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A Team in the Shadows
Experience and science have guided the Parenteral-Enteral Support Service in the evolution of nutritional medicine.

blank From left, nurses Beth McGuire and Sandy Hebert finalize a discharge plan for home parenteral nutrition.
From left, nurses Beth McGuire and Sandy Hebert finalize a discharge plan for home parenteral nutrition.

Hospital food may be the easy target of jokes, but when patients can’t eat solid food because of an accident, surgery or disease, nutrition becomes serious business. Take the case of one of dietitian Trisha

Brown’s recent GI surgery patients. Despite his inability to eat solids, his body still needs calories, protein and fats to heal, build tissue and fight infection. Good nutrition is as essential as any treatment. 
Brown’s patient needs a highly calculated formula. But there are surgical complications to consider, tubes to be placed and monitored, and formulas whose fiber or glucose or lipid concentrations need to be constantly adjusted.

Overseeing each step is the Parenteral-Enteral Support Service in the Department of Surgery, which has been delivering nutrition support to patients for the past 25 years.

“They’re one of those groups sort of in the background,” says Hopkins oncologist Georgia Vogelsang. “People don’t truly know what they do. But without them, there would be chaos.”

Working closely with the medical and surgical providers, the team determines what type of nutrition is best for patients. Depending on their circumstances, they might receive the formula through a tube that enters either directly into their GI tract (enteral feeding) or into a major vein (parenteral feeding).  

“The team members have a tremendous knowledge base,” Vogelsang adds. “Most health care professionals understand the basics of nutrition, but they need the specifics of how to adjust and manage for their patients.”

Vogelsang understands the service intimately. She is also one of its patients and has been on home-based nutritional therapy for more than seven years. That level of follow-up care is part of what sets the service apart. Last year, the team cared for more than 2,000 patients and worked up discharge plans for 1,200. “People underappreciate how hard they work to get people home even when they have fully complicated issues,” says Vogelsang.

“They’re willing to go that extra mile.”

“We often see patients from admission through their critical or acute illness through their recovery and then while they’re home,” says nurse Sandy Hebert. “That’s a big journey from beginning to end for some patients.”

There is a bit of detective work involved for the four dietitians, three nurses, nurse manager, nurse practitioner, physician and administrative assistant who make up the team. Each morning at rounds, some will flesh out new strategies and analyze old ones. Others might discuss how to keep a diabetic patient off insulin injections but on nutrition support, or the latest research on the early indicators of toxicity, immunosuppression or liver dysfunction that parenteral nutrition can cause in some patients. Meanwhile, the team also focuses on maintaining a good quality of life for patients.

“It’s a real balancing act,” explains nurse practitioner Renay Tyler. “For every disease process, there is a little different approach. It may be better for a surgical patient to recover from the stress of a procedure before feeding, but a neuro-trauma patient needs immediate nutrition to help recovery. You need a team tuned into all that.”

Some team members, like Hebert and fellow nurse Beth McGuire, have been with the team nearly since its inception 25 years ago, growing as their specialty has evolved. In the beginning, for example, how and when to feed a patient was based more on experience than science. But in recent years, the team has presented at national meetings and helped to move nutritional medicine to clearer, evidence-based methods.

“The biggest change has been change,” says nurse manager Bev Reynolds. “The most important contribution to come from that change is the continuity of care we can offer our patients and an expertise that no one else has.”          

— Michele McFarland



Johns Hopkins Medicine

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