Team Approach to Nutrition Support John P. Grant, MD Professor 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 Sanders and Sheldon, Am.J.Surg., 132:214, 1976. 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%

Importance of Team Approach Nehme, J.A.M.A., 243:1906, 1980 1980 – Compared complications of nutrition support in two hospitals: One with a nutrition team (164 patients) One without a nutrition team (211 patients).

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 Complication Without Team With Team Electrolyte Imbalance 28% 3.6% pH Imbalance 14.7% TE Deficiency 3.8% 1.2% HHNKD 5.2% (4% died) 0% EFA Deficiency 4.3% Rebound Hypoglycemia 8% (1% died) Nehme, J.A.M.A., 243:1906, 1980

Importance of Team Approach Dalton, JPEN, 8:146, 1984 1984 – Compared complications of nutrition support when delivery changed: From a consultation service, to A TPN Team controlled service

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 Jacobs, J.Am.Coll.Nutr., 3:311, 1984 1984 – Compared complications of nutrition support: Before hiring a TPN Nurse After hiring a TPN Nurse

Importance of Team Approach Complication Without Nurse With Nurse Catheter Insertion Complications 10% 0% Catheter Sepsis 24% 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 Of just over 7000 hospitals in USA, 1500 could have NSS Team: IV Service; > 3 RD’s; and >4 pharmacists Hamaoui, JPEN, 11:412, 1987

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

Team Personnel - Duke 1 Physician and 1 Resident 1 Dietitian 3.0 Nurses 2 Pharmacists Hospital Physical Therapists Hospital Administrators

Duke Nutrition Team Activity

Duke Nutrition Team Activity

Duke Nutrition Team Activity

Duke Nutrition Team Activity

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, MD Professor of Surgery Director Nutrition Support Service Duke University Medical Center