The Nutrition Care Process: Driving Effective Intervention and Outcomes

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The Nutrition Care Process Driving Effective
Intervention and Outcomes
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Nutrition Care Process

• Process for identifying, planning for, and
  meeting nutritional needs
• Malnutrition increases
• morbidity
• length of hospital stay more care
• mortality
• higher costs ()

3

ADA NUTRITION CARE PROCESS
AND MODEL





Screening
Referral



System


Ø

Identify risk factors

Ø

Use appropriate tools
and methods

Ø

Involve
interdisciplinary
collaboration


Nutrition Diagnosis





Ø

Identify and label problem


Nutrition Assessment



Ø

Determine cause/contributing risk




Ø

Obtain/collect timely and

factors




appropriate
data



Ø

Cluster signs and symptoms/



Ø

Analyze/interpret with
defining characteristics

evidence
-
based standards





Ø

Document


Document


Relationship

Between



Patient/Client/Group
Nutrition Intervention



Dietetics

Ø

Plan nutrition intervention




Professional


Formulate goals and

determine a plan of action
Ø

Implement the nutrition intervention




Care is delivered and actions
Nutrition Monitoring and

-
are carried out

Evaluation

Ø

Documen
t
Ø

Monitor progress


Ø

Measure outcome indicators

Ø

Evaluate outcomes

Ø

Document


Outcomes


Management Sys
tem
Ø

Monitor the success of the Nutrition Care
Process implementation

Ø

Evaluate the impact with aggregate data

Ø

Identify and analyze causes of less than
optimal performance and outcomes

Ø

Refine the use of the Nutrition Care

Process






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Central Core of Nutrition Care Model

• The relationship
• between the client
• the dietetics
• professional(s)
• collaborative
• client-focused
• individualized

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Outer Rings of Nutrition Care Model

• Strengths brought to process by dietetics
  professional
• dietetics knowledge
• skills of critical thinking, collaboration,
  communication
• evidence-based practice
• Factors of external environment
• health care system, practice setting
• social support, economics, education level

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ADAs Nutrition Care Process Steps

• Nutrition Assessment
• Nutrition Diagnosis
• Nutrition Intervention
• Nutrition Monitoring and Evaluation

For more information, access the ADA member page
in the Quality Management section.
http//www.eatright.org/Member/83_12962.cfm
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Nutrition Assessment Components

• Gather data, considering
• Dietary intake
• Nutrition related consequences of health and
  disease condition
• Psycho-social, functional, and behavioral factors
• Knowledge, readiness, and potential for change
• Compare to relevant standards
• Identify possible problem areas

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Example of Nutrition Assessment Content

• Type of assessment
• Content component
• Nutritional adequacy
• Fat and cholesterol intake
• Trans fatty acid intake
• Health status
• Lipid profile
• BMI
• Waist circumference
• What are the reliable
• standards (ideal goals)?
• how well, how much,
• how long

Nutrition assessment what data are most
effective for identifying clients nutrition
related problem of interest
What type of assessment data?
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How do we get from Assessment to
Intervention?Nutrition Diagnosis
A crucial element of providing quality nutrition
care
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Nutrition Diagnosis

• Purpose
• Identify and label the nutrition problem
• Nutrition diagnosis
• NOT medical diagnosis
• EXPLICIT statement of nutrition diagnosis
• Note Documentation is an on-going process that
  supports all the steps in the Nutrition Care
  Process

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Nutrition Intervention

• Purpose
• Plan and implement purposeful actions to address
  the identified nutrition problem
• bring about change
• set goals and expected outcomes
• client-driven
• based on scientific principles and best available
  evidence

Note Documentation is an on-going process that
supports all the steps in the Nutrition Care
Process
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Nutrition Monitoring Evaluation

• Purpose
• Determine the progress that is being made toward
  the clients goals or desired outcomes
• Monitoring review and measurement of status
• at scheduled times
• Evaluation systematic comparison with previous
  status, intervention goals, reference standard
• Note Documentation is an on-going process that
• supports all the steps in the Nutrition Care
  Process

