PEG and home nutrition care

Recently, the concept of nutrition support team (NST) has been getting familiar in Japan. However, the activities of NST were confined to the patients staying in the hospital. The author has proposed a new concept of "NST for regional community". This NST is supposed to work in the hospital and in the community on the basis of the same nutritional care standard. The author has also built a "PEG system for regional community" as one of the activities of "NST for regional community". Since then, we have been providing the regional inhabitants with some options of PEG and nutrition care.     

Percutaneous endoscopic gastrostomy (PEG)--analysis in one hospital

Percutaneous endoscopic gastrostomy (PEG) has been investigated over the past 5 years at the author's hospital, together with the establishment of home PEG on a trial basis. PEG was performed in 176 cases from 1995 to 1999 with the goal of nutritional management, and in 26 cases with the goal of decompression drainage of the digestive tract. Patients who could be transferred to home management due to the establishment of the PEG included 92 (52%) with the goal of nutrition and 4 (15%) for decompression drainage. There is no remarkable difference in the effective treatment period between home and hospital management, and patients who could be transferred to their own homes were thus able to spend most of their remaining time at home; therefore, PEG contributes to home care. Complications associated with the establishment of PEG occurred in 17 (8.4%) patients, the majority of which were absesses at the site of insertion. Three patients who underwent PEG at home experienced no complications and could be transferred to parenteral nutrition via PEG. PEG is a useful method for nutritional management and digestive tract drainage, and contributes to home treatment and the improvement of patient quality of life. We would like to attempt further use of these methods including home PEG.     

The trial of the domiciliary nutrition support team in which a home medical care office offers

The function of home care support by a medical office is to offer the best medical care for the patient. It is essential that the medical office is capable of taking a call 24-hour a day and 365-day a year from a patient who needs help at home. Our medical office was specialized in home care treatment. Furthermore, we offer a home rehabilitation or a home nutrition education to the patient. On the other hand, a nutritional support is important as well as medical supports. To offer a high quality medical care at home, we created a nutrient support system in our hospital, and formed an at-home nutrition support team(at-home NST). The team is consisted of a medical staff and dietitian, a physical therapist and a speech therapist. As a result of the at-home NST, We improved the followings: (1) we were able to collect a nutritional data basis including a patient 's height and weight, (2) we made a good use of patient's eating habit at home during the medical treatment, and (3) we could make a good use of medical service to a home care patient by managing the information accumulated by nutritional surveillance. In multidisciplinary collaboration, at-home NST can grasp a versatility status of the patient positively. We continue to offer a medical care that is demanded from a home care patient because the activity of the at-home NST raises a quality of medical service we provide.     

Factors affecting the decision of cancer patients to be cared for at home or in hospital

Community health care and, more specifically, home health care are major developments over recent years. In many European countries there has been serious debate on the necessity of home care, the importance of this type of health care for the patient and family, and those factors influencing patient choice with regard to health care at home or in hospital.
This question of choice between home and hospital care forms the basis of this piece of research, the aim of which is to examine the biosocial factors that influence the decision of cancer patients in Greece to choose health care at home or in hospital.     

The follow-up study of patients with NST discharge summary for a continuous nutritional management

Thenutritionalmanagementofapatientdischargedfromaprimaryhospitalwillnotendjustthere.The nutritional management information issued by the primary hospital is required when a patient moves to a next institute.We,the Nutritional Support Team(NST), make a nutrition summary report in addition to letters written by the doctor and the ward in charge. We investigated a total of 64 patients three months after their discharge, and followed them for a year since April 2008. On some patients, the nutritional care had to be changed in accordance with the facility and the patients' primary disease status.In order for the nutrition management to be continued, a bidirectional communication exchange between the primary hospital and acute phase hospital is essential. In other words, a seamless nutritional management for patients has to be executed. When the disease condition of the patient has changed, the host institution must consult with us about the new nutritional care to the patient. On the other hand, we should keep in touch to reduce a communication distance in the region.     

Usefulness of percutaneous endoscopic gastrostomy (PEG) in home health care--investigation from the viewpoint of cost effectiveness

The use of percutaneous endoscopic gastrostomy (PEG) has widely spread in recent years, even in Japan. In our hospital, we have performed this procedure in over 20 patients per year recently. In this study, we investigated the usefulness of PEG in home health care from the view point of cost effectiveness. We found that medical expenses decreased remarkably when patients underwent PEG because they could switch from hospital care to home health care, shortening there by the period of hospital care. The role of PEG in home health care will be more important also from cost effectiveness.     

