Nutrition Support SOP

Nourish RDs play a critical role in the management of patients on Nutrition Support, both Total Parenteral Nutrition (TPN) as well as Enteral Nutrition (EN or tube feeding). 

Purpose

To provide standardized guidelines for Nourish Registered Dietitians (RDs) to support patients receiving Total Parenteral Nutrition (TPN) or enteral nutrition (EN or tube feeding) support.

This SOP applies to all RDs employed by Nourish who provide telehealth services to patients on TPN or enteral support.

Total Parenteral Nutrition (TPN): The intravenous administration of nutrients to patients whose gastrointestinal tract is non-functional or otherwise compromised.

Enteral Nutrition Support (EN): The delivery of nutrients directly to the gastrointestinal tract via a feeding tube.

Requirements for Specialty (one or more of the following)

• Hold current CNSC credential

• Have >5 years' experience managing enteral feeding and/or parenteral feeding patients

• The following competencies ensure that RDs provide safe, effective, and individualized care for patients requiring parenteral &/or enteral nutrition support:

  • TPN:

    • Understand the indications and contraindications for TPN.

    • Knowledge of the components of TPN solutions, including macronutrients, micronutrients, and electrolytes.

    • Familiarity with conducting a thorough nutrition assessment to determine the need for and appropriateness of TPN.

    • Nutrient requirements for TPN based on patient-specific factors.

    • Collaboration with HCPs to develop and monitor an individualized TPN regimen.

    • Understanding the procedures for preparing and administering TPN.

    • Knowledge of the aseptic techniques required to prevent contamination.

    • Monitoring via telehealth patients for potential complications associated with TPN (e.g., infections, metabolic imbalances).

    • Competence interpreting laboratory results / biochemical parameters as they relate to TPN and nutrition status. 

    • Documenting all aspects of TPN therapy, including assessments, formulations, monitoring results, and adjustments.

  • EN

    • Understand the indications and contraindications for enteral nutrition.

    • Knowledge of different types of enteral formulas (standard, specialized, polymeric, elemental) and their appropriate use.

    • Understanding various types of enteral feeding tubes (nasogastric, nasojejunal, gastrostomy, jejunostomy) and their indications.

    • Understanding the procedures for safe placement and maintenance of enteral feeding tubes

    • Demonstrating knowledge of enteral feeding administration methods (continuous, intermittent, bolus)

    • Calculating energy, protein, fluid, and micronutrient needs based on patient-specific factors (for feedback to HCP writing the order)

    • Developing recommendations for the external provider for an individualized enteral nutrition regimen to meet needs

    • Monitoring clinical and biochemical parameters to assess the effectiveness and safety of enteral nutrition

    • Documenting all aspects of enteral nutrition therapy, including assessments, formula selections, monitoring results, and any adjustments.

Care Provision

Per current guidelines for all MNT delivery at Nourish, RD will follow ADIME in the evaluation/ assessment and ongoing care of patients on nutrition support.

In-Scope Interventions

Referral and Intake:

• Receive and review referral documentation

Nutritional Assessment and Monitoring:

• Assess a patient’s nutritional status and needs

  • Conduct a comprehensive nutrition assessment including dietary history, anthropometric data, biochemical data, clinical status, and current order for nutrition support 

  • Discuss patient's understanding, preferences, and goals related to TPN/enteral support.

• Monitor patient’s nutritional intake and status during nutrition support

Developing and Implementing Nutrition Care Plans:

• Create individualized nutrition support plans, including enteral &/or parenteral nutrition regimens

• Adjust nutrition plans based on patient progress and response, and in coordination with the provider who wrote the order or who referred the patient for recommendations and management of TPN/enteral support. 

Patient and Caregiver Education:

• Educate patients and caregivers about techniques, maintenance, and troubleshooting

• Provide guidance on the proper handling and administration of nutrition support products

How to Use the Nourish Standard Working Order Form

If a provider is referring a patient for recommendations of enteral support and you would like to assist by making those recommendations on an order form you can follow the steps outlined below. In addition to using this form for nutrition support, RDs can use it to make recommendations for oral nutrition supplements (e.g., Boost, Ensure) and submit to a patient's external provider for approval and insurance coverage.

1. Identify Referral and Need for Nutrition Support

• The RD confirms the patient has been referred for enteral nutrition support and management.

2. Review Referral Details

• The RD checks whether this is an initial order requiring the establishment of care with an enteral supplier or an existing order where the patient already has an established supplier. This can be determined by reviewing the referral details from the provider and/or the patient.

• If the patient has an established enteral supplier, include the supplier’s name and fax  number on the order.

• For initial orders, the RD can either recommend a supplier (if preferred by the patient or RD) or leave this section blank.

3. Complete Enteral Order Form

• The link for the 'Nourish Enteral Order Form' is located in internal resources in the Provider Portal. The RD creates a new copy and fills in the relevant patient information from the chart note to complete the form. A new order is suggested anytime there are recommended changes to the patient’s method of administration, formula type, or total formula amount. Adjusting amounts and timing does not require a new order if the total amount of formula recommended per day is not changing.The RD is not required to sign this form; the signature section is designated for the referring provider to approve the orders.

