Development of dietetic staffing requirements for adult intestinal failure services using a best‐practice model

Abstract

Background

The number of people diagnosed with chronic intestinal failure (CIF) worldwide is low. The condition is clinically complex to manage and resource intense. Guidance on best‐practice staffing levels is lacking. This paper proposes a methodology for determining dietetic staffing levels for adult CIF to estimate dietetic staffing levels allowing patients access to best‐practice care.

Methods

After undertaking a literature search, a novel method for developing recommended adequate dietetic staffing within adult CIF services was utilized. This included (1) mapping the current patient journey and best‐practice dietetic care throughout the journey, (2) allocating clinical and nonclinical hours at each phase of the patient journey, and (3) calculating percentage clinical time, and (4) finalizing estimated dietetic staffing requirements per patient.

Results

Current literature informed mapping the patient journey and dietetic best practice for CIF. Australian data were included where possible to reflect patient care locally. Direct and indirect clinical hours were allocated to each activity. Allowing for nonclinical activity of 40% for a senior clinician, total hours required to provide best‐practice care per patient was calculated as 0.028 of a full‐time dietitian per adult with CIF. This equates to the management of 36 people with CIF per full‐time dietitian.

Conclusion

Use of a bottom‐up methodology allows calculation of staffing to meet best practice. Proposed dietetic staffing levels obtained from this study are far greater than current allocated staffing within the Australian adult CIF setting. Adequate dietetic resourcing may reduce patient complications and improve quality of life, resulting in enhanced patient and clinical outcomes.

INTRODUCTION

Chronic intestinal failure (CIF) encompasses a large range of complex clinical conditions in which there is inadequate length and/or function of the small bowel to allow fluid and nutrient absorption for normal physiological functioning. ¹ Most commonly, CIF results from multiple resections secondary to Crohn's disease, surgical complications, intestinal dysmotility, or small bowel mucosal disease. ¹ , ² Individuals with CIF have limited treatment options available and rely on nutrition education and support through the use of tailored dietary advice, enteral nutrition, and/or home parenteral nutrition (HPN). Hence, extensive input from the multidisciplinary team is required to manage this patient group, including specialist dietetic involvement. ³

A dietitian with expertise in intestinal failure is pivotal in the management of the patient with CIF to ensure fluid, electrolyte, micronutrient, and macronutrient requirements are met. Nutrition assessment and monitoring of nutrition status guides nutrition interventions and management. Maintaining oral intake is recommended in the majority of patients with CIF but requires detailed and ongoing dietary education ⁴ to ensure adherence. Dietary recommendations need to be tailored and optimized based on individual anatomy and/or underlying conditions. Intensive individualized oral nutrition education has been shown to allow a reduction of parenteral nutrition volume and frequency. ⁴ Enteral nutrition is often used within the dysmotility cohort ⁵ and also where fistuloclysis ⁶ is possible. Enteral nutrition within these patient populations requires specialist knowledge of gut function to ensure the type of feeding, formula, and rate are optimized. ⁷ HPN involves the infusion of fluid, electrolytes, micronutrients, and macronutrients via a central intravenous catheter. ⁸ Parenteral formulas need to meet the changing nutrition requirements of the patient throughout the course of their illness, with careful monitoring and adjustment. ⁷ Hence, although the number of patients diagnosed with CIF is low, dietetic resourcing is essential to optimize all aspects of nutrition care and prevent complications, including electrolyte and fluid imbalance, metabolic disturbances, and macronutrient and micronutrient inadequacies. ³ Although it is well established that the dietitian is a key member of the multidisciplinary team in management of CIF, ⁹ , ¹⁰ there is a lack of guidance regarding adequacy of dietetic staffing in this clinical specialty.

Calculating workforce requirements is challenging. Workforce data are usually calculated per full‐time equivalent (FTE), where one FTE is equivalent to a full‐time clinician working 38–40 h per week. Much of the literature has focused on calculating workforce requirements using a top‐down approach. ¹¹ One top‐down approach that has been used extensively is to calculate workforce staffing profiles based on current activity to staffing ratios. ¹² This method collects data on the number of staff employed within a particular service compared with the number of patients within the service. Within the nursing profession, this method is often used to determine nurse to patient ratios. ¹³ This method is also common when estimating allied health workforce requirements. ¹² Within CIF, a recent Australian survey of current staffing of adult HPN centers has indicated that the majority of centers had no dietetic FTE allocated to manage patients with CIF. ¹⁴ Another top‐down approach is to benchmark against other similar services. This method has been used to assess dietetic staffing requirements in the intensive care unit but often results in large variation. ¹⁵ Workforce profiling and benchmarking methodologies can be useful when estimating hospital‐wide and/or service‐wide workforce or population projections. ¹¹ , ¹² However, there are major limitations to both of these methods, ¹¹ , ¹² , ¹⁶ with the assumption that current staffing levels are adequate to meet service needs and allow patients access to best practice, which is often not the case.

