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State of Nutrition Support Teams Mark Henry DeLegge and Andrea True Kelley Nutr Clin Pract 2013 28: 691 originally published online 29 October 2013 DOI: 10.1177/0884533613507455 The online version of this article can be found at: http://ncp.sagepub.com/content/28/6/691
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NCPXXX10.1177/0884533613507455Nutrition in Clinical Practice X(X)DeLegge and True Kelley
Invited Review Nutrition in Clinical Practice Volume 28 Number 6 December 2013 691–697 © 2013 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533613507455 ncp.sagepub.com hosted at online.sagepub.com
State of Nutrition Support Teams Mark Henry DeLegge1 and Andrea True Kelley2
Abstract The incidence of malnutrition in hospitalized patients is relatively high (up to 55%) despite breakthroughs in nutrition support therapies. These patients have increased morbidity and mortality, extended hospital stays, and care that is associated with higher costs. These patients are often poorly managed due to inadequate nutrition assessment and poor medical knowledge and practice in the field of nutrition. Nutrition support teams (NSTs) are interdisciplinary support teams with specialty training in nutrition that are often comprised of physicians, dietitians, nurses, and pharmacists. Their role includes nutrition assessment, determination of nutrition needs, recommendations for appropriate nutrition therapy, and management of nutrition support therapy. Studies have demonstrated significant improvements in patient nutrition status and improved clinical outcomes as well as reductions in costs when patients were appropriately managed by a multispecialty NST vs individual caregivers. Despite this, there has been steady decline in the number of formal NST in recent years (65% of hospitals in 1995 to 42% in 2008) as hospitals and other healthcare organizations look for ways to cut costs. Given the importance of nutrition status on clinical outcomes and overall healthcare costs, a number of institutions have introduced and sustained strong nutrition training and support programs and teams, demonstrating both clinical and economic benefit. The benefits of NST, training and implementation strategies, and tips for justifying these clinically and economically beneficial groups to healthcare organizations and governing bodies are discussed in this review. (Nutr Clin Pract. 2013;28:691-697)
Keywords enteral nutrition; parenteral nutrition; nutrition support teams; reimbursement patient care team; nutritional support
Background on Nutrition Support Teams The incidence of malnutrition in the hospitalized patient can vary between 30% and 55%1-6; these patients often have extended hospital stays with more complications, higher costs, higher readmission rates, and increased morbidity and mortality.2-5 Patients who are undernourished or who are at risk of becoming undernourished are often poorly managed due to inadequate nutrition assessment7-9 and medical knowledge and practice in the field of nutrition.10-12 With the development of specialized nutrition therapy (parenteral nutrition [PN] and enteral nutrition [EN]), an interdisciplinary approach was essential for successful transition of these medical breakthroughs from the bench to the bedside. As these new innovations were adopted, interdisciplinary nutrition support teams (NSTs) were created to optimize the effectiveness and safety of this therapy and became the gold standard of nutrition care in the 1980s and 1990s. The structure and function of NSTs vary from one institution to another depending on the local needs, organizational culture, and available personnel. Ideal team composition includes physicians, nurses, dietitians, and pharmacists with specialized nutrition training. In general, functions of an NST include nutrition assessment, determination of macro- and micronutrient needs, recommendations for appropriate EN/PN therapy, management of nutrition support therapy, and training of other support personnel.13 See Table 1 for a list of common NST specialists and their roles.
When evaluating the impact of nutrition care, clinical guidelines, practice standards, and the use of an interdisciplinary NST have been shown to improve outcomes and safety and to have a positive financial impact on healthcare institutions. There are clear benefits to an organized nutrition care format for hospitalized patients. Numerous studies have demonstrated significant improvements in patient nutrition status and improved clinical outcomes, including reduced mortality and reductions in cost, when patients were appropriately managed by a multispecialty NST vs individual caregivers.6,14,15 Despite evidence supporting the health- and cost-related effectiveness of an NST, there has been steady decline in the number of formal NSTs in recent years as hospitals and other healthcare organizations look for ways to cut costs. Based on results from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) 2008 survey, only 42% of respondents, composed largely of those practicing in a hospital setting, had a formal NST, down from 44% in 2005 and 65% in 199516,17 (see Figure 1). From 1Medical University of South Carolina, Charleston, and 2ATK Clinical Consulting, Charleston, South Carolina Financial disclosure: None declared. This article originally appeared online on October 29, 2013. Corresponding Author: Mark Henry DeLegge, Medical University of South Carolina, 25 Courtenay St, Suite 7100A, Charleston, SC 29425, USA. Email: [email protected].
