Consultative total parenteral nutrition teams: the effect on the incidence of total parenteral nutrition-related complications

Nutrition support teams: Institution, evolution, and innovation

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.

Systematic review with meta-analysis: effects of implementing a nutrition support team for in-hospital parenteral nutrition

BACKGROUND

Nutrition support teams (NST) may improve parenteral nutrition (PN) outcomes. No previous systematic review has provided conclusive data on catheter-related infection (CRI) occurrence after NST introduction, nor have previous studies performed meta-analysis or graded the evidence.

AIMS

To systematically evaluate the effects of implementing an NST for hospitalised adults on PN and compare these with standard care.

METHODS

This was a systematic review and meta-analysis, pre-registered in PROSPERO (CRD42020218094). On November 24, 2020, PubMed, Web of science, Scopus, Embase, Cochrane Library, and Clinical Key were searched. Clinical trials and observational studies with a standard care comparator were included. Primary outcome was relative reduction in CRI rate. A random-effects meta-analysis was used to estimate effects, and evidence was rated using Cochrane and GRADE methodologies.

RESULTS

Twenty-seven studies with 8166 patients were included. Across 10 studies, NST introduction reduced the CRI rate (IRR = 0.32, 95% CI: 0.19-0.53) with -8 (95% CI: -12 to -5) episodes per 1000 catheter days compared with standard care. Hypophosphataemia occurred less frequently (IRD = -12%, 95% CI: -24% to -1%) and 30-day mortality decreased (IRD = -6%, 95% CI: -11% to -1%). Inappropriate PN use decreased, both judged by indication (IRD = -18%, 95% CI: -28% to -9%) and duration (IRD = -21%, 95% CI: -33% to -9%). Evidence was rated very low to moderate.

CONCLUSIONS

This study documents the clinical impact of introducing an NST, with moderate-grade evidence for the reduction of CRI occurrence compared with standard care. Further, NST introduction significantly reduced metabolic complications, mortality, and inappropriate PN use.

Impact of Refeeding Syndrome on Short- and Medium-Term All-Cause Mortality: A Systematic Review and Meta-Analysis

BACKGROUND

The refeeding syndrome has been described as a potentially life-threatening complication of renutrition. However, moving from single reports to larger population studies, the real impact of refeeding syndrome on all-cause mortality is still unknown.

METHODS

PubMed/Medline, EMBASE, Cochrane library, and CINAHL databases were systematically searched until September 2020 for studies reporting mortality rates in patients who developed the syndrome at renutrition compared with those who did not develop it. Effect sizes were pooled through a random-effect model.

RESULTS

Thirteen studies were finally considered in the meta-analysis, for a total of 3846 patients (mean age 64.5 years; 58% males). Pooled data showed a nonsignificant trend toward an increased short-term (≤1 month) mortality in patients developing the refeeding syndrome (odds ratio = 1.27, 95% confidence interval 0.93-1.72), mostly driven by studies in which renutrition was not prescribed and supervised by a nutritional support team (P = .01 at subgroup analysis) and by studies published in previous years (P = .04 at meta-regression). When examining medium-term (≤6 month) mortality, an overall statistical significance toward higher risk was observed (odds ratio = 1.54, 95% confidence interval 1.04-2.28).

CONCLUSION

This was the first meta-analysis that specifically assessed the impact of refeeding syndrome on mortality. Our results suggested a nonsignificant trend toward increased mortality in the short term but a significantly increased mortality in the medium term. The supervision/management of the refeeding process by a nutrition specialist might be a key factor for the limitation of this mortality excess.

Demonstrating the Value of the Nutrition Support Team to the C-Suite in a Value-Based Environment: Rise or Demise of Nutrition Support Teams?

Nutrition support teams (NSTs) in the United States have had to justify their existence since their inception in the 1970s. Concomitant with those efforts, changes in healthcare financing have challenged hospital administrators to adapt their reimbursement strategies and methods. NSTs, if they are to survive and/or thrive, must be aware of the convulsive currents of change faced by those who determine which programs move downstream and which find their demise on the banks of the stream. This review provides a historical perspective of both the US healthcare financing system and the NST experiences of nutrition clinicians over the past 4 decades. Focused discussions of 5 teams are provided from individual members of those varied NSTs. Additional recommendations from the administrative side of the equation are presented by 3 administrators. Whether NSTs will "rise or demise" depends on many factors. Understanding what those who control the purse strings are seeking in terms of salutary cost and quality outcomes in the current value-based system will facilitate the NST's communication with them. The demonstration of the NST's value is more likely to succeed when bolstered by current evidence-based data as applied to the specific institution. These efforts can be carried out by a formal NST in larger or academic institutions or a "virtual" team with a single individual coordinating the services in a transdisciplinary fashion, employing the acronym ACT (accountability, communication, [transdisciplinary] teamwork).

The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients

Parenteral nutrition (PN) is a complex and specialized form of nutrition support that has revolutionized the care for both pediatric and adult patients with acute and chronic intestinal failure (IF). This has led to the development of multidisciplinary teams focused on the management of patients receiving PN: nutrition support teams (NSTs). In this review we aim to discuss the historical aspects of IF management and NST development, and the practice, composition, and effectiveness of multidisciplinary care by NSTs in patients with IF. We also discuss the experience of two IF centers as an example of contemporary NSTs at work. An NST usually consists of at least a physician, nurse, dietitian, and pharmacist. Multidisciplinary care by an NST leads to fewer complications including infection and electrolyte disturbances, and better survival for patients receiving short- and long-term PN. Furthermore, it leads to a decrease in inappropriate prescriptions of short-term PN leading to significant cost reduction. Complex care for patients receiving PN necessitates close collaboration between team members and NSTs from other centers to optimize safety and effectiveness of PN use.

