New protocol helps 
      tell when patients are
      ready for oral feeding

New protocol helps tell when patients are ready for oral feeding

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SINGAPORE — Mechanical ventilators are a life-saving measure for critically ill patients who are unable to breathe on their own. But some studies have shown that once the breathing tubes are removed (a procedure called extubation in medical lingo), up to three in five intensive care unit (ICU) patients may experience difficulty swallowing, and may be unable to eat and drink normally. ICU patients tend to have a problem swallowing and generalised weakness due to their critical illness, and three days on the breathing tube is all it takes for swallowing difficulties and other complications like pneumonia to emerge, said Dr See Kay Choong, head and consultant at National University Hospital’s (NUH) Division of Respiratory and Critical Care Medicine. “Without proper care and rehabilitation, these functions may recover slowly or not at all. Patients would then tend to stay longer in hospital and cannot have a good quality of life,” he added. To address this issue, Dr See and his team at NUH developed a new protocol in 2014 to better assess when such patients might be ready for oral feeding. Previously, there were no formal guidelines on assessing swallowing difficulties in ICU patients post-extubation. With the new protocol in place, nurses trained by speech therapists administer a “swallow test” by feeding the patient a small volume of water and checking for signs of choking, said Dr See. This helps determine if patients are ready to start oral feeding, and the type of diet appropriate for them. Patients who pass the screening will then be put on an oral diet, which Dr See said provides a psychological boost. “Patients should be encouraged to resume oral feeding as soon as they are ready. Tube feeding is artificial, increases nursing and family care needs, as well as costs and length of hospital stay,” said Dr See. Those who show signs of choking will continue with tube feeding, and are referred to a speech therapist for further evaluation. The protocol is one of the topics that will be presented at the 4th SG-Anzics Intensive Care Forum this weekend, where local and international practitioners in intensive care medicine will share updated clinical knowledge and practices. The biennial conference is a collaboration between the Society of Intensive Care Medicine (Singapore) and the Australian and New Zealand Intensive Care Society (Anzics). In a study conducted by Dr See’s team which was published in the medical journal Critical Care last year, more than three-quarters (77 per cent) of patients surveyed resumed oral feeding upon discharge from the ICU — up from 61 per cent — since the screening protocol was introduced in NUH in 2014. About 400 ICU patients at NUH undergo the screening each year. The study also found that the group of patients who were on a breathing tube for at least three days, which put them at a higher risk of swallowing difficulties and pneumonia, had a shorter hospital stay from an average of 24 to 18 days. Pneumonia cases after the removal of the breathing tube halved from 16 to 8 per cent, which Dr See said could be due to patients leaving the hospital earlier. Madam Teo Poo Geok, who was admitted to NUH’s ICU after suffering a heart attack and breathing difficulties last month, was one of them. The 77-year-old housewife was initially fed through a tube but nurses assessed that she was ready to resume partial oral feeding on her third day in the ICU. “By the fifth day, I was happy to be able to eat and drink again,” said Mdm Teo, who is now on the mend. INCREASINGLY COMPLEX I.C.U. CASES There are approximately 10,000 ICU admissions in Singapore each year, of which three quarters of patients admitted are at least 60 years old, said Dr Jason Phua, deputy chairperson of National ICU Repository which studies critical illness trends and outcomes of ICU patients in Singapore. While medical advancements have helped to prolong lives, Singapore’s intensive care sector faces the challenge of tackling increasingly complex cases. Due to an ageing population, improved life expectancy and medical advances, a large proportion of these critically ill patients have pre-existing medical conditions such as diabetes, heart, and kidney disease, said Dr Alvin Ng, chairman of the organising committee of the 2017 SG-Anzics Intensive Care Forum. Diabetes rates, for instance, have risen from about 8 per cent of the adult population in 2004 to 11 per cent in 2010. Last year, Health Minister Gan Kim Yong said the disease could potentially affect one million Singaporeans by 2050, with the ministry declaring “war on diabetes” and setting up a national taskforce to address prevention, screening and management of the chronic disease. Diabetics face complications including stroke, heart, and kidney disease. “When superimposed with a critical illness such as severe sepsis, these patients will require ICU specialists to carefully select the right medical resources to tackle the multitude of interacting life-threatening medical conditions,” said Dr Ng. ENGAGING FAMILIES IN CRITICAL CARE Moving forward, there is also a need for critical care teams to educate and involve the family in patient care, he added. Family members are usually the ones whom the ICU team approaches to make decisions on behalf of critically ill patients who are unable to participate in treatment decisions, said Dr Ng. Before they can do so, families will need more information to have a better understanding of the situation. “Time constraints and limited availability of key ICU team members often limit the frequency of information exchanges. At present, family members of critically ill patients are often not invited to be present at bedside rounds. While research regarding family presence at bedside rounds is scant, preliminary studies suggest that family members support this initiative when given an option,” said Dr Ng. Researchers have also noted that participating in bedside rounds allow them to obtain valuable information, and it may impact patient outcomes, he added. Current available resources for families include, a family support website which provides information and resources on critical illness, related procedures and post-ICU care.
19 Apr 2017 - General
I am interested about the swallowing screening guidelines being developed in Singapore. As what I can observed in our practice here in the Philippines, patients from ICU and post extubated patients usually are being transfered in the ward with nasogastric tube and osteurized feeding is given. Few days after, we start giving liquid, gelatin to see if they can tolerate without any aspiration. If so, they can progress to soft diet until such time full diet is being given and eventually the NGT is r...
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