R. Brody

The effects of different IV fat emulsions on clinical outcomes in critically ill patients.

Objective:To examine the effects of different IV fat emulsions on clinical outcomes in critically ill patients. Design:Secondary analysis of data from a prospective multicenter study. Setting:An international sample of ICUs. Patients:Adult patients who were admitted to the ICU for more than 72 hours, were mechanically ventilated within 48 hours, received exclusive parenteral nutrition for more than or equal to 5 days, and did not change IV fat emulsion type during the data collection period. Interventions:Demographic and clinical data were collected for up to 12 days, until death, or discharge from the ICU, whichever came first. Clinical outcomes were recorded at 60 days following ICU admission. Measurements:Lipid-free, soybean, medium-chain triglyceride, olive, and fish oils in parenteral nutrition were compared using an adjusted Cox proportional hazard model to examine time to termination of mechanical ventilation alive, time to ICU discharge alive, and time to hospital discharge alive. Main Results:A total of 451 patients were included in this study: 70 (15.5%) in the lipid-free group, 223 (49.5%) in the soybean oil group, 65 (14.4%) in the medium-chain triglyceride group, 74 (16.4%) in the olive oil group, and 19 (4.9%) in the fish oil group. When compared with lipid-free parenteral nutrition, patients who received fish oil had a faster time to ICU discharge alive (hazard ratio, 1.84; 95% CI, 1.01–3.34; p = 0.05). When compared with soybean oil, patients who received olive oil or fish oil had a shorter time to termination of mechanical ventilation alive (hazard ratio, 1.43; 95% CI, 1.06–1.93; p = 0.02 and hazard ratio, 1.67; 95% CI, 1.00–2.81; p = 0.05, respectively) and a shorter time to ICU discharge alive (hazard ratio, 1.76; 95% CI, 1.30–2.39; p < 0.001 and hazard ratio, 2.40; 95% CI, 1.43–4.03; p = 0.001, respectively). Conclusions:Use of alternative IV fat emulsions in parenteral nutrition, particularly olive and fish oil, was associated with improved clinical outcomes.

The impact of implementation of a nutrition support algorithm on nutrition care outcomes in an intensive care unit.

BACKGROUND A nutrition support algorithm is an operational version of a guideline that is adapted to local requirements and easy to apply in clinical practice. The purpose of this study was to determine the impact of implementing a nutrition support algorithm on nutrition care outcomes in an intensive care unit (ICU) in Switzerland without a designated dietitian. METHODS The retrospective study included data collection on 2 cohorts of critically ill patients before (n = 56) and after (n = 56) implementation of a nutrition support algorithm based on the guidelines published by the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition guidelines. RESULTS There were significant differences between groups for the mean delivery of total energy in the pre- vs postimplementation group (909 ± 444 vs 1097 ± 420 kcal/d; P = .023) and mean delivery of protein per day (35 ± 17.9 vs 59.1 ± 27.3 g; P < .001). For patients staying at least 7 days in the ICU, the cumulative energy deficit decreased from -5664 ± 3613 kcal in the preimplementation group to -2972 ± 2420 kcal (P = .011) in the postimplementation group. No significant differences in the route of feeding and timing of enteral nutrition initiation were found. CONCLUSIONS Implementation of a nutrition support algorithm resulted in improved provision of energy and protein delivery. This may be further improved with routine nutrition assessment by a dietitian or a designated nutrition support team.

Role of Registered Dietitians in Dysphagia Screening

OBJECTIVE To examine the ability of registered dietitians to identify patients at risk for dysphagia and make appropriate diet/feeding recommendations in comparison with the speech-language pathologist, and to determine screening criteria for the registered dietitian to use for prediction of dysphagia risk. DESIGN The dietitian and speech-language pathologist performed dysphagia screening on subjects independently through questioning and/or mealtime observation to identify signs and symptoms of dysphagia. Presence of dysphagia risk and diet/feeding recommendations were determined and results from the dietitian and speech-language pathologist were compared. SUBJECTS/SETTING Thirty-four patients admitted during a 2-month period to a neuroscience unit at an urban teaching hospital were analyzed prospectively. STATISTICAL ANALYSES PERFORMED kappa Statistics were used to assess agreement between the dietitian and speech-language pathologist. A kappa level of less than 0.4 indicated weak agreement, 0.4 to 0.7 indicated moderate agreement, and greater than 0.7 indicated strong agreement. Logistic regression methods were used to evaluate screening criteria as potential predictors of dysphagia risk. RESULTS Moderate agreement (0.61) was found between the dietitian and speech-language pathologist in determination of dysphagia risk. The dietitian predicted the ability of the patient to consume an oral diet with strong agreement with the speech-language pathologist (1.0); various diet consistencies with moderate agreement (0.61); and the need for liquid restrictions with strong agreement (1.0). The most significant screening variables for prediction of dysphagia risk (P < .05) were age (P = .018), history of dysphagia (P = .042), difficulty swallowing solids (P = .0007), observed facial weakness (P < .0001), and a change in voice quality (P = .0007). Self-reported screening variables significantly related to dysphagia risk included drooling of liquids (P = .0009) and solids (P = .0080), facial weakness (P = .0006), change in voice quality (P = .0010), and prolonged eating time (P = .0157). APPLICATIONS/CONCLUSIONS Dietitians can effectively identify patients with dysphagia. Screening for dysphagia can be implemented as part of standard nutrition assessments and may aid in decreasing dysphagia-related complications.

