By: James W. Schurr, PharmD Candidate c/o 2014
Nutrition Support Pharmacy is a specialized practice pertaining to the needs of patients receiving Parenteral (PN) or Enteral Nutrition (EN). Nutrition Support Pharmacists (NSPs) are integral members of the nutritional support team and bring valuable skills and knowledge to the clinical practice setting. The Board of Pharmacy Specialties (BPS) recognizes Nutrition Support Pharmacy as a practice with a certification examination and the designation of Board Certified Nutrition Support Pharmacist (BCNSP). NSPs have active responsibility in direct patient care and promoting the maintenance or restoration of optimal nutrition status as well as designing and modifying treatment regimens according to individualized needs of the patient.1 Furthermore, the American Society of Health-System Pharmacists (ASHP) recognizes and accredits Postgraduate Year Two (PGY2) pharmacy residencies in Nutrition Support. Three programs are listed in the ASHP residency directory; they include Emory Healthcare (located in Georgia), the University of Arizona Medical Center, and the University of Wisconsin Hospital.2
The American Society outlines the standards of practice for Nutrition Support for Parenteral and Enteral Nutrition (ASPEN) and details guidelines for NSPs3. ASPEN guidelines list eight key components of practice including nutrition assessment; development and implementation of the nutrition care plan; compounding the feeding formulation; monitoring parameters and management of nutrition support services; advancement of Nutrition Support Pharmacy practice; research; and ethics. A survey of Nutrition Support Pharmacists revealed areas of knowledge most important to their practice (Table 1).
|Key Knowledge areas of Nutritional Support Pharmacists 4|
|Laboratory tests and findings used to assess nutrition status||Pharmaceutical calculations used in compounding feeding formulations|
|Effects of disease states on nutrition status and vice versa||Guidelines for the parenteral admixture compounding and dispensing|
|Effects of medical and surgical therapies on nutrition status||Compatibility and stability of PN formulations|
|Knowledge of disease states affecting ingestion, digestion, absorption, metabolism, and elimination of nutrients||Therapeutic considerations for the co-administration of medications and PN formulations|
|Indications or contraindications for the use of parenteral nutrition (PN) products and feeding formulations||Knowledge of fluid, electrolyte, and acid-base balances|
|Composition of PN products||Metabolic, nutritional, and clinical responses to specialized nutrition support|
|Indications / contraindications for methods of administering PN formulations||Metabolic complications of specialized nutrition support|
|Infectious complications associated with specialized nutrition support||Methods used to prevent and manage metabolic complications associated with specialized nutrition support|
|Methods used to prevent infectious complications associated with specialized nutrition support||Sources of information regarding compatibility and stability of PN and EN formulations|
The NSP’s role in nutrition assessment involves collaboration with other healthcare professionals to identify patients who are either malnourished or at risk of becoming malnourished. This identification is accomplished through patient interviews, medical record and history reviews (i.e. therapies, laboratory findings, and physical assessments that may factor into their nutritional status), biochemical assessment, and record documentation. The assessment of nutrient requirements involves calculations of daily energy and protein requirements as well as caloric distribution between fats, carbohydrates, and proteins. Vitamins, minerals, fluids, and electrolytes should also be assessed in this process. The NSP is ideal to assessing possible drug-nutrient, nutrient-nutrient, or drug-drug interactions that may be detrimental to nutrition support therapy. Pharmacoeconomic considerations are also made during nutrient assessment in efforts to curb costs and determining the appropriateness of certain Nutrition Support therapy paradigms.2
The nutrition care plan includes an interdisciplinary and evidence-based approach that addresses the goals, communication considerations, route and formulation selection, and nutritional support access needed for each patient.5 During the establishment of the nutrition care plan, the recommendations for a patient-specific formulation, pharmacologic adjuncts to nutrition support (i.e. H2 antagonists, is made by the NSP.2 The selection of the route of administration involves clinical factors requiring astute judgment by the nutrition support team. The NSP should provide insight into the decision, utilizing pharmaceutical knowledge in conjunction with clinical practice guidelines and algorithms, such as those provided by ASPEN.5
