The nutrition support team: surviving and thriving in an era of reform

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).

Once upon a storm: Katrina and nutrition support or the lack thereof

Nutrition support teams face many challenges to establish, fund, maintain, and justify their existence. Some of the challenges can be resolved over time. However, the challenge of providing nutrition in general and nutrition support in specific during a natural disaster is void of the luxury of time experienced with the previously delineated challenges. The experience of Methodist Hospital in New Orleans, Louisiana, during Hurricane Katrina in 2005 in providing nutrition and nutrition support is summarized in this invited article. The recollections of various represented disciplines are bolstered by tables and figures that outline the 7 days before and after Katrina. Transdisciplinarity was exhibited through the performance of nontraditional functions or tasks by a variety of professionals who lived 5 days or longer in the “Methodist Island.” Lessons learned and considerations for disaster preparedness as it relates to nutrition and nutrition support as well as general considerations are provided.

Organizational aspects of starting and running an effective nutritional support service

Setting up and running a Clinical Nutritional Support Team can be challenging and is time consuming. Team members have to be motivated, committed and persistent. High quality working relationships are fundamentally important within the team, between teams and with other healthcare professionals. Good communication, careful planning, sensitive implementation and robust monitoring are the cornerstones of a successful service. Looking forward as well as back will help the team to maintain and improve its position in an ever-changing environment. While nutritional support is everyone's business, an effective multiprofessional Clinical Nutritional Support Team is the best way to ensure that patients receive appropriate and timely treatment. It is also wise to remember that a successful Clinical Nutritional Support Team will be as committed to its own development as it is to the care of the patients referred to it.

Protein-energy undernutrition in hospital in-patients

Impaired nutritional status has been frequently reported in surveys estimating its prevalence amongst patients in hospital. While there is no doubt that protein-energy undernutrition has serious implications for health, recovery from illness or surgery and hospital costs, lack of nationally or internationally accepted cut-off points and guidelines for most nutrition-related variables make nutritional assessment difficult and proper comparisons between studies impossible. In reviewing published work in which the prevalence of undernutrition has been assessed, it can be seen that each study defined undernutrition, or nutritional risk, using different methodology. This present review aims to highlight the problems which arise when deciphering these studies, and the resulting difficulty in determining the true prevalence of undernutrition and nutritional risk, amongst both general and specific groups of hospital in-patients. It is widely agreed that routine hospital practices can further adversely affect the nutritional status of sick patients in hospital. How this occurs, and the potential effects of impaired nutritional status on clinical outcome are examined. The methods currently available to assess nutritional status are evaluated in the knowledge that such assessments are difficult in clinical practice. The review concludes by proposing that if we want the medical and nursing professions to consider the nutritional status of hospital patients seriously, definitions of undernutrition and nutritional risk, and cut-off values for the nutritional variables measured must be agreed to allow evidence-based practice. Outcome measures which allow clear comparisons between groups and treatments must be used in studies assessing the effects of nutritional interventions.

Malnutrition and clinical outcomes: the case for medical nutrition therapy

Malnutrition is not a new or a rare problem. In studies involving more than 1,327 hospitalized adult patients, 40% to 55% were found to be either malnourished or at risk for malnutrition, and up to 12% were severely malnourished. Surgical patients with likelihood of malnutrition are two to three times more likely to have minor and major complications as well as increased mortality; and their length of stay can be extended by 90% compared with the stay of well-nourished patients. Hospital charges are reported to be from 35% to 75% higher for malnourished patients than for well-nourished patients. Obtaining data to assess the nutritional status of patients is essential to optimal patient care, especially for patients at high risk for malnutrition. Nutrition assessment can be done with readily available and relatively inexpensive methods. But it is not enough to assess and identify malnutrition. Outcomes are improved and costs are saved only when appropriate intervention follows. This article identifies many well-conducted, published studies that support the findings that health outcomes of malnourished patients can be improved and that overall use of resources can be reduced by nutrition counseling, oral diet and oral supplements, enteral formula delivered via tube, and parenteral nutrition support via central or peripheral line. Early nutrition assessment and appropriate nutrition intervention must be accepted as essential for the delivery of quality health care. Appropriately selected nutrition support can address the problem of malnutrition, improve clinical outcomes, and help reduce the costs of health care.