STANDARDS OF PRACTICE Standards for Home Nutrition Support AMERICAN SOCIETY FOR PARENTERAL
AND
ENTERAL NUTRITION These Standards of Practice for Home Nutrition
INTRODUCTION
A.S.P.E.N. is a professional society whose members are health care professionals-physicians, nurses, dietitians, pharmacists, and nutritionists-dedicated to
optimum
nutrition support of
A.S.P.E.N. publications: Definitions of Terms Used in A.S.P.E.N. Guidelines and Standards Standards for Nutrition Support, Hospitalized Pa-
patients during hospi-
talization and rehabilitation. A.S.P.E.N.’s diverse professional membership emphasizes the basic importance of good nutrition to good medical practice and the multidisciplinary team approach to sound nutrition. These Standards have been developed, reviewed, and approved by the following A.S.P.E.N. groups: Standards Committee, Executive Committee, and Board of Directors. The following terms were defined during the revision of the home nutrition support standards and are used in these standards. 1. Home nutrition therapy-the provision of nutrients and any necessary adjunctive therapeutic agents to patients by administration into the intestine or stomach or by intravenous infusion for the purpose of improving or maintaining a patient’s nutrition status in the home environ-
tients
Standards of Practice, Nutrition Support Dietitian Standards of Practice, Nutrition Support Pharmacist Standards of Practice, Nutrition Support Nursing Standards of Practice, Nutrition Support Physician A.S.P.E.N. has developed these standards to promote the health and welfare of those patients in need of enteral and parenteral nutrition. The standards represent a consensus of A.S.P.E.N.’s members as to that minimal level of practice necessary to assure safe and effective enteral and parenteral nutrition care. A.S.P.E.N. disclaims any liability to any health care provider, patient, or other persons affected by these standards. ORGANIZATION STANDARDS
ment.
2.
Standard 1. The referring
Referring physician, the physician who develops
4.
sup-
physician who has expertise in home parenteral and enteral nutrition support is primarily responsible for the patient’s nutrition care. The physician acts in concert with a registered nurse, a dietitian, and a registered pharmacist. Each of these health care professionals shall have appropriate education, specialized training, and experience in home parenteral and enteral nutrition. 2. Home nutrition support services shall be initiated, modified, supervised, evaluated, and coordinated by the physician/NST. Standard 2. The physician/NST caring for home parenteral and enteral nutrition patients shall be guided by written policies and procedures specifically designed to address the needs of the home patient or the patient in transition to home care. 1. There shall be written policies and procedures concerning the scope and provision of home parenteral and enteral nutrition services. 2. These written policies and procedures shall be developed by the physician/NST in conjunction with other professionals, as appropriate. 1. The
Physician/nutrition support team-physician or nutrition support team under the guidance of a physician. Treatment plan-orders established and signed by the referring physician for the care of the home patient (ie, the medical orders including: nutrients, medications, activity orders, access
site orders, etc). 5. Care plan-a plan of professional clinical activities developed by the home nutrition therapy
_
physician/nutrition
port team (NST) responsible for home nutrition support shall be clearly identified and their roles defined.
and retains the ultimate authority for the patient’s treatment plan. 3.
Sup-
port should be used in conjunction with the following
provider to implement the treatment plan. 6. Home nutrition therapy provider-the organizations providing the nutrients, medications, supplies, equipment, and professional clinical services to a home nutrition therapy patient in accordance with these standards. 7. Feeding formulation-a ready-to-administer mixture of nutrients.
65
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66 3. These
policies and procedures shall be reviewed appropriate
at least every 3 years and revised as to reflect optimal standards of care.
4. Written policies and procedures shall include but not be limited to: 4.1 The roles, responsibilities, and 24-hour availability of care from the physician/NST
4.2
4.3
4.4 4.5
and home nutrition therapy provider. Defined criteria for patient eligibility and selection, which might include: medical suitability; rehabilitative potential; social and economic factors; and educational, psychological, and emotional factors pertinent to the patient and others who are significantly involved in this care. A mechanism for referral to a knowledgeable and experienced home nutrition therapy provider for acquisition and delivery of enteral or intravenous nutrients, equipment, and supplies, with consideration for patient’s freedom of choice. Education of patient/caregiver. A mechanism for patient monitoring (eg, frequency of follow-up contact, laboratory studies, response to nutrition therapy, and
physical examination). 4.6
A mechanism for referral to consultative medical services and services of other professionals (eg, psychologists and social workers) and nonprofessionals (eg, patient
support groups), 4.7 4.8
as
appropriate.
