出院回家开始家庭肠外肠内营养的评价

　　专业的营养支持团队（NST）包含多学科成员，可帮助患者制定合适的营养策略。然而自1995年以后，美国医院正式的NST数量呈逐年下滑趋势。接受家庭肠外或肠内营养的患者常常由未接受过营养专科培训的内科医生管理，不恰当的营养支持方案不仅不利于患者康复，还会加重其经济负担。

　　美国家庭输液服务机构（Option Care）回顾分析了187例家庭肠外营养（HPN）患者和349例家庭肠内营养（HEN）患者。

　　结果发现，管理HPN患者最常见的是内科医生（29%）和消化内科生（19%），其中过度喂养比例达23%，13%的HPN配合不合适；管理HEN最常见的医生是内科医生（57%）和肿瘤科医生（12%），其中缺乏必要的管道冲洗医嘱的患者比例高达38%。

JPEN J Parenter Enteral Nutr. 2017;41(2):292.

Evaluation of initial home parenteral and enteral nutrition (HPEN) orders upon hospital discharge to the home setting.

Noreen A. Luszcz.

Nutrition Program, Option Care, Bannockburn, Illinois, USA.

Purpose: Nutrition support is a complex therapy that requires experienced clinicians assessing patient needs and writing orders to meet those needs. Improperly prescribed nutrition support may result in serious harm. Patients managed by qualified interdisciplinary nutrition support teams (NSTs) results in improved outcomes and reductions in healthcare costs. Since 1995, there has been a steady decline in the number of formal NST in hospitals. Since the largest number of nutrition referrals comes from the hospital and most home parenteral and enteral nutrition (HPEN) patients receive their care from internists who may or may not be trained in nutrition support, it is critical that home NSTs evaluate HPEN orders upon admission to service. The objective of this study was to evaluate the appropriateness of initial HPEN orders.

Methods: A retrospective study examined data randomly collected by home infusion dietitians on adult HPEN patients on service between December 1, 2015, and May 30, 2016. Since the attempt was to evaluate nonnutrition support team-driven referrals, orders from large university hospitals with nutrition support teams were excluded. Data were extracted from the initial discharge order, assessments, and the medical record, including prescriber, therapy indication, and macronutrient and fluid needs. Determination of appropriate use of HPEN and nutrition requirements were based on the patients' overall clinical condition and American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines and standards.

Results: Eighty-three dietitians submitted data on 187 home parenteral nutrition (HPN) patients and 349 home enteral nutrition (HEN) patients. For HPN, the average age was 53 years; the top 2 prescribing physicians were internal medicine (29%) and gastroenterologist (19%); 13% (24) of the orders were inappropriate for HPN, 22% (41) did not meet fluid needs, 26% (48) did not meet amino acid needs, 21% (39) did not meet dextrose needs, 18% (34) did not meet lipid needs, and 27% (51) did not meet total kcal needs. For HEN, the average age was 66 years; the top 2 prescribing physicians were internal medicine (57%) and oncologist (12%); 4% (13) of the orders had an inappropriate delivery method, 38% (133) did not include water flushing orders, 4% (15) had inappropriate formulas, 93% (323) met nutrition needs, 3% (10) were overfed, and 5% (18) were underfed.

Conclusions: Initial HPN orders demonstrated unmet macronutrient needs on average 23% of the time. Overprescribed and underprescribed nutrients may result in complications. If the average amount of overprescribed amino acids for the 23 patients in this study continued for 90 days (often considered the average length of therapy [LOT] for HPN), it would result in an excess cost of $7819 per patient or $179,837. Extrapolating this to our annual census and similar LOT, correction of amino acids alone in 12% of HPN orders may result in $5.2 million healthcare dollars saved. For HEN, the majority of orders met nutrition needs except for the exclusion of water flushing orders. This could result in dehydration and potential rehospitalization of the patient. One limitation to this study is that it was difficult to verify whether hospital dietitians were involved in discharge order writing leading to more appropriate orders, especially with HEN. In addition, patient-reported oral intake was factored into the estimated needs but is not an exact calculation. Due to the complexities of HPEN, without the involvement of home infusion NSTs, inappropriate feeding regimens could go unnoticed, leading to potential complications and increased cost associated with overfeeding or rehospitalization. Additional research is warranted with a larger patient base to further explore the findings in this study.

DOI: 10.1177/0148607116686023