screening nutrition care process
TRANSCRIPT
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/Group & 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 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 performance 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 plan of action
Implement the nutrition intervention Care is delivered and actions
are carried out Document
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
Nutritionassessmentwhat data are most
effective for identifying
clients’ nutrition related
problem of interest
Type of assessmentContent component Nutritional adequacy Fat and cholesterol intake Trans fatty acid intake Health status
Lipid profile BMI Waist circumference
What are the reliablestandards (ideal goals)?
• how well, how much, how 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
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
client’s goals or desired outcomes Monitoring: review and measurement of statusat scheduled times Evaluation: systematic comparison with previous status,
intervention goals, reference standard
Note: Documentation is an on-going process thatsupports 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 QuestionnaireNutrition 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, 12 th 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, 12 th 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 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 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 PtsPopulation Criteria Prevalence
Warnold etal, 1984
Noncancer pts inSweden (n=215)
Wt loss, Wt/Ht,s. alb, AMC
12%
Messner etal, 1991
VA patients(n=500)
s. alb, TLC, wtloss
55%
Robinson etal, 1987
Medicine pts(n=100)
Wt loss, lab data,anthropometrics
40%
Chima et al,1997
Medicine pts(n=173)
s. alb, wt loss,wt/ht
32%
Thomas, etal, 2002
Subacute pts(837)
Lab data,anthropometrics,MNA score
29%
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%
Does Your Health Care Organization Screen Patients for Nutrition Risk?
99
63
0
10
20
30
40
50
60
70
80
90
100
Inpatient (n=522) Ambulatory (n=345)
% of Respondents
(with accredited ambulatory clinics)
Screening in Acute Care
Who Has Primary Responsibility for Nutrition Screening (Inpatient)?
6.5
74
83
68.5
1710 8
50
10
20
30
40
50
60
70
80
90
Nursing Nutrition Other
1987 CNM survey(n=46)2003 CNM survey(n=110)2007 CNM (n=514)
*In the 1987 survey, only 60% of 77 respondents reported admission nutrition screening
% of Respondents
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?
0
10
20
30
40
50
60
70
ReadilyAvailable
Easy toUse
No ClinicalExpertise
EvidenceBased
Testedand
Validated
Seem toWork Well
TJCRequires
It
% ofrespondents(n=442)
Where Are Nursing Screening Results Documented in the MR?
0
10
20
30
40
50
60
70
Nursing AdmittingAssessment
Other Specific Form ComputerizedRecord
InterdisciplinaryForm
% ofRespondents(n=442)
How Are + Nursing Screens Communicated to Nutrition Staff?
0
10
20
30
40
50
60
70
80
90
Fax Phone Computer Other N/A
% ofRespondents,n=438
If Nursing Screens, Do Nutrition Staff Do a Secondary Screen?
57
43
0
10
20
30
40
50
60
Yes No
% of respondents(n=441)
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
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
Who Is Responsible for Secondary Nutrition Screening?
0
10
20
30
40
50
60
70
Dietitians DTR BS Nutr Clerk Other
% ofRespondents(n=256)
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?
15
28 28
23
5
0
5
10
15
20
25
30
ChartForm
Computer ProgressNote
Not Doc InterdForm
% ofRespondentsn=260
Criteria Used by Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient)
95
53
81
43
75
54
7974 72
5345
31
0
10
20
30
40
50
60
70
80
90
100
Wt Loss Poor IntakePTA
Chewing/Swallowing
EN/PN Skin Brkdwn Preg/Lactating
% of RespNursing Scrnn= 442
% RespNutritionScreenn=252
Criteria Used By Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient)
24
62
38
86
33 33 36 37
0
10
20
30
40
50
60
70
80
90
100
Spec Diets Dx Ger Surg Education
% RespNursing Scrnn=442
% RespNutritionScrn n=252
Criteria Used By Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient)
16
30
17
46
23
34
1017 19
74
12
61
0
10
20
30
40
50
60
70
80
90
100
Age wt/ht FoodAllergy
ConcFormula
NPO/Clr VisceralPro
% RespNursingScrnn=442
% RespNutrScrnn=252
How Many Levels of Risk Does Your Screening System Include?
4341
16
0
5
10
15
20
25
30
35
40
45
Two Three Four or More
% of Respondentsn=522
Has Your Inpt Screening System Been Validated for Sensitivity/Specificity?
26
74
26
74
0
10
20
30
40
50
60
70
80
Sensitivity Specificity
Yes
No
% of respondents
How Well Do Inpt Screening Criteria Effectively Identify Nutrition Risk?
71
34
15
54
1
813
4
0
10
20
30
40
50
60
70
80
All/Most of theTime
Sometimes Half to Never n/a
Nutrition StaffcriteriaNursing StaffCriteria
Validation of Nutrition Screening Tools in Acute Care
Criteria Population Comment
Kovacevichet al, NCP1997
Dx, intake,IBW, Wt hx
Adult acutecare ptsn=186
Sensitivity 84.6%;specificity 62.6 byPAB. (Nearly fullpage screen form)
FergusonM.Nutrition 1Jun 1999
Appetite,unintentionalwt loss
Adult acutecare ptsn=408(Australia)
High inter-raterreliability (93-97%)High sensitivity/specificity vs SGA
Laporte M,JNHA 1 Jan2001
BMI + wtlossBMI +albumin
Elderlyacute /LTCn=142(Canada)
Validity 60.5%-93.1% vs RDnutrition assessment
Validation of Nutrition Screening Tools in Acute Care Criteria Population Comment
Mezoff A. Pediatrics 1 Apr 1996
Lngth/ht, wt/ht %ile, wt hx, dx, lab data
PICU pts w/ RSV
High nutr risk score associated with poor outcome; (nearly full page form)
Burden ST. J Hum Nutr Diet 2001
BMI, MUAC, wt hx, intake vs needs
100 med/surg/ elderly hospital pts (UK)
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. 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 ClinicsChildren <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)
8
39
13
2523
86 5
0
5
10
15
20
25
30
35
40
EN/PN Wt Loss Intake Education Skin Preg/Lact Age ConcFeeds
# of Pts, n=101
% of Positive Nutrition Screens Classified as High Risk after Review (by Criterion)
100
70
82
53
61
17
00
10
20
30
40
50
60
70
80
90
100
EN Skin Intake Wt Education Age Preg/Lact
% ofPositiveScreens
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,
Children’s Hospital, Dayton, Oh, practitioner Judy Porcari, MBA, MS, RD, Clinical Manager Annalynn Skipper, PhD, RD, FADA, Consultant