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Auditing the efficacy of nutritional support identifies a subset of patients at risk
TUESDAY, OCTOBER 26 POSTER SESSION: QUALITY ASSURANCE/QUALITY IMPROVEMENT ,-
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IMPLEMENTATION OF A COMPUTERIZED RESIDENT CARE SYSTEM FOR ENHANCEMENT OF PATIENT CARE AND DIETARY SERVICES IN A LONG-TERM CARE FACILITY. M.A. Boyle, MBA, RD, and B.E. Richardson, RD, Sandalwood Convalescent Home, Oxford, MA Nursing Homes have felt the impact of increased medical record documentation and demands for overall higher quality patient care with the outcome focus of the Omnibus Reconciliation Act of 1987 (OBRA 87). To meet regulatory requirements, save documentation time, promote team work, and deliver higher quality care, Sandalwood Convalescent Home implemented a computerized resident care system (RCS). The system maintains information in four major areas of resident care: resident and weight information, assessments, care plans, and physician's orders. Data is collected from professional staff including physicians, nurses, dietitians, social workers, activity directors, and rehabilitation professionals. Specifically, dietitians are responsible for completing the dietary portion of the data collection tool. This tool then generates the nutritional assessment and patient tray card. The dietary data also triggers Minimum Data Set (MDS) automatic and potential nutrition related triggers on the All patient care plan and Resident Assessment Protocols (RAPs). disciplines complete their data collection tool in a similar manner as dietary. All data is input into the computer; then, a true comprehensive assessment and comprehensive care plan is generated for the resident as well as a MDS and RAP. The RCS is updated on a continual basis so additional valuable reports can be generated such as weight variance trends, albumin levels, food preferences, and dietary cardexes. Implementation of RCS requires facility readiness, orientation and training The system has saved the dietary workshops and team support. department alone a minimum a four hours/week by speeding up dietitian documentation and decreasing tray card sorting time; this does not account for the increased accuracy of tray cards and time saved in changing tray cards. With time saved and accuracy improved in all departments, RCS encourages team work within the facility and assists the health care team in providing quality patient care.
PEDIATRIC NUTRITION SCREENING. M.R. Burck, MS, RD, Poudre Valley Hospital, Fort Collins, CO. In 1992 the Food and Nutrition Department at Poudre Valley Hospital, a 235 bed community hospital, received approval from the Medical Executive Committee to expand nutrition screening to include the pediatric unit. The primary goal of the clinical nutrition team in implementing nutrition screening was to provide early identification of patients who would benefit from nutrition intervention. The first step was to develop a pediatric nutrition screening tool. A combination of anthropometric, biochemical, clinical, and dietary parameters were reviewed. The indicators had to be available, quick and easy to access, and reliable. The four indicators chosen were 1) serum albumin or serum prealbumin; 2) current weight as a percent of standard; 3) percent p.o. intake of meals since admission, patients on tube feeding, TPN, or patients NPO, dextrose and/or unsupplemented clear liquid diet > 3 days; and 4) a nutrition related diagnosis. The screening tool allows for classification of patients nutritional status as no detectable risk, potential for nutrition risk, or at nutrition risk. All pediatric patients are screened after 72 hours of admission. The form is placed in the medical chart and when a patient is identified to be at risk the physician order section is stamped to alert the physician of the patients compromised nutritional status. Pediatric nutrition screening has provided several benefits. First and foremost, early identification increases prospects for improved patient outcome and reduces the risk of additional complications and does so in a much more cost effective manner than later identification. Secondly, it provides a standard and systematic approach that provides consistent quality nutrition care to all patients. Last, screening identifies those patients who are most likely to benefit from nutrition intervention as well as those who are obviously not at risk so that personal resources can be concentrated on those who are.
AND APPEARANCE TEXTURE, TASTE, ENHANCING PRESENTATION OF PUREED FOODS IMPROVES RESIDENT QUALITY OF LIFE AND WEIGHT STATUS. D.Cassens, RD, E. Johnson, RD, LD, Care Enterprises, Tustin, CA Approximately 20% of residents in skilled nursing facilities (SNF) require pureed food (PF) for chewing Altered appearance and and swallowing problems. diminished palatability of PF results in decreased loss. Advances in food weight intake and subsequent technology have provided commercially available products that enhance PFs by creating improved texture and appearance. The purpose of this study was two-fold; 1) to determine whether these food enhancers were a costaffective means of improving PF, and 2) whether lower :ost ingredients could be used in place of commercially available enhancers to attain the same goal. A 42-day :ross-over study was done in 24 SNF residents. The first 21 days, residents were served their regular pureed nenu. During the following 21 days, the same menu was ised but meat and vegetable recipes were amended using food enhancers. Foods were shaped to simulate regular nenu items. A qualitative score was obtained using a uestionnaire for staff and residents that measured impact on quality of life. Quantitative score was the using a form food intake of total Percentage ;pecifically designed for this study. Percent of food ~aten increased by 14.6% during the test period, Short :erm weight gain was 1%, Long term results are being :ollected and will be reported. The cost of using the :ommercially prepared enhancers was 3-6C/serving. This was offset by a decrease in nourishments and meal replacements given. Thickening agents like gelatin and hydrolyzed cornstarch were successfully used in cold :oods and they did not add any cost. This presentation ;ill provide study results and describe food preparation :echniques that successfully improved appearance and Palatability of PFs, increased resident food intakes and lid not add significantly to food cost.
