营养失调与治疗杂志

抽象的

2016 年营养大会：临床营养综合支持软件的开发 - Pedro Javier Siquier Homar - Hospital Comarcal de Inca

佩德罗·哈维尔·西奎尔·霍马尔

目标： 1. 推进专用营养支持的计算机软件演示，将其集成到电子临床记录中，可以自动、早期地检测出营养不良的患者或有出现营养不良风险的患者，确定改进的机会点和评估结果。

2. 描述用于辅助肠外和肠内营养电子处方的新型计算机程序的特点。定义营养支持过程中涉及的不同处方辅助，目的是标准化营养支持并将其纳入方案。

3. 任何通行证均需通过印加总医院的电子临床记录进行确认。

方法：考虑西班牙医院药学协会 (SEFH) 营养工作组发布的标准以及西班牙肠外和肠内营养协会 (SENPE) 药学组的建议。根据这些质量标准，营养支持必须包括后续的医疗保健阶段或子过程：营养筛查、营养评估和营养护理计划、处方、准备和管理。

根据西班牙医院药学协会 (SEFH) 新技术评估小组 (TECNO Group) 的建议以及 SEFH 营养工作组发布的临床实践标准，在开发计算机软件时考虑了所有应用于药物使用的新技术应具备的特征。根据上述质量标准，营养支持系统必须涵盖的医疗阶段或流程包括：营养筛查、营养评估、营养护理计划、处方、准备、给药、监测和治疗结束。下面介绍了每个子流程的特征以及实施的不同处方辅助。

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.

该软件允许从多学科的角度标准化专业营养支持，引入每个流程的内部控制概念，并将患者作为主要客户。关于条目，在 Comarcal de Inca 医院的具体案例中，使用电子信息交换标准集 HL7 版本 2.5。这与中心的临床记录相结合：生命常数（收缩压、舒张压、体温、心率、部分氧饱和度）、临床测试单元（血液测试和生化测试）和入院（住院、转院和出院）。

传

Pedro Javier Siquier Homar 已完成圣地亚哥德孔波斯特拉大学的药学学位和维戈大学综合医院的医院药剂师研究。他是印加科马卡尔医院 (Hospital Comarcal de Inca) 复合领域的医院药剂师，也是一流的 Bio-Soft 服务 Salutic 开发部的总监。

注：该研究部分在 2016 年 6 月 16 日至 17 日于意大利罗马举行的第五届国际营养会议和展览会、第五届欧洲营养和饮食学会议上发表。