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시완 류(유)
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1 Original Article J Clin Nutr 2016;8(2):58-65 pissn ㆍ eissn 국내대형병원에서경장또는정맥영양공급을받은환자의임상적특성및임상경과 설은미 1,2, 서윤석 1,3,6, 주달래 1,4, 배혜정 1,5, 이혁준 1,3,6 서울대학교병원 1 영양집중지원팀, 2 간호본부, 3 위장관외과, 4 급식영양과, 5 약제부, 6 서울대학교의과대학외과학교실및암연구소 Characteristics and Clinical Course of Patients Who Received Enteral or Parenteral Nutrition in Tertiary Referral Hospitals in Korea Eunmi Seol 1,2, Yun-Suhk Suh 1,3,6, Dal Lae Ju 1,4, Hye Jung Bae 1,5, Hyuk-Joon Lee 1,3,6 1 Nutritional Support Team, 2 Department of Nursing Service, 3 Division of Gastrointestinal Surgery, 4 Department of Food Service and Nutrition Care, 5 Department of Pharmacy, Seoul National University Hospital, 6 Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea Purpose: The purposes of this study are to evaluate clinical characteristics of malnourished patients who received nutritional therapy and to compare their clinical courses according to nutritional support team (NST) consultation in tertiary referral hospital in Korea. Methods: From June 2014 to May 2015, 43,954 admitted patients who were more than 18 years old were retrospectively investigated. Characteristics of patients who received enteral nutrition (EN) or parenteral nutrition (PN) for more than 3 days (nutritional therapy group) were compared to the patients without nutritional therapy (control group). In addition, clinical courses according to NST consultation (NST group and non-nst group) were compared through propensity score matching (PSM). Results: EN or PN was applied in 4,599 patients for more than 3 days (nutritional therapy group: 10.5%). For characteristics, there were significant differences between two groups (nutritional therapy group vs. control group) with age, male proportion, body weight, body mass index. All laboratory data at admission were significantly worse in nutritional therapy group. And for clinical courses, there were significant differences in length of stay (LOS), rate of intensive care unit (ICU) admission, LOS in ICU, Acute Physiology and Chronic Health Enquiry (APACHE Ⅱ) score, days of nutritional therapy, mortality rate. NST consultation was made in 39% of nutritional therapy group. Among departments, Thoracic Surgery showed the highest rate of NST consultation (68.5%) otherwise Neurosurgery showed the lowest rate (18.7%). When PSM between NST group vs. non-nst group were made, significant differences was shown only in the rate of ICU admission, EN or PN support days, cholesterol at discharge. Conclusion: In tertiary referral hospital in Korea, more than 10% of patients still needed active nutritional therapy. NST consultation rate varies among departments. We failed to find significant differences between NST group and non-nst group. Key Words: Nutrition therapy, Nutrition Support Team, Treatment outcome Received Aug 4, 2016; Revised Aug 12, 2016; Accepted Aug 18, 2016 Correspondence to Hyuk-Joon Lee Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: , Fax: , appe98@snu.ac.kr Conflict of interest: None. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. c 2016, The Korean Society for Parenteral and Enteral Nutrition. All Rights Reserved.