Feeding tube use in patients with head and neck cancer.

Use of a prophylactic feeding tube before concurrent chemotherapy and radiotherapy (CRT) for patients with head and neck cancer is often debated.

Identifying Components of Advanced-Level Clinical Nutrition Practice: A Delphi Study

The dietetics profession lacks a comprehensive definition of advanced-level practice. Using a three-round Delphi study with mailed surveys, expert consensus on four dimensions of advanced-level practice that define advanced practice registered dietitians (RDs) in clinical nutrition was explored. Purposive sampling identified 117 RDs who met advanced-level practice criteria. In round 1, experts rated the essentiality of statements on a 7-point ordinal scale and generated open-ended practice activity statements regarding the following four dimensions of advanced-level practice: professional knowledge, abilities and skills, approaches to practice, roles and relationships, and practice behaviors. Median ratings of 1.0 to 3.0 were defined as essential, 4.0 was neutral, and 5.0 to 7.0 were nonessential. In rounds 2 and 3, experts re-rated statements not reaching consensus by evaluating their previous responses, group median rating, and comments. Consensus was reached when the interquartile range of responses to a statement was ≤2.0. Eighty-five experts enrolled (72.6%); 76 (89.4%) completed all rounds. In total, 233 statements were rated, with 100% achieving consensus; 211 (90.6%) were essential to advanced practice RD clinical practice. Having a masters degree; completing an advanced practice residency; research coursework; and advanced continuing education were essential, as were having 8 years of experience; clinical nutrition knowledge/expertise; specialization; participation in research activities; and skills in technology and communication. Highly essential approaches to practice were systematic yet adaptable and used critical thinking and intuition and highly essential values encompassed professional growth and service to patients. Roles emphasized patient care and leadership. Essential practice activities within the nutrition care process included provision of complex patient-centered nutrition care using application of advanced knowledge/expertise and interviewing and counseling strategies approached in a comprehensive yet discriminating manner. Communication with patients and the health care team is a priority. An advanced-level practice model in clinical nutrition was proposed depicting the requisite attributes and activities within four dimensions of professional practice.

Framework for Analyzing Supply and Demand for Specialist and Advanced Practice Registered Dietitians

The number of credentialed dietetics specialists--approximately 15% of the profession--is proportionately higher than those in other allied health and nursing professions. Credentialed specialists seem to receive greater compensation earlier in their career, but this advantage neutralizes as length of time in the profession increases. A larger proportion of younger registered dietitians (RDs) are specialists, which may mean an increase in supply of specialists in the future. There is considerable interest in creation of health promotion and foodservice management credentials. Consideration should be given to collaborating with other organizations to explore new models of recognition or credentialing for narrow areas of focus. Creating a methodology that can differentiate the tasks and approaches to practice that are unique to advanced practitioners compared with specialists has been a challenge. Prior research has not succeeded in identifying the differences in what advanced practitioners do. Future research to isolate advanced practice must take practice approach into account. A new, research-based, credential for advanced practitioners is possible, or a recognition program for advanced practice RDs could be considered. Precise supply and demand for specialty and advanced practice RDs cannot be measured. Thus, in this technical article, the authors share the available information regarding supply and demand with regard to dietetics specialists and advanced practitioners. It seems there are distinctions among the various levels of practice and recognition of their value to the profession and to the health of the public.

