Basics of Clinical Nutrition YK Joshi
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The Rationale for Nutritional Support and Organization of a Nutrition Support ServiceCHAPTER 1

K Sriram,
Eva Panizales
The importance of nutritional support (NS) was realized in the late 1970s. NS is not merely administering calories and proteins; it also includes the provision of all nutritional substrates to facilitate the biological processes of inflammation and healing. Nutrition support teams (NSTs) were started in hospitals to assist physicians in the nutritional care of patients. Some institutions used the term “Nutrition Support Service” while other used the term “Metabolic Support Service” a more apt expression. Several national nutrition societies were responsible for the spread of this concept and for defining NSTs as “a multidisciplinary, professional and scientific organization committed to promoting quality patient care, education and research in the field of nutrition and metabolic support in all health care settings.”1 It was also important to get hospital-based and iatrogenic malnutrition recognized as disease entities.
Establishment of NSTs was also responsible to elevate the status of dieticians in health care. Community-based nutrition alone was emphasized earlier, and hospital-based malnutrition was neglected. The importance of nutritional intervention was realized only after the differences between stressed starvation and simple starvation were better understood.
 
 
Need for Nutritional Support
In this day of specialization, it is difficult to find physicians with a sole interest in nutrition. The volume of knowledge, rapidity of growth, and changing concepts are also difficult to keep up with, especially due to the ease electronic dissemination. It is therefore important that the NST in each hospital functions as the “gatekeeper” for all aspects of NS. Members of the NST are responsible to review the literature, make changes in hospital policies, procedures and protocols, and to educate other members of the health care team on advances in NS. The most widely used and quoted guidelines are those published by the American Society for Parenteral and Enteral Nutrition.2 More recently regional 2guidelines such as those from Malaysia and Australia have been published. Regional guidelines take into account the prevailing local health care options and practice patterns, as well as cultural differences. Only recently have scientists recognized genetic variability in drug and nutrient metabolism.
The prevalence of malnutrition (as defined by currently accepted methods of nutritional assessment) in hospitalized patients even in developed countries is 30–50 percent.3, 4 The incidence, diagnosis, causes and effects of malnutrition and indications for NS have been reviewed.5 The effects of malnutrition on patient outcome are serious. Malnutrition affects practically every part of the body (e.g. muscle function, mental function, and immunity) and all organ systems. This results in an increase of morbidity, mortality, cost and period of convalescence. Several studies have shown a negative impact of malnutrition on clinical outcome.6, 7 Despite other advances in medical sciences, malnutrition continues to be a problem in hospitalized patients and a correlation continues to exist between malnutrition and poor patient outcome.8–10
Early detection and preventive intervention of malnutrition (sometimes even before biochemical or clinical markers become evident) can be expected to result in improved outcome. The science of metabolic support has advanced to such an extent and its necessity so blatantly obvious, that at present it is unethical to withhold NS to a group of patients for purposes of scientific study. In addition to improvement in the patient's sense of well-being and psychological status, definite improvements in cellular chemistry and therefore organ function11 as well as wound healing12 have been demonstrated. A meta-analysis of randomized controlled clinical trials on the usefulness of enteral nutrition in patients with critical illness and cancer concluded that there is significant reduction in developing infectious complications and a reduction in the overall length of stay, though there was no significant effect on mortality.13 Appropriate NS improves survival even six months after discharge from an intensive care unit.14
A nutrition support team has four important functions:15
  1. Assessments: Baseline nutritional assessment and follow-up assessments.
  2. Plan intervention: If malnutrition is currently detected, or the potential for the same is high, a patient-specific intervention is planned.
  3. Order intervention: The plan is put into action; enteral or parenteral nutrition (or combinations thereof) is provided.
  4. Monitor course: The clinical course is monitored by bedside evaluation, and assessment of laboratory parameters.3
 
Functions of the Team Members
The interdisciplinary team can be modified depending on the needs of a specific institution (Table 1.1). A detailed description of the responsibilities of members of an NST is provided below. Information in the format of an institutional policy with job descriptions is provided as an addendum to this chapter. The ideal team consists of:
Table 1.1   Organizational chart of nutrition support service
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Physicians16
A part-time physician of any specialty (medicine, surgery, gastroenterology, nephrology, critical care, anesthesiology, etc.) functions as the director. The physician must have a passion for nutrition and a thorough understanding of the subject. When differences of opinion occur between a dietitian and a member of the medical staff, the physician-leader must be willing to intervene, in the interest of patient care. It is also advisable to have two physicians designated to be members or co-directors of the NST for cross-coverage. The physician plays a pivotal role in the organization and function of a nutrition support team and is ultimately the final decision maker when conflicts of opinion regarding the plan of care occur.
 