Alternatively, Bam et al. ¹⁶ has proposed a bottom‐up staffing framework to guide the process of determining staffing requirements at a practice level. This is a seven‐step approach assessing time demands at a microlevel. Therefore, the aim of this study is to develop dietetic staffing requirements within an adult CIF service that allows for the provision of best practice. Because of the scarcity of clear guidance on calculating workforce requirements, this paper will propose an adaptation of the Bam et al. ¹⁶ staffing framework.

METHODS

Using an adaptation of the Bam et al. ¹⁶ staffing framework as outlined in Table 1, the following methodology was employed to allow for calculating workforce to deliver best‐practice care for patients with CIF.

Table 1.

Modified seven‐step staffing framework.

Step 16	Modified approach	Actions and/or function
Step 1: Define purpose and focus	Step 1: Define purpose and focus	Define the purpose and focus of the workforce activity. Define the clinical diagnosis and/or illness, health professional, and scope. Is the focus within one specific clinical setting (eg, in‐hospital admission only)? Consider geographic location.
Step 2: Collect basic data	Step 2: Mapping the patient journey	Determine the patient journey across the specified purpose and focus. This may require review of the literature or local data considering length‐of‐stay data, hospital readmission rates, and recommended review schedules.
Step 3: Calculate available time and leave relief	Step 3: Map best practice throughout the patient journey	Determine best practice for the specified health professional across the specified purpose and focus. Determine frequency of identified best‐practice duties. This may require review of the literature, best‐practice guidelines, or expert consensus. Consider direct and nondirect clinical care, such as multidisciplinary activities.
Step 4: Develop task list	Step 4: Allocate time for best practice throughout the patient journey	Determine an allocation of time for each best‐practice duty. This may require review of the literature, best‐practice guidelines, time‐and‐motion studies, expert consensus, or review of local data.
Step 5: Determine activity duration and frequency	Step 5: Determining seniority of the role and accounting for clinical and nonclinical time	Determine the seniority of the position, and determine the percentage of clinical and nonclinical time allocation based on local policy.
Step 6: Calculate required FTE	Step 6: Calculate FTE per patient	Calculate the average hours per year required to provide best‐practice care. Divide by total number of hours of work per 1 FTE per year to obtain FTE per patient.
Step 7: Analyze and interpret results	Step 7: Analyze and interpret results	Analyze results against the current clinical environment, and develop strategies for aligning services with best‐practice recommendations.

Abbreviation: FTE, full‐time equivalent.

Step 1: Define purpose and focus

As highlighted by Bam et al., ¹⁶ the patient group, scope, and purpose of workforce calculations need to be clearly defined. Because of differences across countries, the focus should also be specific to the country and clinical setting.

Step 2: Mapping the patient journey

The patient journey for CIF was mapped using the following information: (1) review of the databases Medline (Ovid), Embase, and CINAHL using search terms and strategies optimized for each database, including combinations of “intestinal failure,” “home parenteral nutrition,” “nutrition assessment,” “dietitian,” and “care pathway,” with limits set to adult patient cohorts with nonmalignant intestinal failure etiologies; and (2) local hospital data. Relevant information specific to the patient journey was gathered, including length of stay for initial hospital admission and HPN training, recommended review schedule on discharge from hospital, hospital readmission rates, and length of stay for readmissions. These data were collated to help determine the expected patient journey for CIF.

Step 3: Map best practice throughout the patient journey

Best‐practice dietetic clinical management (both direct and nondirect patient care) related to assessment, monitoring, and education was added at each point of the patient journey for CIF and was identified using the search strategy outlined for step 2, along with clinical guidelines that were not identified through the literature search. Best‐practice dietetic clinical management was added for parenteral, enteral, and oral alimentation.

Step 4: Allocate time for best practice throughout the patient journey

A dedicated time in hours was allocated to each of the clinical management tasks across the patient journey map. Because of the scarcity of data within the literature and guidelines, local hospital data and author consensus were also used to allocate a set time for conducting best‐practice clinical care.

