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|Research: Support of Treatment at Home|
Denise Konrad, RD, LD, CNSC, and Mandy Corrigan, MPH, RD, LD, CNSC, FAND
Denise and Mandy were awarded Oley’s HomePN Research Prize, sponsored by Nutrishare, Inc., in 2013, for their research on dehydration. Their research, undertaken in conjunction with Cindy Hamilton MS, RD, LD, Ezra Steiger, MD, FACS, FASPEN, and Donald F. Kirby, MD, CNSC, of the Cleveland Clinic, Cleveland, Ohio, is summarized here.
At Cleveland Clinic, additional bags of intravenous fluids (HIVF) were provided to home parenteral nutrition (HPN) and HIVF patients who were at high-risk of developing dehydration. These HIVFs were ordered by the HPN physician for immediate use in the home when the patient displayed the signs and symptoms of dehydration. High-risk patients were defined as those with high-output ostomies, fistulas, and/or drains. These patients were taught how to identify dehydration before they were discharged, and were advised to contact the hospital’s home nutrition support service as soon as these symptoms developed and before using the additional HIVFs. The goal was to help them avoid emergency room (ER) treatment or hospital admissions.
We defined dehydration as having greater fluid losses (urine, stool, vomiting, drain output) than fluid intake (oral liquids, enteral nutrition, HPN, HIVF) based on the patient’s intake and output (I/O) records, with at least one physical symptom and/or alteration in labs compared to the patient’s baseline. Standard treatment of dehydration was 1 liter HIVF daily for 3 days, plus prescribed infusions. We considered their dehydration resolved when the labs were back to normal, or they no longer had the physical symptoms.
The NumbersWe looked at the records of 308 home nutrition support patients (both HPN and HIVF) managed during 2010. We found the most common diagnoses were Crohn’s disease and cancer with malabsorption, fistula, or obstruction. Most patients had an ostomy. Following hospital protocol in identifying high-risk patients, HIVFs were ordered in 161 of the 308 patients.
Among these 161 patients, over half required additional HIVFs due to at least one episode of dehydration. Many patients had multiple episodes, with a total of 201 episodes reported. We noticed that for every 5 year increase in age, the odds of having more than one dehydration episode increased 20 percent. Older patients, those with increased ostomy output, and/or those with negative I/O data were more likely to have more than one episode of dehydration. Eighty percent of the time, I/O data was consistent with the signs and symptoms of dehydration.
More than three-quarters (84.5%) of the 201 episodes of dehydration were successfully treated at home with additional HIVFs. There were only 9 ER admissions (4.5%) and 22 hospital admissions for dehydration (11%). One patient, who was non-compliant, had 4 admissions.
ConclusionsDehydration is common in HPN/HIVF patients, especially those with malabsorption and an ostomy. A protocol to identify HPN/HIVF patients at risk of dehydration with provision of additional HIVF on-hand in the home can reduce ER treatment or hospitalization. This is easier on the patient, and could potentially save health care costs.
LifelineLetter, May/June 2014