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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