The “Other” Professional

Beth E Taylor, MS, RD, LD, CNSD, FCCM
Barnes-Jewish Hospital
St. Louis, Missouri, USA

The critical care dietitian focuses on finding the safest and most effective route of nutrition support for the ICU patient and on the composition of that nutrition support.

Critical care dietitians are proud to be among the social workers, clergy, occupational therapists, physical therapists, speech therapists, physician assistants, etc. who comprise the “other” category, but they should be recognized for their day-to-day involvement in patient care. Over the last two decades, critical care dietitians’ scope of practice has evolved into one that defines them as clinicians, educators and researchers with specialized skills in nutrition and metabolic support of critically ill patients.

Every year, more and more dietitians undergo specialized training (e.g., certified nutrition support dietitian–CNSD) and join multiprofessional nutrition support societies (e.g., American Society of Parenteral and Enteral Nutrition) as well as international critical care organizations such as SCCM. During SCCM’s 2004 Congress, a critical care dietitian became the first in that profession to become a Fellow in the American College of Critical Care Medicine. This recognition acknowledges the critical care dietitian as a vital member of the intensivist-led multiprofessional team.

Participating in daily multiprofessional rounds allows the critical care dietitian to give timely input on a patient’s macro- and micronutrient needs, appropriate route and timing of nutrition support, optimal nutritional access, fluid and electrolyte issues and blood glucose control. In teaching hospitals, the critical care dietitian participates in the education of students, interns, residents and fellows from several disciplines through experiential intensive care unit (ICU) rotations.

Nutrition support is recognized as an important component of care for the critically ill patient. In 2002, the American Society of Parenteral and Enteral Nutrition (ASPEN) updated its standards of practice for specialized nutrition support.1 The Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated Critically Ill Adult Patients followed in 2003.2 Presently, an SCCM committee is developing international guidelines for nutritional support of the critically ill patient. Dietitians are members of these and other important multiprofessional committees.

A fair amount of literature related to nutrition support of critically ill patients is published yearly. It is the dietitian’s responsibility to read these studies critically, to evaluate the efficacy of their results and to report the findings to the ICU team. Critical care dietitians also participate in research in this area. Four recent studies led by dietitians have helped to answer the question, “how accurate are our caloric and protein estimates in critically ill patients?”3-6 This is an important issue because malnutrition in critically ill patients can increase morbidity and mortality.

The critical care dietitian focuses on finding the safest and most effective route of nutrition support for the ICU patient and on the composition of that nutrition support. At present, there are controversies in this area with regard to critically ill patients. A dietitian who is well versed in the current literature and patient assessment will be an asset to the ICU team when deciding on the best option for patient care.

In this era of defined protocols for consistent, safe, high-quality care in the ICU, critical care dietitians are doing their part. They have championed nutrition support protocols for feeding route, nutrient requirements, advancement of feeds and continual monitoring for several patient types.3, 4, 7, 8 They have also ventured into new areas, leading multiprofessional teams that developed protocols for electrolyte repletion and glycemic control.9, 10 Several certified nutrition support dietitians (CNSD) practicing in the ICU have increased their technical skills as well, demonstrating expertise in the placement of small bowel feeding tubes at the bedside in critically ill patients.11-14 This has cut the cost and the risk of transporting critically ill patients to the radiology department for tube placement, as well as decreasing the inappropriate use of parenteral nutrition. By providing expert nutritional advice and technical skill, critical care dietitians can decrease costs associated with nutrition support in ICU patients while improving patient safety.5, 15, 16 It would behoove hospitals to promote their inclusion on the ICU multiprofessional team by providing the necessary resources, including salary support.

Much of what critical care dietitians have achieved might not have occurred without the institution of the intensivist-led ICU team. In this atmosphere, they have been encouraged to expand their knowledge and technical skills. Hopefully, critical care dietitians will leave the “other” category behind one day soon and become an integral component of the ICU team.