Pour l’implantation des équipes transversales de nutrition clinique à l’hôpital : le plaidoyer du pédiatreNutrition support teams in the hospitals: why and how?

Despite major advances in the quality of care in many other areas, the prevalence of malnutrition in hospitals is high and has not decreased over the last 20 years. Young children are especially threatened. Malnutrition is associated with an increase in morbidity and mortality in hospitalized patients, induces an increase in length of stay and thus, in hospital costs. The nutritional risk in hospitalized patients is related to the underlying disease and to the organization of feeding and nutrition in the hospitals. Moreover, most of the physicians and other professionals do not have enough knowledge in the area of nutrition. Therefore, the intervention of professionals specialized in nutrition is needed. These professionals must be well organized and coordinated. Two different kinds of nutritional support boards exist in hospitals. Nutrition advisory (steering) boards which include all categories of professionals involved in feeding and nutrition, set broad policies about patients’ meal service and nutrition, but do not envisage patients on an individual basis. By contrast, nutrition (support) teams (NT) are little clinical units (even without devoted beds), involving a small number of nutrition specialists including at least one senior physician, to which patients should be referred individually. The main objective of the NT is to set up optimum nutrition according to each individual situation, especially in case of need for artificial nutrition. The impact of NT intervention, in terms of patients’ outcome as well as financial benefits, has been shown for long.     

Crossing the quality chasm: building a safe nutrition system

Recent reports to Congress and the public from the Institute of Medicine underscore concern about the quality of healthcare in America. The nutrition community has focused most of its attention on the report titled The Role of Nutrition in Maintaining Health in the Nation's Elderly, which evaluated nutrition services coverage for the Medicare population. Of equal importance was the recent publication of two reports from the Committee on Quality of Health Care in America: To Err is Human--Building a Safer Health System and Crossing the Quality Chasm--A New Health System for the 21st Century. IV nutrition support was a breakthrough in medical care that has become a standard tool in treating patients who cannot eat for prolonged periods of time. It is also a medical treatment that can result in harm to patients. As problems with patient safety associated with the use of IV nutrition were documented, safer methods to deliver this life-saving form of treatment were developed and evaluated. Although an interdisciplinary team approach has been shown to be the safest way to administer IV nutrition, this system is costly and not universally used. Alternatives to the interdisciplinary team approach should be evaluated to assure that patients receive optimum nutrition care. The tools that can be used to improve patient safety include self-assessment of practitioners who routinely use nutrition support in their practice, curricular-based continuing education programs, board certification in nutrition support practice, and the use of clinical guidelines to assist in making clinical decisions. By developing and promoting these tools, A.S.P.E.N. is committed to building a safe nutrition system so every patient receives optimal nutrition care.     

Home health care: A new worksite for dietitians monitoring nutrition support

Dietitians have been practicing in the home setting for many years. However, monitoring patients receiving home parenteral and enteral nutrition has been performed primarily on an outpatient basis by dietitians affiliated with hospital-based nutrition support teams. Changes in physician familiarity with these specialized therapies and expansion of the home infusion therapy industry have resulted in oppurtunities for dietitians to monitor nutrition support in a patient's home. This article describes the role of the home nutrition support dietitian, the work environment, and the training needed to prepare the practitioner for effective work in this field. Practical concerns of interest to the dietitian monitoring home nutrition support include equipment, resources, and communication tools. Home visits impart several benefits to dietetics practice by enriching the contact between patient and dietitian. A case study describes a dietitian's involvement in and potential cost-effectiveness of treatment of a patient whose parenteral nutrition therapy was initiated and completed without hospitalization. The home is emerging as a worksite for dietitians who monitor nutrition support. As providers of home infusion therapy continue to expand, widespread availability of dietitians' services for patients receiving parenteral and enteral support at home must be ensured.     