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Table 1. Specialists on Nutrition Support Teams (NSTs) and their Roles. Practitioner
Potential Role(s) in NST
Physicians
Must be familiar with all aspects of nutrition care, including: ● Patient screening, assessment, development and implementation of nutrition care plan, patient monitoring, and termination of therapy ● Lead the nutrition care implementation structure in many institutions ● Surgeons/radiologists may participate in placement of central venous lines and gastrostomies and lead postsurgical care and management of patients (eg, gastroenterologists) ● Supervise care provided by dietitians, nurses, and pharmacists; engage in all aspects of direct patient care and nutrition needs, as indicated ● Conduct individualized nutrition screening and assessment ● Develop and implement nutrition care plans ● Monitor patient’s response to the nutrition care delivered ● Develop transitional feeding care plan or termination of nutrition support, as appropriate ● Compound parenteral or other nutrition formulation prescribed; provide direct patient care ● Manage specialized nutrition support program and improve quality; educating other healthcare professionals, students, patients, and caregivers ● Conduct nutrition-related research or participate in research activities Varies with the educational background, position, and practice environment. May include: ● Directing patient care, including intravenous access ● Recognizing side effects and complications of stomas/central lines ● Education and training of patients and caregivers ● Participation in research activities ● Advice on desensitization and safety of oral feeding and swallowing
Dietitians
Pharmacists
Nurses
Possibly speech/ language therapists
Figure 1. Changes in percentage of nutrition support teams over time based on American Society for Parenteral and Enteral Nutrition survey respondents.16
Reductions in NSTs: Impact on Patient Care and Costs Results of the 2008 A.S.P.E.N. survey demonstrated that the most common reasons for not having an NST when one previously existed included the following: decentralized nutrition support services (37%), financially not feasible (33%), lack of physician support (23%), and lack of time (7%).16 Of survey respondents who formerly had NSTs that were disbanded, 40% responded that patient care had been adversely affected by this change, while 30% felt individual clinicians were adequately managing nutrition support services and 30% believed that care had not been adversely affected.16 Today, financial considerations are still at the forefront of healthcare delivery. Convincing healthcare management to
allocate staff for NSTs can be difficult, especially when personnel are at a premium. However, this cost-center focus can have serious consequences for patient outcomes. For example, the incidence of malnutrition in the hospitalized patient can vary between 30% and 55%,1-6 and these patients have extended hospital stays, higher costs, and increased mortality rates.2-5 Furthermore, it has been shown that organized and effective nutrition support by an NST actually reduces costs and justifies NST involvement.18-21 These 2 concepts, cost containment and quality care, appear to be at odds with one another. In a meta-analysis, Cangelosi et al22 estimated the impact of the accurate selection of the appropriate nutrition therapy (EN vs PN) on adverse events, treatment duration, and length of hospital stay. Estimates were converted to population economic impacts by assuming 10% of PN patients are suitable candidates for EN. Compared with PN, the use of EN reduced the risk of major, potentially life-threatening infections (relative risk [RR], 0.58; 95% confidence interval [CI], 0.44–0.77); reduced the risk of major, potentially life-threatening noninfection events (RR, 0.73; 95% CI, 0.59–0.91); and suggested a reduction in mortality (RR, 0.70; 95% CI, 0.45–1.09). The use of EN also reduced inpatient length of stay, time in the intensive care unit (ICU), and length of nutrition treatment. Compared with PN, the use of EN resulted in savings from reduced adverse events at an average of nearly $1500 per patient; savings from reduced hospital length of stay amounted to nearly $2500 per patient. To highlight the cost savings provided by appropriate assessment and therapy selection, a shift
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of only 10% of patients inappropriately treated with PN therapy to EN therapy would save ~$35 million annually due to reduced adverse events and another $57 million due to shorter hospital stays.22 In one of the few studies to demonstrate the economic benefit of an NST when considering the actual costs of the nutrition support team itself, Hassell et al23 evaluated the NST management of enterally fed patients. They assessed potential improved clinical outcomes of individually managed patients compared with patients managed by an NST. Elderly patients receiving EN support for >24 hours over a 3-month period (n = 136) were studied, and cost calculations included salaries for clinicians and support personnel for the NST vs costs for nonteam management. Differences were statistically significant for both severity of illness, which was higher in the NST group (P < .001), and complication rate, which was greater in the nonteam group (P < .001). In the NST-managed group, there was a 23% reduction in adjusted mortality rate, an 11.6% reduction in the adjusted length of hospital stay, and a 43% reduction in adjusted readmission rate. Cost-benefit analysis revealed that for every $1 invested in nutrition support team management, a benefit of $4.20 was realized. Trujillo et al6 prospectively studied 209 patients started on PN over a 4-month period; they reviewed appropriateness for initiation of PN therapy against A.S.P.E.N. guidelines. For patients followed by an interdisciplinary NST, only 18% of PN starts were not indicated vs 56% of PN starts for patients not followed by the NST (P < .005). Avoidable charges calculated based on PN were $20.57 per day for NST-managed patients vs $94.57 per day for non–NST-managed patients. Overall reduced charges of approximately $430,000 annually were projected based on these data. However, the cost of overhead, substitute therapy, and NST management of patients were not included in cost savings calculations. In another study by Kennedy and Nightingale,24 the investigators sought to determine whether an NST could show tangible cost savings (equipment, monitoring, and medication costs) from managing patients considered for PN. The study’s secondary aims were related to the quality issues of placement of PN catheters, catheter-related sepsis (CRS), duration of PN, and mortality. They compared findings for 2 years: one before NST involvement and one after implementation of a formal NST (historical control). The results were significantly in favor of an NST; CRS was dramatically reduced from 71% to 29% (P < .05) from the pre-NST to the NST year, respectively. In-hospital mortality for patients receiving PN was also significantly reduced when patients were managed by an NST (43% vs 24%; P < .05). In addition, tangible cost savings were observed in the NST year (~$77,249) compared with the preNST year, derived primarily from avoided PN episodes and a reduced incidence in CRS. According to the authors, these cost savings justify the salaries of a nutrition nurse specialist and a senior dietitian as part of an NST.
