Transcript Document 7116061

The Nutrition Care Process: Driving Effective
Intervention and Outcomes
Nutrition Care Process
 Process for identifying, planning for, and
meeting nutritional needs
 Malnutrition increases:
–
–
–
–
morbidity
length of hospital stay = more care
mortality
higher costs ($$$$$$$)
ADA NUTRITION CARE PROCESS AND MODEL
Screening & Referral
System


Identify risk factors
Use appropriate tools
and methods
 Involve
interdisciplinary
collaboration
Nutrition Assessment
 Obtain/collect timely and
appropriate data
 Analyze/interpret with
evidence- based standards
Document
Nutrition Diagnosis
 Identify and label problem

Determine cause/contributing risk
factors
 Cluster signs and symptoms/
defining characteristics
 Document
Relationship
Between
Patient/Client/Group
& Dietetics
Professional
Nutrition Monitoring and
Evaluation

Monitor progress

Measure outcome indicators

Evaluate outcomes
 Document




Outcomes
Management System
Monitor the success of the Nutrition Care
Process implementation
Evaluate the impact with aggregate data
Identify and analyze causes of less than
optimal performance and outcomes
Refine the use of the Nutrition Care
Process
Nutrition Intervention
 Plan nutrition intervention

Formulate goals and
determine a plan of action
Implement the nutrition intervention
 Care is delivered and actions
are carried out
 Document
Central Core of
Nutrition Care Model
The relationship
between the client &
the dietetics
professional(s)
– collaborative
– client-focused
– individualized
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
ADA’s 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
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
Example of Nutrition Assessment
Content
Nutrition
assessment
what data
are most
effective for
identifying
clients’
nutrition
related
problem
of interest
Type of assessment
Content component
What type
of
assessment
data?
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
How do we get from Assessment to
Intervention?
Nutrition Diagnosis
A crucial element of
providing quality
nutrition care
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
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
Nutrition Monitoring &
Evaluation
Purpose
 Determine the progress that is being made toward the clien
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
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
Characteristics of Nutrition
Screening
 Simple and easy to complete
 Routine data
 Cost effective
 Effective in identifying nutritional
problems
 Reliable and valid
Nutrition Questionnaire
Nutrition Screening Tools
 Acute-care hospital or residential setting
 Perinatal service
 Pediatric practice
 Malnutrition Universal Screening Tool
(MUST)
 Nutrition Screening Initiative (NSI)
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
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
Physical Risk Factors
 Extreme age (adults >80 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
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
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
Medications
 Chronic use
 Multiple and concurrent use
(polypharmacy)
 Drug-nutrient interactions
Joint Commission Standards Drive
Nutrition Screening in Health Care
Organizations
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
Standard PC.2.20:The 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
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
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
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
Commonly Used Criteria for Nutrition
Risk Screening-Acute Care
 Diagnosis
 Problems with
 Weight
chewing or
swallowing
 Diarrhea
 Constipation
 Food dislikes or
intolerance
 Weight change
 Need for diet
modification or
education
 Laboratory values (s.
albumin, cholesterol,
hemoglobin, TLC
Institute of Medicine, 1999
Nutrition Screening and Assessment Tool
Courtesy Carolinas Medical Center, Charlotte, N.C.
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
Malnutrition in Hospitalized Pts
Population
Criteria
Prevalence
Warnold et
al, 1984
Noncancer pts in Wt loss, Wt/Ht,
Sweden (n=215) s. alb, AMC
12%
Messner et
al, 1991
VA patients
(n=500)
55%
s. alb, TLC, wt
loss
Robinson et Medicine pts
al, 1987
(n=100)
Wt loss, lab data, 40%
anthropometrics
Chima et al, Medicine pts
1997
(n=173)
s. alb, wt loss,
wt/ht
Thomas, et
al, 2002
Lab data,
29%
anthropometrics,
MNA score
Subacute pts
(837)
32%
CNM Nutrition Screening Survey
Chima 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%
Does Your Health Care Organization
Screen Patients for Nutrition Risk?
100
99
90
80
70
63
60
50
% of Respondents
40
30
20
10
0
Inpatient (n=522)
Ambulatory (n=345)
(with accredited ambulatory clinics)
Screening in Acute Care
Who Has Primary Responsibility for
Nutrition Screening (Inpatient)?
90
83
80
74
70
68.5
60
% of
Respondents
1987 CNM survey
(n=46)
2003 CNM survey
(n=110)
2007 CNM (n=514)
50
40
30
17
20
10
6.5
10
8
5
0
Nursing
*In
Nutrition
Other
the 1987 survey, only 60% of 77 respondents reported
admission nutrition screening
Criteria Used by Nursing in
Nutrition Screening (n=442)
Criterion
History of weight loss
Poor intake pta
Patient is on nutrition support
Chewing/swallowing issues
Skin breakdown
Pregnant/lactating mother off OB
