Utilization of the Nutrition Care Process in International Settings Sylvia Escott-Stump, MA, RD, LDN escottstumps@ecu.eduedu Today s Objectives Participants will be able to discuss the importance of using standardized language and the nutrition care process in any environment. Participants will identify at least one behavioral change they will make after the seminar. Quality Nutrition Care and Professional Performance Who Demands it? Funding Agencies Accrediting Organizations What About Others? Other Disciplines Have Diagnoses Medicine Nursing Physical Therapy Occupational Therapy Other Countries The Dutch have a 5- step process including Intake, Assessment, Nutrition Diagnosis, Intervention, Monitoring-Evaluation. Consumers International Nutrition Diagnostic and Terminology (INDT), th ed. Progress in Other Countries Several countries are validating or adopting international standardized nutrition terminology. Canada, Great Britain, and others have made great strides. Australia and Mexico are using nutrition diagnoses. 1
This Study Purpose To describe the current status of Nutrition Care Process and standardized terminology internationally. To share sample training and template ideas. Survey Assumptions The Nutrition Care Process and Model (NCP) provides a consistent structure in the delivery of care given by dietitians. Consistency in the steps of nutrition assessment and nutrition diagnosis i will lead to more effective interventions and outcomes. Use of standardized language validates nutrition care, will increase the demand for services, and predict patient outcomes more reliably. Methods A twenty-question survey was emailed to 5 dietitians in 8 countries: 19 surveys were completed. The survey contained questions using a hedonic scale and open ended questions about: use of a standardized d nutrition language in medical record documentation use of nutrition diagnosis and PES statements opinions on the helpfulness of the documentation in their specific facilities. The questions also addressed the current format of charting at the facilities, demographic information, and interest in a training seminar on the use and implementation of the NCP. Results The following graphs summarize: demographics of the surveyed population the current use of the NCP in various settings perceptions of this process. Demographics Years experience in Dietetic Practice 0% Hospitals 30% Nursing homes 7 10% Community settings # of dietitians 3 years of experience
Use of Nutrition Diagnosis/ PES Statements in Charting Usefulness of Standardized Language and Process in Your Work Setting 1 10 8 s # of participants 0 3 11 1 Positive Negative Neutral Unsure 1 1 10 Positive 8 Negative Neutral Unsure 3 1 0 # of participants 13 Key: Positive indicates an answer of always or sometimes. Negative indicates an answer of rarely or never Key: Positive indicates a response of definitely yes. Negative indicates a response of definitely no; neutral indicates a response of maybe. Open to Use of International Standardized Nutrition Terminology 1 10 8 0 # of participants 1 0 5 Positive Negative Neutral Unsure Other Comments: Why Use the NCP? It streamlines my work. It is more efficient. It clarifies communication between dietitians and with other healthcare professionals. It supports consistency between different settings (community, hospital, nursing home.) Key: Positive reflects a response of definitely yes, negative reflects a response of definitely no, and neutral reflects a response of maybe. Survey Conclusion Solutions?? Few dietitians are consistently using the process and language in their documentation. The majority are open to being trained. Training Practice Sample templates Training Templates Practice Increased Adoption 3
Training Emphasize the Importance Training Implementation Offer Training Sessions Different days Different times Assess competency Complete the training exercises Finish checklist Nutrition Care Process: -Steps Recommended Training Sequence Week 1: Assessment & Nutrition Diagnosis Week : Goals/Interventions/ Nutrition Prescriptions Week 3: Monitoring/Evaluation Week : Full documentation The Nutrition Care Process and Model Lacey & Pritchett, JADA August 003; updated 008 The Nutrition Care Process NCP is a systematic problem-solving method that dietetics professionals use to critically think and make decisions to address nutrition related problems and provide safe and effective quality nutrition care. Use of the NCP results in a higher probability of producing desired outcomes.
