Nutrition support is the provision of nutrients via a tube placed into the stomach or small intestine, or intravenously for patients who are unable to eat adequately when provided a normal diet. These two types of nutrition support are called enteral nutrition and parenteral nutrition.
- Learn More - What is Enteral Nutrition? (American Society of Parenteral and Enteral Nutrition)
- Learn More - What is Parenteral Nutrition? (American Society of Parenteral and Enteral Nutrition)
Enteral and parenteral nutrition are usually administered to patients for short periods of time in the hospital, but are occasionally needed for extended periods of time for patients at home or in long-term care facilities.
At Cleveland Clinic, nutrition support is provided by highly specialized teams of clinicians to both inpatients and outpatients.
Cleveland Clinic's Nutrition Support Team (NST) was established in 1975 by Dr. Ezra Steiger. Dr. Steiger trained at the University of Pennsylvania in Philadelphia with Drs. Harry Vars, Jonathan Rhodes, and Stanley Dudrick who were credited as one of the leading groups involved with the development of parenteral nutrition.
The original NST at Cleveland Clinic included a general surgeon, nurse, pharmacist, and dietitian, but eventually grew into one of the largest and longest-tenured multidisciplinary teams in the world. An early milestone for the NST occurred in 1976 when it discharged its first patient home with parenteral nutrition. This led to the development of the Cleveland Clinic Home Nutrition Support Service (HNSS) which is currently one of the largest, single-institution providers of home parenteral nutrition and intravenous fluids in the U.S.
Another milestone for NST occurred in 2008 with the addition of Dr. Donald Kirby as Director, Center for Human Nutrition. Dr. Kirby came from the Virginia Commonwealth University Medical Center where his many areas of specialty included enteral access, malabsorption, and nutrition support.
The NST is recognized as a national and international leader in the field of nutrition support and its members have conducted multiple research studies, authored numerous publications in scientific journals, presented countless lectures, and held many leadership positions in local and national professional organizations.
Department Contact Info:
9500 Euclid Ave/ TT2
Cleveland, OH 44195
Meet Our Clinicians
Robert DeChicco, MS, RD, LD, CNSC
Kathy Logan Coughlin, MS, RD, LD, CNSC
Andrea K. JeVenn, RD, LD, CNSC
Amy Nishnick, RD, LD, CNSC
Christy Hummell, MS, RD, LD, CNSC
Diane Nowak, RD, LD, CNSC
Desiree Gordillo, MS, RD, LD, CNSC
Mary Rath, RD, LD, CNSC
Bethany Benesh, RD, LD, CNSC
Christan Bury, MS, RD, LD, CNSC
Alyssa Paglia, RD, LD, CNSC
Ashley Ratliff, MS, RD, LD, CNSC
Elizabeth Gallant, RD, LD, CNSC
Brian Dubiel, RD, LD
Marie (Dorothy) Emery, RN
- Recommendations for appropriate nutrition support access and care
- Management of electrolytes / fluids
- Dietitians specialized in nutrition-focused physical exams and assessment
- Physician led daily bedside rounds on hospitalized patients needing parenteral nutrition
- Coordination of services with physicians, Gut Rehabilitation and Transplant, Home Parenteral Nutrition clinicians, Home Health Care, and other multi-disciplinary services
- Placement of small bowel feeding tubes
- Provision of parenteral nutrition education to GI fellows, ICU residents, pharmacy residents, dietetic interns, visiting dietitians
Statistics / Accomplishments
- More than 11,000 bags of TPN written last year (2011) by the Nutrition Support Team
- Over 1,200 consults for parenteral nutrition in the hospital during 2011
Publications & Research
- Dowhan L, DeChicco R. Developing and Implementing Competencies for Nutrition Support Dietitians. Support Line 2011:33(6):21.
- Moccia L, DeChicco R. Abdominal Examinations: A Guide for Dietitians. Support Line 2011:33(2):16-21.
- Austhof SI, Habib MA. Parenteral Feeding in Diabetes Patients. Today’s Dietitian 2011:13(12):44-7.
