Sylvia Escot Stump - Utilization of the nutrition care process in international settings

By: Sylvia Escott-Stump, MA, RD, LDN

Past President, Academy of Nutrition and Dietetics

East Carolina University Greenville, North Carolina, USA

[email protected]

© S. Escott-Stump 1

mailto:[email protected]

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.


Funding Agencies

Accrediting Organizations

Quality Nutrition Care and

Professional Performance

…Who Demands it?

Consumers © S. Escott-Stump 3

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.


International Nutrition Diagnostic and Terminology (INDT)

–updated annually


Progress in Other Countries

Several countries are validating or adopting international standardized nutrition terminology.

Canada, Great Britain, Australia, Netherlands


This Study Purpose

To describe the current status of Nutrition Care Process and standardized terminology internationally.

To share sample

training and template ideas.


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 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.

Survey Assumptions


A twenty-question survey was emailed to 25 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 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.

Methods


Results

The following graphs summarize:

demographics of the surveyed population

the current use of the NCP in various settings

perceptions of this process.


Demographics

60% Hospitals

30% Nursing homes

10% Community settings


Years experience in Dietetic Practice

years of experience

# o

f die

titians

2

6

7

3


0

2

4

6

8

10

12

Positive

Negative

Neutral

Unsure

Use of Nutrition Diagnosis/ PES Statements in Charting

# o

f p

art

icip

an

ts

Key: Positive indicates an answer of always or sometimes.

Negative indicates an answer of rarely or never

3

11

4

1


0

2

4

6

8

10

12

14

Positive

Negative

Neutral

Unsure

Usefulness of Standardized Language and Process in Your Work Setting

# o

f p

art

icip

an

ts

Key: Positive indicates a response of definitely yes. Negative indicates a response of

definitely no; neutral indicates a response of maybe.

3

2

13

1


0

2

4

6

8

10

12

Positive

Negative

Neutral

Unsure

Open to Use of International Standardized Nutrition Terminology

# o

f p

art

icip

an

ts

Key: Positive reflects a response of definitely yes, negative reflects a response of

definitely no, and neutral reflects a response of maybe.

12

0

5

2


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.)


Survey Conclusion

Few dietitians are

consistently using the process and language in their documentation.

The majority are open to being trained.


Solutions??

Training

Practice

Sample templates

Increased Adoption

Practice

Templates

Training


Training

Emphasize the Importance

Offer 2 Training Sessions

Different days

Different times


Training Implementation

Assess competency

Complete the training

exercises

Finish checklist


Nutrition Care Process: 4-Steps


Recommended Training Sequence

Week 1: Assessment &

Nutrition Diagnosis

Week 2: Goals/Interventions/

Nutrition Prescriptions

Week 3: Monitoring/Evaluation

Week 4: Full documentation


Nutrition Care Process and Model Lacey & Pritchett , JADA August 2003; updated 2008


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 Monitoring

and Evaluation

ADIME


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, 2011


Begin with Assessment

Changes in nutritional intake, appetite or weight are essential components of nutrition assessment.


ABCDs

Anthropometrics

Biochemical Assessment

Clinical (Physical) Assessment

Dietary Assessment

Assessment Factors


Sample Color-coded Assessment Forms


Nutrition Nutrition Nutrition Nutrition

Assessment Diagnosis Intervention Mon-Eval

Problem Etiology Signs & Symptoms

STEP 2: Nutrition Diagnosis…


Problem-Etiology-Signs/Symptoms (P-E-S)

Write an accurate P-E-S statement:

Problem (nutrition diagnosis)

its Etiology (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 51.2) Inadequate vitamin intake (NI

54.1) Inadequate mineral intake (NI

55.1) Food medication interaction

(NC 2.3) Food-nutrition-related

knowledge deficit (NB 1.1) Limited adherence to

nutrition-related recommendations (NB 1.6)

DIABETES Inappropriate intake of food

fats (NI 51.3) Inadequate carbohydrate

intake (NI 53.1) Excessive carbohydrate intake

(NI 53.2) Inappropriate intake of types

of carbohydrate (NI 53.3) Inconsistent carbohydrate

intake (NI 53.4) Altered nutrition-related

laboratory values (NC 2.3) Overweight/obesity (NC 3.3) Food and nutrition-related

knowledge deficit (NB 1.1)


There are 4 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.