Parenteral Nutrition Complications in Children Undergoing Bone Marrow Transplantation

BACKGROUND

Parenteral nutrition (PN) seems to be a practical solution to face the negative nutritional effects of bone marrow transplantation.

OBJECTIVE

Report and describe all observed PN-related complications in children undergoing allogenic bone marrow transplantation in a tertiary center and determine the possible risk factors.

MATERIALS AND METHODS

This was a retrospective and observational study including 51 allografted children 2 to 17 years of age. We collected from medical patient records any noticed PN-related complications using an assessment causality method. The independent risk factors for complications were investigated by multivariate analysis.

RESULTS

A total of 92% of patients (n=47) developed a total of 136 complications attributable to PN. The incidence rate of complications was 5 for 100 patient days of PN. Infectious complications (32.3%) and electrolytic disorders (27.9%) were the most common conditions identified during our study. Multivariate analysis showed that the duration of PN exposure, age, and hyperglycemia were the risk factors for the onset of these complications.

CONCLUSIONS

Although we have noticed multiple complications attributable to PN, a certain causal link is difficult to establish in this particular context. Emphasizing enteral nutrition in bone marrow graft protocols would be the best way to avoid these complications.

Parenteral Nutrition Electrolyte Abnormalities and Associated Factors Before and After Nutrition Support Team Initiation

BACKGROUND

Studied since the 1940s, refeeding syndrome still has no universal definition, thus making comparison of studies difficult. Negative outcomes (eg, metabolic abnormalities) may occur with the use of specialized nutrition, such as parenteral nutrition (PN). Less than half of medical institutions have a nutrition support team (NST) managing PN. Interdisciplinary team management of PN may reduce negative outcomes of PN. The objective of this study was to show the value of the NST by measuring differences in PN variables, especially electrolyte abnormalities (EAs), before and after NST initiation at a large medical center and to identify factors associated with EAs among adult subjects receiving PN.

MATERIALS AND METHODS

During this retrospective study, computerized medical charts (N = 735) from 2007-2010 were reviewed for electrolyte changes (particularly potassium, magnesium, and phosphorus) the first 3 days following PN initiation in hospitalized adults. Changes in EAs with other variables were compared before and after NST implementation. Equivalent samples sizes were collected to better evaluate the impact of the team.

RESULTS

Following the implementation of the NST, fewer EAs were seen in PN patients (53%; χ2  = 10.906, P = .004); significantly less potassium, phosphorus, and magnesium intravenous piggyback supplementation (88.8% vs 94%; χ2  = 5.05, P = .026) was used; and mortality within 30 days of PN cessation was significantly less (12.7% vs 10.6%, P = .012).

CONCLUSION

Our study complements existing research, finding that an NST was associated with a decreased occurrence of EAs and mortality in the hospitalized adult receiving PN.

A.S.P.E.N. Statement on Parenteral Nutrition Standardization

In response to questions regarding use of standardized parenteral nutrition (PN) formulations, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) developed a Task Force to address some of these issues. A.S.P.E.N. envisions standardized PN as a broader issue rather than simply using a standardized, commercially available PN product. A standardized process for PN must be explored in order to improve patient safety and clinical appropriateness, and to maximize resource efficiency. A standardized process may include use of standardized PN formulations (including standardized, commercial PN products) but also includes aspects of ordering, labeling, screening, compounding, and administration of PN. A safe PN system must exist which minimizes procedural incidents and maximizes the ability to meet individual patient requirements. Using clinicians with nutrition support therapy expertise will contribute to that safe PN system. The purpose of this statement is to present the published literature associated with standardized PN formulations, to provide recommendations, and to identify areas in need of future research.

Limited long-term survival after in-hospital intestinal failure requiring total parenteral nutrition

BACKGROUND

Total parenteral nutrition (TPN) is an invasive and advanced rescue feeding technique that has acceptable short-term survival although at costs of substantial risks. Survival after the clinical use of TPN >6 mo is unknown.

OBJECTIVE

We determined long-term survival after clinical TPN use in a consecutive cohort who were attending an academic hospital.

DESIGN

The study included a prospective cohort with a retrospective analysis of all 537 consecutive episodes of TPN in 437 patients between January 2010 and April 2012. Follow-up was until October 2013 with a total follow-up of 608 patient-years. Survival was analyzed by using Kaplan-Meier and Cox regression.

RESULTS

Survival was 58% in 437 patients with a first-time use of TPN at an average of 1.5 y after the initiation of TPN. The mortality rate was 30 deaths/100 patient-years. Older age, admission at an intensive care unit or a nonsurgical department, lower body mass index, and an underlying malignancy were positively associated with mortality.

CONCLUSION

TPN use, if correctly indicated, is a clinical sign of intestinal failure and a surrogate marker for markedly increased risk of mortality even >1.5 y after TPN use. This trial was registered at clinicaltrials.gov as NCT02189993 with protocol identification name TPN-01.

