Conclusions on the nutritive aspect activities

The Serbian Ministry of Health Expert Group on Liver Deseases proposes the following organizational structure of medical services in the field of nutrition:

I. REPUBLICAN COUNCIL ON NUTRITION

The Council is organized by the Serbian Ministry of Health. It includes all the activities linked to nutrition of the Serbian population. Specific activities shall be determined by the Council Statute (or some other regulation). The Council has many sections among which:

The Clinical Nutrition Section, engaged in clinical nutrition during patient treatment (nutrition as a part of therapeutic patient treatment). This section performs the following activities:

1. Drafts the working standards to reach high quality and equalization at work,

2. Drafts educational plans and programmes for all profiles of medical personnel occupied in the field of nutrition (doctors - dieticians, nutritionists, dieticians), and also for the population (for the whole population or for some categories of the population),

3. Approves and recommends diagnostic and therapeutic methods in the field of clinical nutrition (diagnostic methods and dietetic-therapeutic protocols are suggested by the expert groups and adopted at the consensus conferences; they are later confirmed by the Council and become acceptable and obligatory). The Council also issues recommendations for certain enteral and parenteral nutrition products.

4. Approves clinical nutrition education programmes (certifies course topics and lecturers recommended by the relevant departments of the School of Medicine).

5. Cooperates with appropriate organizations in the country and abroad.

II. ORGANIZATION IN HEALTH CARE INSTITUTIONS

II A) Primary Health Care Centre (PHCC) should include a Nutrition Counseling Service, where patients come by themselves, or have been reffered to from other departments of the PHCC. Each patient file should have the relevant data noted in chronological order (BM, BH, BMI, etc.; the expert group will precisely define these parametres for different groups of diseases), while the making of notes in the file is obligatory. The Nutrition Counseling Service should use standardized protocols, such as nutrition history, estimates, antropometric and other measurements, biochemical estimates and nutrition physical examination).

A dietician or a nutritionist are employed in the Nutritional Counseling Service (the nurse performs antropometric measurements, and doctor-dietician takes the medical history, notes the diagnosis and prescribes the dietetic model (scheme). The patient receives immediately the final diet model if it is typical, or the model is prepared by a nutritionist/dietician based on the doctor-dietician’s request).

The following activities are performed in the Nutrition Counseling Service:

1. The diagnostic technologies and procedures proscribed for the PHCC are applied,

2. The patient nutritional status is determined and a nutritional disease related diagnosis is confirmed/rejected,

3. Appropriate dietetic and/or other therapy is proscribed,

4. Appropriate standardized documentation/evidence is maintained in the Service,

5. Patient health condition is followed-up (effects of dietetic therapy control)

6. Patients are reffered to higher level of care, if needed.

II B) GENERAL HOSPITALs should have a nutrition department with an appropriate policlinic. The department deals both with examinations and treatment as well as observations of in- and out-patients. The patients are sent to the department either by doctors of the same Hospital or of the authorized PHCC.

A doctor-dietician, nutritionist and dietician work at the nutrition department. This team has got a close cooperation with relevant department (internal medicine, surgery, anesthesia). In the department:

1. Additional diagnostic methods are used in order to estimate the degree of nourishment and the diagnosis of the disease related to nutrition is confirmed or rejected,

2. Appropriate dietetic therapy and/or other therapy is prescribed,

3. Appropriate nutrition is prescribed for hospital in-patients including enteral and parenteral nutrition,

4. Hospital patient nutrition is supervised,

5. Patient health condition is observed (examining the effects of dietetic therapy),

6. Keeping appropriate, standardized documentation/evidence,

7. Educating the personnel of surgical and internal medicine departments linked to the application of enteral and parenteral nutrition,

8. Giving advice to patients who are discharged from the hospital in relation to further nutrition (general principles, specific diseases etc.)