Across a network of hospitals in Europe, a prospective investigation of the function, structure, and organization of an NST composed of physicians, nurses, and dietitians among 3071 hospitals was completed.25 Established NSTs were in place at 98 hospitals (3.2%), and their main activities were creating nutrition regimens (100%), education (87%), and monitoring nutrition therapy (92%). In general, the NSTs were affiliated with a hospital specialty discipline (eg, surgery). Seventy-one percent of the physicians, 40% of the nurses, and 69% of the dietitians in the NST held a nutrition-specific additional qualification, and a total of 12% of the physicians, 37% of the nurses, and 46% of the dietitians were exclusively responsible for the NST. Since implementation of the NST, a reduction in complications by 88% and a cost saving of 98% have been noted.25 The authors concluded that special efforts should be aimed at continuing education of NST members and financing of teams given the positive impact of an NST on health outcomes and healthcare finances. In addition, home NSTs have also been shown to improve outcomes and dramatically improve costs by preventing hospitalizations of patients receiving home-based EN/PN therapy. Home-based NST interventions by an interdisciplinary team of nurses, pharmacists, and dietitians from a commercial home infusion company, working closely with physicians, improved patient care and potentially prevented more than 429 hospitalized days over a 3-month period.26 Interventions included correcting over- and underfeeding, preventing dehydration, reducing/eliminating diarrhea, managing hyperglycemia, managing electrolyte imbalances, transitioning patients from PN to oral eating, and starting patients on PN therapy in the home vs the hospital. The cost savings of these interventions were estimated at >$850,000 during the 3-month period.26
Nutrition Training and Implementation of Practice Guidelines Practice guidelines are developed through a systematic review of the available research evidence and contain therapy-specific recommendations with the intent of minimizing practice variation. The “Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient,” published by the Society of Critical Care Medicine (SCCM) and A.S.P.E.N., are the most comprehensive and current North American practice guidelines on the implementation of nutrition support therapy for the critically ill patient.27 As described above, implementation of these evidence-based guidelines is believed to be critical to the success of NSTs and the delivery of appropriate nutrition therapy. However, many issues must be taken into consideration to successfully implement these guidelines in the clinical setting. These include an awareness of existing guidelines among clinicians, consensus among clinicians on which guidelines to adopt, and finally, an adherence by the practitioner to the guidelines. This process is also
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influenced by the organizational culture as a whole and requires professionals with adequate training in nutrition for successful implementation.28 Results from the 2008 NST A.S.P.E.N. survey showed that, in the absence of an NST, individual clinicians are largely responsible for managing the nutrition support needs of patients.16 Despite the importance of appropriate nutrition therapy on positive outcomes, this increased burden of nutrition support on physicians has not been supplemented by most institutions with additional and adequate nutrition training.29-31 While this has long been recognized as an issue, most U.S. medical schools still did not provide at least 25 hours of nutrition education during the past decade as recommended by the National Academy of Sciences32 or require a separate nutrition course. In addition, most physician residency programs have devoted little time and effort to formal nutrition education.33-36 Recognizing this shortcoming, several groups have implemented training programs to identify and address the nutrition knowledge gap. For example, a nutrition vertical integration group at a university in Boston was founded to review nutrition medicine in the school curriculum.37 The group developed a novel student-centered model of nutrition medicine education that focused on medical student–mentored extracurricular activities to develop, evaluate, and sustain nutrition medicine education. Their team-based approach focused on case-based learning in the classroom, practice-based learning in the clinical setting, extracurricular activities, and a virtual curriculum to improve medical students’ knowledge, attitudes, and practice skills in nutrition across their 4-year training program. Their nutrition education program fell just short of the 25 hours recommended by the National Academy of Sciences. However, most of their nutrition pre-clerkship curriculum objectives were covered during their 4-year period. At the hospital level, another university has implemented a comprehensive nutrition training and practice program.38 Nutrition care at this institution is described as a process in which patients are (1) screened to identify risk, (2) given full nutrition assessments to confirm status when risk is suspected, (3) provided nutrition therapy to meet individual needs, and (4) routinely monitored for changes in nutrition needs with care adjusted as the patient’s nutrition status changes. Their program centers on adoption and implementation of evidencebased nutrition practices. In particular, EN is used preferentially over PN and, when necessary, begins within 24–48 hours after admission. In addition, another university center offers a nutrition support practicum where attendees gain clinical experience and are eligible for 40 professional education units from the Commission on Dietetic Registration, the credentialing agency for the American Dietetic Association.39 Participants spend 5 days working with members of an interdisciplinary nutrition support team in an ICU setting. These trainings are carried out by nutrition specialists from the Nutrition Consultation Service, which has been active for over 20 years.
This interdisciplinary training approach is supported by Weinsier et al,40 who studied teaching practices of nationally recognized nutrition programs and identified the following critical elements in creating and implementing strong programs: (1) a clinically active physician-nutritionist role model, (2) nutrition elective rotations, (3) practical learning materials and conferences, and (4) an interdisciplinary nutrition support team. Based on the success of these programs, DeChicco et al36 describe a process for developing an effective training program for multispecialty NST. This detailed program includes the following steps: (1) formulation of general goals of the program, (2) specification of learning objectives, (3) assessment of each student’s current level of knowledge and educational goals, (4) determination of educational strategies and learning activities that will best meet the goals of each student and the program, and (5) creation of a method to evaluate the performance of each student and the program as a whole. Several postgraduate nutrition support training programs also exist. One commercial EN manufacturer provides handson clinical experience to attendees.41 Its 4-week EN fellowship for medical and surgical fellows allows the attendees to spend 2 weeks on site working with each of 2 faculty members who are leaders in the field of nutrition support. Attendees are encouraged to submit a manuscript on a nutrition-related topic for publication and participate in national or international nutrition conferences. Other effective strategies for implementation of A.S.P.E.N. guidelines without an NST have been described. Kiss et al42 reported on the use of a nutrition support algorithm that significantly improved the nutrition status of hospitalized ICU patients. The nutrition support algorithm, as described, is an operational version of a guideline that is adapted to local requirements and easy to apply. Despite demonstration of significantly positive outcomes in the mean delivery of total energy and protein pre- and postalgorithm application, it is unclear if the algorithm made a significant impact at the clinical level (eg, reduced stay and cost, reduced mortality). The authors note that their findings and outcomes may be further improved with routine nutrition assessment by a dietitian or a designated NST. At the country level, after recognizing up to a 70% prevalence of malnutrition in their health care facilities, Canadian healthcare officials investigated how they delivered nutrition care. The results-oriented Canadian Malnutrition Task Force (CMTF) was tasked with improving nutrition care in Canada and has made great strides.38 Similar to a U.S. university experience, the group first identified best nutrition practices for healthcare facilities and implemented a stepwise strategy to (1) screen all patients for malnutrition and nutrition risk, (2) conduct full assessment for those identified to have risk, (3) develop and implement a nutrition plan for each high-risk patient, and (4) then monitor each patient regularly to update the plan as needed. Findings from a survey conducted by the group showed that of 260 hospitalized patients, an overall
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malnutrition prevalence of 43% existed and that caregivers did not assess nutrition status at admission or at discharge for all patients. The survey also found that 1 of every 3 patients ate less than 50% of their meals, even though food quality was rated as high. As a result, the CMTF developed a nutrition care action plan detailed below, which may serve as a model for others: •• Implement standardized, mandatory screening protocols •• Develop programs to educate administrators, physicians, and nurses about how to integrate nutrition care into everyday practice •• Emphasize protected, patient-focused mealtimes •• Make use of an interdisciplinary nutrition care team
Making a Case for Comprehensive Nutrition Support at Your Institution Leaders from successful nutrition support programs, including Dr Jane Ryan and healthcare system chief operating officer Dr Ninfa Saunders, described helpful suggestions for making a strong case to convince organizations of the value provided by comprehensive nutrition support services during a commercially sponsored Nutrition Summit in 2011.38 Key steps included (1) collecting nutrition status data to document a need for change, (2) seeking the support of hospital leaders to promote nutrition care, and (3) making and presenting a plan for improvements in hospital nutrition practices. Detailed tips for making a successful pitch included the following38: •• Preparation: Plan carefully for your meeting. Develop a focused message and a compelling agenda for your meeting with the leader, and think about what questions you might have to answer. •• Approach: Practice your presentation but do not memorize it; be sincere and direct with your opening message. Describe the benefits by making them vivid and attainable. Be crisp and cogent in your presentation. •• Content: Have the end result in mind as you make your presentation. What is your main goal? Your leader will appreciate if you discuss the deal but not the details at this first meeting. •• Next steps and follow-up: Don’t stop by presenting your idea alone. What are the next actions needed? Do you need funding for a pilot project? Do you need to go onto the agenda for a committee meeting? Remember that hospital executives and leaders are very busy. You may need to follow up and remind the leader of your request. Be persistent.