Adaptation of dental home care--report number 2: Attempt at a new system of dental home care

In the first report we revealed some problems in visiting dental treatment, and concluded that a new dental care system should be constructed for the solution of those problems. Therefore, we started a new system which included dental treatment under hospitalization in our dental hospital. For home patients this system aims at treating, managing smoothly and providing better dental treatment, due to the choice of hospitalization, outpatient care, or home visits in the medical process. In the period from March, 1993, when our dental hospital was established, until December, 1998 treatment was given 1,527 times with 420 patients under this system, and 127 of these patients chose dental treatment under hospitalization. Dental treatment under hospitalization is the management method not found in usual dental treatment, but it is indispensable to our system. When we decide hospitalization, we must make an overall estimate of the patient's general condition, contents of treatment, eating function and nutritional condition, background, and the wishes of the patient and family. In principle, visiting dental treatment is intended for a patient who has finished dental treatment. When treatment is necessary, it should be limited to simple treatment, first aid and maintenance. The oral care of many home patients under the present circumstances is not practiced sufficiently, and cooperation of medical and welfare workers is required to improve such conditions.     

An awareness survey of home parenteral nutrition (HPN) in a local medical society

Since we initiated home parenteral nutrition (HPN) in 1989 at our hospital, we have experienced a total of 96-patient cases. However, most of the patients were not accepted by the local medical society because of their own administration related problems. In the recent movement for the promotion of home medical care, a monthly joint study meeting between the NST and the local medical society was initiated in February 2003. Since HPN was a requested theme for this meeting, we carried out a questionnaire survey aimed at about 100 physicians, who belong to the Medical Society of Minoh City, to evaluate the awareness of HPN. The state of HPN practice was investigated, and questions, problems, and various opinions of HPN were assessed as well. Because of this survey, we could directly obtain opinions, questions, and problems of physicians who belong to the medical society in providing useful information to the future establishment of an HPN cooperation system. It appears that the future problems, that we can anticipate, are to understand actual differences between hospital medical care and home medical care, and to take measures to reduce the gap.     

Themes of nutrition-related cooperation pass candidates made by medical association

Hospitals in Shinagawa-ku and Ota-ku, the secondary medical sphere of Tokyo, have been working on various medical care tasks in order to provide a seamless transition from hospital to home medical care. In the area of nutritional medical therapy, the Shinagawa and Ota nutrition workshop was founded in 2006 to share the information, which contains thoroughly from a special nutrition therapy to a general therapy. In September 2007, a nutrition questionnaire survey was conducted for the members of Ebara-, Shinagawa-, Omori-, Kamata- and Denen-Chofu-medical association to make themes of nutrition related cooperation pass candidates. Then, we debated on the theme of priorities based on the result of the survey. In the scientific meeting held in May 2010, we examined the candidates, and decided to enrich the present diabetes passes and to a new establishment of PEG management.     

Rethinking the visiting nurse system at a major regional hospital

The authors' hospital is a National Health Insurance System Hospital near four cities. It serves as the central hospital for a region with a population of about 330,000 people. The hospital has 585 beds and sees an average of 1,500 outpatients each day. The average number of hospitalized patients each day is 500. Its visiting nurse department is located in a regional medical center and functions as a "Visiting Nurse Center". The purpose of the present study was to review the visiting nurse system at our hospital that has been operating for the past 8 years. The motivation for this review was our intention to actively increase the number of people advantage of such services, and attempt to provide continuous care for each individual patient. By looking back on the system as it has been practiced, its procedures, and results during the 8 years from 1990 to 1997, we can consider points for improvement from among the problem points discovered. The problems uncovered in our practice of home nursing care are listed below. 1. It is difficult to present a list with an estimated period for the release from the hospital. 2. Instructions for leaving the hospital are not sufficiently detailed. 3. Arranging the schedule and actual visits for diagnosis and treatment is complex. 4. The system for cooperation with the activities that are done in the hospital is insufficient. 5. The system for cooperation with local public health nurses is insufficient. 6. The system for managing equipment is insufficient. 7. The 24-hour support system for terminal patients is inadequate.     

