Nutrition Consultation Research Articles

Compliance with Joint Commission on Hospital Accreditation Requirement Pe 1.6.1

LEARNING OUTCOME: Decreased nutrition screening time by the dietitian through use of nursing assessment with automatic nutrition referral to identify patients at nutrition risk Currently the dietitian screens patient charts or interviews the patient to obtain information found on the nursing assessment form. This may take up to four hours a day. The nursing assessment form has been set up with triggers to identify patients potentially at nutrition risk. Nursing staff origin ally were trained to enter a nutrition consult in the computer when patients gave responses that had automatic triggers. The triggers were for weight change, poor intake and difficulty chewing. This information when obtained via consult along with diagnosis, weight, diet order and albumin would allow the dietitian to screen and risk the patient without accessing the chart. A performance indicator was developed to determine nursing completion of the nutrition section and referral to nutrition services. Findings: ♦ In 98% of the charts reviewed the nutrition section was completed but a consult to nutrition services was not generated. ♦ Without this information we would miss 21% of patients at high nutrition risk. ♦ The dietitian is duplicating efforts of nursing staff. ♦ Patients are asked the same questions twice. ♦ The dietitian tune not always well utilized. Results: When issue was presented to nursing, the consensus was that the form was not user friendly. A committee was appointed to investigate, redesign the form, and provide the necessary in servicing

Integration of Dietitian Services in a Hospital-Based Pediatric Home Health Care Department

LEARNING OUTCOME: To describe how limited dietitian hours can be used to provide nutrition services for the hospital's Home Health Care patientsSince July 1994 a dietitian liaison from the hospital's Nutrition Department has been a member of the Home Health Care (HHC) team. This dietitian acts as a resource to HHC staff and organizes weekly patient case conferences for enteral and total parenteral nutrition (TPN) patients. The dietitian liaison also assisted HHC in the development of a nutrition screening assessment used prior to hospital discharge. Weekly case conferences include the dietitian liaison, a HHC nursing supervisor or metabolic nurse, and a HHC pharmacist. Each person gathers information from appropriate primary care providers and the family, before a round table style discussion and documentation process. Patients are systematically reviewed so that all enteral feeding patients are discussed at least every 6 months and all TPN patients at least every month.Because of the dietitian's involvement, the HHC Department has been able to meet and exceed the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. Prior to this program, only about 75% (57/73) of the HHC patients receiving enteral feedings and/or TPN had any involvement with a dietitian, even on an inconsistent basis. As a result of the case conferences, patients have been identified who appear to be using less product than prescribed, HHC services have been terminated or nursing visits restarted in a more timely manner, and complete nutrition reassessments have been initiated to ensure that the patient continues to receive the desired intake. When HHC field nurses were surveyed in March 1996, all nurses responding indicated they had consulted with a hospital dietitian in the past 6 months. These nurses also indicated an interest in written guidelines or periodic inservices on nutrition related topics. A repeat survey of the nurses a year later and documentation of patients identified for further nutrition consultation are tools for evaluating how well the dietitian is used as a resource within the HHC Department.

Dietary Habits of Two Olympic Female Athletic Teams

LEARNING OUTCOME: To identify four key strategies for promoting optimal performance in world class female athletes.Female athletes tend to restrict energy to lose or maintain wt. Low intake of total energy may influence micronutrient intake. Dietary composition, such as >60% kcal from carbohydrates (CHO) can negatively influence protein and fat, compromising training and performance outcomes. US Women's Soccer (S) and Field Hockey (FH) Teams (N=54), ranked 1st and 2nd in the world respectively, completed 3-day food records, attended 2 nutrition education sessions and a grocery shopping tour, and had individual nutrition consults during Jan. and April, ‘96. Mean energy intake was 2500 kcal/day based on self-reported food records. Mean hours of daily practice = 7. Supplements were used by 14% of FH players and 100% of S Players. Adequate fruit and vegetable intake, based on Food Guide Pyramid recommendations, was met by 16%. Misconceptions pertaining to CHO and protein were noted by 100% of athletes. Disordered eating was identified on both teams. Grocery shopping tours assisted in food selection and reinforced nutrient composition lessons. Follow-up phone conversations revealed a positive change in food selection patterns with regard to all food groups and fat. Nutrition education for Olympic athletes must be improved at the level of each National Governing Body within the US Olympic Committee. R.D.'s who maintain expertise in athletics are positioned to assume roles with teams who have not identified dietitians as an integral part of the training program.