AUDITING THE EFFICACY OF NUTRITIONAL SUPPORT IDENTIFIES A SUBSET OF PATIENTS AT RISK. D. J. Chapman, M.S., RD., S. L. Rowley, RD., J.M. Wolski, RD., L.E. Matson, K.P. Keating, M.D., University of Connecticut Health Center, Farmington, CT. Previous investigators have documented a deterioration in nutritional parameters in as many as 75% of hospitalized patients. As part of a quality assurance audit, we sought to determine our overall efficacy rate for nutritional support and to evaluate the impact of delivery method and patient diagnosis on response to support. Serum prealbumin is well established as a marker for adequacy of nutritional support in patients without renal failure. Patients were considered responders if normal prealbumin levels were maintained or increased
over a subnormal baseline. Patients were considered nonresponders if prealbumin deteriorated to subnormal levels or failed to increase over a subnormal baseline. Nutritional support was divided into three categories: total parenteral nutrition (TPN); tube feeding (TF); combined (TPN/TF). Over a three month period, 25 patients receiving nutritional support had a baseline prealbumin and at least one follow-up determination made and were available for analysis. Results indicate that 76% (19/25) of patients were responders, with breakdown as follows: 60% (3/5) in the TF group, 73% (11/15) in the TPN group and 100% (5/5) in the TPN/TF group. 67% (4/6) of the nonresponders had a diagnosis of malignancy. This audit enabled us to identify a subset of patients, those with malignancy, who are not responding adequately to our current efforts at nutritional support. We will now begin to evaluate the efficacy of regimens formulated specifically for this patient subset Current numbers are too small to make meaningful comparisons of efficacy based on mode of nutritional support.
JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / A-39
,
.
_
=
IMPLEMENTATION OF A COMPUTERIZED RESIDENT CARE SYSTEM FOR ENHANCEMENT OF PATIENT CARE AND DIETARY SERVICES IN A LONG-TERM CARE FACILITY. M.A. Boyle, MBA, RD, and B.E. Richardson, RD, Sandalwood Convalescent Home, Oxford, MA Nursing Homes have felt the impact of increased medical record documentation and demands for overall higher quality patient care with the outcome focus of the Omnibus Reconciliation Act of 1987 (OBRA 87). To meet regulatory requirements, save documentation time, promote team work, and deliver higher quality care, Sandalwood Convalescent Home implemented a computerized resident care system (RCS). The system maintains information in four major areas of resident care: resident and weight information, assessments, care plans, and physician's orders. Data is collected from professional staff including physicians, nurses, dietitians, social workers, activity directors, and rehabilitation professionals. Specifically, dietitians are responsible for completing the dietary portion of the data collection tool. This tool then generates the nutritional assessment and patient tray card. The dietary data also triggers Minimum Data Set (MDS) automatic and potential nutrition related triggers on the All patient care plan and Resident Assessment Protocols (RAPs). disciplines complete their data collection tool in a similar manner as dietary. All data is input into the computer; then, a true comprehensive assessment and comprehensive care plan is generated for the resident as well as a MDS and RAP. The RCS is updated on a continual basis so additional valuable reports can be generated such as weight variance trends, albumin levels, food preferences, and dietary cardexes. Implementation of RCS requires facility readiness, orientation and training The system has saved the dietary workshops and team support. department alone a minimum a four hours/week by speeding up dietitian documentation and decreasing tray card sorting time; this does not account for the increased accuracy of tray cards and time saved in changing tray cards. With time saved and accuracy improved in all departments, RCS encourages team work within the facility and assists the health care team in providing quality patient care.
