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Special Report
Nutrition in Clinical Practice
Standards for Nutrition Support: Adult Hospitalized Patients Volume00Number0
xxxx 2018 1–15
C 2018 American Society for
Parenteral and Enteral Nutrition
DOI:10.1002/ncp.10204
wileyonlinelibrary.com
1 2
AndrewUkleja, MD,AGAF ;KarenGilbert,RN,MSN,CNSC,ACNP ;
3
Kris M. Mogensen, MS, RD-AP, LDN, CNSC ;ReneeWalker,MS,RD,LD,CNSC,
FAND4;CeressaT.Ward,PharmD,BCPS,BCNSP,BCCCP5;JoeYbarra,PharmD,
6 7
BCNSP ;BeverlyHolcombe,PharmD,BCNSP,FASHP,FASPEN ; Task Force
on Standards for Nutrition Support: Adult Hospitalized Patients, the American Society
for Parenteral and Enteral Nutrition
Abstract
TheAmericanSocietyforParenteralandEnteralNutritiondefinesstandardsasbenchmarksrepresentingarangeof performance
of competent care that should be provided to assure safe and efficacious nutrition care in most circumstances. Standards
are documents that define the structure needed to provide competent care. These Standards for Nutrition Support for Adult
Hospitalized Patients are an update of the 2010 Standards. These practice-based standards are intended for use by healthcare
professionals charged with the care of adult hospitalized patients receiving nutrition support therapy in any hospital with or
without a formal nutrition support service or team. These Standards address professional responsibilities as they relate to patient
assessment, diagnosis, education, care plan development, implementation, clinical monitoring, evaluation, and professional issues
aroundnutrition support. (Nutr Clin Pract. 2018;00:1–15)
Keywords
enteral nutrition; hospitalization; nutrition assessment; nutrition support; parenteral nutrition; standard of care
Introduction usuallyaddressprofessionalresponsibilitiesastheyrelateto
The American Society for Parenteral and Enteral Nu- patient assessment, diagnosis, education, care plan devel-
trition (ASPEN) is dedicated to improving patient care opment, implementation, clinical monitoring, evaluation,
by advancing the science and practice of clinical nutri- and professional issues. ASPEN publishes discipline-based
tion and metabolism. Founded in 1976, ASPEN is an (eg, dietitian, nurse, pharmacist, or physician) and practice-
interdisciplinary organization whose members are involved based(eg,adulthospitalizedpatients,pediatrichospitalized
in the provision of clinical nutrition therapies, including patients, home and alternate site care) standards. Standards
parenteral and enteral nutrition. With more than 6,500 arepresentedinthemostgenerictermspossible.Thedetails
membersfromaroundtheworld,ASPENisacommunityof of specific tests, therapies, and protocols are left to the
dietitians, nurses, pharmacists, physicians, scientists, stu-
dents, and other health professionals from every facet of Fromthe 1BethIsrael Deaconess Medical Center, Division of
nutrition support clinical practice, research, and educa- Gastroenterology, Boston, Massachusetts, USA; 2Thomas Jefferson
tion. ASPEN envisions an environment in which every University Hospital, Philadelphia, Pennsylvania, USA; 3Department
patient receives safe, efficacious, and high-quality nutrition of Nutrition, Brigham and Womens Hospital, Boston,
Massachusetts, USA; 4Michael E. DeBakey Veteran Affairs Medical
care. ASPENs mission is to improve patient care by Center, Houston, Texas, USA; 5Emory Healthcare, Atlanta, Georgia,
advancing the science and practice of clinical nutrition USA;6MedicalCityMcKinney,McKinney,Texas,USA;and
and metabolism. These Standards for Nutrition Support 7AmericanSocietyfor Parenteral and Enteral Nutrition, Silver
for Adult Hospitalized Patients are an update of the 2010 Spring, Maryland, USA.
1
standards. They are intended for use by any hospital with Financial disclosure: None declared.
or without a formal nutrition support service (or team). Conflicts of interest: None declared.
ASPEN defines standards as benchmarks representing This article originally appeared online on xxxx 0, 0000.
a range of performance of competent care that should be Corresponding Author:
provided to assure safe and efficacious nutrition care in Beverly Holcombe, PharmD, BCNSP,FASHP,FASPEN,ASPEN,
2
most circumstances. Standards are documents that define 8401Colesville Rd, Suite 510, Silver Spring, MD 20910.
the structure needed to provide competent care. Standards Email: beverlyh@nutritioncare.org
2 Nutrition in Clinical Practice 00(0)
discretion of individual healthcare facilities. Each health- Chapter I: Organization
carefacility shall strive to provide the best nutrition support Standard 1. Nutrition Support Service (or
care that is possible given the resources of the organization.