Clinical Dietitians17
A full-time dietitian functions as co-director and head of the service. The clinical dietitian must be trained in enteral and parenteral nutrition and 4preferably must have completed a postgraduate certificate or diploma course in NS. The dietitian must keep up with the literature and must serve as a role model for the other (and perhaps younger) members. The more confident the dietitians are, the more respect they would command from hospital staff. All administrative and educational activities are coordinated by the full-time dietitian.
The responsibilities of the dietitian are numerous. After nutritional assessment is performed, a detailed report is written in the patient's records. Specific order sheets (for example, for parenteral nutrition or for nasoenteral feeding), must be placed in the patient's records. Follow-up evaluations are done including clinical and biochemical monitoring (Table 1.2). Intolerance to feeding regimens and early detection of potential complications are immediately brought to the attention of the physician.
The NST dieticians should ideally not have any kitchen responsibilities. If the hospital requires a dietitian to be in charge of the kitchen, a separate position is created for this function. The NST dietitian will merely serve to co-ordinate with the kitchen staff without any actual responsibility in its day to day functions.
 
Clinical Pharmacists18
The services of a clinical pharmacist are invaluable when cost-effective NS, especially parenteral, needs to be provided. The appropriate amounts of nutrients (dextrose, amino acids, fat emulsion, electrolytes, trace elements, vitamins and some medications) are mixed in the correct order and proportion, using aseptic techniques. In institutions where a large number of patients receive parenteral nutrition, especially when standard formulations are not adequate, a pharmacy-based parenteral nutrition mixing unit is essential. In other institutions where the use of parenteral nutrition is not as frequent, several commercial preparations are available with multiple compartments, making it somewhat easier, though more expensive, to provide a total parenteral nutrient admixtures. Even in such situations, the services of a pharmacist are invaluable. Pharmacists may be involved in dispensing enteral nutrition too. An important role of the pharmacist is to identify drug-nutrient interactions.
 
Nurses19
The main responsibility of a nurse is maintenance of peripheral and central vein catheters, and feeding ostomies (gastrostomy, jejunostomy). Instructions to the patient and family about the care of these devices after discharge are also nurse's responsibility. Nurses in renal departments familiar with catheter care, those in endoscopy departments who help to insert percutaneous gastrostomy tubes, and nurses involved in critical care are ideally suited to be assigned to the NST.
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Table 1.2   Algorithmic approach to nutritional support
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To summarize, the physician as a leader is an important component of a successful NST. A senior dietitian and several clinical dietitians are absolutely essential. The services of a part-time nurse might suffice for nursing-related activities of the NST. A pharmacist's involvement in NST is crucial. The specific roles of various members are not fixed and an 6overlap is essential. No job is too menial for any member of the team. Providing good quality health care without the help of an NST is akin to a pilot flying a jet airplane without a flight engineer or a cardiac surgeon performing complicated surgery without a perfusion technologist.
 
General Responsibilities of NST
  1. All high-risk patients (e.g. over age 50, critically ill, trauma, cancer, nephrology) are seen by the NST for a baseline nutritional screening. A detailed note is written. Re-evaluation is done in 3 days if the initial evaluation did not reveal any malnutrition or risk for same. The patient is seen daily by the NST. Appropriate interventions (enteral or parenteral nutrition, or combinations thereof) are recommended as soon as the risk of malnutrition is identified and modified depending on the requirements of the patient.
  2. Protocols for enteral and parenteral nutrition are set up by the NST, approved by hospital administration and the medical staff, and implemented. All aspects of NS including adherence to the set protocols are supervised by the NST.
  3. Formal teaching rounds lead by the physician-director, with the entire team, are conducted and all interesting cases are discussed periodically but at least twice a week.
  4. Journal clubs, meetings, case discussions and other educational aspects.
  5. Research (clinical and basic science).
 
