A novel discharge pathway for patients with advanced cancer requiring home parenteral nutrition

Abstract

Background The use of home parenteral nutrition (HPN) for palliative indications is increasing internationally and is the leading indication in some countries. Discharge on HPN can be complex in metabolically unstable patients and requires intestinal failure expertise. Methods Between 2012 and 2018, we performed a retrospective analysis aiming to assess the impact of a novel remote discharge pathway for palliative HPN patients. This was evaluated using a quality improvement approach. Results One hundred and twenty‐five patients with active malignancy [mean (range) age 58 (25–80) years] were referred to the intestinal failure unit (IFU) for remote discharge. Of 82 patients were discharged from the oncology Centre on HPN using the pathway. The remaining 43 patients either declined HPN or the Oncology team felt that the patient became too unwell for HPN or died prior to discharge. There was an increase in patients referred for remote discharge from 13 in 2012 to 43 in 2017. The mean number of days between receipt of referral by the IFU to discharge on HPN from the oncology centre reduced from 29.4 days to 10.1 days. Following remote discharge, the mean number of days on HPN was 215.9 days. Catheter‐related blood stream infection rates in this cohort were very low at 0.169 per 1000 catheter days. Conclusions This is the first study to demonstrate the remote safe, effective and rapid discharge of patients requiring palliative HPN between two hospital sites. This allows patients with a short prognosis more time in their desired location.

Considerations for the management of home parenteral nutrition during the SARS-CoV-2 pandemic: A position paper from the Home Artificial Nutrition and Chronic Intestinal Failure Special Interest Group of ESPEN

“…Thus, the remote discharge of new patients requiring establishment on HPN from non-IF centres may need to be considered during the SARS-CoV-2 pandemic, if inter-hospital transfer to an IF centre is not possible and/or deemed to place an excessive risk to the patient. The safety and efficacy of such an approach was recently demonstrated by a U.K. CIF centre [3]. If such an approach is adopted, it is vital that there are clear channels of communication between the IF and non-IF centre, with both centres agreeing that the patient is metabolically stable and suitable for HPN.…”

Catheter‐related infection rates in patients receiving customized home parenteral nutrition compared with multichamber bags

“…The CRBSI incidence rates observed in HPN patients in this study (0.21-0.51/1000 catheter days) are comparable to previous data from the same unit (0.31/1000 catheter days). 9 The cohort newly starting on MCBs included a high proportion of individuals with malignancy who have previously also been shown to have a low CRBSI rate despite the risk of immunosuppression related to underlying cancer and any oncological therapy. 9 A cancer diagnosis, as a cause for IF, was not found to significantly impact CRBSI incidence.…”

“…9 The cohort newly starting on MCBs included a high proportion of individuals with malignancy who have previously also been shown to have a low CRBSI rate despite the risk of immunosuppression related to underlying cancer and any oncological therapy. 9 A cancer diagnosis, as a cause for IF, was not found to significantly impact CRBSI incidence.…”

Cost-Effectiveness Analyses of Home Parenteral Nutrition for Incurable Gastrointestinal Cancer Patients

“…Despite the insufficient awareness and prompt treatment in daily clinical practice, some researchers believed that it is an expenditure of social resources with limited benefits ( 14 , 15 ). In addition, it could increase the risk of infection, family burden, and generate additional costs, including costs of drugs, injections, training, complications, and readministrations ( 16 ). A recent randomized clinical trial (RCT) (NCT02066363) demonstrated the efficacy of sHPN in patients with incurable gastrointestinal cancers, suggesting an improvement in muscle condition [fat-free mass (FFM), fat-free mass index (FFMI)] and quality of life.…”