Recommendations for Specialty Formula 

• When recommending a specialty formula (e.g., diabetic, renal, semi-elemental, or elemental), include detailed justification. This should explain why a standard formula is not appropriate, such as symptoms or signs of intolerance (e.g., bloating, diarrhea, or nausea) or clinical conditions that necessitate a specialty formula.

Recommendations for Feeding Pump

• When recommending a feeding pump, provide detailed reasoning to support the recommendation. Examples include symptoms or signs of intolerance to bolus or syringe feeding (e.g., vomiting, discomfort), the presence of a J-tube, high aspiration risk, or other clinical considerations requiring continuous feeding.

4. Upload SWO to Patient's Documents in Provider Portal

• To upload the document to the provider portal, follow these steps:

• Navigate to the 'Documents' section.

• Click on 'Patient Documents.'

• Select the 'Upload' button to upload the necessary document from your computer.

• Once uploaded, the document will be accessible in the patient’s file within the portal.

• After uploading, please make sure to delete the document from your computer to maintain HIPAA compliance and safeguard patient confidentiality.

5. Email Enteral Order to Support

• The RD emails support@usenourish.com requesting that the 'Nourish Enteral Order Form' be faxed to the referring provider. The email should include:

  1.  The name of the referring provider

2. Patient ID or profile link [you can click the square icon next to the patient's name in their Nourish profile to copy their patient ID or you can copy the website URL to the patient's profile]

3. PDF copy of the completed enteral order form

• Note that the RD should not be sending anything directly to the enteral supplier unless they are included on the patient's ROI.

6.Support faxes to Referring/Prescribing Provider

• The Support team will fax the order to the referring provider, or the prescribing provider listed on the patient’s ROI. The provider will review, sign, and fax the order to the supplier to fill the order.

Collaborate with Healthcare Team:

• The prescriber is responsible for determining the appropriate type, composition, and dosage of the nutrition support based on the patient's medical condition and nutrition needs.

• The RD communicates regularly with the patient's healthcare team to coordinate care and make adjustments to the nutrition plan as needed.

• If RD has recommendations for order modifications these should be documented in the Intervention section of the note.

• In the case the patient’s provider that wrote the nutrition support order is not the referring provider, the RD should ensure that they are listed on the ROI.

• If the patient claims to not have any providers, the RD should follow steps in Emergent Care Coordination SOP to secure a provider for care coordination of a tube feed or TPN patient.

Manage Complications Related to Nutrition Support:

• Identify and address nutrition-related complications such as tube clogging, feeding intolerance, and metabolic imbalances.

• Provide recommendations for managing side effects and optimizing nutrition delivery.

Documentation 

RD’s are required to follow charting best practice as outlined in training here.

When documenting the intervention section of a chart note for nutrition support, it is essential to provide clear, concise, and actionable details that reflect the care provided and the rationale for decisions made. The following elements are typically required:

1. Specific Nutrition Interventions

Route of Nutrition Support: Enteral (e.g., tube feeding) or parenteral (e.g., IV nutrition). Specify the type and mode of delivery (e.g., continuous, bolus) and the type of access (e.g., PICC, PEG tube).

Formula/Regimen: Include the name, composition, and rate of the formula or solution (e.g., polymeric, elemental, kcal/mL, protein content).

Goals: Specify calorie, protein, and fluid goals based on assessment and calorie, protein, and fluid provided from PN/EN at goal rate.

2. Monitoring Plan

Parameters: Identify what will be monitored (e.g., weight, labs like electrolytes, glucose, BUN, creatinine, albumin).

Frequency: Include how often parameters will be monitored (e.g., daily, weekly).

Adjustments: Note when or how adjustments to the regimen will be made (e.g., titration of rates or formula changes based on tolerance).

3. Patient Tolerance and Considerations

Tolerance: Document any information about the patient’s tolerance of nutrition support, including gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea, constipation).

Special Considerations: Include considerations for comorbidities, allergies, or preferences affecting the intervention (e.g., low electrolyte formula for refeeding syndrome risk).

4. Education and Collaboration

Education Provided: Include any teaching done with the patient or caregivers about the intervention (e.g., tube feeding instructions, pump setup).

Interdisciplinary Collaboration: Note communication or coordination with the care team (e.g., provider, pharmacist, case manager).

5. Justification

Medical Necessity: Clearly explain the reason for nutrition support, especially if it involves insurance or prior authorization (e.g., "Patient unable to meet nutrition needs orally due to dysphagia"). Include specialty formula and/or pump justification if indicated.

6. Follow-Up Plan

Include when the patient will be reassessed or when changes will be reviewed (e.g., "Reassess tolerance and labs in 1 week").

Here is a suggested smart phrase example template you can use to document your recommendations

Out of Scope Interventions

Prescribing:

• Nourish RDs cannot prescribe TPN, tube feeding orders, medications or alter medication regimens.

Performing Medical Procedures:

• Nourish RDs cannot insert feeding tubes or performing any invasive medical procedures.

Diagnosing Medical Conditions:

• Nourish RDs cannot make medical diagnoses or interpret diagnostic tests beyond their nutrition implications. 

Making Independent Medical Decisions:

• Nourish RDs cannot make medical decisions without consulting the appropriate medical professionals (e.g., care team members).