Clinical interdisciplinary development of a home-based enteral nutrition initiation and refeeding monitoring model of care for patients with chronic liver disease.

Abstract

Background and aims: Malnutrition and sarcopenia are prevalent in 20 to 70% of adults with chronic liver disease (CLD) and are independently associated with increased mortality. Enteral nutrition (EN) can promote muscle mass restoration and improve objective liver function markers including Child-Pugh score. Malnourished CLD patients, and those with alcohol abuse, are at risk of refeeding syndrome on commencing EN. Inpatient capacity for EN initiation and monitoring was reduced during the COVID-19 pandemic. We developed an interdisciplinary home-based model of care to safely commence EN and monitor for complications in CLD patients. Method(s): Monash Health is the second largest Australian tertiary healthcare network. Between February and June 2022, an interdisciplinary team of dietitians, gastroenterologists, general physicians, pharmacists, and nurses developed a home-based model of care. The protocol was derived from existing internal protocols and international guidelines for enteral feeding and refeeding management. Key elements include initiating, progressing, monitoring, escalation and ceasing enteral nutrition. Result(s): We created an organisation-wide framework for supportive and collaborative patient care between multiple hospital departments (Hepatology, Hospital in the Home [HITH] and Dietetics). Our protocol includes roles and responsibilities, escalation pathways, instructions for initiating enteral feeding, precautions for refeeding management and a checklist for HITH nurses. Training for monitoring of these patients was completed at regular intervals to optimise stakeholder engagement. Communication pathways were developed to streamline inter-disciplinary collaboration. Our measures of success for this model of care include preventing hospital admissions, adverse events (including severe electrolyte requiring IV replacement or tube displacement), patient tolerance, weight restoration and improvement in Child-Pugh score. Two CLD patients successfully completed the feeding program without requiring inpatient admission. There was one tube dislodgement and one IV electrolyte replacement, successfully managed as outpatients. Conclusion(s): We have developed and piloted a new model of care for home-based EN initiation program within a large tertiary healthcare network. This provided safe and effective EN therapy to a vulnerable group without requiring hospitalisation. The safety, efficacy, acceptability, and cost effectiveness of this model of care compared to traditional inpatient management will be evaluated as part of our feasibility study.Copyright © 2023 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.