Area Wide Nutritional Suppo rt Ser vice Richard E. Dean, M.D.
Abstract: Nutritional deficiencies have been identified as a problem of major concern t o all persons involved in health care delivery. Development of nutri-
tional services in several medical centers across the country has demonstrated the effectiveness of this program as an adjunct to improved patient care. Expansion of these benefits through an Area Wide Nutritional Support Service has been organized through a network of educational programs, organization of hospital nutrition committees, and communication links. Involvement of physicians, nurses, dietitians, and pharmacists in a Nutrition Team a t the local and area-wide level is essential t o the success of the program. A Physician-Director, Nurse-Educator, and Dietitian in a major community medical center are responsible for the ongoing educational programs directed t o physicians, nurses, and paramedical personnel in t h e surrounding communities and t h e maintenance of a model Nutritional Support Service a t t h e medical center. Educational and research affiliations with several colleges and universities have provided a model clinical resource for the education of medical students, residents, and clinical experiences for pharmacists and dietitians.
The introduction of hyperalimentation by Dudrick et all in 1968 signalled the beginning of a new era in clinical
Dr. Deati is Associate Professor of Surgery, Col1ege of Hujnatl hledicbie. Alicliigari State University, and Director o f Surgery, Grand Rapids Campus. Reqirests for reprints should be addressed to Richard E. Dean, hL D., 220 Cherry Street, S.E., Grand Rapids, Alichigari 49502.
THE JOURNAL OF PARENTERAL AND ENTERAL NUTRITION
nutrition. The ability to provide total nutritional support parenterally to the clinically ill patient has offered a unique opportunity for the clinician in his efforts t o improve patient care and has provided a new tool for the research nutritionist. Knowledge in this area has expanded rapidly in recent years as a result of these developments. Numerous methods of providing nutritional support enterally and parenterally have been developed, and a variety of commercial products are now available to meet specific patient needs. The complexities inherent in these multiple techniques and specialized products have confused many clinicians. Sporadic use of hyperalimentation and other nutritional support techniques by physicians using numerous products and multiple formulations in a single institution without corresponding educational programs has produced confusion and frustration of the paramedical staff. Personal review of hospital records in several community hospitals where hyperalimentation is practiced. sporadically has identified catheter sepsis rates up to 20 percent and mortalities of 5 percent. In those institutions where a single nutritional support service has been established, patients with protein-calorie malnutrition are identified early and appropriate nutritional support measures are instituted with minimal risk and maximum benefit to the patient.* In an attempt to provide comparable quality care to patients in multiple hospitals over a large geographic area 105
AREA WIDE SUPPOIlT
(western hlichigan), an Area Wide Nutrition Team has been established. The primary goal of this team lias been to: 1. Improve the quality of nutritional care of hospitalized patients. 2. Provide educational programs for physicians, nurses, pharmacists, and dietitians. 3. Establish communication linkages with medical and paramedical personnel involved in nutrition throughout the region. 4. Establish a model clinical nutrition service in a medical center hospital. 5. Develop a working relationship with regional academic and research institutions involved in nutrition. 6 . Provide a clinical educational experience for medical students, residents, dietetic, nursing, and pharmacy students. 7. Provide practical nutritional support to outlying smaller hospitals. The Area Wide Nutrition Team in western hlichigan is located on the Grand Rapids Campus of hlichigan State University. The chairman of this team is a university surgeon whose major clinical interests are in the area of nutrition and metabolism. Members of the team include physicians, house staff, pharmacists, dietitians, and nurses, representing each of the hospitals in Grand Rapids. Additional members include interested physicians, dietitians, and pharmacists from other hospitals located in western hlichigan. A member of the faculty of the Department of Food Science and Human Nutrition, Michigan State University, and pharmaceutical representatives interested in nutrition are also team members. hleetings are held at regular intervals to discuss current problems and recent developments at each of the involved institutions. Recent advances in nutrition are presented by team members, and priorities for team activities are established. Affiliation with the Department of Food Science and Human Nutrition at Michigan State University has provided an opportunity to integrate clinical and research resources as a method of dealing with complex nutritional problems in patients. Activities of the Area Wide Nutrition Team have included: 1. Organization and conduct of a continuing medical ’ education symposium entitled “New Concepts in Nutrition.” 2. Development of a model Nutrition Support Service at the medical center. 3. Outreach educational programs. 4. Dissemination of practical nutritional information throughout the area. 5. Participation in a cancer outreach program focusing on nutrition as a component part of cancer care. The continuing medical education Nutrition Symposium was totally organized and conducted by the Area Wide Nutrition Team. Involvement of dietitians, physicians, nurses, and pharmacists added greatly to the success of this 106