Step 5: Determining seniority of the role and accounting for clinical and nonclinical time

The seniority of the dietitian and percentage of time allocated for nonclinical duties were determined based on the literature review outlined above, clinical guidelines, author consensus, and local hospital data. Each clinical healthcare position has clinical and nonclinical requirements. Nonclinical activities include completion of mandatory training requirements, undertaking quality, and research and education duties. The percentage of time allocated for nonclinical activities is usually related to the seniority of the position, with more senior positions having a higher expectation to contribute to nonclinical activities. A 52‐week year was used, acknowledging the allocation of annual leave, sick leave, and long service leave, with no backfill of hours during leave.

Step 6: Calculate FTE per patient with CIF

The following equation was used to determine the total FTE required to deliver best‐practice dietetic care per CIF:

$$\text{FTE}\text{per}\text{patient}=\frac{\text{Average}\text{hours}\text{allocated}\text{per}\text{year}+\text{additional}\text{non}-\text{clinical}\text{time}(40\%)}{\text{Total}\text{hours}\text{worked}\text{over}\text{the}\text{year}(7.6\text{hours}/\text{day}\times 5\text{days}/\text{week}\times 52\text{weeks}/\text{year})}$$

Step 7: Analyze and benchmark results

The final step in the Bam et al. ¹⁶ staffing framework is to use the findings to allow for benchmarking at a service or broader level and to develop specific staffing strategies to address inconsistencies or deficiencies.

RESULTS

Step 1: Define purpose and focus

For the current study, dietetic workforce will be calculated to determine staffing requirements that would allow patients with CIF to have access to best‐practice nutrition management within the Australian setting throughout the patient journey (inpatient and outpatient settings).

Step 2: Mapping the patient journey

Minimal Australian data describing the journey of the patient with CIF were identified within the literature. Siu et al., ¹⁷ along with local data from three individual hospitals, described the HPN journey including a 28–32‐day initial admission and two readmissions per year lasting 11–12 days. ¹⁷ Siu et al. ¹⁷ reports median length of HPN being 14–15 months, whereas data extracted from a large international multicenter survey from seven Australian sites indicate an HPN duration of 42 months. ¹⁸ No single source was found within the peer review literature that described the patient journey through CIF or HPN, commencement to stabilization, or weaning and/or cessation. Nevertheless, information collated from practice guidelines, review, and research papers outline a consistent approach to the clinical nutrition requirements at the points of HPN commencement, and so the patient journey was divided into the following: (1) newly diagnosed CIF inpatient admission, (2) new person living with CIF recently transitioned from hospital to outpatient‐based care and now being managed as an outpatient, (3) inpatient readmission or unstable outpatient, and (4) stable in home‐based care and managed as an outpatient (Table 2). Several important aspects in the patient journey were not covered in any of the identified literature. These included management of a change in clinical condition and/or circumstances resulting in periods of destabilization, management of patients with developing intestinal failure but before decision to commence HPN, management of those commencing glucagon‐like peptide‐2 analogues (GLP‐2) and other novel medications to assist in the weaning from HPN, and management leading up to and following intestinal transplantation. Although most of the identified literature described the patient journey for those receiving HPN, these data were extrapolated to incorporate the wider scope of patients seen within a CIF service (ie, those with intestinal insufficiency requiring intensive dietary, fluid, and medication management and/or home intravenous fluid provision; those formerly receiving HPN who require ongoing monitoring and management; and those being supported with GLP‐2 medications).

Table 2.

Mapping the patient journey, best practice, and frequency of reviews required to perform best practice within the dietetics role in managing type 3 intestinal failure.