Reimbursement mechanisms for payment for services, equipment, and supplies. Preparation, storage of, and techniques for administering a feeding formulation in the home. 4.8.1 Feeding schedules. 4.8.2 Care of feeding tubes and equipment for patients receiving enteral formulas. 4.8.3 Care of catheters and tubing for patients receiving intravenous nutrition. 4.8.4 Care and maintenance of infusion pumps.
4.8.5 Care and maintenance of feeding formulations. 4.9
Prevention, management, and timely response to complications in the home, and emergency consultation with professional staff.
4.10 A mechanism for
timely communication and collaboration among the physician/ NST, home nutrition therapy provider, patient, caregiver, and other health care professionals involved. 4.11 A mechanism for quality assurance, which shall include but not be limited to mortality, hospital readmission, and complications.
Standard 3. Home parenteral and enteral nutrition services shall be documented. 1. Medical records shall be maintained for every patient receiving home parenteral and enteral nutrition and shall include but not be limited to: 1.1 Designation of a physician with expertise in parenteral and enteral nutrition having primary responsibility for patient’s home nutrition care, see &dquo;Standards of Practice, Nutrition Support Physician,&dquo; Nutrition in Clinical Practice 1988;3:154-6. 1.2 All pertinent patient diagnoses and prognoses, including long- and short-term treatment
objectives.
A nutrition assessment and medical evaluations, with follow-up as appropriate. 1.4 Scope and results of initial and ongoing education of patient/caregiver. 1.5 Treatment plan shall include orders established and signed by the referring physician for care of the patient (which include medical orders for nutrients, medications, activity level, access-site care). 1.6 A care plan including consideration of functional limitations of the patient, activities permitted, psychosocial needs, suitability of home environment for provision of home nutrition services, and name(s) of other individual(s) who will assist in care of the patient if required. 1.7 A current medication profile including prescription and nonprescription drugs, home remedies, and known allergies or sensitivities. 1.8 Signed and dated progress notes for each contact between the patient and physician/ NST or home nutrition therapy provider (eg, home visit, clinic visit, telephone contact, and rehospitalization). Progress notes shall report response to nutrition therapy including but not limited to results of serial monitoring, complications, and revisions in the therapeutic regimen. 1.9 Signed and dated progress notes for each contact between the home nutrition therapy provider and the physician/NST including but not limited to results of serial monitoring, complications, and revision in the therapeutic regimen. 1.10 A summary statement at termination of nutrition therapy including but not limited to the reason for terminating treatment, complications, patient outcome, and follow1.3
up.
Standard 4. The home parenteral and enteral nutrition treatment and care plan shall be reviewed, evaluated, and updated regularly by the physician/NST to determine overall appropriateness, effectiveness,
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67
status, activity level, and growth require-
and safety. 1. Evaluation of patient’s need for and response to home parenteral and enteral nutrition shall be the responsibility of the physician/NST. 2. This review and evaluation shall be performed and documented periodically as dictated by patient’s medical and nutrition status. 3. The treatment and care plan shall be revised based on the review, and changes shall be communicated and implemented.
ments.
The anticipated duration and route of nutrient administration shall be determined. The goals for home parenteral or enteral nutrition support shall be established in consideration of the immediate and longterm needs of the patient.
4.2
4.3
TREATMENT PLAN STANDARDS PATIENT SELECTION STANDARD
Standard 5. Indications and contraindications for home parenteral and enteral nutrition are as follows: 1. The patient shall be carefully evaluated prior to selection for home parenteral and enteral nutrition. 1.1 A patient who is a candidate for home enteral nutrition should be unable to meet nutrient requirements by voluntary oral intake. A patient who is a candidate for home parenteral nutrition should be unable to meet nutrient requirements via the gastrointestinal tract safely and adequately. 1.2 The patient’s home environment should be such that the physician, in consultation with the appropriate social worker or other health professional, concludes that home therapy is more appropriate than long-term institutional care. 1.3 The treatment and care plan should be designed to achieve the home parenteral or enteral nutrition objectives. 1.4 The patient’s home environment should be appropriate for the safe use of home parenteral or enteral nutrition support. 1.5 The patient/caregiver should be willing and able to perform home parenteral or enteral nutrition support procedures. 1.6 The patient/caregiver should be knowledgeable about therapeutic expectations, risks, benefits, and responsibilities (financial and other) of home parenteral or enteral nutrition and should agree to partici-
pate.
patient/caregiver should understand the rationale, risks, benefits, and therapeutic options regarding nutrition support. The patient and/or family should understand the
2. The
3.
cost of
equally suitable nutrition support apand alternatives, insurance coverage,
proaches
and financial
responsibilities.