Commercial enteral formulas and nutrition support teams improve the outcome of home enteral tube feeding

BACKGROUND

The benefits of home enteral tube feeding (HETF) provided by nutrition support teams (NSTs) have been questioned recently, given the growing costs to the healthcare system. This study examined the effect of a specialized home enteral nutrition program on clinical outcome variables in HETF patients.

METHODS

The observational study included 203 patients (103 women, 100 men; mean age 52.5 years) receiving HETF with homemade diets for at least 12 months before starting a specialized home nutrition program for another 12 months consisting of provision of commercial enteral formulas and the guidance of an NST. Both study periods were compared regarding the number of hospital admissions, length of hospital and intensive care unit (ICU) stay, and costs of hospitalization.

RESULTS

A specialized HETF program significantly reduced the number of hospital admissions and the duration of hospital and ICU stays. The need for hospitalization and ICU admission was significantly reduced, with odds ratios of 0.083 (95% confidence interval, 0.051-0.133, P < .001) and 0.259 (95% confidence interval, 0.124-0.539, P < .001), respectively. Specialized HETF was associated with a significant decrease in the prevalence of pneumonia (24.1% vs 14.2%), respiratory failure (7.3% vs 1.9%), urinary tract infection (11.3% vs 4.9%), and anemia (3.9% vs 0%) requiring hospitalization. The average yearly cost of hospital treatment decreased from $764.65 per patient to $142.66 per year per patient.

CONCLUSIONS

The specialized HETF care program reduces morbidity and costs related to long-term enteral feeding at home.

Nutrition support teams: how they work, are set up and maintained

Safe cost effective nutritional support is provided by a multidisciplinary team whose activity is overseen by a Nutrition Steering Group that reports directly to the Hospital Trust Board. When a nutrition support team (NST) is first formed, a nutrition nurse specialist enables parenteral nutrition to be given safely. An NST needs to have a clearly agreed scope of practice and needs to be able to justify its presence in terms of quality and cost savings.

Organisation, regulations, preparation and logistics of parenteral nutrition in hospitals and homes; the role of the nutrition support team - Guidelines on Parenteral Nutrition, Chapter 8

PN (parenteral nutrition) should be standardised to ensure quality and to reduce complications, and it should be carried out in consultation with a specialised nutrition support team whenever possible. Interdisciplinary nutrition support teams should be established in all hospitals because effectiveness and efficiency in the implementation of PN are increased. The tasks of the team include improvements of quality of care as well as enhancing the benefit to cost ratio. Therapeutic decisions must be taken by attending physicians, who should collaborate with the nutrition support team. “All-in-One” bags are generally preferred for PN in hospitals and may be industrially manufactured, industrially manufactured with the necessity to add micronutrients, or be prepared “on-demand” within or outside the hospital according to a standardised or individual composition and under consideration of sterile and aseptic conditions. A standardised procedure should be established for introduction and advancement of enteral or oral nutrition. Home PN may be indicated if the expected duration of when PN exceeds 4 weeks. Home PN is a well established method for providing long-term PN, which should be indicated by the attending physician and be reviewed by the nutrition support team. The care of home PN patients should be standardised whenever possible. The indication for home PN should be regularly reviewed during the course of PN.

[Multicenter study on the prevalence of hyperglycemia among hospitalized patients with parenteral nutrition]

OBJECTIVE

The aim of this cross-sectional national multicentric study was to determine the prevalence of hyperglycemia in patients with parenteral nutrition and to assess other clinical factors associated with this complication.

METHOD

All Spanish hospital pharmacy services were invited to participate in the study.

RESULTS

Twenty eight (28) pharmacy services agreed to participate. The study included 442 patients. The prevalence of hyperglycemia (plasma levels > 200 mg/dL) was 26.7%. Eighty four point two per cent of the patients received less than 3.5 mg/kg/minute of glucose, this infusion rate being considered as the safe threshold. In most patients, follow-up of glycemia was based on capillary blood determination with reactive strips and in 27.6% of the cases in which insulin was prescribed, it was added to the parenteral nutrition bag, in full or in part. No significant correlations were found between glycemia and the clinical factors studied (disorders, fever, medication), except for insulin.

CONCLUSIONS

This national multicentric study of the prevalence of hyperglycemia among patients with parenteral nutrition, leaded by hospital pharmacists, was a joint effort aimed to better understand this metabolic complication. Findings are consistent with those reported by other authors and have allowed us to describe the current situation.

Atuação da equipe multidisciplinar na terapia nutricional de pacientes sob cuidados intensivos

Pacientes hospitalizados podem ter necessidades nutricionais especiais em função da desnutrição e dos desequilíbrios metabólicos impostos pelas doenças. A terapia nutricional, principalmente nos estágios críticos das enfermidades, deve ser administrada de modo seguro e eficaz. Vários estudos têm avaliado o papel da equipe multidisciplinar na administração da terapia nutricional. Com o objetivo de identificar os problemas inerentes à administração da terapia nutricional em pacientes hospitalizados e verificar o impacto da atuação de uma equipe multidisciplinar na qualidade dos procedimentos, foi realizada uma revisão que analisou artigos publicados entre 1980 e 2004 sobre o papel da atuação de equipes multidisciplinares no cuidado e na evolução nutricional de pacientes hospitalizados, principalmente os que se encontravam sob cuidados intensivos. Os termos utilizados na pesquisa foram: "multidisciplinary team", "nutritional support", "parente-ral nutrition", "enteral feeding", "critically ill", "intensive care unit","critically ill child". Dos 130 estudos inicialmente identificados, foram selecionados 24, dos quais 14 compararam o padrão de terapia nutricional com e sem a presença da equipe multidisciplinar. Os principais problemas detectados na administração de terapia nutricional em pacientes hospitalizados foram a oferta inadequada de nutrientes, as complicações infecciosas e metabólicas e o uso excessivo de nutrição parenteral. Nos estudos comparativos, a presença da equipe multidisciplinar melhorou o padrão de oferta nutricional, reduziu a incidência de complicações e os custos.

