Clinical Nutrition Staff Research Articles

The status of clinical nutrition in hospitals of Guilan province, Iran - A mixed-method study.

nutritional therapy has an important role in the development of medical care services, and quantitative and qualitative assessments of the status of clinical nutrition in hospitals is crucial. This study aimed to explore the current status of clinical nutrition in hospitals of Guilan province, Iran. this quantitative-qualitative (mixed method) study was performed on public hospitals in Guilan province, Iran (N = 26). The required information was collected by visiting the hospitals and interviewing with hospital dietitians. The data collection tool had two quantitative and qualitative subscales. The quantitative subscale included a 21-item checklist containing information about the referral system, cooperation of hospital staff in clinical nutrition, clinical nutrition staff status, enteral nutrition, and parenteral nutrition. in more than 40 % of hospitals the patients were not adequately referred to a dietitian. In 35 % of hospitals, cooperation of other departments in the field of clinical nutrition was insufficient. In 55 % of hospitals with intensive care unit (ICU), enteral nutrition was not provided properly. None of the hospital properly provided parenteral nutrition for their patients. The most important problems mentioned by hospital dietitians included noncompliance of the food sector employer with food programs, insufficient number of hospital dietitians, and nonpayment of consulting fees to dietitians. Coverage of diet services by health insurance was the most common suggestion of dietitians to promote diet therapy in hospitals. the situation of providing nutritional services to patients in public hospitals is not favorable in terms of quantity and quality in Guilan province, Iran. Designing the necessary policies to reorient the clinical nutrition system in hospitals and ultimately promote health and accelerate patient recovery is warranted.

Clinical Leadership and Innovation Help Achieve Malnutrition Quality Improvement Initiative Success

Malnutrition is a frequent, but often overlooked clinical issue that can significantly impact patient health outcomes and thus has been identified as a critical target for quality improvement. One recent advancement helping build momentum in quality improvement is the Malnutrition Quality Improvement Initiative (MQii). Frameworks like the MQii need clinical leadership to achieve success. A new taxonomy for clinical dietetics leadership describes five components of leadership behaviors—change, patient focus, self-direct, technical, and relationship—that align with the MQii tools and resources. Qualitative interviews were conducted with four clinical nutrition leaders from three health care systems or institutions who were part of the 2018-2019 MQii Learning Collaborative and had reported success and innovations using the MQii framework. The clinical dietetics leadership taxonomy was applied to describe how the clinical nutrition leaders demonstrated and supported leadership opportunities for clinical nutrition staff through implementation of the MQii. Funding/SupportPublication of this supplement was supported by Abbott. The Academy of Nutrition and Dietetics does not receive funding for the MQii. Avalere Health's work to support the MQii was funded by Abbott.

Clinical ladders are positively associated with job satisfaction and career advancement for registered dietitians in clinical nutrition management

Background: Following a change in reporting structure, Registered Dietitian Nutritionists (RDNs) in a Virginia hospital system provided patients with better care, cost savings, and almost doubled clinical nutrition staff from 2008 to 2013. Objective The study was conducted to determine if the administrative alignment of RDNs in their place of employment 1) allows them to perform to their greatest scope of practice and 2) influences job perceptions.Methods: A survey was developed and distributed nationally to CNMs and their coworkers. Statistical analyses: Using SPSS 24, univariate descriptive statistics and bivariate analyses were conducted. Contingency tables were generated and Pearson Chi-square tests and as appropriate Fishers’ exact tests were used to draw statistical inferences.Results: Respondents (n=508) represented four regions of the US with various job titles. Some reported to vice presidents of support services (34%) and others reported to vice presidents overseeing both clinical and support services (26%). Respondents, regardless of alignment, were either ‘satisfied’ (47%) or ‘very satisfied’ (36%) with their current positions. Most (74%) were in a nutrition department separate from food service. There was no difference in education (p=0.87) or pay (p=0.62) dependent on reporting structure. However, when RDNs reported to a clinical nutrition department, separate from food service, it was more likely that there was a clinical ladder for RDNs and there were more levels on the clinical ladder.Conclusion: This survey suggests alignment of a clinical nutrition department is associated with a higher likelihood that RDNs will have a clinical ladder to promote career advancement.

