Oct. 22, 2019
Mayo Clinic in Rochester, Minnesota, has 2,059 licensed beds on two hospital campuses. Each campus has a Nutrition Support Service (NSS) directed by an Endocrinology consultant with rotating house staff: an Internal Medicine resident or Endocrinology or Gastroenterology fellow trainee, dietitians, nurses, and pharmacists.
Nationally, endocrinologists are infrequently involved in hospital nutrition. M. Molly McMahon, M.D., with Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic in Rochester, Minnesota, and who is also immediate past president of the American Society for Parenteral and Enteral Nutrition (ASPEN) and NSS medical director, says, "With our additional training, our expertise in metabolism makes us valuable specialists for this field. National surveys continue to report that clinicians are undertrained in nutrition. We are committed to educating rotating learners and consulting with primary service providers. We are fortunate to have institutional and divisional support, as our value results from the synergy of all disciplines. Our team has been recognized as a team of distinction by ASPEN."
Meera Shah, M.B., Ch.B., with Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic in Rochester, Minnesota, and the endocrine rotation director for the Internal Medicine Residency, says: "Assigned cases allow house staff to learn basic nutrition principles and to apply nutrition to specific patient conditions. House staff rotations are shorter in duration than other rotations, so NSS team members created case-based videos to address nutrition topics that would otherwise not be covered."
Malnutrition, common in patients who are hospitalized, is associated with longer length of stay, poorer outcomes and higher cost of care. Nutrition support is a costly form of therapy that provides substantial benefits when used appropriately, but it also carries risks.
Dr. McMahon notes: "Our service provides recommendations about whether nutrition support is indicated and, if so, which route — gastric or jejunal tube feeding or parenteral nutrition (PN) — is optimal. Subsequently, we recommend a nutrition program tailored to the patient and provide a metabolic monitoring program.
"One of our goals is to prevent or minimize the frequency of nutrition-related complications, such as unnecessary initiation of nutrition support or overfeeding. We follow the use of short-term PN (less than seven days) as a quality marker, as the expected benefits do not outweigh the risks to the patients for shorter use. Mandatory NSS consults are required for patients on medicine services prior to PN initiation. Subsequently, the percentage of short-term PN use has significantly decreased.
"Consults are also required before placement of a long-term tube feeding access. This approach ensures long-term feeding is appropriate for clinical and ethical situations and addresses reimbursement requirements, selects best tube and site (pre-pyloric or post-pyloric) for administration, and develops nutrition programs."
Frequent consult requests on NSS include assessments for PN or long-term tube feeding in patients with complex medical and surgical histories, and evaluation and management of vitamin and mineral deficiencies. The NSS consultant reviews the patient's medical and surgical history and labs, examines the patient, and with team members, develops the optimal nutrition and monitoring program. Dietitians provide expertise in specialized oral diets and tube feeding formulas. Nurses offer input on types of enteral tubes and site-care issues for nutrition-related tubes and catheters. Dietitians and nurses educate patients and caregivers on tube feeding administration post-hospital dismissal. They also work closely with the home enteral and home parenteral teams for patients dismissed on these therapies.
Dr. McMahon adds: "A current nursing focus is introducing the use of ENFit, a new connection device for enteral tubing. Enteral tubing misconnection occurs when enteral devices are connected to nonenteral devices, such as intravenous lines. To improve safety, this global initiative makes all tube feeding devices specific to tube feeding so that one can only use products designed for tube feeding access.
"Pharmacists provide expertise with PN program design, drug-nutrient interactions and drug shortage management. In addition, the dietitians, nurses and pharmacists play the key role of interfacing with clinicians of all disciplines regarding nutrition issues throughout the hospital campuses. Patients are assessed daily and the nutrition program is altered as needed.
"The multidisciplinary nature of the nutrition support service allows for a better educational experience for learners and ultimately better patient care."
Common clinical situations encountered by Nutrition Support Services
Glucose management: Review for overfeeding; initiation or cessation of parenteral nutrition (PN) dextrose; and dextrose from other crystalloid infusion. Account for calories provided by renal replacement therapy acid citrate-dextrose solution; medications that can affect glucose levels such as corticosteroids, propofol and sympathomimetics; and glucose trends.
Volume excess: Evaluate the need for fluid-restricted nutrition programs.
Obesity, hypertriglyceridemia or both: Initiate permissive underfeeding with adequate protein.
Propofol use: Check triglyceride value and reassess PN fat content.
Re-feeding risk: Avoid overfeeding; administer thiamin; review electrolyte and mineral values and supplement as needed.
Diarrhea: Review drug-nutrient issues and ensure medications are administered by correct route in light of osmolality and mechanism of drug action.
Dialysis: Review nutrition program protein and minerals to be certain appropriate for type of dialysis.
Long-term PN in hospital: Choose desired central catheter for nutrition; reassess PN trace element doses; and for patients with PN-associated liver disease, consider use of IV fat emulsion using nonsoybean sources to increase the omega-6 polyunsaturated fatty acid content.