Building Nutrition Support Teams
Today’s Dietitian
By Sharon Palmer, RD
Vol. 7, No. 1, p. 34

A strong nutrition support team must work together to demonstrate its value in a cost-cutting healthcare economy.

For the past few decades, nutrition support teams (NSTs) have been budding across the globe with the lofty goal of bringing the benefits of a multidisciplinary team approach to the management of parenteral and enteral nutrition in the healthcare setting. During the 1970s and 1980s, NST became the term for providing optimal nutrition support in hospitals, no doubt fostered by the landmark study by Nehme showing dramatic differences in complication rates between total parenteral nutrition (TPN) patients monitored by an NST and those monitored by individual physicians.1

But recently the growth of these teams has leveled off, partially because of capitated healthcare systems and because professionals with less nutrition support experience and expertise are being enlisted to do the job. Pressures of economic and healthcare reform have forced administrators to cut unnecessary and unproven services.2,3 “Proving the cost benefit of having a nutrition support team in this day and age is a challenge,” says Susan Roberts, MS, RD, LD, CNSD, clinical nutrition manager at Baylor University Medical Center in Dallas and chair-elect of Dietitians in Nutrition Support (DNS).

“Our team has been in existence since 1979, a time when many hospitals had formal nutrition support teams,” says Ainsley Malone, MS, RD, LD, CNSD, in the department of pharmacy at Mt. Carmel West Hospital in Columbus, Ohio, and secretary for DNS. “Several in our area did have nutrition support teams. Since that time, many of the teams have disbanded. Currently, only two other hospitals in our immediate area have nutrition support teams.”

Marion Winkler, MS, RD, LDN, CNSD, of Rhode Island Hospital in Providence, will become the first dietitian-president of the board of directors of The American Society for Enteral and Parenteral Nutrition (ASPEN). “Most of the large academic medical centers still have intact nutrition support teams with very committed physicians,” reports Winkler, who believes many NSTs have gone by the wayside due to nutrition support integration into standard medical therapy.

According to the Institute of Medicine, facilities have eliminated NSTs based on the rationale that the work they perform can be done by less specialized staff. But most regulatory agencies and hospitals continue to accept the multidisciplinary NST as the gold standard of care for enteral and parenteral nutrition.3

NSTs Improve Outcomes
The magic that NSTs offer is a better solution to the complexities of managing specialized forms of nutrition support. “Nutrition support teams can offer consistent patient management and care. Multi-disciplinary nutrition support teams can provide interventions from multiple perspectives that ultimately improve the delivery of nutrition support,” says Malone.

Even the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) became a cheerleader for NSTs by focusing on the interdisciplinary nutrition therapy plan. According to a 1999-2000 survey conducted by Healthcare Quality Improvement Resources, Inc. (HQIR), in 54 hospitals prior to their JCAHO surveys, 81.5% of hospitals were not in compliance with the standard for interdisciplinary nutritional care, spurring HQIR to suggest that the physician, dietitian, nurse, and pharmacist participate in developing a nutritional plan for patients at high nutritional risk.4

Nutritional deficits have long been recognized as contributing factors to morbidity and mortality of hospitalized patients. A multidisciplinary team approach to nutrition support has been shown in various studies to surpass a non-team approach. This team approach has demonstrated a proclivity in identifying patients in need of nutrition support, reducing the complications associated with enteral and parental nutrition, and providing cost-effective nutrition support in a variety of hospital environments.5,6,7 One study of enterally fed patients revealed a benefit of $4.20 for every $1 invested in NST management. NSTs repeatedly document their ability to reduce metabolic abnormalities of TPN, which in turn can reduce patient morbidity and hospital cost.5

Roberts started a nontraditional NST at Baylor University Medical Center in 1999. “All of the clinical dietitians get to do nutrition support at our facility. Our NST is aimed at education and research,” says Roberts, who reports that results of her NST study were published in Critical Care Nurse in 2003 and that she has plans of writing the results of a second study. According to Roberts, the data from this study showed that patients seen earlier by dietitians were discharged from the hospital and taken off the ventilator sooner.

An NST may indeed be the best way to ensure that patients receive appropriate nutritional support, but starting an NST from scratch is not an easy endeavor. The team members must be highly motivated, committed, and persistent. The working relationships among the team members must be strong, and good communication must rule the day. The healthy NST requires careful planning, sensitive implementation, and plenty of monitoring to make it successful. To maintain its position in a constantly changing environment, the NST must have the ability to look forward to patient outcome and discharge, as well as backward to historical data to monitor effectiveness. And a successful NST will be as committed to its own development as it is to the care of the individual patient.8

Role Playing in NSTs
“It can be challenging to develop a team with specific roles. Most teams include a pharmacist, nurse, and physician, in addition to the registered dietitian with loosely defined roles among each discipline,” says Jennifer Lefton, RD, CNSD, of Jackson Health System in Miami and editor of DNS’s Support Line. In many hospitals, strong political leaders may question the need for an NST. The NST involves projecting the roles of all members of the interdisciplinary team into the big picture.