Perceptions of Dietitians on Director Management Background, Customer Satisfaction, and Clinical Nutrition Staff Participation in the Foodservice Department

The focus of this research is to assess the differences between registered dietitians (RDs) and non-RDs as Foodservice Directors. Foodservice Directors in the participants' (N = 236) facility were both RDs (118; 52%) and non-RDs (107; 48%). Participants felt that their facility would benefit if an RD was the Foodservice Director (219; 89%). The majority (175; 77%) of clinical RD staffs were housed within the foodservice department, which was felt to be an advantage (119; 53%). Statistical analysis found that there was a significant difference (p = .048) between food quality scores in the patient food category between RD and non-RD Directors, with non-RDs providing higher scores.

Performance improvement in a clinicalnutrition staff's activities: A stratified model of nutritional status classification and timing of medical nutrition intervention therapy to meet the changing healthcare needs of a community teaching health center

Performance improvement in a clinicalnutrition staff's activities: A stratified model of nutritional status classification and timing of medical nutrition intervention therapy to meet the changing healthcare needs of a community teaching health center

Strategies for Implementation of Consistent Carbohydrate Meal Patterns

Carbohydrate counting has been recommended as an appropriate method of meal planning for diabetic patients in hospitals as a means of meeting patients' nutrition needs and facilitating improved metabolic control for patients in acute care settings.Although meal plans utilizing consistent carbohydrate content were used in patient education, the clinical nutrition staff identified the continued use of “ADA-type” patterns in the patient food service as an obstacle to utilizing the patient menu and meal tray in reinforcing educational principles. Concerns were also identified with implementing a menu system that only utilized carbohydrate counting, i.e., meeting medical staff requirements, patient expectations, and increasing work for the diet office.Consistent carbohydrate meal patterns were developed with ranges of caloric content to accommodate most patients' nutrition needs. Diabetic menus were based on a cardiac-type diet pattern to provide an appropriate fat content for most patients. Guidelines for diet content were also established to facilitate meal correction: consistent selection of entrees by patients, maximum number of fruit servings allowed per meal, and goal for maximum number of fat servings/day. The use of sucrose-containing foods was limited at the time of implementation, although this may be modified in the future with continued education of the staff and greater public knowledge about consistent carbohydrate as a means of diabetic menu planning.

Development of Clinical Nutrition Staffing Model

Study objectives were to (1) determine which patient and organizational variables affect time spent by clinical nutrition staff in performing direct patient care activities; (2) incorporate these variables into a model for predicting staffing requirements for the provision of clinical nutrition services at VA medical centers (VAMCs); and (3) validate the model. Approximately 230 registered dietitians and dietetic technicians in 27 randomly selected VAMCs completed logs of time spent and direct patient care services provided over a two-week period, resulting in time data on 1289 inpatient episodes and 1074 outpatient visits. Automatic Interaction Detection analysis software was used to identify the variables with the most significant main and interaction effects on time requirements. Model validation was performed by comparing model predictions with actual FY 1996 staffing at 80 VAMCs. The resultant inpatient model includes 18 patient groups categorized by nutrition status, bedsection, and length of stay. These groups account for 32% of the variance in time requirements. The outpatient model consists of six patient groups categorized by education services (yes/no), interventions (yes/no), visit type (recurring or non-recurring), and medical center type. These groups account for 25% of the variance in time requirements. The model accurately predicted (within 95% confidence interval) 1996 staffing for 69 of the 80 validation sites (69%, predictive validity). All sites except one (99%) accepted the model as valid (face validity). Results demonstrate that a simple, valid model with modest data requirements can be developed which accounts for a significant portion of the variability in time spent providing clinical nutrition services. The model can be used for determining staffing requirements and monitoring productivity.

