Revista de trastornos nutricionales y terapia

Abstracto

Congreso de Nutrición 2016: Desarrollo de software integrado de apoyo a la nutrición clínica- Pedro Javier Siquier Homar- Hospital Comarcal de Inca

Pedro Javier Siquier Homar

Objetivos: 1. Avanzar en la demostración de un software informático incorporado de soporte nutricional específico, integrado en la historia clínica electrónica, que detecte de forma automática y precoz aquellos pacientes desnutridos o con riesgo de desnutrición emergente, definiendo puntos de oportunidad para la mejora y valoración de los resultados.

2. Describir las características de un nuevo programa informático para la prescripción electrónica asistida de nutrición parenteral y enteral. Definir las diferentes ayudas a la prescripción que intervienen en el proceso de soporte nutricional, con el objetivo de estandarizar el soporte nutricional e incorporarlo en los protocolos.

3. Definir los pases que puedan llevar a la historia clínica electrónica del Hospital Comarcal de Inca.

Métodos: Se tienen en cuenta los estándares de calidad publicados por el Grupo de Trabajo de Nutrición de la Sociedad Española de Farmacia Hospitalaria (SEFH) y por tanto las recomendaciones del Grupo de Farmacia de la Sociedad Española de Nutrición Parenteral y Enteral (SENPE). Según estos estándares de calidad, el soporte nutricional debe incluir las siguientes etapas o subprocesos asistenciales: cribado nutricional, valoración nutricional y plan de cuidados nutricionales, prescripción, preparación y administración.

Para el desarrollo del software informático se han tenido en cuenta las características que deben reunir todas las nuevas tecnologías aplicadas al uso de medicamentos, según las recomendaciones del Grupo de Evaluación de Nuevas Tecnologías (Grupo TECNO) de la Sociedad Española de Farmacia Hospitalaria (SEFH), así como los estándares de práctica clínica publicados por el Grupo de Trabajo de Nutrición de la SEFH. De acuerdo con dichos estándares de calidad, las etapas o procesos asistenciales que debe cubrir el sistema de soporte nutricional son: cribado nutricional, valoración nutricional, plan de cuidados nutricionales, prescripción, preparación, administración, seguimiento y fin del tratamiento. A continuación se describen las características de cada subproceso, así como las diferentes ayudas a la prescripción implantadas.

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 estandarizar el soporte nutricional especializado desde un punto de vista multidisciplinar, introduciendo el concepto de control interno por procesos e incluyendo al paciente como cliente principal. En cuanto a los registros, en el caso concreto del Hospital Comarcal de Inca, se utiliza el conjunto de estándares de intercambio electrónico de información HL7 versión 2.5, que se integra con la historia clínica del centro: constantes vitales (presión sistólica, presión diastólica, temperatura, frecuencia cardíaca, saturación parcial de oxígeno), unidad de pruebas clínicas (analítica sanguínea y pruebas bioquímicas) y admisión (hospitalización, traslado y alta hospitalaria).

Biografía

Pedro Javier Siquier Homar es Licenciado en Farmacia por la Universidad de Santiago de Compostela y Farmacéutico Hospitalario por el Complexo Hospitalario Universitario de Vigo. Es Farmacéutico Hospitalario del área de compuestos del Hospital Comarcal de Inca y Director de Desarrollos Salutic, un servicio de primer nivel de Bio-Soft.

Nota: Este trabajo se presenta parcialmente en la 5ª Conferencia y Exhibición Internacional sobre Nutrición, 5ª Conferencia Europea de Nutrición y Dietética, del 16 al 17 de junio de 2016, celebrada en Roma, Italia.