Charting Acronym: A-D-I-ME Assessment Diagnosis Intervention ADIME Monitoring and Evaluation Malnutrition Yields Undesirable Outcomes!! Malnutrition leads to depression of the immune system impaired wound healing muscle wasting longer lengths of hospital stay higher treatment costs increased mortality Screening and implementation of published best-practice guidelines may effectively reduce hospital malnutrition and save costs -Barker et al, 011 Begin with Assessment Changes in nutritional intake, appetite or weight are essential components of nutrition assessment. Assessment Factors ABCDs Anthropometrics Biochemical Assessment Clinical (Physical) Assessment Dietary Assessment Sample Color-coded Assessment Forms STEP : Nutrition Diagnosis Nutrition Nutrition Nutrition Nutrition Assessment Diagnosis Intervention Mon-Eval Problem Etiology Signs & Symptoms 5
Modify rate/conc/comp/schd Insert EN feeding tube Commercial food Modified beverage Multi-trace element Vit A Vit C Vit D Vit K Vit E Riboflavin Niacin Folate Vit B Dose change Form change Odors Distractions Form change Route change Recommended modifications Adv. or related topics Purpose of the nutrition Recommended modifications Adv. or related topic Goal Setting Self monitoring Problem solving Social support Team meeting Referral to RD Site Care Discontinue Specific beverage or food group Modified food Purpose Vit B1 Thiamin Calcium Chloride Iron Magnesium Potassium Phosphorus Sodium Zinc Route Change Administration schedule Discontinue Meal set-up Mouth care Table height Room Temperature Administration schedule Discontinue Result interpretation Skill development Result interpretation Skill development Social learning theory Transtherortical/Stages Stress management Stimulus control Cognitive restricting Relapse prevention Rewards/contingency management Collaboration/referral Referral to community Problem-Etiology-Signs/Symptoms (P-E-S) Write an accurate P-E-S statement: Problem (nutrition diagnosis) its Etiology l (cause) Signs and symptoms (measurable indicators) This requires deep critical thinking by the qualified dietitian. Common Nutrition Diagnoses CARDIOVASCULAR DISEASES Excessive energy intake (NI 1.5) Excessive fat intake (NI 51.) Inadequate vitamin intake (NI 5.1) Inadequate mineral intake (NI 55.1) Food medication interaction (NC.3) Food-nutrition-related knowledge deficit (NB 1.1) Limited adherence to nutritionrelated recommendations (NB 1.) DIABETES Inappropriate intake of food fats (NI 51.3) Inadequate carbohydrate intake (NI 53.1) Excessive carbohydrate intake (NI 53.) Inappropriate intake of types of carbohydrate (NI 53.3) Inconsistent carbohydrate intake (NI 53.) Altered nutrition-related laboratory values (NC.3) Overweight/obesity (NC 3.3) Food and nutrition-related knowledge deficit (NB 1.1) Week : Intervention/Goals There are domains of Intervention: Food/Nutrient Delivery, Nutrition Education, Nutrition Counseling, and Coordination of Care. The assessment/consult condenses each domain s labels to relevant factors. Planning: reviewing the diagnosis, policies and guides, and conferring with patient and medical team members. Implementing: carrying out and communicating, continuing, and/or revising the plan of care. Nutrition Intervention is directed toward the etiology of the problem. In some cases the etiology can not be changed. The intervention should reduce the impact of the signs and symptoms. First Three Steps of the NCP Meals and Snacks General healthy diet Modify type beverage or food group Enteral and Parenteral Initiate Nutrition Assessment: Gather signs/symptoms Understand etiology Medical Food Supplements Commercial beverage Vitamin and Mineral Supplements Multivitamin/mineral Determine Nutrition Diagnosis: write as PES Bioactive Substance Supplement Initiate Feeding Assistance Adaptive equipment Feeding Position Feeding Environment Lighting Nutrition Related Medication Management Initiate Dose change Nutrition Intervention: Based on etiology of Dx Nutrition Education, Initial/Brief Purpose of education Comprehensive Education, Instruction Indepth Skills Counseling, Theoretical basis/approach Cognitive-behavior theory Health belief model Counseling Strategies Motivational interviewing Coordination of Other Care during Nutrition Care Coordination of DC/Transition Collaboration/referral Referral to community