Future Directions for Nutrition Support There is an abundance of evidence demonstrating improved quality of care, improved outcomes, and reductions in healthrelated cost when patients requiring specialized nutrition care
are appropriately managed by a multispecialty NST. However, little published data exist showing what staffing and supporting a well-rounded NST actually costs (in dollars) for healthcare organizations to achieve these improvements and savings. Given the increasing costs of providing adequate healthcare and increased focus on good clinical outcomes for obtaining reimbursement, this is an increasingly important point to consider when justifying the existence of an NST. The state of medicine as a whole is changing in the United States and internationally. The hospital setting is ripe for cost adjustment to deal with new realities—doing more with less. The average cost for a hospital stay in the United States per day is $1625.00.43 Nineteen percent of hospital leaders interviewed recently still felt they needed to reduce their operating budgets by an additional 11%.44 Hospitals previously receiving yearly federal funds for seeing an abundance of Medicare patients have seen this program winding down, further straining hospital budgets.45 Healthcare system cost cutting often includes a reduction in full-time employment positions in addition to work hour reduction. Therefore, every discipline and function tied to the hospital budget will need to demonstrate clinical efficacy and cost-effectiveness. The impetus of the Patient Protection and Affordable Care Act (ACA) is to shift focus from disease treatment to disease prevention. An initial examination of the ACA does highlight medical nutrition therapy for chronic diseases and employee wellness programs. However, it does not state that registered dietitians are essential providers of those services or credit dietitians as reimbursable practitioners across the healthcare spectrum.46 It also does not allocate the funds for these proposed new programs. The typical NST is an inpatient service and is not in the business of disease prevention. Most members of the NST (except the physician) are unable to bill for their services and therefore are part of the “valueadded” services provided by the hospital or healthcare system. There is no federal mandate to use an NST prior to ordering nutrition support therapy. Therefore, the NST is “optional” and is often not available in most U.S. hospitals. In order for NSTs and the field of nutrition support to advance, either services provided will need to be reimbursed to the NST (billed services) or the value of the NST will need to be demonstrated in the new healthcare environment. However, this value cannot be built solely around reducing access to PN as the justification for an NST’s existence. This value will need to be demonstrated by the following: 1. Having a universally accepted biomarker that clearly identifies patients who are malnourished 2. Linking the malnutrition biomarker to other clinical outcomes (eg, hospital length of stay, functional status) 3. Delivering early, effective, and safe nutrition therapy to identified patients 4. Offering the right nutrition therapy to patients, EN or PN, dependent not only on the safety or the cost of the
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therapy but also on the likelihood that it will reverse or impede malnutrition 5. Creating a scenario where unaddressed malnutrition is a “never event” Because NSTs do have an “economic cost” that includes salary, benefits, physical plant overhead, and continuing education, allocating the NST to the patients with the greatest need would also ensure that this resource was being used appropriately. Data presented by Hassell et al23 demonstrated impressive cost savings when a multispeciality NST managed highly complex patients when the cost of the NST was taken into consideration. With this in mind, perhaps justifying and implementing involvement by the NST only for patients with the most complex nutrition needs might be more appropriate. More routine PN or EN patients could be managed by a clinician following standard guidelines for patient assessment and appropriate nutrition product implementation and monitoring. NSTs are dwindling in number across the U.S. healthcare landscape. Their survival is directly linked to the value we place on nutrition support (both clinical and economic), the clinicians, and the consumer’s belief in nutrition as a critical component of patient care and future federal/state mandates for improvements in the diagnosis and treatment of malnutrition throughout our healthcare systems.
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36. DeChicco R, Neal T, Guardino JM. Developing an education program for nutrition support teams. Nutr Clin Pract. 2010;25(5):481-489. 37. Lenders C, Gorman K, Milch H, et al. A novel nutrition medicine education model: the Boston University experience. Adv Nutr. 2013;4(1):1-7. 38. Opportunities and Challenges for Medical Nutrition. Abbott Park, IL: Abbott Nutrition Health Institute; 2011. 39. Rush ICU Nutrition Support Practicum. http://www.rushu.rush.edu/servlet/ Satellite?MetaAttrName=meta_university&ParentId=1197303075496 &ParentType=RushUnivLevel3Page&c=content_block&cid=11963712 07837&level1-p=3&level1-pp=1192572153118&level1-ppp=119257215 3118&pagename=Rush%2Fcontent_block%2FContentBlockDetail. Accessed April 23, 2013. 40. Weinsier RL, Boker JR, Brooks CM, et al. Nutrition training in graduate medical (residency) education: a survey of selected training programs. Am J Clin Nutr. 1991;54(6):957-962. 41. Nestlé Nutrition Institute Clinical Nutrition Fellowship for Physicians. http://www.nestlefellowship.com/. Accessed April 23, 2013.
