Does a multidisciplinary total parenteral nutrition team improve patient outcomes? A systematic review

Naylor, Carlie-Jane; Griffiths, Rhonda; Fernandez, Ritin

doi:10.1177/0148607104028004251

Cited by 75 publications

(56 citation statements)

References 9 publications

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“…No problems 151 (32) 163 (34) Slight problems 110 (24) 104 (22) Moderate problems 103 (22) 99 (21) Severe problems 65 (14) 62 (13) Extreme problems 38 (8) 45 (10) Pain/discomfort…”

Section: Results: Cost-effectivenessmentioning

confidence: 99%

“…infectious complications) compared with the enteral route 2-4 but recent improvements in the delivery, formulation and monitoring of PN justify further comparison and evaluation of these routes of nutritional support, particularly in the early phase of the illness. 9,10 Economic evidence surrounding the optimum route of delivery of nutritional support is largely based on evidence of effectiveness of questionable methodological quality and narrow focus on upfront acquisition costs, and full economic evaluation is lacking. 11 In view of this, in late 2007, the National Institute for Health Research (NIHR) Health Technology Assessment programme put out a call for a large pragmatic randomised controlled trial to be conducted to determine the optimal route of delivery of early nutritional support in critically ill adults.…”

Section: Background and Rationalementioning

confidence: 99%

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A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Harvey

Parrott

Harrison

et al. 2016

Health Technol Assess

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BackgroundMalnutrition is a common problem in critically ill patients in UK NHS critical care units. Early nutritional support is therefore recommended to address deficiencies in nutritional state and related disorders in metabolism. However, evidence is conflicting regarding the optimum route (parenteral or enteral) of delivery.ObjectivesTo estimate the effect of early nutritional support via the parenteral route compared with the enteral route on mortality at 30 days and on incremental cost-effectiveness at 1 year. Secondary objectives were to compare the route of early nutritional support on duration of organ support; infectious and non-infectious complications; critical care unit and acute hospital length of stay; all-cause mortality at critical care unit and acute hospital discharge, at 90 days and 1 year; survival to 90 days and 1 year; nutritional and health-related quality of life, resource use and costs at 90 days and 1 year; and estimated lifetime incremental cost-effectiveness.DesignA pragmatic, open, multicentre, parallel-group randomised controlled trial with an integrated economic evaluation.SettingAdult general critical care units in 33 NHS hospitals in England.Participants2400 eligible patients.InterventionsFive days of early nutritional support delivered via the parenteral (n = 1200) and enteral (n = 1200) route.Main outcome measuresAll-cause mortality at 30 days after randomisation and incremental net benefit (INB) (at £20,000 per quality-adjusted life-year) at 1 year.ResultsBy 30 days, 393 of 1188 (33.1%) patients assigned to receive early nutritional support via the parenteral route and 409 of 1195 (34.2%) assigned to the enteral route had died [p = 0.57; absolute risk reduction 1.15%, 95% confidence interval (CI) −2.65 to 4.94; relative risk 0.97 (0.86 to 1.08)]. At 1 year, INB for the parenteral route compared with the enteral route was negative at −£1320 (95% CI −£3709 to £1069). The probability that early nutritional support via the parenteral route is more cost-effective – given the data – is < 20%. The proportion of patients in the parenteral group who experienced episodes of hypoglycaemia (p = 0.006) and of vomiting (p < 0.001) was significantly lower than in the enteral group. There were no significant differences in the 15 other secondary outcomes and no significant interactions with pre-specified subgroups.LimitationsBlinding of nutritional support was deemed to be impractical and, although the primary outcome was objective, some secondary outcomes, although defined and objectively assessed, may have been more vulnerable to observer bias.ConclusionsThere was no significant difference in all-cause mortality at 30 days for early nutritional support via the parenteral route compared with the enteral route among adults admitted to critical care units in England. On average, costs were higher for the parenteral route, which, combined with similar survival and quality of life, resulted in negative INBs at 1 year.Future workNutritional support is a complex combination of timing, dose, duration, delivery and type, all of which may affect outcomes and costs. Conflicting evidence remains regarding optimum provision to critically ill patients. There is a need to utilise rigorous consensus methods to establish future priorities for basic and clinical research in this area.Trial registrationCurrent Controlled Trials ISRCTN17386141.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 28. See the NIHR Journals Library website for further project information.

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“…No problems 151 (32) 163 (34) Slight problems 110 (24) 104 (22) Moderate problems 103 (22) 99 (21) Severe problems 65 (14) 62 (13) Extreme problems 38 (8) 45 (10) Pain/discomfort…”