2 Enteral or Parenteral Nutrition in Tertiary Referral Hospitals 서 론 대상및방법 영양불량은병원입원환자에서흔하게발생하는문제중하나로, 질병치료지연뿐아니라감염률, 합병증발생률, 사망률, 재원기간의증가및의료비용상승과밀접한상관관계를보인다. 1-5 이러한이유로최근입원환자의영양불량정도파악및적절한영양지원은질병의임상적회복을위한필수적인요소로인식되고있다. 외국의경우, 병원입원환자의영양불량유병률은 20% 50% 정도로알려져있고, 국내의경우도 20% 55% 정도로외국과크게다르지않으나국내영양불량환자유병률의대부분은노인, 중환자, 암환자등특정환자군을대상으로조사한것으로전체입원환자를대상으로한영양불량정도파악은아직까지부족한실정이다. 6-9 한편, 영양집중지원팀 (Nutrition Support Team, NST) 은의사, 간호사, 약사, 영양사로구성된다학제적팀으로경장영양 (enteral nutrition, EN) 및정맥영양 (parenteral nutrition, PN) 공급을받는환자의영양상태를평가하고적절한영양공급방법을제시하여환자의영양상태호전, 합병증예방을통해결과적으로질병회복을돕는역할을한다. 5,10 Shang 등 11 이유럽 98개의병원을대상으로시행한연구에따르면 NST에의한영양관리는전체병원중 88% 에서합병증발생률감소, 98% 에서의료비용절감효과를나타냈다고하였고, Senkal 등 12 이시행한연구에서도전체 47개의병원중 38.3% 에서합병증발생률감소, 34% 에서의료비용절감효과를나타냈다고보고한바있다. 이처럼조직적인 NST 활동을통한영양관리가입원환자의합병증발생률및의료비용을감소시킨다는연구결과가보고되면서국내외병원에서는 NST 활동에대한관심이더욱증가하고있다. 국내에서는 2014년 8월보건복지부고시를통해 집중영양치료료 (Therapy by Nutrition Support Team) 수가화가적용되었다. 수가화이후영양관리의중요성에대한인식과함께 NST 수는점차증가해현재상급종합병원및종합병원을포함한전국 100여곳에서 NST가설치, 운영되고있다. 13 이러한사회적분위기속에서국내병원에서는 NST를통한입원환자의영양지원을위해각자나름의노력을기울이고있는것으로생각되지만, NST 활동정도는병원에따라큰차이를보이고있는실정이다. 이에본연구진은 3일이상 EN 또는 PN 공급을받은환자 ( 영양치료군 ) 와영양치료를받지않은환자 ( 대조군 ) 의비교를통해서두군간의임상적특성과임상경과를평가하고자하였다. 또한, 영양치료군의 NST 의뢰여부에따른임상경과를비교하여 NST 활동의효과를평가하고자본연구를시행하였다. 1. 연구대상 2014년 6월 1일부터 2015년 5월 31일까지 1년동안서울대학교병원에입원한 18세이상성인환자 43,954건을대상으로하였다. 3일미만단기입원한환자및검사및임상연구시행목적으로입원한환자는연구대상자에서제외되었다. 본연구는서울대학교병원임상시험윤리위원회승인하에시행되었으며, 후향적연구로연구대상자에대한동의서는면제되었다 (IRB no. H ). 2. 연구내용및방법 3일이상입원한연구대상자중서울대학교병원에서 3일이상 EN 또는 PN 공급을받은환자를영양치료군 (n=4,599) 으로, 영양치료군을제외한환자를대조군 (n=39,355) 으로분류하였다. EN 공급을받은환자는전자의무기록을이용하여경관식사발행내역중식사형태가경관미음이거나 EN 영양액약품코드가처방된환자로정의하였고, PN 공급을받은환자는총정맥영양지원약품코드가처방된환자로정의하여, 이들환자중 3일이상 EN 또는 PN 공급을받은환자를추출하였다. 전자의무기록을통하여대상환자의임상적특성및임상경과를조사하였다. 임상적특성으로는나이, 성별, 몸무게, 체질량지수 (body mass index, BMI), 입원시혈액검사결과 (albumin, cholesterol, total lymphocyte count [TLC], hemoglobin [Hb], C-reactive protein [CRP]), 서울대학교병원영양검색도구 (Seoul National University Hospital-Nutrition Screening Index, SNUH-NSI) 를이용한영양불량위험도를포함하였다. SNUH-NRI는서울대학교병원에서개발하여사용중인영양검색도구로총 11가지영양평가지표를이용하여입원환자의영양상태를평가하고그정도에따라영양불량고위험군 (P1), 중등도위험군 (P2), 저위험군 (P3) 으로분류한다 (Table 1). SNUH- NRI는위절제수술환자를대상으로시행한연구에서그타당도가검증된바있다 임상경과로는재원기간, 중환자실입실여부, EN 및 PN 투여기간, 퇴원시혈액검사결과 (albumin, cholesterol, Hb, CRP), 퇴원형태를포함하였고, 중환자실에입실한환자의경우중환자실재원기간, Acute Physiology and Chronic Health Enquiry (APACHE II) score를포함하였다. 또한, 영양치료군중재원기간이 300일이상으로연구결과에영향을줄수있는 6건을제외한총 4,593건을대상으로나이, 성별, BMI, 재원기간, SNUH-NSI를이용한영양불량위험도, 입원시혈액검사결과를 propensity score matching을통해보정후, NST 의뢰가시행된 NST 의뢰군 (n=809) 과 NST 의뢰 Volume 8, Number 2, August