Optimizing Recovery of Billing for Nutrition Services in the Hospital Based Outpatient Setting

It was our objective to review recovery of fees for nutrition consults provided by RD's in two different areas of our facility where patients were seen for malnutrition, but where billing practices differed. In one setting adolescents with eating disorders are seen as part of a team effort based in a physician practice plan. Fees for RD nutrition consults were billed under a physician provider number (CPT code), using a psychiatric diagnosis code (ICD-9 code), and identified on the patient bill as “nutrition consult”. In contrast, dietitians saw patients in other clinics as part: of the Nutrition Services Dept., Hospital based cost center. These patients were billed under the UB 92 code for the institution, using the medical diagnosis codes (ICD-9 codes for malnutrition) and identified on the patient bill as “nutrition consult”. In the physician practice plan 38 patients were seen for 154 nutrition sessions over 12 months in 1994; recovery of fees for nutrition consults by 3/95 as 49%. In contrast, fees to 143 patients seen in 185 sessions in the Hospital based clinics under the medical diagnosis codes for malnutrition resulted in 75% recovery over the same time period. In both settings, insurance coverage included commercial insurance, managed care plans, and public insurance. Further study is need to know if the more favorable reimbursement in one setting was due to the medical ICD-9 coding instead of psychiatric, or if the Hospital based setting vs the physician based practice setting was more responsible for the improved recovery of fees. Recovery of fees for nutrition services was substantial in both areas; billing as RD providing nutrition consultation in a Hospital based clinic using a medical ICD-9 code for malnutrition resulted in 50% better recovery of fees than from patients billed for a psychiatric diagnosis involving malnutrition in a physician office.

Customizing Patient Diet Lists by Downloading Mainframe Data to a Local Computer Network

Registered Dietitians (RDs), like nurses, doctors and other patient care givers in the hospital environment, rely on the gathering and processing of information and data as an essential component of their clinical practice. Computers can streamline this process by freeing the care giver from the repetitive task of gathering data from multiple sources RDs at a large teaching hospital have traditionally relied on diet lists produced from the hospital mainframe Diet Order Entry System (DOES). These lists contain basic information such as the patient's name, location, current diet order, information regarding snacks and whether a nutritional consultation is required. This information is then supplemented by additional data collected by the RD from other mainframe computer databases and medical records.Mainframe diet lists have recently been replaced by customized diet lists. The Food and Nutrition Services (FANS) department developed a program to download, combine, sort and filter data from several mainframe computer applications in order to build a single database on the department's local network of personal computers. Applications such as the DOES, the Patient Management System, and the Pharmacy Medication Order System are “tapped” in order to include the patient's registration number, birth and admission dates, the medical service, the nature of the RD consult, and the diagnosis.The RDs worked together to define a format for the presentation of this data. They found that changing fonts in the printed report to highlight critical information and emphasizing messages by the addition of graphic images made the report easier to use. The flexibility of having a database on the network also allows the FANS department to filter data needed by a specific RD, such as a list of all patients on tube feedings or a list of all patients followed by the trauma service. In the near future, data will be incorporated into the database to identify medications that have significant nutrient interactions so they can be noted and flagged on the diet list in accordance with the standards of the Joint Commission on Accreditation of Healthcare Organizations.The customized diet list enables RDs to have relevant information, such as admission date, mode of feeding, and diagnosis, contained in one source. This increases efficiency and productivity and streamlines the prioritization of daily work.

