The Nutrition Care Process: Nutrition Screening

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

Patient/Client/Group & Dietetics Professional Nutrition Monitoring and Evaluation Monitor progress Measure outcome indicators Evaluate outcomes Document 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 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 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 Nutrition assessment what data are most effective for identifying

clients nutrition related problem of interest Type of assessment Content component What type of assessment data? Nutritional adequacy Fat and cholesterol intake Trans fatty acid intake Health status Lipid profile BMI Waist circumference What are the reliable

standards (ideal goals)? how well, how much, how long 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 clients 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 Weight Problems with Weight change Need for diet modification or education Laboratory values (s. albumin, cholesterol, hemoglobin, TLC

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 Pts Population Criteria Prevalence Warnold et al, 1984 Noncancer pts in Wt loss, Wt/Ht, Sweden (n=215) s. alb, AMC 12% Messner et al, 1991

VA patients (n=500) 55% s. alb, TLC, wt loss Robinson et Medicine pts al, 1987 (n=100) Wt loss, lab data, 40% anthropometrics Chima et al, Medicine pts 1997 (n=173) s. alb, wt loss, wt/ht

Thomas, et al, 2002 Lab data, 29% anthropometrics, MNA score Subacute pts (837) 32% 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 70 68.5

60 % of Respondents 1987 CNM survey (n=46) 2003 CNM survey (n=110) 2007 CNM (n=514) 50 40 30 17 20 10 0 *In 6.5

Nursing 10 Nutrition 8 5 Other the 1987 survey, only 60% of 77 respondents reported admission nutrition screening Criteria Used by Nursing in Nutrition Screening (n=442) Criterion History of weight loss Poor intake pta Patient is on nutrition support Chewing/swallowing issues Skin breakdown

Pregnant/lactating mother off OB Diagnosis Need for education Geriatric surgical patient N 418 360 349 333 319 197 167 160 148 % 95% 81% 79% 75% 72%

45% 38% 36% 33% Criteria Used by Nursing in Nutrition Screening (n=442) Criterion Specific diet orders Food allergy NPO/Clear liquid in-house Weight for height criterion Age (premature or geriatric) Visceral proteins (albumin, PAB) Infant on concentrated formula Body mass index Other N 105 103 84

75 71 51 43 38 111 % 24% 23% 19% 17% 16% 12% 10% 9% 25% How Were Nursing Screening Criteria Chosen? 70 60

50 40 30 % of respondents (n=442) 20 10 0 Readily Available Easy to No Clinical Evidence Use Expertise Based Tested Seem to TJC 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 Assessment

Computerized Record Interdisciplinary Form How Are + Nursing Screens Communicated to Nutrition Staff? 90 80 70 60 50 40 % of Respondents, n=438 30 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% by NU screens

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 % Nutrition staff (NS) screens use 61% different data than NU n 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?

70 60 50 40 % of Respondents (n=256) 30 20 10 0 Dietitians DTR BS Nutr Clerk Other

Criteria Used by Nutrition Staff in Secondary Screening (n=258) Criterion Diagnosis NPO/Clear in-house Patient on nutrition support Specific diet orders Visceral proteins (albumin, PAB) Chewing/swallowing issues Skin breakdown History of weight loss Weight for height criterion N 223 192 190 161 158 139 137

136 119 % 86% 74% 74% 62% 61% 54% 53% 53% 46% Criteria Used by Nutrition Staff in Secondary Screening (n=258) Criterion Poor intake prior to admission Need for education BMI Food allergy Geriatric surgical patient

Pregnant/lactating outside OB Age (premature or geriatric) Infant on concentrated formula Other N 110 95 93 89 83 79 78 44 40 % 43% 37% 36 35% 33

31% 30% 17% 15% Where Is Secondary Screening Documented in the Medical Record? 30 28 28 23 25 20 15 15 10 5

5 0 Chart Form Computer Progress Note Not Doc Interd Form % of Respondents n=260 Criteria Used by Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient) 100

95 90 81 80 70 60 50 40 79 75 53 74 72

53 54 45 43 31 30 20 10 0 Wt Loss Poor Intake PTA Chewing/ Swallowing

EN/PN Skin Brkdwn Preg/ Lactating % of Resp Nursing Scrn n= 442 % Resp Nutrition Screen n=252 Criteria Used By Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient) 100 90 86

80 70 62 60 50 38 40 30 20 33 33 36 37 24

% Resp Nutrition Scrn n=252 10 0 Spec Diets % Resp Nursing Scrn n=442 Dx Ger Surg Education Criteria Used By Nursing/Nutrition to Identify Patients at Nutrition Risk

(Inpatient) 100 90 80 70 60 50 40 30 20 10 0 74 61 46 34 30 16 17

Age wt/ht 23 17 10 Food Allergy 19 12 Conc NPO/Clr Visceral Formula Pro % Resp

Nursing Scrn n=442 % Resp Nutr Scrn n=252 How Many Levels of Risk Does Your Screening System Include? 45 43 41 40 35 30 25 16

20 15 10 5 0 Two Three Four or More % of Respondents n=522 Has Your Inpt Screening System Been Validated for Sensitivity/Specificity? 74 80 74

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

How Well Do Inpt Screening Criteria Effectively Identify Nutrition Risk? 80 70 71 60 54 50 40 34 Nutrition Staff criteria Nursing Staff Criteria

30 20 15 8 10 0 13 4 1 All/Most of the Time Sometimes Half to Never n/a

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

Mezoff A. Lngth/ht, PICU pts w/ Pediatrics 1 wt/ht %ile, RSV Apr 1996 wt hx, dx, lab data Burden ST. BMI, J Hum Nutr MUAC, wt Diet 2001 hx, intake vs needs 100 med/surg/ elderly hospital pts (UK) Comment High nutr risk score associated with poor outcome; (nearly

full page form) 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 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) 39 40 35 30 25 25 23 20 15 10 # of Pts, n=101

13 8 8 6 5 Age Conc Feeds 5 0 EN/PN Wt Loss Intake

Education Skin Preg/Lact % of Positive Nutrition Screens Classified as High Risk after Review (by Criterion) 100 100 90 82 80 70 70

61 60 53 % of Positive Screens 50 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 atrisk 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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