Week 2: Intervention/Goals


First Three Steps of the NCP Nutrition Assessment:

Gather signs/symptoms

Understand etiology

Determine Nutrition Diagnosis:

write as PES

Nutrition Intervention:

Based on etiology of Dx


Step 3 Intervention


Enteral and Parenteral □ Initiate

□ Modify rate/conc/comp/schd

□ Insert EN feeding tube

□ Site Care

□ Discontinue

Meals and Snacks □ General healthy diet

□ Modify type beverage or food

group

□ Specific beverage or food group

Medical Food Supplements □ Commercial beverage

□ Commercial food

□ Modified beverage

□ Modified food

□ Purpose

Vitamin and Mineral

Supplements

□ Multivitamin/mineral

□ Multi-trace element

□ Vit A

□ Vit C

□ Vit D

□ Vit K

□ Vit E

□ Riboflavin

□ Niacin

□ Folate

□ Vit B6

□ Vit B12

□ Thiamin

□ Calcium

□ Chloride

□ Iron

□ Magnesium

□ Potassium

□ Phosphorus

□ Sodium

□ Zinc

Bioactive Substance

Supplement

□ Initiate

□ Dose change

□ Form change

□ Route Change

□ Administration schedule

□ Discontinue

Feeding Assistance □ Adaptive equipment

□ Feeding Position

□ Meal set-up

□ Mouth care

Feeding Environment □ Lighting

□ Odors

□ Distractions

□ Table height

□ Room Temperature

Nutrition Related Medication

Management

□ Initiate Dose

change

□ Form change

□ Route change

□ Administration schedule

□ Discontinue

Nutrition Education, Initial/Brief □ Purpose of education

□ Recommended modifications

□ Adv. or related topics

□ Result interpretation

□ Skill development

Comprehensive Education,

Instruction In-depth Skills

□ Purpose of the nutrition

□ Recommended modifications

□ Adv. or related topic

□ Result interpretation

□ Skill development

Counseling, Theoretical

basis/Approach

□ Cognitive-behavior theory

□ Health belief model

□ Social learning theory

□ Transtherortical/Stages

Counseling Strategies □ Motivational interviewing

□ Goal Setting

□ Self monitoring

□ Problem solving

□ Social support

□ Stress management

□ Stimulus control

□ Cognitive restricting

□ Relapse prevention

□ Rewards/contingency management

Coordination of Other Care

during Nutrition Care

□ Team meeting

□ Referral to RD

□ Collaboration/referral

□ Referral to community

Coordination of DC/Transition □ Collaboration/referral □ Referral to community


Nutrition Prescription 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.


Step 4 Monitoring & Evaluation


Nutrition Nutrition Nutrition Nutrition

(re)Assessment Diagnosis Intervention Mon-Eval

Problem Etiology Signs & Symptoms

Review and Evaluate for Success


Full Documentation Old Assessment Note New Assessment Note


Sample Template


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________________________________.



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 #___________________

Sample A-D-I-ME Paper Form


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.


Top Priority for RD: Nutrition Diagnoses, including but

not limited to: Inadequate Energy Intake NI-1.4

Inadequate oral food/beverage intake NI - 2.1

Inadequate intake from enteral/parenteral nutrition NI – 2.4

Inappropriate infusion of enteral/parenteral nutrition NI-2.5

Inadequate fluid intake NI-3.1

Malnutrition NI 5.2

Inadequate protein-energy intake NI 5.3

Inadequate protein intake NI 52.1

Inadequate vitamin intake NI-54.1

Food-medication interaction NC – 2.3

Involuntary weight loss NC - 3.2

Food and Nutrition related knowledge deficit NB1.1

Care Levels - Example


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.


ADA. Nutrition Care Process and Model Part 1: The 2008 Update. J. Am Diet Assoc. 2008; 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. 2008; 108: 1287-1293.

Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health 2011; 8:514-27.

Hakel-Smith N, Lewis N, Eskridge K. Orientation to Nutrition Care Process Standards Improves Nutrition Care Documentation by Nutrition Practitioners. J. Am Diet Assoc. 2005; 105: 1582-1589.

Lacey K, Pritchett E. Nutrition Care Process and Model: ADA Adopts Road Map to Quality Care and Outcomes Management. J. Am Diet Assoc. 2003; 103: 1061-1072.

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. 2005; 105: 1636-1640.

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 2010; 29.1: 12-13.

References


Thank you, MDA!


Sylvia Escot Stump - Utilization of the nutrition care process in international settings

Health & Medicine

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