The Role of Nutrition in the Development and Use of a Clinical Care Pathway for the Treatment of Hyperemesis

Hyperemesis was identified as a diagnosis that could benefit by being developed into a clinical care pathway at our facility.The nutrition paramenters developed for admission include any of the following: no retention of solids and/or liquids times three days, no retention of solids times five days, thirteen pound weight loss or ten percent of total weight loss from pre-pregnant weight, not responding to intravenous hydration.A nutrition consult is obtained within the twenty-four observation period and the patient is counseled on a six small meal hyperemesis prevention diet. Patients that tolerate six small meals are discharged within forty-eight hours of the twenty-four hour observation status. For enteral tube feeding/parenteral nutrition candidates, the dietitian writes the formula with physician approval. In all cases, the dietitian provides follow-up phone calls every seventy-two hours or until food consumption has met seventy-five percent of pregnancy needs over a seventy-two hour time frame.In a one year post-pathway follow-up, total admissions decreased fifty-four percent and in-patient days decreased sixty-four percent. Clinical outcomes have also been positive with the mean gestational age at delivery thirty-nine weeks and the mean birthweight three thousand four hundred eighty four grains.

Nutrition Training for Medical and Surgical Residents

It is well-documented that malnutrition during hospitalization frequently adds unnecessary costs to patient care and even lengthens hospitalization. In order to prevent these avoidable expenses, physicians need to recognize nutrition problems in the patient and to administer appropriate treatments. To that end, the Nutrition Committee at this 907-bed tertiary care teaching hospital directed the incorporation of clinical nutrition training into the medical education program in the 1994–95 academic year. The training is offered to both the medicine and surgery departments through which 230 residents and fellows rotate each year. Four class sessions are presented to each of the two groups. Major subject areas covered in the curriculum include: nutrition assessment, specialized diets, enteral and parenteral nutrition and current topics in nutrition research. The classes are taught by a multi-disciplinary team of endocrinologists, intensivists, nutrition support staff and dietitians, with the latter providing the major portion of the presentations. Case studies are presented at the end of each session to enable immediate application of information learned. The response to the curriculum has been overwhelming. Over 90% of the residents have rated the classes as being extremely useful to their practice. They also stated that their knowledge of nutrition assessment and therapy was significantly enhanced by the classes. Furthermore, a 5 to 10% increase in physician requests for nutrition consults was noted after each training session.

Nourish check athlete Sports Nutrition Consultants, 3539 Keswick Dr, Atlanta, GA 30341; 404/458-1957. 1993. Price $190. Includes software in either 3.5-in or 5.25-in diskette format, and a 64-page user's manual that is also available online

Nourish check athlete Sports Nutrition Consultants, 3539 Keswick Dr, Atlanta, GA 30341; 404/458-1957. 1993. Price $190. Includes software in either 3.5-in or 5.25-in diskette format, and a 64-page user's manual that is also available online

Effectiveness of early postoperative feeding for major elective abdominal surgery utilizing a patient controlled diet

The objective of this study was to determine the effect of patient controlled diet progression, after major elective abdominal surgery, on length of hospital stay (LOS). The population of this study included 56 patients undergoing major open elective intra-abdominal surgery. Nutritional consults and information regarding the patient controlled diet (PCD), was completed and discussed with all patients prior to surgery. After surgery, irregardless of bowel sounds, patients were to start with clear liquids as desired and then to progress with their diet under their own control with respect to quantity and type of oral intake. Calorie counts were used to monitor patients' intake until they were discharged. Patients were further monitored for symptoms of nausea and vomiting, need for naso-gastric (NG) tube and other medical complications. LOS was noted.