II C) CLINICS AND INSTITUTES have a structure similar to the General hospital plus:

9. Scientific research work.

II D) CLINICS AND CLINICAL CENTRES have a structure dependant of the size and impotance of the Centre itself. The Centre should have a nutrition department which has its own policlinic.

The department/section is engaged in enteral and parenteral nutrition employing specially trained doctors (gastroenterologist, nutritionist or anesthesiologist).

Parenteral nutrition in domestic conditions is defined, implemented and controlled by the Clinical centres.

NUTRITION IN HEPATOLOGY

The existance of protocols for nutrition are necessary for certain diseases, including liver disease.

Note: Any patient history must have the appropriate set of data related to the degree of nourishment (BM,BH,BMI, maybe some elements more like DKN traces/% fat,W/H). However, patients coming to the Policlinic for nutrition and dietetic therapy, as well as each in-patient who receives dietetic therapy as part of treatment, must have an adequate individualized nutritional “history” (a few pages: general and personal history, antropometry, biochemical, nutrition questionnaire, prescribed dietetic model...).

Ekspertska grupa za bolesti jetre pri Ministarstvu za zdravlje Republike Srbije predlaže sledeću organizacionu strukturu medicinskih službi za ishranu:

I) REPUBLIČKI SAVET ZA ISHRANU

Formira ga Ministarstvo za Zdravlje RS. Savet obuhvata sve delatnosti vezane za ishranu celokupnog stanovništva Republike. Precizan oblik delatnosti se definiše statutom Saveta (ili nekim drugim pravnim aktom). Savet ima više sektora, od kojih se

SEKTOR KLINIČKE ISHRANE bavi problemom kliničke ishrane u lečenju bolesnika( ishrana kao deo terapijskog tretmana pacijenta). Ovaj sektor obavlja sledeće delatnosti:

1. Donosi standarde za rad, kako bi se postigao visok kvalitet i ujednačenost u radu,

2. Donosi plan i program edukacije svih profila zdravstvenih radnika koji se bave problemima ishrane (lekari-djetolozi, nutricionisti, dijetetičari), kao i stanovništva (obrazovanje opšte populacije, ili pojedinih kategorija stanovništva),

3. Odobrava i preporučuje dijagnosticke i terapijske metode u oblasti kliničke ishrane ( dijagnosticke metode i dijetoterapijske protokole predlažu ekspertske grupe a usvajaju se na konsenzus konferencijama. Potom ih potvrdjuje Savet, čime postaju opsteprihvacene i obavezujuće). Takođe, daje preporuke za pojedina sredstva za enteralnu i parenteralnu nutriciju.

4. Odobrava programe edukacije is oblasti klnicke ishrane (na predlog i u saradnji sa odgovarajucim Katedrama MF potvrđuje teme kurseva.i predavače,

5. Sarađuje sa odgovarajućim organizacijama u zemlji i inostranstvu.

II) ORGANIZACIJA U POJEDINIM ZDRAVSTVENIM USTANOVAMA

IIA) DOM ZDRAVLJA u svom sastavu treba da ima Savetovalište za ishranu, u koji pacijenti dolaze samoinicijativno, ili su upućeni iz drugih ambulanti istog DZ. Svaki karton pacijenta treba da ima hronološki notirane odgovarajuce podatke (TM, TV, BMI itd..... ovi parametri ce biti precizno definisani od strane ekspertske grupe za pojedine grupe oboljenja), a notiranje u kartonu je obavezno. Takođe, u svim savetovalištima se koriste standardizovani protokoli, kao što su istorija ishrane i procena, antropometrijska i druga merenja, biohemijska procena i nutritivni fizikalni pregled).

U Savetovalištu DY radi dijetolog ili nutricionista (med. tehničar radi antropometrijska merenja, a lekar dijetolog uzima anamnezu, upisuje dijagnozu/e i propisuje dijetnu shemu. Dijetnu shemu potom pacijent dobija kao gotovu, ako je klasicno tipska ili je sastavlja nutricionista/dijeteticar na osnovu zahteva koji je dobio od dijetologa).

