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Table 83Nutrition support teams: enteral nutrition

Bibliographic referenceStudy TypeEvidence levelNo. of patientsPatients characteristicsInterventionComparisonLength of follow upOutcome measuresEffect sizeComments (including source of funding)
Brown et al 198748Obs.
Comparative.
Concurrent control
102 patients

Team: n=50

No team: n=52
Patients who were started on ETF.

Mean (+/− SD) age:
Team: 43.6 +/− 20.3
No team: 60.5 +/− 17.4 [p<0.01]

Male/Female:
Team: 31/19
No team: 25/27

ICU patients:
Team: n= 27
No team: n= 12 [p<0.01]

Mean (+/− SD) Basal
Energy Expenditure:
Team: 1476 +/− 292
No team: 1312 +/− 225 [p< 0.01]

Exclusion criteria: Patient receiving ETF for less than 24 hr
Nutritional support team: general surgery residents, pharmacists, nurses, and clinical dietitian.

Team patients were referred by consultation from each patient’s primary physician to the NST for ETF management.
No team. Enteral feeding was managed by primary staff and residents physicians in multiple specialitiesUntil end of ETFTeam: n= 50
No team: n= 52
All patients were monitored by one of the authors, independent of the nutritional support team. Non-team physicians did not know that the study was being conducted.

NST patients were significantly younger than no NST patients.

Significantly more team patients were administered ETF in an ICU.

Funding: Research grants from Mead Johnson Nutritional Division, Evansville, IN, and Ross Laboratories, Columbus, OH
Total feeding daysTeam: 632
No team: 398
Total feeding days/patientTeam: 12.6 +/− 12.1
No team: 7.7 +/− 6.2 [p<0.01]
Laboratory testTeam: 466
No team: 241
Laboratory test/patientTeam: 9.3 +/− 9.1
No team: 4.6 +/− 5.2 [p<0.01]
Laboratory test/dayTeam: 0.74
No team: 0.61 [p<0.01]
Patients attaining 1.2 X BEETeam: 37
No team: 26 [p<0.05]
Days patients attained 1.2 x BEETeam: 348
No team: 133 [p<0.01]
Patients receiving nitrogen balance studiesTeam: 23
No team: 1
Number of nitrogen balance studies performedTeam: 45
No team: 1
Monitoring parameters:
- Gastric residualsTeam: 49
No team: 8
- Glucose monitoringTeam: 45
No team: 10
MortalityTeam: 5
No team: 11 [Not significant]
Complications:Total:
Team: 398
No team: 390

- complications/day:
Team: 0.63
No team: 0.98 [p<0.01]

Pulmonary:
Team: 0
No team: 2

- Complications/day:
Team: 0
No team: 0.01

Mechanical complications:
Team: 23
No team: 47

- Complications/day:
Team: 0.04
No team: 0.12 [p<0.01]

Comparison of mechanical and GI abnormalities: none of the differences were statistically significant. (Data not extracted)

GI complications:
Team: 55
No team: 55

- Complication/day:
Team: 0.09
No team: 0.14 [p<0.05]

Metabolic complications:

Team: 311
No team: 290

- Complication/day:
Team: 0.49
No team: 0.72 [p<0.01]

Metabolic complications- Number (abnormality/day) (only those parameters statistically significant have been included):

Hypokalemia:
Team: 32 (0.05)
No team: 36 (0.01) [p<0.05]

Hyperglycemia:
Team: 63 (0.10)
Mp team: 77 (0.19) [p<0.01]

Hypophosphatemia:
Team: 20 (0.03)
No team: 31 (0.08) [p<0.01]

Untreated metabolic abnormalities:
Team: 32 (0.05)
No team: 60 (0.15) [p<0.01]
Powers et al 1986280101 patients

Team : n= 50
No team : n= 51
Patients receiving ETF.

Exclusion criteria: Any patient receiving ETF for less than 24 hr.
Mean (+/− SD) age:

Team: 64.3 +/− 16.1
No team: 64.5 +/− 11.9

ICU patients:
Team: 14
No team: 8

Medicine:
Team: 24
No team: 32

Surgery:
Team: 26
No team: 19

Mean BEE (kcal/d):
Team: 1347.2 +/− 222.3
No team: 1375.4 +/− 179.4
NST. Patients were referred by consultation from the patient’s physician for ETF management. NST: physicians, clinical pharmacist, nutrition support nurse and clinical dietitian.No team. Managed by their primary physician (intern, resident, or staff).Team: n= 50; No team: n= 51The collection of data was coordinated by the primary investigator independent of the nutritional support team.

