Frequently asked questions about Nutrition in the Nursing Home Setting
1. Isn’t TPN difficult to do?
If you can manage a PICC line, then you can do parenteral nutrition. The nutrition program at Trios will make it easy for the nursing home or home care company to be able to do with confidence and success.
2. I thought TPN was only done in the hospital like ICU setting?
Well, it certainly is done in those settings. What the nutrition program at Trios involves what should be called PPN. It is really peripheral parenteral IV nutrition. There is no need for a central line. As mentioned above, the nutrition formula will be given through a peripheral IV line like a PICC line, which more homes are used to doing and managing on a regular basis.
3. We have limited nursing staff and RN coverage. How can we do this PPN on top of the other duties?
The formulas and IV bags can be customized to your needs. We can make it such that the IV nutrition is provided to you so that it is changed when RN coverage is available. This means anything from 1, 2 or 3 liter bags, which means changing it from every shift to only once a day. The nutrition program at Trios will custom design a schedule to meet your nursing needs.
4. What if we know nothing about IV nutrition? Is there education available?
Trios has been always committed to education of nursing homes on nutrition and lining up assistance with wound care products and protocols. We will make sure you and your staff understand the basics of IV nutrition, how to identify those at risk for malnutrition and malabsorption, but mainly on how to handle the IV nutrition on a daily basis.
5. Why do we even need to worry about IV nutrition? We give oral supplements?
Unfortunately, with sicker, more complex and complicated patients, oral supplements or even tube feedings are not enough. A recent study done looked at tube fed nursing home patients with pressure ulcers [PubMed Index 3084610]. It showed that despite increased calorie and protein intake, patient with pressure ulcers still showed evidence of weight loss, low albumin levels, and anemia. So just giving oral supplements may not be enough.
6. How come giving patients oral supplements or tube feeding is not enough to heal wounds?
Remember that many of the patients we now see coming into the nursing home are sicker, complex and may have had a prolonged period of not eating or using their gut. If the gut is not used, then it loses its ability to absorb nutrients. That is why so many people coming out of the hospital have diarrhea. Their gut simply cannot process and absorb all the nutrients you are trying to give them. In addition, we forget all of the other sources of volume and protein loss that we never calculate into a person’s nutritional needs. High levels of protein can be lost due to a large open wound. High fluid loss can occur with profuse sweating, diarrhea, as well as those heavily draining wounds.
7. So does everyone need IV nutrition?
No, only those residents who are screened and identified as having malnutrition and/or malabsorption will qualify for IV Nutrition. Otherwise, other supplemental nutrients beside protein like zinc, Vit C and other micronutrients may be recommended in oral form.
8. So who needs IV nutrition?
Medicare will cover IV nutrition under specific diagnoses and conditions. They include:
9. What are the screening tests for malnutrition and malabsorption?
Besides the history of weight loss and the other conditions mentioned above, there are some simple lab test that can be done to further evaluate and diagnose malnutrition and malabsorption.
10. If someone does meet criteria, doesn’t this now require a physician order? What if the physician does not understand or want to do the orders?
Yes, IV nutrition will require a physician order. We understand that many physicians may be hesitant to consider IV nutrition since it means following lab work and figuring out formulas and so forth. The nutrition program at Trios has made this process as seamless as possible for the physicians. All of the information gathered is analyzed by board certified nutritional pharmacist and nurse in nutrition so all formulas and follow up modifications will be presented to physicians for review and signature. Thus, all the guesswork has been done already. Physicians simply need to review and sign off on the orders. A protocol is already established to determine what labs need to be drawn and when. This data will again be analyzed and nutrition formulas adjusted, if needed, according to the new data.
If you have any other questions, please contact Trios Parenteral Nutrition 888-778-3450 or email at angie@triospn.com or baxter@triospn.com.
We look forward to working with you with our nutrition program designed to help you achieve even better outcomes.
1. Isn’t TPN difficult to do?
If you can manage a PICC line, then you can do parenteral nutrition. The nutrition program at Trios will make it easy for the nursing home or home care company to be able to do with confidence and success.
2. I thought TPN was only done in the hospital like ICU setting?
Well, it certainly is done in those settings. What the nutrition program at Trios involves what should be called PPN. It is really peripheral parenteral IV nutrition. There is no need for a central line. As mentioned above, the nutrition formula will be given through a peripheral IV line like a PICC line, which more homes are used to doing and managing on a regular basis.
