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Training and monitoring patients on home parenteral nutrition (HPN)

Learning objectives Understand the importance of training and monitoring patients on home parenetral nutrtion Learn about common practice on training and monitoring Summary

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Training and monitoring patients on home parenteral nutrition (HPN)

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  1. Learning objectives Understand the importance of training and monitoring patients on home parenetral nutrtion Learn about common practice on training and monitoring Summary Home parenteral nutrition is a lifesaving treatment for patients with chronic intestinal failure. It is a complex, expensive treatment with risk of serious complications, that can be prevented if the patients are given the relevant knowledge and technical skills (1). When discharged from hospital with HPN, patients will need to be monitored in order to cope with the problems arising. Most often, monitoring of anthropometry and biochemistry is carried out by the specialised teams in hospital at intervals of about 3 months for the stable patient (2). Studies of training and monitoring practice are needed. Refrences, links Slide from course Santarpia et al, Clin Nutr (PDF file) Slide from course Santarpia et al, Clin Nutr Slides from course Training and monitoring patients on home parenteral nutrition (HPN)

  2. Training patients for HPN • Training objectives • The European practice • Selection of patients for HPN • The teaching program • How to teach the patients ? • Where are patients trained for HPN? • Monitoring the skills • Guidelines • Conclusions

  3. Training objectives • Patients or relatives able to manage procedures safely • Learn about complications and how to handle • Low rate of complications • To obtain the best quality of life

  4. Teaching practice in Europe • Questionnaire based study • 51 centres in 7 countries • Range 0-95 patients on HPN, 63 % of centres < 10 patients • Contraindication criteria • Teaching • Guidelines Home parenteral nutrition (HPN) teaching practice in Europe A. Micklewright. A.A. Prins, F. Bozzett!2, X. Hebuterne, J.M. Moreno Villares, M. Pertkiewicz, L. Pironi, M. Staun, P. Thul A. Van Gossum and the HAN-W group, Clin Nutr 2002; 21, 42, abstract.

  5. Selection of patients for HPN • Criteria to exclude patients in 62 % of centres • Intellect (33%) • Physical disability (24 %) • Social situation, education (25%) • Underlying disease (18%) • Age (16%) Home parenteral nutrition (HPN) teaching practice in Europe A. Micklewright. A.A. Prins, F. Bozzett!2, X. Hebuterne, J.M. Moreno Villares, M. Pertkiewicz, L. Pironi, M. Staun, P. Thul A. Van Gossum and the HAN-W group, Clin Nutr 2002; 21, 42, abstract.

  6. The teaching program The European survey reported the following: • Catheter care (100%) • Preventing and recognising complications (98%) • Most common mistakes (92%) • Pump care (92%) • Managing complications (90%) • Adding vitamins (55%) • Bag preparation (50%) • Intravenous medication (50%) Home parenteral nutrition (HPN) teaching practice in Europe A. Micklewright. A.A. Prins, F. Bozzett!2, X. Hebuterne, J.M. Moreno Villares, M. Pertkiewicz, L. Pironi, M. Staun, P. Thul A. Van Gossum and the HAN-W group, Clin Nutr 2002; 21, 42, abstract.

  7. The impact of HPN training • Group A • Oral instruction, two sessions ’hands on’ • 91 port-a-cath, 26 tunnelled cath. • Group B • Detailed instruction theoretical and practical, written material etc • 68 port-a-cath, 45 tunnelled cath • Fewer infections in B (p<0.001) Santarpia L, Pasanisi F, Alfonsi L, et al. Clin Nutr. 2002;21:207-11.

  8. How to teach the patients ? • Written manuals with photographic instructions • Videotapes • Interactive programs • ‘HPN-school’ with demonstrations, hands on and exercises by patients/relatives and community nurses • PC-based ?

  9. Teaching the patient in the ward

  10. Where are the patients trained for HPN? • At the ward of the discharging hospital • Involving the nutrition team • By far the most common procedure according to survey data • At home • By the team as an outgoing service • By a home care agency

  11. Monitoring skills • Aim • Quality of life • Reduce rate of complications • Monitoring skills • When readmitted • Periodic surveys • Following the occurrence of complications

  12. Guidelines training • The survey showed • 96% of centres had guidelines for training • 26 % had local guidelines • Guidelines based on national standards in some centres Home parenteral nutrition (HPN) teaching practice in EuropeA. Micklewright. A.A. Prins, F. Bozzett!2, X. Hebuterne, J.M. Moreno Villares, M. Pertkiewicz, L. Pironi, M. Staun, P. Thul A. Van Gossum and the HAN-W group, Clin Nutr 2002; 21, 42, abstract.

  13. Training conclusions • Practice varies between centres • Training at hospital / home • Current practice based on local experience and guidelines • Prospective studies of different training regimens are warranted

  14. Monitoring patients on HPN • Monitoring goals • Monitoring practice of HPN patients in Europe • Guidelines • Conclusions

  15. Why monitoring HPN patients ? • Quality of life • Manage complications • Line infections • Mechanical problems • Thrombosis • Metabolic problems • Depression, social life

  16. Monitoring practice in Europe • Questionnaire based study in 2002 • 42 centres in 8 countries • Experience 2-30 years, 0-125 patients • 934 patients, 90% non-malignant disease, 54% on HPN > 1 year Wengler, A. Micklewright, X. Hebuterne, F. Bozzetti, M. Pertkiewicz, J. Moreno, L. Pironi, P. Thul, A. Van Gossum and M. Staun and The ESPEN HAN Working Group. Clin Nutr 2003;22:s87

  17. Where HPN patients are monitored • The specialised unit monitored 73% • Local hospital 12% • GP 11% • Home care agency 4%

  18. Which personnel are responsible for the monitoring process ? • Responsibility was assigned to one person in 90 % of centres • Physician 60% • Nurse 33%

  19. Intervals between monitoring visits • 60% of centres at 3 months intervals • 25% at 0-1 month interval • 15% at longer intervals

  20. 50 40 No. centres 30 20 Every visit 10 0 Not at every visit Mood Pulse Only in case of problems Hydration Oral intake Body temp. Blood press Body weight No inform Parameters evaluated at monitoring visits. Clinical parameters monitored

  21. 50 40 30 No. centres 20 10 0 Every visit BMD s-alb. Liver funct s-chol/trig s-glucose Vit AED,B12 s-crea/K/Na Not at every visit s-Ca/Mg/Ph Haematology Trace elements Only in case of problems No inform Biochemical parameters monitored

  22. 35 30 Always 25 No. centres Usually 20 15 Occasionally 10 Never 5 0 GP HPN-team Local Hospital Training Hospital Outpatient clinic Community Nurse Home Care Agency Pharmaceutical company Who will the patients get in touch with in case of problems ?

  23. Guidelines monitoring HPN • No official European guidelines available • The 2002 survey on monitoring: • 66% of centres had some kind of guidelines • Centres had used input from National health board or clinical nutrition society • Locally developed guidelines most common Wengler, A. Micklewright, X. Hebuterne, F. Bozzetti, M. Pertkiewicz, J. Moreno, L. Pironi, P. Thul, A. Van Gossum and M. Staun and The ESPEN HAN Working Group. Clin Nutr 2003;22:s87

  24. Summary and conclusion for monitoring HPN • Monitoring usually at discharging hospital • Access to specialised team • Intervals between visits vary, being on average 3 months • The unstable patient needs more attention • Biochemistry, anthropometry at all visits • Trace elements, vitamins and BMD occasionally • Official guidelines for monitoring not available • Prospective studies warranted

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