栄養障害と治療のジャーナル

概要

栄養会議 2016: 臨床栄養のための統合サポート ソフトウェアの開発 - Pedro Javier Siquier Homar - Hospital Comarcal de Inca

ペドロ・ハビエル・シキエル・オマール

目的: 1. 電子臨床記録に統合された専用の栄養サポート用の統合コンピュータ ソフトウェアのデモンストレーションを進め、栄養不足の患者または栄養不足の危険がある患者を早期に自動的に検出し、結果の改善と評価の機会を定義します。

2. 非経口および経腸栄養の電子処方を支援する新しいコンピュータ プログラムの特徴について説明します。栄養サポートを標準化し、それをプロトコルに組み込むことを目的として、栄養サポート プロセスに関係するさまざまな処方支援を定義します。

3. Hospital Comarcal de Inca の電子臨床記録に関連するパスを定義します。

方法:スペイン病院薬学会 (SEFH) の栄養作業グループが発行した標準規格と、スペイン静脈・経腸栄養学会 (SENPE) の薬学グループによる推奨事項が考慮されています。これらの品質規格によると、栄養サポートには、栄養スクリーニング、栄養評価、栄養ケア計画、処方、準備、投与という、その後のヘルスケア段階またはサブプロセスが含まれている必要があります。

コンピュータ ソフトウェアの開発では、スペイン病院薬学会 (SEFH) の新技術評価グループ (TECNO グループ) の推奨事項、および SEFH の栄養作業グループが発行した臨床実践基準に従って、薬剤の使用に適用されるすべての新技術に備わっているべき特性が考慮されました。上記の品質基準によると、栄養サポート システムでカバーする必要があるヘルスケアの段階またはプロセスは、栄養スクリーニング、栄養評価、栄養ケア プラン、処方、準備、投与、監視、および治療終了です。各サブプロセスの特性については、実装されているさまざまな処方支援とともに、以下で説明します。

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.

このソフトウェアは、専門的栄養サポートを多分野の観点から標準化し、プロセスごとの内部管理の概念を導入し、患者を主な顧客として含めることを可能にします。エントリに関しては、インカ病院の特定のケースでは、電子情報交換の標準セット HL7 バージョン 2.5 が使用されています。これは、センターの臨床記録、つまりバイタル定数 (収縮期血圧、拡張期血圧、体温、心拍数、部分酸素飽和度)、臨床検査ユニット (血液検査および生化学検査)、および入院 (入院、転院、および退院) と統合されています。

バイオグラフィー

ペドロ・ハビエル・シキエ・オマールは、サンティアゴ・デ・コンポステーラ大学で薬学の学位を取得し、コンプレクソ・ホスピタリオ・ウニベルシタリオ・デ・ビーゴで病院薬剤師の学位を取得しました。彼は、コマルカル デ インカ病院の配合エリアの病院薬剤師であり、最高のバイオソフト サービスである Salutic Developments のディレクターでもあります。

注: この研究の一部は、2016 年 6 月 16 日〜 17 日にイタリアのローマで開催された第 5 回国際栄養会議および展示会、第 5 回ヨーロッパ栄養学会議で発表されました。