Standards of Practice for Nutrition Support Physicians

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is a professional society of physicians, nurses, dietitians, pharmacists, allied health professionals, and researchers dedicated to assuring that every patient receives optimal nutrition care. A.S.P.E.N.'s mission is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. The diversity of our membership emphasizes both the importance of good nutrition in clinical practice and the necessity for a team approach. These Standards of Practice for Nutrition Support Physicians are an update of the 2003 standards.1 A.S.P.E.N. has developed these as general guidelines for physicians. They present a range of performance of competent care that should be subscribed to by any Nutrition Support Physician within or outside the context of a formal nutrition support team (also known as a nutrition support service). Their application in any individual case, however, should be determined by the best judgment of the professional. Through training, culture, and expertise, the physician plays a unique role in the medical care system. Experience with team building, management, and the pathophysiology of nutrition and metabolism within the context of health and disease are critical elements that a physician can uniquely bring to interdisciplinary nutrition care. A Physician Nutrition Specialist (PNS) has been defined as a physician with training in nutrition who devotes a substantial career effort to nutrition and who can assume a leadership role in coordinating interdisciplinary clinical nutrition services and education in a variety of healthcare settings.2 Their scope of practice spans the continuum from nutrition in health promotion and disease prevention to the role of nutrition in disease. This knowledge is based upon an in-depth understanding of nutrient metabolism, digestion, and absorption.2 The Nutrition Support Physician is more focused in scope, defined as a physician who devotes a significant part of his or her professional activities of the nutrition support process. The nutrition support process is defined as the assessment, diagnosis, ordering, preparation, distribution, administration, and monitoring of nutrition support therapy.3 It may also include the use of pharmacologic agents to modify nutrition status in patients with acute or chronic conditions. The activities of a Nutrition Support Physician may include direct patient care as primary provider or consultant, research in nutrition fields, teaching, and management. These standards are not intended for the physician who provides occasional nutrition support to his or her own patients but rather for those who by virtue of education, training, experience, and personal interest wish to be identified as a Nutrition Support Physician and provide their expertise to the institution and other practitioners. Organized nutrition support teams have generally provided valuable assistance to primary physicians. These teams are associated with improved patient outcomes, decreased length of hospitalization, and improved cost-effectiveness.4 A nutrition support team should be led by a Nutrition Support Physician. If an institution does not have a defined nutrition support team, it is recommended that nutrition support therapy (defined as parenteral and/or enteral nutrition3) be provided by an ad hoc interdisciplinary team with the participation and leadership provided by the primary physician responsible for the care of each individual patient. These physician standards are presented in general terms. The details of patient care are left to the discretion of individual physicians and nutrition support teams, under the aegis of appropriate institutional committees. The standards aim to promote best practices, including optimal use of enteral and parenteral nutrition, for patients in all care settings (including hospitals, long-term care facilities, and homes). “Shall” indicates that Standards are to be followed strictly. “Should” indicates that among several possibilities one is particularly suitable, without mentioning or excluding others, or that a certain course of action is preferred but not necessarily required. “May” indicates a course of action that is permissible within the limits of recommended practice. These standards do not constitute medical or other professional advice and should not be taken as such. To the extent that the information published herein may be used to assist in the care of patients, this is the result of the sole professional judgment of the attending healthcare professional whose judgment is the primary component of quality medical care. The information presented in these Standards is not a substitute for the exercise of such judgment by the healthcare professional. These standards have been developed by the Task Force on Standards for Nutrition Support Physicians, reviewed by the A.S.P.E.N. Clinical Practice Committee and physician experts, and approved by the A.S.P.E.N. Board of Directors. These Standards of Practice for Nutrition Support Physicians shall be used in conjunction with the previously published A.S.P.E.N. guidelines and standards, which can be accessed at A.S.P.E.N. Documents Library