Marsha Orr

Clinical Pathways in Home Nutrition Support

In home-care settings, physicians with various medical specialties may order home enteral and/or parenteral nutrition support. Clinical pathways may be used to provide a clear, concise, standardized method for ordering and monitoring home nutrition support. The clinical pathways should be appropriate for 80% of the patients placed on the pathways, allowing for a 20% variance, or deviation, from the pathway. In one home-care facility, disease-specific clinical pathways have been used for longer than 1 year for patients with a variety of diseases requiring home nutrition support. To determine the usefulness of the home nutrition support clinical pathways, data obtained from 20 patients were analyzed. Patients were followed up while being treated using home nutrition support clinical pathways designed for oncology (9 patients), human immunodeficiency virus/acquired immunodeficiency syndrome (2 patients), short bowel syndrome (6 patients), and hyperemesis (3 patients) for 191 weeks. Overall, an average variance (deviation from the pathway) of 22% (the number of variances divided by the total weeks of therapy) was observed. The use of the pathways to provide enteral or parenteral nutrition facilitated more cost-effective care by following pathway guidelines for obtaining laboratory values and patient visits. Communication between the home-care staff and the physician was also improved. Clinical pathways can enable standardization of care for patients receiving nutrition support at home.

The Peripherally Inserted Central Catheter: What Are the Current Indications for Its Use?

The use of peripherally inserted central catheters (PICCs) has dramatically increased since first being used for IV therapy in the 1980s. Currently, sales of PICCs are second only to acute care central venous catheters and exceed all other types of long-term venous access devices. The use of PICCs has also increased dramatically in the home care setting. A number of studies have examined the incidence of PICC complications in comparison to other central venous access devices. Although complications differ, most reports have concluded that the type and rate of PICC complications compare favorably with other access devices in the short-term; however, dwell times beyond a few weeks have been associated with decreased complication-free days and lower device survivability rates. The PICC seems to be most appropriate for acute care or short-term home care use and may not be the ideal central venous access device when the need for long-term access is anticipated.

Intestinal placement of pH-sensing nasointestinal feeding tubes

Intestinal access for enteral nutrition can be achieved by spontaneous intestinal nasogastric tube passage or by endoscopic, fluoroscopic, or surgical placement methods. Each of these methods has limitations that may compromise clinical utility. pH-sensing nasointestinal feeding tubes allow active placement with minimal equipment and expertise; however, this method requires an acidic gastric pH. We sought to determine whether antiulcer regimens used at our institution would preclude intestinal pH-sensing tube placement. Twenty-five patients had 25 (81%) successful intestinal placements in 31 attempts. Observed pH values and calculated pH changes were compared within and between successful and unsuccessful groups by using a Students t test. Initial, lowest, and final pH values did not differ significantly between groups. The pH change initial-to-lowest (4.7 +/- 0.18 vs 3.6 +/- 0.59, p < .03) and lowest-to-final (5.0 +/- 0.18 vs 3.0 +/- 0.47, p < .0001) differed significantly between groups, whereas the pH change initial-to-final did not. Cost analysis of endoscopic (

Vascular Access Device Selection for Parenteral Nutrition

782), fluoroscopic (

High Tech Home Care: Surviving and Prospering in a Changing Environment

341 to

Nutrition support nursing: a specialty practice: historical development.

382), spontaneous (

Taking your show on the road: the concept of a mobile nutrition support team.

167 to

Combined Intradialytic and Peripheral Parenteral Nutrition: A Case Report

212), and pH-sensing (

Nutrition support nursing : core curriculum

162) methods revealed 3% to 79% savings when the pH-sensing placement method was used. We conclude that the antiulcer therapies used in our patient population did not preclude intestinal pH-sensing tube placement. If the pH changes from initial-to-lowest and lowest-to-final were greater than 4, successful intestinal placement occurred in 91% of attempts. Finally, the method was cost-effective at our institution.

Home Care Patients in Managed Care: Three Perspectives

Selection of vascular access devices is a collaborative, multifactorial process that includes patient factors, device characteristics, therapeutic issues, and duration of therapy. Infants and children have additional unique needs. Newer technology is focused on the reduction of complications associated with central venous access and the hazards posed to health care workers when inserting devices and providing patient care.