4. An evaluation of the nutrient needs of the patient shall be performed prior to the initiation of home
parenteral or enteral nutrition support. 4.1 Nutrition requirements shall take into account the patient’s disease state, nutrition
Standard 6. The home parenteral or enteral nutrition treatment plan shall be determined and documented prior to the initiation of treatment and on an ongoing basis. 1. Elements of the treatment plan should include but are not limited to: 1.1 Nutrition goals 1.2 Prescribed nutrients (type and dose of calories, protein, fluid volume, vitamins, minerals, trace elements, and electrolytes). 1.3 Infusion times and rates. 1.4 On-and-off tapering schedule. 1.5 Specialized techniques of preparation and administration in the home setting. 1.6 Care of access device, equipment, solutions, and formulas. 1.7 Prescriptions for home parenteral or enteral solutions, medications, items, etc. 1.8 Clinical monitoring (see Standard 13). 1.9 Laboratory monitoring (see Standard 13). 1.10 When appropriate, methods for transition from parenteral to enteral or oral nutrition and from enteral to oral nutrition. 2. Short-term goals should be developed and may include resolution of disease progression, wound healing, progression to enteral support, and oral nutrition. 3. Long-term goals should be developed and may include maintenance of normal nutrition and rehabilitation to physical and social independence.
Objectives should be developed prior to the initiation of nutrition support and on an ongoing basis as needed dependent on medical and nutrition evaluations. Standard 7. The route(s) selected to provide home parenteral or enteral nutrition support shall be appropriate to meet assessed nutrient requirements and achieve treatment plan goals and objectives. 1. The safest, most cost-effective route that meets the patient’s needs and preferences should be used. 2. The physician/NST should recognize that as the patient’s therapy progresses, the optimal feeding 4.
mode may change and may, at times, include a combination of oral, enteral and parenteral feed-
ings.
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68 3. Use of the enteral route is
preferred for patients who have a functioning and accessible gastrointestinal tract that can be safely used. Standard 8. The selected home parenteral or enteral formula shall be appropriate for the disease process and compatible with other medications, therapy, and access route, and shall meet nutrient needs. 1. The formulation selection and modification should be directed by the physician/NST. 2. The patient should be given a copy of the prescriptions for the feeding formulation and other medications. IMPLEMENTATION STANDARD
Standard 9. The access device and infusion method shall be appropriate for home use. 1. Selection of the access device should be based on safety and efficacy, and consideration should be
given to patient preference. placement of parenteral and enteral devices should be performed or supervised by a physician proficient in such placement.
2. The
2.1
2.2
Parenteral access 2.6.1 Central venous lines or implanted ports should be placed by a physician. 2.6.2 Peripherally inserted central catheter (PICC) lines should be placed by a physician or a nurse (where allowed by state nursing licensure boards). Enteral access 2.2.1 Nasogastric tubes should be placed by a health care professional or patient/ caregiver who has been properly trained and is proficient in such
placement. 2.2.2 Nasoduodenal or nasojejunal tubes must be placed by a physician or a
health care professional designated by the physician. 2.2.3 Percutaneous enterostomy (gastrostomy or jejunostomy) tubes must be placed by a physician or under the guidance of a physician; subsequent replacement may be done by a health care professional or patient/caregiver proficient in such placement, as designated by the physician. 3. Policies and procedures shall be established to address access to implanted ports and central venous lines, and reintroduction of each type of feeding tube. 4. The nutrient infusion method or pump selected should be suitable for home use. 4.1 Selection should be based on safety and cost-effectiveness. 4.2 Consideration should be given to patient preference, volume to be infused, type of
regimen (cyclic, continuous, or intermittent), and activity level of the patient. Standard 10. The patient/caregiver shall receive education and demonstrate competence in the preparation and administration of home parenteral and enteral nutrition support. 1. The patient/caregiver receiving home parenteral nutrition should be instructed in: 1.1 Proper storage of formulated and admixed parenteral feeding formulations. 1.2 Inspection of home parenteral nutrition containers and contents. 1.3 Aseptic technique required for the admixture procedure and administration via access device. 1.4 Compatibility and stability of nutrition and coadministered solutions under refrigeration or at room temperature. 1.5 Infusion method. 1.6 Use of parenteral infusion equipment. 1.7 Proper disposal of used containers, tubing, and needles. 1.8 Drug-nutrient and nutrient-nutrient interactions. 1.9 Medication information and administration. 2. The patient/caregiver receiving home enteral nutrition should be instructed in: 2.1 Proper storage for ready-to-feed or formula that requires mixing. 2.2 Inspection of enteral products for contents and expiration date. 2.3 Clean technique for preparation of formula, administration, and reuse of supplies and 2.4 2.5 2.6
2.7
equipment. Stability of formula at
room
temperature.
