Activities

Welcome to the IAPEN - Workshop on Enteral Nutrition, 23-25 August, 2013, M.S. Ramaiah Insitute of Technology, Bangalore, India

Background

Early administration of enteral nutrition (EN) maintains gastrointestinal integrity and functioning, thus minimizing the translocation of organisms. These accrued benefits translate into a reduced complication rate, reduced length of the ICU stay, and decreased risk of death.

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However series of studies have shown that in many ICUs, EN is not started in all eligible patients and there is delay in administration

Feedings started within the time frame of 24-72 hours, compared with feedings started later (after 72 h), are associated with less gut permeability, diminished activation and release of inflammatory cytokines, that is, tumor necrosis factor, and reduced systemic endotoxemia.

Awareness of the nutritional requirements of inpatients has been sadly neglected for many years. Students in colleges are taught little about clinical nutrition and the role of the dietitian.

Recent changes and developments in nutritional support have offered an exciting and interesting challenge to dietitians, who with their well established background in nutrition, can play an important part in the nutritional care team.

Role of dietitians in enteral feeding

Dietitians need to bring evidence-based decision-making to their practice and adhere to established standards of practice or evidence based guidelines.

  1. Identification of patients requiring nutritional support
  2. Patient monitoring
  3. Reviewing products, systems and products literature
  4. Education
  5. Standardization of feeding systems and hospital procedures
  6. Research and development

Multidisciplinary team approach

Multidisciplinary, in the context of health care, means that health care providers from different professions work together to collaboratively provide diagnoses, assessments and treatment within their scope of practice areas of competence.

Recently there has been a noticeable impetus to establish formal nutrition teams. The nursing staffs are in the best position for observing a patient’s nutritional intake and good communication between the nurse and dietitian is vital.

 Aims and Objectives

The workshop was designed for medical, nursing & nutrition professionals who were interested enteral nutrition, how enteral nutrition affects patients recovery at hospitals, to understand the basics principles in enteral nutrition & important of comprehensive care/team approach in preventing iatrogenic malnutrition in hospitalized critically ill patients. The workshop was attended by dietitians, nurses, doctors working in various hospitals in and around Bangalore.

The aim of this module based workshop is to train professionals for the safe provision of enteral nutrition support to all adult patients receiving enteral tube feedings. Participants were encouraged to develop and improve the standard of enteral nutrition therapy given to adult patients.

A training module was developed with the aim of examining the available literature related to the ordering, preparation, delivery, and monitoring of enteral nutrition and establishing evidence-based practice guidelines for the safe and effective use of enteral nutrition. The following information gives a description of the training module on Basics of enteral nutrition and presents a detailed evaluation by participants.

The training module contains the following main sessions:

Session 1: Introduction to enteral nutrition – Overview, indications

Session 2: Assessment of Nutritional Status

Session 3: Feeeding Route selection

Session 4: Enteral nutrition needs calculation and formula selection

Session 5: Administration of Enteral feedings and monitoring

Session 6: Nutrient drug interactions in enteral nutrition

Each session comprises interactive opportunities and group work including:

  • assessment of the pre-existing knowledge and motivation of health professionals dealing with enterally fed patients
  • methods to assess the nutritional quality of enteral nutrition provided
  • designing feeding plans on enteral nutrition provision and monitoring
  • group work on four specific case studies
  • a skill test at the end of the final session

Objectives of the training module

By the end of the training module the participants will be able to

  1. Understand the indications and contraindications for enteral nutrition,
  2. Write nutritional diagnosis & calculate nutritional needs of the patient,
  3. Identify the most appropriate administration route depending on the clinical condition of a patient,
  4. Select the appropriate type/s of enteral formula for a particular patient’s needs & initiate EN feeding & transition to oral diets.
  5. Understand the complications with enteral feeding, and to prevent and manage them.

 Participants and speakers

The workshop on enteral nutrition was attended by 14 participants: 1 paediatrician, 5 nurses and 8 dietitians from Bangalore. The module topic on overview of enteral nutrition was presented by Dr.Asna Urooj, Professor, Department of Food Science and Nutrition, University of Mysore. The topics of nutritional assessment, calculation of enteral nutrition needs, nutrient drug interactions in enteral nutrition were presented by spakers cum facilitators from Bangalore chapter of IAPEN Mrs.Shobhaa.H. and S.Chandan Vinay. The topic on enteral feeding route selection was presented by Dr. Sreekar.A.Pai, from Department of Surgery, M.S.Ramaiah Teaching Hospital and the lecture on method of feeding was presented by Ms.Lissy John, Nursing superintendent from M.S.Ramaiah Teaching Hospital, Bangalore.

Workshop Overview

The Workshop was scheduled over three days and consisted of information sessions and group discussion time. Each day commenced at around 9.00 and finished around 17.00.

The topics at the workshop were chosen to ensure that health care workers gained an appreciation of the role that enteral nutrition plays an important role in restoring health and preventing complications in critically ill patients.

On arrival and in the course of the Workshop, each participant was provided with a module on enteral nutrition in English. Participants were also given pens, note pads and papers to present the results of case studies and to prepare a nutrition care plan.

Overall, the facilities were good with clean rooms and spacious surroundings. The necessary equipment (laptop, overhead projector with the screen) were available and worked well.