The standards aim to ensure sound and efficient nutrition Team)
care for those in need of nutrition support therapy. A nutrition support service (or team) should assess and
Important Note in collaboration with patients primary teams, manage the
nutrition support therapy of patients who require or may
These standards do not constitute medical or other pro- require nutrition support therapy. These patients are of-
fessional advice and should not be taken as such. To the ten, but not always, determined to be nutritionally-at-risk
extent that the information published herein may be used at admission or upon subsequent evaluation.3 Organized
to assist in the care of patients, this is the result of the sole nutrition support services (or teams) are associated with
professional judgment of the attending healthcare profes- improved patient outcomes, decreased length of hospital-
sionalwhosejudgmentistheprimarycomponentof quality ization, and improved cost effectiveness.4-19 If a hospital
medical care. The information presented in these standards does not have a designated nutrition support service (or
is not a substitute for the exercise of such judgment by the team), the care used to provide nutrition support therapy
healthcare professional. Circumstances in clinical settings should be interprofessional. The scope and design of the
and patient indications may require actions different from nutrition support service (or team) and their respective
thoserecommendedinthisdocumentandinthosecases,the activities vary according to the unique attributes of each
judgment of the treating professional should prevail. hospital. Among various organizations, management of
nutrition support may comprise a spectrum of activities
Audience for Standards including no formal structure, an administrative nutrition
committeeonly, a consultative nutrition support service (or
These practice-based standards are intended for use by team), or a nutrition support service (or team) that assumes
healthcare professionals charged with the care of adult responsibility for the nutrition care of patients who receive
hospitalized patients receiving nutrition support therapy. nutrition support therapy.
Level of Care 1.1 When an organized nutrition support service (or
As limited by the Important Note above, these Standards team) exists, it shall be directed by a clinician who
of Practice present a range of performance of competent hasappropriateeducation,specializedtraining,pa-
care that should be provided by healthcare professionals tient care experience, or experience in managing
caring for adult hospitalized patients receiving nutrition nutrition support services (teams).
support therapy. Terminologies included in each standard 1.2 An organized nutrition support service (or team)
are specified as: should include a physician, nurse, dietitian, and
pharmacist, each following the standards of prac-
tice for their discipline, as available.20-23
(a) “Shall”: Indicates standards to be followed strictly. 1.3 If a nutrition support service (or team) is not
(b) “Should”:Indicatesthatamongseveralpossibilities established, nutrition support therapy should be
one is particularly suitable, without mentioning or managed with an interprofessional approach that
excluding others, or that a certain course of action includes the patients physician, nurse, dietitian,
is preferred but not necessarily required. andpharmacist.
(c) “May”:Indicatesacourseof actionthat is permis-
sible within the limits of recommended practice. Standard 2. Policies and Procedures
Written policies and procedures for providing nutrition
These standards have been developed by the ASPEN support therapy shall be current.
Task Force on Standards for Nutrition Support: Adult
Hospitalized Patients, reviewed by the ASPEN Clinical 2.1 Thepoliciesandproceduresshallbedevelopedwith
Practice Committee, and approved by the ASPEN Board the input of and review by all members of the
of Directors on July 25, 2018. These Standards of Prac- nutritionsupportservice(orteam)and/ornutrition
tice should be used in conjunction with the previously support committee.
published ASPEN Clinical Guidelines, Standards, Position 2.2 The policies and procedures shall be reviewed
Papers, and other Board Approved documents, which can periodically and revised as appropriate to define
beaccessedattheASPENDocumentsLibrary,http://www. optimalpatientcareandtherapeuticoutcomes.(See
nutritioncare.org/Clinical_Practice_Library/. 3.2.)
