Annalynn Skipper

Nutrition Screening Tools An Analysis of the Evidence

In response to questions about tools for nutrition screening, an evidence analysis project was developed to identify the most valid and reliable nutrition screening tools for use in acute care and hospital-based ambulatory care settings. An oversight group defined nutrition screening and literature search criteria. A trained analyst conducted structured searches of the literature for studies of nutrition screening tools according to predetermined criteria. Eleven nutrition screening tools designed to detect undernutrition in patients in acute care and hospital-based ambulatory care were identified. Trained analysts evaluated articles for quality using criteria specified by the American Dietetic Associations Evidence Analysis Library. Members of the oversight group assigned quality grades to the tools based on the quality of the supporting evidence, including reliability and validity data. One tool, the NRS-2002, received a grade I, and 4 tools-the Simple Two-Part Tool, the Mini-Nutritional Assessment-Short Form (MNA-SF), the Malnutrition Screening Tool (MST), and Malnutrition Universal Screening Tool (MUST)-received a grade II. The MST was the only tool shown to be both valid and reliable for identifying undernutrition in the settings studied. Thus, validated nutrition screening tools that are simple and easy to use are available for application in acute care and hospital-based ambulatory care settings.

Refeeding Syndrome or Refeeding Hypophosphatemia A Systematic Review of Cases

Nutrition support clinicians refer to the abnormalities in laboratory data and changes in clinical signs and symptoms that follow refeeding of starved or malnourished patients as refeeding syndrome. Theoretical descriptions of refeeding syndrome include a complex and extensive list of changes, such as hypophosphatemia, hypomagnesemia, hypokalemia, hyponatremia, hypocalcemia, hyperglycemia, and vitamin deficiency--all of which are accompanied by clinical signs and symptoms. In practice, clinicians see asymptomatic refeeding hypophosphatemia more often than a full-blown syndrome with multiple laboratory and clinical abnormalities. Confusion results because there is no widely accepted or uniformly applied set of defining characteristics for diagnosing refeeding syndrome. To gain insight into the clinical characteristics of refeeding syndrome described in the literature, a systematic review of reported cases and case series was conducted. Since 2000, 20 authors described 27 cases that contained sufficient data for review. Hypophosphatemia occurred in 26 patients (96%). While 19 patients (71%) experienced at least 1 other laboratory abnormality, only 14 (51%) exhibited a consistent pattern of abnormally low phosphorus and magnesium levels. Seven patients had hypocalcemia (26%), and hyponatremia was reported in 3 patients (11%). There were no reports of hyperglycemia. Mean data reported in case series containing data from 63 patients showed that hypophosphatemia was a consistent finding but that other abnormalities were not consistently identified. Findings suggest that refeeding hypophosphatemia is not accompanied by a consistent pattern of biochemical or clinical abnormalities among case reports or case series of patients reported to have refeeding syndrome.

Banana Flakes Control Diarrhea in Enterally Fed Patients

Diarrhea occurs frequently in the critically ill tube-fed population and may result from a multitude of causes. Despite the availability of antidiarrheal medications, diarrhea associated with enteral feedings remains a problem for clinicians and for the patients affected by it. We tested the hypothesis that administration of banana flakes would control diarrhea in critically ill patients receiving enteral feedings. Thirty-one patients with diarrhea and receiving enteral feedings were randomized to receive either banana flakes or medical treatment for diarrhea. Medical treatments included the use of pharmacological agents according to the discretion of the patients physician or reducing feeding rates. Both banana flakes and medical treatments reduced the severity of diarrhea in critically ill tube-fed patients. Over the course of treatment, mean diarrhea scores were 21.64 +/- 7.81 for the banana flake group and 25.41 +/- 9.76 for the medical group. These differences were not statistically significant. Both groups achieved similar levels of nutrition support. The banana flake group had less diarrhea clinically, with 57% of the subjects diarrhea free on their last study day as opposed to 24% of the medically treated subjects. This occurred despite a threefold increase in the number of patients testing positive for Clostridium difficile toxin in the banana flake group. We conclude that banana flakes can be used as a safe, cost-effective treatment for diarrhea in critically ill tube-fed patients. Banana flakes can be given concurrently with a workup for C. difficile colitis, thereby expediting treatment of diarrhea.

Validation of the Academy/A.S.P.E.N. Malnutrition Clinical Characteristics

To achieve a consistent and accurate definition of malnutrition, the Academy of Nutrition and Dietetics (AND), along with the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.), has developed six malnutrition clinical characteristics (MCCs): weight loss over time, inadequate energy intake compared with estimated needs, muscle loss, fat loss, fluid accumulation, and diminished grip strength. While some studies have shown a relationship between the MCCs and other outcomes, there is still no standard use of the MCCs. Therefore, a pilot study was conducted to test the validity of the six MCCs.

Is There a Role for Nonprotein Calories in Developing and Evaluating the Nutrient Prescription

The concept of nonprotein calories has been used in a variety of ways by nutrition support clinicians. Nonprotein calories may refer to the combined energy from lipid and carbohydrate but are also used to describe the balance between energy and protein in the form of the nonprotein calorie-to-nitrogen ratio. Nonprotein calories have been used as the basis for calculating nutrient needs, but this practice is no longer recommended as it may result in overfeeding. The purpose of this paper is to examine the nonprotein calorie concept using a clinical scenario and review of the literature.

