สถานการณ์ 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

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

Nutrition Support “Prevention is better than cure.” Nutrition Support 4

Nutrition Therapy 5

Nutrition Support Team Ward NST members Physician Dietitian - Diagnosis - Calories count - Placement of CVC - Enteral Nutrition - Team Leader - Transitional Feedings Nurse Pharmacist - Maintenance of CVC - Admixture Preparation - Physical Assessment - Admixture Formulation - Patient Training - Drug-Nutrient Interaction

HA ตอนที่ 3(4.3) กระบวนการดูแลผู้ป่วย ผู้ป่วยที่มีปัญหาด้านโภชนาการได้รับการประเมินภาวะโภชนาการ วางแผนโภชนบำบัด ได้รับอาหารที่มีคุณค่าทางโภชนาการเพียงพอ

Making Awareness 9

Surin Hospital is a regional public hospital with a 700 beds facility, located in the north eastern of Thailand and a close border to Cambodia There are more 2000 out patients a day. 12 operating theatres 24 ICU 20 HCU

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 Nutrition support team (NST) has been set up at Surin hospital since 2002 by the scientific support from SPENT. The team consist of Doctors Pharmacists Nurses Dietitians A simple nutrition screening tool was used to identify malnutrition risk in all admitted patient and follow up these identified to be malnourished and “at risk of developing malnutrition”. 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

Department of Surgery, Surin Hospital 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 14

University of Hospital Nottingham: A. Mickewright Nutrition Risk Screening 1 2 3 4 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 1=yes Stress factors 0=none 1=moderate 2=severe Total University of Hospital Nottingham: A. Mickewright 15

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 17

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) 18

Subjective global assessment (SGA) น้ำหนัก ไม่เปลี่ยนแปลง น้ำหนักลด < 5% ใน 1 เดือน หรือ < 10% ใน 6 เดือน น้ำหนักลง > 5% ใน 1 เดือน หรือ > 10% ใน 6 เดือน หรือลดลงเรื่อยๆ การกินอาหาร ปกติ ลดลง กินอาหารได้น้อยมากๆ อาการ ไม่มีอาการที่มีผลต่อการกินหรืออาการดีขึ้น มีอาการมีผลต่อการกิน เช่น ปวดท้อง อาเจียน ท้องเสีย เบื่ออาหาร มีอาการตามข้อ B > 2 สัปดาห์ ความสามารถในการทำงาน ทำงานได้ลดลง ทำงานได้ลดลงมาก ทำงานไม่ไหว การตรวจร่างกาย มีลักษณะของการขาดอาหาร เช่น ขมับบุ๋ม แก้มตอบ ผอมลง มีลักษณะการขาดอาหารชัดเจน เช่น ผอมมาก บวมน้ำ Nutrition Screening in Ramathibodi Hospital. Roongpisuthipong C .

Subjective global assessment (SGA) น้ำหนัก ไม่เปลี่ยนแปลง น้ำหนักลด < 5% ใน 1 เดือน หรือ < 10% ใน 6 เดือน น้ำหนักลง > 5% ใน 1 เดือน หรือ > 10% ใน 6 เดือน หรือลดลงเรื่อยๆ การกินอาหาร ปกติ ลดลง กินอาหารได้น้อยมากๆ อาการ ไม่มีอาการที่มีผลต่อการกินหรืออาการดีขึ้น มีอาการมีผลต่อการกิน เช่น ปวดท้อง อาเจียน ท้องเสีย เบื่ออาหาร มีอาการตามข้อ B > 2 สัปดาห์ ความสามารถในการทำงาน ทำงานได้ลดลง ทำงานได้ลดลงมาก ทำงานไม่ไหว การตรวจร่างกาย มีลักษณะของการขาดอาหาร เช่น ขมับบุ๋ม แก้มตอบ ผอมลง มีลักษณะการขาดอาหารชัดเจน เช่น ผอมมาก บวมน้ำ X X X X X Nutrition Screening in Ramathibodi Hospital. Roongpisuthipong C .