Nutrition Prescription Step 3 Monitoring & Evaluation The nutrition prescription drives the intervention selection. Consider Recommended Dietary intake, nutrient intake, evidence guides, and health condition of the patient. Dietitian then makes recommendations to the medical team to resolve the patient s nutrition diagnosis. Review and Evaluate for Success Nutrition Nutrition Nutrition Nutrition (re)assessment Diagnosis Intervention Mon-Eval Problem Etiology Signs & Symptoms Step : Full Documentation Old Assessment Note New Assessment Note Sample Template 7
Sample A-D-I-ME Paper Form ASSESSMENT: Summary of subjective and objective data from chart review and patient/caregiver. Ht Current Wt Usual Weight IBW range Current IBW % Estimated needs for Energy kcals Protein gms/ Kg Fluid cc Other Nutrients (specify) Summary of Diet History: Intake approximately % at meals and/or % from TF and/or % from PN Abnormal lab values Liquids, Nausea, Vomiting, Diarrhea >5 days yes/no Usual Meds Side effects? Yes/no Current Meds Side effects? Yes/no Food allergies Food intolerances: Sample A-D-I-ME Paper Form NUTRITION DIAGNOSIS(ES): related to as evidenced by. related to as evidenced by. related to as evidenced by. INTERVENTIONS: Food and Nutrient Delivery: Education (imparting of information only): Counseling (1:1 in-depth): Coordinatiion of Care: MONITORING: Previous Wt Current Wt %Change Comment on Progress Previous labs compared with current labs: Food-drug interaction potential and status: Other potential problems or risks: Refeeding syndrome Unintentional weight loss EVALUATION: Previous Clinical Concerns: Comment on Progress Previous Behavioral-Environmental Concerns: Comment on Progress Previous Intake compared with Current Intake: Comment on Progress Previous Educational Needs and Sessions Provided: Comment on Progress Date: Dietitian (RD) Nutrition Provider # Study Implications Further surveys should be conducted to determine how the NCP can be used: In other acute care units In long-term care In community settings, including home care. Care Levels - Example Top Priority for RD: Nutrition Diagnoses, including but not limited to: Inadequate Energy Intake NI-1. Inadequate oral food/beverage intake NI -.1 Inadequate intake from enteral/parenteral nutrition NI. Inappropriate infusion of enteral/parenteral nutrition NI-.5 Inadequate fluid intake NI-3.1 Malnutrition NI 5. Inadequate protein-energy intake NI 5.3 Inadequate protein intake NI 5.1 Inadequate vitamin intake NI-5.1 Food-medication interaction NC.3 Involuntary weight loss NC - 3. Food and Nutrition related knowledge deficit NB1.1 Conclusion Health care payers, medical team members, and administrators will be able to identify the true cost-benefit of dietitian services when similar terminology crosses international borders of care. References ADA. Nutrition Care Process and Model Part 1: The 008 Update. J. Am Diet Assoc. 008; 108: 1113-1117. ADA. Nutrition Care Process Part II: Using the International Dietetics and Nutrition Terminology to Document the Nutrition Care Process. J. Am Diet Assoc. 008; 108: 187-193. Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health 011; 8:51-7. Hakel-Smith N, Lewis N, Eskridge K. Orientation to Nutrition Care Process Standards Improves Nutrition Care Documentation by Nutrition Practitioners. J. Am Diet Assoc. 005; 105: 158-1589. Lacey K, Pritchett E. Nutrition Care Process and Model: ADA Adopts Road Map to Quality Care and Outcomes Management. J. Am Diet Assoc. 003; 103: 101-107. Mathieu J, Foust M, Ouellette P. Implementing Nutrition Diagnosis, Step Two in the Nutrition Care Process and Model: Challenges and Lessons Learned in Two Health Care Facilities. J Am Diet. Assoc. 005; 105: 13-10. McCarthy, M. A Renal Nutrition Forum Series with Practice-Based Examples of the Nutrition Care Process (NCP): What s Happening Among Dialysis Providers? Renal Nutrition Forum 010; 9.1: 1-13. 8