1、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 ($),Relationship,Between,Patient/Client/Gro
2、up,&,Dietetics,Professional,-,Nutrition Diagnosis,Identify and label problem,Determine cause/contributing risk,factors,Cluster signs and symptoms/,defining characteristics,Nutrition Assessment,Obtain/collect timely and,appropriate,data,Analyze/interpret with,evidence,-,based standards,Identify risk
3、factors,Use appropriate tools,and methods,Involve,interdisciplinary,collaboration,Screening,& Referral,System,Outcomes,Management Sys,tem,Monitor the success of the Nutrition Care,Process implementation,Evaluate the impact with aggregate data,Identify and analyze causes of less than,optimal performa
4、nce and outcomes,Refine the use of the Nutrition Care,Process,ADA NUTRITION CARE PROCESS,AND MODEL,Document,Nutrition Monitoring and,Evaluation,Monitor progress,Measure outcome indicators,Evaluate outcomes,Document,Nutrition Intervention,Plan nutrition intervention,Formulate goals and,determine a pl
5、an of action,Implement the nutrition intervention,Care is delivered and actions,are carried out,Documen,t,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,
6、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 Ste
7、ps,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 intak
8、e 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 m
9、osteffective foridentifying clientsnutrition related problem of interest,Type of assessment Content componentNutritional adequacy Fat and cholesterol intake Trans fatty acid intake Health statusLipid profileBMI Waist circumferenceWhat are the reliable standards (ideal goals)?how well, how much, how
10、long,What type of assessment data?,How do we get from Assessment to Intervention? Nutrition Diagnosis,A crucial element of providing quality nutrition care,Nutrition Diagnosis,PurposeIdentify and label the nutrition problemNutrition diagnosis NOT medical diagnosisEXPLICIT statement of nutrition diag
11、nosisNote: 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 scienti
12、fic 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 clients goals or desired outcomesMonitoring: review and measu
13、rement of status at scheduled times Evaluation: systematic comparison with previous status, intervention goals, reference standardNote: 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
14、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
15、 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 Nut
16、rient 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 unw
17、illingness 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 feedi
18、ng 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 Kraus
19、e, 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
20、fat and muscle storesNOTE: 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, AI
21、DS, 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 (choles
22、terol, 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-
23、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
24、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 assessme
25、nt and reassessment,Elements of Performance The information.to be gathered during the initial assessment includes the following, as relevant.: Each patients nutrition and hydration status, as appropriate The hospital has defined criteria for when nutritional plans must be developed,Standard PC.2.120
26、: 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 patients needs or condition, is completed within no more than 24 hours of inpatient admission CAMH online version, 2006,Standards Relat
27、ing 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 nu
28、trition 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
29、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,Nutrition Screening and Assessment Tool,Courtesy
30、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 mo
31、re than 50% There is little published data regarding nutrition screening for other purposes,Malnutrition in Hospitalized Pts,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 surv
32、eys were returned, for a response rate of 31%,Does Your Health Care Organization Screen Patients for Nutrition Risk?,(with accredited ambulatory clinics),Screening in Acute Care,Who Has Primary Responsibility for Nutrition Screening (Inpatient)?,*In the 1987 survey, only 60% of 77 respondents report
33、ed admission nutrition screening,% of Respondents,Criteria Used by Nursing in Nutrition Screening (n=442),Criteria Used by Nursing in Nutrition Screening (n=442),How Were Nursing Screening Criteria Chosen?,Where Are Nursing Screening Results Documented in the MR?,How Are + Nursing Screens Communicat
34、ed to Nutrition Staff?,If Nursing Screens, Do Nutrition Staff Do a Secondary Screen?,Why Do Nutrition Staff (NS) Do Secondary Screening?,Characteristics of Secondary Nutrition Screening,Who Is Responsible for Secondary Nutrition Screening?,Criteria Used by Nutrition Staff in Secondary Screening (n=2
35、58),Criteria Used by Nutrition Staff in Secondary Screening (n=258),Where Is Secondary Screening Documented in the Medical Record?,Criteria Used by Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient),Criteria Used By Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatien
36、t),Criteria Used By Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient),How Many Levels of Risk Does Your Screening System Include?,Has Your Inpt Screening System Been Validated for Sensitivity/Specificity?,% of respondents,How Well Do Inpt Screening Criteria Effectively Identify Nu
37、trition Risk?,Validation of Nutrition Screening Tools in Acute Care,Validation of Nutrition Screening Tools in Acute Care,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
38、 =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 (
39、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 prob
40、lems/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 90 %ile weight/lengthChildren 2-18 Years 85 %ile BMI/age,Nursing Admission Screens: Most C
41、ommon Criteria MHMC (Feb 17-Mar 2, 2003),% of Positive Nutrition Screens Classified as High Risk after Review (by Criterion),Nutrition Screening at MetroHealth,Consistent with national practice in terms of criteria, procedures, and time frames With the exception of TJC-mandated criteria, specificity
42、 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 professional
43、s 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 va
44、lidate 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
45、, 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,