Step	Newly diagnosed CIF inpatient admission (acute and/or early adaptation)	New patient with CIF recently transitioned to outpatient‐based care (stable and/or early adaptation)	CIF inpatient readmission or unstable outpatient (acute and/or unstable)	Patient with CIF stable at home (adaptation and maintenance)
Step 2: Mapping the patient journey	Average 32‐day admission 17	Approximately 3 months*	2 readmissions per year of 11 days each 17	Average length of HPN estimated at 42 months 18
Step 3: Mapping nutrition best practice throughout the patient journey Assessment	Comprehensive history of nutritionally relevant aspects, including but not limited to Nutrition status, including anthropometry, body composition and weight history, and baseline micronutrient status 3 , 19 Surgical history and current gut anatomy and/or function 3 , 19 Current nutrition intakes and absorption, 3 , 19 routes of feeding, and if relevant, previous nutrition history Hydration 3 , 19 : input and output volumes Bowel outputs 19 Medication management of GI condition necessitating HPN 19 Estimation of nutrition and fluid requirements, 3 , 20 which may include Indirect Calorimetry or Nitrogen studies 20 , 21 as well as clinical assessment and judgment of overall clinical situation. 21 Nutrition prescription 21 , 22 including the following PN prescription, with consideration of cyclic provision in setting of QOL for home 21 Dietary modifications Fluid modifications Use of EN/ONS	Quantification of nutrition intake from all sources, including adherence to nutrition support plans and dietary modification recommendations	Quantification of nutrition intake from all sources, including adherence to nutrition support plans and dietary modification recommendations	Quantification of nutrition intake from all sources, including adherence to nutrition support plans and dietary modification recommendations
		Revision of nutrition and fluid requirements based on monitoring of anthropometry, biochemistry, and inputs and outputs	Revision of nutrition and fluid requirements based on monitoring of anthropometry, biochemistry, and inputs and/or outputs	Revision of nutrition and fluid requirements based on monitoring of anthropometry, biochemistry, and inputs and outputs
		Review with a view to revision of nutrition support regimen to	Review with a view to revision of nutrition support regimen to	Review with a view to revision of nutrition support regimen to
		optimize oral and EN 3 , 23 provision optimize and/or reduce PN provision with a view to improve QOL for patients (ie, reducing hours and considering cyclic nocturnal PN) 3 , 23	optimize oral and EN 3 , 23 provision optimize and/or reduce PN provision with a view to improve QOL for patients (ie, reducing hours and considering cyclic nocturnal PN) 3 , 23	optimize oral and EN 3 , 23 provision optimize and/or reduce PN provision with a view to improve QOL for patients (ie, reducing hours and considering cyclic nocturnal PN) 3 , 23
Monitoring	Nutrition status, including weekly weight, BIA, and HGS 3 , 24 Biochemistry, including electrolytes, acid/base 3 , 22 , 24 and baseline micronutrients 7 Fluid status, 3 , 22 including inputs vs outputs 23 Oral intake 25 Tolerance of nutrition support 7 , 20 Glycemic monitoring, especially preinfusions and postinfusions when commencing cyclic PN 7 , 21 Functional status, including 6‐m walk test 24	Nutrition status, including weekly weight, BIA, and HGS 19 Biochemistry, including electrolytes, acid/base 19 Fluid status, including changes to inputs vs outputs 19 , 23 Oral intake 25 Tolerance of nutrition support 19 Glycemic monitoring, especially preinfusions and postinfusions when commencing cyclic PN 19 Functional status, including 6‐m walk test QOL 8	Nutrition status, including weekly weight, BIA, and HGS Biochemistry, including electrolytes, acid/base Fluid status, including changes to inputs vs outputs Oral intake Tolerance of nutrition support Glycemic monitoring, especially preinfusions and postinfusions when commencing cyclic PN Functional status, including 6‐m walk test	Nutrition status, including weekly weight, 8 , 22 body composition and BIA, 8 and HGS Biochemistry, including electrolytes, acid/base, LFTs, renal function, FBC, 22 and micronutrients 7 Fluid and hydration status, 8 , 22 , 25 including changes to inputs vs outputs 19 , 23 Oral intake 25 Tolerance of nutrition support 19 Glycemic monitoring, especially preinfusions and postinfusions when commencing cyclic PN Functional status, including 6‐m walk test QOL 8 , 22 Evidence of overfeeding or underfeeding 25
Education and counselling	Individualized 4 patient education using written and visual resources 7 , 20 focused on helping patients understand the following: Underlying illness 20 Basic and altered GI anatomy and function 4 , 20 Rationale for dietary and fluid changes 4 , 24 Interaction between medications and food intakes 4 Reason for HPN 20 Self‐monitoring for recognition of nutrition or fluid status changes 8 Postdischarge follow‐up plans 20 , 24 Reinforce nutritional prescription: Dietary modifications Fluid modifications IV/EN/ONS nutrition support prescription, administration, and product management 20 , 24	Individualized 4 patient education using written and visual resources 7 , 20 focused on helping patients understand the following: Changes to dietary, fluid, and EN and/or PN recommendations Changes to outputs and/or absorption* Reinforce nutrition prescription: Dietary modifications 19 Fluid modifications IV/EN/ONS nutrition support prescription Reinforce: Self‐monitoring	Individualized 4 patient education using written and visual resources 7 , 20 focused on helping patients understand the following: Changes to dietary, fluid, and EN and/or PN recommendations Changes to outputs and/or absorption* Reinforce nutrition prescription: Dietary modifications 19 Fluid modifications IV/EN/ONS nutrition support prescription Reinforce: Self‐monitoring	Individualized 4 patient education using written and visual resources 7 , 20 focused on helping patients understand the following: Changes to dietary, fluid, and EN and/or PN recommendations Changes to outputs and/or absorption* Reinforce nutrition prescription: Dietary modifications 19 Fluid modifications IV/EN/ONS nutrition support prescription Reinforce: Self‐monitoring
Step 4: Allocating time for best practice throughout the patient journey	Daily to every few days Regular reviews individualized to patient needs 8 Attendance at multidisciplinary ward rounds and team meetings	Decreasing frequency of review within increasing medical stabilization 8 and adaptation to HPN within home environment. In practice, this may reflect contact every few days, 8 , 22 then weekly, 7 , 8 , 19 , 20 , 22 and then monthly 8 , 22 , 24 Attendance at multidisciplinary team meetings	Regular reviews individualized to patient needs 8 Increased monitoring frequency after change in patient's clinical condition 8 Attendance at multidisciplinary ward rounds and team meetings	Regular reviews individualized to patient needs, decreasing in frequency as the patient becomes more stabilized 8 Suggested intervals are monthly 22 , 24 to quarterly 8 but ultimately individualized to the patient's clinical situation 23 Attendance at multidisciplinary team meetings