Training approach

This workshop was designed so that it provides a lot of opportunities for interaction and discussion. Participants were encouraged to think through and discuss with colleagues an array of specific problems and tasks they may encounter in their professional work.

Especially useful was the group discussion and demonstration on variations in prescribing dosage of various enteral nutrition products and evaluating the consistencies of the final enteral feed prepared. The participants acquired the basic skills of evaluating the enteral nutrition need quickly and eagerly. After the exercise, many of them were quite surprised how quickly this evaluation, crucial to formulating advice for their patients, can be carried out.

The group work on case studies was also very productive. First, participants were given case studies to work on individually, and then a consensus was drawn from the individual evaluations during group discussions. The participants expressed two important issues concerning this activity. First, work on the case studies allowed them to reiterate and further develop skills on planning enteral nutrition support. Secondly, it was important that the case studies were based on real patient scenarios common in the intensive care units and thus were relevant to their practical experience-building process.

Finally, it should be mentioned that such a “learning” approach as opposed to “teaching”, was a novel experience for most of the participants. They were used to a more authoritarian style of teaching where free discussions and question asking was not more evident. Everyone, however, seemed to enjoy this learning approach.

Recommendations

Several useful lessons were learned from this workshop which can and should be applied when planning and organizing similar workshops in the future. Also, the training module itself will be further revised and implemented to make it easier to understand and also based on the feedback received.

Target Audience

This workshop’s experience confirmed the earlier recommendation that equal number of doctors, nurses and dietitians should be invited to participate. During this Workshop, participants themselves several times pointed out the importance of having professionals from different fields working together on priority problems in special nutrition support planning and provision. Clearly, the key strength of this approach is that it brings together groups of professionals that would normally not have the opportunity to meet together and discuss issues in provision of optimal enteral nutrition support.

Venue

The seminar hall in the basement of M.S.Ramaiah Memorial Hospital, Bangalore was a suitable venue for the workshop with all necessary audio visual aids available.

Preparation of module materials

This module gives a brief yet comprehensive overview of the indications / contra indications for enteral nutrition and includes various National /International guidelines and recommendations. The participation of non dietetic professionals in this workshop was awaited thus basic data on calculation of enteral nutrition needs, various formulae required for anthropometry, recommendations on specific nutrients were also included in the workshop module.

Future health professionals

Taking into account the present situation in the health sector, there is clearly a need to find a way to disseminate updated nutrition information more widely among health care professionals. There is still a complete lack of understanding of modern scientific nutritional knowledge and most health professionals still follow the out-dated information. The Workshop on Basics of Enteral Nutrition is currently unique in the sense that this type of training is not provided by any other institution specific for enteral nutrition practice.

The long term aim should be to encourage national institutions to continue nutrition education and to develop a network of trained lecturers and facilitators able to disseminate the knowledge among health professionals in various hospital settings and among health professionals involved in patient care. This would also facilitate the process of development and implementation of national and regional nutrition policies.

Detailed Programme Schedule

23/08/2013 : Introduction to Enteral Nutrition and Nutition assessment

9:00 am – 10:00 am: Registration
10:00 am – 10:45 am: Inauguration of the workshop
10:45 am – 11:00 am: Tea Break
11:00 am – 12:30 pm: Enteral Nutrition Overview
12:30 pm- 1:30 pm: Lunch Break
1:30 pm – 3:30 pm: Nutrition Assessment
3:30 pm – 4:30 pm: Skill Test

24/08/2013 : Feeding Routes, Formula Selection and Enteral Nutrition Calculations

9:00 am – 10:45 am: Feeding routes selection
10:45 am – 11:00 am: Tea Break
11:00 am – 1:00 pm: Enteral nutrition needs and calculations
1:00 pm – 2:00 pm: Lunch Break
2:00 pm – 3:30 pm: Formula Selection
3:30 pm – 4:30 pm: Skill Test

25/08/2013 : Administration of feeding, monitoring and reassesment and Case studies
9:00 am – 10:00 am: Administration of feedings and monitoring
10:00 am – 10:15 am: Tea Break
10:15 am – 1:00 pm: Reassessment, Drug Nutrient interaction in enteral feeding
1:00 pm – 2:00 pm: Lunch Break
2:00 pm – 4:30 pm: Skill test and two case studies
4:30 pm- 5:00 pm: Results, certificate issuing and valedictory function

Guest Speakers

Dr.Asna Urooj
Professor, Department of studies in Food Science and Nutrition
University of Mysore, Mysore

Ms.Lissy John
Nursing Superintendent
M. S. Ramaiah Medical college, Bangalore

Mrs.Manjula.H.
Clinical Dietitian, Department of Clinical Nutrition
M.S.Ramaiah Medical College, Bangalore 

Dr. Sreekar Pai
Associate Professor in general surgery
Department of General Surgery
M.S.Ramaiah College and Hospitals, Bangalore, India.

S. Chandan Vinay
Dietitian, HOSMAT Hospital
Bangalore

Facilitators

    
1. Mrs. Shobha

Honarary Executive Director
IAPEN, Bangalore

 2. S.Chandan Vinay
Dietitian, Regional Officer,        
IAPEN, Bangalore