Cost savings of an adult hospital nutrition support team

OBJECTIVES

A hospital-based nutrition support team (NST) may need to demonstrate cost savings and quality benefits. The primary aim of this study was to determine whether an NST could show tangible cost savings (equipment, investigations, and medication costs) from managing patients considered for parenteral nutrition (PN). Secondary aims related to the quality issues of placement of PN catheters, catheter-related sepsis (CRS), duration of parenteral nutrition, and mortality.

METHODS

An NST was formed in 1999 and worked in all adult areas of a university hospital (Leicester Royal Infirmary). Comparative data about all patients given PN were collected for 2 consecutive years (a retrospective pre-NST year and a prospective NST year).

RESULTS

In the pre-NST year there were 82 PN episodes (54 patients), 665 PN days, and a CRS rate of 71% (seven infections/100 PN days). In the NST year, there were 133 referrals for PN but only 78 PN episodes (75 patients, 59% of referrals), 752 PN days, and a decreased overall CRS rate of 29% (three infections/100 PN days, P < 0.05) but a rate of 7% (0.6 infection/100 PN days) in the final 3 mo of the NST year. Tangible cost savings for the NST year were derived from 55 avoided PN episodes (42741 pounds sterlings) and 35 avoided CRS episodes (7974 pounds sterlings). Thirty-nine percent of PN catheters were inserted by the NST with no insertion-related complications. Competency-based training of ward nursing staff decreased the CRS rate. Mean duration of PN increased from 8 to 10 d (P not significant). In-hospital mortality for patients who had PN was 23 of 54 (43%) in the pre-NST year compared with 18 of 75 (24%) in the NST year (P < 0.05).

CONCLUSIONS

Although the number of PN days increased with an NST, tangible cost savings of 50715 pounds sterlings were demonstrated within the NST year by avoided PN episodes and a decreased incidence of CRS. These savings justify the salaries of a nutrition nurse specialist and a senior dietitian.

Outcomes in a pediatric intensive care unit before and after the implementation of a nutrition support team

BACKGROUND

We evaluated the effect of parenteral nutrition (PN) and enteral nutrition (EN) on in-pediatric intensive care unit (PICU) mortality before and after a continuous education program in nutrition support that leads to implementation of a nutrition support team (NST).

METHODS

We used a historical cohort study of infants hospitalized for >72 hours at the PICU from 1992 to 2003. Five periods were selected (P1 to P5), considering the modifications incorporated into the program: P1, without intervention; P2, basic themes and original articles discussion; P3, clinical and nursing staff participation; P4, clinical visits; P5, NST. The samples were compared in terms of sex, age, admitting service (ie, medical vs surgical), prognostic index of mortality, length of stay (LOS), duration of mechanical ventilation, in-PICU mortality rate, and percentage of time receiving EN and PN for each patient. Bi- and multivariate analyses were performed. Statistical significance was set at 0.05 level.

RESULTS

Progressive increase was observed in EN use (p = .0001), median values for which were 25% in P1 and rose to 67% by P5 in medical patients; there was no significant difference in surgical patients. A reduction was observed in PN use; in P1 medians were 73% and 69% for medical and surgical patients respectively, and decreased to 0% in P5 for both groups (p = .0001). There was significant reduction in-PICU mortality rate during P4 and P5 among medical patients (p < .001). The risk of death was 83% lower in patients that received EN for >50% of LOS (odds ratio, 0.17; confidence interval, 0.066-0.412; p = .000).

CONCLUSIONS

The program motivated an increase in EN and a decrease in PN use, mainly after implementation of NST and reduced in-PICU mortality rate.

A Nutrition Support Team Led by General Surgeons Decreases Inappropriate Use of Total Parenteral Nutrition on a Surgical Service

The purpose of this study was to decrease the number of inappropriate orders for total parenteral nutrition (TPN) in surgical patients. From February 1999 through November 2000 and between July 2001 and June 2002, the surgeon-guided adult nutrition support team (NST) at a university hospital monitored new TPN orders for appropriateness and specific indication. In April 1999, the NST was given authority to discontinue inappropriate TPN orders. Indications, based on the American Society for Parenteral and Enteral Nutrition (ASPEN) standards, included short gut, severe pancreatitis, severe malnutrition/catabolism with inability to enterally feed ≥5 days, inability to enterally feed ≥50 per cent of nutritional needs ≥9 days, enterocutaneous fistula, intraabdominal leak, bowel obstruction, chylothorax, ischemic bowel, hemodynamic instability, massive gastrointestinal bleed, and lack of abdominal wall integrity. The number of inappropriate TPN orders declined from 62/194 (32.0%) in the first 11 months of the study to 22/168 (13.1%) in the second 11 months ( P < 0.0001). This number further declined to 17/215 (7.9%) in the final 12 months of data collection, but compared to the second 11 months, this decrease was not statistically significant ( P = 0.1347). The involvement of a surgical NST was associated with a reduction in inappropriate TPN orders without a change in overall use.