http://www.nutritioncare.org/Library.aspx. The structure and design of the nutrition support process may vary according to the unique attributes of each healthcare institution. These processes may be structured in various ways: a primary nutrition support team that assumes responsibility for the care for all patients receiving nutrition support therapy; an administrative nutrition committee only; a consultative nutrition support service or team; or no formal structure. On occasion, even within an institution, there may be hybrid systems with greater or lesser involvement of a formal team, sometimes according to the complexity of the patient. Ideally, each healthcare institution should have a formal interdisciplinary team responsible for managing and monitoring nutrition support therapy. When this is not feasible, each institution shall strive to provide the best nutrition support process that is possible given the resources of the institution. Nutrition care is always provided within the context of a set of medical and social factors. Understanding the interactions between nutrition, disease pathophysiology, and psychosocial milieu is crucial if nutrition care is to be optimized. In this context, although nutrition expertise is often distributed among a number of disciplines and professionals, the Nutrition Support Physician should play a lead role to confirm that the nutrition care plan is medically appropriate and is communicated clearly to the primary treating physician and the healthcare team. The nutrition care plan is defined as a formal statement of the nutrition goals and interventions prescribed for an individual using the data obtained from a nutrition assessment. The plan should include statements of nutrition goals and monitoring/evaluation parameters, the most appropriate route of administration of nutrition therapy, method of nutrition access, anticipated duration of therapy, and training and counseling goals and methods.3 The unique contribution made by the Nutrition Support Physician is the ability to coordinate nutrition care in the context of complex medical issues and problems. Furthermore, because much healthcare institution governance is presided over by physicians, many of the managerial and oversight responsibilities for nutrition care are best led by a Nutrition Support Physician. To fulfill these responsibilities and the collaborative and leadership roles required, the Nutrition Support Physician should be familiar with all aspects of nutrition care, including patient screening and assessment, developing a nutrition care plan, implementing the nutrition care plan, patient monitoring, reassessing and updating the nutrition care plan, and terminating therapy. Furthermore, the Nutrition Support Physician should effectively understand and be capable of managing the array of policy, procedure, personnel, management, education, finance, and quality improvement issues often confronted by a nutrition support team. A Nutrition Support Physician should be able to provide education to the members of the nutrition support team and practicing clinicians, including dietitians, nurses, physicians, pharmacists, speech language pathologists, and other related healthcare professionals at their institution. The Nutrition Support Physician shall be aware of the current literature regarding nutrition support therapy and incorporate that knowledge into their practice. Finally, the Nutrition Support Physician should be an effective collaborator with members of other disciplines on the team. These demands require that a Nutrition Support Physician should be able to accept varied levels of involvement with patient care. The Nutrition Support Physician should be able to directly supervise care provided by other professionals, should be facile in delegating responsibility to appropriately trained and capable members of the team, should be comfortable with managerial oversight of clinical operations and clinical care performed by others, and be willing and able to participate in all aspects of direct care of patients’ nutrition needs as indicated. 1.1 Demonstration of competence shall include documentation of: 1.1.1 American Board of Medical Specialties (ABMS) or American Osteopathic Association Board eligibility or certification in anesthesiology, family medicine, internal medicine, obstetrics and gynecology, pediatrics, or surgery. AND 1.1.2 Certification as a Nutrition Support Clinician by the National Board of Nutrition Support Certification, Inc., or certification as a Physician Nutrition Specialist by the American Board of Physician Nutrition Specialists; OR completion of a residency or fellowship program which includes significant or recognized formal education and training in nutrition care; OR dedicated time devoted to the practice of nutrition care; AND 1.1.3 Active participation in the nutrition support activities of an institution (eg, development, implementation, and evaluation of protocols for administration of nutrition support therapy; teaching responsibilities; quality improvement initiatives; clinical research protocols); AND 1.1.4 Clinical involvement as a nutrition support physician; AND 1.1.5 Active membership in professional societies devoted