Nutrition is a cornerstone of recovery and rehabilitation in ICU patients, and the appointment of qualified dietitians can help to attain best results in a number of ways.
Here we provide some of the key reasons to include a dietitian within your ICU team.
1. Sensible guidelines: Having a dietitian on hand within the ICU is important towards forming and adhering to guidelines for initiating nutrition support whenever a patient is admitted, even out of hours. Guidelines would ideally be designed by the lead dietitian, whilst supervised junior dietetic staff can provide valuable support (Core Standards for Intensive Care Units).
2. Individualised nutrition support: Whilst feeding protocols have long been standard practice on the ICU, evidence continually suggests that their use in isolation is not sufficient to prevent nutritional deficits; thus, individualised nutrition support is recommended (Heidegger 2013). This may be in the form of supplemental parenteral nutrition or post-pyloric feeding, which require careful review to avoid complications, says Ella Segaran in her ICU Management article “Dietitians in Critical Care: A Fundamental and Evolving Role”. Qualified dietitians who focus on this key area are thus required to provide high standards in individual nutrition support.
3. Reduce errors: Assigning a dietitian, or team of dietitians, to your ICU can reduce the incidence of errors. When new patients are admitted to the ICU, the dietitian will ensure that they commence enteral or parenteral nutrition to ensure adequate nutrition for their rehabilitation. In cases where this is not appropriate, the dietitian will clearly document the reasons for this. This well-defined channel for nutritional care can reduce the incidence of human error and the likelihood for adequate nutrition to be overlooked or misjudged.
The difficulties encountered are maximal during the first week of a very sick patient’s ICU admission, putting these patients at high risk of undernutrition (Villet et al. 2005). As well as being a contentious issue, provision of an optimum quantity of feeding without overfeeding is delicate and requires regular monitoring.
4. Better performance: The presence of a critical care dietitian was associated with better performance in terms of compliance with guidelines, providing at least 80% of target energy, the use of enteral nutrition, initiating enteral nutrition within 24 hours and the use of strategies to optimise delivery (Heyland et al. 2010).
5. Focused guidance: The role of a dietitian in the ICU is to apply and reinforce nutrition support protocols. The lead dietitian will be intricately involved in the assessment, implementation and management of a suitable nutrition support route, involving collaboration with the rest of the ICU team Core Standards for Intensive Care Units).
Even with the recognition of the importance of nutrition in critically ill patients and the use of protocols to promote nutritional care, a difference between knowledge and actual practice exists (Alberda et al. 2009; Heyland et al. 2004; 2014). On average critically ill patients only receive approximately 60% of calories and 57% of protein prescribed (Alberda et al. 2009; Heyland et al. 2014, says Segaran.
Dietitians are best placed to provide nutritional advice to the multidisciplinary team on the optimal way to manage the nutritional needs of critically ill patients as they have a solid science-based educational background, informed by current evidence, and are therefore perfectly positioned to be able to evaluate and advise on the complex relationship between critical illness and nutritional status, explains Segaran.
6. Encourage a collaborative working environment. The addition of a dietitian on the ICU presents another clinician to help in solving problems and making decisions via a collective approach. This collaboration encourages medical professionals to think actively, bring different thought patterns together, and to coordinate these to come to effective solutions in what is a functional learning environment.
7. Evidence of great benefits: According to Segaran, evidence is emerging that nutritional care is better provided, and superior patient outcome achieved, when a critical care dietitian is involved in the multidisciplinary team (Doig et al. 2008; Braga et al. 2006). One study showed that patients had a significantly shorter length of stay when they received enteral nutrition according to the advice of a critical care dietitian (Braga et al. 2006).
8. Recommendation: The British Dietetic Association advises that there should be a dietitian as part of the ICU multidisciplinary team. Its recommendation is 0.05-0.1 WTE dietitian per one bed and that the lead dietitian for ICU should be at least a band 7.
9. Cost-effective: The presence of a dedicated ICU dietitian is directly correlated with better provision of nutrition support which in turn is associated with an improvement in patient outcomes and a reduction in healthcare costs (Dietitian Key Facts: Critical Care, BDA)
Video credit: MyHealthCareer
Here we provide some of the key reasons to include a dietitian within your ICU team.