The Shrinking of Formalized Nutrition Education in Health Professions Curricula and Postgraduate Training

The quantity of formalized nutrition education is shrinking in curricula of health professions, such as physicians, nurses, dietitians, and pharmacists. The current nutrition education being taught in U.S. schools of healthcare professionals does not appropriately prepare students for identification of patients at nutrition risk or management of undernourished hospitalized patients with specialized nutrition therapies. In U.S. schools of pharmacy, parenteral nutrition is considered a highly specialized and advanced practice so little time is devoted to this area and more attention is focused on chronic disease state management (ie, hypertension, diabetes mellitus, and congestive heart failure). Nutrition support fellowships for physicians and nutrition support residency programs for pharmacists have dwindled in number over the years so that only a handful of these healthcare professionals are produced each year from the remaining formalized programs. Physicians, nurses, pharmacists, and dietitians can positively affect patient care, but each profession must first determine how best to integrate basic and applied nutrition concepts into their professional curricula and training programs. There must also be consensus among the healthcare professions as to the depth of nutrition education and the stage of training at which these integrations should occur. Only by having these crucial conversations among all disciplines will we be able to develop new strategies to expand nutrition education in the training of future medical practitioners.     

Quest for excellence: inspiration from the ileum

The occasion of the American Society for Parenteral and Enteral Nutrition 33rd Presidential Address was used to glean wisdom and inspiration from the ileum. Not only is this intestinal segment so central to the chief organ involved in specialized nutrition support, but it is a complex, yet elegant system that: (1) is interdisciplinary with actions coordinated to achieve a common goal; (2) looks to the future by mentoring the next generation of leaders; (3) constantly seeks evidence of its effectiveness and accordingly adjusts its practice; and (4) strategically forges synergistic partnerships with other habitants within its environment. As relevant within many other realms, it remains true that much can be learned from looking within.     

Surveying acute care providers in the U.S. to explore the impact of HIT on the role of nurses and interdisciplinary communication in acute care settings

In 2005, the Healthcare Information and Management Systems Society's Nursing Informatics Task Force surveyed acute care providers across the United States to explore the impact of health information technology on the role of nurses and interdisciplinary communication in acute care settings. More than 1,700 healthcare professionals responded to the online survey and provided numerous insights into the impact that clinical information systems have in their daily communication and workflow patterns. This paper provides an overview of survey results from four large healthcare delivery systems with a focus on how the results will be employed to support an evidence-based approach to improving acute care IT systems across the following healthcare delivery systems: Partners and Lifespan Health Systems in the Northeast, Baptist Health South Florida in the Southeast, and Providence HealthSystem in the Northwest.A case study approach is employed to describe survey findings at the healthcare system level and then provide a set of recommendations to leverage findings to capitalize on the strengths of existing IT applications and tools, and work towards overcoming barriers to interdisciplinary communication or acute care workflows.     

Australian occupational therapy practice in acute care settings

Anational sample of occupational therapists was surveyed to explore the nature of Australian occupational therapy practice in acute care settings. Self-care was the major client need that therapists reported they addressed, with an initial interview being the most common assessment procedure. Client education was the most frequently used intervention. The most important skills therapists reported for effective practice in acute care were time management, quick clinical reasoning and lateral thinking. Important workplace characteristics included a cooperative healthcare team and early referral. Therapists reported that their most important resources were supportive senior therapists and a well-resourced equipment pool. Three attitudinal factors emerged. Therapists in interdisciplinary teams and those with more experience had more positive attitudes. Younger therapists experienced more concern about not being able to do more for their patients. Results suggest a need for graduates to be better prepared in some skill areas and to have more realistic expectations of practice in this area. Department managers need to ensure younger therapists receive adequate support from senior therapists. Further research is needed to determine how best to provide this support and to further examine the influence of the education experience on practice expectations.     

Checklist to meet ethical and legal obligations to critically ill patients at the end of life

Despite improvements in communication, errors in end-of-life care continue to be made. For example, healthcare professionals may take direction from the wrong substitute decision-maker, or from family members when the patient is capable; permit families to propose treatment plans; conflate values and beliefs with prior expressed wishes or fail to inquire about prior expressed wishes. Sometimes healthcare professionals know what prior expressed wishes are but do not respect them; others do not believe they have enough time to have an end-of-life discussion or lack the confidence, willingness and skills to manage one. As has been shown in initiatives to improve in surgical safety, the use of a checklist presents opportunities to potentially minimize common mistakes and errors. When engaging in end-of-life care, a checklist can help focus on what needs to be communicated rather than how it needs to be communicated. We propose a checklist to support healthcare professionals in meeting their ethical and legal obligations to patients at the end of life. The checklist should minimize common mistakes, and in situations where irreconcilable conflict is unavoidable, it will ensure that both healthcare teams and family members are informed and prepared.     

