The Brigham and Women's Hospital Inpatient Clinical Nutrition Service provides nutritional care and education to all patients and families admitted to the Brigham.
At BWH, the licensed registered dietitians (RDN) work in teams. The patient care load is divided into 4 teams. The teams are lead by Team Leader Dietitians, who are Certified Nutrition Support Dietitians (CNSD). The CNSD is especially trained in the assessment and care of the forced fed, metabolically compromised patient. Our nutrition care is integrated with the Nutrition Support Service (NSS) to ensure expert nutritional interventions for the most complex nutritional deficiencies.
The Team Leader Dietitian and the NSS physicians meet 3 times per week to consult on new patients and review nutrition plans on current parenterally fed patients. An integrated note signed by both the NSS Physician and the Team Leader Dietitian is documented in the medical record. The NSS Physician and Team Leader Dietitian have the responsibility of approving or disapproving all new parenteral nutrition orders and any new order for anabolic steroids. If an order is not approved, the NSS physician or dietitian notifies the ordering physician, explaining the reason for non-approval, and offers alternative recommendations.
Daily monitoring of enteral and parenteral feedings is completed by the dietitian to ensure adequacy of intake and to make additional recommendations for advancement or modification of the feeding. The dietitians calculate and record all information pertaining to parenteral, enteral and oral intake in the medical record. The dietitians document on-line in a note that has been specially designed for their use only. The note details objective criteria, classification of malnutrition, and assessment/recommendations for medical nutrition therapy.
The dietitians attend work rounds with the house staff. They are assigned patients by physician team or service line to ensure effective communication and continuity of patient care throughout the patient's hospitalization.
Patients admitted to the hospital are screened for nutritional risk as part of the Nursing assessment. Once a patient is identified by the nurse, the dietitian assesses the patient and determines the level of risk and complexity of assessment, including: age; diagnosis/procedure or treatment; NPO/enteral status; metabolic/mechanical problems; height/weight changes; and laboratory values. A formal physician referral is not required for nutrition assessment.
Patients are educated on their modified diet prior to discharge. The dietitians educate patients and families in individualized sessions. The Dietitians are actively involved in the discharge process of the patients. Any patient being discharged to home or a facility on enteral or parenteral feedings is educated by the dietitian prior to discharge. The Dietitian completes a "Discharge Nutrition Care Plan," which is distributed to the primary care MD and home care company.
We also staff our Newborn Intensive Care Unit (NICU) with 1.5 FTE dietitians. They are responsible for the screening, assessment, daily monitoring and nutritional discharge plan for all infants in the NICU.
The dietitians participate in many nutrition related rounds and conferences. Each week the dietitians and dietetic interns assigned to clinical rotations attend NSS patient care rounds for 1 hour. During this time the dietitians present challenging and interesting cases to the NSS Attending Physician for discussion and further recommendations.
Gastrointestinal and Surgical ICU fellows rotate through the Nutrition Service and present cases and presentations at rounds. Journal Club, led by one of the clinicians, is once per month. Bimonthly the dietitians attend Teaching Rounds which include outside speakers who present different aspects of nutritional management. Monthly, the dietitians attend Longwood Medical Rounds. These rounds are organized by Harvard Medical School and the Nutrition Departments of the hospitals in the Longwood Medical Area (Brigham and Women's, Children's Hospital, and Beth Israel-Deaconess Medical Center). National and local experts in nutrition present their latest research or clinical expertise to the dietitians at Longwood Rounds.
Kathy McManus, MS, RDN
Kathy McManus, MS, RDN, LDN
Director, Department of Nutrition
Brigham and Women's Hospital
75 Francis Street
Boston, MA 02115
Phone: 617-732-5577
email: kmcmanus@bwh.harvard.edu
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