Abbreviations: BIA, bioelectrical impedance analysis; CIF, chronic intestinal failure; EN, enteral nutrition; FBC, full blood count; GI, gastrointestinal; HGS, handgrip strength; HPN, home parenteral nutrition; IV, intravenous; LFT, liver function test; ONS, oral nutritional supplement; PN, parenteral nutrition; QOL, quality of life.

^*Expert opinion in the absence of published data.

Step 3: Map best practice throughout the patient journey

There is a lack of detailed guidelines, protocols, and high‐level interventions to guide dietetic best practice throughout the journey of the patient with CIF. Current literature is focused on usual practice and consensus around best practice. To allow further progression through the adapted Bam et al. ¹⁶ methodology, nutrition care aspects were extrapolated from the literature and mapped against the patient journey (Table 2). Where aspects of care were not discussed within the literature, the authors’ clinical experience and expertise was used.

Step 4: Allocate time for best practice throughout the patient journey

The proportion of clinical and/or nonclinical time allocated to provide appropriate nutrition care throughout the patient journey is not present in the current literature. One Australian‐based conference abstract reported clinical and financial benefits from the addition of 0.2 FTE dietitians to the CIF multidisciplinary team that had previously only had provision for gastroenterology and nursing staff. ²⁶ This equated to an additional ~1.33 h per patient managed by the service; however, the specific time allocation to nutrition management tasks undertaken were not specified. ²⁶ The suggested frequency of clinical follow‐up is addressed in general terms in some published papers at various stages within the patient journey in HPN. These recommendations were inclusive of, but not specific to, nutrition management requirements and can be seen in Table 2. Because detailed allocation of hours attributable to tasks across the different aspects of the patient journey were not outlined in current literature, hours attributed were based on complexity of best‐practice dietetic care, author experience, and consensus.

Step 5: Determining seniority of the role and accounting for clinical and nonclinical time

No reference to the seniority or experience of dietetic staff required to perform the outlined tasks listed in Table 2 was specified in the current literature. Given the complexity of the disease and treatment options and based on author consensus, it was determined that the role required a clinically experienced, senior‐level dietitian. Percentage of time spent on clinical care compared with nonclinical activities for a senior dietitian is estimated at 60%. ²⁷

Step 6: Calculate FTE per patient with CIF

Based on published length‐of‐stay data, local data, and author consensus, each phase of the patient journey was allocated a time (in hours) to carry out best‐practice clinical care for one patient. Based on the most current and comprehensive Australian data, ¹⁸ 42 months was taken as the average length of time of HPN. Time allocations for each phase were set for (1) a newly diagnosed CIF inpatient admission (34.35 h over 32 days); (2) a new patient with CIF recently transitioned to outpatient‐based care (12 h over 3 months); (3) CIF readmissions (55 h over 42 months); and (4) patient with CIF stable at home for 35 months of a 42‐month patient journey (35 h over 42 months). For a 42‐month HPN journey, this equates to 38.93 h per year and 54.5 h per year when taking nonclinical duties of 40% into account. This is equivalent to 0.028 FTE per patient with CIF per year, or alternatively, one FTE dietitian can manage 36 patients with CIF. See Figure 1 and Supplementary Data for detailed calculations.