3 Eunmi Seol, et al. Table 1. Seoul National University Hospital-Nutrition Screening Index (SNUH-NSI) Variable R1 R2 R3 Appetite Bad - Normal/good Change of weight Yes - No Difficulty in digesting - Yes No Diet type Fluid diet Soft blended diet or NPO Normal regular diet Serum-albumin (g/dl) < Serum-cholesterol (mg/dl) - < Total lymphocyte count (cells/mm 3 ) < ,500 1,500 Hemoglobin (g/dl) - Male<13.0 Male 13.0 Female<12.0 Female 12.0 CRP (mg/dl) - >1 1 Body mass index (kg/ m 2 ) <18 or Age (y) - >75 75 Status of malnutrition: P1 = high risk group of malnutrition: (more than 2 of R1) or (1 of R1 and more than 2 of R2); P2 = medium risk group of malnutrition: (1 of R1) or (more than 2 of R2); P3 = low risk group of malnutrition; the others. R = risk factor; NPO = nothing by mouth; CRP = C-reactive protein. Fig. 1. Study participants. EN = enteral nutrition; PN = parenteral nutrition; NST = Nutrition Support Team. 가시행되지않은 NST 미의뢰군 (n=809) 으로분류하여임상경과를비교하였다 (Fig. 1). 3. 자료분석방법영양치료군과대조군의임상적특성및임상경과분석을위하여연속형변수는평균 ± 표준편차로요약하고 Wilcoxon rank sum test를이용하여비교하였고, 범주형변수는빈도와백분율로요약하고 chi-square test 또는 Fisher s exact test를이용하여비교하였다. 영양치료군의 NST 의뢰여부에따른임상경과는 propensity score matching을통해비교하였고, 연속형변수는 Wilcoxon signed ranks test를이용하고, 범주형변수는 Bowker s test of symmetry를이용하여비교하였다. 본연구를통해수집된자료는 SAS version 9.13 (SAS Institute, Cary, NC, USA) 을이용하여분석하였고, P값이 0.05 미만인경우통계적으로유의하다고판단하였다. 결과 1. 영양불량유병률전체입원환자는총 43,954건으로그중 SNUH-NRI를이용한영양불량위험도평가결과영양불량위험군 (P1+P2) 으로측정된환자는 57.6% (25,324건) 로나타났다. 전체입원환자중영양치료군은 4,599건 (10.5%), 대조군은 39,355건 (89.5%) 이었고, 각군의영양불량위험군은각각 4,036건 (87.8%), 21,288 건 (54.5%) 으로측정되었다. 2. 영양치료군 vs. 대조군의임상적특성비교영양치료군은전체입원환자중 4,599건 (10.5%) 이었다. 영양치료군과대조군의임상적특성을비교하였을때, 영양치료군 (vs. 대조군 ) 의평균나이 61.5±15.6세 (vs. 55.7±16.2세 ), 남성비율 58.3% (vs. 47.1%), 평균몸무게 57.6±11.6 kg (vs. 61.9±11.8 kg), 평균 BMI 21.9±3.8 kg/m 2 (vs. 23.5±3.6 kg/m 2 ), SNUH-NRI를이용한영양불량위험도평가결과영양 60 Journal of Clinical Nutrition

4 Enteral or Parenteral Nutrition in Tertiary Referral Hospitals 불량위험군 (P1+P2) 87.8% (vs. 54.5%), 입원시혈중 albumin 3.4±0.7 g/dl (vs. 3.7±0.7 g/dl), cholesterol 147.0±50.3 mg/dl (vs ±48.4 mg/dl), TLC 1,198.7±1,141.5 cells/mm 3 (vs. 1,422.6±48.4 cells/mm 3 ), Hb 11.2±2.4 g/dl (vs. 12.0±2.2 g/dl), CRP 7.3±8.7 mg/dl (vs. 4.2±6.6 mg/dl) 로나타났고, 모든특성에대하여두군간에통계적으 로유의한차이를보였다 (Table 2). 영양치료군과대조군의임상경과를비교하였을때, 영양치료군 (vs. 대조군 ) 의재원기간 26.1±30.3일 (vs. 9.1±9.7일 ), 중환자실입실비율 31.6% (vs. 9.1%), 중환자실재원기간 10.3±17 일 (vs. 2.1±2.5일 ), APACHE II score 24.5±11.5 (vs. 16.2± 8.4), EN 또는 PN 투여기간 13.6±20.0일 (vs. 1.4±0.5일 ), 퇴 Table 2. Statistical comparison of clinical characteristics of nutritional therapy group vs. control group (n=43,954) Variable Nutritional therapy group (n=4,599, 10.5%) Control group (n=39,355, 89.5%) P-value Age (y) 61.5± ±16.2 < a Male (%) 2,680 (58.3) 18,534 (47.1) < b Body weight (kg) 57.6± ±11.8 < a Body mass index (kg/m 2 ) 21.9± ±3.6 < a Status of malnutrition < b P1 2,507 (54.5) 6,994 (17.9) P2 1,529 (33.3) 14,294 (36.6) P3 561 (12.2) 17,772 (45.5) Serum-albumin at adm. (g/dl) 