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.

The international declaration on the human right to nutritional care: A global commitment to recognize nutritional care as a human right.

Access to nutritional care is frequently limited or denied to patients with disease-related malnutrition (DRM), to those with the inability to adequately feed themselves or to maintain their optimal healthy nutritional status which goes against the fundamental human right to food and health care. That is why the International Working Group for Patient's Right to nutritional care is committed to promote a human rights based approach (HRBA) in the field of clinical nutrition. Our group proposed to unite efforts by launching a global call to action against disease-related malnutrition through The International Declaration on the Human Right to Nutritional Care signed in the city of Vienna during the 44th ESPEN congress on September 5th 2022. The Vienna Declaration is a non-legally binding document that sets a shared vision and five principles for implementation of actions that would promote the access to nutritional care. Implementation programs of the Vienna Declaration should be promoted, based on international normative frameworks as The United Nations (UN) 2030 Agenda for Sustainable Development, the Rome Declaration of the Second International Conference on Nutrition and the Working Plan of the Decade of Action on Nutrition 2016-2025. In this paper, we present the general background of the Vienna Declaration, we set out an international normative framework for implementation programs, and shed a light on the progress made by some clinical nutrition societies. Through the Vienna Declaration, the global clinical nutrition network is highly motivated to appeal to public authorities, international governmental and non-governmental organizations and other scientific healthcare societies on the importance of optimal nutritional care for all patients.

Update on use of enteral and parenteral nutrition in hospitalized patients with a diagnosis of malnutrition in the United States.

BACKGROUND: Malnutrition continues to be associated with outcomes in hospitalized patients. METHODS: An updated review of national data in patients with a coded diagnosis of malnutrition (CDM) and the use of nutrition support (enteral nutrition [EN] and parenteral nutrition [PN]) was conducted using the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project and Medicare Claims data. RESULTS: Results demonstrated a growing trend in CDM accompanied by continued low utilization of PN and EN. CONCLUSION: Underutilization of nutrition support may be due to product shortages, reluctance of clinicians to use these therapies, undercoding of nutrition support, strict adherence to published guidelines, and other factors.

Nutritional care is a human right: Translating principles to clinical practice.

We have previously advocated that nutritional care be raised to the level of a human right in a close relationship to two well recognized fundamental rights: the right to food and the right to health. This paper aims to analyze the implication of nutritional care as a human right for healthcare practitioners. We will focus on the impact of the Human Rights Basic Approach (HRBA) on health care professionals (HCPs), namely how they can translate HRBA into routine clinical practice. Ethics and human rights are guiding values for clinical nutrition practitioners. Together they ensure a patient-centered approach, where the needs and rights of the patients are of the most significant importance. Human rights are based on the powerful idea of equal dignity for all people while expressing a set of core values, including fairness, respect, equality, dignity, and autonomy (FREDA). Through the analysis of FREDA principles, we have provided the elements to understand human rights and how a HRBA can support clinicians in the decision-making process. Clinical practice guidelines in clinical nutrition should incorporate disease-specific ethical issues and the HRBA. The HRBA should contribute to build conditions for HCPs to provide optimal and timely nutritional care. Nutritional care must be exercised by HCPs with due respect for several fundamental ethical values: attentiveness, responsibility competence, responsiveness, and solidarity.

Nutritional care is a human right: Translating principles to clinical practice.

We have previously advocated that nutritional care be raised to the level of a human right, in close relationship to two well-recognized fundamental rights: the right to food and the right to health. This article aims to analyze the implication of nutritional care as a human right for healthcare practitioners. We will focus on the impact of the Human Rights Basic Approach (HRBA) on healthcare professionals (HCPs), namely how they can translate HRBA into routine clinical practice. Ethics and human rights are guiding values for clinical nutrition practitioners. Together they ensure a patient-centered approach, in which the needs and rights of the patients are of the most significant importance. Human rights are based on the powerful idea of equal dignity for all people while expressing a set of core values, including fairness, respect, equality, dignity, and autonomy (FREDA). Through the analysis of FREDA principles, we have provided the elements to understand human rights and how an HRBA can support clinicians in the decision-making process. Clinical practice guidelines in clinical nutrition should incorporate disease-specific ethical issues and the HRBA. The HRBA should contribute to building conditions for HCPs to provide optimal and timely nutritional care. Nutritional care must be exercised by HCPs with due respect for several fundamental ethical values: attentiveness, responsibility competence, responsiveness, and solidarity.