Figure 1.

Calculating FTE across the journey of the patient with CIF. CIF, chronic intestinal failure; FTE, full‐time equivalent; HPN, home parenteral nutrition.

Step 7: Analyze and benchmark results

Recently published data on Australian resourcing for HPN indicate centers are managing a median of 12 (interquartile range [IQR] 6–25) people requiring HPN and have a median dietetic funding level of 0 FTE (IQR 0–0.2 FTE). ¹⁴ Hence, current dietetic staffing in Australia is well below the recommended staffing calculated.

DISCUSSION

This is the first study to use a bottom‐up staffing framework to calculate best‐practice dietetic staffing within an adult CIF setting. It quantifies the requirement for dietetic staffing of 0.028 FTE per patient with CIF. This means one FTE dietitian can provide best‐practice care for 36 patients with CIF, including management of inpatient admissions and outpatient care. This estimate, extrapolated from the available literature, far exceeds the current dietetic staffing allocated for CIF within the Australian setting, in which many centers report to have no dedicated funding. ¹⁴ Patients with CIF have a significantly reduced quality of life and length of life, both of which may be improved with the provision of best‐practice nutrition care delivered by a coordinated specialized multidisciplinary team. The current low funding for dietetics (and other multidisciplinary team members) in the Australian setting as highlighted by Wong et al. ¹⁴ may account for differences in outcomes compared with international data as seen in length of survival while receiving HPN. ¹⁷ , ¹⁸ This paper provides a strong foundation for developing an appropriate staffing model for the management of this complex patient group.

This study is specific to dietetics within CIF, but the proposed methodological framework provides a structured approach for all disciplines within the CIF multidisciplinary team to analyze staffing needs within their service to ensure resourcing can meet clinical demand. Furthermore, the application of the proposed methodological framework is not limited to CIF caseloads and could feasibly be used by clinicians across other clinical specialties to analyze staffing needs within their service.

There are many benefits of having clearly recommended staffing ratios. It provides services the opportunity to benchmark against a “gold standard” as opposed to benchmarking against other potentially underresourced services. Multiple healthcare systems worldwide have documented ²⁸ and, in some cases, mandated minimum staffing levels. ²⁹ Hence, the existence of staffing requirements allows advocacy from clinicians, professional societies, and consumers to lobby for access to high‐quality care. Organizations also have the benefit of choosing to resource their service to provide best practice, and equally, where there is underresourcing, they do so knowing the possible consequences, including higher complication and readmission rates and reduced quality of life. ³

The ability to use this bottom‐up methodology in determining staffing requirements is limited by current knowledge on what constitutes best practice and documentation of the current patient journey. Hence, publication of cohort outcomes remains important. The process of determining staffing requirements for any service is complex and requires careful consideration related to the nuances of each individual service, patient characteristics, geographical location, and model of care. ³⁰ Several cautions must be stated specifically related to the generalizability of these findings within the CIF setting. Firstly, because of the heterogeneity of people presenting with CIF, staffing requirements may vary based on different CIF subgroups. For example, the patient presenting with dysmotility or palliative obstruction may have different time demands compared with those with surgical complications leading to short gut. More detailed mapping would be required to determine this. Secondly, this study has only assessed adult dietetic requirements within a clinical scope. There are CIF centers in which the dietitian takes on greater responsibility not limited to care coordination and administrative duties. These additional duties have not been considered within the scope of this research. Similarly, the additional clinician time required to undertake increasingly accessible clinical technologies such as indirect calorimetry require further consideration when considering dietetic workload in this patient cohort. Thirdly, much of the data related to CIF are described only in the context of HPN. CIF represents a continuum ranging from intestinal insufficiency, which may be managed with intensive dietary and oral fluid modifications with or without intravenous fluids, to intestinal failure, which requires HPN to supply the bulk of nutrition and/or hydration requirements. ¹ Many centers managing HPN will also manage patients with CIF along this care continuum but still require long‐term specialist CIF follow‐up. This may include individuals with intestinal insufficiency who do not yet require HPN but are likely to do so in the future and/or those who have been weaned off HPN because of spontaneous adaptation, successful pharmaceutical interventions (ie, teduglutide), or intestinal transplant. Interpretation of the results from this study should not be limited to those patients receiving HPN only, as all patients with CIF, regardless of HPN dependence, require considerable dietetic assessment, intervention, and monitoring. Furthermore, the calculations in this study encompass inpatient and outpatient management of CIF and would need recalculating in services in which clinician duties are split between inpatient and outpatient services. In summary, calculating staffing requirements for a specific service should consider the unique patient characteristics of the service, consider the scope of dietetic role within the service, and encompass the entirety of the clinical needs of patients with CIF managed by the service, not just that related to HPN alone.