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Nutrition Screening

• Purpose To quickly identify individuals who are
  malnourished or at nutritional risk and to
  determine if a more detailed assessment is
  warranted
• Usually completed by DTR, nurse, physician, or
  other qualified health care professional
• At-risk patients referred to RD

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Characteristics of Nutrition Screening

• Simple and easy to complete
• Routine data
• Cost effective
• Effective in identifying nutritional problems
• Reliable and valid

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Nutrition Questionnaire
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Nutrition Screening Tools

• Acute-care hospital or residential setting
• Perinatal service
• Pediatric practice
• Malnutrition Universal Screening Tool (MUST)
• Nutrition Screening Initiative (NSI)

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Food and Nutrient Intake Risk Factors

• Calorie or protein, vitamin and mineral intake
  greater or less than required
• Swallowing difficulties
• Gastrointestinal disturbances, bowel irregularity
• Impaired cognitive function or depression
• Unusual food habits (pica)
• Misuse of supplements
• Restricted diet
• Inability or unwillingness to consume food
• Increase or decrease in activities of daily
  living

Hammond KA. Assessment Dietary and Clinical
Data. In Krause, 12th edition, p. 386
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Psychological/Social Risk Factors

• Language barriers
• Low literacy
• Cultural or religious factors
• Emotional disturbances associated with feeding
  difficulties (e.g., depression)
• Limited resources for food preparation or
  obtaining food or supplies
• Alcohol or drug addiction
• Limited or low income
• Lack of ability to communicate needs
• Limited use or understanding of community
  resources

Hammond KA. Assessment Dietary and Clinical
Data. In Krause, 12th edition, p. 386
19
Physical Risk Factors

• Extreme age (adults gt80 years, premature infants,
  very young children)
• Pregnancy adolescent, closely spaced, or three
  or more pregnancies
• Alterations in anthropometric measurements,
  marked overweight/ underweight for age, height,
  both depressed somatic fat and muscle stores
• NOTE recent unintentional weight loss is more
  predictive of morbidity/mortality than wt/ht
  status

Hammond KA. Assessment Dietary and Clinical
Data. In Krause, 12th edition, p. 386
20
Physical Risk Factors (cont)

• Chronic renal/cardiac disease, diabetes, pressure
  ulcers, cancer, AIDS, GI complications,
  hypermetabolic stress, immobility, osteoporosis,
  neurological impairments, visual impairments

Hammond KA. Assessment Dietary and Clinical
Data. In Krause, 12th edition, p. 386
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Abnormal Laboratory Values

• Visceral proteins (albumin, prealbumin,
  transferrin)
• Lipid profile (cholesterol, HDL, LDL,
  triglycerides)
• Hemoglobin, hematocrit, other blood tests
• BUN, creatinine, electrolytes
• Fasting and PP blood glucose levels, A1C

Hammond KA. Assessment Dietary and Clinical
Data. In Krause, 12th edition, p. 386
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Medications

• Chronic use
• Multiple and concurrent use (polypharmacy)
• Drug-nutrient interactions

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Joint Commission Standards Drive Nutrition
Screening in Health Care Organizations
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Nutrition Care Process Screening

• The Joint Commission (TJC) requires that
  nutritional risk be identified within 24 hrs in
  all hospitalized pts
• TJC also requires nutrition screening in
  accredited ambulatory facilities
• Standards of Care protocols determines process
  evidence-based guidelines
• Use simple techniques, available info
• May be done by other than RD
• Usually simple form with targeted info

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Standard PC.2.20The hospital defines in writing
the data and information gathered during
assessment and reassessment

• Elements of Performance
• The information...to be gathered during the
  initial assessment includes the following, as
  relevant...
• Each patient's nutrition and hydration status, as
  appropriate
• The hospital has defined criteria for when
  nutritional plans must be developed

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Standard PC.2.120 The hospital defines in
writing the time frame(s) for conducting the
initial assessment(s).