Infusion method. Use of enteral feeding equipment. Timing, method of administration, and compatibility of any medications via enteral access.
Drug-nutrient and nutrient-nutrient
interactions. 2.9 Medication information and administration. 2.10 Product hang time. 3. Educational material tailored to the patient and the therapy is provided to the patient/caregiver for use at home. 4. Patient/caregiver education should include periodic reassessment and retraining as needed. Standard 11. The patient/caregiver shall receive education and demonstrate competence in access 2.8
route care. 1. The patient/caregiver
receiving parenteral
infu-
sions should be trained in: 1.1
Aseptic techniques the
access
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device.
to
access
and maintain
69 1.2
1.3
Connecting and disconnecting the intravenous tubing to the catheter. Post-infusion flushing to prevent catheter
occlusion. The patient/caregiver receiving enteral feedings should be trained in: 2.1 Clean techniques for handling the tube. 2.2 Maintaining the access site. 2.3 Flushing the tube to maintain patency. Standard 12. The patient/caregiver shall receive education and demonstrate competence in the recognition and appropriate response to complications. 1. Patient/caregiver should be able to recognize and respond to indications of potential metabolic 2.
2.
2. Routine monitoring should include: 2.1 Continued need for therapy. 2.2 Nutrient intake. 2.3 Review of current medications. 2.4 Signs of intolerance to therapy. 2.5 Weight changes. 2.6 Biochemical, hematologic, and other pertinent data including clinical signs of nu-
trient deficiencies and excesses. 2.7 Adjustment to therapy. 2.8 Changes in lifestyle. 2.9 Psychosocial problems. 2.10 Changes in the home environment. 3. Assessment of the patient’s major organ functions should be made periodically. 4. Psychosocial aspects of the patient/caregiver should be reassessed periodically.
complications. Patient/caregiver should be able to recognize mechanical and procedural problems that include but
not limited to: Catheter or tube occlusion,
are
leakage, breakdislodgement. 2.2 Equipment malfunction or breakage. 2.3 Infusate contamination or precipitate or inhomogeneity. Patient/caregiver should be able to recognize and report any signs/symptoms of a localized or sys2.1
age,
3.
or
temic infectious process. 4. Patient/caregiver should know when and whom to contact when complications occur.
PATIENT MONITORING STANDARD
TERMINATION OF THERAPY STANDARD
Standard 14. Prior to discontinuation of parenteral enteral nutrition support one of the following criteria shall be applicable: 1. Parenteral nutrition should not be discontinued until nutrient requirements can be met by enteral or
or
oral nutrition.
2. Enteral nutrition should not be discontinued until nutrient requirements can be met by oral nutrition. 3. Parenteral or enteral nutrition support should be discontinued whenever the patient’s medical
condition, especially complications, so indicates. or enteral nutrition support should be terminated when the physician and patient judge that the patient no longer benefits from the
4. Parenteral
Standard 13. The patient shall be monitored for therapeutic efficacy, adverse effects, and clinical changes that may influence specialized nutrition sup-
port. 1. Protocols should be developed for periodic review of the patient’s clinical and biochemical status.
therapy. The decision to discontinue support must be made according to accepted community standards of medical care and in compliance with applicable law.
