January 2009 Issue

Team Spirit: Pulling Together to Create Effective Nutrition Support Teams
By David Yeager
Today’s Dietitian
Vol. 11 No. 1 P. 44

Being part of a team means filling a valuable role. The best teams have people who complement each other and push the group’s performance beyond that of the individual. In a healthcare setting, this concept is especially important. Physicians, nurses, pharmacists, and dietitians each play important roles, but their efficacy increases when they work together.          

One area where teamwork can have a profound effect is in the delivery of enteral and parenteral nutrition. “One of the main benefits that we’ve found is the consistency, especially in ordering practices,” says Wendy Phillips, RD, CNSD, CLE, of Kern Medical Center in Bakersfield, Calif. “We’re a teaching hospital, and we have a lot of residents coming in and out. There were a lot of inconsistencies with ordering nutrition support, whether it was enteral or parenteral nutrition support.”

Since Kern instituted nutrition support teams (NSTs) in November 2007, there has been an 85% reduction in ordering errors related to enteral and parenteral nutrition.

More Than the Sum of Its Parts
NSTs take advantage of expertise in various disciplines. A fully staffed NST may consist of dietitians, physicians, nurses, and pharmacists. Some teams also include respiratory therapists and surgeons. Within that framework, dietitians are able to provide greater detail about a patient’s nutritional needs when a doctor sees a patient. They also provide valuable help with following the patient’s progress.

“We’re looking for electrolyte imbalances; complications, whether they’re infectious or metabolic complications; adequacy of the support if the patient’s losing weight; if there are changes in their lab values; any medications that may have been ordered that may be incompatible; or perhaps medications that should have been ordered to improve the nutrition support tolerance,” says Phillips.

In addition, NSTs allow clinicians to start nutrition support earlier, when necessary, and assess the proper route (the digestive tract or the bloodstream) for feeding, says Jennifer Wooley, MS, RD, CNSD, nutrition services manager at the University of Michigan Hospital in Ann Arbor.

“Home nutrition support follow-up is another benefit of having an NST because it allows continuity of care,” says Theresa A. Fessler, MS, RD, CNSD, a nutrition support dietitian at the University of Virginia Hospital. “We know the patients’ home plans and how they are tolerating nutrition support before and after hospital admissions and can share notes with other team members.”

Physicians also benefit from the dietitians’ expertise, says Fessler. “The doctors get more expert [information] because the nutrition support dietitians are more knowledgeable in the areas of enteral and parenteral nutrition, fluid and electrolyte management, and the different disease states that usually need parenteral or enteral nutrition,” she says. “The doctors really appreciate our input. We e-mail with them. We talk to them face-to-face, and they have us do a lot of things they don’t want to do, like entering parenteral and enteral nutrition orders.”

Proving Their Value
The first, most important step for building an NST is getting buy-in from key people. “Dietitians are pro-nutrition support team all the way, but we are one member of the team,” says Wooley. “You need a strong administrator or physician champion to really make this work.” Building relationships with other stakeholders demonstrates broad support for the project and increases its profile.

When Phillips pitched NSTs to her hospital, she came armed with plenty of reports and data but also with the names of the physicians, pharmacists, nurses, and dietitians who had agreed to take part. Her request was approved easily, “partially because two of the very well-respected pharmacists had signed on and two of the very well-respected physicians had signed on,” she says. “So, since we’d already built relationships with them, it gave a lot of respect to the project.”

With all of the benefits that NSTs offer, you might expect that they are the standard of care, but that’s not the case. When parenteral nutrition first became popular in the 1970s, there were a lot of errors related to the therapy, Wooley says. Because of this situation, the idea of interdisciplinary teams designed to optimize therapy and improve safety was born.

“All through the ’80s and early ’90s, nutrition support teams were being created across the country,” says Wooley. But difficult economic times in the early ’90s put the brakes on these initiatives. “The financial justification for nutrition support teams became questioned,” she says, “and a lot of nutrition support teams around the country disbanded.”

Today, financial considerations are still at the forefront of healthcare delivery. Convincing management to allocate staff for NSTs can be difficult, especially when personnel are at a premium. “That seems to be the biggest challenge that I’ve seen in the hospitals that I’ve worked at,” Fessler says. “And I guess you just have to convince the management that the care is going to be superior.”

“We have to show that we make a difference, that nutrition support teams, if they can become and stay cost-effective, can realize benefits to patients at minimal costs to the institution,” adds Wooley.

Dietitians are working to demonstrate that while NSTs may add costs in terms of staffing, they reduce costs in other ways. “There are some studies on the appropriateness of parenteral nutrition use. When there’s a team involved, usually it helps to prevent inappropriate use of parenteral nutrition, which is a problem in hospitals that don’t have teams,” says Fessler.

“Some of the strongest arguments for a nutrition support team are that these highly trained, interdisciplinary members recognize and treat malnutrition early and efficiently, and that translates into reduced morbidity and mortality,” says Wooley.

