Jornal de Distúrbios Nutricionais e Terapia

Abstrato

Congresso de Nutrição 2016: Desenvolvimento de software de suporte integrado para nutrição clínica- Pedro Javier Siquier Homar- Hospital Comarcal de Inca

Pedro Javier Siquier Homar

Objetivos: 1. Progredir na demonstração de um software informático incorporado para suporte nutricional dedicado, integrado no registo clínico eletrónico, que detecte automática e precocemente os doentes subnutridos ou em risco de desenvolver subnutrição, definindo pontos de oportunidade de melhoria e valorização dos resultados.

2. Descrever as características de um novo programa computacional para prescrição eletrônica assistida de nutrição parenteral e enteral. Definir as diferentes assistências de prescrição envolvidas no processo de suporte nutricional, com o objetivo de padronizar o suporte nutricional e incluí-lo em protocolos.

3. Definir quaisquer passes conduzidos com o prontuário clínico eletrônico do Hospital Comarcal de Inca.

Métodos: Os padrões padrão publicados pelo Grupo de Trabalho de Nutrição da Sociedade Espanhola de Farmácia Hospitalar (SEFH) e, portanto, as recomendações do Grupo de Farmácia da Sociedade Espanhola de Nutrição Parenteral e Enteral (SENPE) são levados em consideração. De acordo com esses padrões de qualidade, o suporte nutricional deve incluir as etapas ou subprocessos subsequentes de assistência à saúde: triagem nutricional, avaliação nutricional e plano de cuidados nutricionais, prescrição, preparação e administração.

Para o desenvolvimento do software de computador, foram levadas em consideração as características que todas as novas tecnologias aplicadas ao uso de medicamentos devem incluir, de acordo com as recomendações do Grupo de Avaliação de Novas Tecnologias (Grupo TECNO) da Sociedade Espanhola de Farmácia Hospitalar (SEFH), bem como os padrões de prática clínica publicados pelo Grupo de Trabalho em Nutrição da SEFH. De acordo com esses padrões de qualidade, as etapas ou processos de assistência à saúde que devem ser cobertos pelo sistema de suporte nutricional são: triagem nutricional, avaliação nutricional, plano de cuidados nutricionais, prescrição, preparação, administração, monitoramento e fim do tratamento. As características de cada subprocesso são descritas abaixo, juntamente com as diferentes assistências de prescrição implementadas.

The map of the healthcare process of the nutritional support in said software is initiated with the inclusion of patients through computer entry in the admission department. All patients will be screened within the first 48 hours since admission. The nutritional screening selected for adult patients was NRS-2002 (26) or who are severely undernourished, or who have certain degrees of severity of disease in combination with certain degrees of under nutrition. Results of sternness of syndrome and under nutrition were well-defined as inattentive, mild, moderate or severe from data sets during a selected number of randomized controlled trials RCTs and FILNUT as computer screener27. For paediatric patients, the PYMS Nutritional Selection System was selected28. This section also includes an alternate method developed by British Association for Parenteral and Enteral Nutrition (BAPEN), to work out patient size supported distance between olecranon and ulnar styloid process, and the age and gender of patients.

If the adult patient has no nutritional risk, the appliance won’t request the screening until after one week, as long as there's no FILNUT score of risk; and in paediatric patients, this will depend on the PYMS score.

Adult patients with nutritional risk are assessed according with the Nutritional Assessment Registry, and paediatric patients are assessed according to the recommendations by the Spanish Society of Paediatrics (AEPED). If the patient is not undernourished, the program will classify him/her as a patient without nutritional risk. The plan for nutritional care is defined for those patients who present undernourishment; said plan features an alarm system, which will inform if the limits of intake of different nutrients are exceeded, and if the way of administration chosen is adequate, according with the estimated duration of the specialized nutritional support. If during the estimation of requirements, the planned osmolality for parenteral nutrition is superior to 800mOsm/L, the software will indicate that the parenteral nutrition must be administered through a central line. In central lines, except for the umbilical for paediatric patients, the left or right side can be selected. After determining the plan of care, the pharmacist must validate the prescription.

In the specific case of parenteral nutrition, according to the formulations for three-chamber, two-chamber and saline bags included in the program database, together with the stability conditions that any preparation must present, the program will generate automatically the preparation which better adjusts to said conditions. If it was decided to modify said preparation due to clinical criteria, this can be confirmed again with the aim to determine its physical-chemical stability. If there is any physical-chemical incompatibility, the program will issue an alert through the relevant warning signals.

For treatment monitoring, there is a section for collection of Vital Constants (systolic pressure, diastolic pressure, temperature, heart rate, and partial oxygen saturation), fluid balance, and record of test results. Regarding the end of treatment, the following options were determined as possible causes: hospital discharge, death, oral or enteral transition, loss of line, indisposition, worsening of the condition, or others. In this last case, there is a Notes section for specifying the cause that was the reason for ending treatment. To obtain Quality Indicators, a module was selected for searching into the software database, in order to generate those indicators considered relevant, because it allows relating all variables collected in sub-processes, as well as any prescription assistance implemented.

Results: This software allows conducting in an automatic way, a selected nutritional assessment for those patients with nutritional risk, implementing, if necessary, a nutritional treatment plan, conducting follow up and traceability of outcomes derived from the implementation of improvement actions and quantifying to what extent our practice is on the brink of the established standard.

Conclusions: Finally, it is worth highlighting that a closed module with the quality indicators published so that was not implemented, because said software allows to meet some of them per se, like an universal screening of all hospital population, and nutritional diagnostic coding of patients. So that the application can be more versatile, all information contained can be used through the generation of dynamic tables combining all variables of different sub-processes; for example, it is possible to determine the relationship between patients at nutritional risk and the level of undernourishment, the prevalence of undernourishment, the number of days on nutritional support based on level of undernourishment, etc. All these data can be exported in excel, csv and pdf format, so that they can be treated with other information systems for subsequent treatment, if required. Summing up, this software introduces the concept of quality control by processes in specialized nutritional support, with the objective to determine any points of likely improvement, as well as the assessment of its outcomes. Once the software has been developed, it is necessary to set it into production, in order to determine if the standardization of specialized nutritional support with said tool will translate into an improvement in quality standards, and in order to assess its limitations.

Este software permite padronizar o suporte nutricional especializado desde um ponto de vista multidisciplinar, introduzindo o conceito de controle interno por processos e incluindo o paciente como cliente principal. Em relação às entradas, no caso específico do Hospital Comarcal de Inca, é utilizado o conjunto de padrões para troca eletrônica de informações HL7 versão 2.5. Este é integrado com o registro clínico do centro: constantes vitais (pressão sistólica, pressão diastólica, temperatura, frequência cardíaca, saturação parcial de oxigênio), unidade de teste clínico (exame de sangue e testes bioquímicos) e admissão (hospitalização, transferência e alta hospitalar).

Biografia

Pedro Javier Siquier Homar formou-se em Farmácia pela Universidade de Santiago de Compostela e em Farmacêutico Hospitalar pelo Complexo Hospitalário Universitário de Vigo. Ele é Farmacêutico Hospitalar da área de manipulação do Hospital Comarcal de Inca e Diretor de Salutic Developments, um serviço de primeira linha da Bio-Soft.

Nota: Este trabalho foi parcialmente apresentado na 5ª Conferência e Exposição Internacional sobre Nutrição, 5ª Conferência Europeia de Nutrição e Dietética, realizada de 16 a 17 de junho de 2016 em Roma, Itália.