Past President Letter in Critical Care Medicine

July 11, 2022 - A letter to the editor from Past President Kevin L. Sauer (2021-22), PhD, RDN, LD, FAND, replying to an article in the December 2021 issue of the journal Critical Care Medicine regarding the role of registered dietitian nutritionists on the critical care interdisciplinary team, was published in CCM's July 2022 issue. The text of the letter is below; a subscription is required to access the published letter.

To the Editor:

I am writing regarding the article in the December 2021 issue of Critical Care Medicine titled "The Society of Critical Care Medicine at 50 years: Interprofessional practice in critical care: Looking back and forging ahead." Registered dietitian nutritionists (RDNs) value interprofessional collaboration; however, the article lacks a recognition of their crucial role and expertise on the critical care interdisciplinary team, specifically with inclusion in Table 2.

The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition have jointly written the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient and Expert) in Nutrition Support. This Standards document highlights how RDN's execute their role on the critical care interdisciplinary team with a valuable depth of nutrition knowledge. Specifically, RDNs provide: "expertise on the identification of risk or presence of malnutrition, macro- and micronutrient requirements, type of nutrition support therapy (e.g., enteral or parenteral) and appropriate nutrition support access and route (e.g., nasogastric vs nasojejunal or tunneled catheter vs port)."; a thorough nutrition assessment that leads to a nutrition intervention/plan of care and nutrition monitoring and continued evaluation (see figure 2); and "...have the knowledge, skills and experience in the application of principles and guidelines in delivering nutrition support, along with general knowledge of all potential comorbidities of a patient/client, in order to appropriately address and provide quality nutrition care and services..."

The Critical Care Medicine article did note in the Overview that the ICU interdisciplinary team consists of clinicians who, while each contributing a unique expertise, collaborate to provide the best possible patient outcomes and "dieticians and dietician/nutritionist's" are mentioned. However, the important work of critical care dietitians has been demonstrated for numerous disease states, including heart failure; cystic fibrosis; COPD; and COVID-19 (also https://pubmed.ncbi.nlm.nih.gov/32799322/).

In addition, the Institute of Medicine's Committee on Nutrition Services for Medicare Beneficiaries has noted:
"The provision of nutrition support is optimally managed by a multidisciplinary team consisting of a physician, dietitian, pharmacist and nurse who work together to recommend, initiate and monitor enteral and parenteral forms of nutrition... The dietitian is the main advocate for nutrition therapy in the overall care plan and understands how nutrition therapy relates to other forms of treatment."

The Scope of Practice for the RDN notes: RDN's "(work) within the interprofessional team and with the patient/client and family and/or advocate on nutrition-related aspects of a treatment plan, including risks/burdens of nutrition intervention; participate in interprofessional rounds; provide MNT [medical nutrition therapy]; and conduct nutrition education, counseling, discharge planning and care coordination and management to address prevention and treatment of one or more acute or chronic conditions or disease.”

I hope this information clarifies the important part the RDN plays as a key team member in the ICU working to improve patient outcomes. We are requesting that you publish this letter to adequately outline and recognize the RDN’s vital role to individualized critical care in the ICU.