Surgical management of high output enterocutaneous fistulae: a 24-year experience

PURPOSE OF REVIEW

Enterocutaneous fistulae are abnormal communications between the small or large bowel and the skin, which may be lined with epithelium or associated with intra-abdominal sepsis. Patients with high fluid and electrolyte losses are best managed in a nutrition unit by a dedicated team of physicians and other healthcare workers. Despite recent advances in the management of these patients, the mortality rate ranges between 10 and 20%. It is therefore imperative that attention must be paid to well-designed management protocols.

RECENT FINDINGS

A total of 494 patients with high-output enterocutaneous fistulae were reviewed over a 24-year period. The overall mortality rate of the patients was 13%. A pilot study evaluating somatostatin in combination with total parenteral nutrition showed promise in the conservative management of high-output enterocutanous fistulae, but the use of somatostatin is controversial, and it should not be used routinely. Although H2 receptor antagonists and proton pump inhibitors decrease gastric secretions, they do not help in closing enterocutaneous fistulae.

SUMMARY

Sepsis, in all its forms, is an important cause of morbidity and mortality and requires aggressive treatment. Definitive surgical closure of the fistula should only be performed when the patient is apyrexial and in good nutritional status, and if the fistula effluent shows no signs of decreasing in volume after 4-6 weeks of nutritional support. All reviews of patients with enterocutaneous fistulae reveal that the best results with the least morbidity are obtained by definitive resection and end-to-end anastomoses.

Effectiveness of a multidisciplinary total parenteral nutrition team in the hospital setting

BACKGROUND

Total parenteral nutrition (TPN) is a form of nutritional support that has become an essential adjunct to the management of patients who are unable to obtain adequate nutrition either via the oral or enteral route. Previous studies indicate that TPN can be administered safely and effectively to patients; however, there are associated risks with this form of nutritional support. Researchers have indicated that due to the complexity of TPN therapy a high level of knowledge and expertise is required in the management of these patients. The multidisciplinary team approach has been supported for its ability to assess the patients' nutritional status, prescribe the nutritional requirements, and reduce the incidence of metabolic complications through regular monitoring. However, contradictory views on the effectiveness of multidisciplinary TPN teams in health-care facilities have also been reported.

AIM

The aim of this review was to critically analyse the literature and present the best available evidence that investigated the effectiveness of multidisciplinary TPN teams in the provision of TPN to adult hospitalised patients. The primary outcomes included: incidence of catheter-related complications, types of catheter-related complications, incidence of metabolic and electrolyte abnormalities, provision of nutritional requirements, estimated nutritional requirements, number of patients whose nutritional goals were met and the amount of energy and protein provided. Secondary outcomes included cost effectiveness of nutritional support teams and physician compliance with team recommendations.

SEARCH STRATEGY

The literature search sought to identify both published and unpublished studies utilising various search strategies and the Internet. The Cochrane Library (2001, Issue 4) was initially searched to identify randomised controlled trials. The other electronic databases searched included CINAHL, Complete Medline, Complete Biomedical Collection, Complete Nursing Collection, and EMBASE. Experts and company representatives were contacted to identify published reports as well as research in progress relevant to this review. Professional bodies were contacted and included the British Association for Parenteral and Enteral Nutrition (BAPEN) and the Australasian Society for Parenteral and Enteral Nutrition (AuSPEN).

SELECTION CRITERIA

All randomised and non-randomised controlled trials comparing the effectiveness of multidisciplinary TPN teams, in the provision of TPN to adult hospitalised patients, were considered for inclusion in this review. Trials were included if they reported objective or subjective measures of nutritional, metabolic and catheter-related complications and cost effectiveness. To minimise publication bias studies reported in other languages were also considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

The eligibility of studies for inclusion, the methodological quality and data extraction were undertaken independently by two reviewers and cross-checked by a third reviewer. The studies included in the review have been synthesised as a narrative overview.

RESULTS

Eleven studies comparing the effectiveness of a multidisciplinary TPN team in the hospital setting were analysed in this review. Six studies that investigated the incidence of total mechanical complications reported a higher incidence of these complications in patients who were managed by their physician. Catheter-related sepsis was investigated in seven studies of which five reported a reduction and two reported an increase in catheter-related sepsis in patients managed by the team. One study reported no statistically significant difference in the total metabolic and electrolyte abnormalities and four studies reported fewer of these abnormalities in patients cared for by the nutrition team. Overfeeding and underfeeding in patients not managed by the TPN team were reported in five studies. The most appropriate route of feeding was investigated in four studies. Two of the four studies reported that patients managed by the team were more likely to be fed by the most appropriate route and the findings from the remaining two studies were unclear. Cost effectiveness of the TPN team was reported in two studies and a reduction in costs was demonstrated in both studies when the patients were managed by the TPN team. Compliance by physicians to recommendations made by the TPN team was investigated in two studies, and both reported that physicians complied with at least 50% of the recommendations.

