SPECIAL REPORT Nutrition Support Teams—Alive, Well, and Still Growing Results of a 1991 A.S.P.E.N.

Survey

MARSHA REGENSTEIN American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland

ABSTRACT: This report summarizes data collected from 1680 hospitals that responded to the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Nutrition Support Team Survey. The survey was conducted primarily to determine the prevalence, composition, and funding of existing and planned Nutrition Support Teams. Results tend to verify the importance of the Nutrition Support Team within the hospital’s organizational structure. In addition, A.S.P.E.N. hoped to develop a national directory of Nutrition Support Teams as a byproduct of the survey. Details about the Nutrition Support Team Directory appear at the conclusion of this report.

In July 1991 the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) conducted a survey of all large (>150 beds) acute-care hospitals in the United States. The survey focused on the prevalence, composition, and funding of Nutrition Support Teams (NSTs). This report summarizes the methodology and results of the survey and discusses possible conclusions that can be drawn from the data gathered.

Figure 1. Hospitals indicating that they once had a Nutrition Support Team or that they plan to organize one. Of the 1680 hospitals responding to the survey, 484 a Nutrition Support Team. Of the 1196 hospitals that do not have a team, 12% indicated that they used to have an NST in their institution, and 17% stated that they have plans to start a team within the next 24 months (Fig 1).

(29%) indicated that they have

SURVEY METHODOLOGY

Based on input from A.S.P.E.N. staff and commitmembers, a questionnaire was designed by Association Research Inc to meet the overall objectives of the NST Survey. A four-page survey instrument and cover page were sent by first-class mail in July 1991 to the Chief Clinical Dietitian at all large (150+ beds) acute-care hospitals in the United States. The mailing list was purchased from the American Hospital Association and included 2600 hospitals fitting the survey criteria. The 1680 respondents (out of 2600) represented a response rate of 64.6%. Some of the responding hospitals reported having fewer than 150 beds.

tee

FINDINGS

The types of services provided by the responding hospitals were quite diverse. Ninety-one percent of responding hospitals indicated that they have a medical intensive care unit (ICU), and 77% report having a surgical ICU. The remaining types of hospital services provided (neonatal ICU, pediatric ICU, major transplants, trauma center, and other services) were listed by fewer than one third of the respondents, with neonatal ICU (30%) being cited most frequently. Figure 2 compares these responses according to hospitals with and without NSTs. In each case, hospitals with NSTs are more likely to have more sophisticated service components than are the hospitals without them. 296

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297 The size of the NST is fairly evenly divided among three categories: teams with one to four professionals (37%), teams with five to six (29%), and teams with seven or more

(34%).

The survey found that 60% of the hospitals responding had between 200 and 500 beds. Approximately another 18% had more than 500 beds. The remaining 22% had fewer than 200 beds. Figure 5 breaks out these figures for hospitals with or without an NST. A direct correlation seems to exist between bed size of the institution and likelihood that the institution has an NST. In fact, most of the hospitals with more than 500 beds have NSTs. FUNDING SUPPORT 2. Services provided and without an NST.

Figure

by responding hospitals

with

Half of all 1680 respondents to the A.S.P.E.N. NST survey indicated that they work in private, not-for-

profit institutions. Almost one quarter (24%) of the respondents are from public hospitals. Only 13% of respondents said they work in private, for-profit hospitals, although an equal percentage did not answer this question. These numbers were very similar for hospitals with Nutrition Support Teams versus those that did not have a team (Fig 3). About half of the NSTs are part of private, not-for-profit institutions. Fewer teams appear to exist in private for-profit hospitals; however, nearly one quarter of hospitals with teams did not respond to this question. Therefore, it is not possible to draw conclusions about how the actual distribution of teams according to type of hospital may differ from the

sample percentages. Most hospitals responding to the survey (70%) are not affiliated with a medical school or university; more hospitals with NSTs (17%) have this affiliation than do hospitals without an NST (8%). Half of the hospitals stated that they have medical residents; of those, an overwhelming majority (92%) do not rotate them on an

Most NST funding support for physicians, nurses, dietitians, and pharmacists does not come from a nutrition support service, but rather from a different

department (Table 1). In general, dietitians are the most likely (19%) to receive funding from the nutrition support service. Nurses were reported to receive nutrition support service funding 16% of the time. Physicians (11%) and pharmacists (8%) are less likely to receive funding from the nutrition support service. No PhDs in the survey reported receiving funding from their nutrition support service. The likelihood of receiving funding from the service and the number of years the NST has been active seem to be related. For the NSTs in operation over 10 years, the number of physicians funded by the nutrition support service is almost double the average (19% versus 11%), and in all cases is significantly higher than the average. Likewise, NST professionals in larger hospitals appear to be funded more frequently by the nutrition support service, although this relationship is not as strong. Private, for-profit hospitals have higher rates of funding by nutrition support service for nurses,

NST. As stated above, 29% of the NST Survey respondents reported that their hospital has an NST. Of the hospitals having an NST, over half (63%) reported that their team has been active 5 or more years (Fig 4), and 21% reported that their team has been active over 10 years.