Step 7, as outlined by Bam et al., ¹⁶ was not undertaken within its entirety but does allow benchmarking of services. Given this is the first study to quantify dietetic staffing, validation of this novel methodology is required. One possibility would be to validate using a time‐in‐motion study within a service that has adequate staffing to allow best practice. Identifying services with adequate dietetic staffing would also allow assessment of clinical outcomes compared with services with inadequate dietetic staffing.

Another limitation is that there is a paucity of literature within the Australian setting to inform what the Australian CIF journey may look like and, more broadly, how much dietetic time is required to conduct best‐practice clinical care. It should also be noted that provision of best‐practice care may also alter the patient journey, ideally with fewer hospital readmissions and fewer complications. Hence, all available data were used to determine the current patient journey and dietetic resourcing. However, the findings from this study would need to be revised should more accurate data become available or if the patient journey were to change.

In many settings, CIF centers have developed according to individual clinician interest and evolving patient need. This often results in services emerging without adequate staffing. ³¹ Hence, the clinical benefit of this research is to allow CIF services a benchmark to audit against and provide clinicians a platform to engage and advocate with their health administrators for adequate resourcing. It is also important that staffing levels are linked to clinical and patient‐reported quality auditing, which is generally absent from the literature. Hence, clinicians should be encouraged to undertake further research and publish their findings regarding these important topics.

Because of the lack of published literature, local data and author consensus were used for calculating time allowances. Given the heterogeneity in patient cohorts across CIF centers worldwide, there will always be patients who experience greater clinical instability during their time receiving HPN and thus require more hospitalizations and dietetic input than may be incorporated in a 0.028 FTE allocation. Conversely, otherwise stable patients who may have a much longer HPN duration than 42 months may require relatively little dietetic input for long periods of time. As the number of patients being managed within a CIF service increases, it would be anticipated that these variations should balance themselves out between the clinical demands of the patient cohort as a whole. Based on the lack of data around the patient journey for those with non‐HPN CIF‐related care, additional work will be required to validate whether HPN allocations are appropriate to generalize to the wider CIF population's dietetic needs. In the absence of these data, however, it would be a reasonable starting point from which to work given the complexity of the patient cohort with CIF as a whole.

CONCLUSION

Although there remain many limitations in determining staffing requirements with all methodologies, the modified Bam et al. ¹⁶ bottom‐up approach proposed in this paper allows calculation of staffing to meet best practice. Within CIF, nutrition input is well recognized as essential and specialized, yet dietetic resourcing continues to be inadequate. This paper proposes a staffing level of 0.028 FTE per patient with CIF to ensure patients are managed according to best practice. This is far greater than current CIF dietetic staffing levels within the Australian setting. Adequate dietetic resourcing may reduce patient complications and improve quality of life, resulting in enhanced patient and clinical outcomes.

AUTHOR CONTRIBUTIONS

Sharon Carey and Emma Osland contributed to the conception and design of the research. Sharon Carey, Brooke Chapman, and Emma Osland contributed to the acquisition, analysis, and interpretation of the data. Sharon Carey and Emma Osland drafted the manuscript, and all authors critically revised the manuscript. Sharon Carey agrees to be fully accountable for ensuring the integrity and accuracy of the work. All authors read and approved the final manuscript.

CONFLICT OF INTEREST STATEMENT

None declared.

Supporting information

Supporting information.

Carey S, Chapman B, Osland E. Development of dietetic staffing requirements for adult intestinal failure services using a best‐practice model. Nutr Clin Pract. 2025;40:1146‐1157. 10.1002/ncp.11308