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Barrocas A, Schwartz DB, Bistrian BR, Guenter P, Mueller C, Chernoff R, Hasse JM. Nutrition support teams: Institution, evolution, and innovation. Nutr Clin Pract 2023; 38:10-26. [PMID: 36440741 DOI: 10.1002/ncp.10931] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022] Open
Abstract
The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.
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Affiliation(s)
- Albert Barrocas
- Department of Surgery, Tulane University School of Medicine, Atlanta, Georgia, USA
| | - Denise Baird Schwartz
- Bioethics Committee, Providence Saint Joseph Medical Center, Burbank, California, USA
| | - Bruce R Bistrian
- Division of Clinical Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peggi Guenter
- American Society for Parenteral and Enteral Nutrition (ASPEN), Moses Lake, Washington, USA
| | - Charles Mueller
- Department of Nutrition and Food Studies, New York University/Steinhardt, New York, New York, USA
| | - Ronni Chernoff
- Donald Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jeanette M Hasse
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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Moyer AM, Abbitt D, Choy K, Jones TS, Morin TL, Wikiel KJ, Barnett CC, Moore JT, Robinson TN, Jones EL. A dedicated feeding tube clinic reduces emergency department utilization for gastrostomy tube complications. Surg Endosc 2022; 36:6969-6974. [PMID: 35132448 DOI: 10.1007/s00464-022-09065-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/17/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Enteral access is required for a variety of reasons from neuromuscular disorders to dysphagia. Gastrostomy tubes (GTs) can be placed endoscopically, surgically, or radiographically and complications include infection, bleeding, leakage and unintentional removal. Routine post-procedural follow-up is limited by inconsistent guidelines and management by different specialty teams. We established a dedicated GT clinic to provide continuity of care and prophylactic GT exchange. We hypothesized that patients followed in the GT clinic would have reduced Emergency Department (ED) utilization. METHODS A retrospective review of patients who underwent GT placement from January 2010 to January 2020 was conducted. Baseline demographics, indications for GT placement, number and reason for ED visits and utilization of a multidisciplinary GT clinic were studied. RESULTS A total of 97 patients were included. The most common indication for placement was dysphagia (88, 91%) and the most common primary diagnosis was head and neck malignancy (51, 51%). The GT clinic is a multidisciplinary clinic staffed by surgeons and residents, dieticians, and wound care specialists and cared for 16 patients in this study. Three patients (19%) in the GT clinic group required ED visits compared to 44 (54%) in the standard of care (SOC) group (p < 0.05). There was an average of 0.9 ED visits per patient (range 0-7) in the GT clinic group vs 1.6 ED visits per patient (range 0-20) in the SOC group (p = 0.34). Feeding tubes were prophylactically exchanged an average of 7 times per patient in the GT clinic group vs 3 times per patient in the SOC group (p < 0.05). CONCLUSION A multidisciplinary clinic dedicated to GT care limits ED visits for associated complications by more than 50%. Follow-up in a dedicated clinic with prophylactic tube exchange decreases ED visits and should be considered at facilities that care for patients with GTs.
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Affiliation(s)
- Amber M Moyer
- Department of Surgery, University of Colorado School of Medicine & Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA.
