Annals of Clinical Nutrition and Metabolism

Original Articles

The Influence of Pediatric Nutrition Support Team on Hospitalized Pediatric Patients Receiving Parenteral Nutrition: Sijin Baek, Juhyun Rho, Hyung Wook Namgung, Eunsook Lee, Euni Lee, Hye Ran Yang; J Clin Nutr 2020;12(1):7-13. Published online June 30, 2020; DOI: https://doi.org/10.15747/jcn.2020.12.1.7

Abstract PDF: Purpose: Malnutrition is a common problem in hospitalized patients that can increase the risk of complications, including infections and length of hospitalization. Appropriate nutritional support is important, particularly in pediatric patients, because growth and development are closely related to the nutritional supply. This study examined the status of nutritional support for pediatric patients in general wards to determine if interventions of the pediatric nutrition support team (pNST) contribute to appropriate nutritional support and help improve their nutritional status.
Methods: Between July 2016 and June 2017, all pediatric inpatients who received parenteral nutrition support at the Seoul National University Bundang Hospital were recruited and divided into the NST group and non-NST group according to the activities of pNST. The nutritional status was assessed in all subjects, and the calories and proteins delivered through nutritional support in each group were calculated and then compared with the recommended requirements in pediatric patients.
Results: The number of patients recruited was 174: 100 (57.5%) in the NST group and 74 (42.5%) in the non-NST group. Significantly more calories and protein were supplied in the NST group than the non-NST group in hospitalized children aged between four and 17 years (P<0.05). In the non-NST group, the amounts of calories supplied were insufficient compared to the recommended requirements. The proportion of patients supplied with the appropriate number of calories was 60.0% in the NST group and 20.0% in the non-NST group (P<0.001), and the proportion of cases supplied with the appropriate amount of protein was 87.0% in the NST group and 62.2% in the non-NST group (P<0.001).
Conclusion: Interventions of the pediatric nutrition support team contributed to the sufficient supply of calories and protein and the improvement of clinical outcomes in hospitalized children on parenteral nutrition therapy.

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Analysis of Compliance and Clinical Outcomes by Expanding Physician’s Departments in Pediatric Nutrition Support Team: Hae Won Lee, Min Jae Jung, Ji Eun Park, Hee Kwon, Jae Song Kim, Hong Go, Eun Sun Son; J Clin Nutr 2019;11(2):42-51. Published online December 31, 2019; DOI: https://doi.org/10.15747/jcn.2019.11.2.42

Abstract PDF: Purpose:
Malnutrition in hospitalized children has an impact on growth, morbidity, and mortality. For this reason, the implementation of pediatric nutrition support team (PNST) has been suggested. On April 2017, in Severance Hospital, more PNST physician’s departments participated in PNST, and a PNST physician assigning system was changed to be the same departments with the attending physician and PNST physician. This study performed a comparative analysis of the compliance and clinical outcomes after expanding the participation of the PNST physician’s department.
Methods:
Pediatric patients, who were referred to a PNST consultant, were divided into two groups: an unmatched group (different departments with the attending physician and PNST physician [154 patients, 233 consultations from May 2016 to October 2016]), and a matched group (same departments with the attending physician and PNST physician [169 patients, 302 consultations from May 2017 to October 2017]). The PNST compliance and clinical outcomes, such as the total delivered/required caloric and protein ratio, % ideal body weight (%IBW), serum total protein, and serum albumin, in the two groups were compared.
Results:
The compliance was significantly higher in the matched group than the unmatched group (63.4% vs. 47.3%, P=0.005). Although there was no significant difference, the total delivered/required caloric and protein ratio, and %IBW in the matched group tended to increase. The serum total protein (0.7±0.7 g/dL vs. –0.4±1.3 g/dL, P=0.004) and serum albumin (0.5±0.5 g/dL vs. –0.1±0.6 g/dL, P=0.003) were significantly higher in the matched group.
Conclusion:
After expanding the physician’s departments in PNST, the compliance was significantly higher in the matched group and the clinical outcomes tended to better. The physician assigning system to be matched with the departments between the attending physician and the PNST physician may help increase the compliance of NST consultations, resulting in an improvement of the patient’s clinical outcomes.

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Characteristics and Clinical Course of Patients Who Received Enteral or Parenteral Nutrition in Tertiary Referral Hospitals in Korea: Eunmi Seol, Yun-Suhk Suh, Dal Lae Ju, Hye Jung Bae, Hyuk-Joon Lee; J Clin Nutr 2016;8(2):58-65. Published online August 31, 2016; DOI: https://doi.org/10.15747/jcn.2016.8.2.58

Abstract PDF: Purpose:
The purposes of this study are to evaluate clinical characteristics of malnourished patients who received nutritional therapy and to compare their clinical courses according to nutritional support team (NST) consultation in tertiary referral hospital in Korea.
Methods:
From June 2014 to May 2015, 43,954 admitted patients who were more than 18 years old were retrospectively investigated. Characteristics of patients who received enteral nutrition (EN) or parenteral nutrition (PN) for more than 3 days (nutritional therapy group) were compared to the patients without nutritional therapy (control group). In addition, clinical courses according to NST consultation (NST group and non-NST group) were compared through propensity score matching (PSM).
Results:
EN or PN was applied in 4,599 patients for more than 3 days (nutritional therapy group: 10.5%). For characteristics, there were significant differences between two groups (nutritional therapy group vs. control group) with age, male proportion, body weight, body mass index. All laboratory data at admission were significantly worse in nutritional therapy group. And for clinical courses, there were significant differences in length of stay (LOS), rate of intensive care unit (ICU) admission, LOS in ICU, Acute Physiology and Chronic Health Enquiry (APACHE II) score, days of nutritional therapy, mortality rate. NST consultation was made in 39% of nutritional therapy group. Among departments, Thoracic Surgery showed the highest rate of NST consultation (68.5%) otherwise Neurosurgery showed the lowest rate (18.7%). When PSM between NST group vs. non-NST group were made, significant differences was shown only in the rate of ICU admission, EN or PN support days, cholesterol at discharge.
Conclusion:
In tertiary referral hospital in Korea, more than 10% of patients still needed active nutritional therapy. NST consultation rate varies among departments. We failed to find significant differences between NST group and non-NST group.