42. Kiss CM, Byham-Gray L, Denmark R, Loetscher R, Brody RA. The impact of implementation of a nutrition support algorithm on nutrition care outcomes in an intensive care unit. Nutr Clin Pract. 2012;27(6):793801. 43. Oh J. Average cost per inpatient day across 50 states in 2010. Becker’s Hospital Review. 2012. http://www.beckershospitalreview.com/lists/ average-cost-per-inpatient-day-across-50-states-in-2010.html. Accessed March 15, 2013. 44. Commins J. Hospital chiefs: cut costs with care. HealthLeaders. 2013. http://www.healthleadersmedia.com/content/LED-289113/HospitalChiefs-Cut-Costs-with-Care.html. Accessed April 12, 2013. 45. McArdle P. Hospital sees staff reductions as part of cost-cutting efforts. 2013. Rutland Herald. http://www.rutlandherald.com/article/20130424/ NEWS02/704249860. Accessed April 15, 2013. 46. Tuma P. An overview of the intentions of healthcare reform. J Acad Nutr Diet. 2012;112(suppl 1):S56-S63.
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State of Nutrition Support Teams Mark Henry DeLegge and Andrea True Kelley Nutr Clin Pract 2013 28: 691 originally published online 29 October 2013 DOI: 10.1177/0884533613507455 The online version of this article can be found at: http://ncp.sagepub.com/content/28/6/691
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NCPXXX10.1177/0884533613507455Nutrition in Clinical Practice X(X)DeLegge and True Kelley
Invited Review Nutrition in Clinical Practice Volume 28 Number 6 December 2013 691–697 © 2013 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533613507455 ncp.sagepub.com hosted at online.sagepub.com
State of Nutrition Support Teams Mark Henry DeLegge1 and Andrea True Kelley2
Abstract The incidence of malnutrition in hospitalized patients is relatively high (up to 55%) despite breakthroughs in nutrition support therapies. These patients have increased morbidity and mortality, extended hospital stays, and care that is associated with higher costs. These patients are often poorly managed due to inadequate nutrition assessment and poor medical knowledge and practice in the field of nutrition. Nutrition support teams (NSTs) are interdisciplinary support teams with specialty training in nutrition that are often comprised of physicians, dietitians, nurses, and pharmacists. Their role includes nutrition assessment, determination of nutrition needs, recommendations for appropriate nutrition therapy, and management of nutrition support therapy. Studies have demonstrated significant improvements in patient nutrition status and improved clinical outcomes as well as reductions in costs when patients were appropriately managed by a multispecialty NST vs individual caregivers. Despite this, there has been steady decline in the number of formal NST in recent years (65% of hospitals in 1995 to 42% in 2008) as hospitals and other healthcare organizations look for ways to cut costs. Given the importance of nutrition status on clinical outcomes and overall healthcare costs, a number of institutions have introduced and sustained strong nutrition training and support programs and teams, demonstrating both clinical and economic benefit. The benefits of NST, training and implementation strategies, and tips for justifying these clinically and economically beneficial groups to healthcare organizations and governing bodies are discussed in this review. (Nutr Clin Pract. 2013;28:691-697)
Keywords enteral nutrition; parenteral nutrition; nutrition support teams; reimbursement patient care team; nutritional support
Background on Nutrition Support Teams The incidence of malnutrition in the hospitalized patient can vary between 30% and 55%1-6; these patients often have extended hospital stays with more complications, higher costs, higher readmission rates, and increased morbidity and mortality.2-5 Patients who are undernourished or who are at risk of becoming undernourished are often poorly managed due to inadequate nutrition assessment7-9 and medical knowledge and practice in the field of nutrition.10-12 With the development of specialized nutrition therapy (parenteral nutrition [PN] and enteral nutrition [EN]), an interdisciplinary approach was essential for successful transition of these medical breakthroughs from the bench to the bedside. As these new innovations were adopted, interdisciplinary nutrition support teams (NSTs) were created to optimize the effectiveness and safety of this therapy and became the gold standard of nutrition care in the 1980s and 1990s. The structure and function of NSTs vary from one institution to another depending on the local needs, organizational culture, and available personnel. Ideal team composition includes physicians, nurses, dietitians, and pharmacists with specialized nutrition training. In general, functions of an NST include nutrition assessment, determination of macro- and micronutrient needs, recommendations for appropriate EN/PN therapy, management of nutrition support therapy, and training of other support personnel.13 See Table 1 for a list of common NST specialists and their roles.
When evaluating the impact of nutrition care, clinical guidelines, practice standards, and the use of an interdisciplinary NST have been shown to improve outcomes and safety and to have a positive financial impact on healthcare institutions. There are clear benefits to an organized nutrition care format for hospitalized patients. Numerous studies have demonstrated significant improvements in patient nutrition status and improved clinical outcomes, including reduced mortality and reductions in cost, when patients were appropriately managed by a multispecialty NST vs individual caregivers.6,14,15 Despite evidence supporting the health- and cost-related effectiveness of an NST, there has been steady decline in the number of formal NSTs in recent years as hospitals and other healthcare organizations look for ways to cut costs. Based on results from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) 2008 survey, only 42% of respondents, composed largely of those practicing in a hospital setting, had a formal NST, down from 44% in 2005 and 65% in 199516,17 (see Figure 1). From 1Medical University of South Carolina, Charleston, and 2ATK Clinical Consulting, Charleston, South Carolina Financial disclosure: None declared. This article originally appeared online on October 29, 2013. Corresponding Author: Mark Henry DeLegge, Medical University of South Carolina, 25 Courtenay St, Suite 7100A, Charleston, SC 29425, USA. Email: [email protected].