3.4± ±0.7 < a Serum-cholesterol at adm. (mg/dl) 147.0± ±48.4 < a Total lymphocyte count at adm. (cells/mm 3 ) 1,198.7±1, ,422.6±48.4 < a Hemoglobin at adm. (g/dl) 11.2± ±2.2 < a CRP at adm. (mg/dl) 7.3± ±6.6 < a Values are presented as mean±standard deviation or number (%). P1 = high risk group of malnutrition: (more than 2 of R1) or (1 of R1 and more than 2 of R2); P2 = medium risk group of malnutrition: (1 of R1) or (more than 2 of R2); P3 = low risk group of malnutrition; the others; adm.= admission; CRP = C-reactive protein. a P-values were obtained by Wilcoxon rank sum test for continuous variables. b P-values were obtained by Fisher s exact test for categorical variables. Table 3. Statistical comparison of clinical courses of nutritional therapy group vs. control group (n=43,954) Variable Nutritional therapy group (n=4,599, 10.5%) Control group (n=39,355, 89.5%) P-value LOS (d) 26.1± ±9.7 < a ICU admission < b Yes 1,453 (31.6) 3,576 (9.1) No 3,146 (68.4) 35,779 (90.9) LOS in ICU (d) 10.3± ±2.5 < a EN or PN support days 13.6± ±0.5 < a APACHE II score 24.5± ±8.4 < a Serum-albumin at discharge (g/dl) 3.2± ±0.6 < a Serum-cholesterol at discharge (mg/dl) 140.1± ±46.0 < a Hemoglobin at discharge (g/dl) 10.6± ±2.0 < a CRP at discharge (mg/dl) 4.3± ±4.3 < a Discharge type < b Death 515 (11.2) 313 (0.8) Recovery 3,983 (86.6) 38,868 (98.8) Etc. 93 (2.0) 110 (0.3) Values are presented as mean±standard deviation or number (%). LOS = length of stay; ICU = intensive care unit; EN= enteral nutrition; PN = parenteral nutrition; APACHE II = Acute Physiology and Chronic Health Enquiry II; CRP = C-reactive protein. a P-values were obtained by Wilcoxon rank sum test for continuous variables. b P-values were obtained by chi-square test or Fisher s exact test for categorical variables. Volume 8, Number 2, August

5 Eunmi Seol, et al. 원시혈중 albumin 3.2±0.6 g/dl (vs. 3.6±0.6 g/dl), cholesterol 140.1±47.0 mg/dl (vs ±46.0 mg/dl), Hb 10.6±1.8 g/dl (vs. 11.5±2.0 g/dl), CRP 4.3±6.1 mg/dl (vs. 3.3±4.3 mg/dl), 퇴원형태중사망률 11.2% (vs. 0.8%) 로나타나모든특성에대하여두군간에통계적으로유의한차이를보였다 (Table 3). 3. 영양치료군의 NST 의뢰에따른임상경과비교영양치료군 4,599건중재원기간 300일이상으로연구결과에영향을줄수있는 6건을제외한총 4,593건의자료를이용하여분석하였다. 이들의 NST 의뢰에따른임상경과를비교하기위하여나이, 성별, BMI, 재원기간, SNUH-NRI를이용한영양불량위험도, 입원시 albumin, cholesterol, TLC, Hb, CRP를보정한후, NST 의뢰군과 NST 미의뢰군을 1:1 비율로 propensity score matching한결과전체 4,593건중 1,618건 (NST 의뢰군 809건, NST 미의뢰군 809건 ) 의자료가매칭되었다. NST 의뢰군과 NST 미의뢰군의임상적특성을비교하였을 때 NST 의뢰군 (vs. NST 미의뢰군 ) 의평균나이 60.1±15.9세 (vs. 60.7±16.2세 ), 남성비율 63.7% (vs. 62.8%), 평균 BMI 21.7±4.0 kg/m 2 (vs. 21.8±3.7 kg/m 2 ), 재원기간 26.7±20.2일 (vs. 26.8±19.6일 ), SNUH-NRI를이용한영양불량위험도평가결과영양불량위험군 (P1+P2) 85.8% (vs. 86.1%), 입원시혈중 albumin 3.4±0.7 g/dl (vs. 3.4±0.7 g/dl), cholesterol 148.9±49.2 mg/dl (vs ±52.6 mg/dl), TLC 1,212.8± 