| | - Danielle Abbitt
- Department of Surgery, University of Colorado School of Medicine & Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA
| | - Kevin Choy
- Department of Surgery, University of Colorado School of Medicine & Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA
| | - Teresa S Jones
- Department of Surgery, University of Colorado School of Medicine & Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA
| | - Theresa L Morin
- Department of Surgery, University of Colorado School of Medicine & Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA
| | - Krzystof J Wikiel
- Department of Surgery, University of Colorado School of Medicine & Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA
| | - Carlton C Barnett
- Department of Surgery, University of Colorado School of Medicine & Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA
| | - John T Moore
- Department of Surgery, University of Colorado School of Medicine & Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA
| | - Thomas N Robinson
- Department of Surgery, University of Colorado School of Medicine & Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA
| | - Edward L Jones
- Department of Surgery, University of Colorado School of Medicine & Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA
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Boeykens K, Duysburgh I. Prevention and management of major complications in percutaneous endoscopic gastrostomy. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000628. [PMID: 33947711 PMCID: PMC8098978 DOI: 10.1136/bmjgast-2021-000628] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 12/17/2022] Open
Abstract
Background Percutaneous endoscopic gastrostomy is a commonly used endoscopic technique where a tube is placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition. Several placement techniques are described in the literature with the ‘pull’ technique (Ponsky-Gardener) as the most popular one. Independent of the method used, placement includes a ‘blind’ perforation of the stomach through a small acute surgical abdominal wound. It is a generally safe technique with only few major complications. Nevertheless these complications can be sometimes life-threatening or generate serious morbidity. Method A narrative review of the literature of major complications in percutaneous endoscopic gastrostomy. Results This review was written from a clinical viewpoint focusing on prevention and management of major complications and documented scientific evidence with real cases from more than 20 years of clinical practice. Conclusions Major complications are rare but prevention, early recognition and popper management are important.
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Affiliation(s)
- Kurt Boeykens
- AZ Nikolaas, Nutrition Support Team, Sint-Niklaas, Oost-Vlaanderen, Belgium
| | - Ivo Duysburgh
- AZ Nikolaas, Nutrition Support Team, Sint-Niklaas, Oost-Vlaanderen, Belgium
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Arvanitakis M, Gkolfakis P, Despott EJ, Ballarin A, Beyna T, Boeykens K, Elbe P, Gisbertz I, Hoyois A, Mosteanu O, Sanders DS, Schmidt PT, Schneider SM, van Hooft JE. Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:81-92. [PMID: 33260229 DOI: 10.1055/a-1303-7449] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.
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Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Asuncion Ballarin
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Torsten Beyna
- Department of Gastroenterology and Therapeutic Endoscopy, Evangelisches Krankenhaus Düsseldorf, Germany
| | - Kurt Boeykens
- Nutrition Support Team, AZ Nikolaas Hospital, Sint-Niklaas, Belgium
| | - Peter Elbe
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Gisbertz
- Department of Gastroenterology, Bernhoven Hospital, Uden, The Netherlands
| | - Alice Hoyois
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Ofelia Mosteanu
- Department of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital and University of Sheffield, United Kingdom
| | - Peter T Schmidt
- Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Stéphane M Schneider
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Gastroentérologie et Nutrition, Nice, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Evans PT, Smith MC, Collins NE, Prendergast KM, Schneeberger SJ, Kopp EB, Dennis BM, Guillamondegui OD. Multidisciplinary Bedside Procedure Service. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Paine P, McMahon M, Farrer K, Overshott R, Lal S. Jejunal feeding: when is it the right thing to do? Frontline Gastroenterol 2019; 11:397-403. [PMID: 32884631 PMCID: PMC7447283 DOI: 10.1136/flgastro-2019-101181] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 02/04/2023] Open
Abstract
The decision to commence jejunal feeding in patients with structural abnormalities, which prevent oral or intragastric feeding, is usually straightforward. However, decisions surrounding the need for jejunal feeding can be more complex in individuals with no clear structural abnormality, but rather with foregut symptoms and pain-predominant presentations, suggesting a functional origin. This appears to be an increasing issue in polysymptomatic patients with multi-system involvement. We review the differential diagnosis together with the limitations of available functional clinical tests; symptomatic management options to avoid escalation where possible including for patients on opioids; tube feeding options where necessary; and an approach to weaning from established jejunal feeding in the context of a multidisciplinary approach to minimise iatrogenesis.
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Affiliation(s)
- Peter Paine
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, Salford, UK
| | - Marie McMahon
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, Salford, UK
| | | | - Ross Overshott
- Department of Liaison Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
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