Section: Results: Cost-effectivenessmentioning

confidence: 99%

Section: Background and Rationalementioning

confidence: 99%

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Harvey

Parrott

Harrison

et al. 2016

Health Technol Assess

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show abstract

“…26 Aynı şekilde daha önce yapılan çalışmalarda hastaya özel PN desteği sağlayan KNÜ'nün bulunduğu multidisipliner merkezlerde, PN'nin etkinlik, gü-venirlilik ve kalitesinde kayda değer bir artışla beraber, malnütrisyon hastalarının hastanede kalış süresi, morbidite ve mortalite oranlarını düşürdüğü bildirilmektedir. [27][28][29][30][31][32][33] Yine, yapılan çalışmalarda BDE'lerin sıkı laboratuvar ve klinik monitorizasyona bağlı olarak elektrolit dengesizlikleri gibi metabolik komplikasyonları önemli ölçüde azalttığı, sepsis, pnömotoraks gibi kateterle ilişkili komplikasyonların, nütrisyon konusunda eğitimli bir takım ve/veya tecrübeli hekimlerle azalabilmekte olduğu ve klinik bakımın kalitesini artırarak maliyeti azalttığı; nütrisyon takımının önerilerinin mali avantajlar sağlayabileceği bildirilmiştir 4,5,[34][35][36][37][38][39] Bununla beraber, compounder sisteminin uygulanabilmesi için aseptik ortam şartı ve dolum işleminde görevli eğitimli personel şartı vardır. 40,41 Dolayısıyla ideal sonuçlar için günlük parenteral beslenen hasta sayısı çok önemlidir.…”

Section: Bulgularunclassified

Premixed Multichamber Bags Versus Compounded Parenteral Nutrition (Cost Debate)

Atabey¹,

Aslan²,

Doğanay³

et al. 2016

Turkiye Klinikleri J Med Sci

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A An na ah ht ta ar r K Ke el li im me el le er r: : Parenteral beslenme; parenteral beslenme solüsyonları; maliyet kontrolü A AB BS ST TR RA AC CT T O Ob bj je ec ct ti iv ve e: : We aimed to compare unit and total cost of Parenteral Nutrition (PN) products that is tailored to the patient in hospital settings and purchase price and total purchase price of premixed multichamber bags according to 2013 product preparation protocol of Ankara Numune Training and Research Hospital (ANERH) Clinical Nutrition Unit (CNU). M Ma at te er ri ia al l a an nd d M Me et th ho od ds s: : According to 2013 compounded parenteral nutrition preparation protocol of ANERH CNU and data of 2013 actual and maximum capacity and the total cost of production unit, 3 peripheral (A,B,C) and 3 central (D,E,F) PN product is prepared. It is calculated with full and actual cost method. R Re e--s su ul lt ts s: : It is found that the unit cost of compounded parenteral nutrition a preparation is cheaper than a premixed multi chamber bags purchase price. But it seems that other PN compounded parenteral nutrition (B, C, D, E, F) costs are cheaper than premixed multichamber bags unit purchase price. When daily average of 38 PN compounded parenteral nutrition is prepared in actual capacity, maximum capacity of compounded parenteral nutrition is 96 in ANERH CNU. It is shown that the total annual cost of the actual capacity of compounded parenteral nutrition which is tailored to patient (495, 257, 45 ₺) is cheaper than the compounded parenteral nutrition unit costs, calculate according to the maximum capacity with the total cost calculate according to the number of actual capacity (411, 258, 70 ₺) and the total cost of buying premixed multichamber bags calculated based on the number of actual capacity (410, 948, 43 ₺). C Co on nc cl lu us si io on n: : Compounded parenteral nutrition that is tailored to the patient is much more costly than premixed multichamber bags. If the number of compounded parenteral nutrition is increased in CNUs unit, the difference between total cost of compounded parenteral nutrition that is tailored to the patient and premixed multichamber bags seems to be decreased.

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“…Previous studies have pointed out that NST activities lead to shorter hospital stay, lower mortality rate, reduced complications and improved nutrition as indices of patient treatment eŠects. 6,7) These activities may also help save medical expenses as the most suitable and cost-eŠective nutritional materials are oŠered to patients and their side eŠects are properly handled. 8,9) One example of the advantages that NSTs have to oŠer is improvement in the way nutrition is supplied.…”

Section: Introductionmentioning

confidence: 99%

Effects of Nutrition Support Team Services on Outcomes in ICU Patients

Rhee

Lee

2011

YAKUGAKU ZASSHI

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This study examined the eŠects of nutrition support team (NST) services on nutrition supply type and patient outcomes in the intensive care unit (ICU) of a general hospital in South Korea. We retrospectively analyzed hospital records of patients who received either parenteral or enteral nutrition support during their ICU stays in the second half of NST (Nutrition Support Team) year 1 (2008) and NST year 2 (2009). Several measures of year 1 were compared with those of year 2, when more NST interventions were conducted. Number of nutrition prescriptions delivered to the ICU was 629 in year 1 and 677 in year 2. The increase in NST interventions led to a reduction in costly parenteral nutrition use, especially in surgical units. Number of patients selected for outcome measures was 40 in year 1 and 45 in year 2. There was an average 3.7 days reduction in the length of hospital stays between the two study terms. The average days of fasting were 3.3 days in year 1 and 1.3 days in year 2, which is statistically a signiˆcant decrease (p＝0.02). The duration of parenteral nutrition decreased from 5.6 to 5.0 days as recommended. Compared with the amount of calories required, an average of 89.4％ calories was delivered in year 1, and an average of 99.8％ calories was delivered in year 2. Providing NST services in the ICU enhanced adequate nutrition support, cost savings, and better outcomes of the patients.

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Does a multidisciplinary total parenteral nutrition team improve patient outcomes? A systematic review

Cited by 75 publications

References 9 publications

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Premixed Multichamber Bags Versus Compounded Parenteral Nutrition (Cost Debate)

Effects of Nutrition Support Team Services on Outcomes in ICU Patients

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