- Logan K, Austhof S, Hamilton C, Nutrition Support: Indications and Efficacy. In: The Dietitian’s Hand book of Enteral and Parenteral Nutrition. 3rd Edition. Skipper A (ed.) pp22-45. Jones and Bartlett Publishers, Inc. 2011.
- Rivera R, Campana J, Hamilton CH, Lopez R, Seidner DL. Small Bowel Feeding Tube Placement Using an Electromagnetic Tube Placement Device: Accuracy of Tip Location. JPEN. 2011:35(5):636-42.
- DeChicco R, Neal T, Guardino J. Developing an Education Program for Nutrition Support Teams. Nutr Clin Pract. 2010:25:481-9.
- Rhoda KM, Chhatriwalla EG, Parekh NR. Transitional Feeding: Challenges and Approaches. Support Line. 2008:30(4):21-28.
- DeChicco R, Seidner DL, Brun C, Steiger E, Stafford J, Lopez R. Tip Position of Long-Term Central Venous Access Devices Used for Parenteral Nutrition. JPEN. 2007:31(5):382-7.
- Parekh NR, McCrae JA. “Parenteral Nutrition” Lysen L. (Ed.) Quick Reference to Clinical Dietetics, 2nd ed. Jones and Bartlett Publishers, Inc., Sudbury, MA, 2006.
- Gasser E, Parekh NR. Parenteral nutrition: Macronutrient composition and requirements. Support Line. 2005;27(6):6-12.
- DeChicco R, Austhof S, Rivera R, Speerhas R, Corrigan M, Steiger E. Type and Prevalence of Adverse Events During Cycling Process in Patients Being Prepared for Hospital Discharge on Parenteral Nutrition. Presented at the American Society for Parenteral and Enteral Nutrition Clinical Nutrition Week, Vancouver, Canada, 2011.
- Rhoda K, DeChicco R. Support Knowledge of Physicians and Dietetic Interns Before and After a Comprehensive Training Program by a Multidisciplinary Nutrition Support Team. ASPEN, Las Vegas February 2010 - Clinical Nutrition Week
- (Roundtable) Emery M. Guide Patients in the Selection of Their Vascular Access Device for the Home Parenteral Nutrition Patient. ASPEN Clinical Nutrition Week, Las Vegas, NV 2/2010.
- (Podium) DeChicco R. Documenting Severe and Non-Severe Malnutrition: A Hands-on Approach. Nutrition-Focused Physical Assessment. Pre-FNCE Workshop. San Diego, CA, 9/24/11
Nutrition Support Team Handbook
3rd Edition, 2010
Kathy Logan Coughlin, MS, RD, LD, CNSD
Robert DeChicco, MS, RD, LD, CNSC
Cindy Hamilton, MS, RD, LD, CNSD
Learn from leaders in the field
The Nutrition Support Team Handbook is an ideal resource for medical professionals who are seeking a comprehensive resource on nutrition support practices. This handbook has been newly updated and expanded in 2010 to include the most recent standards of practice from ASPEN/SCCM Guidelines for Adult Critically Ill Patients and the Canadian Clinical Practice Guidelines, as well as a new section on intestinal rehabilitation and small bowel transplantation.
- Comprehensive Nutrition Assessment
- Estimating Nutritional Requirements
- Enteral Nutrition and Access Issues
- Calculating Parenteral Nutrition Prescriptions
- Management of Metabolic Complications Associated with Parenteral Nutrition
- Management of Nutrition Support in the Home Setting
- A New Section on intestinal rehabilitation and small bowel transplantation
- An Expanded Section on Special Disease Considerations in Nutrition Support
PLUS – included free with every order – a Pocket Card Guide for estimating nutritional requirements and calculating parenteral nutrition prescriptions.
