Nutrition support team recommendations can reduce hospital costs

Nutrition support teams: Institution, evolution, and innovation

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.

Demonstrating the Value of the Nutrition Support Team to the C-Suite in a Value-Based Environment: Rise or Demise of Nutrition Support Teams?

Nutrition support teams (NSTs) in the United States have had to justify their existence since their inception in the 1970s. Concomitant with those efforts, changes in healthcare financing have challenged hospital administrators to adapt their reimbursement strategies and methods. NSTs, if they are to survive and/or thrive, must be aware of the convulsive currents of change faced by those who determine which programs move downstream and which find their demise on the banks of the stream. This review provides a historical perspective of both the US healthcare financing system and the NST experiences of nutrition clinicians over the past 4 decades. Focused discussions of 5 teams are provided from individual members of those varied NSTs. Additional recommendations from the administrative side of the equation are presented by 3 administrators. Whether NSTs will "rise or demise" depends on many factors. Understanding what those who control the purse strings are seeking in terms of salutary cost and quality outcomes in the current value-based system will facilitate the NST's communication with them. The demonstration of the NST's value is more likely to succeed when bolstered by current evidence-based data as applied to the specific institution. These efforts can be carried out by a formal NST in larger or academic institutions or a "virtual" team with a single individual coordinating the services in a transdisciplinary fashion, employing the acronym ACT (accountability, communication, [transdisciplinary] teamwork).

Indications and complications of inpatient parenteral nutrition prescribed to children in a large tertiary referral hospital

BACKGROUND

Parenteral Nutrition (PN) is prescribed to children with intestinal failure. Although life saving, complications are common. Recommendations for indications and constituents of PN are made in the 2005 guidelines by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). The aim of this study was to establish if the indications for prescribing PN in a tertiary children's hospital were appropriate, and to identify complications encountered. Data were compared to those published by the National Confidential Enquiry into patient outcome and death (NCEPOD) carried out in the United Kingdom in 2010.

METHODS

Children and newborns receiving inpatient PN over a 6 months period were entered into the study and data was collected prospectively. The appropriate indications for the use of PN were based on the ESPGHAN guidelines. Recorded complications were divided into metabolic, central venous catheter (CVC) related, hepatobiliary and nutritional.

RESULTS

A total of 303 children (67 newborns) were entered into the study. The main indications for the start of PN were critical illness (66/303), surgery (63/303) and bone marrow transplantation (28/303). The ESPGHAN recommendations were followed in 91.7% (278/303) of cases (95.5% of newborns, 90.7% of children). PN was considered inappropriate in 12/303 patients and equivocal in 13. The mean PN duration was 18 days (1-160) and the incidence of complications correlated to the length of PN prescribed. Metabolic, hepatobiliary and CVC related complications affected 74.6, 24.4, 16.4% of newborns and 76.7, 37.7 and 24.6% of children respectively. In relation to the appropriate indications for the start of PN our results mirrored those reported by the NCEPOD audit (92.4% of newborns and 88.6% children). However, the incidence of metabolic disturbances was higher in our cohort (74.6% vs 30.4% in children, 76.7% vs 14.3% in newborns) but CVC related complications lower amongst our newborns (16,4% vs 25%).

CONCLUSIONS

Although the indications for inpatient PN in children is mostly justified, there is still a proportion who is receiving PN unnecessarily. PN related complications remain common. There is a need for better education amongst health professionals prescribing PN and access to nutritional support teams to reduce unwanted side effects.

The Use of Parenteral Nutrition in an Acute Care Hospital

Introduction: Parenteral nutrition (PN) is an important supportive therapy. However, it is expensive and associated with significant complications. Our aim is to describe the patients given PN in 2006, to compare with the 2001 cohort and determine if PN had been prescribed for the appropriate indications. Materials and Methods: A retrospective cohort study of adult patients receiving PN between January and December 2006 was undertaken in a single institution. Appropriateness of indications for PN was based on the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines 2002. Results: One hundred and eighty-two patients received 194 courses (102 males, 92 females) of PN. Median age was 62 years (range, 16 to 100). Eighty-two percent were surgical patients and 18% were medical patients. Median PN duration was 9 days (range, 2 to 115). Common indications were surgeons’ anticipation of non-functioning gut postoperatively [47 (24.2%) courses], postoperative complications [33 (17.0%) courses] and postoperative ileus [31 (16.1%) courses]. Indications for PN met A.S.P.E.N. guidelines in 93.3% of cases compared to 78.3% in 2001. In 1.5% of cases, we were unable to determine if the indications met the guidelines. Ten courses did not meet the guidelines; 3 had PN for <7 days preoperatively, 6 had PN because the managing team thought the patients were critically ill and 1 was given PN for refusal to eat because of depression. Conclusion: Since 2001, there has been an increase in the proportion of PN given for appropriate indications. However, physician education with respect to the benefit of PN for preoperative and critically ill patients with functioning guts needs reinforcing. Key words: American Society for Parenteral and Enteral Nutrition (A.S.P.E.N) guidelines, Indications of Parenteral Nutrition, Inappropriate use of Parenteral Nutrition