• Elements of Performance
• A nutritional screening, when warranted by the
  patient's needs or condition, is completed within
  no more than 24 hours of inpatient admission
• CAMH online version, 2006

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Standards Relating to Nutrition Assessment

• Standard PC.2.130
• Initial assessments are performed as defined by
  the hospital.
• Standard PC.2.150
• Patients are reassessed5 as needed. CAMH online
  version, 2006

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Screening for Malnutrition in Acute Care Settings

• The consensus of the committee is that while
  screening for nutrition risk in the acute care
  setting is crucial, the JCAHO requirement that
  nutrition screening be completed within 24 hours
  of admission is not evidence-based and may
  produce inaccurate and misleading results.
• Institute of Medicine, 1999

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Commonly Used Criteria for Nutrition Risk
Screening-Acute Care

• Diagnosis
• Weight
• Weight change
• Need for diet modification or education
• Laboratory values (s. albumin, cholesterol,
  hemoglobin, TLC

• Problems with chewing or swallowing
• Diarrhea
• Constipation
• Food dislikes or intolerance

Institute of Medicine, 1999
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Nutrition Screening and Assessment Tool
Courtesy Carolinas Medical Center, Charlotte,
N.C.
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Prevalence of Nutrition Risk in Acute Care

• The prevalence of nutrition risk will vary
  depending on the population screened and the
  criteria used for screening
• In published studies, prevalence of malnutrition
  in hospitalized patients has ranged from 12 to
  more than 50
• There is little published data regarding
  nutrition screening for other purposes

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Malnutrition in Hospitalized Pts
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CNM Nutrition Screening SurveyChima and Seher,
2007

• Blast email sent to 1668 members of the Clinical
  Nutrition Management dietetic practice group in
  May, 2007
• 522 usable surveys were returned, for a response
  rate of 31

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Does Your Health Care Organization Screen
Patients for Nutrition Risk?
(with accredited ambulatory clinics)
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Screening in Acute Care
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Who Has Primary Responsibility for Nutrition
Screening (Inpatient)?
of Respondents
In the 1987 survey, only 60 of 77 respondents
reported admission nutrition screening
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Criteria Used by Nursing in Nutrition Screening
(n442)
Criterion N
History of weight loss 418 95
Poor intake pta 360 81
Patient is on nutrition support 349 79
Chewing/swallowing issues 333 75
Skin breakdown 319 72
Pregnant/lactating mother off OB 197 45
Diagnosis 167 38
Need for education 160 36
Geriatric surgical patient 148 33
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Criteria Used by Nursing in Nutrition Screening
(n442)
Criterion N
Specific diet orders 105 24
Food allergy 103 23
NPO/Clear liquid in-house 84 19
Weight for height criterion 75 17
Age (premature or geriatric) 71 16
Visceral proteins (albumin, PAB) 51 12
Infant on concentrated formula 43 10
Body mass index 38 9
Other 111 25
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How Were Nursing Screening Criteria Chosen?
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Where Are Nursing Screening Results Documented in
the MR?
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How Are Nursing Screens Communicated to
Nutrition Staff?
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If Nursing Screens, Do Nutrition Staff Do a
Secondary Screen?
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Why Do Nutrition Staff (NS) Do Secondary
Screening?
n
NS screens identify patients missed by NU screens 62 158
Criteria used by NS may not identify pts at nutrition risk 46 117
NU screens may not be completed 50 129
NU screens may be unreliable 34 86
NS staff may not be notified of NU screens 46 118
Other 24 61
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Characteristics of Secondary Nutrition Screening
n
Nutrition staff (NS) screens use different data than NU 61 156
Nutrition staff (NS) collect the same data as NU 12 30
NS utilize criteria that require nutrition expertise 55 139
Other 6 14
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Who Is Responsible for Secondary Nutrition
Screening?
46
Criteria Used by Nutrition Staff in Secondary
Screening (n258)
Criterion N
Diagnosis 223 86
NPO/Clear in-house 192 74
Patient on nutrition support 190 74
Specific diet orders 161 62
Visceral proteins (albumin, PAB) 158 61
Chewing/swallowing issues 139 54
Skin breakdown 137 53
History of weight loss 136 53
Weight for height criterion 119 46
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Criteria Used by Nutrition Staff in Secondary
Screening (n258)
Criterion N
Poor intake prior to admission 110 43
Need for education 95 37
BMI 93 36
Food allergy 89 35
Geriatric surgical patient 83 33
Pregnant/lactating outside OB 79 31
Age (premature or geriatric) 78 30
Infant on concentrated formula 44 17
Other 40 15
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Where Is Secondary Screening Documented in the
Medical Record?
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Criteria Used by Nursing/Nutrition to Identify
Patients at Nutrition Risk (Inpatient)
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Criteria Used By Nursing/Nutrition to Identify
Patients at Nutrition Risk (Inpatient)
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Criteria Used By Nursing/Nutrition to Identify
Patients at Nutrition Risk (Inpatient)
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How Many Levels of Risk Does Your Screening
System Include?
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Has Your Inpt Screening System Been Validated for
Sensitivity/Specificity?
of respondents
54
How Well Do Inpt Screening Criteria Effectively
Identify Nutrition Risk?
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Validation of Nutrition Screening Tools in Acute
Care
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Validation of Nutrition Screening Tools in Acute
Care
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Adult-Geriatric Inpatient Screening Criteria at
MHS

