Home Feeding Patients May Not be Getting the Nutrition They Need

ORLANDO, Fla. (February 15, 2017)—Nutrition support orders upon discharge from the hospital often don’t meet the needs of patients, according to Option Care data presented at the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Nutrition Week (CNW) conference. If orders are not corrected, patients may be overfed or underfed, both of which put them at health risk and in the case of overfeeding, adds unnecessary costs.

Option Care researchers determined orders upon discharge from the hospital for home parenteral (intravenous) nutrition (HPN) did not meet the patients’ needs nearly one-quarter of the time. While nutrition needs were more likely to be met for home enteral (tube-fed) nutrition (HEN) patients, 38 percent of orders did not meet fluid (hydration) needs. Option Care registered dietitians reviewed all orders, performed nutritional assessments when the patients were discharged to homecare and made recommended changes to the nutrition order if warranted, based on the patient’s lab values, activity level and overall medical condition.

“Nutrition support is complex and quality patient care provided in the home setting requires close collaboration between referring clinicians and a qualified home nutrition support team that has nutrition support expertise, including a registered dietitian, pharmacist and nurse,” said Noreen Luszcz, RD, MBA, CNSC, lead author of the study and nutrition program director for Option Care. “When a patient leaves the hospital, it is vital that the home infusion dietitian complete a nutrition assessment to ensure the order follows A.S.P.E.N. guidelines and the patient’s current needs are being met.”

Overfeeding can lead to metabolic problems and cause excess weight gain, as well as increasing costs by providing more nutrition than required. Underfed patients may not gain weight adequately or heal as quickly as they should.

Named an A.S.P.E.N. CNW Poster of Distinction for excellence and innovation, the research involved an analysis of nutrition orders for 187 HPN patients and 349 HEN patients who were discharged from hospitals that did not have dedicated nutrition support teams to guide the order writing.

For the 187 Option Care HPN patients, researchers determined the original orders did not meet the patient’s needs 23 percent of the time on average. They found:

• 41 (22 percent) did not meet fluid needs
• 48 (26 percent) did not meet amino acid (protein) needs
• 39 (21 percent) did not meet dextrose (carbohydrate) needs
• 34 (18 percent) did not meet lipid (fat) needs
• 51 (27 percent) did not meet total caloric needs

Additionally, 24 patients (13 percent), were inappropriately prescribed HPN, when they should have received nutrition via other less costly routes such as HEN and/or oral intake. HPN should only be prescribed for patients whose gastrointestinal systems cannot adequately process nutrients. The top two prescribing physicians were internal medicine specialists (29 percent) and gastroenterologists (19 percent).

In the case of protein, patients were provided initial orders that would have led to overfeeding 48 percent of the time and underfeeding 52 percent of the time. In the remaining categories, patients were much more likely to be given initial orders that would have led to underfeeding. Researchers estimate the average amount of overprescribed protein would result in an extra $179,837 per patient who received HPN for 90 days, the average length of time on the therapy. They determined that correcting the protein prescription in 12 percent of HPN orders alone would result in $5.2 million in saved health care costs.

Among the 349 Option Care HEN patients, researchers assessing the original orders determined:

• 133 (38 percent) did not include water flushing orders (so the patient would not have received enough fluid)
• 15 (4 percent) were prescribed formulas that were not the most appropriate for their condition
• 10 (2 percent) would have been overfed
• 18 (5 percent) would have been underfed

A variety of factors may lead to hospital discharge nutrition orders not meeting the patient’s needs, researchers note. They are often prescribed by physicians, who may lack specialized nutrition expertise and do not have a qualified nutrition support team—including a registered dietitian, nurse and pharmacist—to guide them. Additionally, nutritional needs change over time. A patient with an acute injury might require more protein while healing, but the need may decrease by the time the patient is discharged home. If the order isn’t adjusted, the person may receive inappropriate protein levels, which add up over time. Lastly, there is a high level of scrutiny when qualifying a patient for home nutrition support (especially with Medicare) whereas hospitals are not under that same level of review.

Option Care’s Nutrition Support Program follows a multidisciplinary team approach to care including infusion nurses, pharmacists and dietitians certified in nutrition support who work closely with physicians to provide the highest quality of care to HPN and HEN patients. Every Care Management Center is supported by a registered dietitian nationwide.

Patients are prescribed HPN or HEN because they cannot meet their nutrition needs orally due to conditions such as cancer, stroke, gastrointestinal disease or surgical complications. Both therapies can be temporarily administered in the hospital, however about 40,000 HPN patients and 344,000 HEN patients annually receive their nutrition therapy safely and with less cost at home avoiding the risk of exposure to hospital-acquired infections, returning to work and living active lives. Although some people receive these therapies short term many are on for a longer period and some lifelong.

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