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