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Table 1. Specialists on Nutrition Support Teams (NSTs) and their Roles. Practitioner
Potential Role(s) in NST
Physicians
Must be familiar with all aspects of nutrition care, including: ● Patient screening, assessment, development and implementation of nutrition care plan, patient monitoring, and termination of therapy ● Lead the nutrition care implementation structure in many institutions ● Surgeons/radiologists may participate in placement of central venous lines and gastrostomies and lead postsurgical care and management of patients (eg, gastroenterologists) ● Supervise care provided by dietitians, nurses, and pharmacists; engage in all aspects of direct patient care and nutrition needs, as indicated ● Conduct individualized nutrition screening and assessment ● Develop and implement nutrition care plans ● Monitor patient’s response to the nutrition care delivered ● Develop transitional feeding care plan or termination of nutrition support, as appropriate ● Compound parenteral or other nutrition formulation prescribed; provide direct patient care ● Manage specialized nutrition support program and improve quality; educating other healthcare professionals, students, patients, and caregivers ● Conduct nutrition-related research or participate in research activities Varies with the educational background, position, and practice environment. May include: ● Directing patient care, including intravenous access ● Recognizing side effects and complications of stomas/central lines ● Education and training of patients and caregivers ● Participation in research activities ● Advice on desensitization and safety of oral feeding and swallowing
Dietitians
Pharmacists
Nurses
Possibly speech/ language therapists
Figure 1. Changes in percentage of nutrition support teams over time based on American Society for Parenteral and Enteral Nutrition survey respondents.16
Reductions in NSTs: Impact on Patient Care and Costs Results of the 2008 A.S.P.E.N. survey demonstrated that the most common reasons for not having an NST when one previously existed included the following: decentralized nutrition support services (37%), financially not feasible (33%), lack of physician support (23%), and lack of time (7%).16 Of survey respondents who formerly had NSTs that were disbanded, 40% responded that patient care had been adversely affected by this change, while 30% felt individual clinicians were adequately managing nutrition support services and 30% believed that care had not been adversely affected.16 Today, financial considerations are still at the forefront of healthcare delivery. Convincing healthcare management to
allocate staff for NSTs can be difficult, especially when personnel are at a premium. However, this cost-center focus can have serious consequences for patient outcomes. For example, the incidence of malnutrition in the hospitalized patient can vary between 30% and 55%,1-6 and these patients have extended hospital stays, higher costs, and increased mortality rates.2-5 Furthermore, it has been shown that organized and effective nutrition support by an NST actually reduces costs and justifies NST involvement.18-21 These 2 concepts, cost containment and quality care, appear to be at odds with one another. In a meta-analysis, Cangelosi et al22 estimated the impact of the accurate selection of the appropriate nutrition therapy (EN vs PN) on adverse events, treatment duration, and length of hospital stay. Estimates were converted to population economic impacts by assuming 10% of PN patients are suitable candidates for EN. Compared with PN, the use of EN reduced the risk of major, potentially life-threatening infections (relative risk [RR], 0.58; 95% confidence interval [CI], 0.44–0.77); reduced the risk of major, potentially life-threatening noninfection events (RR, 0.73; 95% CI, 0.59–0.91); and suggested a reduction in mortality (RR, 0.70; 95% CI, 0.45–1.09). The use of EN also reduced inpatient length of stay, time in the intensive care unit (ICU), and length of nutrition treatment. Compared with PN, the use of EN resulted in savings from reduced adverse events at an average of nearly $1500 per patient; savings from reduced hospital length of stay amounted to nearly $2500 per patient. To highlight the cost savings provided by appropriate assessment and therapy selection, a shift
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of only 10% of patients inappropriately treated with PN therapy to EN therapy would save ~$35 million annually due to reduced adverse events and another $57 million due to shorter hospital stays.22 In one of the few studies to demonstrate the economic benefit of an NST when considering the actual costs of the nutrition support team itself, Hassell et al23 evaluated the NST management of enterally fed patients. They assessed potential improved clinical outcomes of individually managed patients compared with patients managed by an NST. Elderly patients receiving EN support for >24 hours over a 3-month period (n = 136) were studied, and cost calculations included salaries for clinicians and support personnel for the NST vs costs for nonteam management. Differences were statistically significant for both severity of illness, which was higher in the NST group (P < .001), and complication rate, which was greater in the nonteam group (P < .001). In the NST-managed group, there was a 23% reduction in adjusted mortality rate, an 11.6% reduction in the adjusted length of hospital stay, and a 43% reduction in adjusted readmission rate. Cost-benefit analysis revealed that for every $1 invested in nutrition support team management, a benefit of $4.20 was realized. Trujillo et al6 prospectively studied 209 patients started on PN over a 4-month period; they reviewed appropriateness for initiation of PN therapy against A.S.P.E.N. guidelines. For patients followed by an interdisciplinary NST, only 18% of PN starts were not indicated vs 56% of PN starts for patients not followed by the NST (P < .005). Avoidable charges calculated based on PN were $20.57 per day for NST-managed patients vs $94.57 per day for non–NST-managed patients. Overall reduced charges of approximately $430,000 annually were projected based on these data. However, the cost of overhead, substitute therapy, and NST management of patients were not included in cost savings calculations. In another study by Kennedy and Nightingale,24 the investigators sought to determine whether an NST could show tangible cost savings (equipment, monitoring, and medication costs) from managing patients considered for PN. The study’s secondary aims were related to the quality issues of placement of PN catheters, catheter-related sepsis (CRS), duration of PN, and mortality. They compared findings for 2 years: one before NST involvement and one after implementation of a formal NST (historical control). The results were significantly in favor of an NST; CRS was dramatically reduced from 71% to 29% (P < .05) from the pre-NST to the NST year, respectively. In-hospital mortality for patients receiving PN was also significantly reduced when patients were managed by an NST (43% vs 24%; P < .05). In addition, tangible cost savings were observed in the NST year (~$77,249) compared with the preNST year, derived primarily from avoided PN episodes and a reduced incidence in CRS. According to the authors, these cost savings justify the salaries of a nutrition nurse specialist and a senior dietitian as part of an NST.