Charting by Exception: a Solution to the Challenge of the 1996 JCAHO's Nutrition Care Standards

With charting by exception, only significant findings or exceptions to the norms are documented in script by the nursing staff. Upon admission, patients are screened for nutrition risk or need for nutrition education by nursing staff using an interdisciplinary patient database. Patients with predetermined criteria indicating nutritional risk or with nutrition education needs are referred to nutrition services. Using specified criteria, the clinical nutrition staff assign referred patients to a level of care. Nutrition care or education is provided and documented within 48 hours. Documentation varies with the level of nutrition care. J Am Diet Assoc. 1997;97(suppl 2):S131–S138.

Cost-Effective Nutritional Interventions in a Chronic Disease Facility

LEARNING OUTCOME: To identity opportunities for decreasing cost, while maintaining the quality of nutritional care. Our hospital is a 200 bed chronic disease and rehabilitation facility with 5 long-term units. The clinical nutrition staff was faced with the challenge of “ensuring quality of care is sustained and enhanced while reducing the cost of providing care” as per the hospital goal. The standard of practice on these units was all patients were scheduled for a bi-annual nutritional reassessment for which labs were automatically ordered. Our aim was to prioritize care based on degree of nutritional risk instead of automatically providing nutritional inventions to all patients. The steps used to work toward cost-efficiency were prioritizing patients, educating staff and coordinating schedules. The nutrition policies and standards were revised so the frequency of intervention would be determined through the interdisciplinary process. Ongoing education about the most cost-effective lab ordering practices was provided to the Nutrition Support Committee and medical staff. Each dietitian (RD) then worked on coordinating patient reassessment schedules to maximize use of existing lab work. The process has been ongoing for three years with the following results: 115 fewer “automatic” reassessments, therefore, saving $3897.35, in lab costs that would have been associated with them. Patients’ schedules were adjusted to take advantage of existing lab work with a savings of $1660.61, over the three years. The percentage of time labs were ordered specifically for the nutritional reassessment over the last three years were as follows: 53%, 52%, and 60%, respectively. This project has promoted interdisciplinary coordination of services by the RD to ensure patients receive quality nutritional care while controlling costs.

Our Partners in Nutrition Assessment: Shifting Nursing Paradigms

LEARNING OUTCOME: To describe how one health care institution adapted to meet Joint Commission of Accreditation of Healthcare Organizations (JCAHO) nutritional assessment requirements. Standards of practice for nutritional screening and assessment would not meet the 1996 JCAHO standards. Our data from chart review indicated only 60% of patients at risk had a nutrition care plan by day five of admission partially due to difficulty of retrieving indicators of nutritional risk. The medical and nursing records contained nutritional risk parameters, but this information was not readily accessible to the clinical staff. We needed a new approach. The clinical nutrition staff was able to garner support from hospital administration by presenting 1) the new JCAHO standards that state the hospital is responsible for identifying patients at nutritional risk upon admission and 2) the average length of stay savings from early and frequent nutrition intervention. A multidisciplinary task force was officially formed by the hospital quality improvement team to design an efficient nutrition screening process. The team restructured our current process to one that gave the admissions nurse an active role in identifying patients that would benefit from nutrition intervention. Partnering among disciplines on the team led to designing a new admission form, changing procedures to collect data, encouraging compliance with an incentive program and implementing an educational campaign. The multidisciplinary task force activity changed the paradigm of nutrition's services from “nice to have” to “cost effective and necessary for healing” and improved availability of data which will result in more rapid nutrition intervention.

Restructuring Clinical Nutrition Services from a Traditional Model to Shared Governance