Sports and Nutrition - An Out-Patient Program for Adipose Children (Long-Term Experience)

Sports activity (3 times per week), nutritional changes and modification of behavior are the basic tenets of an outpatient program run for 9- to 12-year-old adipose children since 1987. The following goals are to be attained: increase in physical performance capacity and body awareness, long-lasting change in eating habits, weight loss to under 20% overweight compared to the age-normal (height/normal weight), and understanding of the permanence of body weight problems. Individual nutritional consultation is offered in addition to the initial examination consisting of physical examination, skin fat-fold measurement, blood chemical parameters, spiroergometry and a detailed consultation with parents and children. The eating habits of the children are recorded in a dietary history (3-day dietary protocol, questionnaire) and discussed in individual meetings with the parents and children. Moreover, the nutritional program includes regular nutritional consultations and parents' meetings every month. Cooking instructions for children and parents provide practical knowledge of food preparation to preserve nutrients in an energy-reduced, tasty diet, as well as theoretical basics of nutrition. The control examinations show individual weight loss or stability and improvement in blood lipid parameters. Awareness and controlled nutritional habits were learned especially by the children of parents who, for their part, tried to tailor their nutrition to be better balanced, more nutritional and more need-oriented. Children who maintain the learned nutritional habits after completion of the outpatient program, and who remain active in sports, show long-lasting constant weight. Prevention must begin in childhood. Intensive nutritional support combined with an appropriate sports program should be offered as a preventive measure.

A nutrition and exercise intervention program for persons with developmental disabilities

A retrospective study was conducted on 50 people with developmental disabilities, 24 females and 26 males. Residents live in intermediate care facilities with a staff of care providers who are responsible for menu planning, food purchasing and preparation. The consultant dietitian has made an initial nutritional assessment of all clients and provides periodic six month nutrition updates. Nutrition consultation to the staff encourages a Heart Healthy approach to menu planning. Since the dietitian is also a Health/Fitness Instructor certified by the American College of Sports Medicine, clients have been encouraged to participate in routine exercise protocols. Currently all houses are equipped with treadmills and stationary recumbent bicycles. Data collected for the study was age, weight, height, total cholesterol, HDL and ratio of total cholesterol/HDL. Body Mass Index (BMI) was calculated. Paired t-test were used to determine if there has been significant improvement in risk for heart disease. Analysis of the 24 girls over a 2.5 year time period showed the following changes to be statistically significant at the p .05: mean total cholesterol was lowered from 186 mg/dl to 169 mg/dl, HDL were increased from 50 to 54, and total cholesterol/HDL was lowered from 3.83 to 3.22. Mean BMIs were not changed significantly. At the beginning of the study 42% of the females had serum cholesterol of 200 mg/dl or higher, at the end of the study the number had been reduced to 16%. Analysis of the data for the 26 males in the study showed the only significant change was for the BMI, which increased from 23 to 24. There was a trend for the total cholesterol to be reduced. At the beginning of the study 27% of the males had serum cholesterol levels higher than 200 mg/dl, at the end of the study this was reduced to 15% of the male population. The results show that the consulting dietitian has been effective in improving desired health parameters in a residential setting for developmentally disabled persons. This provides additional support for the requirement for a dietitian in intermediate care facilities.