PEDIATRIC NUTRITION SCREENING. M.R. Burck, MS, RD, Poudre Valley Hospital, Fort Collins, CO. In 1992 the Food and Nutrition Department at Poudre Valley Hospital, a 235 bed community hospital, received approval from the Medical Executive Committee to expand nutrition screening to include the pediatric unit. The primary goal of the clinical nutrition team in implementing nutrition screening was to provide early identification of patients who would benefit from nutrition intervention. The first step was to develop a pediatric nutrition screening tool. A combination of anthropometric, biochemical, clinical, and dietary parameters were reviewed. The indicators had to be available, quick and easy to access, and reliable. The four indicators chosen were 1) serum albumin or serum prealbumin; 2) current weight as a percent of standard; 3) percent p.o. intake of meals since admission, patients on tube feeding, TPN, or patients NPO, dextrose and/or unsupplemented clear liquid diet > 3 days; and 4) a nutrition related diagnosis. The screening tool allows for classification of patients nutritional status as no detectable risk, potential for nutrition risk, or at nutrition risk. All pediatric patients are screened after 72 hours of admission. The form is placed in the medical chart and when a patient is identified to be at risk the physician order section is stamped to alert the physician of the patients compromised nutritional status. Pediatric nutrition screening has provided several benefits. First and foremost, early identification increases prospects for improved patient outcome and reduces the risk of additional complications and does so in a much more cost effective manner than later identification. Secondly, it provides a standard and systematic approach that provides consistent quality nutrition care to all patients. Last, screening identifies those patients who are most likely to benefit from nutrition intervention as well as those who are obviously not at risk so that personal resources can be concentrated on those who are.
AND APPEARANCE TEXTURE, TASTE, ENHANCING PRESENTATION OF PUREED FOODS IMPROVES RESIDENT QUALITY OF LIFE AND WEIGHT STATUS. D.Cassens, RD, E. Johnson, RD, LD, Care Enterprises, Tustin, CA Approximately 20% of residents in skilled nursing facilities (SNF) require pureed food (PF) for chewing Altered appearance and and swallowing problems. diminished palatability of PF results in decreased loss. Advances in food weight intake and subsequent technology have provided commercially available products that enhance PFs by creating improved texture and appearance. The purpose of this study was two-fold; 1) to determine whether these food enhancers were a costaffective means of improving PF, and 2) whether lower :ost ingredients could be used in place of commercially available enhancers to attain the same goal. A 42-day :ross-over study was done in 24 SNF residents. The first 21 days, residents were served their regular pureed nenu. During the following 21 days, the same menu was ised but meat and vegetable recipes were amended using food enhancers. Foods were shaped to simulate regular nenu items. A qualitative score was obtained using a uestionnaire for staff and residents that measured impact on quality of life. Quantitative score was the using a form food intake of total Percentage ;pecifically designed for this study. Percent of food ~aten increased by 14.6% during the test period, Short :erm weight gain was 1%, Long term results are being :ollected and will be reported. The cost of using the :ommercially prepared enhancers was 3-6C/serving. This was offset by a decrease in nourishments and meal replacements given. Thickening agents like gelatin and hydrolyzed cornstarch were successfully used in cold :oods and they did not add any cost. This presentation ;ill provide study results and describe food preparation :echniques that successfully improved appearance and Palatability of PFs, increased resident food intakes and lid not add significantly to food cost.
AUDITING THE EFFICACY OF NUTRITIONAL SUPPORT IDENTIFIES A SUBSET OF PATIENTS AT RISK. D. J. Chapman, M.S., RD., S. L. Rowley, RD., J.M. Wolski, RD., L.E. Matson, K.P. Keating, M.D., University of Connecticut Health Center, Farmington, CT. Previous investigators have documented a deterioration in nutritional parameters in as many as 75% of hospitalized patients. As part of a quality assurance audit, we sought to determine our overall efficacy rate for nutritional support and to evaluate the impact of delivery method and patient diagnosis on response to support. Serum prealbumin is well established as a marker for adequacy of nutritional support in patients without renal failure. Patients were considered responders if normal prealbumin levels were maintained or increased
over a subnormal baseline. Patients were considered nonresponders if prealbumin deteriorated to subnormal levels or failed to increase over a subnormal baseline. Nutritional support was divided into three categories: total parenteral nutrition (TPN); tube feeding (TF); combined (TPN/TF). Over a three month period, 25 patients receiving nutritional support had a baseline prealbumin and at least one follow-up determination made and were available for analysis. Results indicate that 76% (19/25) of patients were responders, with breakdown as follows: 60% (3/5) in the TF group, 73% (11/15) in the TPN group and 100% (5/5) in the TPN/TF group. 67% (4/6) of the nonresponders had a diagnosis of malignancy. This audit enabled us to identify a subset of patients, those with malignancy, who are not responding adequately to our current efforts at nutritional support. We will now begin to evaluate the efficacy of regimens formulated specifically for this patient subset Current numbers are too small to make meaningful comparisons of efficacy based on mode of nutritional support.
JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / A-39