Ways to make cooperation between hospital nurse and home visiting nurse in treating a final stage cancer patient at home

Due to a payment system based on Comprehensive Medical Evaluation has been adopted, both a shorter hospitalization and the use of home nursing care have been increasing. A good cooperation between hospital and home visiting nurses is desired in order to transfer continued nursing. Regarding a home nursing care service for the most terminal cancer patients, we conducted a survey of 459 home visiting nurses with twelve questions in five categories: (1) Before transferring to home care, (2) Right after the transfer to home care, (3) Patient in a stable period, (4) Time of near death and (5) Other (Requests to hospital nurses). The following issues became clearer in terms of how hospital and home visiting nurses should be cooperating with the handling of last stage terminal cancer patients: (1) A home visiting nurse should have a coordinating role with a hospital nurse when the patient is discharged from the hospital. (2) A participation of home visiting nurses on the coordination guidance at the time of a patient discharge is influenced by a manpower of the nursing station. (3) Even though home visiting nurses found a discrepancy between the hospital information and what patients and their families were getting from the hospital, home visiting nurses have learned through the job to clarify what patient and family needs were, and they responded accordingly. (4) A coordination between hospital and home visiting nurses was needed quite often when the patient's time has come to die at home.     

One successful end-of-life home care handled by three physicians

Aging population has been advancing in Ito city located in the northern part of Izu peninsula. Many elderly people are hoping to receive an end-of-life care at home, but there is no home care section in Ito municipal hospital, a flagship hospital in this region. One of the end-stage leukemia patients of our hospital hoped to die at home. We report a case that three physicians joined together to take care of this terminal patient with a cooperation from nurses, home-visit nursing care station and a care manager.     

Examination of local alliances in clinical path (home parenteral nutrition)

In revising compensation for medical treatment, shifts in home care systems such as management of lifestyle-related diseases, management of a patient within reach of a daily medical treatment, and an attempt to curtail hospitalization are suggested as concrete means of planning medical expenses to be appropriate. In doing this, it is getting more important that the medical institution pursue its purpose and must select the course of treatment and to solidify a medical cooperation among the institutions because a medical treatment is often not concluded at only one medical institution. Although a revision of compensation for medical treatment is getting more difficult due to three consecutive negative revisions in the past, a new clinical path for a local solidarity of femoral neck fracture has been found. Because of this revision, we think that it is necessary to make a system able to shift medical treatment and to care from hospital to facilities in the district and at home. We studied the clinical path in order to develop an effective and solidified cooperation with people of the district with regard to home parenteral nutrition, which is the most frequent medical treatment in case of a home care shift from that of our hospital's support for patients leaving the hospital.     

Roles of the hospital pharmacist and the cooperation between hospital pharmacy and insurance pharmacy in the introduction of home parenteral nutrition

In the introduction of home parenteral nutrition (HPN), roles of the pharmacist are important from the viewpoint of drug therapy. In our hospital, patients are to be shifted to home medical care under the adequate guidance and proper adjustment by the cooperation between the clinical pharmacists and home medical care pharmacists. We are also enhancing the cooperation with the pharmacists in insurance pharmacies. At present, however, there are few insurance pharmacies that can concoct the injection of medicine, resulting in our insufficient responses to the needs of the patients. It is necessary and quite important to increase the number of insurance pharmacies that are allowed to manage the patient's medication as well as the concoction of injecting medicine. The cooperation between hospital pharmacy and insurance pharmacy (Yaku-Yaku Renkei in Japanese) is indispensable in order to promote home medical care; especially "the sharing of information" is most required between the two pharmacy groups.     

Current status of our home care

We report a current status of our home care cases. Our home care has provided for 76 patients (46 men, 30 women) since July 1996. The average age was 73 (range 32-92) years old. The shortest period of home care was for 1 day, and the longest period of home care was achieved for 5 years and 5 months. 70 of the 76 patients suffered from malignant diseases. Of these patients, 53 patients were terminally ill cancer patients. 63 patients of the 76 had died, and over half of them (35 out of the 63 patients) had died at home. 14 of the 76 patients who were treated by other hospitals and clinics came to our hospital by means of referral, and we provided them our home care with the cooperation of these hospitals and clinics. No problems existed in our hospital with issues regarding discharge planning and nursing cooperation.     