LEARNING OUTCOME: To describe a method of restructuring clinical nutrition services in a hospital from a traditional department to shared governance. The medical center leadership undertook restructuring in an effort to improve quality and continuity of care, streamline services and decrease layers of supervision. Clinical staff and over 20,000 patients were reassigned to four Strategic Health Groups (SHG's), Medicine, Surgery, Mental Health and Geriatrics, Rehab and Extended Care. Prior to 1996, clinical dietitians were organized along traditional hospital lines. As reorganization started, workload statistics, projected programs and staff preferences for each SHG were used to assign the correct number of clinical nutrition staff to each SHG. The Chief Clinical Dietitian position was eliminated. The Chief Clinical Dietitian was moved to Chief Nutrition and Food Services (N&FS), and named technical advisor to the dietitians, arranging inter-SHG staff coverage, quality monitoring, planning and Joint Commission standards. Supervision and coordination are shared between Chief N&FS and SHG leadership. Dietitians now are moving toward shared governance which is a collaborative management structure where each staff member has input, ownership and accountability over clinical practice issues and decisions. Dietitians belong to a council with every dietitian taking a turn as the coordinator. Business decisions are made by administration, not the council. Keys to the successful transition were good communication, goal setting and successful goal achievement. Benefits to patients and staff include streamlined systems, close interdisciplinary relationships and empowered employees.

Implementation of Nutrition Screening within 24 Hours of Admission for Early Identification of Malnourished Patients

LEARNING OUTCOME: To identify a methodology for a nutritional screen performed by nonnutrition staff within 24 hours of admission. Current Joint Commission on Accreditation of Healthcare Organizations standards require a nutritional screening of patients within 24 hours of admission. Staffing of dietitians and technicians is generally not available to perform this task within 24 hours. The clinical nutrition staff developed five screening criteria which were included on the “Interdisciplinary Admission/Screening for Special Needs” form which is completed by the registered nurse admitting the patient. The criteria, 1) Patient had involuntary weight loss of 10 pounds or greater over past 6 months, 2) Patient admitted with symptoms of nausea/vomiting or diarrhea, 3) Patient does not appear alert enough to eat or appears to have chewing/swallowing/appetite problems that affect food intake, 4) Patient has draining wound or pressure sore, and 5) Patient is emaciated or malnourished by appearance, were chosen because these questions can be answered on admission and do not require the nurse to review other information or wait for lab data. If any one of the questions is answered yes, a consult is sent via computer to the dietitian who does the nutritional evaluation. This process was implemented using plan, do, check, act, Continuous Quality Improvement principles. Initial data indicated a 15 percent referral rate of patients who were actually moderately or severely malnourished by dietitian assessment. Most recent data show this referral rate to have increased to 56 percent of those patients who should be referred for possible malnutrition actually being referred from the initial 24-hour screen. Two major areas of improvement identified were to provide increased education to nursing staff on proper completion of the form and sending a dietitian consult for one question answered yes instead of two yes answers. When an adequate number of patients are referred via this process, dietitians will no longer perform nutritional screening on all patients, but would operate by referral only. This provides for early intervention and allows more time for medical nutrition therapy for malnourished patients.

Interdisciplinary Nutritional Screening

LEARNING OUTCOME: To develop an interdisciplinary nutritional screening program that meets JCAHO requirements and appropriately identifies high risk patients. The Joint Commission on Accreditation of Healthcare Organizations requires that every patient admitted to a hospital be screened for nutritional risk. Traditionally, nutritional screening has been the role of the Clinical Nutrition staff. In order to properly evaluate a patient's nutritional risk, it is vital to obtain a nutrition history which entails a chart review and patient interview. This process is time consuming and labor intensive. With decreasing patient days and staff reductions, the opportunity presents itself to redesign the nutritional screening process. An interdisciplinary approach was taken to conduct a nutritional screening upon admission utilizing the nursing admission history. A task force of nursing and clinical nutrition personnel developed the procedure. Upon admission the patient answers nutrition questions of which an answer of yes indicates a nutritional risk and is weighted with a numeric score. The admitting nurse totals the score and enters it in the hospital information system. This timely evaluation (<24 hours upon admission) allows for immediate nutrition intervention. Several barriers have been resolved to improve staff support and timely completion and intervention. This tool has been adapted to achieve the same goal in various clinical settings.