The composition of existing NSTs is most likely to consist of at least one member from each of the four principal health care professions involved in nutrition support, commonly referred to as disciplines. These four disciplines are medicine, nursing, dietetics, and pharmacy. Also, on average, half the teams include one additional discipline as a member of the team, eg, a social worker, respiratory therapist, or PhD.

Figure 3. Types of hospitals responding according to those with teams and those without teams.

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298

Figure 4. Number ofyears a responding hospital has had an active NST (n=475).

Figure 5. Distribution of responding hospitals by number of beds (n=1659). A direct correlation seems to exist between the size of the hospital and the presence of an NST.

Figure

dietitians, and pharmacists. Also, hospitals that rotate residents or medical students on the NST appear to consist of more professionals funded by the nutrition support service.

average spend nearly three fourths of their time on nutrition support activities. As might be expected, physicians consistently reported the lowest percentage of time providing nutrition support; however, physicians’ participation is consistent with two trends: (1) the larger the hospital, the more time physicians spend delivering nutrition support, and (2) the longer the team has been active, the greater the physician activity.

PERCENTAGE OF TIME PROVIDING NUTRITION SUPPORT

NST dietitians spend the largest percentage (58%) of their time providing nutrition support, followed by nurses (52%), pharmacists (36%), PhDs (31%), and physicians (17%). These percentages vary substantially, however, according to the number of years the NST has been active and to the bed size of the hospital. The larger the hospital, the greater the percentage of professional time is spent on nutrition support (Fig 6a). Likewise, the more years the NST has been active, the more time is likely spent on nutrition support activities (Fig 6b). This is true for all discipline categories except PhD, in which the results may be skewed because of the low number of responses. For example, dietitians in general spend the most time on nutrition support activities. However, nurses on NSTs that have been active for more than 10 years

6. Amount of time team members spend providing nutrition support activities, by number of beds in the hospital, a, and by number of years the team has been active, b. on

NST CONSULTANTS

Over three fifths (61%) of the respondents having an NST reported that they do not have consultants. An NST is most likely to have a consultant when it has been active 1 to 2 years (50%) and when the composition ofthe NST is fewer than four disciplines (50%). This seems to suggest that consultants are more likely to be used when an NST is just starting and relatively few health care professionals are involved. Of those respondents using NST consultants, 74% reported that physicians are the most likely health care professionals to be used as a consultant. The percentage is even higher if an NST has been active for more than 10 years (88%) or consists of seven or more people (87%).

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299 Table 1. Amount of

funding support

for team members

supplied by a nutrition support

PARENTERAL AND ENTERAL SERVICES MANAGED

Over three fourths (82%) of the respondents reported that their parenteral and enteral services are managed or monitored. This percentage is higher for hospitals with an NST (95%) than for those without an NST (77%). The management responsibility for parenteral and enteral services is divided among several departments and committees. Nutrition support teams/ services (28%) and nutrition support committees (23%) received the highest response rates. Separate nutrition support departments received a 9% response rate. Mandatory nutrition consulting is not prevalent but is higher in hospitals with an NST. Only 9% of all respondents require nutrition consulting before tube enteral feeding is initiated. Similarly,16% of all respondents reported that their hospitals require nutrition consultations before initiating total parenteral nutrition (TPN). Figure 7 shows this response for NSTs by the number of

years the NST has been active. It is clear

that as an NST becomes more established, the hospital is much more likely to require a nutrition consultation before TPN is initiated; in fact, over 40% of hospitals with teams active for 10 or more years require nutrition consultations prior to initiation of TPN. This trend is not true of tube enteral nutrition, in which the number of years the team has been active has little correlation

service

with the hospital’s requirement for a nutrition consultation. PARENTERAL AND ENTERAL PATIENTS

The A.S.P.E.N. NST Survey asked respondents to estimate how many patients receive parenteral or enteral nutrition in a typical month. Over two thirds (68%) of all respondents reported that they have 29 or fewer patients receiving tube enteral nutrition monthly. The number of patients receiving parenteral nutrition is much smaller; 70% of respondents estimated that they have 19 or fewer patients receiving parenteral nutrition (Fig 8). Over half the respondents reported that fewer than 25% of their nutrition support patients are children; 60% report that their pediatric patients receive enteral nutrition, and 56%, parenteral nutrition. Additionally, more than one third reported they have no pediatric enteral or parenteral nutrition patients. The percentage of patients receiving parenteral or enteral nutrition who are 65 years of age or older is much higher. Over half (56%) the participants indicated that 75% of these patients receive enteral nutrition ; fewer than 2% of the respondents stated that none of their senior patients receive enteral nutrition.

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300

Figure 7. Hospitals with NSTs that require a consultation before the initiation of total parenteral nutrition, by num-

Figure 8. Number of nutrition support patients treated by NSTs in a typical month.

ber of years the NST has been active.