Diagnosis
Need for education
Geriatric surgical patient
N
418
360
349
333
319
197
167
160
148
%
95%
81%
79%
75%
72%
45%
38%
36%
33%
Criteria Used by Nursing in
Nutrition Screening (n=442)
Criterion
Specific diet orders
Food allergy
NPO/Clear liquid in-house
Weight for height criterion
Age (premature or geriatric)
Visceral proteins (albumin, PAB)
Infant on concentrated formula
Body mass index
Other
N
105
103
84
75
71
51
43
38
111
%
24%
23%
19%
17%
16%
12%
10%
9%
25%
How Were Nursing
Screening Criteria Chosen?
70
60
50
40
30
% of
respondents
(n=442)
20
10
0
Readily
Available
Easy to No Clinical Evidence
Use
Expertise Based
Tested Seem to
TJC
and
Work Well Requires
Validated
It
Where Are Nursing Screening
Results Documented in the MR?
70
60
50
40
30
% of
Respondents
(n=442)
20
10
0
Nursing Admitting Other Specific Form
Assessment
Computerized
Record
Interdisciplinary
Form
How Are + Nursing Screens
Communicated to Nutrition Staff?
90
80
70
60
50
40
% of
Respondents,
n=438
30
20
10
0
Fax
Phone
Computer
Other
N/A
If Nursing Screens, Do Nutrition
Staff Do a Secondary Screen?
60
57
50
43
40
30
% of respondents
(n=441)
20
10
0
Yes
No
Why Do Nutrition Staff (NS) Do
Secondary Screening?
%
NS screens identify patients missed 62%
by NU screens
Criteria used by NS may not
46%
identify pts at nutrition risk
NU screens may not be completed 50%
n
158
NU screens may be unreliable
34%
86
NS staff may not be notified of +
NU screens
Other
46%
118
24%
61
117
129
Characteristics of
Secondary Nutrition Screening
Nutrition staff (NS) screens use
different data than NU
Nutrition staff (NS) collect the
same data as NU
NS utilize criteria that require
nutrition expertise
Other
%
n
61%
156
12%
30
55%
139
6%
14
Who Is Responsible for
Secondary Nutrition Screening?
70
60
50
40
% of
Respondents
(n=256)
30
20
10
0
Dietitians
DTR
BS Nutr
Clerk
Other
Criteria Used by Nutrition Staff in
Secondary Screening (n=258)
Criterion
Diagnosis
NPO/Clear in-house
Patient on nutrition support
Specific diet orders
Visceral proteins (albumin, PAB)
Chewing/swallowing issues
Skin breakdown
History of weight loss
Weight for height criterion
N
223
192
190
161
158
139
137
136
119
%
86%
74%
74%
62%
61%
54%
53%
53%
46%
Criteria Used by Nutrition Staff in
Secondary Screening (n=258)
Criterion
Poor intake prior to admission
Need for education
BMI
Food allergy
Geriatric surgical patient
Pregnant/lactating outside OB
Age (premature or geriatric)
Infant on concentrated formula
Other
N
110
95
93
89
83
79
78
44
40
%
43%
37%
36
35%
33
31%
30%
17%
15%
Where Is Secondary Screening
Documented in the Medical Record?
30
28
28
23
25
20
15
15
10
5
5
0
Chart
Form
Computer Progress
Note
Not Doc
Interd
Form
% of
Respondents
n=260
Criteria Used by Nursing/Nutrition to Identify
Patients at Nutrition Risk (Inpatient)
100
95
90
81
80
70
60
53
50
40
79
75
74
72
53
54
45
43
31
30
20
10
0
Wt Loss
Poor Intake
PTA
Chewing/
Swallowing
EN/PN
Skin Brkdwn
Preg/
Lactating
% of Resp
Nursing Scrn
n= 442
% Resp
Nutrition
Screen
n=252
Criteria Used By Nursing/Nutrition to Identify
Patients at Nutrition Risk (Inpatient)
100
90
86
80
70
62
60
50
38
40
30
33
33
36 37
24
% Resp
Nutrition
Scrn n=252
20
10
0
Spec Diets
% Resp
Nursing Scrn
n=442
Dx
Ger Surg
Education
Criteria Used By Nursing/Nutrition to
Identify Patients at Nutrition Risk
(Inpatient)
100
90
80
70
60
50
40
30
20
10
0
74
61
46
34
30
16
17
23
17
10
Age
wt/ht
Food
Allergy
19
12
Conc NPO/Clr Visceral
Formula
Pro
% Resp
Nursing
Scrn
n=442
% Resp
Nutr
Scrn
n=252
How Many Levels of Risk Does
Your Screening System Include?
45
43
41
40
35
30
25
16
20
15
10
5
0
Two
Three
Four or More
% of Respondents
n=522
Has Your Inpt Screening System Been
Validated for Sensitivity/Specificity?
74
80
74
70
60
50
40
30
26
26
20
10
0
Sensitivity
% of respondents
Specificity
Yes
No
How Well Do Inpt Screening Criteria
Effectively Identify Nutrition Risk?
80
70
71
60
54
50
40
34
Nutrition Staff
criteria
Nursing Staff
Criteria
30
20
15
8
10
13
4
1
0
All/Most of the
Time
Sometimes
Half to Never
n/a
Validation of Nutrition Screening Tools
in Acute Care
Criteria
Population
Comment
Kovacevich Dx, intake, Adult acute Sensitivity 84.6%;
et al, NCP IBW, Wt hx care pts
specificity 62.6 by
1997
n=186
PAB. (Nearly full
page screen form)
Ferguson
Appetite,
Adult acute High inter-rater
M.
unintentional care pts
reliability (93-97%)
Nutrition 1 wt loss
n=408
High sensitivity/
Jun 1999
(Australia) specificity vs SGA
Laporte M, BMI + wt
Elderly
Validity 60.5%JNHA 1 Jan loss
acute /LTC 93.1% vs RD
2001
BMI +
n=142
nutrition assessment
albumin
(Canada)
Validation of Nutrition Screening Tools
in Acute Care
Criteria
Population
Mezoff A. Lngth/ht,
PICU pts w/
Pediatrics 1 wt/ht %ile,
RSV
Apr 1996 wt hx, dx, lab
data
Burden ST. BMI,
J Hum Nutr MUAC, wt
Diet 2001 hx, intake vs
needs
100
med/surg/
elderly
hospital pts
(UK)
Comment
High nutr risk
score associated
with poor
outcome; (nearly
full page form)
Sensitivity 78%;
specificity 52% vs
nutrition
assessment
(overestimates pts
at moderate risk)
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 >=10 lb. in
past 1-2 months
 3 Patient DESIRES EDUCATION on a
therapeutic diet
 4. Patient unable to take oral or other feedings
>=5 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)
Infant-Child-Adolescent
Inpatient Screening Criteria at MHS