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AND
ENTERAL NUTRITION These Standards of Practice for Home Nutrition
INTRODUCTION
A.S.P.E.N. is a professional society whose members are health care professionals-physicians, nurses, dietitians, pharmacists, and nutritionists-dedicated to
optimum
nutrition support of
A.S.P.E.N. publications: Definitions of Terms Used in A.S.P.E.N. Guidelines and Standards Standards for Nutrition Support, Hospitalized Pa-
patients during hospi-
talization and rehabilitation. A.S.P.E.N.’s diverse professional membership emphasizes the basic importance of good nutrition to good medical practice and the multidisciplinary team approach to sound nutrition. These Standards have been developed, reviewed, and approved by the following A.S.P.E.N. groups: Standards Committee, Executive Committee, and Board of Directors. The following terms were defined during the revision of the home nutrition support standards and are used in these standards. 1. Home nutrition therapy-the provision of nutrients and any necessary adjunctive therapeutic agents to patients by administration into the intestine or stomach or by intravenous infusion for the purpose of improving or maintaining a patient’s nutrition status in the home environ-
tients
Standards of Practice, Nutrition Support Dietitian Standards of Practice, Nutrition Support Pharmacist Standards of Practice, Nutrition Support Nursing Standards of Practice, Nutrition Support Physician A.S.P.E.N. has developed these standards to promote the health and welfare of those patients in need of enteral and parenteral nutrition. The standards represent a consensus of A.S.P.E.N.’s members as to that minimal level of practice necessary to assure safe and effective enteral and parenteral nutrition care. A.S.P.E.N. disclaims any liability to any health care provider, patient, or other persons affected by these standards. ORGANIZATION STANDARDS
ment.
2.
Standard 1. The referring
Referring physician, the physician who develops
4.
sup-
physician who has expertise in home parenteral and enteral nutrition support is primarily responsible for the patient’s nutrition care. The physician acts in concert with a registered nurse, a dietitian, and a registered pharmacist. Each of these health care professionals shall have appropriate education, specialized training, and experience in home parenteral and enteral nutrition. 2. Home nutrition support services shall be initiated, modified, supervised, evaluated, and coordinated by the physician/NST. Standard 2. The physician/NST caring for home parenteral and enteral nutrition patients shall be guided by written policies and procedures specifically designed to address the needs of the home patient or the patient in transition to home care. 1. There shall be written policies and procedures concerning the scope and provision of home parenteral and enteral nutrition services. 2. These written policies and procedures shall be developed by the physician/NST in conjunction with other professionals, as appropriate. 1. The
Physician/nutrition support team-physician or nutrition support team under the guidance of a physician. Treatment plan-orders established and signed by the referring physician for the care of the home patient (ie, the medical orders including: nutrients, medications, activity orders, access
site orders, etc). 5. Care plan-a plan of professional clinical activities developed by the home nutrition therapy
_
physician/nutrition
port team (NST) responsible for home nutrition support shall be clearly identified and their roles defined.
and retains the ultimate authority for the patient’s treatment plan. 3.
Sup-
port should be used in conjunction with the following
provider to implement the treatment plan. 6. Home nutrition therapy provider-the organizations providing the nutrients, medications, supplies, equipment, and professional clinical services to a home nutrition therapy patient in accordance with these standards. 7. Feeding formulation-a ready-to-administer mixture of nutrients.
65
Downloaded from ncp.sagepub.com at OAKLAND UNIV on June 6, 2015
66 3. These
policies and procedures shall be reviewed appropriate
at least every 3 years and revised as to reflect optimal standards of care.
4. Written policies and procedures shall include but not be limited to: 4.1 The roles, responsibilities, and 24-hour availability of care from the physician/NST
4.2
4.3
4.4 4.5
and home nutrition therapy provider. Defined criteria for patient eligibility and selection, which might include: medical suitability; rehabilitative potential; social and economic factors; and educational, psychological, and emotional factors pertinent to the patient and others who are significantly involved in this care. A mechanism for referral to a knowledgeable and experienced home nutrition therapy provider for acquisition and delivery of enteral or intravenous nutrients, equipment, and supplies, with consideration for patient’s freedom of choice. Education of patient/caregiver. A mechanism for patient monitoring (eg, frequency of follow-up contact, laboratory studies, response to nutrition therapy, and
physical examination). 4.6
A mechanism for referral to consultative medical services and services of other professionals (eg, psychologists and social workers) and nonprofessionals (eg, patient
support groups), 4.7 4.8
as
appropriate.
