1. The Nutrition Care Process: Driving Effective Intervention and Outcomes

2. Nutrition Care Process
Process for identifying, planning for, and meeting nutritional needs
Malnutrition increases:
morbidity
length of hospital stay = more care
mortality
higher costs ($$$$$$$)

3. ADA NUTRITION CARE PROCESS AND MODEL
Screening
& Referral
System Ø
Identify risk factors Ø
Use appropriate tools
and methods Ø
Involve
interdisciplinary
collaboration
Nutrition Diagnosis Ø
Identify and label problem
Nutrition Assessment Ø
Determine cause/contributing risk Ø
Obtain/collect timely and
factors
appropriate
data Ø
Cluster signs and symptoms/ Ø
Analyze/interpret with
defining characteristics
evidence -
based standards Ø
Document Ø
Document
Relationship
Between
Patient/Client/Group
Nutrition Intervention
&
Dietetics Ø
Plan nutrition intervention
Professional
Formulate goals and
determine a plan of action Ø
Implement the nutrition intervention
Nutrition Monitoring and
Care is delivered and actions
Evaluation
are carried out - Ø
Monitor progress Ø
Documen t Ø
Measure outcome indicators Ø
Evaluate outcomes
Over the next few slides we will look at the steps and systems of the Nutrition Care Process and Model. Since this slide doesn’t project well, please refer to your handout of the diagram of the Nutrition Care Process and Model though out the next few slides.
The model is intended to depict the relationship with which all of these components overlap, interact, and move in a dynamic manner to provide the best quality nutrition care possible. Ø
Document
Outcomes
Management Sys
tem Ø
Monitor the success of the Nutrition Care
Process implementation Ø
Evaluate the impact with aggregate data Ø
Identify and analyze causes of less than
optimal performance and outcomes Ø
Refine the use of the Nutrition Care
Process

4. Central Core of Nutrition Care Model
The relationship
between the client &
the dietetics
professional(s)
collaborative
client-focused
individualized
Central to providing nutrition care is the relationship between the client and the dietetics professional or team of dietetics professionals.
The clients' previous educational experiences and readiness to change influence this relationship.
The education and training that dietetics professionals receive have very strong components devoted to interpersonal communication such as listening, empathy, coaching, and positive reinforcement.

5. 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
Of the two outer rings in the model, the first outer ring refers to the strengths dietetics professionals bring to this process. These include our knowledge, the code of ethics, skills of critical thinking, collaboration, and communication. Evidence based practice is another key component of the model.
The second outer ring identifies environmental factors such as practice settings, health care systems, social systems, and economics. These factors impact the ability of the client to receive and benefit from the interventions of nutrition care. It is essential that dietetics professionals assess these factors and be able to evaluate the degree to which they may be either a positive or negative influence on the outcomes of care.

6. ADA’s Nutrition Care Process Steps
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Nutrition Monitoring and Evaluation
The 4 quadrants around the core represent the four steps of the nutrition care process: nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation.
Each of the steps is preceded by the word nutrition. This was a conscious decision to make the Nutrition Care Process unique and specific to dietetics professionals.
Even though each step builds on the previous one, the process is not linear. Critical thinking and problem solving will frequently require that dietetics professionals revisit previous steps to reassess, add, or revise nutrition diagnoses; modify intervention strategies; and/or evaluate additional outcomes.
The first step we’ll look at is the Nutrition Assessment
For more information, access the ADA member page in the Quality Management section.

7. 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

8. Example of Nutrition Assessment Content
Type of assessment
Content component
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
Nutrition
assessment
what data
are most
effective for
identifying
clients’
nutrition
related
problem
of interest
What type of assessment data?
Using the content, process and quality concept that we just reviewed a few slides ago, in this slide we can see how we use critical thinking during the nutrition assessment.
During the assessment, we consider what data are most effective for identifying the nutrition related problems. Two examples of types of assessment data are nutrition adequacy and health status.
To further clarify this, if we consider a client with hyperlipidemia, fat and cholesterol intake and trans fatty acid intake are examples of nutrition adequacy data.
Lipid profile, BMI and waist circumference are examples of health status data
We demonstrate critical thinking as we consider the latest scientific, evidence-based recommendations for the types of assessment data that will indicate a nutrition problem.
When we talk about the nutrition problem, this is the nutrition diagnosis- the next step of the nutrition care process.

9. How do we get from Assessment to Intervention? Nutrition Diagnosis
A crucial element of providing quality nutrition care
Once the nutrition assessment is completed, similar to a roadmap where we following a certain path to get to our destination, we need to consider the next step in the Nutrition Care Process, the nutrition diagnosis.
If we jump directly from data gathered in the nutrition assessment to nutrition intervention, we leave out a crucial element of providing quality nutrition care. These elements are implicit, but often are not explicit.
These crucial elements include- problem definition, cause identification, and cause-and-effect linkages-- which is essentially the Nutrition Diagnosis.
We must overcome the tendency to jump from assessment to care planning, and we must prevent the care plan team from doing this until they go through other steps in the process.
So let’s look at this next very important step, the nutrition diagnosis.

