S3-Guideline of the German Society for Nutritional Medicine (DGEM) in Cooperation with the GESKES and the AKE Nutritional Support in the Homecare and Outpatient Sector

Purpose: Nutritional support in the homecare and outpatient sector comprises home parenteral nutrition (HPN) and home enteral nutrition (HEN) as well as oral nutritional supplements (ONS), being administered in the patient's home or in nursing homes. In most cases the HPN/HEN starts following an in-patient treatment in hospital. The present guideline offers evidence-based recommendations for nutritional support in the outpatient or homecare sector. Methods: A systematic literature search about HEN, HPN, and ONS in the homecare sector was conducted. The results were discussed in an interdisciplinary working group that consisted of physicians, pharmacists, nutrition scientists and dietitians. Based on this discussion and the literature, the working group developed recommendations, which were presented, discussed, partly modified and finally passed at the consensus conference on December 1st, 2012. Results: The guideline includes 54 recommendations for nutritional support in the outpatient sector. The indication for nutritional support in the outpatient sector does not differ basically from the indication for the in-patient treatment. Criteria like prognosis, quality of life and ethical considerations play a more important role in the outpatient sector. The appropriate way of administration nutritional support in the homecare setting depends on the functional integrity of the gastrointestinal tract. In case of a long-term HEE a percutaneous endoscopic gastrostomy (PEG) tube should be preferred towards surgical gastrostomy procedures, because of lower complication rates. In case of relevant disorders of transport and absorptive capacity of the small intestine intravenous nutrition should be chosen. The nursing care of the tubes and catheters for HEN and HPN should be carried out by professional care attendants according to evidence-based guidlines and nursing standards in order to achieve a high hygiene quality. For the exclusive and long-term HEN via gastrointestinal tube and for nutritional support by ONS nutritionally complete formula ("balanced diets") should be used because they meet the D-ACH recommendations and EU guidelines. For HPE, all-in-one bags/three-chamber-bags should be used because these are considered as safe, effective and risk-reducing standards for HPN. Conclusion: HEN and HPN are accepted as safe procedures, if they are performed following standardized routines according to up-to-date scientific evidence, and if they are coordinated preferably by an interdisciplinary nutrition support team (NST). The NST can enhance the quality of treatment and reduce complication rates. Nutritional support in the homecare and outpatient sector can contribute substantially to an improvement of the patient's quality of life and of cost efficiency of medical procedures.