Home Parenteral Nutrition
In 1976, Cleveland Clinic created the Home Nutrition Support Service (HNSS), one of the first multidisciplinary programs of its kind in the United States, dedicated to care for patients at home with intestinal failure. High-tech catheters, pumps, and nutritionally complete intravenous fluids were used to safely “feed” these patients outside of a hospital setting. Specialists in these procedures taught patients how to monitor the overnight infusions, prepare the solutions, and care for their catheters while having access to the team professionals 24 hours a day, 7 days a week. Because of the new demand, a Cleveland Clinic home infusion company was established in the 1980’s to provide supplies and services in a more integrated fashion for patients living in Ohio and the surrounding region.
The HNSS has cared for people throughout the United States, as well as from other countries. Since its inception, over 1600 patients have been discharged on home parenteral nutrition (HPN) for reasons most often due to obstructive tumors, Crohn’s disease-related short bowel syndrome, adhesive obstructions, fistulas, and high output ostomies. Now the program has grown to require physicians, dietitians, nurses, a pharmacist, and clerical support to safely provide this complex therapy. HPN may only be required for short periods of time until the medical conditions allow for return to eating and drinking or tube feeding. HPN might also be required for years while still leading healthy, happy, and productive lives. Currently, the HNSS cares for several patients who have required HPN therapy for more than 20 years, and will continue to do so for the rest of their lives.
Department Contact Info
9500 Euclid Ave. TT2
Cleveland, OH 44195
HNSS advocates 24-hour clinician support (available by pager) and infection prevention, not only through optimal catheter-care, but also through the use of ethanol lock technology.
A comprehensive approach is applied to evaluate and care for patients in need of HPN including:
- Physicians to oversee patient care, education, training, and research related to HPN therapy.
- Nutrition Support dietitians perform nutrition assessments, establish individual nutrient needs, assist with determining home-going formulas and help ensure patient wellness and safety.
- The Nutrition Support pharmacist reviews and optimizes parenteral formulas, monitors drug therapy dosing and drug-nutrient interactions, and assists with ensuring proper compounding and compatibility of HPN solutions.
- Nutrition Support nurses provide evaluation and one-on-one training and education of infusion techniques, catheter care, pump operations, and home self-monitoring.
- Case Managers identify insurance benefits and establish homecare pharmacy and nursing services.
- Social Work and Psychiatric Services identify and help with social, emotional, and adjustment concerns.
After a home-going nutrition support formula is established and technical training is complete, patients are discharged from Cleveland Clinic with a visiting nurse who will continue to teach procedures in the home as needed. The HNSS clinicians work closely with home health care services and pharmacies throughout the country, including Cleveland Clinic Home Care. Regular laboratory work, intake and output records, and follow-up appointments with a Nutrition Support Team physician are necessary program components to avoid complications and to optimize outcomes. Dedicated HNSS clinicians attentively coordinate the care of all patients and are available to assist with immediate concerns.
Meet Our Clinicians
Denise Konrad, RD, LD, CNSC
- Title: Home Nutrition Support Clinician
- Education: BS Nutritional Science, Penn State, State College, PA; Dietetic Internship: Cleveland Clinic, Cleveland, Ohio
- Others: Member of Academy of Nutrition and Dietetics
Ronelle Mitchell, RD, LD, CNSC
- Title: Home Nutrition Support Clinician
- Education: MA Physical Education/Exercise Science, California State University, Fresno, CA; BS Food Science & Nutrition, Colorado State University, Fort Collins, CO
- Specialty: Home Parenteral Nutrition, Nutrition Support
- Others: Member of Academy of Nutrition and Dietetics; Member of Dietitians in Nutrition Support Group; Member of American Society of Enteral and Parenteral Nutrition
Statistics / Accomplishments
- Grown to be one of the largest programs of its kind in the world - currently manages 5 times more patients than 10 years ago
- Record number of patients (202) received care with the Cleveland Clinic HNSS in March 2012
- Use of ethanol lock technology has prevented reoccurrence of blood stream infections. Our readmission rate for CRBSI/1000 catheter days is lower than the national average
Research / Publications
- Corrigan M, Pogatschnik C, Konrad D, Kirby DF. Hospital Re-admissions for Catheter Related Blood Stream Infection and Use of ethanol lock therapy: Comparison of Patients Receiving Parenteral Nutrition in the Home versus a Skilled Nursing Facility. (Accepted for publication 3/2012 JPEN).
