Nutrition Services Rules-Based System Optimizes Patient Care and Efficiency

Feeding effectively using electronic data

Mayo Clinic Hospital Nutrition Support Services (NSS) is staffed by consultants from the divisions of endocrinology, gastroenterology, and preventive medicine. M. Molly McMahon, M.D., of the Division of Endocrinology, Diabetes, Metabolism and Nutrition at Mayo Clinic in Minnesota, says, "Although many hospital nutrition services are not staffed by endocrinologists, we believe that our role is important in this field. Each hospital team also includes dietitians, nurses, pharmacists, and house staff."

"Nutrition support is a costly form of therapy that provides substantial benefits when used appropriately, but it also carries risks," says Dr. McMahon. "Initially, we advise whether nutrition support is indicated and, if so, which route — gastric or jejunal tube feeding or parenteral nutrition (PN) — is optimal. Subsequently, we recommend the nutrition program tailored to the patient and the patient's clinical condition and provide a metabolic monitoring program. One of our goals is to prevent or minimize the frequency of nutrition-related complications, including overfeeding (with potential for hyperglycemia). We also address nutrition access device concerns, site care issues, and drug-nutrient interactions."

Mayo Clinic has a hospital rules-based system (HRBS). Mayo's HRBS is a Web-based program developed to identify and communicate needed information rapidly to clinicians to optimize patient care and safety, standardize care, and enhance workload efficiency.

John W. Wilson, M.D., of the Division of Infectious Diseases at Mayo Clinic in Minnesota, chairs the HRBS Oversight Committee and oversees development and resource allocation for each of the HRBS subsystems. Dr. Wilson explains, "Compilation and integration of patient information from various sources had been estimated to consume up to one-third of a physician's time. HRBS markedly decreases this onerous task by integrating computerized data from hospital admissions, laboratory, microbiology, PN, and pharmacy databases into one place that can be used by a number of subsystems."

FEED program

"The Feeding Effectively Using Electronic Data (FEED) program was developed in 1999 for use on our hospital nutrition services. Other subsystems are used for computer-based antimicrobial monitoring (the initial program and template), pharmaceutical care, surveillance of infection and heparin dosing," says Dr. Wilson.

FEED uses rules created by nutrition physicians and incorporated into computerized logic algorithms by the information technology programmers. The rules can use information from any of the integrated electronic data systems. Rules tested include:

• PN calories prescribed compared with the Harris-Benedict estimate of daily caloric requirement
• PN protein based on body weight and as a percentage of total calories
• PN fat as a percentage of total calories
• Nutrient substrate (levels of glucose, sodium, potassium, triglycerides, international normalized ratio, and minerals)
• Organ function (renal, hepatic, pancreatic, and thyroid laboratory results)
• PN or intravenous insulin with no glucose determination in the past 24 hours

"A list was created for medications with drug-nutrient or tube-feeding interactions or with metabolic or gastrointestinal effects," notes Dr. McMahon. "FEED tests rules daily at 6 a.m. and flags the name of patients for whom PN formulas or laboratory results are out of range. In the future, tube-feeding formula information will be added to allow testing of rules."

FEED also has a calculator component. Automated calculations are performed and displayed, including body mass index and the Harris-Benedict equation, to estimate basal daily caloric requirements. A specialized calculator can compute a PN formula, including maintenance fluid or fluid-restricted formulas, and osmolarity, which is needed for peripheral PN formula design.

The FEED system displays data from multiple electronic sources in a specially formatted report used for daily rounds. The report offers information about:

• Nutrition data
• PN composition (macronutrient and micronutrient composition and PN insulin)
• Biochemical and microbiology results (e.g., blood culture results for patients with PN catheters)
• Radiologic studies (e.g., position of central catheter tip)
• Surgical reports (e.g., amount of bowel resected)

FEED provides information about the prescribed PN content (compared with estimated needs), metabolic and laboratory test data, and medication profiles. Team members can review biochemical data with knowledge of specific PN formulas and additives. Patients requiring more focused PN analysis are efficiently identified.

"This Web-based system communicates needed patient information, improves safety, standardizes care, enhances efficiency of daily rounds, and improves team satisfaction but does not take away from the value of the clinician's judgment," says Dr. McMahon.