Impact of a nutrition support therapy on hospital-acquired infections: A value analysis.

BACKGROUND: Hospital-acquired conditions (HACs) have a direct impact on value, as they decrease quality and increase costs. Numerous interventions have been tried, including nutrition support therapy, with unknown effect on value. Therefore, a value analysis of nutrition support therapy on HACs was performed. METHODS: An extensive literature search was performed. Using the Medicare Parts A and B Claims 5% Sample data set, analytic claims modeling was conducted. RESULTS: The search identified 1099 studies, with eight meeting the inclusion criteria. All studies were performed on adult critically ill patients and focused on HA infections (HAIs) as the HAC. One study underwent Medicare claims modeling and revealed nutrition therapy has the potential of saving at least $104 million annually in Medicare patients with HAIs. CONCLUSION: Nutrition support therapy has the potential to reduce costs of Medicare spending in respect to HAIs.

Value of nutrition support therapy in patients with gastrointestinal malignancies: a narrative review and health economic analysis of impact on clinical outcomes in the United States.

Malnutrition, particularly under-nutrition, is highly prevalent among adult patients with a diagnosis of gastrointestinal (GI) cancer and negatively affects patient outcomes. Malnutrition is associated with clinical and surgical complications for patients undergoing therapy for GI cancers and the costs associated with those complications is a high burden for the US health system. Our objective was to identify high-quality evidence for nutrition support interventions associated with cost savings for patient care, followed by a complex economic value analysis to project cost savings for the US health system. A narrative literature search was conducted in which combined keywords in the areas of therapeutic nutrition (nutrition, malnutrition), a specific therapeutic area [GI cancer (esophageal, gastric, gallbladder, pancreatic, liver/hepatic, small and large intestine, colorectal)], and clinical outcomes and healthcare cost, to look for nutrition interventions that could significantly improve clinical outcomes. Medicare claims data were then analyzed using the findings of these identified studies and this modeling exercise supported identifying the cost and healthcare resource utilization implications of specific populations to determine the impact of nutrition support on reducing these costs as reflected in the summary of the evidence. Eight studies were found that provided clinical outcomes and health cost savings data, 2 of those had the strongest level of evidence and were used for Value Analysis calculations. Nutrition interventions such as oral diet modifications, enteral nutrition (EN) supplementation, and parenteral nutrition (PN) have been studied especially in the peri-operative setting. Specifically, peri-operative immunonutrition administration and utilization of enhanced recovery pathways after surgery have been associated with significant improvement in postoperative complications and decreased length of hospital stay (LOS). Utilizing economic modeling of Medicare claims data from GI cancer patients, potential annual cost savings of $242 million were projected by the widespread adoption of these interventions. Clinical outcomes can be improved with the use of nutrition interventions in patients with GI cancers. Healthcare costs can be reduced as a result of fewer in-hospital complications and shorter lengths of hospital stay. The application of nutrition intervention provides a positive clinical and economic value proposition to the healthcare system for patients with GI cancers.

Ethical Aspects of Artificially Administered Nutrition and Hydration: An ASPEN Position Paper.

The American Society for Parenteral and Enteral Nutrition (ASPEN) Position Paper focus is on applying the 4 ethical principles for clinician's decision-making in the use of artificially administered nutrition and hydration (AANH) for adult and pediatric patients. These basic principles are (1) autonomy, respect the patient's healthcare preferences; (2) beneficence, provide healthcare in the best interest of the patient; (3) nonmaleficence, do no harm; and (4) justice, provide all individuals a fair and appropriate distribution of healthcare resources. Preventing and resolving ethical dilemmas is addressed, with an emphasis on a collaborative, interdisciplinary approach. Optimizing early communication and promoting advance care planning, involving completion of an advance directive, including designation of a surrogate decision-maker, are encouraged. Clinicians achieve respect for autonomy when they incorporate the patient, family, community, country, geographical, and presumed cultural values and religious belief considerations into ethical decision-making for adults and children with a shared decision-making process. These discussions should be guided by the 4 ethical principles. Hospital committees and teams, limited-time trials, clinician obligation with conflicts, and forgoing of AANH are addressed. Specific patient conditions are addressed because of the concern for potential ethical issues: coma, decreased consciousness, and dementia; advanced dementia; cancer; eating disorders; and end-stage disease/terminal illness. Incorporated in the Position Paper are ethical decisions during a pandemic and a legal summary involving ethical issues. International authors presented the similarities and differences within their own country or region and compared them with the US perspective.