3. We have limited nursing staff and RN coverage. How can we do this PPN on top of the other duties?
The formulas and IV bags can be customized to your needs. We can make it such that the IV nutrition is provided to you so that it is changed when RN coverage is available. This means anything from 1, 2 or 3 liter bags, which means changing it from every shift to only once a day. The nutrition program at Trios will custom design a schedule to meet your nursing needs.
4. What if we know nothing about IV nutrition? Is there education available?
Trios has been always committed to education of nursing homes on nutrition and lining up assistance with wound care products and protocols. We will make sure you and your staff understand the basics of IV nutrition, how to identify those at risk for malnutrition and malabsorption, but mainly on how to handle the IV nutrition on a daily basis.
5. Why do we even need to worry about IV nutrition? We give oral supplements?
Unfortunately, with sicker, more complex and complicated patients, oral supplements or even tube feedings are not enough. A recent study done looked at tube fed nursing home patients with pressure ulcers [PubMed Index 3084610]. It showed that despite increased calorie and protein intake, patient with pressure ulcers still showed evidence of weight loss, low albumin levels, and anemia. So just giving oral supplements may not be enough.
6. How come giving patients oral supplements or tube feeding is not enough to heal wounds?
Remember that many of the patients we now see coming into the nursing home are sicker, complex and may have had a prolonged period of not eating or using their gut. If the gut is not used, then it loses its ability to absorb nutrients. That is why so many people coming out of the hospital have diarrhea. Their gut simply cannot process and absorb all the nutrients you are trying to give them. In addition, we forget all of the other sources of volume and protein loss that we never calculate into a person’s nutritional needs. High levels of protein can be lost due to a large open wound. High fluid loss can occur with profuse sweating, diarrhea, as well as those heavily draining wounds.
7. So does everyone need IV nutrition?
No, only those residents who are screened and identified as having malnutrition and/or malabsorption will qualify for IV Nutrition. Otherwise, other supplemental nutrients beside protein like zinc, Vit C and other micronutrients may be recommended in oral form.
8. So who needs IV nutrition?
Medicare will cover IV nutrition under specific diagnoses and conditions. They include:
- Malnutrition and weight loss – Someone has lost 5% of their usual body weight in 30 days or 10% weight loss in 180 days.
- Malabsorption – As we discussed, many patients coming from the hospital are still catabolic, which means they are using protein for energy and thus they have lost protein and gut function and cannot absorb nutrients. This leads to malabsorption and weight loss, despite giving oral supplements or even tube feeds.
- Non-healing wounds – Despite everything that is being done to heal a wound, if there are signs of improvement in 4 weeks time and other factors like pressure relief, infection, compliance have been addresses, then a nutritional work up should be done.
- Other conditions – for patients who are renal dialysis, hx of cancer or receiving cancer treatments, or inability to eat for whatever reason should be screened for malnutrition and/or malabsorption.
9. What are the screening tests for malnutrition and malabsorption?
Besides the history of weight loss and the other conditions mentioned above, there are some simple lab test that can be done to further evaluate and diagnose malnutrition and malabsorption.
- CMP – Getting a complete metabolic panel will give enough base line values to help determine the overall condition of the person. Serum albumin is a snapshot of the nutritional state over the past month or so and is a good screening test for malnutrition.
- CBC w Diff – Getting the differential is also important since calculating a total lymphocyte count has been correlated with malnutrition.
- Fecal Fat test – This is still the test approved by Medicare as a diagnostic tool to determine malabsorption. It does take tome, but is not hard to do and your nursing staff will be shown how to do this collection.
10. If someone does meet criteria, doesn’t this now require a physician order? What if the physician does not understand or want to do the orders?
Yes, IV nutrition will require a physician order. We understand that many physicians may be hesitant to consider IV nutrition since it means following lab work and figuring out formulas and so forth. The nutrition program at Trios has made this process as seamless as possible for the physicians. All of the information gathered is analyzed by board certified nutritional pharmacist and nurse in nutrition so all formulas and follow up modifications will be presented to physicians for review and signature. Thus, all the guesswork has been done already. Physicians simply need to review and sign off on the orders. A protocol is already established to determine what labs need to be drawn and when. This data will again be analyzed and nutrition formulas adjusted, if needed, according to the new data.
If you have any other questions, please contact Trios Parenteral Nutrition 888-778-3450 or email at angie@triospn.com or baxter@triospn.com.
We look forward to working with you with our nutrition program designed to help you achieve even better outcomes.