program. Through group efforts, topics of interest were selected on the basis of need as determined by each of the involved medical and paramedical groups, and responsibilities of promoting and conducting this symposium were shared. The program featured a faculty of nationally recog nized experts in clinical nutrition who addressed problems re1 a t i n g to nutritional assessment, hyperalimentation, enteral diets, and nutrition and neoplasia. The symposium was an overwhelming success with 425 physicians, nurses, pharmacists, and dietitians attending. A Nutrition Fund, established from monies generated at this symposium and controlled by the Area Wide Nutrition Team, will be used to sponsor an annual nutrition symposium and provide financial support for the administrative expenses of nutritional programs conducted throughout western hlichigan. A model Nutritional Support Service has been organized at one of the medical center hospitals. This service provides consultation, directs the management of patients on hyperalimentation and elemental diets, conducts clinical studies, and ensures quality nutritional care of nutritionally depleted hospitalized patients. A full-time nurse, assigned house staff, and students complete a nutritional assessment on.all patients referred to this service and reassess these patients at weekly intervals. The nurse and resident participate in the care of all patients on the service, collect and record all data on each patient, and gather information for clinical research. These individuals prepare and conduct educational programs and provide practical assistance in the management of patients with nutritional problems in outlying hospitals. Patients referred to this service are presented at a weekly conference, at which time problems involving current patients are discussed. Representatives from Michigan State University Department of Food Science and Human Nutrition and members of the Area Wide Nutrition Team participate in these conferences. hlembers of the Nutrition Support Service continue their involvement with these patients on an ambulatory basis as long as the nutrition problem persists, The outreach educational programs conducted by the Area Wide Nutrition Team involve a variety of approaches. Initial efforts have focused on programs of a general nature which would appeal t o medical and paramedical personnel. House staff, students, nurses, and dietitians from the medical center Nutrition Service have assisted the chairman of the Nutrition Team in these programs. The presence of multiple team members has demonstrated the commitment of the Area Wide Nutrition Team t o problems of malnutrition in the hospitalized patient. Subsequent outreach programs have included Inservice Education Programs focusing on specific areas in nutrition and practical assistance in the management of individual patients with identified nutritional problems. Information of a practical nature such as newer feeding tubes, tube feeding programs, standardized hyperalimentation solutions, guidelines for catheter care, total parenteral nutrition (TPN) care kits, TPN flow sheets, VOLUhfE 1/ NUhlBER 21 1977
and literature emphasizing practical methods have been distributed to all team members. Specific information regarding the management of individual patient problerns has h e n provided on request from resources available at the medical center. Patients with complicated nutritional problems requiring services best provided by the Nutrition Support Service are transferred to the medical center. Recent interest by the National Cancer Institute in nutrition as a component of cancer therapy and its interest in extending this influence outside of the medical center has utilized the potential of this organizational approach to nutritional support with considerable enthusiasm. It is hoped that sufficient funding will become available through this program to extend thus model of nutritional support for all cancer patients in the area. Plans for the future include expansion of the present model Nutrition Support Service into other hospitals in the medical center. Educational opportunities available on the model service will be expanded to involve greater numbers of medical students, residents, and paramedical personnel. Clinical research and basic science research projects are planned for the coming year, and basic science research projects will be developed in conjunction with the Department of Food Science and Human Nutrition at Micligan State University.
Funding for the Nutrition Support Service has been developed from nutritional grants, hospital charges for patient care, and physician fees. Additional income from hospital subscription fees to an Area Wide Nutrition Support Service is being explored as an alternative for the future. Federal funding from a “start-up grant” could provide the additional personnel and resources needed t o complete the team. The organization of an Area Wide Nutrition Team and a Nutrition Support Service has provided a method of effecting improved care to the nutritionally depleted patients in multiple hospitals covering a large geographic area. The association of multiple professions from different institutions and areas of expertise has been essential to the effectiveness of the program presented.
n1E JOURNAL OF PARENTERAL AND ENTERAL NUTRITION
107
REFEREWES 1.Dudrick SJ, Wilmore DW, Vars Hhl et al: Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery 64:134-142,1968. 2.Sanders RA and Sheldon GF: Septic complications of total parenteral nutrition: a five year experience. Am J Surg 1323214-220, 1976.
