Team Approach to Nutrition Support John P. Grant, MD Professor of Surgery Director Nutrition Support...
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Team Approach to Nutrition Support John P. Grant, MD Professor of Surgery Director Nutrition Support Service Duke University Medical Center
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Team Approach to Nutrition Support
John P. Grant, MDProfessor of Surgery
Director Nutrition Support Service
Duke University Medical Center
Importance of Team Approach
Delivery of nutrition support requires multidisciplinary expertise: Physicians – patient selection,
medical management, feeding access Dietitians – nutritional evaluation,
enteral and oral nutrition Nurses – Dressing management,
patient teaching Pharmacists – Compounding, drug-
nutrient pharmacology
Importance of Team Approach
The incidence of catheter-related infections during TPN was recorded over a 5-year period during which time a TPN Consultation Service was established:
There was a decrease in catheter-related infections from 28.6% to 4.7%
Sanders and Sheldon, Am.J.Surg., 132:214, 1976.
Importance of Team Approach
1980 – Compared complications of nutrition support in two hospitals:
One with a nutrition team (164 patients)
One without a nutrition team (211 patients).
Nehme, J.A.M.A., 243:1906, 1980
Importance of Team Approach
Complication Without Team
With Team
Catheter Insertion Complications
33% 3.2%
Catheter Sepsis 26.2% 1.3%
Line Days 8.7 18.6
Unnecessary line removal for ? sepsis
30.4% 11.3%Nehme, J.A.M.A., 243:1906, 1980
Importance of Team Approach
Nehme, J.A.M.A., 243:1906, 1980
ComplicationWithout Team
With Team
Electrolyte Imbalance
28% 3.6%
pH Imbalance 14.7% 3.6%
TE Deficiency 3.8% 1.2%
HHNKD 5.2% (4% died)
0%
EFA Deficiency 4.3% 0%
Rebound Hypoglycemia
8% (1% died) 0%
Importance of Team Approach
1984 – Compared complications of nutrition support when delivery changed:
From a consultation service, to
A TPN Team controlled service
Dalton, JPEN, 8:146, 1984
Importance of Team Approach
Complication Consult TPN Team
Catheter Insertion 35% 11%
Unnecessary removal
36% 10%
Metabolic 47.7% 26.3%
Dalton, JPEN, 8:146, 1984
Importance of Team Approach
1984 – Compared complications of nutrition support: Before hiring a TPN Nurse After hiring a TPN Nurse
Jacobs, J.Am.Coll.Nutr., 3:311, 1984
Importance of Team Approach
Complication Without Nurse
With Nurse
Catheter Insertion Complications
10% 0%
Catheter Sepsis 24% 0%
Metabolic 0.4% 0.1%
Jacobs, J.Am.Coll.Nutr., 3:311, 1984
Advantages of Team Approach
Fewer Mechanical Complications
Fewer Septic Complications
Fewer Metabolic Complications
Advantages of Team Approach Better Patient Selection
Under- vs Over-utilization More Use of Enteral vs
Parenteral Nutrition Cost-Savings
Enteral vs Parenteral Less wastage
Improved Monitoring
Structure of Nutrition Team
Advisory Board or Nutrition Committee
Consult Service
Defined Nutrition Team
Advisory Board or Nutrition Committee Develop care policies
Develop standard forms
Standardize products and supplies
Resolve conflicts
Consult Service Available to assist as requested
Work to standardize products and supplies
Monitor care delivery and make suggestions for improvement
Observe for potential complications
Usually a Nurse or a Dietitian
Defined Nutrition Team Typically control all aspects of
specialized nutrition care Nutritional assessment Placement of feeding access Writing of nutrition orders Monitoring clinical course Avoidance and recognition of
complications
Defined Nutrition Team Usually composed of:
Physician(s) Dietitian(s) Nurse(s) Pharmacist(s)
Goal of Team Approach
Identify patients at nutritional risk.
Perform nutritional assessment to document status and response to therapy.
Provide safe and effective nutrition support.
Physician’s Role Evaluate all patients referred for
nutritional care
Place intravenous or enteral access
Review and approve all nutritional support orders
Oversee all activities of the Team
Dietitian’s Role Perform initial and interval
nutritional assessments Determine nutrient requirements Monitor enteral fed patients daily
altering orders as necessary Assist in transition from TPN to
Enteral to oral nutrient intake
Nurse’s Role Conduct assessment of all patients Assist in patient-family relations Assist in TPN catheter insertion Maintain catheter dressings Perform home TPN training and
monitoring On 24 hour call for home patients
Pharmacist’s Role See all patients on TPN daily, review
laboratory values, and write formula orders.
Oversee compounding and monitor for solution incompatibility and breaks in sterile technique
Monitor for drug-nutrient interactions
Physical Therapist’s Role
Hospital Physical Therapists
Evaluate patients for muscle strengthening and increased activity
Perform passive range of motion for unresponsive patients
Administrator’s Role Hospital Administrators
Document cost/benefit of Team Represent Team with rest of
administration to support Team’s activities
Work to enhance billing and collections for Team activities
Nutrition Support Teams in USA
Hamaoui, JPEN, 11:412, 1987
Of just over 7000 hospitals in USA, 1500 could have NSS Team: IV Service; > 3 RD’s; and >4 pharmacists
Growth in Number of Teams
0
200
400
600
800
1000
1200
1400
1600
78 80 82 84 86 88 90 92 94 96 98 00
Year
Num
ber
of T
eam
s
Future Trends in USA
The number of TPN Teams is decreasing Budgetary Concerns Consolidation of Hospitals
The need for Team expertise is increasing Severity of Illness increasing Variety of specialty products
Nutrition Support Teams in USA
Hamaoui, JPEN, 11:412, 1987
Size of Nutrition Team
0
10
20
30
40
50
60
0 2 4 6 8 10 12 14 16 18 20
Number of Members
Num
ber
of T
eam
s
Team Personnel - Duke 1 Physician and 1 Resident
1 Dietitian
3.0 Nurses
2 Pharmacists
Hospital Physical Therapists
Hospital Administrators
Duke Nutrition Team Activity
Number of Consults
0
200
400
600
800
1000
91 92 93 94 95 96 97 98 99 2000 2001
Year
Nu
mb
er
Duke Nutrition Team Activity
Number of Assessments
0100200300400500600700800
91 92 93 94 95 96 97 98 99 2000 2001
Year
Nu
mb
er
Duke Nutrition Team Activity
Number of Patients Given TPN
0
100
200
300
400
500
91 92 93 94 95 96 97 98 99 2000 2001
Year
Nu
mb
er
Duke Nutrition Team Activity
Number of Patients Given TF
0
50
100
150
200
250
300
350
91 92 93 94 95 96 97 98 99 2000 2001
Year
Nu
mb
er
Duke Nutrition Team Results
Complication Incidence
Catheter Insertion (2560 insertions)
43 (1.6%)
Metabolic Abnormalities (2747 courses)
915 (33%)
Symptomatic Abnormalities 11 (0.4%)
Catheter-Related Sepsis
Type Catheter
Possibly Infected
Secondary Infection
True Infection
Single Lumen 479 Catheters
10 (2.1%) 11 (2.3%) 19 (4.0%)
Triple Lumen 89 Catheters
5 (5.6%) 2 (2.4%) 8 (9.0%)
Team Approach to Nutrition Support
John P. Grant, MDProfessor of Surgery
Director Nutrition Support Service
Duke University Medical Center
