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Enteral Nutrition and Its Impact on Hospital Length of Stay

Scott Austin. Dietetic Intern. Sodexo. Distance Dietetic Internship. 1/27/2015. Learning Objectives. Understand the differences involved with pre- and post pyloric feeding routes. Understand the effects of minimizing the duration of postoperative fasting.

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Enteral Nutrition and Its Impact on Hospital Length of Stay






Presentation on theme: "Enteral Nutrition and Its Impact on Hospital Length of Stay"— Presentation transcript:

Slide1

Enteral Nutrition and Its Impact on Hospital Length of Stay

Scott AustinDietetic InternSodexo Distance Dietetic Internship1/27/2015

Slide2

Learning Objectives

Understand the differences involved with pre- and post pyloric feeding routesUnderstand the effects of minimizing the duration of postoperative fastingUnderstand the importance of glycemic specific formulas

Slide3

Background

Enteral Nutrition (EN) dates back 3500 years Einhorn – 1910Weighted rubber nasogastric tubeBolus feeding

C.R. Jones – 1916

Continuous feed

JADA, March 2002, Volume 102, Issue 3, Pages 399-404

Slide4

Background

Critical PatientsEbb PhaseTypically 12-48 hours post-injuryCharacterized by 

Cardiac output

Respiratory rate

Tachycardia

Gut ileus

Acute Flow Phase

Goals:

Identify highest risk patientsEstimate energy needsEvaluate ability to tolerate feedings

Adaptive Flow PhaseGoals:Repletion of body tissue and micronutrient storesMaintain BW within 10% of pre-injury weight if possible

Flow Phase

Slide5

Background

Additional Immune NutrientsL-Argininen-3’sL-glutamine

Debats

IB, Wolfs TG,

Gotoh

T,

Cleutjens

JP, Peutz-Kootstra CJ, van der Hulst RR. Role of arginine in superficial wound healing in man. Nitric Oxide 2009;21:175–83.

Slide6

The Research

Optimal timing for the initiation of enteral and parenteral nutrition in critical medical and surgical conditions A review paperJose E. de Aguilar-Nascimento M.D., Ph.D., Alberto

Bicudo-Salomao

M.D.,

M.S,

Pedro E.

Portari-Filho

M.D., Ph.D.

Nutrition 28 (2012) 840–843

Slide7

The Research – Optimal Timing

Worldwide more than 90% of Physicians and Dietitians strongly recommend the initiation of either EN or PN within 24-48 hours after the patient is admitted to an ICUHowever in practice this is not the case

Cahill NE,

Narasimhan

S,

Dhaliwal

R,

Heyland DK. Attitudes and beliefs related to the Canadian critical care nutrition practice guidelines: an international survey of critical care physicians and dietitians. JPEN J Parenter Enteral Nutr

2010;34:685–96

Slide8

The Research – Optimal Timing

Modern guidelines endorse the initiation of EN regardless of traditional parameters, such as the presence of bowel sounds or flatusUnderfeeding the critical or surgical patient is valid due to gastrointestinal dismotility or hemodynamic conditions

Slide9

The Research – Optimal Timing

Withholding EN post GI resectionRestart feeding once bowel movements appearBoth elective and emergency surgeries

Lewis SJ, Andersen HK, Thomas S. Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. J

Gastrointest

Surg

2009;13:569–75.

Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database

Syst

Rev; 2006 Oct 18:CD004080.

Osland

E, Yunus RM, Khan S, Memon MA. Early versus traditional post- operative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN J Parenter Enteral Nutr 2011;35:473–87.

Slide10

The Research – Optimal Timing

Post-operative EN is associated with a 45% reduction in total complications when early feeding was prescribed.However….

Slide11

The Research – Optimal Timing

NGT reinsertion was more commonNo clear advantage of early EN with regard to:MortalityLength of Stay

Osland

E,

Yunus

RM, Khan S,

Memon

MA. Early versus traditional post- operative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN J Parenter Enteral Nutr

2011;35:473–87.

Slide12

The Research – Optimal Timing

Trauma patients:Meta-analysis of 3 RCT’s with n=126Early EN was associated with reduced mortalityDoig

GS,

Heighes

PT, Simpson F,

Sweetman

EA. Early enteral nutrition reduces mortality in trauma patients requiring intensive care: a meta- analysis of

randomised controlled trials. Injury 2011;42:50–6.