1. Sensible guidelines: Having a dietitian on hand within the ICU is important towards forming and adhering to guidelines for initiating nutrition support whenever a patient is admitted, even out of hours. Guidelines would ideally be designed by the lead dietitian, whilst supervised junior dietetic staff can provide valuable support (Core Standards for Intensive Care Units).
2. Individualised nutrition support: Whilst feeding protocols have long been standard practice on the ICU, evidence continually suggests that their use in isolation is not sufficient to prevent nutritional deficits; thus, individualised nutrition support is recommended (Heidegger 2013). This may be in the form of supplemental parenteral nutrition or post-pyloric feeding, which require careful review to avoid complications, says Ella Segaran in her ICU Management article “Dietitians in Critical Care: A Fundamental and Evolving Role”. Qualified dietitians who focus on this key area are thus required to provide high standards in individual nutrition support.
3. Reduce errors: Assigning a dietitian, or team of dietitians, to your ICU can reduce the incidence of errors. When new patients are admitted to the ICU, the dietitian will ensure that they commence enteral or parenteral nutrition to ensure adequate nutrition for their rehabilitation. In cases where this is not appropriate, the dietitian will clearly document the reasons for this. This well-defined channel for nutritional care can reduce the incidence of human error and the likelihood for adequate nutrition to be overlooked or misjudged.
The difficulties encountered are maximal during the first week of a very sick patient’s ICU admission, putting these patients at high risk of undernutrition (Villet et al. 2005). As well as being a contentious issue, provision of an optimum quantity of feeding without overfeeding is delicate and requires regular monitoring.
4. Better performance: The presence of a critical care dietitian was associated with better performance in terms of compliance with guidelines, providing at least 80% of target energy, the use of enteral nutrition, initiating enteral nutrition within 24 hours and the use of strategies to optimise delivery (Heyland et al. 2010).
5. Focused guidance: The role of a dietitian in the ICU is to apply and reinforce nutrition support protocols. The lead dietitian will be intricately involved in the assessment, implementation and management of a suitable nutrition support route, involving collaboration with the rest of the ICU team Core Standards for Intensive Care Units).
Even with the recognition of the importance of nutrition in critically ill patients and the use of protocols to promote nutritional care, a difference between knowledge and actual practice exists (Alberda et al. 2009; Heyland et al. 2004; 2014). On average critically ill patients only receive approximately 60% of calories and 57% of protein prescribed (Alberda et al. 2009; Heyland et al. 2014, says Segaran.
Dietitians are best placed to provide nutritional advice to the multidisciplinary team on the optimal way to manage the nutritional needs of critically ill patients as they have a solid science-based educational background, informed by current evidence, and are therefore perfectly positioned to be able to evaluate and advise on the complex relationship between critical illness and nutritional status, explains Segaran.
6. Encourage a collaborative working environment. The addition of a dietitian on the ICU presents another clinician to help in solving problems and making decisions via a collective approach. This collaboration encourages medical professionals to think actively, bring different thought patterns together, and to coordinate these to come to effective solutions in what is a functional learning environment.
7. Evidence of great benefits: According to Segaran, evidence is emerging that nutritional care is better provided, and superior patient outcome achieved, when a critical care dietitian is involved in the multidisciplinary team (Doig et al. 2008; Braga et al. 2006). One study showed that patients had a significantly shorter length of stay when they received enteral nutrition according to the advice of a critical care dietitian (Braga et al. 2006).
8. Recommendation: The British Dietetic Association advises that there should be a dietitian as part of the ICU multidisciplinary team. Its recommendation is 0.05-0.1 WTE dietitian per one bed and that the lead dietitian for ICU should be at least a band 7.
9. Cost-effective: The presence of a dedicated ICU dietitian is directly correlated with better provision of nutrition support which in turn is associated with an improvement in patient outcomes and a reduction in healthcare costs (Dietitian Key Facts: Critical Care, BDA)
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Video credit: MyHealthCareer