1.
2.
3.
4.
5.
Recent weight loss
On special diet and NEEDS EDUCATION
Has feeding tube or on parenteral feedings
Diabetic
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
MHS Adult Ambulatory Screen
MHS Peds Ambulatory Screen
MetroHealth Screening Prompt
Criteria in Peds Ambulatory Clinics
Children <2 Years
 <10 %ile weight/length
 >90 %ile weight/length
Children 2-18 Years
 < 10 %ile BMI/age
 >85 %ile BMI/age
Nursing Admission Screens: Most Common
Criteria MHMC (Feb 17-Mar 2, 2003)
39
40
35
30
25
25
23
20
15
10
# of Pts, n=101
13
8
8
6
5
Age
Conc
Feeds
5
0
EN/PN
Wt Loss
Intake
Education
Skin
Preg/Lact
% of Positive Nutrition Screens Classified as
High Risk after Review (by Criterion)
100
100
90
82
80
70
70
61
60
53
% of
Positive
Screens
50
40
30
17
20
10
0
0
EN
Skin
Intake
Wt
Education
Age
Preg/Lact
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?)
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 atrisk patients are referred to nutrition
professionals less than half the time
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
ADA Screening Evidence Analysis
Work Group
 Convened fall, 2007
 Will develop definitions and formulate
questions for evidence analysis regarding
nutrition screening
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,
Children’s Hospital, Dayton, Oh, practitioner
 Judy Porcari, MBA, MS, RD, Clinical Manager
 Annalynn Skipper, PhD, RD, FADA, Consultant