Patient-specific Responsibilities
After the initial evaluation and intervention, the NST makes rounds on patients periodically, the frequency depending on the capabilities of the primary physician's confidence in handling nutritional issues and hospital policies. A responsible member of the team systematically evaluates the patient with a focus on nutrition and metabolism.
  1. Chart review:
    • Temperature, intake-output
    • Emesis, bowel movements (diarrhea and constipation)
    • Physicians' notes (daily progress notes, further plans)
    • Nurses' notes (problems with parenteral or enteral access)
    • Medication list (for potential drug-nutrient interactions)
    • Laboratory tests (especially electrolytes, glucose, blood urea nitrogen)
    • Imaging studies (e.g. position of central intravenous catheters, feeding tubes).
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  2. Patient review:
    • General
      • Sensorium
      • Tolerance to feeding, satiety/hunger, gastric residue volume, bowel movements
      • Hydration status.
    • Focused physical examination
      • Intravenous access sites
      • Position of feeding tube.
  3. Discussion with primary physician(s) and nurses.
  4. Documentation of visit, detailed written notes, suggestions for modi-fications. An example of the items to be covered in a follow-up note is provided in the addendum to this chapter.
 
Cost-effectiveness
The NST can become cost-effective by various mechanisms.20 The appropriateness of use of parenteral nutrition increases with involvement of a team, saving large amounts of resources for the institution and decreasing health costs for the patient. An aggressive approach by an NST to provide enteral nutrition decreases the unnecessary use of parenteral nutrition.21 Experience in accessing the jejunum for feeding purposes also results in a decrease in the inappropriate use of parenteral nutrition.22 It has even been reported that NSTs lead by general surgeons decreases inappropriate use of parenteral nutrition, though this may not be universally applicable.23 Unfortunately, even at present nutrition support, especially parenteral nutrition, continues to be used inappropriately.24
A difference in morbidity and mortality in an individual hospital cannot be easily demonstrated unless a well-controlled study is performed. It is difficult to do such a study and may even be unethical to withhold NS or the service of the NST. Thus, the way to convince hospital administrators about the cost-effectiveness of NS would be to first emphasize on its various beneficial effects namely a decrease in period of hospitalization, period of convalescence and a decrease in complications.
The literature strongly supports this concept.25 The importance of a NST has been shown clearly in both adult26 and pediatric patients.27
In addition, the use of pharmacy and laboratory services increase due to active involvement by the NST. The services of dietitians (in terms of initial assessments and consultations, re-assessments, outpatient counseling, home enteral nutrition training) can be cost-accounted, whether or not the department gets any direct financial benefit. The funds generated by these services are far greater than the expenditure to establish and maintain such a service.8
Standardized care can be provided only when the NST is actively involved in patient care, especially when disease-specific NS is administered. Monitoring by the NST also results in a more rapid resumption of enteral (and oral) intake and thus a decrease in the duration on parenteral nutrition, with obvious cost benefits. In summary, the role of an NST in diminishing complications of both parenteral28 and enteral nutrition29 is well-recognized. Reviews of trials have found that teams facilitate appropriate, effective and efficient use of NS.30–32
 