Ethical Framework for Nutrition Support Resource Allocation During Shortages: Lessons From COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has impacted all aspects of our population. The "Troubling Trichotomy" of what can be done technologically, what should be done ethically, and what must be done legally is a reality during these unusual circumstances. Recent ethical considerations regarding allocation of scarce resources, such as mechanical ventilators, have been proposed. These can apply to other disciplines such as nutrition support, although decisions regarding nutrition support have a diminished potential for devastating outcomes. The principal values and goals leading to an ethical framework for a uniform, fair, and objective approach are reviewed in this article, with a focus on nutrition support. Some historical aspects of shortages in nutrition supplies and products during normal circumstances, as well as others during national crises, are outlined. The development and implementation of protocols using a scoring system seems best addressed by multidisciplinary ethics and triage committees with synergistic but disparate functions. Triage committees should alleviate the burdens of unilateral decisions by the healthcare team caring for patients. The treating team should make every attempt to have patients and the public at large update or execute/develop advance directives. Legal considerations, as the third component of the Troubling Trichotomy, are of some concern when rationing care. The likelihood that criminal or civil charges could be brought against individual healthcare professionals or institutions can be minimized, if fair protocols are uniformly applied and deliberations well documented.

Value of Nutrition Support Therapy: Impact on Clinical and Economic Outcomes in the United States.

OBJECTIVE: Healthcare leaders seek guidance on prudent investment in programs that improve patient outcomes and reduce costs, which includes the value of nutrition therapy. The purpose of this project was to conduct an evidence review and evaluate claims analyses to understand the financial and quality impact of nutrition support therapy on high-priority therapeutic conditions. METHODS: Task 1 included a review of existing literature from 2013 to 2018 to identify evidence that demonstrated the clinical and economic impact of nutrition intervention on patient outcomes across 13 therapeutic areas (TAs). In Task 2, analytic claims modeling was performed using the Medicare Parts A and B claims 5% sample dataset. Beneficiaries diagnosed in 5 selected TAs (sepsis, gastrointestinal [GI] cancer, hospital-acquired infections, surgical complications, and pancreatitis) were identified in the studies from Task 1, and their care costs were modeled based on nutrition intervention. RESULTS: Beginning with 1099 identified articles, 43 articles met the criteria, with a final 8 articles used for the Medicare claims modeling. As examples of the modeling demonstrated, the use of advanced enteral nutrition formula could save at least $52 million annually in a sepsis population. The total projected annual cost savings from the 5 TAs was $580 million. CONCLUSION: Overall, optimization of nutrition support therapy for specific patient populations is estimated to reduce Medicare spending by millions of dollars per year across key TAs. These findings demonstrate the evidence-based value proposition of timely nutrition support to improve clinical outcomes and yield substantial cost savings.

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 Troubling Trichotomy 10 Years Later: Where Are We Now?

A decade ago, "Nutrition Support and The Troubling Trichotomy: A Call To Action" was published in this journal, identifying existing conflicts among technological, ethical, and legal aspects of nutrition support therapy, particularly in terminal or end-of-life situations. Over the past 10 years, the American Society for Parenteral and Enteral Nutrition and others have responded to the action call. A "state of the trichotomy" reveals that while much has been achieved, differences in all 3 aspects will continue to exist due to their dynamic and ever-changing states. The technology arena has made it possible to increase the delivery of nutrition support in alternative settings with the use of telemedicine and social media. Critical/crucial conversations and earlier declarations of individual wishes for care and treatment while having decision-making capacity have been enhanced with the focus on patient-centered and family-centered care. The definition of death as brain death has been challenged in at least one instance. Conflicts between the state's interests and the individual's interests have added to recent legal controversies. Notwithstanding the progress made over the past 10 years, several challenges remain. The future challenges presented by the Troubling Trichotomy can be best confronted if we ACT-Accountability, Communication, and Teamwork. The focus of teamwork should move from multidisciplinary and interdisciplinary teams to transdisciplinary teams, reflecting the shift to function rather than form presented by the new healthcare environment. The transdisciplinary team will be able address the opportunities of the Troubling Trichotomy in the next decade by incorporating the 12 Cs, as detailed in the article.

Have the Answers to Common Legal Questions Concerning Nutrition Support Changed Over the Past Decade? 10 Questions for 10 Years.

