Patients requiring nutrition support need help from a range of healthcare professionals including dietitians, clinical nutrition specialist, medical specialist, general practitioners, pharmacists, laboratory specialists, nurses, care assistants, speech and language therapists, occupational therapists, physiotherapists, general and hospital management. It is therefore important that all healthcare workers involved in direct patient care should appreciate the value of providing their patients with adequate nutrition and be familiar with the possibilities for providing nutrition support if needed. The composition and organization of multidisciplinary teams for nutrition support will differ in community and hospital settings.
The organization of nutrition support in the hospital needs to ensure that all patients’ nutritional needs are met whenever possible. It requires coordinated activity by catering, dietetic departments and multi-disciplinary Nutrition Support Teams (NSTs), working with all ward-based nurses and care assistants. The departments or clinicians involved in the provision of adequate nutrition for patients have differing roles:
There are numerous good reasons for hospitals to provide adequate quantities of high-quality food, of which one is the need to limit unnecessary use of nutrition support. The food should also be served in an environment conducive to eating, with help given to those who can potentially eat but who are unable to feed themselves.
Dietitians are involved in nutritional screening and assessment, as well as with the provision of supplementary nutrition through oral, enteral and parenteral routes. All hospitals should, therefore, ensure that patients who are either at risk of or have malnutrition should have access to a dietitian if necessary.
The relatively small number of dietitians in most hospitals means that some of their roles must be delegated to other ward staff. The dietitians, therefore, need to develop hospital protocols and care pathways on nutrition support and to participate in the nutritional education of the entire clinical workforce. The aim should be that all hospital health care professionals should understand the importance of nutrition in patient care and the means available to provide it safely and efficiently.
- Ward nurses
Although there are no relevant scientific studies, all ward nurses should be acutely aware of the importance of patients meeting their nutritional needs and should understand the likely benefits and risks of nutrition support by oral, enteral and parenteral routes. Furthermore, nurses looking after patients other than those explicitly excluded from the nutritional screening will often need to undertake the screening process and to instigate associated care pathways.
- Specialist nutrition support nurses
Many hospitals employ specialist nurses or nurse consultants to take responsibility for ensuring that nutrition support is delivered as safely and efficiently as possible. Such nurses will train other healthcare professionals, will monitor adherence to protocols for enteral and parenteral nutrition and will usually coordinate the nutritional care of patients in hospitals and between hospitals and the community.
- Nutrition support teams (NST)
The aim of a hospital NST is to ensure that specialised nutrition support is given safely and efficiently to those patients who need it. The NST should be formally recognised and should comprise dietitians, nutrition nurses, pharmacists and clinicians with useful biochemistry and microbiology laboratory support. NST clinicians are often gastroenterologists, GI surgeons or intensivists or chemical pathologists with a specific interest in nutritional problems but whatever their background, they should have also received specific training in nutrition support. Hospital NSTs may take on total responsibility for the nutritional care of patients, particularly those on PN, or act in an advisory (consultative) role. The potential advantages of NSTs include:
a. reduction of unnecessary treatments
b. prevention of complications (mechanical, infective and metabolic)
c. pharmaceutical advice on stability and compatibility of drugs
d. production or support of existing guidelines
e. education and training of other staff, patients and careers
g. acting as advocates for patients
h. The point of contact for patients and professionals
Delivering excellent nutritional care across the many specialist units of a large, complex hospital requires co-ordination. Standards must be set and audited, education and training delivered, equipment chosen and procured, and this must all co-ordinate with other governance, including, for example, infection control and risk management. This is the reason why a supervisory Nutrition Steering Committee is needed and why it must be multi-professional. Nutritional support is therefore delivered via catering, ward nurses and the patient’s medical team, supported by specialist advice and an authoritative, specialist-derived management structure which fosters excellence and responsiveness to external drivers. A Nutrition Support Team (NST) brings together, in a group which is seen to be primarily supervisory but nonetheless functional at ward level, the expertise of at least a doctor, nurse, dietitian and pharmacist with specialist skills in nutrition support. If all patients are to have nutritional screening and a nutritional plan, it is self evident that this cannot be delivered by a single small NST. The role of this team (and others) in nutritional education and training is therefore emphasised. There should be an over-arching nutrition policy for the whole hospital, which can be used, with appropriate adaptation, at individual ward and specialist unit level. Specialist unit and ward nutrition policy must be in concordance with hospital policy. Staff moving from one unit to another within the hospital should recognise a uniformity of approach.