGs system

Unit Cost IPD (2006)

LOS=4.2days 14,019.37 Baht

รายงานประจําป ของสํานักพัฒนาระบบบริการสุขภาพ ประจําป งบประมาณ 2549 58

Thai DRGs Version

1 2 3.0 3.1 3 3.3 3.5

Refined

Diagnosis code

Procedure code

Groups

Implement

ICD-10 (WHO) 1992

ICD-9-CM 2000

511

พย.2541

ICD-10 (WHO) 1992

ICD-9-CM 2000

511

กพ.2544

5 levels

ICD-10 (WHO) 1992

ICD-9-CM 2000

1,283

ตค.2546

5 levels

ICD-10 (WHO) 1992

ICD-9-CM 2000

1,283

เมย.2548

5 levels

ICD-10 (WHO) 2005 ICD-10 (WHO) 2005

ICD-9-CM 2005

1,283

กพ.2549

ICD-9-CM 2005

1,467

ICD-10 (WHO) 2007 + ICD-10-TM*

ICD-9-CM 2007 with extension

1,920

มค.2551

5 levels 5 levels

* For data entry only (not for new classification)

โครงสรางของ DRG opened cholecystectomy, w mild to mod CC

0 7 0 5 2 MDC=โรคตับ และทอทางเดิน น้ําดี

DC (Disease Cluster)

เลขซึ่งสัมพันธ กับ CC ไดแก 0, 1, 2, 3, 4 และ 9 60

Possible ICD-10 codes Malnutrition E40-E46

Malnutrition

E43

Severe degree malnutrition

E44.0

Moderate degree malnutrition

E44.1

Mild degree malnutrition

E46

Not specified PEM

E64.0

Consequences of PEM

E77.8

Hypoproteinemia

E88.0

Hypoalbuminemia

R63.3

Nutrition problems and improper nutrition

R64

Cachexy 61

ICD-10 codes Metabolic disorders E87.5, E87.6

Hyper-, Hypo-kalemia

E87.0, E87.1

Hyper-, Hypo-natremia

E83.4

Hypomagnesemia

E83.5

Hypocalcemia

E68

Sequelae of hyper-alimentation

E87.2, E87.3

Acidosis, Alkalosis

E87.8

Other Electrolyte imbalance

E61

Deficiency of other nutrient elements

DRG & Nutrition issues â&#x20AC;˘ Provide financial incentive to provider â&#x20AC;˘ Encourage efficiency & cost effectiveness

Acute Cholecystitis Pricipal diagnosis

summary1

summary2

Acute Cholecystitis (K810)

SDx1

Moderatemalnutrition (E44.0)

SDx2 SDx3 Procedure

Opened Cholecystetomy (5122)

DRG

07050 No CC

07052 Moderate CC

2.2817

3.0947

Cellulitis > 17 yr Pricipal diagnosis

summary1

summary2

summary4

NF (L088)

Pancreatitis (K859)

Mild malnutrition (E44.1)

Moderatemalnutriti on (E44.0)

SDx1

SDx2 SDx3 Procedure

Debridement (8660)

DRG

09060 No CC

09063 Severe CC

1.5044

3.2367

Acute Pancreatitis Pricipal diagnosis

summary1

summary2

summary3

summary4

summary5

Pancreatitis (K859)

Mild malnutrition (E44.1)

Moderatema Severe lnutrition malnutrition (E44.0) (E43)

Severe malnutrition (E43)

SDx1

SDx2

Hypokalemia (E87.6)

SDx3 Procedure

PPN (9915)

DRG

07530 No CC

07532 Moderate CC

07533 Severe CC

1.0068

1.4107

2.3798

Enterocutaneous Fistula Pricipal diagnosis

summary1

summary2

summary3

summary4

summary5

Enterocutan eous Fistula (K632)

Enterocutane ous Fistula (K632)

Mild malnutrition (E44.1)

Moderatema Severe lnutrition malnutrition (E44.0) (E43)

SDx1

SDx2

Severe malnutrition (E43) Hypokalemia (E87.6)

SDx3 Procedure

PPN (9915)

TPN (9915)

DRG

06600 No CC

06603 Moderate CC

06604 Severe CC

1.7043

2.1178

2.3798

CA Esophagus Pricipal diagnosis

summary1

summary2

summary3

summary4

summary5

CA Esophagus (C15.9)

Moderatema Severe lnutrition malnutrition (E44.0) (E43)

Severe malnutrition (E43)

Hypo K (E87.6)

PPN (9915)

SEMS Stent (4281)

Gastrostomy (43.19)

SDx1

SDx2 SDx3 Procedure DRG

06550 No CC

06503 Severe CC

06164 06504 Catastrophic CC

06014

1.5334

2.5773

3.7863

9.0348

6.8600

CA Stomach summary1 Pricipal diagnosis

summary2

summary3

summary4

summary5

CA Stomach CA Stomach CA Stomach CA Stomach CA Stomach (C16.9) (C16.9) (C16.9) (C16.9) (C16.9)

SDx1

malnutrition (E44.0)

SDx2

malnutrition (E43)

Hypo K (E87.6)

Gastrostom y (43.19)

Gastrectomy (43.89)

SDx3 Procedure

TPN (9915)

DRG

06500 No CC

06503 Severe CC

06014 06504 Catastrophic CC

06304

1.5334

2.5773

3.7863

12.6030

9.0348

Trauma summary1

summary2

summary3

summary4

summary5

Injury to large bowel (S36.5)

SDx1

malnutrition (E43)

Fx Femur (S72.9)

SDx2

Hypo K (E87.6)

malnutrition (E43)

Malnutrition (E43) + Hypo K (87.6)

ORIF (79.35)

Pricipal diagnosis

Procedure Procedure

Repair large bowel (46.75)

DRG

06030 No CC

06034

24100

24103

24104

3.8865

9.8118

6.1573

8.1515

12.0640

Burns Pricipal diagnosis

summary1

summary2

summary3

summary4

summary5

Burns (T300)

malnutrition (E43)

Hypo K (E87.6)

Anemia (D649)

Septicemia (A419)

PPN (9915)

Debridement (8622)

SDx1

SDx2 SDx3 Procedure DRG

22520 No CC

22522

22523

22524

0.8565

1.5278

3.5348

4.8587

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 you Department 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

Dr.Winai Ungpinitpong

Surin Hospital