Conclusion
It is possible to run an organized NST even in facilities with limited resources. The importance of NS must be realized by all clinicians and administrators involved in hospital management, and by administrators. It makes no sense to spend funds on expensive equipment when an organized nutritional support service does not exist. Nutrition support teams are an integral part of evidence-based practice.33
REFERENCES
  1. American Society for Parenteral and Enteral Nutrition: Definition of terms used in ASPEN guidelines and Standards. J Parenter Enteral Nutr 2002;26:1S–138S.
  1. ASPEN Board of Directors: Guidelines for the use of parenteral and enteral nutrition in adults and pediatric patients. J Parenter Enteral Nutr 1993;17(4 suppl).
  1. Bistrian RR, Blackburn GL, Vitale J, et al. Prevalence of malnutrition in general medical patients. JAMA 1976;235:1567–70.
  1. Hill GL, Pickford I, Young GA, et al. Malnutrition in surgical patients—an unrecognized problem. Lancet 1977;1:689–92.
  1. Bettany GEA, Powell-Tuck J. Malnutrition: Incidence, diagnosis, causes, effects and indications for nutritional support. Eur J Gastroent and Hepatol 1995;7:494.
  1. Buzby GP, Mullen JL, Matthews DC, et al. Prognostic nutritional index in gastrointestinal surgery. Am J Surg 1980;139:160–67.
  1. Mullen JL, Buzby GP, Matthews DC, et al. Reduction of operative mortality and morbidity by combined preoperative and postoperative nutritional support. Ann Surg 1980;192:604–13.
  1. Giner M, Laviano A, Meguid MM, et al. In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition 1996;12(1):23–29.
  1. Pennigton CR. Malnutrition in hospital practice (editorial comment). Nutrition 1996;12(1):56–57.
  1. Von Meyenfeldt MF, Meyerink WJWJ, Rouflart MMJ, et al. Perioperative nutritional support—A randomized clinical trial. Clin Nutr 1992;11:180–86.
  1. Windor JA, Hill GL. Weight loss with physiologic impairment—A basic indicator of surgical risk. Ann Surg 1988;207:290–96.
  1. Haydock DA, Hill GL. Impaired wound healing in surgical patients with varying degrees of malnutrition. J Parent Enteral Nutr 1986;10:550–54.
  1. Heys SD, Walker LG, Smith I, et al. Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer. A meta-analysis of randomized controlled clinical trials. Ann Surg 1999;229(4):467–77.
  1. 9 Griffiths RD, Jones C, Palmer TEA. Six-month outcome of critical ill patients given glutamine-supplemented parenteral nutrition. Nutrition 1997;13(4):295–302.
  1. Buzby K, Colaizzo-Anas T. The nutrition support team. IN Contemporary nutrition support practice, a clinical guide, Matarese LE and Gottschlich MM (Eds): WB Saunders Co  Philadelphia:  1998;3–14.
  1. ASPEN (American Society for Parenteral and Enteral Nutrition) Board of Directors, Standards of practice for nutrition support physicians. Nutr Clin Practice 2003;18:270–75.
  1. ASPEN (American Society for Parenteral and Enteral Nutrition) Board of Directors, Standards of practice for nutrition support physicians. Nutr Clin Practice 2000;15:53–59.
  1. ASPEN (American Society for Parenteral and Enteral Nutrition) Board of Directors, Standards of practice for nutrition support physicians. Nutr Clin Practice 1999;14:275–81.
  1. ASPEN (American Society for Parenteral and Enteral Nutrition) Board of Directors, Standards of practice for nutrition support physicians. Nutr Clin Practice 2000;16:56–62.
  1. Nelson JK. Economics of nutrition support. In Contemporary nutrition support practice, a clinical guide, Matarese LE and Gottschlich MM (Eds): WB Saunders Co  Philadelphia:  1998;643–50.
  1. Newton R, Timmis L, Bowling TE. Changes in parenteral nutrition supply when the nutrition support team controls prescribing. Nutrition 2001;17:347–50.
  1. Mahesh C, Sriram K, Lakshmiprabha V. Extended indications for enteral nutritional support. Nutrition 2000;16:129–30.
  1. Saalwachter AR, Evans HL, Willcutts KF, et al. A nutrition support team lead by general surgeons decreases inappropriate use of total parenteral nutrition on a surgical service. American Surgeon 2004;70:1107–11.
  1. Chan SL, Luman W. Appropriateness of the use of parenteral nutrition in a local tertiary care hospital. Annals Acad of Med (Singapore) 2004;33(4):494–98.
  1. Hall JC. Nutritional assessment of surgery patients. J Am Coll Surg 2006;202(5):837–43.
  1. Mackenzie SL, Zygun DA, Whitmore BL. Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit. J Parenter Enteral Nutr 2005;29(2):74–80.
  1. Gurgueria GL. Leite HP, Taddei JAAC. J Parenter Enteral Nutr 29(3): Hall JC. Nutritional assessement 2005;176–85.
  1. Dalton MJ, Schepers G, Gee JP. Consultative total parenteral nutrition teams: The effect on the incidence of total parenteral nutrition related complications. J Parenter Enteral Nutr 1984;8:146.
  1. Brown RO. Enteral nutritional support management in a university teaching hospital: Team versus nonteam. J Parenter Enteral Nutr 1987;11:52.
  1. Gales BJ, Gales MJ. Nutritional support teams—A review of comparative trials. Ann Pharmacother 1994;28:227–35.
  1. Hassel JT, Games AD, Shaffer B, et al. Nutrition support team management of enterally fed patients in a community hospital is cost beneficial. J Am Diet Assoc 1994;94(9):993–98.
  1. Tucker HN, Miguel SG. Cost containment through nutrition intervention. Nutr Rev 1996;54:111–21.
  1. Schneider, PJ. Nutrition support teams: an evidence-based practice. Nutr Clin Pract 2006;21(1):62–67.
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POLICY
 