Compounding formulations for nutrition support therapy is an area of practice in which the NSP is uniquely qualified to provide both clinical decision-making and physical product preparation. Nutrition support can be provided as either enteral or parenteral formulations, both in which the pharmacist plays an active role. As previously mentioned, the survey of NSPs showed that approximately 95% of compounding activities were related to parenteral formulations and only 5% to enteral formulation.4 Parenteral nutrition (PN) support preparations are compounded, prepared, and stored according to United States Pharmacopoeia chapter <797>: Pharmaceutical Compounding-Sterile Products.6 The NSP is also integral in developing policies and procedures for the compounding of PN preparations that include aseptic technique, recommended safe practices, methods for detection and/or prevention of formulation incompatibilities or instabilities, and staff education and training.3 Moreover, NSPs are involved in preparation of enteral nutrition (EN) formulations in providing proper training to personnel, utilization of aseptic technique, and clinical judgment in modifications to formulation.5 In addition, automated compounding devices should be monitored by the pharmacist with proper adherence to guidelines. 7
The NSP participates in monitoring activities for their patients and include nutrient intake, tolerance of therapy, inspection of feeding formulation, laboratory parameters monitoring pertinent to clinical and nutritional status, changes in nutrient requirements, organ function, pharmacotherapy, gastrointestinal tract function, weight and growth rate, and fluid balance. The pharmacist uses these findings to participate in the follow-up plan for the patient’s therapy. The efficacy of the nutrition support therapy chosen for the patient must be evaluated throughout the duration of treatment including both parenteral and enteral orders and any complications that arise.2 Frequency of monitoring depends on severity of illness, level of metabolic stress, and degree of malnutrition.8
Management of nutrition support services is yet another administrative function of the NSP. Activities involve the development, documentation, and review of organizational policies, protocols, and procedures. Ensuring continuity of care for patients through all levels of healthcare is an important role of the pharmacist requiring administrative skills and the ability to serve as a liaison between the nutrition support team and other medical teams while maintaining professional relationships in order to facilitate communication and workflow. Development and maintenance of a nutrition support formulary is a key role of the NSP in providing appropriate care for patients that is also cost-effective for the health system.2 Pharmacist-to-pharmacist communication is another essential process for the continuity of care in terms of discharges to other care setting.5
Advancement and professional progress of nutritional support is achieved through participation in interdisciplinary teams, education of colleagues and students, participating in research activities, professional organization affiliations, and maintenance of ethical code. Evidence based research is a cornerstone of practice for NSPs. Active participation in research in paramount in identifying nutrition related clinical problems and methods of resolution. In addition, participation in research committees, analyzing research for application, developing research based policies and protocols, education of others, and participating in data collection are key aspects of professional growth.2
Nutrition Support Pharmacy has been a recognized specialty area of practice by the Board of Pharmaceutical Specialties since 1988. It continues to be an area in which clinical pharmacists provide exceptional patient care. Professional organizations such as ASPEN recognize the important value of the Nutrition Support Pharmacist as a part of the nutrition support team evidenced by pharmacist inclusion into practice guidelines.2,5 With the advancement of clinical pharmacy practice, NSPs have established themselves as invaluable clinicians in improving outcomes for patients in need of nutrition support therapy.
- Nutrition Support Pharmacy. Board Certified Specialties. Board of Pharmacy Specialties, n.d. Web. Accessed 15 Aug 2012. http://www.bpsweb.org/specialties/nutrition.cfm
- Online residency search directory. American Society of Health-System Pharmacists. Accessed 15 Aug 2012. http://accred.ashp.org/aps/pages/directory/residencyProgramDirectory.aspx?pageno=1
- Rollins C, Durfee SM, Holcombe BJ, et al. Standards of practice for nutrition support pharmacists. Nutr Clin Pract. 2008;23(2):189—94.
- Holcombe BJ, Thorn DB, Strausburg KM, et al. Analysis of the practice of nutrition support pharmacy specialists. Pharmacotherapy. 15(6):806—13.
- Ukleja A, Freeman KL, Gilbert K, et al. Standards for nutrition support: adult hospitalized patients. Nutr Clin Pract. 2010;25(4):403—14.
- Pharmaceutical compounding – sterile preparations (general information chapter 797). In: The United States pharmacopoeia, 30th rev, and the National Formulary. 25th ed. Rockville MD: The United States Pharmacopeial Convention; 2007: 334—51
- American Society Health-System Pharmacists. ASHP guidelines on the safe use of automated compounding devices for the preparation of parenteral nutrition admixtures. Am J Health-Syst Pharm. 2000;57:1343—8
- ASPEN Board of Directors and the clinical guidelines task force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26:1SA—138SA