Across a network of hospitals in Europe, a prospective investigation of the function, structure, and organization of an NST composed of physicians, nurses, and dietitians among 3071 hospitals was completed.25 Established NSTs were in place at 98 hospitals (3.2%), and their main activities were creating nutrition regimens (100%), education (87%), and monitoring nutrition therapy (92%). In general, the NSTs were affiliated with a hospital specialty discipline (eg, surgery). Seventy-one percent of the physicians, 40% of the nurses, and 69% of the dietitians in the NST held a nutrition-specific additional qualification, and a total of 12% of the physicians, 37% of the nurses, and 46% of the dietitians were exclusively responsible for the NST. Since implementation of the NST, a reduction in complications by 88% and a cost saving of 98% have been noted.25 The authors concluded that special efforts should be aimed at continuing education of NST members and financing of teams given the positive impact of an NST on health outcomes and healthcare finances. In addition, home NSTs have also been shown to improve outcomes and dramatically improve costs by preventing hospitalizations of patients receiving home-based EN/PN therapy. Home-based NST interventions by an interdisciplinary team of nurses, pharmacists, and dietitians from a commercial home infusion company, working closely with physicians, improved patient care and potentially prevented more than 429 hospitalized days over a 3-month period.26 Interventions included correcting over- and underfeeding, preventing dehydration, reducing/eliminating diarrhea, managing hyperglycemia, managing electrolyte imbalances, transitioning patients from PN to oral eating, and starting patients on PN therapy in the home vs the hospital. The cost savings of these interventions were estimated at >$850,000 during the 3-month period.26
Nutrition Training and Implementation of Practice Guidelines Practice guidelines are developed through a systematic review of the available research evidence and contain therapy-specific recommendations with the intent of minimizing practice variation. The “Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient,” published by the Society of Critical Care Medicine (SCCM) and A.S.P.E.N., are the most comprehensive and current North American practice guidelines on the implementation of nutrition support therapy for the critically ill patient.27 As described above, implementation of these evidence-based guidelines is believed to be critical to the success of NSTs and the delivery of appropriate nutrition therapy. However, many issues must be taken into consideration to successfully implement these guidelines in the clinical setting. These include an awareness of existing guidelines among clinicians, consensus among clinicians on which guidelines to adopt, and finally, an adherence by the practitioner to the guidelines. This process is also
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influenced by the organizational culture as a whole and requires professionals with adequate training in nutrition for successful implementation.28 Results from the 2008 NST A.S.P.E.N. survey showed that, in the absence of an NST, individual clinicians are largely responsible for managing the nutrition support needs of patients.16 Despite the importance of appropriate nutrition therapy on positive outcomes, this increased burden of nutrition support on physicians has not been supplemented by most institutions with additional and adequate nutrition training.29-31 While this has long been recognized as an issue, most U.S. medical schools still did not provide at least 25 hours of nutrition education during the past decade as recommended by the National Academy of Sciences32 or require a separate nutrition course. In addition, most physician residency programs have devoted little time and effort to formal nutrition education.33-36 Recognizing this shortcoming, several groups have implemented training programs to identify and address the nutrition knowledge gap. For example, a nutrition vertical integration group at a university in Boston was founded to review nutrition medicine in the school curriculum.37 The group developed a novel student-centered model of nutrition medicine education that focused on medical student–mentored extracurricular activities to develop, evaluate, and sustain nutrition medicine education. Their team-based approach focused on case-based learning in the classroom, practice-based learning in the clinical setting, extracurricular activities, and a virtual curriculum to improve medical students’ knowledge, attitudes, and practice skills in nutrition across their 4-year training program. Their nutrition education program fell just short of the 25 hours recommended by the National Academy of Sciences. However, most of their nutrition pre-clerkship curriculum objectives were covered during their 4-year period. At the hospital level, another university has implemented a comprehensive nutrition training and practice program.38 Nutrition care at this institution is described as a process in which patients are (1) screened to identify risk, (2) given full nutrition assessments to confirm status when risk is suspected, (3) provided nutrition therapy to meet individual needs, and (4) routinely monitored for changes in nutrition needs with care adjusted as the patient’s nutrition status changes. Their program centers on adoption and implementation of evidencebased nutrition practices. In particular, EN is used preferentially over PN and, when necessary, begins within 24–48 hours after admission. In addition, another university center offers a nutrition support practicum where attendees gain clinical experience and are eligible for 40 professional education units from the Commission on Dietetic Registration, the credentialing agency for the American Dietetic Association.39 Participants spend 5 days working with members of an interdisciplinary nutrition support team in an ICU setting. These trainings are carried out by nutrition specialists from the Nutrition Consultation Service, which has been active for over 20 years.