to the promotion of safe and effective nutrition support therapy and obtaining a minimum of 20 hours annually of continuing medical education (CME) credit in nutrition care. 2.0 The Nutrition Support Physician shall participate in the nutrition support team and be familiar with all aspects of the nutrition support process, including screening, nutrition assessment, developing of the nutrition care plan, implementing the nutrition care plan, evaluating and reassessing the patient, interpreting laboratory data, updating of the nutrition care plan, transitional feeding, evaluating the setting of care, discharge planning, and terminating the therapy. The Nutrition Support Physician, as part of the discharge planning process, should assume responsibility for appropriate transition of the patient care authority to an appropriate clinician. This includes planning of communication with home care, long-term care, or intermediate-care agencies to allow for the seamless transition of nutrition care plans for patients discharged from the hospital. 2.1 When an organized nutrition support team exists, it shall be directed by a practitioner who, by appropriate education, specialized training, or experience, is knowledgeable in the delivery of nutrition support therapy. Most often, the team leader is a Nutrition Support Physician. 2.2 An organized nutrition support team should ideally include a Nutrition Support Physician, nurse, dietitian, and pharmacist, each having appropriate education, specialized training, and/or experience, with the nutrition support process. 2.3 The Nutrition Support Physician shall participate in the management of the nutrition support program. 2.4 The Nutrition Support Physician shall participate in the clinical activities of the nutrition support team or, if none exists, the interdisciplinary patient care team, to promote optimal provision of nutrition support therapy. 2.5 The Nutrition Support Physician shall collaborate with other members of the nutrition support team to establish, review, revise, and publish policies and procedures for the provision of nutrition support therapy. 2.6 The Nutrition Support Physician should then guide the approval of these policies and procedures through the managerial structure of their particular institution. 2.7 The Nutrition Support Physician should act as a liaison between the nutrition support team, the healthcare organization, and the medical staff, as appropriate. 2.8 The Nutrition Support Physician should participate in planning, implementing, and evaluating institutional educational programs on the nutrition support process. 2.9 The Nutrition Support Physician should plan, participate in, and implement patient safety and quality improvement programs. 2.10 The Nutrition Support Physician should participate in developing and reviewing the nutrition support process, including nutrition screening, assessment, care plan development, implementation, monitoring, and termination of therapy. 2.11 The Nutrition Support Physician should direct and/or participate in quality improvement initiatives. 3.0. The Nutrition Support Physician should be knowledgeable that patients who are nutritionally-at-risk shall be identified by an appropriate screening process within 24 hours of hospital admission and undergo periodic rescreening.56–7 3.1 The Nutrition Support Physician should be knowledgeable that all patients identified as nutritionally-at-risk by a patient screening mechanism shall undergo a formal nutrition assessment. The nutrition assessment shall be documented and be available to all patient care providers. The screening and assessment parameters used should be evidence-based, to the extent feasible.67–8 3.2 The Nutrition Support Physician should be knowledgeable about all aspects of nutrition assessment in all care settings and, as such, be available to interact with and assist intermediate-care facilities and homecare companies when nutrition care is required upon hospital discharge. 3.3 The Nutrition Support Physician should collaborate in developing a nutrition assessment protocol to be performed by or under the supervision of a member of a nutrition support team or a registered dietitian within a time frame specified by institutional policy. 3.3.1 The Nutrition Support Physician should participate directly in nutrition assessment when consulted or as part of oversight of the nutrition support team members, when appropriate. 3.3.2 The formal assessment of the patient's nutrition status should be summarized and appropriately documented, and communicated to the patient's primary healthcare team. The nutrition assessment shall include a subjective and objective assessment of the patient's nutrition status and nutrition requirements. The nutrition assessment should include an evaluation of psychosocial, economic, cultural, and other factors as indicated that may influence prescription and administration of nutrition support therapy. These assessments shall be summarized and documented in the patient's medical record. 3.3.3 The Nutrition Support Physician should document the nutrition diagnosis. 