Reimbursement mechanisms for payment for services, equipment, and supplies. Preparation, storage of, and techniques for administering a feeding formulation in the home. 4.8.1 Feeding schedules. 4.8.2 Care of feeding tubes and equipment for patients receiving enteral formulas. 4.8.3 Care of catheters and tubing for patients receiving intravenous nutrition. 4.8.4 Care and maintenance of infusion pumps.
4.8.5 Care and maintenance of feeding formulations. 4.9
Prevention, management, and timely response to complications in the home, and emergency consultation with professional staff.
4.10 A mechanism for
timely communication and collaboration among the physician/ NST, home nutrition therapy provider, patient, caregiver, and other health care professionals involved. 4.11 A mechanism for quality assurance, which shall include but not be limited to mortality, hospital readmission, and complications.
Standard 3. Home parenteral and enteral nutrition services shall be documented. 1. Medical records shall be maintained for every patient receiving home parenteral and enteral nutrition and shall include but not be limited to: 1.1 Designation of a physician with expertise in parenteral and enteral nutrition having primary responsibility for patient’s home nutrition care, see &dquo;Standards of Practice, Nutrition Support Physician,&dquo; Nutrition in Clinical Practice 1988;3:154-6. 1.2 All pertinent patient diagnoses and prognoses, including long- and short-term treatment
objectives.
A nutrition assessment and medical evaluations, with follow-up as appropriate. 1.4 Scope and results of initial and ongoing education of patient/caregiver. 1.5 Treatment plan shall include orders established and signed by the referring physician for care of the patient (which include medical orders for nutrients, medications, activity level, access-site care). 1.6 A care plan including consideration of functional limitations of the patient, activities permitted, psychosocial needs, suitability of home environment for provision of home nutrition services, and name(s) of other individual(s) who will assist in care of the patient if required. 1.7 A current medication profile including prescription and nonprescription drugs, home remedies, and known allergies or sensitivities. 1.8 Signed and dated progress notes for each contact between the patient and physician/ NST or home nutrition therapy provider (eg, home visit, clinic visit, telephone contact, and rehospitalization). Progress notes shall report response to nutrition therapy including but not limited to results of serial monitoring, complications, and revisions in the therapeutic regimen. 1.9 Signed and dated progress notes for each contact between the home nutrition therapy provider and the physician/NST including but not limited to results of serial monitoring, complications, and revision in the therapeutic regimen. 1.10 A summary statement at termination of nutrition therapy including but not limited to the reason for terminating treatment, complications, patient outcome, and follow1.3
up.
Standard 4. The home parenteral and enteral nutrition treatment and care plan shall be reviewed, evaluated, and updated regularly by the physician/NST to determine overall appropriateness, effectiveness,
Downloaded from ncp.sagepub.com at OAKLAND UNIV on June 6, 2015
67
status, activity level, and growth require-
and safety. 1. Evaluation of patient’s need for and response to home parenteral and enteral nutrition shall be the responsibility of the physician/NST. 2. This review and evaluation shall be performed and documented periodically as dictated by patient’s medical and nutrition status. 3. The treatment and care plan shall be revised based on the review, and changes shall be communicated and implemented.
ments.
The anticipated duration and route of nutrient administration shall be determined. The goals for home parenteral or enteral nutrition support shall be established in consideration of the immediate and longterm needs of the patient.
4.2
4.3
TREATMENT PLAN STANDARDS PATIENT SELECTION STANDARD
Standard 5. Indications and contraindications for home parenteral and enteral nutrition are as follows: 1. The patient shall be carefully evaluated prior to selection for home parenteral and enteral nutrition. 1.1 A patient who is a candidate for home enteral nutrition should be unable to meet nutrient requirements by voluntary oral intake. A patient who is a candidate for home parenteral nutrition should be unable to meet nutrient requirements via the gastrointestinal tract safely and adequately. 1.2 The patient’s home environment should be such that the physician, in consultation with the appropriate social worker or other health professional, concludes that home therapy is more appropriate than long-term institutional care. 1.3 The treatment and care plan should be designed to achieve the home parenteral or enteral nutrition objectives. 1.4 The patient’s home environment should be appropriate for the safe use of home parenteral or enteral nutrition support. 1.5 The patient/caregiver should be willing and able to perform home parenteral or enteral nutrition support procedures. 1.6 The patient/caregiver should be knowledgeable about therapeutic expectations, risks, benefits, and responsibilities (financial and other) of home parenteral or enteral nutrition and should agree to partici-
pate.
patient/caregiver should understand the rationale, risks, benefits, and therapeutic options regarding nutrition support. The patient and/or family should understand the
2. The
3.
cost of
equally suitable nutrition support apand alternatives, insurance coverage,
proaches
and financial
responsibilities.