Abstract: Nutritional deficiencies have been identified as a problem of major concern t o all persons involved in health care delivery. Development of nutri-
tional services in several medical centers across the country has demonstrated the effectiveness of this program as an adjunct to improved patient care. Expansion of these benefits through an Area Wide Nutritional Support Service has been organized through a network of educational programs, organization of hospital nutrition committees, and communication links. Involvement of physicians, nurses, dietitians, and pharmacists in a Nutrition Team a t the local and area-wide level is essential t o the success of the program. A Physician-Director, Nurse-Educator, and Dietitian in a major community medical center are responsible for the ongoing educational programs directed t o physicians, nurses, and paramedical personnel in t h e surrounding communities and t h e maintenance of a model Nutritional Support Service a t t h e medical center. Educational and research affiliations with several colleges and universities have provided a model clinical resource for the education of medical students, residents, and clinical experiences for pharmacists and dietitians.
The introduction of hyperalimentation by Dudrick et all in 1968 signalled the beginning of a new era in clinical
Dr. Deati is Associate Professor of Surgery, Col1ege of Hujnatl hledicbie. Alicliigari State University, and Director o f Surgery, Grand Rapids Campus. Reqirests for reprints should be addressed to Richard E. Dean, hL D., 220 Cherry Street, S.E., Grand Rapids, Alichigari 49502.
THE JOURNAL OF PARENTERAL AND ENTERAL NUTRITION
nutrition. The ability to provide total nutritional support parenterally to the clinically ill patient has offered a unique opportunity for the clinician in his efforts t o improve patient care and has provided a new tool for the research nutritionist. Knowledge in this area has expanded rapidly in recent years as a result of these developments. Numerous methods of providing nutritional support enterally and parenterally have been developed, and a variety of commercial products are now available to meet specific patient needs. The complexities inherent in these multiple techniques and specialized products have confused many clinicians. Sporadic use of hyperalimentation and other nutritional support techniques by physicians using numerous products and multiple formulations in a single institution without corresponding educational programs has produced confusion and frustration of the paramedical staff. Personal review of hospital records in several community hospitals where hyperalimentation is practiced. sporadically has identified catheter sepsis rates up to 20 percent and mortalities of 5 percent. In those institutions where a single nutritional support service has been established, patients with protein-calorie malnutrition are identified early and appropriate nutritional support measures are instituted with minimal risk and maximum benefit to the patient.* In an attempt to provide comparable quality care to patients in multiple hospitals over a large geographic area 105
AREA WIDE SUPPOIlT
(western hlichigan), an Area Wide Nutrition Team has been established. The primary goal of this team lias been to: 1. Improve the quality of nutritional care of hospitalized patients. 2. Provide educational programs for physicians, nurses, pharmacists, and dietitians. 3. Establish communication linkages with medical and paramedical personnel involved in nutrition throughout the region. 4. Establish a model clinical nutrition service in a medical center hospital. 5. Develop a working relationship with regional academic and research institutions involved in nutrition. 6 . Provide a clinical educational experience for medical students, residents, dietetic, nursing, and pharmacy students. 7. Provide practical nutritional support to outlying smaller hospitals. The Area Wide Nutrition Team in western hlichigan is located on the Grand Rapids Campus of hlichigan State University. The chairman of this team is a university surgeon whose major clinical interests are in the area of nutrition and metabolism. Members of the team include physicians, house staff, pharmacists, dietitians, and nurses, representing each of the hospitals in Grand Rapids. Additional members include interested physicians, dietitians, and pharmacists from other hospitals located in western hlichigan. A member of the faculty of the Department of Food Science and Human Nutrition, Michigan State University, and pharmaceutical representatives interested in nutrition are also team members. hleetings are held at regular intervals to discuss current problems and recent developments at each of the involved institutions. Recent advances in nutrition are presented by team members, and priorities for team activities are established. Affiliation with the Department of Food Science and Human Nutrition at Michigan State University has provided an opportunity to integrate clinical and research resources as a method of dealing with complex nutritional problems in patients. Activities of the Area Wide Nutrition Team have included: 1. Organization and conduct of a continuing medical ’ education symposium entitled “New Concepts in Nutrition.” 2. Development of a model Nutrition Support Service at the medical center. 3. Outreach educational programs. 4. Dissemination of practical nutritional information throughout the area. 5. Participation in a cancer outreach program focusing on nutrition as a component part of cancer care. The continuing medical education Nutrition Symposium was totally organized and conducted by the Area Wide Nutrition Team. Involvement of dietitians, physicians, nurses, and pharmacists added greatly to the success of this 106