“In some facilities, there are challenges about the dietitian’s role. I have witnessed struggle and overlap regarding who should be doing what,” remarks Lefton. But NSTs offer dietitians an opportunity to become integral in nutrition support, often occupying leadership roles on the healthcare team. Dietitians need to collaborate with all healthcare professionals, which should come naturally as the nature of dietetics is to draw on the knowledge of many disciplines to develop nutritional care plans. Zooming in on improving standards of care, which includes developing clinical pathways and applying practice standards and guidelines, is a role dietitians can sink their teeth into.9

“There are many variations of what one might call a nutrition support team. Some hospitals have a dietitian and pharmacist who are based in separate departments and function as a nutrition support team, while others have multiple positions,” says Malone.

In Japan, a new system for interdisciplinary NSTs is referred to as the potluck party method, in which each participant brings a single “dish of food to share.” The NST is operated and managed by each department, which contributes a small amount of staff and resources at one time. One or two staff members are selected from each department to carry out the work on the NST as they go about their routine duties. This form of NST demonstrated results such as decreases in the number of nutritional management problem cases, reductions in the incidence of catheter sepsis, reductions in the number of patients with poor food intake, prevention of pressure ulceration, attempts to eradicate nosocomial infections, decreases in mean length of hospital stay, and a total cost benefit of at least U.S. $1 million per year.10

NSTs have found a home away from hospital beds as well. Carol Ireton-Jones, PhD, RD, LD, CNSD, national director of nutrition services for Coram Healthcare, has successfully applied the NST model to home care. With more than 70 infusion branches throughout the country, the NSTs started in a few locations but grew to include every branch. “Now it’s not an option—they all have nutrition support teams,” says Ireton-Jones. Her team analyzed the data on their NSTs, looking at the outcomes of the management of patients using NSTs. According to Ireton-Jones, the data showed decreased length of therapy, decreased days of hospitalization and rehospitalization, an increase in ways to improve eating and tolerate food better, reduction of nutrition support needs, and increased quality of life. The results were published in an abstract in Nutrition in Clinical Practice.

NSTs up Close and Personal
“Patients are very challenging to work with now; the acuity is going up,” comments Lefton. These sorts of challenges direct the dietitian to focus on tasks of nutritional assessment, measuring whether the nutritional support is adequate, recommending or prescribing the best nutritional therapy for each patient, managing the nutrition support therapy, preventing complications during nutritional therapy, and responding to consultations on nutritional support. The responsibilities should be structured to include clinical nutritional therapy, home nutrition, education, research, quality improvement, leadership in promoting quality nutrition support practice, self-assessment, and to provide continuing professional education while keeping in mind ethical manner, focus on outcome performance, direct observation, evaluation of care plan, review of results, and mentoring and peer review.9,13

Winkler challenges NST members to “truly look at patient safety issues such as complex treatments, monitor them, and look at possible outcomes.”

Start-Up Suggestions
1. What does your hospital need? “The nutrition support team must fit the culture of your hospital,” says Roberts. There is no exact science in developing the perfect NST. Deciding what model best fits your hospital is important in ensuring that it will work.

2. Test the political waters. “You must have administrative support,” advises Roberts. “It is especially challenging to convince the hospital administrator to put a team together,” says Lefton. Dietitians would be well-advised to hone their political skills and persuasive abilities when it comes to convincing administrators that NSTs are essential elements in their hospitals.11

3. Establish cost benefits. “Quantify potential cost savings of having a team assist with managing patients receiving parenteral nutrition—for example, reduced waste of compounded [parenteral nutrition] bags,” says Malone. NSTs must understand the financial and operational climate of the hospital to weather changes. Cost-benefit analysis must be done to get hospital administration behind the NST. The challenge of each individual on the team is to produce proof of its effectiveness, looking beyond improved nutritional care. Focusing on issues such as TPN waste and reduced costs in products, equipment, techniques, or services are methods to support the NST.12

4. Create a skillful team. “The dietitian is an essential part of the nutrition support team,” says Ireton-Jones. Certification in nutrition support has been available to dietitians since 1988 for the purpose of setting standards for basic nutrition support competency. Roberts developed a nutrition support exam focused on TPN in her facility and put together a binder on practical information to set up a competency program for her dietitians.

“Identify a partner, department, or professional that shares a common interest and desire to improve care in nutrition support patients,” suggests Malone. Getting a physician with whom you have a good rapport and who is also willing to devote time to a nonreimbursable pursuit might pose a challenge, but it is important in promoting the goals of the NST. “Partner with a strong physician in your facility who can support your plan or proposal, especially to managers and administrators,” suggests Malone.

Other competent individuals may be wooed, especially those with skills and practice-based competencies such as feeding tube insertion, establishment of venous access, prescriptions for nutrition support therapies, drug interactions, preparation of enteral and parental formulations, management of feeding devices, care of access site, and age-specific competencies, depending on clinical privileges in various settings.13

5. Set goals of the committee. What will the NST tackle? Perhaps they may address feeding solutions, equipment, patient advocacy, assessments, estimation of needs, mentoring, glucose management, and troubleshooting. “Identify areas of nutrition support practice where improvements can be made with a team approach,” adds Malone.

