Effectiveness of a multidisciplinary total parenteral nutrition team in the hospital setting

Background Total parenteral nutrition (TPN) is a form of nutritional support that has become an essential adjunct to the management of patients who are unable to obtain adequate nutrition either via the oral or enteral route. Previous studies indicate that TPN can be administered safely and effectively to patients; however, there are associated risks with this form of nutritional support. Researchers have indicated that due to the complexity of TPN therapy a high level of knowledge and expertise is required in the management of these patients. The multidisciplinary team approach has been supported for its ability to assess the patients’ nutritional status, prescribe the nutritional requirements, and reduce the incidence of metabolic complications through regular monitoring. However, contradictory views on the effectiveness of multidisciplinary TPN teams in health-care facilities have also been reported.

Aim The aim of this review was to critically analyse the literature and present the best available evidence that investigated the effectiveness of multidisciplinary TPN teams in the provision of TPN to adult hospitalised patients. The primary outcomes included: incidence of catheter-related complications, types of catheter-related complications, incidence of metabolic and electrolyte abnormalities, provision of nutritional requirements, estimated nutritional requirements, number of patients whose nutritional goals were met and the amount of energy and protein provided. Secondary outcomes included cost effectiveness of nutritional support teams and physician compliance with team recommendations.

Search strategy The literature search sought to identify both published and unpublished studies utilising various search strategies and the Internet. The Cochrane Library (2001, Issue 4) was initially searched to identify randomised controlled trials. The other electronic databases searched included CINAHL, Complete Medline, Complete Biomedical Collection, Complete Nursing Collection, and EMBASE. Experts and company representatives were contacted to identify published reports as well as research in progress relevant to this review. Professional bodies were contacted and included the British Association for Parenteral and Enteral Nutrition (BAPEN) and the Australasian Society for Parenteral and Enteral Nutrition (AuSPEN).

Selection criteria All randomised and non-randomised controlled trials comparing the effectiveness of multidisciplinary TPN teams, in the provision of TPN to adult hospitalised patients, were considered for inclusion in this review. Trials were included if they reported objective or subjective measures of nutritional, metabolic and catheter-related complications and cost effectiveness. To minimise publication bias studies reported in other languages were also considered for inclusion in the review.

Data collection and analysis The eligibility of studies for inclusion, the methodological quality and data extraction were undertaken independently by two reviewers and cross-checked by a third reviewer. The studies included in the review have been synthesised as a narrative overview.

Results Eleven studies comparing the effectiveness of a multidisciplinary TPN team in the hospital setting were analysed in this review. Six studies that investigated the incidence of total mechanical complications reported a higher incidence of these complications in patients who were managed by their physician. Catheter-related sepsis was investigated in seven studies of which five reported a reduction and two reported an increase in catheter-related sepsis in patients managed by the team. One study reported no statistically significant difference in the total metabolic and electrolyte abnormalities and four studies reported fewer of these abnormalities in patients cared for by the nutrition team. Overfeeding and underfeeding in patients not managed by the TPN team were reported in five studies. The most appropriate route of feeding was investigated in four studies. Two of the four studies reported that patients managed by the team were more likely to be fed by the most appropriate route and the findings from the remaining two studies were unclear. Cost effectiveness of the TPN team was reported in two studies and a reduction in costs was demonstrated in both studies when the patients were managed by the TPN team. Compliance by physicians to recommendations made by the TPN team was investigated in two studies, and both reported that physicians complied with at least 50% of the recommendations.

Conclusions The general effectiveness of the TPN team has not been conclusively demonstrated. There is evidence that patients managed by TPN teams have a reduced incidence of total mechanical complications; however, it is unclear if there is a reduction in catheter-related sepsis. The conflicting results relating to the benefit of the TPN teams in the reduction of electrolyte and metabolic abnormalities indicate that further research is needed to clarify the impact of TPN teams on this outcome. The provision of the patients estimated energy requirements are positively influenced when managed by the TPN team; however, the evidence relating to the effectiveness of the TPN team in the provision of protein requirements remains unclear. From this review it is unclear if management of the patients by the TPN team prevented the inappropriate use of TPN. The limited data obtained from the studies provide evidence of a clinically important difference between groups in terms of cost effectiveness.