PROVISION OF SPECIALIZED NUTRITION SUPPORT IS THE RESPONSIBILITY OF THE INTERDISCIPLINARY NUTRITION SUPPORT TEAM
The Team consists of and practices the following duties and responsibilities:
  1. Nutrition Support Physician:
    1. Collaborate with other members of the NST to establish written policies and procedures for the provision of the specialized nutrition support (NS).
    2. Supervise all aspects of NS– nutritional assessment, development and implementation of care plan, monitoring, re-evaluation and termination of therapy.
    3. Act as liaison between the NST, the administrative and medical staff emphasizing the role of NS in the provision of high quality, safe appropriate and cost-effective nutrition care.
    4. Participate in planning, implementation, and evaluation of the educational programs in NS.
    5. Participate in clinical rounds to monitor the medical condition, nutritional status and progress of patients receiving NS.
    6. Participate in quality improvement activities to ensure compliance to standards of care set forth by the accrediting and supervising bodies.
  2. Nutrition Support Dietitian:
    1. Assess the nutritional status of the patient, employing clinical and diet histories, anthropometric measurements, laboratory data, physical examination and laboratory tests.
    2. Integrate above data to determine the patient's nutritional requirements and identify selection of parenteral or enteral formulations appropriate for the disease process and accessibility of routes.
    3. Participate in the daily NST patient rounds to monitor the nutritional status/progress of patients. The monitoring parameters include body weights, nutrient intake, fluid input and output, signs of intolerance to nutrition therapy and biochemical, hematological and other diagnostic data.
    4. Act as liaison between the NST and medical staff should problems or questions arise regarding the management and implementation of parenteral or enteral nutrition.
    5. Implement corrective actions should any metabolic, mechanical or other problems related to nutrition support occur.
    6. Evaluate termination of parenteral nutrition support and facilitate smooth transition to an enteral feeding regimen or oral diet.
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    7. Communicate with the unit dietitian regarding the patient's nutrition goal and endorse need for follow-up care for transitional feeding regimen.
    8. Document all nutrition intervention activities – assessment, monitoring, and reassessment of needs and care plan/recommendation in patient's medical record in a timely manner.
    9. Participate in quality improvement activities to ensure compliance to standard of care as set forth by accrediting agencies.
    10. Documentation in patient's medical records.
  3. Nutrition Support Nurse:
    1. Participate in initial nutrition assessment of patient referred to NST, employing clinical examination and laboratory data.
    2. Collaborate with the NST to integrate the above information to determine the indication for nutritional therapy and patient's needs/goals.
    3. Perform daily follow-up visits and data collection including weight, intake-output records, vital signs, laboratory results including electrolytes and glucose levels.
    4. Formulate and implement any corrective actions for metabolic, mechanical or other problems related to NS.
    5. Communicate with the primary physician or service requesting NS regarding any issues with the patient's nutritional care plan and recommendations.
    6. Participate in insertion of central or peripheral venous access devices, or enteral feeding tubes.
    7. Perform routine care of access routes used in the delivery of specialized nutrition support following standard protocol and infection control guidelines.
    8. Participate in an on-going educational activities.
    9. Educate patients and care-givers regarding parenteral nutrition therapy and or enteral feeding as part of discharge planning.
    10. Document in patient's medical record in a timely manner as indicated.
  4. Nutrition Support Clinical Pharmacist:
    1. Evaluate patient's requirements for electrolytes, trace elements and vitamins and recommend changes to enteral or parenteral nutrition to meet individual needs for particular disease states.
    2. Determine whether medications can be added to parenteral nutrition (PN) solution, or if any current drug therapy is affecting PN or vice-versa.
    3. Evaluate and monitor patients receiving specialized NS for any drug-nutrient interactions, and provide appropriate recommendations.
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    4. Evaluate PN solutions for compatibility (including base solutions, electrolytes, trace elements, etc) and ease of compounding.
    5. Monitor patients of any metabolic abnormalities (including electrolyte, acid-base balance abnormalities and serum glucose levels), making recommendations to adjust the PN solution accordingly.
    6. Monitor all aspects of pharmacotherapy especially drug-drug and drug-nutrient interactions.
 
Nutrition Support Team Follow-up Note
  • Current diagnosis
  • Significant 24-hour events
  • Weight used for calculations
  • Current diet order
  • Enteral nutrition ordered:
    • Route, product, rate of administration, total calories/day, total protein/day
  • Parenteral nutrition ordered:
    • Route, rate, total calories/day, total protein/day
  • Patient currently receives:
    • Total calories/day, total calories/kg/day
    • Total protein/day, total protein/kg/day
  • Assessment of access route (enteral)
  • Assessment of access route (parenteral)
  • Pertinent laboratory results
  • Miscellaneous information
  • Plans.