Registered Dietitian-Led Nutrition Support: A Specialized and Vital Need

Malnutrition is a growing problem in hospitals, particularly among patients with cancer and gastrointestinal issues, who have had abdominal surgery or who are elderly. Ideally, nutrition support teams work with physicians, nurses and other healthcare providers to identify patients who are malnourished and recommend American Society of Parenteral and Enteral Nutrition (ASPEN) guideline-adherent treatment.

Unfortunately, while the need for nutrition expertise is growing, there has been a decline in hospital-based nutrition support teams because dietitian services often are not covered by insurance. When patients are discharged on home parenteral nutrition (HPN) or home enteral nutrition (HEN), it is therefore vital they are cared for by a high-quality provider that offers robust clinical management featuring specialized nutrition support led by registered dietitians.

In the home infusion setting, registered dietitians can offer much-needed expertise to help ensure patients receive appropriate nutrition. For example, Option Care registered dietitians can:

Ensure patient needs are supported with specialized nutrition expertise. After a patient is discharged home on nutrition support, the Option Care dietitian assesses the nutrition order to be sure it is meeting the patient’s needs. Sometimes the initial order – often written by a physician who lacks specialized nutrition expertise and has no nutrition support team to offer guidance – provides inadequate nutrients, resulting in overfeeding or underfeeding. Further, a patient’s nutritional needs may change over time. For example, a patient with an acute injury might require a significant amount of protein early in the healing process, but that level may be excessive by the time the patient is discharged home. A recent study of 187 Option Care HPN patients and 349 HEN patients determined original nutrition support orders provided upon discharge from the hospital did not meet HPN patients’ nutritional needs 23 percent of the time on average (including protein, carbohydrate and total caloric needs).3 While HEN orders were much more likely to meet patients’ needs, 38 percent did not meet their fluid needs. Registered dietitians reviewing the orders can make guideline-adherent recommended changes, resulting not only in better care for the patients, but significant cost savings.

Recommend the most appropriate type of nutrition therapy. While ASPEN guidelines note patients should be prescribed HPN only when their gastrointestinal tracts are not functioning or when HEN is not feasible, in reality HPN is often overprescribed. Involving registered dietitians in the management of home nutrition helps address this issue. An Option Care study of 505 HPN patients found as the percentage of patients managed by registered dietitians increased, the rate of those on HPN decreased.4 While 75 percent of patients were managed by registered dietitians in 2010, that number increased to 91 percent by 2014, and during that time period, the number of days patients received HPN decreased by 33 percent.

Provide interventions that improve care and save costs. As the experts on the frontline of home infusion, registered dietitians can intervene early to prevent problems from escalating (and leading to hospital readmission). In a three-month Option Care study of 2,500 HEN and 270 HPN patients, interventions by registered dietitians (alone or conjunction with other members of the home nutrition support team, including pharmacists and nurses) improved patient care such as by correcting overfeeding or underfeeding, preventing dehydration, managing hyperglycemia and electrolyte imbalances and reducing or eliminating diarrhea.5 These interventions helped patients avoid hospital stays, saving significant cost. In the study, these interventions resulted in an estimated 87 hospital days avoided for HEN patients, saving $174,000, and an estimated 342 hospital days avoided for HPN patients, saving $684,000.

Increasingly, healthcare providers recognize the expertise of registered dietitians and turn to them for guidance in the delivery of quality home nutrition. An Option Care study of 399 HPN determined that, over a 4-1/2-year period, the number of orders written by registered dietitians increased from 66 percent at the beginning of the study to 94 percent by the end.6

Registered dietitians certified in nutrition support have the training and expertise to counsel healthcare providers in the provision of the most appropriate home nutrition therapy, which is not only beneficial for patients, but reduces costs. Clearly, it is vital for patients who leave the hospital on home nutrition to receive care from a home infusion company offering a high level of expertise and a multidisciplinary approach to support them throughout the continuum of care.