Nutritional Risk Score 0-2 = Low risk 85% Assessment every week 3-4 = Moderate risk 10% Consult to NST 5-7 = High risk 5%

“Computerization helps to improve nutrition support delivery in Surin hospital, and seem to identify the patient at risk at the early phase”

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 1611 20.0 Surin Hospital 2004 672 10.8 *Cross sectional study of surgical patients in 2004 at Surin Hospital 26

Nutrition Depletion in Hospital Study Patients assessed on admission In Hospital > 7 days Nutrition Depletion in Hospital Mc Whirter and Pennington, 1994 500 112 64% Cornish et al, 1998 569 189 62% Surin Hospital, 2004 322 174 54% 27

l Nutrition Management Everything should be made as simple as possible but not simpler.

Department of Surgery, Surin Hospital Make it EZ EZ Calculate requirement EZ Appropriate route of administration Monitor the effect : objective parameters ~ BW, CBC, Electrolyte, albumin, etc Manage complications 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 Once the physician identifies and evaluates a patient in need of nutrition therapy, the patient’s energy and macronutrient requirements should be determined. In this course we identified two methods for calculating energy requirements; the Harris-Benedict Equation with applied stress factor, and the rule of thumb (25-30 kcal per kg of body weight). Indirect calorimetry is another method for determining energy requirements. Once energy requirements are determined, the other macronutrient needs should be calculated, particularly protein. For stable patients, we recommend using 0.8-1.0 g/kg body weight, and for stressed patients who need additional protein for anabolism, we suggest 1.2-2.0 g/kg body weight. 31

"If the gut works, use it” 32

Which Route/Access? Combination of EN and PN 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 33

Monitoring Every week Every 2 week NRS / CBC BS BUN/Cr Electrolyte 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 Metabolic Catheter sepsis Thrombophlebitis Catheter occlusion Pneumothorax Metabolic Hyperglycemia Abnormal LFTs Fluid retension Excessive CO2 production

Parenteral Nutrition 40

Combination of EN and PN TPN PPN >14 d <14 d Restrict fluid NA No Sepsis >900 mOsm/L <900mOsm/L 41

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 Putting the evidence into practice: To solve the problems in workplace: skin and soft tissue infection is the common problem at Surin Hospital.

Necrotizing Fasciitis(NF) Life-threatening infection affecting the superficial fascia and subcutaneous tissue 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. 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. 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 Lower Extremities NF N= 55 Resuscitation Empiric Antibiotics Extensive Debridement NRS and Assessment Early Nutrition Support within 4 days N=28 Conventional Support N=27 Wound Assessment Duration before STSG Random

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 52

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 P 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 5. Cirrhosis 25.0 37.0 Albumin 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 55

Day0 Day0 Day0 Day3 Day10 Day13

DRGs system

Unit Cost IPD (2006) รายงานประจำปี ของสำนักพัฒนาระบบบริการสุขภาพ ประจำปี งบประมาณ 2549 14,019.37 Baht LOS=4.2days 58

Thai DRGs * For data entry only (not for new classification) Version Refined Diagnosis code Procedure code Groups Implement 1 No ICD-10 (WHO) 1992 ICD-9-CM 2000 511 พย.2541 2 กพ.2544 3 3.0 5 levels 1,283 ตค.2546 3.1 เมย.2548 3.3 ICD-10 (WHO) 2005 ICD-9-CM 2005 กพ.2549 3.5 1,467 - 4 ICD-10 (WHO) 2007 + ICD-10-TM* ICD-9-CM 2007 with extension 1,920 มค.2551 * For data entry only (not for new classification)

โครงสร้างของ DRG opened cholecystectomy, w mild to mod CC 7 5 2 เลขซึ่งสัมพันธ์กับ CC ได้แก่ 0, 1, 2, 3, 4 และ 9 MDC=โรคตับและท่อทางเดินน้ำดี DC (Disease Cluster)