This interdisciplinary training approach is supported by Weinsier et al,40 who studied teaching practices of nationally recognized nutrition programs and identified the following critical elements in creating and implementing strong programs: (1) a clinically active physician-nutritionist role model, (2) nutrition elective rotations, (3) practical learning materials and conferences, and (4) an interdisciplinary nutrition support team. Based on the success of these programs, DeChicco et al36 describe a process for developing an effective training program for multispecialty NST. This detailed program includes the following steps: (1) formulation of general goals of the program, (2) specification of learning objectives, (3) assessment of each student’s current level of knowledge and educational goals, (4) determination of educational strategies and learning activities that will best meet the goals of each student and the program, and (5) creation of a method to evaluate the performance of each student and the program as a whole. Several postgraduate nutrition support training programs also exist. One commercial EN manufacturer provides handson clinical experience to attendees.41 Its 4-week EN fellowship for medical and surgical fellows allows the attendees to spend 2 weeks on site working with each of 2 faculty members who are leaders in the field of nutrition support. Attendees are encouraged to submit a manuscript on a nutrition-related topic for publication and participate in national or international nutrition conferences. Other effective strategies for implementation of A.S.P.E.N. guidelines without an NST have been described. Kiss et al42 reported on the use of a nutrition support algorithm that significantly improved the nutrition status of hospitalized ICU patients. The nutrition support algorithm, as described, is an operational version of a guideline that is adapted to local requirements and easy to apply. Despite demonstration of significantly positive outcomes in the mean delivery of total energy and protein pre- and postalgorithm application, it is unclear if the algorithm made a significant impact at the clinical level (eg, reduced stay and cost, reduced mortality). The authors note that their findings and outcomes may be further improved with routine nutrition assessment by a dietitian or a designated NST. At the country level, after recognizing up to a 70% prevalence of malnutrition in their health care facilities, Canadian healthcare officials investigated how they delivered nutrition care. The results-oriented Canadian Malnutrition Task Force (CMTF) was tasked with improving nutrition care in Canada and has made great strides.38 Similar to a U.S. university experience, the group first identified best nutrition practices for healthcare facilities and implemented a stepwise strategy to (1) screen all patients for malnutrition and nutrition risk, (2) conduct full assessment for those identified to have risk, (3) develop and implement a nutrition plan for each high-risk patient, and (4) then monitor each patient regularly to update the plan as needed. Findings from a survey conducted by the group showed that of 260 hospitalized patients, an overall
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malnutrition prevalence of 43% existed and that caregivers did not assess nutrition status at admission or at discharge for all patients. The survey also found that 1 of every 3 patients ate less than 50% of their meals, even though food quality was rated as high. As a result, the CMTF developed a nutrition care action plan detailed below, which may serve as a model for others: •• Implement standardized, mandatory screening protocols •• Develop programs to educate administrators, physicians, and nurses about how to integrate nutrition care into everyday practice •• Emphasize protected, patient-focused mealtimes •• Make use of an interdisciplinary nutrition care team
Making a Case for Comprehensive Nutrition Support at Your Institution Leaders from successful nutrition support programs, including Dr Jane Ryan and healthcare system chief operating officer Dr Ninfa Saunders, described helpful suggestions for making a strong case to convince organizations of the value provided by comprehensive nutrition support services during a commercially sponsored Nutrition Summit in 2011.38 Key steps included (1) collecting nutrition status data to document a need for change, (2) seeking the support of hospital leaders to promote nutrition care, and (3) making and presenting a plan for improvements in hospital nutrition practices. Detailed tips for making a successful pitch included the following38: •• Preparation: Plan carefully for your meeting. Develop a focused message and a compelling agenda for your meeting with the leader, and think about what questions you might have to answer. •• Approach: Practice your presentation but do not memorize it; be sincere and direct with your opening message. Describe the benefits by making them vivid and attainable. Be crisp and cogent in your presentation. •• Content: Have the end result in mind as you make your presentation. What is your main goal? Your leader will appreciate if you discuss the deal but not the details at this first meeting. •• Next steps and follow-up: Don’t stop by presenting your idea alone. What are the next actions needed? Do you need funding for a pilot project? Do you need to go onto the agenda for a committee meeting? Remember that hospital executives and leaders are very busy. You may need to follow up and remind the leader of your request. Be persistent.
Future Directions for Nutrition Support There is an abundance of evidence demonstrating improved quality of care, improved outcomes, and reductions in healthrelated cost when patients requiring specialized nutrition care
are appropriately managed by a multispecialty NST. However, little published data exist showing what staffing and supporting a well-rounded NST actually costs (in dollars) for healthcare organizations to achieve these improvements and savings. Given the increasing costs of providing adequate healthcare and increased focus on good clinical outcomes for obtaining reimbursement, this is an increasingly important point to consider when justifying the existence of an NST. The state of medicine as a whole is changing in the United States and internationally. The hospital setting is ripe for cost adjustment to deal with new realities—doing more with less. The average cost for a hospital stay in the United States per day is $1625.00.43 Nineteen percent of hospital leaders interviewed recently still felt they needed to reduce their operating budgets by an additional 11%.44 Hospitals previously receiving yearly federal funds for seeing an abundance of Medicare patients have seen this program winding down, further straining hospital budgets.45 Healthcare system cost cutting often includes a reduction in full-time employment positions in addition to work hour reduction. Therefore, every discipline and function tied to the hospital budget will need to demonstrate clinical efficacy and cost-effectiveness. The impetus of the Patient Protection and Affordable Care Act (ACA) is to shift focus from disease treatment to disease prevention. An initial examination of the ACA does highlight medical nutrition therapy for chronic diseases and employee wellness programs. However, it does not state that registered dietitians are essential providers of those services or credit dietitians as reimbursable practitioners across the healthcare spectrum.46 It also does not allocate the funds for these proposed new programs. The typical NST is an inpatient service and is not in the business of disease prevention. Most members of the NST (except the physician) are unable to bill for their services and therefore are part of the “valueadded” services provided by the hospital or healthcare system. There is no federal mandate to use an NST prior to ordering nutrition support therapy. Therefore, the NST is “optional” and is often not available in most U.S. hospitals. In order for NSTs and the field of nutrition support to advance, either services provided will need to be reimbursed to the NST (billed services) or the value of the NST will need to be demonstrated in the new healthcare environment. However, this value cannot be built solely around reducing access to PN as the justification for an NST’s existence. This value will need to be demonstrated by the following: 1. Having a universally accepted biomarker that clearly identifies patients who are malnourished 2. Linking the malnutrition biomarker to other clinical outcomes (eg, hospital length of stay, functional status) 3. Delivering early, effective, and safe nutrition therapy to identified patients 4. Offering the right nutrition therapy to patients, EN or PN, dependent not only on the safety or the cost of the
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therapy but also on the likelihood that it will reverse or impede malnutrition 5. Creating a scenario where unaddressed malnutrition is a “never event” Because NSTs do have an “economic cost” that includes salary, benefits, physical plant overhead, and continuing education, allocating the NST to the patients with the greatest need would also ensure that this resource was being used appropriately. Data presented by Hassell et al23 demonstrated impressive cost savings when a multispeciality NST managed highly complex patients when the cost of the NST was taken into consideration. With this in mind, perhaps justifying and implementing involvement by the NST only for patients with the most complex nutrition needs might be more appropriate. More routine PN or EN patients could be managed by a clinician following standard guidelines for patient assessment and appropriate nutrition product implementation and monitoring. NSTs are dwindling in number across the U.S. healthcare landscape. Their survival is directly linked to the value we place on nutrition support (both clinical and economic), the clinicians, and the consumer’s belief in nutrition as a critical component of patient care and future federal/state mandates for improvements in the diagnosis and treatment of malnutrition throughout our healthcare systems.
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