The Nutrition and Metabolic Support Service (NMSS) at Emory University Hospital (EUH) has been recognized with the Clinical Nutrition Team Distinction Award of the American Society for Parenteral and Enteral Nutrition (ASPEN). The award tributes excellence in clinical nutrition practice in programs that meet specific criteria and compliance with ASPEN national standards, guidelines, and values involving screening, evaluation, assessment of therapeutic effectiveness, management, rehabilitation, risk analysis, technology assessment, or treatment relating to a specific disease, condition, or therapeutic avenue.
Nutrition support therapy uses oral, enteral, and parenteral approaches to maintain or restore optimal nutrition status and health to often critically ill patients. The enteral and parenteral methods are administered when patients are unable to swallow. Enteral nutrition delivers a blend of protein, sugars, fats, vitamins, minerals, and other nutrients through a tube into the patient's stomach or small intestine, while parenteral nutrition delivers a blood-compatible mixture into the veins through an intravenous tube.
When W. Dean Warren, MD, chair of the Emory Department of Surgery from 1971-1989, initiated EUH's NMSS in 1979, it was one of only two such services in the country to involve the multidisciplinary collaboration of physicians, pharmacists, nurses, and dietitians. In 1983, John Galloway, MD, started rotating on the service as a general surgery resident. After joining the Emory Surgery faculty in 1987, he was appointed director of the NMSS, beginning a tenure that has lasted to the present day. Now a professor of surgery, he co-directs the service with Tom Ziegler, MD, professor of medicine.
"At first, I was attracted to the fact that hospital-based nutrition is a surgical invention, which makes perfect sense since the relationship between nutrition and/or malnutrition and surgical outcomes is well established," says Galloway. "IV feeding with complex nutritional formulas containing proteins, carbohydrates, and fats was developed by Dr. Stanley Dudrick, and was first used in 1967 before becoming widely available in the early 1970's. But more than history has kept me here. When I started going on surgical missions to Pakistan and other countries, which I still do, I saw firsthand how serious a problem poor nutrition can become. Those experiences inspired me to do all I could to help patients at Emory, as well as others that aren't so lucky to be here."
The EUH team's original principle of relying on the interaction of diverse skillsets to serve its patients remains intact today. Ziegler joined Galloway as associate director of the service in 1993, and became co-director in 2007. He is also the team's research coordinator, and his studies have been continuously funded by the National Institutes of Health since 1996. The pharmacological members include nutritional specialist and clinical pharmacist Dan Griffith, RPh, who has been on the service since 1988, and former Emory nutrition support residents Nisha Dave, PharmD, and Vivian Zhao, PharmD. The group's dieticians are Glen Bergman, CNSD, RD/LD, and Erin McAllister, CNSD, RD/LD, and its nurses are Therese McNally, RN, and recent hire Laura Jones, RN, who joined the practice following the retirement of longstanding Emory nutritional support nurse Cindy Battey, RN. All team members are board certified in nutrition and metabolic support under their respected disciplines through ASPEN.
The number of staff and their combined knowledge and experience have influenced the growth of the Emory NMSS into the most high-volume program of its type in the country, with an average of 90 inpatients per-day on its consult service and approximately 100 outpatients. Unlike most nutrition support services, which can only act on a consultant basis regarding the specialized formulas that patients require, the EUH team also has primary order-writing approval.
In addition to clinical performance, the ASPEN award acknowledges substantial emphasis on research and quality efforts and academic vitality. "We’ve done many different quality improvement projects over the years, and collaborate regularly with the departments of medicine and surgery, the nursing school, and other Emory groups," says Galloway. "Dr. Ziegler leads a vigorous research program in both our inpatient and outpatient populations. Research studies involving outpatient services with home health companies are particularly important to us, since enteral and parenteral nutrition can now be lifelong therapies in patients with various eating disorders and intestinal failure syndromes."
Current research being conducted by the EUH NMSS includes studies of adequate glucose control in patients receiving nutrition support; developing protocols for monitoring patients' blood for infections from central line catheters, a major complication of intravenous feeding; designing methods of alleviating nutrition loss in dialysis patients; and determining the timing and delivery of the ideal amount of protein and calories in the septic ICU patient.
Nutrition support residents rotate on the service (Griffith and Dave codirect the residency, one of only two in the nation), and team members train and mentor pharmacy residents from the critical care, transplant, hematology/oncology, and infectious disease programs, as well as advanced pharmacy students from Emory and such outside institutions as Mercer, Georgia State University, and the University of Georgia. They also work with dietetic interns, critical care and anesthesiology residents, nursing staff, medical students, GI fellows, and foreign physicians.
Team members publish regularly in such high impact journals as the New England Journal of Medicine, Annals of Surgery, and the Journal of Parenteral and Enteral Nutrition, and are regular attendees and presenters at national meetings of ASPEN, the Society of Critical Care Medicine, and other organizations.
"The EUH nutrition support team is a tremendous benefit to our institution," says Jahnavi Srinivasan, MD, associate professor of surgery. "Dr. Galloway and his colleagues have poured an incredible amount of work into shaping the program into one of the most exemplary in the country, and I always know that my patients will be in very good hands if they need the team's services."