10. Nutrition Diagnosis Purpose Identify and label the nutrition problem
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
At the end of the assessment step, data are clustered, analyzed, and synthesized. The nutrition assessment provides the foundation for the nutrition diagnosis- the 2nd step in the Nutrition Care Process.
A nutrition diagnosis, involves the dietetics professional identifying and labeling the nutrition problem. The nutrition diagnosis is written in terms of a client problem for which nutrition related activities provide the primary intervention.
During the diagnosing step of the nutrition care process, the dietetics professional identifies what it is about the client that is the dietetics professional’s unique concern, as opposed to the need for medicine or other services such as Physical Therapy.
An important point to recognize with this step of the Nutrition Care Process and Model is that this is not a medical diagnosis. We are not implying that dietetics professionals infringe upon another healthcare professionals’ right and responsibility to diagnose. Physicians through their scope of practice are legally responsible to determine the client’s medical diagnosis. An example of a medical diagnosis is Type 1 or Type 2 diabetes mellitus.
Next we will look at how we write the nutrition diagnosis.

11. 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
Now that we’ve completed the nutrition assessment and determined the nutrition diagnosis, our next step in the process is the nutrition Intervention. It is a specific set of activities and associated client materials used to address the problem.
Nutrition interventions are purposefully planned actions designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition, or aspect of health status for an individual, target group, or the community at large.
Dietetics professionals work collaboratively with the client, family, or caregiver to create a realistic plan that has a good probability of positively influencing the diagnosis problem. This client-driven process is a key element in the success of this step, distinguishing it from previous planning steps that may or may not have involved the client to this degree of participation.
Note: Documentation is an on-going process that supports all the steps in the Nutrition Care Process

12. Nutrition Monitoring & Evaluation
Purpose
Determine the progress that is being made toward the client’s 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
Moving along in the step of the process, the 4th step is nutrition monitoring and evaluation.
The purpose of monitoring and evaluation is to determine the degree to which progress is being made and whether or not the client’s goals or desired outcomes of nutrition care are being met.
It is more than just “watching” what is happening. Monitoring requires an active commitment to measuring and recording the appropriate outcome indicators or markers relevant to the nutrition diagnosis and intervention strategies. Data from this step are used to create an outcomes management system.
Similar to the nutrition intervention step, the nutrition monitoring and evaluation step includes 3 sub steps.

13. 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

14. Characteristics of Nutrition Screening
Simple and easy to complete
Routine data
Cost effective
Effective in identifying nutritional problems
Reliable and valid

15. Nutrition Questionnaire

16. Nutrition Screening Tools
Acute-care hospital or residential setting
Perinatal service
Pediatric practice
Malnutrition Universal Screening Tool (MUST)
Nutrition Screening Initiative (NSI)

17. 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

18. 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

19. 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

20. 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

21. 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

22. Medications Chronic use Multiple and concurrent use (polypharmacy)
Drug-nutrient interactions

23. Joint Commission Standards Drive Nutrition Screening in Health Care Organizations

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Nutrition Screening and Assessment Tool
Courtesy Carolinas Medical Center, Charlotte, N.C.

31. 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

32. Malnutrition in Hospitalized Pts

33. CNM Nutrition Screening Survey Chima and Seher, 2007
Blast 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%

34. Does Your Health Care Organization Screen Patients for Nutrition Risk?
(with accredited ambulatory clinics)

35. Screening in Acute Care

36. Who Has Primary Responsibility for Nutrition Screening (Inpatient)?
% of Respondents
*In the 1987 survey, only 60% of 77 respondents reported admission nutrition screening

37. 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%

38. 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%

39. How Were Nursing Screening Criteria Chosen?

40. Where Are Nursing Screening Results Documented in the MR?

41. How Are + Nursing Screens Communicated to Nutrition Staff?

42. If Nursing Screens, Do Nutrition Staff Do a Secondary Screen?

43. 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
118
Other
24% 61

44. 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

45. Who Is Responsible for Secondary Nutrition Screening?

46. 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
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
Weight for height criterion
119
46%

47. 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%

48. Where Is Secondary Screening Documented in the Medical Record?

49. Criteria Used by Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient)

50. Criteria Used By Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient)

51. Criteria Used By Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient)

52. How Many Levels of Risk Does Your Screening System Include?

53. Has Your Inpt Screening System Been Validated for Sensitivity/Specificity?
% of respondents

54. How Well Do Inpt Screening Criteria Effectively Identify Nutrition Risk?

55. Validation of Nutrition Screening Tools in Acute Care

56. Validation of Nutrition Screening Tools in Acute Care

57. 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) 

58. 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

59. MHS Adult Ambulatory Screen

60. MHS Peds Ambulatory Screen

61. 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

64. Nursing Admission Screens: Most Common Criteria MHMC (Feb 17-Mar 2, 2003)

65. % of Positive Nutrition Screens Classified as High Risk after Review (by Criterion)

66. 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 %
TJC-mandated criteria are poor predictors of nutrition risk
No data on sensitivity (e.g. what percentage of at risk pts are we discovering?)

67. 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

68. 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

69. ADA Screening Evidence Analysis Work Group
Convened fall, 2007
Will develop definitions and formulate questions for evidence analysis regarding nutrition screening

70. 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