Cost analysis of neonatal and pediatric parenteral nutrition in Europe: a multi-country study

OBJECTIVES

Parenteral nutrition (PN) is critical in neonatal and pediatric care for patients unable to tolerate enteral feeding. This study assessed the total costs of compounding PN therapy for neonates, infants and children.

METHODS

Face-to-face and telephone interviews were conducted in 12 hospitals across four European countries (Belgium, France, Germany and UK) to collect information on resources utilized to compound PN, including nutrients, staff time, equipment cost and supplies. A bottom-up cost model was constructed to assess total costs of PN therapy by assigning monetary values to the resource utilization using published list prices and interview data.

RESULTS

A total of 49,922 PN bags per year were used to treat 4295 neonatal and pediatric patients among these hospitals. The daily total costs of one compounded PN bag for neonates in the 12 hospitals across the four countries equalled euro 55.16 (Belgium euro 53.26, France euro 46.23, Germany euro 64.05, UK Ł 37.43/\[euro]42.86). Overall, nutrients accounted for 25% of total costs, supplies 18%, wages 54% and equipment 3%. Average costs per bag for infants <2 year were euro 84.52 (euro 74.65 in Belgium, euro 83.84 in France, euro 92.70 in Germany and Ł 52.63/euro 60.26 in the UK), and for children 2-18 years euro 118.02 (euro 93.85 in Belgium, euro 121.35 in France, euro 124.54 in Germany and Ł 69.49/euro 79.56 in the UK), of which 63% is attributable to nutrients and 28% to wages.

CONCLUSION

The data indicated that PN costs differ among countries and a major proportion was due to staff time (Ł 1=euro 1.144959).

Organisation, regulations, preparation and logistics of parenteral nutrition in hospitals and homes; the role of the nutrition support team - Guidelines on Parenteral Nutrition, Chapter 8

PN (parenteral nutrition) should be standardised to ensure quality and to reduce complications, and it should be carried out in consultation with a specialised nutrition support team whenever possible. Interdisciplinary nutrition support teams should be established in all hospitals because effectiveness and efficiency in the implementation of PN are increased. The tasks of the team include improvements of quality of care as well as enhancing the benefit to cost ratio. Therapeutic decisions must be taken by attending physicians, who should collaborate with the nutrition support team. “All-in-One” bags are generally preferred for PN in hospitals and may be industrially manufactured, industrially manufactured with the necessity to add micronutrients, or be prepared “on-demand” within or outside the hospital according to a standardised or individual composition and under consideration of sterile and aseptic conditions. A standardised procedure should be established for introduction and advancement of enteral or oral nutrition. Home PN may be indicated if the expected duration of when PN exceeds 4 weeks. Home PN is a well established method for providing long-term PN, which should be indicated by the attending physician and be reviewed by the nutrition support team. The care of home PN patients should be standardised whenever possible. The indication for home PN should be regularly reviewed during the course of PN.

Structure and organisation of 47 nutrition support teams in Germany: a prospective investigation in 2000 German hospitals in 1999

OBJECTIVE

Evaluation. Contrary to the Anglo-American region, very little is known in Germany on the structure and organisation of nutrition support teams (NST).

DESIGN

Prospective investigation of the structure and organisation of German NST, using standardised interview questionnaires.

SETTINGS

Hospitals with more than 250 beds in Germany.

SUBJECTS

German NST (n=47).

INTERVENTIONS

Face-to-face interview in 1999, using a standardised questionnaire.