CONCLUSIONS

The general effectiveness of the TPN team has not been conclusively demonstrated. There is evidence that patients managed by TPN teams have a reduced incidence of total mechanical complications; however, it is unclear if there is a reduction in catheter-related sepsis. The conflicting results relating to the benefit of the TPN teams in the reduction of electrolyte and metabolic abnormalities indicate that further research is needed to clarify the impact of TPN teams on this outcome. The provision of the patients estimated energy requirements are positively influenced when managed by the TPN team; however, the evidence relating to the effectiveness of the TPN team in the provision of protein requirements remains unclear. From this review it is unclear if management of the patients by the TPN team prevented the inappropriate use of TPN. The limited data obtained from the studies provide evidence of a clinically important difference between groups in terms of cost effectiveness.

Extended indications for enteral nutritional support

With the availability of an organized nutrition support team (NST), the use of enteral nutrition (EN) can be extended to patients who would have otherwise received parenteral nutrition (PN). Although the formulation and accuracy of nutrient intake seems easier with PN, it is accepted that EN is cost effective and advantageous and should be used whenever possible. We discuss three cases in which the NST was initially consulted to provide PN. After evaluation by the dietitian, gastrointestinal access was obtained by the NST physician and EN could be initiated. The case studies show that an organized NST consisting of knowledgeable members can extend the use of EN to patients who would have otherwise received PN. The cost saving of such an approach and its efficacy in clinical practice are obvious.

Metabolic and monetary costs of avoidable parenteral nutrition use

BACKGROUND

We prospectively collected data on in patients receiving parenteral nutrition to determine the magnitude of potentially preventable metabolic and monetary costs associated with parenteral nutrition.

METHODS

Parenteral nutrition was prescribed by the treating physicians with optional consultation from a multidisciplinary metabolic support service. Days on parenteral nutrition, appropriateness of parenteral nutrition, metabolic complications, and avoidable parenteral nutrition charges were determined. Parenteral nutrition use was considered "indicated" or "not indicated" based on the American Society for Parenteral and Enteral Nutrition guidelines and "preventable" if the gastrointestinal tract was functional but not accessed when possible.

RESULTS

Of the 209 parenteral nutrition starts, 62% were indicated, 23% were preventable, and 15% were not indicated. Parenteral nutrition starts were deemed indicated in 82% of instances in which a metabolic support service consult was obtained, compared with 56% in which a consultation was not obtained (p = .004). Hyperglycemia was the most common metabolic complication, with an overall incidence of 20%. Metabolic complications occurred less frequently in patients who received a metabolic support service consultation compared with patients who did not (34% vs 66% of parenteral nutrition days, respectively; p = .004). Parenteral nutrition use of < or =5 days duration was significantly less frequent among patients who received metabolic support service consultation (16% vs 35%; p = .002). Parenteral nutrition that was not indicated or preventable resulted in excess annualized patient charges of more than one half million dollars not accounting for charges related to treatment of potentially avoidable parenteral nutrition complications.

CONCLUSIONS

This study illustrates that not-indicated and preventable parenteral nutrition initiation, short-term parenteral nutrition use, and metabolic complications are less likely when patients receive consultation by a multidisciplinary team with expertise in nutrition and metabolic support. Furthermore, the avoidance of inappropriate parenteral nutrition use translates into substantial cost savings.

Insulin secretion and sensitivity in children on cyclic total parenteral nutrition

BACKGROUND

Some children receiving total parenteral nutrition (TPN) have abnormal glucose tolerance.

METHODS

Insulin secretion and sensitivity were studied in 12 patients, aged 5.7 to 19.4 years, receiving cyclic nocturnal TPN. Insulin secretion was measured during an IV glucose tolerance test (IVGTT; 0.5 g/kg) followed by a hyperglycemic clamp (plasma glucose at 10 mmol/L). Insulin sensitivity was assessed by hyperinsulinemic euglycemic clamp (insulin infusion = 1 mU/kg/min).

RESULTS

Patients with normal glucose tolerance receiving TPN had an insulin response to IVGTT similar to that of normal children of the same age. Insulin levels of TPN patients were higher than those in healthy young adults during the hyperglycemic clamp. Whole body glucose disposal was greater in younger than in older children (range, 7.1 to 25.2 mg/kg/min), and this inverse correlation with age was statistically significant (p < .01). Two patients with abnormal glucose tolerance showed a decreased capacity to release insulin, whereas insulin sensitivity was unchanged in one of these two patients. Two patients treated with prednisone or octreotide had insulin levels similar to those of normal TPN children.

CONCLUSIONS

The insulin response to sustained hyperglycemia was stronger in children with normal glucose tolerance on cyclic TPN. Patients with a limited capacity to release insulin, either constitutional or acquired, may not be able to produce enough insulin in these conditions and develop glucose intolerance during TPN. Insulin sensitivity was not a key factor in the alteration of glucose tolerance.

Parenteral nutrition: an overview of current practice

Nutritional support should always be provided via the gastrointestinal tract if possible, but parenteral nutrition, i.e. infusion of nutrients directly into the venous circulation, can be a safe and effective method of nutritional support when used in carefully selected patients and monitored appropriately. A multidisciplinary team approach to patient selection, assessment and monitoring is recommended. Access for parenteral feeding is traditionally via a central vein, but the peripheral route can be used for short-term feeding and should be considered for the majority of patients. Nutritional requirements should be assessed on an individual basis and a feeding regimen designed using standard formulations where possible. The transition back onto oral or enteral nutrition should be closely supervised by a dietitian. Parenteral feeding can be provided to the community if appropriate, but thorough training, monitoring and support are essential.

