ASPEN and other societies such as the American Gastroenterological Association published guidelines for the initiation and management of PN and EN (7
). The ASPEN guidelines for appropriate use of PN are summarized in Table 85.1, and typical indications for EN are summarized in Table 85.2 (7
). These guidelines are detailed and may lead some to believe that dedicated NTTs are unnecessary. However, EN and PN are frequently inappropriately used in the absence of a dedicated specialty team even in large academic medical centers.
Clinical Outcomes and Cost Savings
Decreasing inappropriate PN utilization alone improves patient outcomes and reduces health care costs. PN utilization increases the risk of catheter-related bloodstream infection (CRBSI) up to 10-fold (18
). NTTs have been instrumental in reducing the rate of CRBSIs with implementation of strict aseptic technique for catheter insertion
and protocols for appropriate care of central venous catheters. For example, Nehme (20
) reported a 1.3% infectious complication rate for NTT-managed patients compared with a 26.2% complication rate in patients not managed by NTTs. Similarly, Faubion et al (21
) demonstrated a decrease in catheter-related infection from 24% to 3.5% with implementation of a team to insert catheters used for administration of PN; the team also certified staff to provide routine care for those catheters. In addition, loss of a nurse NTT member in one report (22
) led to a significant increase in relative risk of central line infection, a finding emphasizing the importance of an intact NTT to prevent this severe complication.
Fig. 85.1. Mandatory nutrition therapy team (NTT) approval before initiation of total parenteral nutrition (TPN) has had a sustained impact on inappropriate TPN utilization. (Adapted with permission from Trujillo EB, Young LS, Chertow GM et al. Metabolic and monetary costs of avoidable parenteral nutrition use. JPEN J Parenter Enteral Nutr 1999;23:109-13.)
Thus, NTTs decrease infection risks through two avenues. First, nonindicated PN starts are minimized, thereby reducing the CRBSI risk associated with PN administration. Second, even in those patients who are receiving PN, NTTs have reduced CRBSIs by improving standards of catheter insertion and care.
Minimizing infection rates can translate into potentially huge cost savings for medical institutions. The cost of treating one central-line infection in the United States has been estimated to be $3700 to $29,000 (23
). Hence, the prevention of a small number of CRBSIs can fund most, if not all, of the salaries of a comprehensive NTT. In large medical centers, the cost savings associated with prevention of CRBSIs can exceed the cost of funding an NTT.
Reduction of central-line associated infections is no longer a focus of just NTTs. With the initiation of the 100,000 Lives Campaign (24
), reduction in central line infections has become a priority for all hospitals. Use of the Institute of Healthcare Improvement Central Line Bundle (25
) has been shown to decrease incidence of central line infections (26
). What was once a small outcome measure of the effectiveness of NTTs has grown into a key quality indicator for all hospitals.
Moreover, central line insertion carries with it a real morbidity and mortality risk and financial costs. Catheter insertion can lead to pneumothorax, vascular injury, and discomfort to the patient. Rarely, patients may die from catheter insertions complicated by uncontrollable bleeding from a vascular injury or administration of PN through misplaced catheters whose tips errantly end in the lung or pleural space. Such complications, as well as the cost associated with inserting the catheters and treating these potential mechanical complications, are avoided by limiting inappropriate PN initiation.
Finally, the reduction of inappropriate PN use and the increased use of EN save money. PN is inherently more costly than EN, given the cost of each component of the PN admixture and pharmacy costs associated with compounding time and complex equipment. The cost savings is even higher if the costs associated with PN monitoring, administration, and nursing time are included (29
Many studies looking at reductions in inappropriate PN use evaluated cost savings to the hospital. The reported savings ranged from approximately $6000 for institutions with already low rates of inappropriate PN utilization (17
) to more than $500,000/year in large hospitals in which inappropriate PN use was rampant (12
). These savings easily justify the existence of an NTT.
The role of dedicated NTTs is not just limited to approval of PN and EN initiation and preventing PN-associated infections. Several studies indicated that such teams improve clinical outcome when forced feedings are indicated. For example, Trujillo et al (12
) evaluated 209 PN starts and found that those patients followed by the NTT had a significantly lower incidence of metabolic complications such as electrolyte imbalances and hyperglycemia (34% versus 66% of PN days, p
= .004). Similarly, Nehme (20
) evaluated 211 patients receiving PN who were managed by the NTT compared with 164 patients whose PN was managed by the primary medical or surgical team. Only 3% of the NTT-managed patients experienced an electrolyte imbalance compared with 36% of the patients not managed by an NTT. In addition, no NTT-managed patients experienced hyperglycemia severe enough to lead to hyperglycemic nonketotic dehydration, compared with 7% of the patients who were not managed by an NTT.
In contrast, ChrisAnderson et al (30
) evaluated the impact of an NTT on metabolic complications associated with PN at a large teaching hospital and compared the change from the elective to mandatory consultation of an NTT for all patients receiving PN. No significant differences in metabolic complications were associated with this change. The investigators believed that their institution had a robust nutrition teaching service before the implementation of mandatory consultation that minimized the team’s impact.
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