4. An evaluation of the nutrient needs of the patient shall be performed prior to the initiation of home
parenteral or enteral nutrition support. 4.1 Nutrition requirements shall take into account the patient’s disease state, nutrition
Standard 6. The home parenteral or enteral nutrition treatment plan shall be determined and documented prior to the initiation of treatment and on an ongoing basis. 1. Elements of the treatment plan should include but are not limited to: 1.1 Nutrition goals 1.2 Prescribed nutrients (type and dose of calories, protein, fluid volume, vitamins, minerals, trace elements, and electrolytes). 1.3 Infusion times and rates. 1.4 On-and-off tapering schedule. 1.5 Specialized techniques of preparation and administration in the home setting. 1.6 Care of access device, equipment, solutions, and formulas. 1.7 Prescriptions for home parenteral or enteral solutions, medications, items, etc. 1.8 Clinical monitoring (see Standard 13). 1.9 Laboratory monitoring (see Standard 13). 1.10 When appropriate, methods for transition from parenteral to enteral or oral nutrition and from enteral to oral nutrition. 2. Short-term goals should be developed and may include resolution of disease progression, wound healing, progression to enteral support, and oral nutrition. 3. Long-term goals should be developed and may include maintenance of normal nutrition and rehabilitation to physical and social independence.
Objectives should be developed prior to the initiation of nutrition support and on an ongoing basis as needed dependent on medical and nutrition evaluations. Standard 7. The route(s) selected to provide home parenteral or enteral nutrition support shall be appropriate to meet assessed nutrient requirements and achieve treatment plan goals and objectives. 1. The safest, most cost-effective route that meets the patient’s needs and preferences should be used. 2. The physician/NST should recognize that as the patient’s therapy progresses, the optimal feeding 4.
mode may change and may, at times, include a combination of oral, enteral and parenteral feed-
ings.
Downloaded from ncp.sagepub.com at OAKLAND UNIV on June 6, 2015
68 3. Use of the enteral route is
preferred for patients who have a functioning and accessible gastrointestinal tract that can be safely used. Standard 8. The selected home parenteral or enteral formula shall be appropriate for the disease process and compatible with other medications, therapy, and access route, and shall meet nutrient needs. 1. The formulation selection and modification should be directed by the physician/NST. 2. The patient should be given a copy of the prescriptions for the feeding formulation and other medications. IMPLEMENTATION STANDARD
Standard 9. The access device and infusion method shall be appropriate for home use. 1. Selection of the access device should be based on safety and efficacy, and consideration should be
given to patient preference. placement of parenteral and enteral devices should be performed or supervised by a physician proficient in such placement.
2. The
2.1
2.2
Parenteral access 2.6.1 Central venous lines or implanted ports should be placed by a physician. 2.6.2 Peripherally inserted central catheter (PICC) lines should be placed by a physician or a nurse (where allowed by state nursing licensure boards). Enteral access 2.2.1 Nasogastric tubes should be placed by a health care professional or patient/ caregiver who has been properly trained and is proficient in such
placement. 2.2.2 Nasoduodenal or nasojejunal tubes must be placed by a physician or a
health care professional designated by the physician. 2.2.3 Percutaneous enterostomy (gastrostomy or jejunostomy) tubes must be placed by a physician or under the guidance of a physician; subsequent replacement may be done by a health care professional or patient/caregiver proficient in such placement, as designated by the physician. 3. Policies and procedures shall be established to address access to implanted ports and central venous lines, and reintroduction of each type of feeding tube. 4. The nutrient infusion method or pump selected should be suitable for home use. 4.1 Selection should be based on safety and cost-effectiveness. 4.2 Consideration should be given to patient preference, volume to be infused, type of
regimen (cyclic, continuous, or intermittent), and activity level of the patient. Standard 10. The patient/caregiver shall receive education and demonstrate competence in the preparation and administration of home parenteral and enteral nutrition support. 1. The patient/caregiver receiving home parenteral nutrition should be instructed in: 1.1 Proper storage of formulated and admixed parenteral feeding formulations. 1.2 Inspection of home parenteral nutrition containers and contents. 1.3 Aseptic technique required for the admixture procedure and administration via access device. 1.4 Compatibility and stability of nutrition and coadministered solutions under refrigeration or at room temperature. 1.5 Infusion method. 1.6 Use of parenteral infusion equipment. 1.7 Proper disposal of used containers, tubing, and needles. 1.8 Drug-nutrient and nutrient-nutrient interactions. 1.9 Medication information and administration. 2. The patient/caregiver receiving home enteral nutrition should be instructed in: 2.1 Proper storage for ready-to-feed or formula that requires mixing. 2.2 Inspection of enteral products for contents and expiration date. 2.3 Clean technique for preparation of formula, administration, and reuse of supplies and 2.4 2.5 2.6
2.7
equipment. Stability of formula at
room
temperature.
