Team Approach to Nutrition Support
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Transcript Team Approach to Nutrition Support
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
33%
3.2%
Catheter Sepsis
Line Days
26.2%
8.7
1.3%
18.6
Unnecessary line
removal for ? sepsis
30.4%
11.3%
Catheter Insertion
Complications
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%
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%
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
Catheter Insertion
Unnecessary removal
Metabolic
Dalton, JPEN, 8:146, 1984
Consult
TPN Team
35%
11%
36%
10%
47.7%
26.3%
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%
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
More Use of Enteral vs Parenteral
Nutrition
Cost-Savings
Under- vs Over-utilization
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
Growth in Number of Teams
Hamaoui, JPEN,
11:412, 1987
1600
1400
Number of Teams
Of just over 7000
hospitals in USA,
1500 could have
NSS Team: IV
Service; > 3 RD’s;
and >4 pharmacists
1200
1000
800
600
400
200
0
78 80 82 84 86 88 90 92 94 96 98 00
Year
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
Size of Nutrition Team
60
Number of Teams
50
40
30
20
10
0
0
2
4
6
8
10
12
14
16
Number of Members
Hamaoui, JPEN, 11:412, 1987
18
20
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
1000
Number
800
600
400
200
0
91
92
93
94
95
96
Year
97
98
99
2000 2001
Duke Nutrition Team Activity
Number
Number of Assessments
800
700
600
500
400
300
200
100
0
91
92
93
94
95
96
Year
97
98
99
2000 2001
Duke Nutrition Team Activity
Number of Patients Given TPN
500
Number
400
300
200
100
0
91
92
93
94
95
96
Year
97
98
99
2000 2001
Duke Nutrition Team Activity
Number of Patients Given TF
350
Number
300
250
200
150
100
50
0
91
92
93
94
95
96
Year
97
98
99
2000 2001
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
Secondary
Infection
True
Infection
Single Lumen
10 (2.1%)
479 Catheters
11 (2.3%)
19 (4.0%)
Triple Lumen
89 Catheters
2 (2.4%)
8 (9.0%)
Type Catheter
Possibly
Infected
5 (5.6%)
Team Approach to Nutrition
Support
John P. Grant, MD
Professor of Surgery
Director Nutrition Support Service
Duke University Medical Center