ASHP National Survey of Hospital-based Pharmaceutical Services-1992

The results of a national mail survey of pharmaceutical services in community hospitals conducted by ASHP during summer 1992 are reported and compared with the results of earlier ASHP surveys. A simple random sample of community hospitals (short-term, nonfederal) was selected from community hospitals registered by the American Hospital Association. Questionnaires were mailed to each director of pharmacy. The adjusted gross sample size was 889. The net response rate was 58% (518 usable replies). The average number of hours of pharmacy operation per week was 105. Complete unit dose drug distribution was offered by 90% of the respondents, and 67% offered complete, comprehensive i.v. admixture programs. A total of 73% of the hospitals had centralized pharmaceutical services. Some 83% provided services to ambulatory-care patients, including clinic patients, emergency room patients, patients being discharged, employees, home care patients, and the general public. A computerized pharmacy system was present in 75% of the departments, and 86% had at least one microcomputer. More than 90% participated in adverse drug reaction, drug-use evaluation, drug therapy monitoring, and medication error management programs. Two thirds of the respondents regularly provided written documentation of pharmacist interventions in patients' medical records, and the same proportion provided patient education or counseling. One third provided drug management of medical emergencies. One fifth provided drug therapy management planning, and 17% provided written histories. Pharmacokinetic consultations were provided by 57% and nutritional support consultations by 37%; three fourths of pharmacist recommendations were adopted by prescribers. A well-controlled formulary system was in place in 51% of the hospitals; therapeutic interchange was practiced by 69%. A total of 99% participated in group purchasing, and 95% used a prime vendor. The 1992 ASHP survey revealed a continuation of the changes in many hospital-based pharmaceutical services documented in earlier surveys (e.g., growth in clinical services, ambulatory-care services, computerization) and identified static areas that merit the attention of pharmacy leaders (e.g., provision of complete, comprehensive i.v. services).

Beyond nutrition screening: A systems approach to nutrition intervention: Challenges and opportunities for dietetics professionals

Malnutrition in older Americans involves many disparate and complex causes. Dietetics professionals need to broaden their scope of practice in dealing with nutrition screening and intervention themselves and in providing expert consultation to others. Health and social services generalists such as physicians, nurses, and social workers must become more aware of the presence and risk of nutrition-related problems in the elderly and must adopt a systematic, collaborative approach to their solution. Nutrition screening, intervention, appropriate referral, and consultation must be built into daily practice.The NSI is a challenge and a call to action for all dietetics professionals. Registered dietitians must become active participants on interdisciplinary teams. They must assume a leadership role in areas of nutrition screening, assessment, and intervention. Their knowledge, skills, and expertise must continue to keep pace not only with advances in the science and technology of nutrition but also with relevant areas of related fields.The tools provided by the NSI and partnerships between nutrition and other health and social services professionals provide opportunity for the widespread incorporation of a systematic approach to delivery of nutrition services. Attention to nutritional health is too important to be left solely to health specialists or to generalists; all must become active participants in maximizing the nutritional health of older Americans.

Effect of selenium supplementation on dairy cattle.

The adequacy of current supplemental dietary selenium allowances for dairy cattle has been reviewed from the literature and by monitoring responses of dairy herds in a veterinary practice specializing in nutritional consultation. Both information sources tend to agree that a reference range of 70 to 100 ng of Se/mL of serum is an acceptable target concentration. This range can be attained most often by providing > 6 mg of supplemental Se.animal-1.d-1, but several factors affect the serum Se responses of different cows to specific Se intakes. These factors may include forage types and sources, ruminal environment, supplemental fat, dietary calcium, trace metals, and genetics. The major benefits, observed experimentally, of maintaining optimal Se intakes include minimizing the incidence of mastitis and preventing calf losses associated with myopathy and(or) respiratory disease.

A Nutrition Support Team Quality Assurance Plan

The Nutrition Support Team at the Veterans Affairs Medical Center is responsible for the development of guidelines related to the provision of both total parenteral nutrition and enteral nutrition support. A Quality Assurance plan which was approved by the Joint Commission on Accreditation of HealthCare Organizations was implemented by the Nutrition Support Team. This plan addresses: nutritional assessment and consultation, indications for enteral and parenteral nutrition support, provision of optimal nutrition support including attainment of nutritional goals, and the prevention, detection, and management of complications. The indicators and criteria for each aspect of care are described. This program has provided documentation of the activities of the Nutrition Support Team as well as data defining the patient population requiring specialized nutrition support, and has helped identify areas where improvement is required.