U Savetovalištu Doma zdravlja se obavljaju sledeće delatnosti:

1. Primenjuju se za dom zdravlja propisana dijagnostička sredstva i procedure,

2. utvrđuje stanje uhranjenosti pacijenta i utvrđuje/isključuje dijagnoza oboljenja vezanog za ishranu,.

3. prepisuje odgovarajuća dijetoterapija i/ili druga terapija,

4. vodi odgovarajuća, standardizovana dokumentacija/evidencija,

5. prati zdravstveno stanje bolesnika (kontrolišu efekti dijetoterapije),

6. u slučajevima potrebe šalje bolesnika u ustanovu višeg nivoa stručnosti.

IIB) OPŠTA BOLNICA u svom sastavu treba da ima Odsek za nutriciju sa odgovarajućom polikliničkom ambulantom. Odsek se bavi ispitivanjem i lečenjem, kao i nadzorom stacionarno i poliklinički lečenih bolesnika. Bolesnike u Odsek upućuju lekari iste Bolnice ili nadležnog Doma zdravlja.

U Odseku za nutriciju Opšte bolnice radi dijetolog, ili nutricionista i dijetetičar, Tim blisko sarađuje odgovarajućim službama (interne medicine, hirurgije, anestezije). U Odseku se:

1. primenjuju dodatne dijagnostičke metode u proceni stanja uhranjenosti i utvrđuje/isključuje dijagnoza oboljenja vezanog za ishranu,

2. prepisuje odgovarajuća dijetoterapija i/ili druga terapija,

3. prepisuje odgovarajuća ishrana za stacionarne bolesnike, uključujući i enteralnu i parenteralnu ishranu,

4. vrši nadzor nad ishranom pacijenata u bolnici

5. prati zdravstveno stanje bolesnika (kontrolišu efekti dijetoterapije),

6. vodi odgovarajuća, standardizovana dokumentacija/evidencija,

7. Edukacija osoblja na hirurškim i internim odeljenjima o primeni enteralne i parenteralne ishrane,

8. Saveti bolesnicima koji se otpuštaju iz zdravstvene ustanove o daljoj ishrani (opšti principi, specifična oboljenja i dr.)

IIC) KLINIKE i INSTITUTI imaju istu strukturu kao i Opšte bolnice, uz dodatak tačka 9.: Naučnoistraživački rad.

IID) KLINIČKI i KLINIČKO-BOLNIČKI CENTRI imaju strukturu koja zavisi od veličine samog Centra. U osnovi, Centar treba da sadrži Odelenje/Odsek za ishranu, koje ima i svoju polikliničku ambulantu.

Odelenje/odsek se bavi i enteralnom i parenteralnom nutricijom, a u njemu je za to posebno obučen lekar (gastroenterolog, subspecijalista ishrane ili anesteziolog). U K. Centrima se određuje, sprovodi i kontroliše parenteralna ishrana u kućnim uslovima.

ISHRANA U HEPATOLOGIJI

Neophodno je postojanje protokola za ishranu za pojedina oboljenja, uključujući i oboljenja jetre.

Napomena: Bilo koja istorija bolesti svakog pacijenta mora da ima i odgovarajući set podataka koji se odnosi na stanje uhranjenosti (TM, TV, BMI, mozda jos neke lemente kao sto bi bili DKN tricesa/%masti, W/H). Medjutim, pacijenti koji se javljaju u Ambulantu za ishranu i dijetoterapiju kao i za svaki bolesnik koji u okviru svog lečenja dobija i dijetoterapiju a leži u bolnici na nekom odeljenju, mora da ima i svoju odgovarajuću , posebnu nutricionisticku «istoriju» (na nekoliko strana: opsta i licna anam., antorpometrija, biohemija, anketa ishrane, propisana dijetna shema.....)