Home parenteral nutrition during the COVID-19 pandemic: Experience in a tertiary referral hospital in Malaysia.

We read with interest the position paper by Matras and colleagues regarding home parenteral nutrition (HPN) during the COVID-19 pandemic [1]. In this letter, we describe the management and steps taken by the nutrition support team at Hospital Kuala Lumpur, a public tertiary referral hospital, to ensure appropriate and safe HPN provision during the pandemic. HPN, which involves providing parenteral nutrition (PN) through an intravenous route in a homecare setting, is a life-saving therapy for patients with chronic intestinal failure who cannot meet their nutritional requirements via an oral or enteral route [2].

Home visits are an integral part of our institution's HPN management. We usually conduct an initial home visit for all new patients before they start the HPN programme, with annual home visits for existing patients. Since the beginning of pandemic, we have deferred all such visits to minimise travel and unnecessary contact. Our modified home assessments are carried out using the photos and videos provided by patients. We use a checklist to ensure the general cleanliness of the home environment as well as basic home safety. We also make sure that essential items for PN infusions, transport and storage are available in the homecare setting [3].

We have designed an intensive training and education module for patients and their caregivers, and this is conducted via face-to-face counselling, educational videos, telephone calls and secure messaging. We equip ourselves with personal protective equipment as per protocol when conducting face-to-face counselling [1]. The training encompasses understanding aseptic techniques, the safe handling and administration of PN, catheter and line management, self-monitoring and the prevention of HPN-related complications [3].

We discharge patients requiring HPN therapy as soon as they are metabolically stable, have fulfilled all the criteria on the checklist and given their informed consent [3]. Upon discharge, patients are given the emergency contact numbers of the nutritional support team members and are instructed to contact us immediately if they have any issues. To date, we have successfully discharged two patients during the pandemic.

One of the challenges we have faced during the pandemic is that many patients have been reluctant or have found it difficult to make frequent visits to the hospital due to movement restrictions or COVID-19 exposure concerns [4]. We have therefore reduced the frequency of PN bag collection by providing commercial ready-to-use bags with a longer shelf life for use by stable patients [2]. We perform only blood investigations and consultations that are deemed clinically necessary. While patient readmissions are sometimes inevitable, we have minimised the hospital length of stay while ensuring clinical effectiveness and patient safety. These measures are in line with the recommendations of the ESPEN guidelines [4].

The initiation and provision of an HPN programme are possible and should remain uninterrupted during the COVID-19 pandemic. Based on our experience, a multifaceted approach that includes modified home assessments, intensive HPN training and education and revisions regarding the need for and frequency of hospital visits are essential to ensure the safe and effective provision of HPN during this healthcare crisis.

Funding information

The authors did not receive any external funding for this work.

Author contributions

FH, CC, MHHA contributed equally in writing the manuscript.

Conflict of interest

The authors declare no conflict of interest.