6. Putting protocols into place. “Look at practical issues beyond the hospitals’ philosophy, such as how to cover the weekends,” says Roberts. The NST must set clear guidelines for key activities surrounding nutrition support, such as issues of drug-nutrient interactions, monitoring sites and feeding lines, and covering responsibilities.

7. Establish frequency. Find a formula that will work to schedule meetings, rounds, and educational events.

8. Consider discharge planning. Cover the whole spectrum as part of the team approach—from patient education to home nutrition support. Winkler sees nutrition support in home care as a true opportunity for dietitians to make a difference.

9. Education is integral. Make education of hospital staff and patients on nutrition support a priority in your NST. “Education is a significant part of the nutrition support team,” says Winkler, who is actively involved in training residents and fellows in nutrition support in her hospital.

10. Collect data. Establish a monitoring form for quality management that measures criteria chosen by the team and analyze the data. Rhode Island Hospital’s NST has been in place for 19 years, so Winkler manages years of data that are valuable in analyzing hospital outcome and trends as an educational tool and to help sustain their program.

11. Don’t forget self-assessment. Schedule regular self-assessments of the NST to check performance. Even if you can pat yourself on the back, glowing in the knowledge that your NST is running like a fine-tuned machine, it’s not time to sit back and relax. Malone cautions, “Having a team in place is no guarantee of long-term employment. In this era of financial restraint, nutrition support teams need to critically demonstrate how their role in nutrition support management improves or has the potential to improve patient outcome.”

But perhaps there is a silver lining to the cloud. Winkler adds, “I still think the future is bright. It is a challenging area to work with. Patients are really depending on these therapies to live and there are huge issues of quality of life on the horizon. As more work is done on intestinal rehabilitation and transplantation, there will be more dietitian involvement. With today’s emphasis on gastric bypass, there will be a great number of patients who will need nutrition support management.”

— Sharon Palmer, RD, is a freelance writer in southern California.

Nutrition Support Team Resource

• Dietitians in Nutrition Support: The mission of this American Dietetic
Association dietetic practice group is to advocate for dietetics professionals on all levels of the nutritional support continuum and serve the public through the promotion of optimal nutritional status.
For more information, visit www.dnsdpg.org or call 800-877-1600, ext. 4815.

• The American Society for Enteral and Parenteral Nutrition (ASPEN): This organization’s purpose is to promote professional communication among and within professional disciplines in the broad field of clinical nutrition, including enteral and parenteral nutrition, through meetings, seminars, exhibits, and publications.
For more information, visit www.nutritioncare.org or call 800-727-4567.

• The National Board of Nutrition Support Certification, Inc. (NBNSC): The NBNSC is an independent credentialing board established by ASPEN in 1984 to administer certification programs in specialized nutrition support. The NBNSC currently has certification programs for nurses, physicians, and dietitians.

For more information, visit www.nutritioncare.org or call 301-587-6315.

References
1. Nehme AE. Nutritional support of the hospitalized patient: The team concept. JAMA. 1980;243:1906-1908.

2. Clemmer TP. Nutrition support teams: Role in the new health care environment. Nutr Clin Pract. 1994;9(6):217-220.

3. The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Populations. Institute of Medicine. 2000:173-212.

4. JCAHO Care of Patients Standards that Generated Score 5-Non-Compliance in 1999-2000-Case Studies of 54 Hospitals, Health Care Quality Improvement Resources, Inc. Newsletter, Volume 2, February 6, 2001.

5. Cost-effectiveness of medical nutrition therapy. J Am Diet Assoc. 1995:95:88-91.

6. Wesley JR. Nutrition support teams: Past, present, and future. Nutr Clin Pract. 1995;10(6):219-228.

7. Jones JS, Tidwell B, Travis J, et al. Nutritional support of the hospitalized patient; a team approach. J Miss State Med Assoc. 1995;36(4):91-99.

8. Howard P. Organizational aspects of starting and running an effective nutritional support service. Clin Nutr. 2001;20(4):367-374.

9. The role of the registered dietitian in enteral and parenteral nutrition support – Position of ADA. J Am Diet Assoc. 1997;97:302-304.

10. Higashiguchi T. The roles of a nutrition support team. Nippon Geka Gakkai Zasshi. 2004;105(2):206-212.

11. Tougas JG. Starting a nutrition support team: Short-term pain for long-term gain. Nutr Clin Pract. 1994;9(6):221-225.

12. Suchner U, Dormann A, Hund-Wissner E, et al. Requirement for the structure and function of a nutritional support team. Anaesthesist. 2000;49(7):675-684.

13. Interdisciplinary Nutrition Support Core Competencies, A.S.P.E.N. Board of Directors. NCP. 1999;14:331-333.

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