1,118.0 cells/mm 3 (vs. 1,245.3±1,182.6 cells/mm 3 ), Hb 11.2± 2.3 g/dl (vs. 11.2±2.3 g/dl), CRP 6.2±8.2 mg/dl (vs. 6.3±7.9 mg/dl) 로나타나모든특성에대하여두군간에통계적으로유의한차이를보이지않았다 (Table 4). NST 의뢰에따른임상경과를비교하였을때, NST 의뢰군 (vs. NST 미의뢰군 ) 의중환자실입실비율 31.8% (vs. 23.5%), EN 및 PN 투여기간 14.6±13.7일 (vs. 10.8±11.2일 ), 퇴원시 cholesterol 137.3±45.0 mg/dl (vs ±46.6 mg/dl) 로두군간에통계적으로유의한차이를보였으나, 그외 APACHE II score, 퇴원시혈액검사결과 (albumin, Hb, CRP), 퇴원형태에서는 NST 의뢰에따른임상적차이를보이지않았다 (Table 5). Table 4. Statistical comparison of clinical characteristics of NST group vs. non-nst group used by PSM (n=1,618) Variable NST group (n=809) non-nst group (n=809) P-value Age (y) 60.1± ± a Male (%) 515 (63.7) 508 (62.8) b Body mass index (kg/m 2 ) 21.7± ± a LOS (d) 26.7± ± a Status of malnutrition b P1 431 (53.3) 427 (52.8) P2 263 (32.5) 269 (33.3) P3 115 (14.2) 113 (14.0) Serum-albumin at. adm. 3.4± ± a (g/dl) Serum-cholesterol at adm. (mg/dl) 148.9± ± a Total lymphocyte count 1,212.8±1, ,245.3±1, a at adm. (cells/mm 3 ) Hemoglobin at adm. 11.2± ± a (g/dl) CRP at adm. (mg/dl) 6.2± ± a Values are presented as mean±standard deviation or number (%). NST = Nutrition Support Team; PSM = propensity score matching; LOS = length of stay; adm. = admission; P1 = high risk group of malnutrition: (more than 2 of R1) or (1 of R1 and more than 2 of R2); P2 = medium risk group of malnutrition: (1 of R1) or (more than 2 of R2); P3 = low risk group of malnutrition; the others; CRP = C-reactive protein; a P-values were obtained by Wilcoxon signed rank sum test for continuous variables. b P-values were obtained by Bowker s test of symmetry for categorical variables. Table 5. Statistical comparison of clinical courses of NST group vs. non-nst group used by PSM (n=1,618) Variable NST group (n=809) non-nst group (n=809) P-value ICU admission a Yes 257 (31.8) 190 (23.5) No 552 (68.2) 619 (76.5) LOS in ICU (d) 7.4± ± b EN or PN support days 14.6± ±11.2 < b APACHE II score 23.4± ± b Serum-albumin at 3.2± ± b discharge (g/dl) Serum-cholesterol at 137.3± ± b discharge (mg/dl) Hemoglobin at discharge 10.6± ± b (g/dl) CRP at discharge (mg/dl) 4.3± ± b Discharge type a Death 96 (11.9) 69 (8.5) Recovery 691 (85.4) 724 (89.5) Etc. 22 (2.7) 16 (2.0) Values are presented as number (%) or mean±standard deviation. NST = Nutrition Support Team; PSM = propensity score matching; ICU = intensive care unit; LOS = length of stay; EN = enteral nutrition; PN = parenteral nutrition; APACHE II = Acute Physiology and Chronic Health Enquiry II; CRP = C-reactive protein. a P-values were obtained by Bowker s test of symmetry for categorical variables. b P-values were obtained by Wilcoxon signed rank sum test for continuous variables. 62 Journal of Clinical Nutrition

