Download Morbidity Definition Feeding - Summer 2014. U problems feeding

Morbidity Definition Feeding - Summer 2014.
U
problems feeding (graded)
Liz/Kate
Relatively easy:problem of finding short-term proxy for burden on
family -ie presence rather than occurrence. Ongoing measure of simple feeding
tracheostomy,
weight gain?)
-----------------------------------------------------------------------------------------------------------1. Morbidity name:
Feeding problems ( graded )
-----------------------------------------------------------------------------------------------------------2. Natural timescale for identifying morbidity (e.g. within 7 days of operation, before
discharge from hospital, within 1 month of operation etc):
Select certain points in carepathway. As the study is over a month there would need
to be set points of recording eg
Timing ( of feeding mode pre surgery – oral, NG, PEG, IV )
 48 hrs post opratively
 Feeding mode at 7 days post operatively,
 Feeding mode at discharge
 Feeding at 1 month - cardiology follow maybe
Scoring system would need to be looked at, difficult to valid a tool within such a short
time frame. Feeding is often a long term issue so a month would not give the whole
picture. It is also affected by other events eg NEC, absorption issues, staged surgery
Could just score yes / no for mode of feeding eg grade feeding
1 oral
2 oral fortified milk
3 oral and tube fed
4 tube fed only
5 gastrostomy
6 parental IV
Maybe plus or minus fortification of feed.
Then look at change across the care pathway tied into weight gain / loss. Weight is
known to be a positive predictor or surgical outcome, as well a predictor of timing of
staged surgery in the univentricular group.
Weight gain + ve , loss is a negative plot.
Weight gain/ loss at specific points of care pathway eg
Discharge CICU
Discharge home
1 month post discharge
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Last updated: 04 May. 17
by: Liz Smith
The history of this event if often longer than a month when medications diuretics are
changed and post operative recovery is moving along a pathway out of hospital.
Any delay in discharge with a feeding or growth cause ? Could be looked at as an
additional morbidity related to longer hospital stay either at the tertiary centre of the
district hospital.
Progressive positive weight gain and feeding are frequent delayers of discharge
home. Local services sometimes used as an interim step of care and montoring prior
to going home.
-----------------------------------------------------------------------------------------------------------3a. Do suitable standard, accepted, definitions exist that can be used?
Some standards do exist, but no agreement for cardiology paediatrics. Large work
project done on infants with hypoplastic left heart syndrome by Slicker et al 2012. All
children should have a plot of a WHO child growth chart, and babies will have this
recoreded in their red books or local documentation.
International guidance on monitoring growth standards, WHO Child Growth
Standards and the identification of severe malnutrition in infants and children
http://www.who.int/nutrition/publications/severemalnutrition/9789241598163_eng.pdf
The WHO child growth standards , methods, development and indicators
http://www.who.int/childgrowth/standards/en/
Nutritional guidelines for under 5 years
http://www.thpc.scot.nhs.uk/wordfiles/under5s.pdf
Nutrition Algorithms for Infants with Hypoplastic Left Heart Syndrome; Birth through the
First Interstage Period, by Slicker et al 2012 The Feeding Work Group of the National
Pediatric Cardiology Quality Improvement Collaborative
https://jcchdqi.org/webfm_send/70
Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care
2014, pp 3201-3212 Date: 18 Sep 2013 Nutrition in Congenital Heart Disease: Challenges,
Guidelines and Nutritional Support. Piyagarnt E. Vichayavilas, Heather E. Skillman, Nancy
F. Krebs
http://link.springer.com/referenceworkentry/10.1007%2F978-1-4471-4619-3_164#
Home monitoring programs for first stage Norwood babies – international data on
reduced mortality once discharged home. Weight and feeding significant effect on
timing of surgery and mortality between surgical stages, but these are a specialist
group. Wide published data sets.
http://www.ncbi.nlm.nih.gov/pubmed/22152530 Feeding Growth, Nutrition, and
optimal interstage surveillance for infants with Hypoplastic left heart syndrome: Hier
DA , Cooper DS, Walters, EM, Ghanayem NS : Cardiol Young. 2011 Dec;21 Suppl 2:5964. doi: 10.1017/S1047951111001600.