Metabolic complications of total parenteral nutrition: effects of a nutrition support service

BACKGROUND

The effectiveness of Nutrition Support Services in optimizing parenteral nutrition has not been evaluated since the 1980s.

METHODS

We prospectively monitored medical and surgical patients on total parenteral nutrition (TPN) in a university hospital who did not receive Nutrition Support Service recommendations to compare the incidence of metabolic complications in 1979 (group 1, n = 100) with that in 1992 (group 2, n = 106). The Service provided automatic recommendations on a subsequent group of medical service patients (group 3, n = 128) and compared them with the patients in group 2 who were on the medical service (group 2B, n = 29).

RESULTS

Statistically significant changes between 1979 and 1992 included a decline in the incidence of hyperglycemia from 47% to 22% and in hypokalemia from 12% to 3% of surgical patients and an increase in hypomagnesemia from 0% to 23% of surgical patients and from 2% to 14% of medical patients. The incidence of hypophosphatemia remained > 20% in both medical and surgical patients. Within 1992, the addition of automatic recommendations had little impact on metabolic abnormalities and was associated with slightly but insignificantly lower TPN costs (not counting Service personnel costs).

CONCLUSIONS

Factors such as the general integration of parenteral nutrition into tertiary medical care, standard protocols and order forms, automatic Nutrition Support Service consultations in an affiliated hospital, and nutrition curricula may be responsible for the improvements seen since 1979. However, the addition of automatic Service consultation in 1992 had only a marginal effect on metabolic complications and costs of parenteral nutrition.

Case management in home total parenteral nutrition: a cost-identification analysis

BACKGROUND

Home parenteral nutrition (HPN) requires intensive medical case management by practitioners with expertise in the provision of nutrition support. There is expenditure of considerable time and resources for management of these patients not covered by any of the traditional reimbursement mechanisms. The costs associated with this unreimbursed input and follow-up are most often borne by the Nutrition Support Team or individual practitioners. Reimbursement by home care agencies to physicians for management of patients after discharge cannot be done because this may be construed as a "kick-back" for referral of patients to particular home care agencies.

METHODS

Time and costs associated with management of HPN patients after discharge from the hospital were assessed using a cost-identification analysis of 24 different factors. Daily activity logs were kept by the Nutrition Support Team members over a 2-week period. Costs of space and furnishings were calculated.

RESULTS

On average, a total of 25 h/d was spent by members of the Nutrition Support Team on our HPN patients. Variable activities accounted for 5640.1 hours of time with fixed support at 890.3 hours. This computes to a total annual personnel cost of $168,482 ($1982 per patient). If costs of furnishings and space are also included, the overall cost of all resources was $175,989 per year or $2070 per patient.

CONCLUSION

Significant and currently nonreimbursed costs are involved in HPN patient management. These costs are most often absorbed by the Nutrition Support Team and should be considered when evaluating total costs of HPN.

Taking your show on the road: the concept of a mobile nutrition support team

Nutrition support teams (NSTs) have been in existence since the 1970s and remain an enduring concept of how nutrition support should be provided. The basic model of a NST who serves one institution has changed little over the past two decades. With the expansion of managed care, development of integrated hospital networks, decreasing inpatient census, and downsizing in hospital staff, a new model for the NST that anticipates and addresses these changes in the healthcare environment is needed. This article presents a model for a NST who is mobile and can function within an integrated system to improve the utilization, management, and quality of specialized nutrition therapy.

Nutrition support teams: past, present, and future

Nutrition support teams have evolved rapidly and grown in numbers since the early 1970s. While not all hospitals have or need nutrition support teams, the team approach has been demonstrated to be an excellent mechanism for identifying patients in need of nutrition support, reducing the complications associated with enteral and parental nutrition, and providing cost-effective nutrition support in a variety of hospital environments. The organization of a nutrition support team is reviewed, and suggestions are outlined for team survival in this uncertain era of health care reform. New JCAHO standards are reported which require performance-based interdisciplinary delivery of nutrition support, and make it more likely that efficiently organized nutrition support teams will thrive and continue to make important contributions to safe and cost-effective health care now and in the immediate future.

Review article: artificial nutritional support for improved patient care

Malnutrition is common and undiagnosed in the majority of affected hospital patients; it is associated with impaired organ function, morbidity, and increased length of hospital stay. Artificial nutritional support in malnourished patients leads to improvement in nutritional status and clinical outcome. Nutritional support is required in malnourished patients, patients who are unable to take normal diet and patients with intestinal failure. Gastroenterologists are required to supervise patients with intestinal failure, to insert endoscopic feeding devices, and increasingly to participate in, or lead, nutritional support teams. Major developments in nutrient delivery have included percutaneous endoscopic feeding devices, the recognition that enteral feeding is possible in patients with gastric stasis, and that nutrient needs can be met by peripheral parenteral nutrition. There is much interest in the use of new substrates, or substrates delivered in pharmacological doses such as glutamine and arginine, to manipulate the response to disease. Many hospitals lack an organized approach to artificial nutritional support. Patients continue to suffer from a lack of treatment or the consequences of inappropriate or inadequate treatment. This article reviews the current status of artificial nutritional support and provides guidelines for patient management.