6 Enteral or Parenteral Nutrition in Tertiary Referral Hospitals Table 6. Percentage of NST consultation according to department (n=4,599) Department NST consultation (n) non-nst consultation (n) NST consultation (%) Fig. 2. Number of Nutrition Support Team consultation according to department. IMH = Internal Medicine Hematology; GS = Gastrointestinal Surgery; NR = Neurology; IMG = Internal Medicine Gastroenterology; IMR = Internal Medicine Respiratory; TS = Thoracic Surgery; RH = Rehabilitation Medicine; OL = Ophthalmology; IMN = Internal Medicine Nephrology; OG = Obstetrics and Gynecology; UR = Urology; EMO = Emergency Medicine; NS = Neuro Surgery; IMC = Internal Medicine Cardiology; IMI = Internal Medicine Infection; IMJ = Internal Medicine Rheumatology; OS = Orthopedics Surgery; IME = Internal Medicine Endocrine; NP = Neuro Psychiatry; PS = Plastic Surgery; DM = Dermatology; IMA = Internal Medicine Allergy. 4. 진료과별 NST 의뢰분포 영양치료군중 NST 의뢰건수는총 1,794건 (39%) 으로진료과별 NST 의뢰건수를살펴보았을때, 혈액종양내과 (23.6%), 외과 (15.9%), 신경과 (8.8%), 소화기내과 (8.1%) 순서로의뢰건수가높은경향을보였다 (Fig. 2). 한편, 영양치료군중진료과별 NST 의뢰율을살펴보면흉부외과 (68.5%), 신경과 (66.2%), 재활의학과 (60.4%) 에서높은 NST 의뢰율을보인반면, 신경외과 (18.7%), 응급의학과 (21.5%), 산부인과 (25.5%) 에서는비교적낮은 NST 의뢰율을보였다 (Table 6). 고 찰 본연구는 3일이상 EN 또는 PN 공급을받은환자의임상적특성을파악하고, 이들의임상적특성및임상경과를대조군과비교함으로 1년간서울대학교병원에입원한 18세이상성인환자의영양불량정도를파악할뿐아니라, 영양치료군의 NST 의뢰여부에따른임상경과를비교함으로써 NST 활동의효과를평가하고자시행되었다. 연구결과, 전체입원환자중 58% (25,324건) 가영양불량위험군으로측정되었는데, 이는국내외영양불량유병률로보고 TS NR RH NP OL IMN OS IMR IMI IMC PS IMG IMH GS UR IMJ OG EMO NS Department of less than 10 Nutrition Support Team (NST) consultation for 1 year was excluded. TS = Thoracic Surgery; NR = Neurology; RH = Rehabilitation Medicine; NP = Neuro Psychiatry; OL = Ophthalmology; IMN = Internal Medicine Nephrology; OS = Orthopedics Surgery; IMR = Internal Medicine Respiratory; IMI = Internal Medicine Infection; IMC = Internal Medicine Cardiology; PS = Plastic Surgery; IMG = Internal Medicine Gastroenterology; IMH = Internal Medicine Hematology; GS = Gastrointestinal Surgery; UR = Urology; IMJ = Internal Medicine Rheumatology; OG = Obstetrics and Gynecology; EMO = Emergency Medicine; NS = Neuro Surgery. 되고있는 20% 55% 보다다소높은결과로볼수있고, Lee 등 17 이국내 6개의료기관을대상으로조사한병원입원환자영양불량유병률 (20.2%) 과비교했을때에도비교적높은결과라고생각된다. 3,16 이러한결과는본연구가국내대형병원중하나인서울대학교병원을배경으로시행되었고, 타의료기관과비교하여중증환자입원비율이높다는점을고려할때병원자체적인특성에서비롯된결과로생각된다. 또한 18세미만환자, 검사및임상연구시행목적으로입원한환자, 3일미만단기입원환자를연구대상자에서제외하였기때문에실제영양불량위험군의비율은본연구결과와다소차이가있을것으로예상된다. 본연구에서전체입원환자중영양치료비율은 10.5% 였고, 영양치료군중남성이 58.3% 로여성보다높은비율을차지하였다. 전체입원환자의남성 (vs. 여성 ) 비율이 48.3% (vs. 51.7%) 인것을고려하면영양치료군에서의남성비율 (58.3%) 은보다 Volume 8, Number 2, August