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-----------------------------------------------------------------------------------------------------------3b. If no (or partially no) to part 3a – can you outline a general strategy for how this
morbidity would be identified/diagnosed/monitored? (detailed definitions are not needed
until final 10 morbidities have been chosen, but it is helpful to have some thoughts on this).
Feeding and weight gain ties closely with other surgical morbidities for those babies and
children with other associated complications from surgical repairs or interventions.
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Complications of Gastrointestinal origin eg NEC( higher morbidity )
Chylothorax effects on feeding
Aspiration events
Oral feeding established
Reflux medications needed
Reason for NG feeding, unsafe swallow, laryngeal cord palsy, work of
breathing, calorie intake with reduced energy expenditure
Need for other feeding support strategy eg gastrostomy, parenteral nutrition,
NJ tube
Need for prolonged hospital stay for nutritional support in a hospital setting ( ?
time frame pass EDD for planned cardiac surgery ).
Weight less than 2.5 kg ( higher morbidity ), need to monitor
Specialist cardiac groups eg single ventricles, shunt physiology
-----------------------------------------------------------------------------------------------------------3c. Do the definitions encompass morbidities directly attributable to surgery or to
presence post-surgery (regardless of cause) (During panel meeting, we discussed
potentially having definitions for both “attributable” morbidity & “present” morbidity, or
choosing one or the other).
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Special groups monitored on discharge:
Babies < 2.5 kg ( per surgical present pre surgery )
Babies with single ventricle or shunt type phsyiology ( effect of surgical timing,
complexity, supporting early circulatory effects from poor feeding &
undercurrent illness )
Babies with other morbidities eg long CICU stay
Incidence of laryngeal cord palsy is 5 % in shunt group ( ref )
-----------------------------------------------------------------------------------------------------------4. How feasible is it to monitor this morbidity for EVERY cardiac paediatric patient
(morbidities to be identified within 4-6 weeks following surgery for THIS project)? (e.g.
what are the resource/staffing implications? Is there any subjectivity involved? Are
timescales suitable?)
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Possible to monitor every patient, current practice will vary between hospitals.
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Follow up questions can be asked of family and local support services by
phone at stages defined, or at current follow up cardiology care.
Pathways or SCAMPS would assist prompt of detection and raising concerns
If feeding concerns or support needed local teams involved, Health visitor,
Community paediatric nurse, local team
Groups already defined as high risk eg low weight, long ITU stay, single
ventricle or shunt physiology often have a support package, not standardized
cross servcies
Increased resource implications
Objectivity would need an agreed scoring system or yes or no data collection.
Time scales could be flexible or fit in with predefined monitoring strategies
-----------------------------------------------------------------------------------------------------------5. Any comments on whether this morbidity is a possible consequence of another
morbidity that we are also considering? (e.g. Developmental delay – neurological injury –
these considerations may help the selection panel in its final selection)
Could be a consequence of other morbidity, Gastrointestinal issues eg NEC,
neurological injury, developmental delay, chylothorax, laryngeal palsy, long ITU stay,
See point 3 b.
-----------------------------------------------------------------------------------------------------------6. Any other comments for the selection panel?
Feeding an ongoing concern for families, often used in staged surgery to move to
next surgical intervention or timing of surgery in a baby your child. Weight loss can
demonstrate need to surgical intervention.
Weight monitoring often requested of local services and loss used as an early
warning alert to the tertiary hospital team
Feeding support not equal across the country, no standard practice, no agreed
practice
Involves many different team, eg SALT, Dietician, Health visitor, CCNT, Paediatrician,
GP, Cardiac nurse specialists, local services
Affected by psychosocial events within the individual family.
Families often need local support as well as specialist support from hospital teams.
Difficult to measure level of support, could ensure accessibility to dietician and
paediatrician locally and cardiac nurse specialist for advice and support. Could
monitor referral to local service, but these are variable in access across the UK eg
local dietician,
Most tertiary centres have their own guidelines standards, no consensus on
guidelines outlining best practice for nutritional monitoring or intervention.
Level of evidence often subjective and based on local practice / evidence
Cardiac Nurse Specialists have a critical support and care role in supporting families
with feeding and growth concerns, plans of care and working with local teams.
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Last updated: 04 May. 17
by: Liz Smith