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

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 62

DRG & Nutrition issues Provide financial incentive to provider Encourage efficiency & cost effectiveness

Acute Cholecystitis RW 2.2817 3.0947 summary1 summary2 Pricipal diagnosis Acute Cholecystitis (K810) SDx1 Moderatemalnutrition (E44.0) SDx2 SDx3 Procedure Opened Cholecystetomy (5122) DRG 07050 No CC 07052 Moderate CC RW 2.2817 3.0947

Cellulitis > 17 yr RW 1.5044 3.2367 summary1 summary2 summary4 Pricipal diagnosis NF (L088) Pancreatitis (K859) SDx1 Mild malnutrition (E44.1) Moderatemalnutrition (E44.0) SDx2 SDx3 Procedure Debridement (8660) DRG 09060 No CC 09063 Severe CC RW 1.5044 3.2367

Acute Pancreatitis RW 1.0068 1.4107 2.3798 summary1 summary2 summary3 Pricipal diagnosis Pancreatitis (K859) SDx1 Mild malnutrition (E44.1) Moderatemalnutrition (E44.0) Severe malnutrition (E43) SDx2 Hypokalemia (E87.6) SDx3 Procedure PPN (9915) DRG 07530 No CC 07532 Moderate CC 07533 Severe CC RW 1.0068 1.4107 2.3798

Enterocutaneous Fistula summary1 summary2 summary3 summary4 summary5 Pricipal diagnosis Enterocutaneous Fistula (K632) SDx1 Mild malnutrition (E44.1) Moderatemalnutrition (E44.0) Severe malnutrition (E43) SDx2 Hypokalemia (E87.6) SDx3 Procedure PPN (9915) TPN (9915) DRG 06600 No CC 06603 Moderate CC 06604 Severe CC RW 1.7043 2.1178 2.3798

CA Esophagus RW 1.5334 2.5773 3.7863 6.8600 9.0348 summary1 summary2 Pricipal diagnosis CA Esophagus (C15.9) SDx1 Moderatemalnutrition (E44.0) Severe malnutrition (E43) SDx2 Hypo K (E87.6) SDx3 Procedure PPN (9915) SEMS Stent (4281) Gastrostomy (43.19) DRG 06550 No CC 06503 Severe CC 06504 CatastrophicCC 06164 06014 RW 1.5334 2.5773 3.7863 6.8600 9.0348

CA Stomach RW 1.5334 2.5773 3.7863 9.0348 12.6030 summary1 summary2 Pricipal diagnosis CA Stomach (C16.9) SDx1 malnutrition (E44.0) malnutrition (E43) SDx2 Hypo K (E87.6) SDx3 Procedure TPN (9915) Gastrostomy (43.19) Gastrectomy (43.89) DRG 06500 No CC 06503 Severe CC 06504 CatastrophicCC 06014 06304 RW 1.5334 2.5773 3.7863 9.0348 12.6030

Trauma RW 3.8865 9.8118 6.1573 8.1515 12.0640 summary1 summary2 Pricipal diagnosis Injury to large bowel (S36.5) SDx1 malnutrition (E43) Fx Femur (S72.9) SDx2 Hypo K (E87.6) Malnutrition (E43) + Hypo K (87.6) Procedure ORIF (79.35) Repair large bowel (46.75) DRG 06030 No CC 06034 24100 24103 24104 RW 3.8865 9.8118 6.1573 8.1515 12.0640

Burns RW 0.8565 1.5278 3.5348 4.8587 summary1 summary2 summary3 Pricipal diagnosis Burns (T300) SDx1 malnutrition (E43) SDx2 Hypo K (E87.6) SDx3 Anemia (D649) Septicemia (A419) Procedure PPN (9915) Debridement (8622) DRG 22520 No CC 22522 22523 22524 RW 0.8565 1.5278 3.5348 4.8587

Department of Surgery, Surin Hospital 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