7 Eunmi Seol, et al. 높은결과로생각된다. 2014년통계청자료에의하면우리나라 4대주요중증질환인암, 심장질환, 뇌혈관질환, 희귀난치성질환이환율이남성에서 1.2배높았다고보고한바있어이러한통계결과를고려할때남성에서보인영양치료비율은성별에따른중증질환이환율의차이에의한결과로생각된다. 18 본연구에서영양치료군과대조군의임상적특성및임상경과를비교하였을때, 모든변수에대하여영양치료군에서통계적으로더나쁜결과를보였다. August와 Huhmann 19 은연구대상자중암환자 50% 에서체중감소를관찰하였고, 이러한임상적결과는사망의주요한원인이된다고보고하였다. 이처럼이미많은연구를통해밝혀졌듯이, 암을비롯한중증질환에이환된환자의경우영양치료를시행한다하더라도질병자체만으로심각한영양결핍과체중감소를경험하기쉽고, 이러한임상적결과는환자의부정적예후를기대하게한다. 따라서기존연구결과와본연구에서나타난영양치료군 (vs. 대조군 ) 의영양불량위험군비율 87.8% (vs. 54.5%) 를함께고려해본다면, 영양치료군에서보인임상적결과는영양불량위험요소를가진환자에서영양치료가이루어지고있기때문에나타난결과임을배제할수없겠다. 영양치료군에서의 NST 의뢰율을살펴보면, 39% 에불과한것으로확인되었고, 진료과별 NST 의뢰건수및 NST 의뢰율에도상당한차이를보였다. 본연구결과측정된 NST 의뢰율은 40% 에도미치지못한, 다소낮은수치로생각되지만 NST 가설립된국내의료기관전체를대상으로비교해봤을때이정도의수치가국내최대의뢰율인것을고려한다면영양치료군에서의 NST 의뢰권장은더욱시급한문제라고생각된다 (unpublished data). 한편, 최근에시행된국내연구에따르면의료진들이영양지원의중요성에대해서는충분히인식하고있지만, 영양지원교육부재, 업무과다, 인력부족등을이유로환자에게적절한영양지원을시행하지못하고있다고하였다. 20,21 이처럼영양치료군에서낮은 NST 의뢰율을보인것은영양지원의중요성에대한인식만으로일부진료과에서 NST 의뢰없이무분별한자체영양지원을시행하는것에의한결과로생각된다. 또한진료과에따라 NST에대한인식및이해의차이가상당한것으로짐작되어이러한다양한문제점들을파악하고해결하기위한의료기관별노력이필요할것으로생각된다. NST의효과에대한선행연구를살펴보면, Kennedy와 Nightingale 4 의연구에서는합병증발생률감소및의료비용감소효과가있었다고보고하였고, Shang 등 11 의연구에서도재원기간감소, 합병증발생률감소, 의료비용감소및사망률감소등에효과가있었다고보고한바있다. 또한 Senkal 등 12 의연 구역시합병증감소및의료비용절감에효과가있었다고하였고, 소아를대상으로시행한 Lambe 등 22 의연구에서도사망률감소, 감염발생률감소등에효과가있음을보고하였다. 본연구에서는 NST 의뢰에따라중환자실입실기간및 EN 및 PN 투여기간은더길고, 퇴원형태및퇴원시검사결과에는차이가없는것으로나타나이러한효과를뒷받침하지못하였다. 그러나영양치료군에서 NST 의뢰가될경우 NST 미의뢰군과비교하여보다장기간영양치료가수행됨에도불구하고, NST 미의뢰환자와유사한임상성적을보였다는점을고려할때, NST 의뢰는영양불량으로인한임상경과악화를어느정도예방한것으로생각된다. 본연구는다음과같은한계를갖는다. 영양치료로인한임상경과는연구대상자의기저질환, 진단명, 수술방법등에큰영향을받는데, 본연구는 1년동안본원에입원한 18세이상성인환자전체를대상으로시행한대규모데이터연구로개별환자의차트확인이어려웠다. 따라서본연구결과는이러한부분에대한고려없이추출된통계결과이기때문에추후이에대한면밀한검토를통한추가적인연구가필요할것으로생각된다. 결론 본연구의영양치료군은 10.5% 로측정되었고, 영양치료군에서영양불량위험비율이더높았다. 하지만영양치료군에서의 NST 의뢰율은 39% 에불과했고영양불량위험요소를가진환자상당수에서 NST 의뢰조차이루어지고있지않은것으로나타나, NST 의뢰를권장하기위한의료기관별다양한노력이필요할것으로생각된다. 한편, 유사한영양결핍을보이는환자군에서 NST 의뢰를시행한경우보다긴영양지원및중환자실입실에도불구하고환자의최종임상경과에는큰차이가없는것으로나타났다. REFERENCES 1. Mitchell H, Porter J. The cost-effectiveness of identifying and treating malnutrition in hospitals: a systematic review. J Hum Nutr Diet 2016;29(2): Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22(3): Kiss CM, Byham-Gray L, Denmark R, Loetscher R, Brody RA. The impact of implementation of a nutrition support algorithm on nutrition care outcomes in an intensive care unit. Nutr Clin Pract 2012;27(6): Journal of Clinical Nutrition

8 Enteral or Parenteral Nutrition in Tertiary Referral Hospitals 4. Kennedy JF, Nightingale JM. Cost savings of an adult hospital nutrition support team. Nutrition 2005;21(11-12): Cooper C, Brierley ER, Burden ST. Improving adherence to a care plan generated from the Malnutrition Universal Screening Tool. Eur J Clin Nutr 2013;67(2): Kitson AL, Schultz TJ, Long L, Shanks A, Wiechula R, Chapman I, et al. The prevention and reduction of weight loss in an acute tertiary care setting: protocol for a pragmatic stepped wedge randomised cluster trial (the PRoWL project). BMC Health Serv Res 