Clinical nutrition specialists (CNSs) are often confronted with technological, ethical, and legal questions, that is, what can be done technologically, what should be done ethically, and what must be done legally, which conflict at times. The conflict represents a "troubling trichotomy" as discussed in the lead article of this issue of Nutrition in Clinical Practice (NCP). During Clinical Nutrition Week in 2006, a symposium covering these 3 topics was presented, and later that year, an article covering the same topic was published in NCP In this article, we revisit several legal questions/issues that were raised 10 years ago and discuss current answers and approaches. Some of the answers remain unchanged. Other answers have been modified by additional legislation, court decisions, or regulations. In addition, new questions/issues have arisen. Some of the most common questions regarding nutrition support involve the following: liability, informed consent, medical decisional incapacity vs legal competence, advance directive specificity, surrogate decision making, physician orders for life-sustaining treatment and electronic medical orders for life-sustaining treatment, legal definition of death, patient vs family decision making, the noncompliant patient, and elder abuse obligations. In the current healthcare environment, these questions and issues are best addressed via a transdisciplinary team that focuses on function rather than form. The CNS can play a pivotal role in dealing with these challenges by applying the acronym ACT: being Accountable and Communicating with all stakeholders while actively participating as an integral part of the transdisciplinary Team.

Incorporating Palliative Care Concepts Into Nutrition Practice: Across the Age Spectrum.

A practice gap exists between published guidelines and recommendations and actual clinical practice with life-sustaining treatments not always being based on the patient's wishes, including the provision of nutrition support therapies. Closing this gap requires an interdisciplinary approach that can be enhanced by incorporating basic palliative care concepts into nutrition support practice. In the fast-paced process of providing timely and effective medical treatments, communication often suffers and decision making is not always reflective of the patient's quality-of-life goals. The current healthcare clinical ethics model does not yet include optimum use of advance directives and early communication between patients and family members and their healthcare providers about treatment choices, including nutrition support. A collaborative, proactive, integrated process in all healthcare facilities and across levels of care and age groups, together with measurable sustained outcomes, shared best practices, and preventive ethics, will be needed to change the culture of care. Implementation of a better process, including basic palliative care concepts, requires improved communication skills by healthcare professionals. Formalized palliative care consults are warranted early in complex cases. An education technique, as presented in this article, of how clinicians can engage in critical and crucial conversations early with patients and family members, by incorporating the patient's values and cultural and religious diversity in easily understood language, is identified as an innovative tool.

Once upon a storm: Katrina and nutrition support or the lack thereof.

Nutrition support teams face many challenges to establish, fund, maintain, and justify their existence. Some of the challenges can be resolved over time. However, the challenge of providing nutrition in general and nutrition support in specific during a natural disaster is void of the luxury of time experienced with the previously delineated challenges. The experience of Methodist Hospital in New Orleans, Louisiana, during Hurricane Katrina in 2005 in providing nutrition and nutrition support is summarized in this invited article. The recollections of various represented disciplines are bolstered by tables and figures that outline the 7 days before and after Katrina. Transdisciplinarity was exhibited through the performance of nontraditional functions or tasks by a variety of professionals who lived 5 days or longer in the "Methodist Island." Lessons learned and considerations for disaster preparedness as it relates to nutrition and nutrition support as well as general considerations are provided.

Gastrostomy tube placement in patients with advanced dementia or near end of life.

Based on current scientific literature, gastrostomy tube (G-tube) placement or other long-term enteral access devices should be withheld in patients with advanced dementia or other near end-of-life conditions. In many instances healthcare providers are not optimally equipped to implement this recommendation at the bedside. Autonomy of the patient or surrogate decision maker should be respected, as should the patient's cultural, religious, social, and emotional value system. Clinical practice needs to address risks, burdens, benefits, and expected short-term and long-term outcomes in order to clarify practice changes. This paper recommends a change in clinical practice and care strategy based on the results of a thorough literature review and provides tools for healthcare clinicians, particularly in the hospital setting, including an algorithm for decision making and a checklist to use prior to the placement of G-tubes or other long-term enteral access devices. Integrating concepts of patient-centered care, shared decision making, health literacy, and the teach-back method of education enhances the desired outcome of ethical dilemma prevention. The goal is advance care planning and a timely consensus among health team members, family members, and significant others regarding end-of-life care for patients who do not have an advance directive and lack the capacity to advocate for themselves. Achieving this goal requires interdisciplinary collaboration and proactive planning within a supportive healthcare institution environment.