Teaching the multidisciplinary team approach in a geriatrics miniresidency

The miniresidency program in geriatrics begun in 1985 at the University of California, San Diego, School of Medicine acquaints practicing health professionals with a multidisciplinary team approach to the care of geriatric patients. The two-week program features participation in a multidisciplinary outpatient clinic, home visits, social work and nutrition consultations, and conferences with patients and families. Miniresidency members also participate in neurologic and neuropsychological evaluations and attend day care for demented adults. The 71 health professionals who completed the program during its first 20 months showed significant improvement on their scores between the pre- and posttests: the mean of all scores in the pretest was 51 out of a possible 80 (SD 15); the mean of all scores in the posttest was 75 out of a possible 80 (SD 4); p less than .001. The 77% who returned post-program evaluation questionnaires found the program "useful" or "very useful."

Dairy Production Medicine and Herd Monitoring

In a major shift toward preventive medical services in dairy practice, veterinarians are taking a more active role in the overall management and planning on dairies.1,2 Veterinarians are routinely offering services like nutritional consultation, housing design, and financial advice that were considered outside the realm of veterinary medicine in the past. The dairy practitioner is adapting to the role of herd health and productivity consultant. This evolution will expand the opportunity for veterinary services to dairy farmers, and will be a profitable interchange for practitioner and producer alike. As is always the case, there is a price to pay for this new opportunity. Veterinarians will need to develop the new practice skills to complete in this arena. These areas include nutrition, computers and record systems, finances, and effective marketing of these services. We must convince dairymen to look to veterinarians for new and different services. Veterinarians need to develop effective ways to deliver these services to their clients and to charge for their efforts.1,5

Llama Herd Health

Herd health programs for llama owners offer veterinarians the opportunity to provide preventive care to an expanding market. Some aspects of llama herd health programs are unique but should be based on herd health principles used for other livestock species. Vaccinations, parasite control, nutritional consultation and reproductive examinations, coupled with feet and teeth care, are some areas to cover in herd health programs. Each herd will have slightly different requirements and the program should be tailored to the goals of the producer.

The effects of acute clostridium difficile diarrhea on fecal nitrogen content in adult hospitalized patients.

Clostridium difficile diarrhea (CDD) is a frequent cause of hospital-associated infectious diarrhea and a common reason for nutritional consultation. Limited data are available on fecal nitrogen losses during infectious diarrhea in adults. Eleven patients with acute CDD were studied for stool volume and fecal nitrogen. The mean stool output was 630 +/- 110 g/day and fecal nitrogen 2.5 +/- 0.3 g per 24 hour period (mean +/- SEM). Fecal nitrogen loss was increased from the predicted 12.0 mg/kg BW/day to 38.0 +/- 5.9 mg/kg BW/day. Fecal nitrogen loss in CDD can be an important source of nitrogen loss and should be measured in nitrogen balance studies in such patients.

Progress toward meeting the 1990 nutrition objectives for the nation: nutrition services and data collection in state/territorial health agencies.

Promoting Health, Preventing Disease, Objectives for the Nation, specifies nutrition as a priority area for improving the health of Americans by 1990. Eleven of the 15 nutrition objectives target adults or the public while four address pregnant and lactating women, infants, and children. To determine progress by states toward achieving the nutrition objectives, the Association of State and Territorial Public Health Nutrition Directors conducted a survey in 1985 to which 54 state and territorial nutrition directors responded. Three-fourths of the nutrition personnel focused efforts on maternal and child populations, and were supported largely by federal funds from the Special Supplemental Food Program for Women, Infants, and Children (WIC) and the Maternal and Child Health Block Grant. Only 15 per cent were funded by state and local sources. While most agencies reported using nutrition consultation in adult health programs, only 25 per cent paid for these personnel. Data to monitor progress were commonly available for only five of the 15 objectives. Achievement of the nutrition objectives by states will require a more comprehensive approach to nutrition programming with increased allocation of appropriate resources and expansion of health data systems.