- Corrigan M, Kirby DK. Impact of a National Shortage of Sterile Ethanol on Catheter Sepsis in a Home Parenteral Nutrition Practice: A Case Series. JPEN.
- Online first available
- Corrigan M. Prevent Catheter Sepsis in Home PN Care. Today’s Dietitian. 2012:14(2)60-62.
- Corrigan M, Kirby DF. Lock therapy update: Role in prevention of catheter related blood stream infections. OSPEN Access. 2011:18(3)1-3.
- Corrigan M. Complications of Home Parenteral Nutrition. Support Line. 2011:33(6)3-12.
- Speerhas RA, Seidner DL. Measured versus estimated aluminum content of parenteral nutrient solutions. Am J Health-Syst Pharm. 2005:64:740-46.
- Chadalavada R, Parekh NR, Lopez R, Summers K, Bolwell B, Steiger E, Seidner DL. Adequate home parenteral nutrition does not improve lean body mass in bone marrow transplantation patients with graft versus host disease. Clinical Nutrition. 2005:24(4):S680.
- Corrigan M, Konrad D, Hamilton C, Steiger E, Kirby DK. Identification and Early Treatment of Dehydration in Home Parenteral Nutrition and Home Intravenous Fluid Patients prevents Hospital Admissions. ASPEN CNW 2012, Florida.
- Speerhas, Rex. Adverse Events During Cycling Process in Patients Being Prepared for Hospital Discharge on Parenteral Nutrition, Clinical Nutrition Week, Vancouver, BC, Jan 27, 2011
- Chadalavada R, Parekh NR, Lopez R, Summers K, Bolwell B, Steiger E, Seidner DL. Adequate Home Parenteral Nutrition Does Not Improve Lean Body Mass in Bone Marrow Transplantation Patients with Graft Versus Host Disease.
- Download a poster
- (Roundtable) Speerhas, Rex. Ethanol Lock to Prevent CRBSI; Clinical Nutrition Week, Vancouver, BC, Jan 28, 2011
- (Webinar) Speerhas, Rex. Blood Glucose Management When Transitioning from Hospital to Home on Specialized Nutrition Support; ASPEN webinar, June 8, 2011
- (Presentation) Speerhas, Rex. Emerging Trends in Parenteral Nutrition; Home Healthcare professionals, Columbia Md., July 21, 2011
Small Bowel Feeding Tube
Enteral access nurses are specially trained to place nasally-inserted small bowel feeding tubes, with the aid of an electromagnetic device. These tubes generally benefit patients who have functioning gastrointestinal (GI) tracts, but are unable to take adequate oral nutrition.
The electromagnetic device enables the nurse to visualize the feeding tube as it travels through the GI tract. This technique can be performed quickly at the bedside without additional sedation, personnel assistance, or cost of repeated radiographs to verify tube placement. This facilitates early enteral nutrition, which promotes healing and decreases hospital length of stay. Enteral access nurses are also specially trained in use of nasal bridles to prevent easy dislodgement of the tubes.
Our enteral access nurses perform more than 180 feeding tube placements monthly and have placed more than 5,000 tubes since the program was established. They are also actively involved in training Nutrition and GI Fellows on placing small bowel feeding tubes and the technique for nasal bridling.
Academy of Nutrition and Dietetics
120 South Riverside Plaza, Suite 2000
Chicago, IL 60606-6995
Toll-free: 800.366.1655 or toll-free 800.877.1600
American Society for Parenteral and Enteral Nutrition
8630 Fenton St., Ste. 412
Silver Springs, MD 20910
The Oley Foundation
214 Hun Memorial, A-28
Albany Medical Center
Albany, NY 12208-3478
American College of Gastroenterology
P.O. Box 342260
Bethesda, MD 20827-2260
American Society for Gastrointestinal Endoscopy
1520 Kensington Rd., Suite 202
Oak Brook, IL 60523