Matrix support and reference team: a methodology for interdisciplinary health work management

The authors discuss a theoretical and conceptual management methodology based on reference teams and matrix support. Reference team is a structural organization intended to combine managerial power and interdisciplinary work. Matrix support changes the way traditional health systems work, with specialists organically linked to other teams who periodically require specialized consultation. Besides care support, there is another goal: to build new knowledge for each health professional through a continuing education process. The article analyzes the structural, political, cultural, theoretical, and subjective obstacles to this new model.     

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.     

A rural community-based interdisciplinary curriculum: a social work perspective

Although social workers are frequently part of interdisciplinary teams in health care and community settings, interdisciplinary training is often lacking in social work education (Berg-Weger & Schneider, 1998). This article describes a study of the effects of an interdisciplinary community-based experiential course preparing new health care professionals for work as part of interdisciplinary teams. The interdisciplinary curriculum was established for a summer course taught in 2006 by faculty from five disciplines: social work, nutrition, medicine, nursing, and public health. The course, Quality Improvement in Rural Healthcare, which focused on health literacy in people with a diagnosis of diabetes that live in northeast Tennessee, provided a model environment for learning interdisciplinary teamwork. Evaluation of this course found that social work students displayed a statistically significant increase in positive attitude toward interdisciplinary teamwork. Course strengths, weaknesses, obstacles, and opportunities for curriculum improvement are elaborated.     

Bridging the continuum: nutrition support in palliative and hospice care.

Clinicians and patients in today's technically focused healthcare environment are often faced with decisions of what should be done vs what could be done. The decision to provide or not provide nutrition support during palliative care and hospice care requires an understanding of and respect for patient wishes, an appreciation for the expectations of the patient and family, and open and effective communication. There can be confusion and disagreement concerning what nutrition therapies should be continued and which ones stopped. These decisions can be facilitated by answering the question: When do the burdens of nutrition support outweigh the benefit to the patient? The patient, family members, and healthcare providers should openly discuss and agree upon the goals of nutrition support during palliative care and hospice care.     

Role-based access in a unified electronic patient record

As modern healthcare shifts towards a patient-centric model, there is an increasing emphasis on teamwork. Legacy healthcare information systems are ill equipped to meet new requirements arising from this change. Many projects have been undertaken to address various aspects of the challenge of supporting patient-centric work. In the UK, development and adoption of a unified electronic patient record (EPR) that serves practitioners across the country is a high priority. This article considers what additional support healthcare teams will require beyond the cross-discipline unified EPR. A system that considers practitioners as part of a patient's care team and which tracks teams and professional roles is proposed and evaluated as a means to provide each practitioner with a view of the EPR appropriate to his/her professional role and to provide improved support for collaboration among team members.     

Shared care: the barriers encountered by community-based palliative care teams in Ontario, Canada

To meet the complex needs of patients requiring palliative care and to deliver holistic end-of-life care to patients and their families, an interprofessional team approach is recommended. Expert palliative care teams work to improve the quality of life of patients and families through pain and symptom management, and psychosocial spiritual and bereavement support. By establishing shared care models in the community setting, teams support primary healthcare providers such as family physicians and community nurses who often have little exposure to palliative care in their training. As a result, palliative care teams strive to improve not only the end-of-life experience of patients and families, but also the palliative care capacity of primary healthcare providers. The aim of this qualitative study was to explore the views and experiences of community-based palliative care team members and key-informants about the barriers involved using a shared care model to provide care in the community. A thematic analysis approach was used to analyse interviews with five community-based palliative care teams and six key-informants, which took place between December 2010 and March 2011. Using the 3-I framework, this study explores the impacts of Institution-related barriers (i.e. the healthcare system), Interest-related barriers (i.e. motivations of stakeholders) and Idea-related barriers (i.e. values of stakeholders and information/research), on community-based palliative care teams in Ontario, Canada. On the basis of the perspective of team members and key-informants, it is suggested that palliative care teams experience sociopolitical barriers in an effort to establish shared care in the community setting. It is important to examine the barriers encountered by palliative care teams to address how to better develop and sustain them in the community.     