3.3.4 The Nutrition Support Physician should be knowledgeable of the patient requirements of macronutrients, micronutrients, electrolytes, and fluid, and these should be summarized and documented in the medical record and communicated to the patient's primary healthcare team. 3.3.5 The Nutrition Support Physician should participate in the nutrition assessment that includes an assessment of factors relevant to route of administration of nutrition support therapies. 4.0 The Nutrition Support Physician should participate in development of the nutrition care plan as defined above and shall be developed by the patient's healthcare team and should include input from the patient and/or surrogate. 4.1 This nutrition care plan may be developed by the patient's primary physician, a dietitian, members of the nutrition support team, or an interdisciplinary group, including a combination of these and/or other healthcare personnel. The patient or family should participate in developing the plan. The Nutrition Support Physician should actively participate in and oversee the development of a nutrition care plan for individual patients with complex nutrition issues. 4.1.1 The Nutrition Support Physician should be aware of the objectives of the nutrition care plan as determined and documented. These should include immediate and long-term goals of nutrition therapy, anticipated duration of therapy, and discharge planning and home training if appropriate. 4.1.2 The Nutrition Support Physician should, through the nutrition care plan, address patient/family education about nutrition support therapy and the patient/family's involvement in decisions regarding goals of treatment. This should include the risks and benefits of any nutrition intervention. 4.1.3 The Nutrition Support Physician should, through the nutrition care plan, define optimal route of administration of nutrition support therapy and state nutrition requirements. 4.2 The Nutrition Support Physician shall collaborate with other members of the nutrition support team to create, and periodically review, local or institutional guidelines for developing comprehensive, interdisciplinary nutrition care plans. 5.0 The Nutrition Support Physician should be aware that access devices used to provide nutrition support therapy shall be placed by, or under the supervision of, a physician, nurse, or a specially trained healthcare professional who is proficient in placement and credentialed by the institution. 5.1 The Nutrition Support Physician should collaborate with other members of the nutrition support team and respective institutional device committees to develop and periodically review standards and protocols for access procedures. 5.2 The Nutrition Support Physician shall be knowledgeable in the management of complications related to nutrition support access and may lead the nutrition support team in monitoring and treating enteral or venous access device-related complications. 6.0 The Nutrition Support Physician shall participate in developing and implementing policies for monitoring patients receiving nutrition support therapy. 6.1 Protocols should be developed to obtain appropriate baseline nutrition information and for periodic review of patients’ clinical and laboratory status. 6.2 The Nutrition Support Physician shall lead or advise the nutrition support team on monitoring patients’ progress toward immediate and long-term goals of nutrition therapy as defined in the nutrition care plan. 6.3 The monitoring parameters should be periodically compared with the goals of the nutrition care plan. 7.0 The Nutrition Support Physician shall participate in developing and implementing policies for reassessing and updating the nutrition care plan of patients receiving nutrition support therapy. 7.1 The Nutrition Support Physician shall participate in the periodic reassessment of the patient's nutrition status as per institutional protocol. This information should be evaluated in conjunction with the patient's baseline assessment and goals established in the nutrition care plan. 7.2 The Nutrition Support Physician or other nutrition support clinician should document the patient's ability to tolerate enteral nutrition or to ingest and absorb adequate oral nutrients before discontinuing parenteral nutrition. 7.3 The Nutrition Support Physician should be aware of the patient's nutrient intake as monitored by a nutrition support clinician during transition from one form of nutrition support therapy to another. 7.4 The Nutrition Support Physician should participate in developing discharge planning policies. 8.1 The Nutrition Support Physician shall participate in developing and implementing policies for termination of nutrition support therapy. 8.2 The Nutrition Support Physician should participate, when appropriate, in an individual patient's decision to terminate nutrition support therapy. 8.3 Safe and appropriate methods shall be used to terminate nutrition support therapy. 8.4 The Nutrition Support Physician should lead or advise on decisions regarding nutrition support therapy with respect to prevailing ethical considerations of nutrition support as informed by the latest literature.9 Such decisions should be made in accordance with local practice standards and current local, state, and federal law.

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