Education, implementation, and barriers to clinical dietitians’ use of nutrition-focused physical exams Brooke Kuhn

Introduction Frequency of malnutrition depends on diagnostic criteria, but it is rising 35-55% of patients admitted 25-30% develop while hospitalized (estimates) Results in consequences to patient health, recurrent hospitalization, longer LOS, increased healthcare costs Connection with emerging trend: changing healthcare focus from disease treatment to prevention- new ways to monitor patients for early intervention needs Typically diagnosed w/any two of the following Weight loss Subcutaneous fat loss Reduced functional status (grip strength) Decreased muscle mass Fluid accumulation

Introduction Previous studies on NFPAs: Mackle et al: evaluated use of assessments after training via a dietetic practice group/continuing education program-time constraints were a major barrier to use, and often only parts of assessment performed Esper et al: demonstration & simulation based training during a coordinated dietetics program, then surveyed students about likelihood to use in practice Stankorb et al: studied which portions of NFPA were used most frequently- only about 1/3 of RDs had received training and mostly used anthropometric measurements regularly Ionatta et al: reviewed use of exams in RDs in a practice group, only 35% had received training and used anthropometric measurements most frequently, citing barriers of time and lack of training

Research Objective Determine if/when dietitians receive training in nutrition focused physical exams How often exams are used in daily practice What barriers prevent their use?

Methodology Subjects: RDs from UCMC, HMH, Kernan (UMROI), UMMC, Shore Regional, Midtown, GBMC, Sinai, Levindale, Northwest Study Design: electronic survey open for 3 weeks (February 24-March 16)

Results 55 recipients, 25 responses 64% had previous training Age 20-29 11 44 30-39 7 28 40-49 4 16 50-59 3 12 60+ Gender Male 25 100 Female Facility Acute care hospital 15 60 Hospital Outpatient clinic 2 8 Teaching hospital 1 Tertiary care hospital Acute teaching hospital Acute rehab hospital 55 recipients, 25 responses 64% had previous training 37.5% on the job 25% undergrad 25% dietetic internship Others in grad school, conference/seminar Most commonly performed in suspected malnutrition, critically ill/ICU patient, or when a nutrition consult is received

Results

Results Top 5 most common barriers: Lack of knowledge to successfully perform Time constraints Assessment already performed (by RN, SLP, PT/OT, etc) Uncomfortable with physical contact No identified need for assessment 12 reported never using NFPAs in practice 4 indicated not likely to use NFPAs at all 9 reported daily use of NFPAs 5 reported use of NFPAs in most, if not all of patient cases

Discussion/Conclusions Limitations: small sample size, only Maryland RDs surveyed, brief survey (to encourage more responses)- answers provided less detail Majority of subjects had received some training in NFPAs If it did occur, most training was on the job Most frequent barrier was lack of knowledge to perform Suggests that most training (on the job or otherwise) is not sufficient Assessments that are being performed may not be performed correctly or thoroughly enough Only one participant reported training at a conference and seminar Maybe this specialized education would help in increasing comfort levels & competency Future research could examine what types of training/education would increase knowledge/confidence and in turn, increase use

References White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Parenter Enteral Nutr. 2012; 36:275. http://pen.sagepub.com/content/36/3/275. Accessed November 12, 2014. The Impact of Clinical Dietitians on New Healthcare Delivery Models. Aramark Healthcare. http://www.aramarkhealthcare.com/docs/default-source/position-papers/the-impact-of-clinical-dietitians-on-new- healthcare-delivery-models.pdf?sfvrsn=4. Accessed December 4, 2014. Rhea M, Bettles C. Future Changes Driving Dietetics Workforce Supply and Demand: Future Scan 2012-2022. J Acad Nutr Diet. 2012;112:S10-S24. Mackle TJ, Touger-Decker R, O’Sullivan Maillet J, Holland BK. Registered dietitians’ use of physical assessment parameters in professional practice. J Am Diet Assoc. 2003;103:1632-1638. http://www.ncbi.nlm.nih.gov/pubmed/14647090. Accessed November 20, 2014. Esper DH, Converse A, Yacovone ML, Pohle-Krauza RJ. A Training Program in Nutrition-Focused Physical Assessment for Dietetics Students. J Acad Nutr Diet. 2012;112:A27. http://www.andjrnl.org/article/S2212-2672(12)00891-X/pdf. Accessed December 4, 2014. Stankorb SM, Rigassio-Radler D, Khan H, Touger-Decker R. Nutrition Focused Physical Examination Practices of Registered Dietitians. TICN 2010;335-344. http://journals.lww.com/topicsinclinicalnutrition/Abstract/2010/10000/Nutrition_Focused_Physical_Exami nation_Practices.6.aspx. Accessed December 4, 2014. Iannotta JA, Rigassio Radler D, Parrot JS, Huhmann MB, Touger-Decker R. Nutrition Focused Physical Examination Practices of RD Members of the Oncology Nutrition Dietetic Practice Group and Board Certified Specialists in Oncology Nutrition. J Acad Nutr Diet. 2012;110:A19. http://www.andjrnl.org/article/S0002-8223(10)00767-4/pdf. Accessed December 4, 2014.