Systems thinking, boundaries, and role clarity

Confused or ambiguous expectations among healthcare professionals, and between them and patients, can result in reduced quality of care. Conversely, clear role expectations have benefited, specifically, improved communication and information provided to physicians, and generally have benefited overall healthcare system flexibility and responsiveness. Such benefits are not confined to patient-care teams alone, but can accrue to teams in all phases of healthcare practice and support.     

Nutrition Knowledge of Collegiate Athletes in the United States and the Impact of Sports Dietitians on Related Outcomes: A Narrative Review

In the last decade, the number of full-time registered dietitians (RDs) serving intercollegiate athletes in the United States has more than quadrupled. However, many student athletes may be at increased risk of nutrition-related problems that impact physical and academic performance, which include inadequate macronutrients, inadequate micronutrients, and excessive macronutrients. This narrative review reports the current literature to date on nutrition-related knowledge in collegiate athletes and the impact of sports RDs on student athletes’ nutrition knowledge and behaviors. To date, only observational and quasi-experimental studies have been published with regard to changes in nutrition knowledge and behaviors in NCAA athletes. While these studies report benefits of the RD as a member of the interdisciplinary student athlete support team, more well-designed randomized control trials are warranted to determine benefits related to health outcomes and sport-specific performance outcomes.     

American Society of Parenteral and Enteral Nutrition Presidential Address: food for thought: it's more than nutrition

Three issues were highlighted in the 30(th) Presidential Address to the society: (1) A.S.P.E.N.'s unique interdisciplinary structure; (2) support of the A.S.P.E.N. Rhoads Research Foundation; and (3) the meaning of food from the perspective of the patient who is receiving life-sustaining home enteral or parenteral nutrition. A.S.P.E.N., founded as a multidisciplinary society in the 1970s has evolved into an interdisciplinary society with an expanded and diverse membership of health care professionals and scientists with overlapping interests in clinical nutrition and metabolism. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high quality patient care. The society is committed to advancing the science and practice of nutrition support therapy. In support of this direction, the A.S.P.E.N. Rhoads Research Foundation exists to fund research grants, promote evidence-based practice, and foster training and mentorship in nutrition and metabolic research. The scientific advances and technologic innovations that have enabled our profession to provide enteral and parenteral nutrition to patients has caused practitioners to forget that the meaning of food extends beyond nutrient value. Some individuals receiving long term enteral nutrition or home parenteral nutrition have expressed feelings of anger, anxiety, and depression resulting from the inability to eat normally, from losses of independence, and control of body functions. The ritual of eating may be altered when the enteral or intravenous feedings provide nourishment and, for some, the loss of the eating function is a distressing experience, especially given the cultural focus on social gatherings and meals. The emotional meaning attributed to food, and changes in food preferences and eating behaviors, may become a source of conflict for individuals who have substantial dietary restrictions, or for those individuals dependent on enteral or parenteral nutrition therapy. The value of food intake on social patterns, self-esteem, pleasure, and enjoyment, may impact quality of life. While nutrition support can provide the basic need for nutrients, its impact on human needs associated with food requires further investigation.     

Occupational Therapists in the Interdisciplinary Team Setting

The interdisciplinary team approach to patient care provides an answer to the fragmentation and confusion patients feel when dealing with our complex healthcare system. Even though the team approach has been in use for the past two decades, implementation of a successful team is very difficult and rarely sustained over a significant period of time. This is especially true in general hospitals and in physical rehabilitation programs that spring from general hospitals where the physician and the nurse are the traditional care group. Occupational therapists, as they establish roles on interdisciplinary teams as staff members and team leaders, will require a knowledge of what makes a team function effectively. They can use this knowledge to evaluate the status of their own team and contribute to changes that will insure its long-term success. Six key issues should be addressed during the planning stage of any new healthcare team to insure its continued viability. These issues are: program philosophy, client focus, role clarification, collaboration and information sharing, policies and procedures, and staff supportiveness.