Tantangan Upaya Penanggulangan Malnutrisi di RS

S Sunatrio
Perhimpunan Nutrisi Enteral Parenteral Indonesia (PERNEPARI)

TIM TERAPI GIZI (NST)

Di kebanyakan negara TTG dikembangkan oleh Perhimpunan Nasional Nutrisi Enteral Parenteral Di Indonesia jumlahnya masih dpt dihitung dgn jari Keberadaannya masih dalam tahap awal Perlu dukungan dari DEPKES

The wise men should consider that health is the greatest of human blessings. Let food be your medicine.

---Hippocrates

Hospital Malnutrition: Critical Evidence

The Skeleton in the Hospital Closet

Height not recorded in 56% of cases Body weight not recorded in 23% of cases 61% of those whose weight was recorded lost > 6 kg 37% had albumin < 3.0 g/dL
I am convinced that iatrogenic malnutrition has become a significant factor in determining disease outcomes in many patients.
Butterworth CE. Nutr Today 1974

Hospital Malnutrition: Prevalence

Numerous studies on hospital malnutrition have
been published. Prevalence of malnutrition in U.S. hospitals today ranges from 30% to 50%. Patients nutritional status declines with extended hospital stay.

Coats KG et al. J Am Diet Assoc 1993

Malnutrition Among Hospitalized Patients: A Problem of Physician Awareness

Up to 50% of hospitalized patients may be malnourished on admission Before nutritional assessment training: Only 12.5% of malnourished patients are identified After 4 hours of training: 100% of patients are identified

Roubenoff et al. Arch Intern Med 1987

Prevalence of Malnutrition in Hospitalized Patients

10% Severely Malnourished

69% Adequate Nutritional State

21% Moderately Malnourished

Detsky et al. JPEN 1987

Prevalence of Malnutrition in Hospitalized Patients

In a published British study: 46% of general medicine patients 45% of patients with respiratory problems 27% of surgical patients 43% of elderly patients Percentage of malnourished patients at time of admission
McWhirter et al. Br Med J 1994

Hospital Malnutrition in Brazil

Study of 4,000 patients in 25 hospitals to evaluate the prevalence of hospital malnutrition and awareness by health care providers.
Findings: 12.6% severe malnutrition 35.5% moderate malnutrition Prolonged length of stay directly linked to malnutrition Little awareness about the importance of nutritional status of hospitalized patients
Waitzberg et al. Nutrition 2001

Malnutrition in the hospital

Prevalence of malnutrition in hospitalized patients, SLMC, 2000-2004

Hospital Malnutrition
A problem of physician awareness
Cipto Mangunkusumo Hospital (government) Jakarta 1989: on adm: 45.9% Sumber Waras Hospital (private) Jakarta 1995: on adm: 42.26% Army Hospital (government) Jakarta 2001: on adm: 41.42%; need nutritional intervention: 78.57% Hasan Sadikin Hospital (government) Bandung 2006: on adm: 71.8%, severe: 28.9%

Hospital Malnutrition:
Currently A number of enteral & parenteral formula are available adequate NS could be given

Incidence of Hospital Malnutrition still high + Increased metabolic complication & infection
TNT 12

Problem Identification
The development of the medical D/ equipment large and heterogenic spectrum of diseases Knowledge did not develop equally; high walls lie between different disciplines : Physicians, - Lack of interest in nutritional therapy - Minimal information on clinical nutrition topics in the medical schools and residential training programs

The 11th PENSA

13

 The nutritional management of pts is increasingly gaining interest The gaining is slow, due to inadequacy of doctors knowledge about nutrition Nutrition content in the medical curriculum (under & post graduate) is not sufficient to allow the doctor to provide nutritional thx

Current status of awareness

Varies among specialists Highest : Digestive surgeon, Internal medicine specialist (Gastro-enterologist, Metabolic endocrinologist), Intensivist Lower: other specialists

Problem Identification
Nurses, - Lack of established programs on Nutritional Therapy - Belief of not being the nurses responsibility Registered dieticians, - Lack of knowledge to determine the best way to remedy deficiencies in diets, particularly special dietary needs - Minimal knowledge of the pathophysiology of diseases
The 11th PENSA 16

Solution
Nutritional therapy is based on pathophysiology of the disease & metabolism nutrient of organs Since World War II, experts became aware that management of NT needed more than a single Organ-disease-agent-basespecialist. It required involvement of physicians who had followed specific Nutritional Training & could work as part of a multi-disciplined team
Halsted (1997); Heimburger, (2000); Hark & Morrison (2000) 17

Solution
Heimburger (2000): To Improve the management of Foodservices Department in hospitals Activate the use of Nutritional Specialist Physicians in NST (Nutr.Sp.Ph., Dr, RD, Ns, Pharm. etc)

Do we need a nutrition support team?

Increased referrals and workload to clinical dietitians 1997-98 vs. 2000-03, SLMC

Do we need a nutrition support team?

* p < 0.05 y2001 < y2000A

Days of inadequate intake in stroke tube fed patients were decreasing from 43% to 20% while improvement in adequate intake increased from 57% to 80% (SLMC, 2000-2001)

Do we need a nutrition support team?

SUSUNAN PERSONEL TTG

TTG beranggotakan :
Dokter spesialis gizi klinik/dokter spesialis yg berkompetensi gizi klinik/dokter yg berkompetensi gizi klinik Dietisien Perawat Ahli Farmasi