Answers part 4 quiz

Home Nutrition Support

Test Your Knowledge Answers

1. The correct answer is B.

Coverage for HPN under Medicare is available for patients who have undergone massive small bowel resection
leaving less than 150 cm residual bowel. Operative notes must include documentation of intestinal length.
Patients with anorexia nervosa would not meet Medicare criteria for permanent severe pathology of the
alimentary tract. A patient requiring bowel rest for 6 weeks for severe acute pancreatitis may have an
appropriate clinical indication for HPN; however, per Medicare guidelines, bowel rest must be required for 3
months or longer and the patient must have evidence that EN is contraindicated. A patient who has a
swallowing disorder with or without evidence of aspiration pneumonia would be a candidate for EN.
2. The correct answer is D.
The primary reason to administer HPN using a cyclic or overnight infusion is to allow the patient freedom during
the day and thereby improve quality of life (QOL). Cyclic infusions allow a period of rest and may decrease the
incidence of fatty liver. Off-cycle time allows for administration of other IV medications (eg, vancomycin) that
are incompatible with PN. Cyclic infusions are appropriate if a patient can tolerate the volume of PN over a
shorter period of time as evidenced by frequency of urination, blood glucose control, and absence of
cardiopulmonary distress.
3. The correct answer is C.
Home nutrition support uses complex technical equipment. Ensuring that the patient or caregiver is willing and
able to safely manage this equipment as well as all related procedures reduces the risk for complications. Short-
term goals for the new home nutrition support patient or caregiver are to optimize the organization and safety
of the home environment and identify risks related to potential complications. Long-term goals are to promote
patient independence and adherence, and prevent hospital readmission.
4. The correct answer is D.
Patients who receive long-term HEN or HPN are at high risk for depression, social isolation, and poor QOL.
Patients and their caregivers should have an active role in determining the appropriate access device and
infusion therapy plan to fit their lifestyle. Home care professionals should help patients adapt and cope with the
required lifestyle adjustments by painting a realistic picture of what will occur at home, providing education on
HEN/HPN procedures and technology, and designing a care plan consistent with the patients’ desired goals.
Patients should be introduced to the many organizations that provide important outreach services, educational
materials, and emotional support.

5. The correct answer is D.

The physician managing HEN or HPN patients will need assistance from other providers to monitor patient
adherence to therapy. A multidisciplinary approach involving the dietitian, home health nurse, and infusion
pharmacist is crucial. Patients or caregivers who are unwilling to review the product inventory or report of
excess supplies, or who are not responding appropriately to treatment (ie, experience unintentional weight loss
or unresolved electrolyte imbalances), may not be adhering to the nutrition support plan. Infusion pump reports
may be useful for verifying infusion history for patients receiving PN.

Ethics and Law

Test Your Knowledge Answers
 1. The correct answer is A.
ANH involves technology-assisted administration of nutrients when a patient is unable to swallow or unable to
absorb nutrients through the GI tract.1 ANH is considered a medical intervention.2

2. The correct answer is A.

In the US ethico-legal framework, the primary goal is to provide medical therapies based on the individual’s
quality-of-life goals, as determined by the patient with decision-making capacity or an authorized surrogate.
Completion of advance directives for individuals is encouraged. Beneficence is the fundamental obligation of a
healthcare professional to seek the good of the patient above all other priorities, and nonmaleficence addresses
the aspect of “do no harm.” The justice principle deals with fairness and requires that nutrition support clinicians
equitably treat similar patients similarly and consider only clinically relevant information.1
3. The correct answer is D.
The term forgoing refers to both withholding and withdrawing ANH. There is no ethical or legal distinction
between withholding and withdrawing treatment. However, decisions to withdraw ANH may be more
psychologically and emotionally charged for clinicians, patients, and families than decisions to withhold
intervention.3
4. The correct answer is C.
A patient’s expected survival time affects the evaluation of the benefits vs burdens and risks of the procedure. A
swallow evaluation, family meeting, and presence of an advance directive are not limiting factors for placement
of a long-term feeding tube.

Quality Improvement in Clinical Practice

Test Your Knowledge Answers

1. The correct answer is C.

The goal of QI is to improve a process, a program, a system, or the performance of an individual practitioner by
comparing current processes, programs, systems, or performances with a set of published standards for use
within that facility or system. Clinical outcomes research, on the other hand, aims to answer a clinical question
and test hypotheses to improve knowledge and produce a peer-reviewed publication.
2. The correct answer is B.
Randomized controlled trials and prospective studies aim to test hypotheses to produce generalizable
knowledge and are clinical outcomes research. A needs assessment can be a quality or research project. A
clinical audit may be completed before and during a QI project to assess the baseline and progress with the
change measure.
3. The correct answer is D.
Quality indicators are objective metrics by which quality of care and professional performance can be assessed.
These indicators allow for continuous improvement of processes, procedures, and clinical outcomes. Nutrition
indicators can be derived from published guidelines and standards, the Joint Commission’s National Patient
Safety Goals (NPSGs); the Institute of Medicine (IOM; now known as Health and Medicine Division of the
National Academies of Science) quality aims; treatment or patient outcomes; or by facility consensus. All
answers to the question could be used as quality indicators, but, in this scenario, the most appropriate metric to
measure appropriate ordering of PN would align with guidelines stating that PN is indicated when EN is
contraindicated.

Evidence-Based Medicine and Derivation of Clinical Guidelines

Test Your Knowledge Answers

1. The correct answer is D.

A large, well-conducted RCT, particularly if it is multicenter, provides the highest level of evidence. Even if an
editorial is well written by a recognized expert, it is the lowest grade of evidence and is considered expert
opinion. Nonrandomized cohort studies mean that the study group is compared in a nonrandomized fashion
with either contemporaneous patients who were in the hospital or being treated at the same time or historical
controls who were treated at some time in the past. Such trials provide a low level of evidence. A large
observational trial may represent practice at different institutions around the world, but the absence of a
prospectively randomized control group renders the study a lower level of evidence than a large RCT.

2. The correct answer is A.

Clinical guidelines represent a set of recommendations for practicing clinicians that are derived from a vigorous
review of the literature. Adherence to the guidelines does not guarantee clinical outcome. Guidelines are not
rules or laws and do not distinguish whether someone’s clinical practice is legal or illegal. Guidelines organize
the literature into topics that can direct further study, but they are not designed to be a rigorous guide for
future research.
3. The correct answer is C.
Relative risk is calculated in the meta-analysis and does tend to overestimate the treatment effect. The absolute
risk reduction is calculated by the number of events in both the treatment and control groups divided by the
denominator in each group. The absolute risk reduction is usually lower than the relative risk reduction. The test
for heterogeneity looks at the similarities between studies, not between patients in an individual study. The
overall treatment effect tells whether the outcome parameter being evaluated by the meta-analysis was
significantly different in the study group compared to controls.