• 1. Pregnant or Lactating mother admitted to unit
  other than antepartum or mother-baby 
• 2. Significant unintentional weight loss gt10 lb.
  in past 1-2 months  
• 3 Patient DESIRES EDUCATION on a therapeutic
  diet 
• 4. Patient unable to take oral or other
  feedings gt5 days prior to admission
• 5. Patient on enteral or parenteral feedings 
• 6. Geriatric patient (80 years plus) admitted
  for surgical procedure 
• 7. Patient with skin breakdown (decubitus
  ulcer) 

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Infant-Child-Adolescent Inpatient Screening
Criteria at MHS

• 1. Recent weight loss
• 2. On special diet and NEEDS EDUCATION
• 3. Has feeding tube or on parenteral feedings
• 4. Diabetic
• 5. Receives high calorie feeds/concentrated
  formula
• 6. Food allergy
• 7. Failure to thrive
• 8. Feeding problems/intolerance
• 9. Teen who is pregnant or lactating
• 10. Child being breast fed

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MHS Adult Ambulatory Screen
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MHS Peds Ambulatory Screen
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MetroHealth Screening Prompt Criteria in Peds
Ambulatory Clinics

• Children lt2 Years
• lt10 ile weight/length
• gt90 ile weight/length
• Children 2-18 Years
• lt 10 ile BMI/age
• gt85 ile BMI/age

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Nursing Admission Screens Most Common Criteria
MHMC (Feb 17-Mar 2, 2003)
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of Positive Nutrition Screens Classified as
High Risk after Review (by Criterion)
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Nutrition Screening at MetroHealth

• Consistent with national practice in terms of
  criteria, procedures, and time frames
• With the exception of TJC-mandated criteria,
  specificity ranges from 50-100
• TJC-mandated criteria are poor predictors of
  nutrition risk
• No data on sensitivity (e.g. what percentage of
  at risk pts are we discovering?)

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Issues in Nutrition Screening

• Most nutrition screening in acute and ambulatory
  settings is done by staff other than nutrition
  professionals
• Based on a national survey, identified at-risk
  patients are referred to nutrition professionals
  less than half the time

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Issues in Nutrition Screening

• Much of the research that exists validates more
  comprehensive nutrition screening tools, e.g. MNA
  in the elderly
• Little research has been done to validate or
  evaluate nutrition screening as it currently
  exists in most acute care institutions a process
  using limited data obtained on admission by
  nursing staff.
• There is no gold standard of nutrition status
  that can be used as a benchmark

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ADA Screening Evidence Analysis Work Group

• Convened fall, 2007
• Will develop definitions and formulate questions
  for evidence analysis regarding nutrition
  screening

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Members of Screening EAL Work Group

• Chair Pam Charney, PhD, RD, CNSD, consultant
• Vicki Castellanos, PhD, RD, Florida International
  University, educator
• Cinda Chima, MS, RD, University of Akron,
  educator
• Maree Ferguson, MBA, PhD, RD, Queensland,
  Australia, clinical manager
• Nancy Nevin-Folino, MEd, RD, CSP, LD, FADA,
  Childrens Hospital, Dayton, Oh, practitioner
• Judy Porcari, MBA, MS, RD, Clinical Manager
• Annalynn Skipper, PhD, RD, FADA, Consultant