Slide13

The Research

Is duration of postoperative fasting associated with infection and prolonged length of stay in surgical patients?A prospective cohort study

Michelli

Cristina Silva de

Assis

,

Carla

Rosane de Moraes Silveira, Mariur Gomes

Beghetto

and Elza Daniel de Mello Nutr Hosp. 2014;30(4):919-926 ISSN 0212-1611 • CODEN NUHOEQ

Slide14

The Research – Duration of Postoperative Fasting

Methods:Included: Elective surgery patientsExcluded:No nutritional assessment warranted<72 hour hospital stay

Results:

n

=521

44.1% were fasted ≥1 day

91

% were fasted ≥ 3 days

5.6% were fasted > 5 days

Slide15

Slide16

The Research – Duration of Postoperative Fasting

≥ 1 day postoperative fastingInfection risk increased by 2.04≥ 3 day postoperative fastingInfection risk increased by 2.81> 5 day postoperative fasting Infection risk increased by 2.88

Prolonged hospitalization risk:

2.4 times higher ≥ 1 day

4.44 times higher ≥ 3 day

4.43 times higher > 5 day

Slide17

The Research – Duration of Postoperative Fasting

In summary, The longer the fasting period, the greater the risk for infectionThe longer the fasting period, the longer the length of stay

Slide18

The Research

Inadequate energy delivery during early critical illness correlates with risk of mortality in patients who survive at least seven days: A retrospective studyJong-Rung

Tsai,

Wen-

Tsan

Chang, Chau-Chyun

Sheu, Yu-Ju Wu, Yu-

Heng

Sheu, Po-Len Liu,

Chen-Guo Kerc, Meng-Chuan HuangClinical Nutrition 30 (2011) 209-214

Slide19

The Research – Inadequate energy delivery

295 patients retrospectively studiedHigh and low energy delivery (ED)High and low protein deliveryMean daily intake ≥ 60% estimated needs or <60% estimated needs

Slide20

The Research – Inadequate energy delivery

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The Research – Inadequate energy delivery

In summary,No difference in Hospital or ICU LOS between the low and high groups for either ED or PD.

Pichard

C,

Kreymann

GK,

Weimann

A, Herrmann HJ, Schneider H. Early energy supply decreases ICU and hospital mortality: a multicentre study in a cohort of 1209 patients. Clin

Nutr

2008;3(Suppl. 1):7.

Slide22

The Research

Severity of Illness Influences the Efficacy of Enteral Feeding Route on Clinical Outcomes in Patients with Critical IllnessHsiu-Hua Huang, RD; Sue-Joan Chang, PhD;

Chien

-Wei Hsu, MD; Tzu-Ming Chang, MD;

Shiu

-Ping Kang, RN; Ming-Yi Liu, RD

J

Acad Nutr Diet. 2012;112:1138-1146.

Slide23

The Research – Enteral Feeding Route

GI motility and secretion are regulated by hormones such as CCKSite of nutrient administration affects the magnitude of gut-hormone secretion

Hypothesis – The magnitude of illness severity may affect the efficacy of the enteral feeding route in clinical outcomes

Slide24

The Research – Enteral Feeding Route

n = 101 (randomly assigned to NG or ND group)All patients administered Jevity 1.0 @ 20 increased by 20mL/hr q 4 hr to the patients specific goal rate.

25-30 kcal/kg IBW

1.2-1.5 g pro/kg IBW

Slide25

The Research – Enteral Feeding Route

Results

Slide26

The Research – Enteral Feeding Route

Slide27

The Research – Enteral Feeding Route

In Summary,ND feeding route is more appropriate than NG feeding route in reducing length of ICU stay among patients with high APACHE II scores.No statistical difference in patients with lower APACHE II scores

Slide28

The Research

Differences in resource utilization between patients with Diabetes receiving Glycemia-targeted specialized nutrition vs. standard nutrition formulas in U.S. HospitalsAn observational study – Financial support from Abbott Nutrition*

Osama

Hamdy

, MD,

PhD;

Frank R. Ernst,

PharmD, MS;Dorothy

Baumer

,

MS; Vikkie Mustad

, PhD; Jamie Partridge, PhD, MBA; and Refaat Hegazi, MD, PhD, MPH, MS Journal of Parenteral and Enteral NutritionVolume 38 Supplement 2 November 2014 86S–91S

Slide29

The Research – Glycemic specific formulas

Diabetes Mellitus (DM) Substantial economic burden on patients and hospitalsLonger hospital length of stayHigher hospital mortality

Slide30

The Research – Glycemic specific formulas

Study Objective:To compare the LOS and resource cost of patients with DM receiving Glycemia targeted specialized nutrition (GTSN), with those receiving Standard Nutrition (STDN) during acute care hospitalizations.

Slide31

The Research – Glycemic specific formulas

Data SourcePremier Research DatabasePatient SelectionAdults and Children previously diagnosed T1DM or T2DM, secondary DM, GDM, neonatal DMReceived acute inpatient careExcludes transfer patients, and patients who left AMA.

Slide32

The Research – Glycemic specific formulas

Results

Slide33

The Research – Glycemic specific formulas

Limitations?Unable to establish causalityMiscoded or missing dataStrengths?Large number of patientsRecording of specific data through the Premier Research Database

Slide34

The Research – Glycemic specific formulas

In Summary,Feeding GTSN to patients with DM was associated with significantly reduced LOS and lower costs than patients receiving STDN

Slide35

The Academy

The AND Evidence Analysis Library (EAL) suggests:In fluid-resuscitated, critically ill patients, EN started within 24-48 hours following injury or admission to the ICU may reduce LOS.Actual delivery of intake of approximately 60-70% of EN goal in the first week of ICU admission, is associated with a shorter LOS in critically ill patients, particularly when initiated within 48 hours of injury or admission

Slide36

Questions?