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Effects of Compliance with the Nutrition Support Team in Critically Ill Pediatric Patients: Soo-Jin Park, Ji-Eun Park, Na-Young Kwon, Jae-Song Kim, Eun-Sun Son, Hyun-Ji Yu, Jae-Yeon Bang, Seung Kim, Ho-Seon Eun; J Clin Nutr 2016;8(2):51-57. Published online August 31, 2016; DOI: https://doi.org/10.15747/jcn.2016.8.2.51

Abstract PDF: Purpose:
This study performed a comparative evaluation of nutritional condition’s improvement and clinical effects in accordance with the Nutrition Support Team (NST) consultation compliance of critically ill pediatric patients.
Methods:
The medical records of 64 critically ill pediatric patients (2 to 18 years old), who were officially referred to a NST consultant in pediatric intensive care unit from January to August 2015, were reviewed. The patients were divided into 2 groups according to the compliance of NST consultation answers. The total delivered/required caloric and protein ratio, weight, serum total protein, serum albumin, hemoglobin, and hematocrit were compared.
Results:
According to the NST consultation answer, ‘nutrition support increase’ occupied the largest proportion at 38.5%; ‘maintenance’ and ‘decrease’ accounted for 35.7% and 18.2% respectively. The NST compliance group and non-compliance group were 20 and 14 patients, respectively. Although total delivered/required caloric ratio was significantly increased in the NST compliance group (19.7%, P=0.036), there was no significant difference in the NST non-compliance group (5.1%, P=0.692). The total delivered/required protein ratio was increased (15.1%, P=0.163) in the NST compliance group and decreased (?4.7%, P=0.774) in the NST non-compliance group. The NST non-compliance group (?8.6%, P=0.219) was further reduced weight than the NST compliance group (?1.0%, P=0.820). The serum albumin was significantly increased in the NST compliance group (13.1%, P=0.003), but there was no difference in the NST non-compliance group (7.1%, P=0.433).
Conclusion:
Although 56.7% of NST consultations were needed for nutritional interventions, a lower NST compliance (53.8%) is the limit of nutritional support. The NST compliance group was supplied adequately with more calories and protein than before consultation and a more improved nutritional status. Therefore, aggressive NST consultation can help increase the therapeutic effect by improving the nutritional status. This study will form the basis to seek ways to further enhance NST compliance.

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Review Articles

Survey on the State of Nutrition Support Team (NST) Activity: Comparison of the Questionnaire Survey 2016 vs. 2005 and the State of NST Activity since the Introduction of the Medical Insurance Fee: Ji-Yoon Cho, Jung-Tae Kim, Seoung-Lan Kim; J Clin Nutr 2016;8(2):38-44. Published online August 31, 2016; DOI: https://doi.org/10.15747/jcn.2016.8.2.38

Abstract PDF: The Korean Society of Health-System Pharmacists (KSHP) and Korean Society for Parenteral and Enteral Nutrition (KSPEN) jointly performed a nation-wide questionnaire survey on the current state of Nutrition Support Team (NST) activity from March to May of 2016. The aim of the survey was to suggest ways to develop NST as well as to improve the relationship between the KSHP and KSPEN. Compared to the results of the 2005 survey, some progress was made in the activity of NST over the last decade. Not only was the activity of NST settled, but quantitative and qualitative growth was also achieved by activating rounds and regular meeting. On the other hand, the ratio of hospitals providing home care services has decreased. Therefore, further effort is needed for their revitalization.

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Reimbursement of Nutritional Support Team, What Is the Problem and How Can We Manage It?: Dongwoo Shin; J Clin Nutr 2015;7(1):2-8. Published online April 30, 2015; DOI: https://doi.org/10.15747/jcn.2015.7.1.2

Abstract PDF: Korea Ministry of Health and Welfare launched legislation for reimbursement for Nutrition Support Team (NST) activities from August 1st, 2014, which can be applied as a flat rate fee per day once a week. The indicated patients are those with hypoalbuminemia, on parenteral nutrition or enteral nutrition, critically ill patients in intensive care unit’s, and any patient on suspicion of malnutrition by the physician in charge. NST should be comprised of a professional physician, an educated nurse, an educated pharmacist, and a professional and experienced dietitian. The maximum number of patients that can be treated by one NST is 30 per day. Such a reimbursement system has resulted in some complex problems with NSTs. The low price does not provide adequate reward for the team’s workload because the output of NST belongs to the department in charge and there is no ensured incentive. The Department of Health Insurance Review and Assessment Service cannot detect the quality problem of NST, non-compliance of physicians in charge. There are no stratified codes according to severity of disease and no difference between the first visit and the repeated visit. Every NST should be certified with accreditation and should participate in a qualified education program. Korea Health Insurance does not cover the fees for feeding tubes, formulas, and pumps. Evidence that NST activities can reduce medical cost of hospital-admitted in-patients is needed. Cost-effectiveness can be achieved by quality improvement of NST.

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