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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 Diagnosis
Identify and label problem
Nutrition Assessment Determine cause/contributing risk
Obtain/collect timely and
factors
appropriate data Cluster signs and symptoms/
Analyze/interpret with defining characteristics
evidence- based standards
Document
Document

Relationship
Between
Patient/Client/Group Nutrition Intervention
& Dietetics Plan nutrition intervention
Professional Formulate goals and
determine a plan of action
Implement the nutrition intervention
Nutrition Monitoring and Care is delivered and actions
-
Evaluation are carried out
Monitor progress Document
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
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
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
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
Type of assessment
Nutrition Content component
assessment Nutritional adequacy
what data Fat and cholesterol intake
What type Trans fatty acid intake
are most Health status
of
effective for assessment
Lipid profile
identifying BMI
data? Waist circumference
clients
nutrition What are the reliable
related standards (ideal goals)?
how well, how much,
problem how long
of interest
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
Weight change
swallowing
Diarrhea
Need for diet
modification or Constipation
education Food dislikes or
Laboratory values (s. intolerance
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 Noncancer pts in Wt loss, Wt/Ht, 12%
al, 1984 Sweden (n=215) s. alb, AMC

Messner et VA patients s. alb, TLC, wt 55%


al, 1991 (n=500) loss

Robinson et Medicine pts Wt loss, lab data, 40%


al, 1987 (n=100) anthropometrics

Chima et al, Medicine pts s. alb, wt loss, 32%


1997 (n=173) wt/ht

Thomas, et Subacute pts Lab data, 29%


al, 2002 (837) anthropometrics,
MNA score
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 68.5
70
60 1987 CNM survey
50 (n=46)
% of
2003 CNM survey
Respondents 40 (n=110)
30 2007 CNM (n=514)
20 17
10 6.5 10 8
5
0
Nursing Nutrition Other
*Inthe 1987 survey, only 60% of 77 respondents reported
admission nutrition screening
Criteria Used by Nursing in
Nutrition Screening (n=442)
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%
Criteria Used by Nursing in
Nutrition Screening (n=442)
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%
How Were Nursing
Screening Criteria Chosen?
70

60

50

40

30
% of
20 respondents
(n=442)
10

0
Readily Easy to No Clinical Evidence Tested Seem to TJC
Available Use Expertise Based 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 Computerized Interdisciplinary
Assessment Record Form
How Are + Nursing Screens
Communicated to Nutrition Staff?
90
80
70
60
50
40 % of
Respondents,
30
n=438
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?
% n
NS screens identify patients missed 62% 158
by NU screens
Criteria used by NS may not 46% 117
identify pts at nutrition risk
NU screens may not be completed 50% 129

NU screens may be unreliable 34% 86

NS staff may not be notified of + 46% 118


NU screens
Other 24% 61
Characteristics of
Secondary Nutrition Screening
% n
Nutrition staff (NS) screens use 61% 156
different data than NU
Nutrition staff (NS) collect the 12% 30
same data as NU
NS utilize criteria that require 55% 139
nutrition expertise
Other 6% 14
Who Is Responsible for
Secondary Nutrition Screening?
70

60

50

40
% of
30
Respondents
(n=256)
20

10

0
Dietitians DTR BS Nutr Clerk Other
Criteria Used by Nutrition Staff in
Secondary Screening (n=258)
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%
Criteria Used by Nutrition Staff in
Secondary Screening (n=258)
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%
Where Is Secondary Screening
Documented in the Medical Record?
30 28 28

25 23

20
15
15
% of
10 Respondents
n=260
5
5

0
Chart Computer Progress Not Doc Interd
Form Note Form
Criteria Used by Nursing/Nutrition to Identify
Patients at Nutrition Risk (Inpatient)
100 95
90
81 79
80 75
74 72
70
60 53 54 53
50 45
43 % of Resp
40 Nursing Scrn
31 n= 442
30
20
% Resp
10 Nutrition
Screen
0 n=252
Wt Loss Poor Intake Chewing/ EN/PN Skin Brkdwn Preg/
PTA Swallowing Lactating
Criteria Used By Nursing/Nutrition to Identify
Patients at Nutrition Risk (Inpatient)
100
90 86
80
70 62
60
50
% Resp
40 38 33 33 36 37 Nursing Scrn
30 n=442
24
20 % Resp
Nutrition
10 Scrn n=252
0
Spec Diets Dx Ger Surg Education
Criteria Used By Nursing/Nutrition to
Identify Patients at Nutrition Risk
(Inpatient)
100
90
80 74
70
61
60 % Resp
Nursing
50 46 Scrn
40 34 n=442
30 30
23 % Resp
20 16 17 17 19
12 Nutr
10 10 Scrn
0 n=252
Age wt/ht Food Conc NPO/Clr Visceral
Allergy Formula Pro
How Many Levels of Risk Does
Your Screening System Include?
45 43
41
40
35
30
25
% of Respondents
20 16 n=522
15
10
5
0
Two Three Four or More
Has Your Inpt Screening System Been
Validated for Sensitivity/Specificity?
80 74 74

70
60
50
40 Yes
26 26 No
30
20
10
0
Sensitivity Specificity

% of respondents
How Well Do Inpt Screening Criteria
Effectively Identify Nutrition Risk?
80
71
70
60
54
50
40 34 Nutrition Staff
criteria
30 Nursing Staff
Criteria
20 15 13
8
10 4
1
0
All/Most of the Sometimes Half to Never n/a
Time
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 Comment
Mezoff A. Lngth/ht, PICU pts w/ High nutr risk
Pediatrics 1 wt/ht %ile, RSV score associated
Apr 1996 wt hx, dx, lab with poor
data outcome; (nearly
full page form)
Burden ST. BMI, 100 Sensitivity 78%;
J Hum Nutr MUAC, wt med/surg/ specificity 52% vs
Diet 2001 hx, intake vs elderly nutrition
needs hospital pts assessment
(UK) (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.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
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)

40 39

35

30
25
25 23

20
# of Pts, n=101
15 13

10 8 8
6 5
5

0
EN/PN Wt Loss Intake Education Skin Preg/Lact Age Conc
Feeds
% of Positive Nutrition Screens Classified as
High Risk after Review (by Criterion)
100 100

90
82
80
70
70
61
60 53 % of
50 Positive
Screens
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 at-
risk 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,
Childrens Hospital, Dayton, Oh, practitioner
Judy Porcari, MBA, MS, RD, Clinical Manager
Annalynn Skipper, PhD, RD, FADA, Consultant

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