2013;13: Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr 2008;27(1): Lee JS, Cho MR, Lee GJ. Validation of the developed nutritional screening tool for hospital patients. Korean J Nutr 2010;43(2): Lee H, Kang JH, Kim E, Kim WG. Prevalence of malnutrition in hospitalized elderly Korean patients based on mini nutritional assessment-short form. J Clin Nutr 2014;6(1): Mo YH. Effectiveness analysis of nutrition support team in the intensive care unit [thesis]. Seoul:Sungkyunkwan University; Shang E, Hasenberg T, Schlegel B, Sterchi AB, Schindler K, Druml W, et al. An European survey of structure and organisation of nutrition support teams in Germany, Austria and Switzerland. Clin Nutr 2005;24(6): Senkal M, Dormann A, Stehle P, Shang E, Suchner U. Survey on structure and performance of nutrition-support teams in Germany. Clin Nutr 2002;21(4): Number of Nutritional Support Team in Korea [Internet]. Wonju:Health Insurance Review and Assessment Service (HIRA); 2016 [cited 2016 Apr 21]. Available from: re/bfrinfo/bfrinfolist.do?pgmid=hiraa Kim Y, Kim WG, Lee HJ, Park MS, Lee YH, Kong SH, et al. Comparison of the impact of malnutrition by nutritional assessment and screening tools on operative morbidity after gastric cancer surgery. J Korean Soc Parenter Enter Nutr 2011;4(1): Seol EM, Ju DL, Lee HJ. Nutritional screening tool for in-hospital patients. J Clin Nutr 2016;8(1): Kim Y, Kim WG, Lee HJ, Park MS, Lee YH, Cho JJ, et al. Impact of malnutrition risk determined by nutrition screening index on operative morbidity after gastric cancer surgery. J Korean Surg Soc 2011;80(1): Lee YM, Kim SH, Kim YS, Kim EM, Kim JY, Keum MA, et al. Nutritional status of Korean hospitalized patients: a multi-center preliminary survey. J Clin Nutr 2014;6(2): Life Tables for Korea [Internet]. Daejeon:Statistics Korea (KOSTAT);2014 [cited 2015 Dec 31]. Available from: August DA, Huhmann MB; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr 2009;33(5): Jeong HS, Teong CH, Choi YJ, Kim WJ, Lee AR. Attitudes of medical staff and factors related to nutritional support for patient care in a university hospital. J Clin Nutr 2014;6(1): Choi J, Park E. Different perceptions of clinical nutrition services between doctors and dietitians in the Busan-Gyeongnam area. J Korean Diet Assoc 2013;19(1): Lambe C, Hubert P, Jouvet P, Cosnes J, Colomb V. A nutritional support team in the pediatric intensive care unit: changes and factors impeding appropriate nutrition. Clin Nutr 2007;26(3): Volume 8, Number 2, August

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1.. Volume 12, Number 1, 6~16, Factors influencing consultation time and waiting time of ambulatory patients in a tertiary teaching hospital Jee-In Hwang College of Nursing Science, Kyung Hee University :