The nutrition support team: surviving and thriving in an era of reform

Nutrition support teams today are being buffeted by the winds of change in the health care system. With the emphasis shifting from whether to deliver care to how to do so and to how much that care will cost, nutrition support professionals must stay attuned to their institution's needs--and be prepared to adapt to those needs. This article reviews the types of data collection necessary for teams to remain solid as well as offering tips from experts about ways to harness, and even capitalize on, the changes.

Nutritional support teams: a review of comparative trials

OBJECTIVE

To evaluate the literature describing the influence of nutritional support teams (NSTs) on the provision of nutritional therapy.

DATA SOURCES

A MEDLINE and International Pharmaceutical Abstracts search (key terms: nutritional support, nutritional support service/team, hyperalimentation service/team, metabolic support service/team, service/team) covering 1970-1993 were used to identify pertinent literature.

STUDY SELECTION

The results of comparative trials involving NSTs are presented.

DATA EXTRACTION

Data from comparative trials examining the influence of NSTs on the provision of enteral nutrition (EN) and total parenteral nutrition are discussed.

DATA SYNTHESIS

NSTs dramatically reduced the incidence of catheter-related complications, especially sepsis, by developing central venous catheter insertion and care guidelines. Early studies found that NSTs reduced the incidence of electrolyte and metabolic abnormalities by more stringent laboratory and clinical monitoring, but this was not found consistently in later studies. The ability of consultative NSTs to reduce the incidence of metabolic and electrolyte abnormalities is less clear. NSTs also were more likely to evaluate, document, and subsequently meet a patient's nutritional requirements. Studies examining the financial impact of NSTs frequently reported cost savings, but often failed to include personnel costs in their analysis. The provision of EN by an NST reduced the frequency of complications and increased the adequacy of nutritional supplementation.

CONCLUSIONS

Early nutritional support teams produced significant benefits largely through the development of protocols and standardization. Current NSTs should increase the dissemination of information supporting their continued benefits. To remain viable, NSTs need to expand their roles, document improved patient outcomes, and show cost-effectiveness.

Peripheral versus central intravenous nutrition: comparison of two delivery systems

Forty-six surgical patients who required intravenous nutrition (IVN) were randomly allocated to receive complete IVN by a peripheral (n = 23) or central (n = 23) venous delivery system. The peripheral IVN system combined a fine-bore silicone catheter with lipid-based nutrient solutions whereas the central system used a conventional glucose-based nutrient regimen and a single-lumen central venous catheter. The incidence of catheter complications and the complication-free system function over time were compared. Problems of venous access were not observed with peripheral IVN but occurred with one central catheterization. Three patients with central venous catheters developed bacteraemia but only one incident was thought to be catheter related (bacterial translocation). There were no such episodes with peripheral IVN. Peripheral catheterization was not associated with infective phlebitis, although late-onset chemical phlebitis occurred on four occasions after a mean(s.e.m.) time of 22.8(6.1) days, representing a daily risk of phlebitis of 0.009. There was no significant difference in the probability of complication-free system function with time between peripheral and central IVN (P = 0.14). The fine-bore silicone catheter peripheral IVN delivery system resulted in long-term phlebitis-free infusion for periods that were similar to those of single-lumen central catheterization by life-table analysis.

A retrospective study of the use of total parenteral nutrition in dogs and cats

The records of all dogs and cats receiving total parenteral nutrition (TPN) over a 43-month period were examined retrospectively. Dextrose, amino acids, lipids, electrolytes, and vitamins were administered by central venous catheter according to published nutrient recommendations; 72 dogs and 12 cats were studied, accounting for 380 patient days of TPN. Duration of TPN administration was 1-14 days with a mean of 4.5 days. Most animals required TPN because of gastrointestinal dysfunction, and more than half of them gained weight during TPN administration. Mechanical complications were frequent. Metabolic complications, especially lipid and glucose intolerance, were also commonly seen. Septic complications were the least frequently encountered, but resulted in patient morbidity and may have contributed to mortality. Most animals receiving TPN were returned to enteral nutrition and discharged. For critically ill animals unable to tolerate enteral alimentation, TPN can be supportive therapy in the treatment of the primary disease.

Nutritional support in surgical practice: Part I

Critical evaluation of the therapeutic benefit gained from provision of nutritional support requires knowledge regarding the nutritional status of those to whom it was given. The apparent effect of giving parenteral nutrition or enteral nutrition depends not only on how much and how well it is given, but also on how depleted the recipient is. Thus, nutritional assessment requires close examination before proceeding to assess the efficacy and potential benefits of the remedial measures of parenteral nutrition or enteral nutrition. Although preoperative malnutrition is associated with a poor operative outcome, there appears to be no consensus as to whether perioperative nutritional support can reduce postoperative complications to the level occurring in well-nourished patients undergoing similar procedures. This is partly because reports evaluating the effect of perioperative nutritional support on postoperative outcome vary widely as to numbers of patients studied, primary diagnoses, and the duration and quality of perioperative nutritional support. In Part I, these issues are explored in patients who are undergoing operations for cancer, trauma, or burns. Enteral nutrition appears to be as effective as parenteral nutrition in improving operative outcome, as compared with ad libitum oral nutrition. Postoperative enteral nutrition and parenteral nutrition are equally effective in reducing postoperative complications.