A survey of perceived benefit and differences in therapy provided by credentialed and noncredentialed nutrition support dietitians.

BACKGROUND Benefits of the certified nutrition support dietitian (CNSD) credential to clinicians, their patients, and healthcare administrators have not been defined. A study was designed to measure the difference in cost of therapy provided by credentialed and noncredentialed nutrition support dietitians and to measure the perceived value of the credential to those who hold it. METHODS Using a modified Delphi technique, a questionnaire was developed to obtain demographic information, responses to statements of perceived benefit of the credential, and costs of therapy selected for patients in common clinical scenarios. RESULTS Of the 691 questionnaires mailed, 314 (45%) were returned. For 8 of 10 statements of perceived benefit, mean response scores indicated agreement. Respondents did not agree that salary increases resulted from credentialing. There was no difference between groups in the type of monitoring selected or in the time to complete an initial assessment. Cost of therapy was significantly higher for credentialed versus noncredentialed dietitians (dollar 915.67 +/- dollar 241.73 versus dollar 851.78 +/- dollar 243.44; p = .035), although the survey was not designed to show that the most appropriate care was least expensive. CONCLUSIONS The CNSD credential is of perceived benefit to practitioners except in obtaining salary increases. Credentialed dietitians selected more expensive therapy than noncredentialed dietitians, which would benefit healthcare administrators only if reduction of other costs resulted. More complex models are needed to fully assess the benefit of credentialed nutrition support dietitians to patients and healthcare administrators.

Collecting Data for Clinical Indicators

The Joint Commission for Accreditation of Healthcare Organizations is currently testing clinical indicators that will become an important part of hospital quality assurance programs. Implementation of clinical indicators may necessitate more extensive data collection than is now being done. This article reviews important considerations in the development of a data collection system that facilitates the evaluation of indicators of clinical performance. The evolution of the system currently used by the Nutritional Support Service at Pennsylvania Hospital is provided.

Training for nutrition support dietitians

Nutrition support dietitians have expanded their scope of practice steadily over the last 20 y.’ Technological advances, economic retrenchment, and evolving practice patterns will dictate continued changes over the next decade. These changes will offer abundant opportunities for dietitians who display creativity, continue to be adaptable, and are well trained. Advances in nutrition support knowledge have already resulted in complex guidelines to optimize nutrient intake.2*3 In addition, pharmacologic doses of nutrients are being used to treat or modify the response to disease. Detailed monitoring of nutrient intake will be needed as patients receive increasingly complex, multimodal nutrition therapy. As the demand for multi skilled health care workers increases, dietitians are expanding their skills. Dietitians are currently being trained to perform physical examinations and to insert feeding tubes.4 Other skills will be acquired as needed to provide comprehensive nutrition care. To meet the current economic challenges in health care, hospitals are implementing standard patient care protocols sometimes called clinical pathways or critical pathways.5 As pharmacists have used these vehicles to achieve greater autonomy, 6~7 so too will dietitians. As hospitals reduce physician training programs, dietitians may take advantage of the opportunity to adopt the physician extender’ model pioneered by nurses. To prepare for these challenges, dietitians will need advanced-level nutrition support skills. However, training dietitians in advanced-level nutrition support

Clinical Research: Validation of Objective Criteria for Predicting Tolerance to Enteral Feeding in Medical Intensive Care Unit Patients

The purpose of this study was to determine if indicators of cardiopulmonary function identified critically ill patients who tolerate enteral feeding. Medical records of 149 patients (age, 24 to 100 years) admitted to the medical intensive care unit who had a pulmonary artery catheter placed and were started on enteral feeding were reviewed retrospectively. Of 118 patients with cardiac index 60% and with > 5 cm positive end-expiration pressure, 79 (67%) did not tolerate enteral feedings. Sensitivity was 17% and specificity was 78%. In conclusion, with the aforementioned cutoffs, cardiac index, mean arterial pressure, and oxygen saturation may identify critically ill patients likely to be intolerant of enteral feeding.

comparison of Three Enteral Product Distribution Systems to Determine Methods to Reduce Waste.

Abstract With increasing use, costs of enteral products are an increasing portion of the foodservice budget. Additional costs are incurred if systems for distributing enteral products throughout the hospital result in waste. A study was designed to compare three enteral product distribution systems to determine if waste could be reduced. In addition, labor time and nursing satisfaction were measured for each system. The present system consisted of product delivery to the bedside daily based on physician order. An alternate system involved product delivery as floor stock to locked nourishment rooms on each nursing unit. The second alternate system consisted of product delivery to a locked cabinet accessed with a coded computer keypad. Alternate systems were trialed on two patient care units with a high volume of enteral product use. To control for differences in units, a crossover design was used. Data collection lasted for two weeks following a one week acclimation period between methods. Formula ordered, amount dispensed, patient intake, and stocking time were recorded daily. Daily waste, percent intake, percent dispensed, and percent wasted were calculated. Analysis of variance was used to compare variables for each delivery system. Each of the alternate systems significantly reduced product dispensed and product wasted (p≤0.05). Alternate systems also required less labor and resulted in higher nursing satisfaction ratings (p≤0.05). Based on these results, delivery of enteral products to a central location on the nursing unit rather than to the patient bedside reduced waste and improved nursing satisfaction.