Nutritional support for cancer bearing patients]

A care system for cancer bearing patients at a highly advanced stage should be informed by a better quality of life based on a life style of the patients and their families. These patients are suffering from various types of trouble including pain, loss of appetite and nausea, which preclude oral intake. Radiotherapy or chemotherapy can be another factor aggravating their nutritional state. In terms of nutritional management, intravenous or enteral alimentation is indispensable, but these conventional alimentary supports generally lead to prolonged hospitalization and re-admission. If parenteral nutritional care can be given to patients at home and not in the hospital, it is leading to the improved quality of life would result. We focus on the issue of home alimentary care, especially intravenous alimentation, for cancer patients at the terminal stage from the nursing standpoint.     

Promotion to home-based care from acute phase hospital - the problems and the role of community cooperation

It has been emphasized that problems with the system and a lack of resources for home-based care were ones to blame for preventing a promotion of home-based care. However, the real big problems appear to be laid on the unconsciousness and lack of knowledge of home-based care by acute phase hospital, functionality of community cooperation and lack of communication with patients. We examined the actual condition of home-based care by questionnaires to the doctors who took a palliative care study session. The response rate was 73.3%(93/127). It appeared that the doctors of acute phase hospital realized and expressed the necessity of home based care and their desire to participate. However, they are deficient in experiences and trainings. In the terminal care period, the patient and family thought that a medical treatment of intravenous drip and infusion was important, though the doctor would not regard such treatment was suitable to the patient. In reality, the patient gets what he wants. With regard to consulting of a future discharge plan, it is desirable to have it done as quickly as possible. However, there were many instances where the decision was made at the last moments: when the treatment was reached at the limit, and when to offer a support to leave the hospital. Therefore, we should strive for a fulfillment of home based care study, training and resources. Furthermore, functional community cooperation is essential for a promotion of home based care.     

The planned home care transfer by a local medical support hospital and the introduction to home intravenous hyper alimentation--the making of a home care patient's instruction plan document

It is important to offer continuous medical service without interrupting everyone's various job functions at the Tama Numbu-Chiiki Hospitals in order to secure the quality and safety of home medical care to patients and their families. From 1998 up to the present, home intravenous hyper alimentation (home IVH) has been introduced by individually exchanging information that was based on items such as clinical case, doctor and caregiver in charge of the day, and introductory information. Five years have passed since we started an introduction of home IVH, and it appears that the medical cooperation of home IVH between the Minami-tama medical region and its neighboring area has been established. Then, we arranged an examination of the past 2 years based on the 57 patients who elected to choose home IVH instruction. Consequently, we created "home IVH introduction plan document" in standardizing a flow from home IVH introduction to post-hospital intervention. Since November of 2003, the plan document has been utilized and carried out to 5 patients by the end of February in 2004. This home IVH introduction plan document was able to clarify the role of medical person in connection with the patient. Therefore, we could not only share the information, but also could transfer medical care smoothly from the hospital to the patient's home.     

Shift to home treatment and the function of pharmacies

A crisis point has been reached in the medical health system in Japan, where there has been a rapid aging of the population. The method of providing health system benefits is being reconsidered. As a result, medical treatment has been classified into inpatient, outpatient, and home care systems according to treatment functions. In concrete terms, the insurance system now classifies medical treatment and care separately, payment for medical fees has changed from payment at piece rates to a fixed amount system, and the number of days patients stay in hospital has been reduced. It is predicted that hospital treatment will increasingly rely on early discharge, and patients highly reliant on medical treatment will be shifted to home treatment. For this shift to home treatment, therefore, supplies of injectable agents such as used in total parenteral nutrition, and equipment by specialist pharmacies have become necessary. However, to dispense injectable agents, "standards of compounded sterile pharmaceuticals by licensed pharmacies" is applied, meaning there are very few pharmacies that can meet these standards. In the present survey, we found that 40 pharmacies have been recognized as meeting these standards.     

The management for safety on Home Parenteral Nutrition(HPN)

Nutrition support team(NST)continuously leads a safe and effective home nutritional management for a reliable operation. With regard to home parenteral nutrition(HPN), we provided some pamphlets on HPN for the patient and family and nurses. The utilization of the pamphlets was two folds: (1) a teaching instruction can be unified for the patient and family and nurses, (2) to eliminate the gap among nurses for instructional procedures.For the individual patient's nutritional status information, we made a nutrition summary for the sake of next institute.So we could follow-up the nutritional status of those discharged patients.It also serves a sort of regional communication system with each institution.Our design of nutrition summary and the problems identified with patients could be good feedback information for analysis.