RESULTS

From a total of 2000 German hospitals, NST have been established at 47 hospitals (2.3%). Most NST are affiliated to a large university hospital or an academic teaching hospital. In general, the NST are not independently operating units but are affiliated to a special discipline, and were in operation for an average of 8 y. The NST cared for a median of 65 outpatients annually. At the university hospitals in average, 477 in-patients were treated per year, at the teaching hospitals 400 and at all other hospitals 179. The work of the NST centred on enteral nutrition. A total of 47% of the physicians, 19% of the nurses and 19% of the dietitians in the NST held a nutrition-specific additional qualification. A total of 2% of the physicians, 68% of the nurses and 77% of the dietitians are exclusively responsible for the NST. More than 70% of the financing of the personnel was secured through third-party funds.

CONCLUSION

In Germany, neither uniform nor comprehensive patient care by NST existed in 1999. More than 50% of all NST members do not hold a nutrition-specific additional qualification. Frequently, besides their tasks in the team, the NST staff also carries out other clinical functions. Contrary to the American NST, the German NST are not interdisciplinary operating units but are primarily financed through third-party funds of the industry.

Survey on structure and performance of nutrition-support teams in Germany

BACKGROUND & AIMS

Interdisciplinary nutrition-support teams (NSTs) can improve the efficacy of clinical nutrition. The purpose of this survey was to investigate the prevalence, and structure of German NSTs.

METHOD

Hospitals in Germany with more that 250 beds were screened for the existence of NSTs. Eligible NSTs were interviewed about structural characteristics, administration of clinical nutrition and quality control in a face-to-face manner using a standardised questionnaire.

RESULTS

A total of 47 NSTs existed in Germany revealing a prevalence of 5.6%. Their main activities were creating nutritional regimens (100%), education (98%) and monitoring nutrition therapy (96%). Twenty-two of NST-physicians (50%) had a specific education as compared to 20.9% NST-nurses and 24% NST-dietitians. Only 12.7% of physicians and 17% of dieticians in comparison to 55.3% of nurses received funding support. Improvement of clinical nutrition by means of increased use of enteral nutrition and special diets was indicated by 72%, 23%, respectively. Some NSTs indicated a reduction of complications (38.3%) and cost-saving (34%) since their establishment.

CONCLUSIONS

There is a low prevalence of interdisciplinary NSTs in Germany. Standards of practice, development of guidelines in clinical nutrition and better documentation in NSTs are necessary. Special efforts should be aimed at education of NST members and financing of teams.

Jejunal feeding, even when instituted late, improves outcomes in patients with severe pancreatitis and peritonitis

This study assessed the feasibility and effectiveness of jejunal feeding (JF) after surgery due to secondary peritonitis or failed conservative therapy of severe pancreatitis. Of 60 patients, 30 were randomly assigned to receive postoperative JF and the remaining 30 constituted the control group. Acute Physiology and Chronic Health Evaluation II, nutritional intake, systemic inflammatory response syndrome, and outcomes were measured. Patients in JF group received the daily mean of 1294.6 (362.6) kcal including 830.6 (372.7.0) kcal enterally, versus 472.8 (155.8) kcal daily in the control group (P < 0.0001). There were fewer complications in the JF patients, with no significant difference; length of stay in the intensive care unit and in the hospital did not differ. The frequency of systemic inflammatory response syndrome was similar in both groups, but outcomes differed. The first surgical intervention resulted in 3.3% of relaparotomies in JF patients, caused by unresolved peritonitis, versus 26.7% in the control subjects (P = 0.03). Recovery of bowel transit took significantly less time in the JF patients (mean: 54.6 h versus 76.8 h in control subjects, P = 0.01). JF resulted in 3.3% mortality as opposed to 23.3% in the control group (P = 0.05). In conclusion, JF is feasible and effective in postoperative treatment of patients due to secondary peritonitis or severe pancreatitis. Improved bowel and peritoneal function could be the main impact of JF.

The medical and financial costs associated with termination of a nutrition support nurse

BACKGROUND

Cost-containment pressures have adversely affected hospital nutrition support team staffing. We determined the effect of termination of a nutrition support nurse responsible for patients receiving total parenteral nutrition (TPN) on quality assurance and financial indicators.

METHODS

A retrospective review of all 1,093 patients receiving TPN from fiscal year (FY) 1992 through FY 1998 in a tertiary care community hospital. We documented the changes in care during years when the nutrition support nurse position was staffed, terminated, and restored. Indicators studied included inappropriate TPN, central venous line sepsis, TPN wastage, and estimates of preventable costs.