Ukleja et al 3
Standard 3. Performance Improvement baseline nutrition parameters, identify nutrition risk
The nutrition support service (or team) and/or nutrition factors and specific nutrition deficits, determine individual
supportcommitteeshallregularlyreviewandreportonser- nutrition needs, and identify medical, psychosocial, and
vice performance, quality indicators, patient outcome data, socioeconomic factors that may influence the prescription
andadministration of nutrition support therapy.34,35
and adverse events related to nutrition support therapies.24
These reports shall be shared with all internal stakeholders 5.1 Thenutritionassessmentshallbeperformedwithin
andreported to external agencies as required. thetimeframespecifiedbythehospitalandbya
dietitian or a clinician with documentedspecialized
3.1 Thenutrition support service (or team) and/or nu- expertise in nutrition.
trition support committee shall recommend policy, 5.2 The nutrition assessment shall include evaluation
procedure,orprotocolchangesthatimproveand/or of the patients current nutrition status and nutri-
enhancethesafetyandefficacyof nutritionsupport tion requirements.
therapy. 5.2.1 A malnutrition diagnosis, if present, and
3.2 The review of service performance should assess degree of malnutrition shall be clearly doc-
the appropriateness and effectiveness of nutrition umented to facilitate appropriate diagnosis
support therapy. coding.
Chapter II: Nutrition Care 5.2.2 Degreeof obesity(ie,classI,classII,orclass
III), if applicable, shall also be documented.
Nutrition care and the administration of nutrition support 5.3 The patients nutrition requirements shall be sum-
therapy shall proceed according to a series of steps with marized based on the findings of the nutrition
feedback loops. These steps include nutrition screening, assessment and should include energy, macronutri-
formal nutrition assessment, creation of a nutrition care ent (protein, and as appropriate, carbohydrate and
plan, implementation of the plan, patient monitoring, eval- fat), as well as fluid, electrolyte, and micronutrient
uation of the plan, evaluation of the care setting, and requirements, as appropriate.
reformulation of the plan or termination of therapy. (See 5.4 Nutrition assessment shall include a review and
Figure 1: ASPEN Adult Nutrition Care Pathway.) documentation of factors relevant to delivery of
nutrition support therapy. Relevant factors may
Standard 4. Nutrition Screening include, but are not limited to, the following: ability
to eat safely and adequately, patients goals, assess-
Nutrition screening is defined as “a process to identify ment of aspiration risk, functional status of the
an individual who is malnourished or who is at risk for gastrointestinal tract, cognitive function/abilities,
malnutritiontodetermineif adetailednutritionassessment enteral and vascular access, and results of tests and
1
is indicated.” Patients who are nutritionally-at-risk shall be invasive procedures.
identified by a validated screening process and by periodic
rescreening per institutional policy or standard.3,25-33 This Chapter III: The Nutrition Care Plan
processshouldbecreated,approved,andregularlyreviewed
by a group with organizational authority, preferably a Standard 6. Goals
designated nutrition committee. The process of nutrition care is multifactorial and shall
4.1 Results of the nutrition screening shall be docu- include multiple levels of intervention including screening
mented and communicated and appropriate inter- for nutrition risk factors. The nutrition care plan shall
vention shall be initiated within the time frame be created from a comprehensive review and analysis of
specified by the hospital or as clinically indicated. information gathered from many aspects of the patients
4.2 Aprocedure for rescreening of patients not imme- care. The nutrition care plan should include “statements
diately identified as nutritionally-at-risk should be of nutrition goals and monitoring/evaluation parameters,
implemented and regularly reviewed. the most appropriate route of administration of nutrition
therapy,methodof nutritionaccess,anticipateddurationof
2
Standard 5. Nutrition Assessment therapy, and training and counseling goals and methods.”
A formal nutrition assessment provides the basis for
All patients identified as nutritionally-at-risk based the nutrition care plan. The nutrition care plan guides
on the nutrition screening shall undergo a nutrition comprehensive nutrition therapy by defining its ratio-
assessment.3,27-33 This nutrition assessment shall be nale, describing appropriate intervention and monitoring,
documentedandmadeavailabletoallpatientcareproviders. and delineating recommended reassessment and reevalu-
The intent of the nutrition assessment is to document ation parameters. This process facilitates changes in care
4 Nutrition in Clinical Practice 00(0)
Figure 1. The American Society for Parenteral and Enteral Nutrition adult nutrition care pathway.
appropriate to the clinical setting while considering the Standard 7. Interprofessional Approach
continuumof care.Revisionof thenutritioncareplanbased Thenutrition care plan should be developed using an inter-
on changes in clinical status and achievement of goals of professional team approach involving the patient, caregiver
therapy should occur before discontinuation of nutrition (if applicable), the nutrition support service (or team), the
support therapy.
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