Newsletter

[ Vol. 10 No. 3 ] (September - December 2009 )
Experience from the philippines

Luisito Llido
Philippine Society of Parenteral and Enteral Nutrition, Philippines

Nutrition support teams (NST) have been established to be the gold standard when it comes to implementers of the clinical nutrition program in the hospital¹. It was no surprise, therefore, when the progress of clinical nutrition practice in the Philippines was assessed in year 2008 by the Philippine Society of Parenteral and Enteral Nutrition (PHILSPEN), only those institutions with NST’s were the ones who achieved this somewhat elusive goal. Whereas before year 2008 the number of NST’s was 6/83 (7%), now the number has increased to 22/83 (26%)². The number of hospitals with more than 600 beds needing an NST as required by standards agencies like Joint Commission International (JCIA) is around 83³.

The clinical nutrition program and set-up used and recommended by PHILSPEN is based on the ASPEN recommendations^3,1 from the algorithm of the clinical nutrition process to the composition of the NST. The nutrition support team is essentially made up of a physician, who usually acts as the team leader, a dietitian, a nurse and a pharmacist. The team is in charge of the clinical nutrition policies and guidelines as well as the implementation of these.

These are the factors responsible for the aforementioned change in the number of NST’s: 1) standardized system of clinical nutrition program in all hospitals which require NST’s, 2) Support from the hospital administration, and 3) active partnership with the medical nutrition industry. The clinical nutrition program utilizes a standardized system of nutrition screening forms for both adult and pediatric patients. The patients who are recognized as “nutritionally at risk” will undergo a nutritional assessment form which classifies patients as low risk and high risk patients. All high risk patients need to be followed up by NST. The nutrition assessment form is a composite of the Subjective Global Assessment (SGA)⁴, weight loss data, BMI, albumin, and total lymphocyte count. The NST then performs a nutrition care plan which together with the attending physician’s approval will be implemented and monitored. The nutrition screening form for adults is a composite of the BMI and NRS2002 methods while the pediatric forms are based on the WHO BMI-based classification.

The computerization system⁵ designed under the supervision of PHILSPEN rapidly produces a nutrition surveillance report which will be provided to the medical and nursing staff. Lists of “at risk” patients are regularly generated and the data of intake like calorie counts and other developments are encoded and saved. Data for outcome reports are now easy to process. These are the key outcome data which showed the improvement of the hospital patient care process through the implementation of the clinical nutrition program. 1) Nutrition screening data showed a consistent prevalence of malnutrition data of all admitted patients. 2) The percentage of none or wrong data entries of height and weight has gone down to very low levels. 3) The nutrition assessment form was able to predict the complications and mortality of the “high risk” patients⁶. 4) The nutrition care plan form gives an easy to implement nutrition delivery to the patient through an easy to complete check list form. 5) The calorie and fluid balance sheet can generate a comprehensive summary report of the patient’s actual requirements, percent intake and route of intake.

Patient nutrition care data that showed improved outcome(s) were the following: 1) full utilization of all forms of nutrient delivery from oral to parenteral nutrition⁷, 2) adequacy of intake achieved in difficult to feed patients (i.e. intensive care patients)⁸, 3) more patients achieved adequate intake days compared to inadequate intake days⁹, and 4) more patients were given comprehensive nutrition care by the NST. Overall PHILSPEN have achieved all of these results from the aforementioned factors plus the establishment of a clinical nutrition fellowship training program and a master of science in clinical nutrition. The more vibrant NST’s have a graduate from these programs most especially the clinical nutrition fellowship training program.

However, there are still challenges that need to be hurdled and these are: self sustaining the NST through remuneration and reimbursement of the clinical nutrition service and getting our physician colleagues to fully maximize the services of the NST⁵. Everyone is confident, however, that with time and focus all these will be resolved and the final goal of 100% NST coverage of all major hospitals achieved.

REFERENCES

1. JCAHO. 2004 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH). Oakbrook Terrace, IL, 2004.
2. Nutrition support team. http://www.philspenonline.com.ph/index.htm (accessed May 4, 2009).
3. JCAHO Board of Directors, 1995 Comprehensive Accreditation Manual for Hospitals. JCAHO, Oakbrook, IL 1994.
4. DetskyAS, Mclaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? J Parenter Enteral Nutr 1987; 11(1):8-13.
5. Llido LO. The impact of computerization of the nutrition support process in the nutrition support program in a tertiary care hospital in the Philippines: report for the years 2000-2003. Clin Nutr 2006; 25(1): 91-101.
6. Predicting post-operative complications based on surgical nutritional risk level using the SNRAF in colon cancer patients – a Chinese General Hospital & Medical Center experience. Ocampo R B, Kadatuan Y, Torillo MR, Camarse CM, Malilay RB, Cheu G, Llido LO, Gilbuena AA. Phil J Surg Spec 2007.
7. Effect of nutrition care on post-operative complications predicted by surgical nutrition risk assessment: St Luke’s Medical Center experience. Del Rosario D, Inciong JF, et al. 2008 (for submission).
8. Sioson MS, Inciong JF, Reyes MCS, Navarrete DI, Llido L. Nutrition support team supervision improves intake of critical care patients in a private tertiary care hospital in the Philippines: report from years 2000 to 2006; PENSA 2007 poster presentation (for submission).
9. Sioson M, Inciong JF, Francisco E, Navarette E, Navarette DF. NST supervision improves intake of intensive care and stroke patients in a private tertiary care hospital in the Philippines (years: 2001-2002) (for submission)

From   
PENSA 2009
“Energizing Nutrition Support Practice for Life”
June 5-7 2009, Shangri-La Hotel, Kuala Lumpur, Malaysia 
Page: 43