RESULTS

When the nurse was present, 8.6% of TPN patients had a functional gastrointestinal (GI) tract and inappropriately received TPN compared with 12.1% when the nurse was absent, a risk difference of 3.5% points (95% confidence interval [CI], -.06 to 8.3; p = .069). Risk of TPN-associated line sepsis increased from 8.8% of patients when the nurse was present to 13.2% when the nurse was absent, a difference of 4.4% points (95% CI, 0.06 to 9.2; p = .028). In the absence of the nurse, 26.3% of TPN patients had preventable charges vs 17.5% when the nurse was present (p < .0001). Total preventable charges were higher in the years without a nurse (p < .003). Total preventable costs increased by $38,148 to $194,285 (depending on the estimate for sepsis) in the year after termination. Reinstatement of the nurse resulted in a decrease in costs between $34,485 and $156,654.

CONCLUSIONS

Adequate staffing of a nutrition support team reduced inappropriate TPN and complications of TPN. Financial savings of the same order of magnitude as the nurse's compensation accompany substantial decreases in patient morbidity.

Assessment of physicians' ability to prescribe parenteral nutrition support in a community teaching hospital

OBJECTIVE

To assess the knowledge and skill base of the physicians in our hospital in prescribing parenteral nutrition support.

DESIGN

Physicians completed parenteral nutrition orders for three mock patients. A range of clinically appropriate responses was established before the survey by the hospital Nutrition Support Team. Each case was scored according to set criteria, and the three case scores were averaged to yield a total score of 0 to 100.

SUBJECTS/SETTING

Forty-eight attending, resident, and student physicians in the departments of family practice, internal medicine, and general surgery in a community teaching hospital.

STATISTICAL ANALYSIS

Student's t test was used to compare interval data between two groups, and analysis of variance was used to compare interval data among three or more groups. If Bartlett's test for homogeneity of variance showed differences between the groups, the Kruskal-Wallis one-way analysis of variance was used. If analysis of variance revealed a significant difference, the data were reanalyzed using three different multiple-comparison procedures (Tukey, Scheffe, and Bonferroni) to decrease the possibility of a type I error.

RESULTS

The mean total score was 48.6 +/- 20.8. Total score differed according to the number of nutrition lectures attended during residency. Total score tended to differ by specialty and number of patients treated with parenteral nutrition; however, these differences did not reach statistical significance.

APPLICATIONS/CONCLUSIONS

This tool can be adapted and used by other hospitals, medical schools, and residency programs to assess physicians' knowledge base, design educational programs, and improve the parenteral nutrition ordering process.

A prospective audit of total parenteral nutrition at a major teaching hospital

OBJECTIVE

To examine patterns of use and clinical outcomes of total parenteral nutrition (TPN).

DESIGN

A prospective six-month audit (December 1992-June 1993).

PATIENTS AND SETTING

All inpatients administered TPN at a metropolitan teaching hospital during the audit period.

MAIN STUDY MEASURES

Process measures included data about TPN initiation (bodyweight, period not receiving oral/nasogastric feeding, serum albumin level, compliance with hospital guidelines), TPN delivery data (kilojoules, and nutrient and electrolyte content), and bases for cessation or changes of TPN (biochemistry data, gastric and intestinal function). Outcome measures included body mass change, infection rate, detection of biochemical abnormalities, and death.

RESULTS

During the audit 168 consecutive patients received 175 TPN courses. These patients were followed until discharge or death; 49 patients (29%) died. Intensive care units accounted for 57.7% of TPN use. Deviations from approved hospital guidelines for initiation of TPN were common. Only a minority of patients were malnourished on objective audit criteria; 18% of men and 13% of women were underweight by body mass index criteria and 36% were malnourished when serum albumin level (< 30 g/L) was considered. Early initiation of TPN outside accepted guidelines was common. Complications included bacteraemia (9.1% of patients tested) and catheter-tip sepsis (55.2% of 87 catheters tested). Four patients died; line sepsis caused one death and probably a further two. The incidence of glucose intolerance was 36.5%, and 25% had markers of abnormal liver function.

CONCLUSIONS

TPN use is associated with a high risk of morbidity, and a 1.7% mortality. We recommend better patient selection for TPN, more appropriate use of enteral feeding, better infection control procedures, avoidance of substrate overload (particularly glucose), and earlier change to enteral nutrition.