Utilization of a Productivity Enhancement Program (PEP) to Maximize Efficiency in the Provision of Quality Nutrition Care

LEARNING OUTCOME: To develop a system to assess resource requirements and productivity for a clinical nutrition staff. The clinical nutrition management team, in conjunction with a hospital wide initiative, implemented a system to assess resource requirements and productivity while ensuring the provision of quality patient care. Initially all functions performed by the clinical staff were identified. Data was collected and averaged to determine time requirements for each clinical intervention and supporting functions. All activities were examined to ensure tasks were supportive of a patient care focus reviewing time spent at meetings, rounds, teaching, administrative activities, hospital initiatives, and patient care functions. Clinical documentation was streamlined as this function was identified as a major time consumer. Utilizing the information gathered, a tracking tool was developed to document daily activities and quantify patients not seen and rounds not attended. Three months of historical data was evaluated to calculate staffing need versus current staffing. Through this process, management was able to decrease staffing by one full time equivalent (FTE) and utilize the daily activity sheets to track trends in patient census shifting clinical support to areas of greater need while evaluating individual productivity. In addition, this information has provided an objective tool to reallocate our resources to better meet the changing needs of patient care areas.

Computerized Nutrition Screening and Clinical Nutrition Management System Increases Clinical Productivity

LEARNING OUTCOME: To describe an automated, comprehensive, team-oriented approach to clinical nutrition productivity management and nutrition screeningDirect clinical nutrition services are provided at three separate campuses by three departments. This results in a fragmented, inconsistent approach toward clinical nutrition care for patients. A Performance Improvement team, consisting of dietitians, pharmacists, and nurses, was established to address this issue. The team worked hand-in-hand with the Information Services Department to develop a comprehensive, automated, nutrition screening and clinical productivity management system utilizing the hospital patient information system. The system, implemented in May 1995, features a nutrition screening component which generates nutrition screening reports for all patients directly on the patient care units. It also allows for scheduling of re-screening, initial assessments and re-assessments (follow-ups) by each department providing care. This scheduling information provides the data necessary to create a daily “Nutrition Visitation Report” indicating the clinical duties due and which care provider is responsible for the patient as of that day by nursing units. This report is utilized daily by the clinicians to prioritize their work assignments. The system also generates an audit report which lists past due clinical assignments. This report is utilized by the Clinical Nutrition Manager to identity and trend productivity problems. The system has resulted in an increase in clinical productivity of~40-50%. The largest increase has been experienced in the number of initial assessments and re-assessments completed by the Clinical Nutrition Staff. Additionally, the automated system prevents patients from “falling through the cracks” by providing a mechanism for transferring care from unit to unit and service to service. Most remarkably, these results were realized with a minimal outlay of capital expenditure since the system was designed using the in-house patient information system and in-house system designers and coders. Maintenance on the system is minimal since there is no interface to maintain. Numerous program enhancements are in development to insure the system continues to meet the nutrition needs of the hospital in the future.

Revising the Enteral Formulary to Optimize Nutritional Care at Minimum Cost

In this era of health care reform, cost-containment and, ultimately, hospital cutbacks, dietitians must take a proactive stance to minimize hospital costs versus waiting for hospital administration to mandate cutbacks. In this facility the clinical nutrition staff took it upon themselves to revise the enteral formulary as a cost-containment measure. Initially, the hospital pharmacy and nutrition departments stocked approximately 17 enteral products which cost the hospital nearly $45,000.00 in the six-month period spanning January until June of 1994. The first step was to thoroughly review the scientific literature for justification to retain, add or delete products. This information was compiled into a detailed proposal justifying a decrease in the formulary to seven products. Nutrition support dietitians and pharmacists across the state were interviewed to determine the composition of their various formularies. This information was compiled into chart form to facilitate evaluation of the data and simplify comparison to the proposed formulary changes. Utilizing the proposed formulary while keeping total kilocalories and protein constant, estimated costs for six months totalled only $24,000.00, for a savings of $42,000.00 per year. This information was presented to the hospital's Pharmacy and Therapeutics Committee and met with quick approval and praise from administrators and physicians. It is imperative that dietitians be proactive in pursuing cost containment while assuring patients receive optimal nutritional care.