Figure 9. Percentage of nutrition support patients treated by NSTs. Generally, patients receiving enteral nutrition are less likely to be treated by an NST than are patients receiving parenteral nutrition.

Figure 10. Percentage ofpatients over 65 discharged from the

Figure 9 illustrates the percentage of the total number of enteral and parenteral patients seen by the NST. The percentage of enteral nutrition patients seen by an NST is generally lower than the percentage of parenteral patients seen by the team. Almost two thirds (65%) of the NSTs reported seeing all of the

than 10 patients per month receiving enteral nutrition. Almost all (96%) the respondents reported that fewer than 10 patients per month are discharged receiving parenteral nutrition. The number of patients discharged on home nutrition support by hospitals with NSTs is not significantly different from that by hospitals without NSTs. Patients over 65 are more likely to be discharged on nutrition support than are pediatric patients. Only 5% of teams reported that most of their patients discharged on nutrition support are children, and over half reported that none of these patients are children. On the other hand, as Figure 10 shows, over half the teams said that 50% or more of the patients they discharge on home

hospital’s parenteral patients, and about 10% of the teams indicate that they see fewer than 25% of all parenteral patients. In comparison, only 28% of the NSTs reported seeing all of the hospital’s patients receiving enteral nutrition, while nearly 50% said they see fewer than one fourth (or none) of the hospital’s enteral patients. The survey also asked the participants to estimate how many patients per month are discharged on parenteral or tube enteral nutrition. More patients receiving tube enteral support are discharged to receive their services in the home than are those using parenteral nutrition. More than three quarters (77%) ofthe respondents estimated that they discharge fewer

hospital by nutrition

NSTs to receive either enteral

or

parenteral

support at home.

nutrition support

are

seniors.

Respondents were asked whether their hospital provides nutrition support for home patients. The response was fairly evenly divided, with 52% providing tube enteral nutrition and 46% offering parenteral nutrition (Fig 11). Home nutrition support is provided

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301

greater percentage of the hospital’s parenteral and enteral nutrition patients; have members who devote a greater percentage of their time to nutrition support than teams that have been active for less time; and have more members financed by their own NST department. Thus the data indicate that, overall, the Nutrition Support Team concept is healthy and, further, that there are derivative benefits to a team’s longevity within the institution. This is clearly good news to some of the newly established teams that are struggling to stay afloat amid their hospital’s cost-

Figure 11. Percentage of hospitals providing patients receiving home nutrition support.

services for

a hospital-based home care company (44%), referral to a home care company (42%), a hospital joint venture (26%), or other mechanism (8%).

through

DISCUSSION

A.S.P.E.N. has long supported the NST and encourages hospitals nationwide to provide safe and effective nutrition support through a multidisciplinary group of health professionals who have a special interest and expertise in enteral and parenteral nutrition therapies. The overwhelming response rate to the survey underscores the importance of this topic to thousands of nutrition professionals around the country. The data from the survey demonstrate that NSTs are alive and well. The number of NSTs is relatively

stable, and a significant percentage of hospitals (17%) are

planning

to establish

a

team within the next 2

years.

Several of the survey’s findings may come as no surprise, but they deserve special mention nonetheless because they verify the importance of the team within the hospital structure. NSTs generally (1) have at least one member each from medicine, nursing, dietetics, and pharmacy; (2) exist in hospitals that are affiliated with universities and/or medical schools; and (3) are more likely to be &dquo;veteran&dquo; rather than newly formed. NSTs that have been active for many years are more likely to see a

containment environment. The A.S.P.E.N. survey may actually have underreported the number of NSTs in the country, since the survey itself specifically asked whether the hospital has a nutrition support team, and not how many teams may exist in the hospital. This became apparent during the process of collecting information for the NST Directory, in which several hospitals indicated that they have more than one NST, eg, a pediatric NST and a surgical NST. However, in all but one or two cases for publication in the directory, the hospital listed team members as belonging to the same team. The NST Directory includes the names of over 2100 NST members on 480 teams in 49 states, Puerto Rico, and the District of Columbia (no respondents indicated an NST in Alaska). Very few teams asked not to be included in the directory, although some teams preferred not to list their members’ names, or to list only the team director’s name. Of the 397 teams that listed the name of the team director, 292 indicated that a

physician was the director (or codirector with another physician) or chairman. This number does not include physicians who were listed as &dquo;medical director&dquo; in addition to the team’s director or chairman. More than 100 team directors are not physicians-52 are dieti-

tians, 32 are pharmacists, 13 are nurses. Eight teams have directors from different

disciplines.

ACKNOWLEDGMENT

A.S.P.E.N. would like to thank the 1680 respondents who took the time to answer our lengthy questionnaire. We express our appreciation to over 480 Nutrition Support Teams for their help in what has become a very complete NST directory that includes nutrition support professionals throughout the United States.

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Nutrition support teams--alive, well, and still growing. Results of a 1991 A.S.P.E.N. survey.

This report summarizes data collected from 1680 hospitals that responded to the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Nut...
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