Wooley adds that there are a wide variety of nutritional substrates from which to choose. Some are cost-effective, and some are extremely specialized and expensive. A dietitian on an NST is in a position to advise an attending physician on the most effective choice for a particular patient. “A nutrition support team would help the physician taking care of the patient choose the right substrates to deliver either enterally or parenterally, and that not only cuts cost up front but decreases waste downstream,” she says. “And, ultimately, what we want to do is minimize length of stay in the ICUs [intensive care units] [and] costs related to healthcare and optimize quality of life.”

To prove that NSTs can do that, outcomes need to be tracked. “You have to show that’s there’s a need and that you can recoup the money that you’re going to extend to create those positions. And then you have to have good outcome indicators [to track the efficacy of the program],” says Wooley. She says some outcomes that hospitals may want to track include incidents of catheter sepsis, the number of ventilator days, metabolic complications such as hyperglycemia, and whether patients are getting out of the ICU sooner. “Finding the end point to the outcome indicators will really help to justify the work that you do and then [allow for] creating a billing mechanism.”

Billing for services is an important aspect of maintaining an NST. “If you’re not generating revenue, it’s hard to justify this type of a service,” says Wooley. “And even if you are billing for your services, what kind of revenues do you capture with third-party payers and capitated diagnostic-related groups? It’s hard to get good reimbursement for some of the services that we offer as nutrition support clinicians.”

Building Teams
Because reimbursement is such a challenge and each hospital has its own priorities, NSTs come in various shapes and sizes. “On the nutrition support team that I’m on now, we’re all RDs,” says Fessler. “There is also a GI [gastrointestinal] physician whom we work with on our medicine nutrition support team, and there is a surgeon or several surgeons on the surgery nutrition support team at this hospital.” At a hospital where she previously worked, there were also pharmacists and a certified nutrition support nurse on the NST who helped provide comprehensive care. Although pharmacists and nurses aren’t specifically allocated to Fessler’s current team, she still works closely with them.

In addition, some hospitals offer services to outpatients to defray costs. “Oftentimes, in order to make the team more solvent, because they get better reimbursement for outpatient care, they offer services to both inpatients and outpatients,” says Wooley.

For facilities that would like to start NSTs, there are many ways to educate the participants. “We do journal clubs where we review publications from the various disciplines,” says Phillips. “We do a lot of it from ASPEN [the American Society for Parenteral and Enteral Nutrition] because they are very good at being multidisciplinary already.” The team members also do training within their own disciplines and report back to the group.

In addition, they do case studies on the patients and the hospital, which allow them to voice their concerns about particular events. “We can all put in input about what we might have done in this situation,” Phillips says. “The case studies are actually the ones that facilitate the most learning.”

For new dietitians, learning about NSTs is mainly a hands-on task; there is only a modicum of training about nutrition support teams at most universities. “You get nutrition support practice training, and that would be on the job. There are credentials that you can achieve by taking certification examinations, like the certified nutrition support clinician (CNSC) credential,” says Wooley. “And then, mentorship cannot be [overemphasized]—the peer-to-peer training that happens on the team once you’re functioning.”

Experience is a big determinant of how soon a new hire can be up and running on an NST. “If they’re fresh out of school, it’s going to take about a year to get them to where they’re working on their own without them having to ask a lot of questions. I would say nine months to a year,” says Fessler. “Now, if we hired someone with a lot of experience, it would only take a couple of months.”

Even at hospitals that don’t have specific nutrition support teams, dietitians can still make their presence felt. “I’ve positioned our dietitians to be rounding every day with interdisciplinary teams in the intensive care unit so that they’re present and they’re visible to offer their expertise,” says Wooley. By participating in daily rounds, dietitians are able to directly participate in the decisions that affect a patient’s care for that day in an interdisciplinary setting. “So, even if you don’t have a team, all the disciplines are there discussing the patient every morning,” she says. “We make our recommendations verbally, in addition to the medical record, and we hear the feedback for those. We hear what the other priorities for the patient are that day, and then we fit our recommendations into what’s realistic.”

 Raising NSTs’ Profile            
Although dietitians can still work with other disciplines if their facility doesn’t have an NST, being part of a team has advantages. “I’ve worked on teams at this and another hospital, and I’ve worked at a couple of hospitals that did not have teams, and it was much harder to do what I wanted and to get my orders approved when there was not a team,” says Fessler. “We weren’t as well respected when there wasn’t a team.”

“We realize that there’s room for improvement, and it really doesn’t begin for most disciplines outside dietetics unless they have a personal interest or they have mentors that, once they get into practice, increase their awareness to the point that they’re seeking information on their own, or they’re working at a hospital where a strong team presence is already there,” says Wooley.

Part of the problem, she says, is that nutrition is viewed as an ancillary service. She notes that when those from other disciplines assess a patient, diet is usually fourth on the list of important considerations—airway, breathing, circulation, and then diet.         

“I think there’s room for improvement in the training of other disciplines to appreciate the role of nutrition,” Wooley says. “That’s the dietitians’ biggest battle: to prove the value of nutrition.”

— David Yeager is an editorial assistant at Today’s Dietitian.

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