The development of an oropharyngeal dysphagia team

Successful treatment of the dysphagic patient is dependent on the knowledge base of the healthcare team and the early recognition of the swallowing disorder. If not diagnosed and treated properly, dysphagia can lead to death from pneumonia secondary to aspiration. Untreated dysphagia can also lead to unnecessary tube feedings. The clinical nutrition staff and speech/language pathologists recognized the need for a multidisciplinary team to provide the proper feeding protocol for patients with oropharyngeal dysphagia. An Oropharyngeal Dysphagia Healthcare Team was organized consisting of the dietitians, speech/language pathologists, and registered nurses from neurology and rehabilitation units. A physician advisory panel was formed to solicit support and to advise on the teams function. Through bi-weekly meetings, an 82 page Clinical Handbook was developed to assist in educating staff and to serve as a reference guide. Copies of the handbook are available on all nursing units. Comprehensive flow charts were developed to outline the process of the team functions from identification of patient to therapeutic modalities needed to discharge. The concept of the team approach was presented to the physicians at Medical and Surgical Grand Rounds. Inservices were conducted on all nursing units and other ancillary departments. When a dysphagia team consult is ordered, the speech/language pathologist conducts a bedside screening and determines what feeding protocol is necessary and if further testing is needed. The dietitian completes a nutritional assessment, including tube feeding if needed. The team can proceed without further consult with the physician. The physician is kept up to date by the Dysphagia Team notes in the progress notes in patients medical chart. Menus have been developed, dependent on consistency needed by patient. Data comparison has been made from a 2 month period — January/February 1993 and January/February 1994. There have been 16 Dysphagia Team consults. Of the 16 Dysphagia Team consults received, only 1 was inappropriate. This one was referred for gastrointestinal consult for esophageal dysphagia. A 46% increase in speech/language pathologist consults and 43% increase in the number of Modified Barium Swallows completed. Revenues received from the speech department from increases in speech referrals for 1 month were $24,000; an increase of $17,974. In one year, 28 dysphagia patients started on tube feedings were advanced to regular diets. The Dysphagia Team meets weekly to discuss all patients and updates written in the patients medical chart. This multidisciplinary team has been successful in providing high quality, cost effective care and education to patients with swallowing difficulties.

Utilization of a clinical nutrition staffing tool: A snapshot approach

How many clinical dietitians are needed to provide quality nutritional care? Are current staffing patterns fair and equitable? These are difficult questions that clinical nutrition managers and their staff must address and act upon. At the University of Maryland Medical System, a 750-bed hospital, the clinical nutrition staff developed a tool in an effort to answer the above questions. A time allocation of 5.14 hours per R.D. day for clinical care was determined by subtracting from total available time, non-productive time plus time required for meetings, rounds and delays. Dietitians categorized all of their patients by level of nutritional risk and noted if education was needed. The staff estimated that the amount of time needed to provide adequate clinical care to patients at nutritional risk or in need of education was approximately 45 minutes every 3 days or 15 minutes per day and 30 minutes per day for patients on total parenteral nutrition. Total available time in relation to total needed time to care for patients at nutritional risk or in need of education was assessed for each R.D. Corresponding full time equivalents (FTEs) for R.D. positions were determined. By utilizing the staffing tool, we concluded that our present staffing level was inadequate due to a high patient acuity level (50% of patients were in need of nutritional assessment or counseling). In order to validate our findings, we utilized hospital data on total admissions per year combined with data on the percentage of patients at nutritional risk. This confirmed our findings regarding average number of patients in need of evaluation per R.D. per week. A time utilization study is planned in order to further stratify time requirements for patient care based on complexity. Also, these studies will be utilized to justify dietetic technician staffing and additional R.D. FTEs, if warranted. In summary, the utilization of a clinical nutrition staffing tool can provide a snapshot approach in assessing the adequacy of staffing patterns.

Development of a diet writing handbook for use in training diet office staff

With significant turnover of clinical nutrition staff and reduced number of dietetic technicions, clerks have assumed diet writing responsibilities. A tool was needed which would minimize the decision making process for new staff as well as clerks with limited knowledge and education.