program. Through group efforts, topics of interest were selected on the basis of need as determined by each of the involved medical and paramedical groups, and responsibilities of promoting and conducting this symposium were shared. The program featured a faculty of nationally recog nized experts in clinical nutrition who addressed problems re1 a t i n g to nutritional assessment, hyperalimentation, enteral diets, and nutrition and neoplasia. The symposium was an overwhelming success with 425 physicians, nurses, pharmacists, and dietitians attending. A Nutrition Fund, established from monies generated at this symposium and controlled by the Area Wide Nutrition Team, will be used to sponsor an annual nutrition symposium and provide financial support for the administrative expenses of nutritional programs conducted throughout western hlichigan. A model Nutritional Support Service has been organized at one of the medical center hospitals. This service provides consultation, directs the management of patients on hyperalimentation and elemental diets, conducts clinical studies, and ensures quality nutritional care of nutritionally depleted hospitalized patients. A full-time nurse, assigned house staff, and students complete a nutritional assessment on.all patients referred to this service and reassess these patients at weekly intervals. The nurse and resident participate in the care of all patients on the service, collect and record all data on each patient, and gather information for clinical research. These individuals prepare and conduct educational programs and provide practical assistance in the management of patients with nutritional problems in outlying hospitals. Patients referred to this service are presented at a weekly conference, at which time problems involving current patients are discussed. Representatives from Michigan State University Department of Food Science and Human Nutrition and members of the Area Wide Nutrition Team participate in these conferences. hlembers of the Nutrition Support Service continue their involvement with these patients on an ambulatory basis as long as the nutrition problem persists, The outreach educational programs conducted by the Area Wide Nutrition Team involve a variety of approaches. Initial efforts have focused on programs of a general nature which would appeal t o medical and paramedical personnel. House staff, students, nurses, and dietitians from the medical center Nutrition Service have assisted the chairman of the Nutrition Team in these programs. The presence of multiple team members has demonstrated the commitment of the Area Wide Nutrition Team t o problems of malnutrition in the hospitalized patient. Subsequent outreach programs have included Inservice Education Programs focusing on specific areas in nutrition and practical assistance in the management of individual patients with identified nutritional problems. Information of a practical nature such as newer feeding tubes, tube feeding programs, standardized hyperalimentation solutions, guidelines for catheter care, total parenteral nutrition (TPN) care kits, TPN flow sheets, VOLUhfE 1/ NUhlBER 21 1977
and literature emphasizing practical methods have been distributed to all team members. Specific information regarding the management of individual patient problerns has h e n provided on request from resources available at the medical center. Patients with complicated nutritional problems requiring services best provided by the Nutrition Support Service are transferred to the medical center. Recent interest by the National Cancer Institute in nutrition as a component of cancer therapy and its interest in extending this influence outside of the medical center has utilized the potential of this organizational approach to nutritional support with considerable enthusiasm. It is hoped that sufficient funding will become available through this program to extend thus model of nutritional support for all cancer patients in the area. Plans for the future include expansion of the present model Nutrition Support Service into other hospitals in the medical center. Educational opportunities available on the model service will be expanded to involve greater numbers of medical students, residents, and paramedical personnel. Clinical research and basic science research projects are planned for the coming year, and basic science research projects will be developed in conjunction with the Department of Food Science and Human Nutrition at Micligan State University.
Funding for the Nutrition Support Service has been developed from nutritional grants, hospital charges for patient care, and physician fees. Additional income from hospital subscription fees to an Area Wide Nutrition Support Service is being explored as an alternative for the future. Federal funding from a “start-up grant” could provide the additional personnel and resources needed t o complete the team. The organization of an Area Wide Nutrition Team and a Nutrition Support Service has provided a method of effecting improved care to the nutritionally depleted patients in multiple hospitals covering a large geographic area. The association of multiple professions from different institutions and areas of expertise has been essential to the effectiveness of the program presented.
n1E JOURNAL OF PARENTERAL AND ENTERAL NUTRITION
107
REFEREWES 1.Dudrick SJ, Wilmore DW, Vars Hhl et al: Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery 64:134-142,1968. 2.Sanders RA and Sheldon GF: Septic complications of total parenteral nutrition: a five year experience. Am J Surg 1323214-220, 1976.