Significantly more postoperative patients were referred to the team-managed group.
Total feeding daysTeam: 583
No team: 740 [Not significant]
Mean (+/− SD) feeding daysTeam: 11.7 (9.2)
No team: 14.5 (10.3) [Not significant]
Laboratory tests (n)Team: 1483
No team: 1621 [Not significant]
Laboratory tests/ptTeam: 29.66
No team: 31.78 [Not significant]
Laboratory test/dayTeam: 2.54
No team: 2.19 [Not significant]
Patients attaining 1.2 x BEETeam: 47
No team: 38 [p<0.05]
Total feeding days at 1.2 x BEE (%)Team: 398 (68.6)
No team: 281 (37.2) [p<0.05]
Patients receiving N balance studiesTeam: 43
No team: 2 [p<0.05]
Total number of N balance studiesTeam: 70
No team: 2 [p<0.05]
Patients achieving positive N balanceTeam: 42
No team: 1 [p<0.05]
Patients receiving nutritional assessmentTeam: 50
No team: 5 [p<0.05]
Patients with nutritional plan documentedTeam: 50
No team: 6 [p<0.05]
Verification of tube placement documentedTeam: 49
No team: 21 [p<0.05]
Weights obtainedTeam: 50
No team: 6 [p<0.05]
Intake-output orderedTeam: 50
No team: 18 [p<0.05]
Gastric residuals orderedTeam: 50
No team: 7 [p<0.05]
Urine Sugar and Acetone orderedTeam: 50
No team: 5 [p<0.05]
Patients requiring formula modification (%)Team: 15 (30)
No team: 5 (9.8) [p<0.05]
MortalityTeam: 5
No team: 9 [Not significant]
ComplicationsTeam: 160
No team: 695 [p<0.05]
- PulmonaryTeam: 0
No team: 5 [p<0.05]
- MechanicalTeam: 8
No team: 110 [p<0.05]
- Gastrointestinal (N)Team: 21
No team: 67 [p<0.05]
- Metabolic (N)Team: 131
No team: 513 [p<0.05]

Metabolic complications-Number (abnormality/day) (only those parameters statistically significant have been included):

Hyponatremia:
Team: 11
No team: 27 [p<0.05]

Hyperkalemia:
Team: 5
No team: 30 [p<0.05]

Hyperglycemia:
Team: 23
No team: 84 [p<0.05]

Hypophosphatemia:
Team: 16
No team: 48[p<0.05]

Hypocalcemia:
Team: 22
No team: 48 [p<0.05]

Untreated metabolic abnormalities:
Team: 8
No team: 210 [p<0.05]
Scott et al 2003312RCT112 patients randomised

NST :n=55
8 died within 7 days of PEG insertion.

Non-NST :
n=57
3 died within 7 days of PEG insertion.

Total analysed :
NST : n=47

Non-NST : n=54
Adult patients referred and accepted for a PEG.

No absolute exclusion criteria (patients were only excluded for logistical reasons eg. PEG inserted during NST member leave)

Gender (M/F):
NST: 19/28

Non-NST: 27/27 [Not significant]

Mean (SD) age:
NST:67.4 (17.0)
Non-NST: 68.6 (17) [Not significant]
Intervention started on day 7 following the PEG insertion.

Patients were visited at least weekly by the nutrition team nurse and/or dietitian while in the acute hospital and at least monthly after discharge into the community.

There was liaison between the nutrition team and the ward and primary care professionals, with advice and help on pro-active basis for any problems or questions that were raised. In addition, patients and their carers were counselled, educated and trained in all relevant aspects of nutritional support and were given a telephone number to contact at any time if required.
Patients received non specific input from the nutrition team either before or after discharge. This did not exclude referrals to the team if the ward or community team felt this was necessary. Level of input was generally limited to advice only.12 monthsNST: n= 47; No-NST: n= 548 patients in the NST and 3 patients in the control group died after randomisation within 7 days of PEG insertion (before intervention started).

Funding: Nutricia Clinical Care Ltd, Trowbridge, Wiltshire, UK
Time to removal of PEG (days) (Median-range)NST: 60 (6–366)
Non-NST: 113 (11–366) [Not significant]
Complications:
- Diarrhoea n (%)NST: 23 (49%)
Non-NST: 20 (37%) [Not significant]
- Vomiting n (%)NST: 17 (36%)
Non-NST: 23 (43%) [Not significant]
- Chest infection n (%)NST: 32 (68%)
Non-NST: 34 (63%) [Not significant]
- Peristomal infections episodesNST: 32 (68%)
Non-NST: 36 (67%) [Not significant]
Days of antibiotic therapy: Median (range)NST: 8 (0–43)
Non-NST: 11 (0–158) [Not significant]
LOS (days) in acute hospital Median (range)NST: 19 (1–131)
Control: 22 (1–104) [Not significant]
Number of patients admitted to community hospitalNST: 20 (43%)
Control: 28 (52%) [Not significant]
Days in community hospital for those admitted: Median (range)NST: 76 (1–350)
Control: 92 (1–349) [Not significant]
Number (%) of patients receiving care from NSTNST: 45 (96%)
Control: 12 (22%) [p<0.001]
- 10 min contacts with NST for those receiving care-median (range)NST: 10 (1–50)
Control: 2 (1–4) [No p value reported]
Number of patients receiving contacts with PAMs (Professions Allied to Medicine)NST: 45 (96%)
Control: 53 (98%) [Not significant]
Number of patients with contacts with GPNST: 16 (34%)
Control: 24 (44%) [Not significant]
Number of patients with contacts with district nurseNST: 10 (21%)
Control: 15 (28%) [Not significant]
Number of patients readmittedNST: 10
Control: 21 [Not significant]
Number of readmissionsNST: 18
Control: 29
Days of stay per readmission: Median (range)NST: 9 (1–54)
Control: 14 (1–62) [Not significant]
MortalityNo significant differences between the groups (Data in figure)
QOLThere was an improvement in the social functioning element of the SF36 with NST group over control [p=0.05]. All other elements of the SF36 were similar as were the results of the PEG-specific tool and the patient/carer satisfaction questionnaire (results not presented)
Anthropometric measurementsNo differences between the groups (data not presented)

From: Appendix Four, Evidence Tables

Cover of Nutrition Support for Adults
Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition.
NICE Clinical Guidelines, No. 32.
National Collaborating Centre for Acute Care (UK).
Copyright © 2006, National Collaborating Centre for Acute Care.

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