Infusion method. Use of enteral feeding equipment. Timing, method of administration, and compatibility of any medications via enteral access.
Drug-nutrient and nutrient-nutrient
interactions. 2.9 Medication information and administration. 2.10 Product hang time. 3. Educational material tailored to the patient and the therapy is provided to the patient/caregiver for use at home. 4. Patient/caregiver education should include periodic reassessment and retraining as needed. Standard 11. The patient/caregiver shall receive education and demonstrate competence in access 2.8
route care. 1. The patient/caregiver
receiving parenteral
infu-
sions should be trained in: 1.1
Aseptic techniques the
access
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device.
to
access
and maintain
69 1.2
1.3
Connecting and disconnecting the intravenous tubing to the catheter. Post-infusion flushing to prevent catheter
occlusion. The patient/caregiver receiving enteral feedings should be trained in: 2.1 Clean techniques for handling the tube. 2.2 Maintaining the access site. 2.3 Flushing the tube to maintain patency. Standard 12. The patient/caregiver shall receive education and demonstrate competence in the recognition and appropriate response to complications. 1. Patient/caregiver should be able to recognize and respond to indications of potential metabolic 2.
2.
2. Routine monitoring should include: 2.1 Continued need for therapy. 2.2 Nutrient intake. 2.3 Review of current medications. 2.4 Signs of intolerance to therapy. 2.5 Weight changes. 2.6 Biochemical, hematologic, and other pertinent data including clinical signs of nu-
trient deficiencies and excesses. 2.7 Adjustment to therapy. 2.8 Changes in lifestyle. 2.9 Psychosocial problems. 2.10 Changes in the home environment. 3. Assessment of the patient’s major organ functions should be made periodically. 4. Psychosocial aspects of the patient/caregiver should be reassessed periodically.
complications. Patient/caregiver should be able to recognize mechanical and procedural problems that include but
not limited to: Catheter or tube occlusion,
are
leakage, breakdislodgement. 2.2 Equipment malfunction or breakage. 2.3 Infusate contamination or precipitate or inhomogeneity. Patient/caregiver should be able to recognize and report any signs/symptoms of a localized or sys2.1
age,
3.
or
temic infectious process. 4. Patient/caregiver should know when and whom to contact when complications occur.
PATIENT MONITORING STANDARD
TERMINATION OF THERAPY STANDARD
Standard 14. Prior to discontinuation of parenteral enteral nutrition support one of the following criteria shall be applicable: 1. Parenteral nutrition should not be discontinued until nutrient requirements can be met by enteral or
or
oral nutrition.
2. Enteral nutrition should not be discontinued until nutrient requirements can be met by oral nutrition. 3. Parenteral or enteral nutrition support should be discontinued whenever the patient’s medical
condition, especially complications, so indicates. or enteral nutrition support should be terminated when the physician and patient judge that the patient no longer benefits from the
4. Parenteral
Standard 13. The patient shall be monitored for therapeutic efficacy, adverse effects, and clinical changes that may influence specialized nutrition sup-
port. 1. Protocols should be developed for periodic review of the patient’s clinical and biochemical status.
therapy. The decision to discontinue support must be made according to accepted community standards of medical care and in compliance with applicable law.
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