Report from the Advanced-Level Clinical Practice Audit Task Force of the Commission on Dietetic Registration: Results of the 2013 Advanced-Level Clinical Practice Audit

H ISTORICALLY,THECOMMISSION on Dietetic Registration (CDR) and the Academy of Nutrition and Dietetics (Academy) have used consensus-based definitions of advanced-level practice (ALP) in nutrition and dietetics. Prior research by Bradley and colleagues, Skipper and Lewis, and Brody and colleauges defined attributes of ALP registered dietitian nutritionists (RDNs) in general, medical nutrition therapy, and clinical nutrition and dietetics practice. The Academy broadly defines the ALP RDN as one who “demonstrates a high level of skills, knowledge, and behaviors. The individual exhibits a set of characteristics that include leadership and vision and demonstrates effectiveness in planning, evaluating, and communicating targeted outcomes.” Yet, delineation of job functions representative of ALP has been difficult to elucidate, either generally or in focused areas of practice. From 2005 through 2007, CDR conducted a practice audit to identify and delineate ALP in nutrition and dietetics and to examine theneed for anadvanced practice credential. A common core of advanced practice tasks representing all practice segments was indiscernible from these data. Study conclusions suggested focused practice areas including clinical nutrition, community nutrition, management, business, or education/research were likely to have unique ALP characteristics and practice tasks, justifying the need for future studies to concentrate on only one practice area. Thus, in 2011, the CDR commissioned a second Task Force, the AdvancedLevel Clinical Practice Audit Task Force, to conduct a practice audit in clinical nutrition practice and, if feasible, developan advancedpractice credential for RDNs in clinical practice. Clinical nutrition was selected as the specific practice segment because it represents the segment in which the largest proportionofRDNspractice. In “Developing an Advanced Practice Credential for Registered Dietitian Nutritionists in Clinical Nutrition Practice,” Brody and colleagues describe the charge of the Task Force, the definition of clinical nutrition and dietetics practice, and the process used to explore, define, and design the new certification program recognizing advanced clinical nutrition practice. An important step in that process, once the basic concept and potential value of the certification program had been provisionally proven in the market, was to discover what work those currently practicing in clinical nutrition at an advanced level actually do—the work that sets them apart from entrylevel and beyond-entry-level (BEL) RDNs. Defining the credential in terms of the tasks performed by actual ALP RDNs provides the fundamental justification for certification and credentialing, namely to protect the public by warranting that credentialed practitioners are able to perform their work in a safe and effective manner. Task identification is also a requirement for developing a valid, fair, and legally defensible credentialing exam. According to the National Commission for Certifying Agencies:

A Review of Characteristics of Graduates in the Allied Health and Nursing Professions: Entry-Level and Advanced Practice

The review explores the similarities and differences in graduate outcomes among healthcare professionals who have completed entry-level or advanced degree programs from the disciplines of nursing, dietetics, physical therapy, occupational therapy, and pharmacy. Graduates of advanced degree programs appear to have expanded job scope or functions beyond that of entry-level degree graduates, and higher-level degrees contribute to professional advancement and compensation advantages. Increased confidence, self-esteem, scholarly productivity, and professional involvement are documented outcomes of advanced degrees. More research is needed to discern whether the degree or contributing factors such as work setting, experience, or area of specialization impact graduate outcomes.

Perceived Needs for Graduate Level Clinical Nutrition Education for Registered Dietitians

Registered dietitians (RDs) took an electronic survey regarding the perceived graduate education needs and opinions on pursuing graduate degrees. A sample of 1166 RDs were surveyed. The usable response rate was 39.7%. Respondents were stratified into 3 groups for comparison. Results were reported descriptively, and χ2 and Pearson correlation coefficients were used to test relationships. Reasons for pursuing graduate degrees included enhanced knowledge (77.2%) and personal development (61.6%). Reasons for not pursing graduate degrees included no increased compensation/benefits (66.3%) and insufficient time (49.5%). Significantly more RDs with postprofessional graduate degrees than the other groups perceived the need for the following courses: Applied Physiology (P = .006), Clinical Management (P = .028), Applied Clinical Research (P < .001), and Outcomes Research (P < .001).

Abbreviated Steady State Intervals for Measuring Resting Energy Expenditure in Patients on Maintenance Hemodialysis.

Background: Indirect calorimetry requires a steady state (SS) protocol to determine measured resting energy expenditure (mREE). Achieving stringent criteria for an SS interval may be difficult for patients on maintenance hemodialysis (MHD), as they may become uncomfortable because of the test itself or their health status. The study aim was to explore if a shortened SS interval was within acceptable limits for bias and precision. Materials and Methods: For this cross-sectional secondary analysis, adults (N = 125) who received MHD thrice weekly were enrolled. The indirect calorimetry test was performed for a length of total time ⩽30 consecutive minutes. SS was evaluated in accordance with intervals of 10, 5, 4, 3, and 2 minutes. The mREE at the 10-minute SS was compared with the mREE at 5, 4, 3, and 2 minutes, via t tests and Bland-Altman analysis, to determine degree of bias and level of agreement. The a priori alpha level was set at ⩽0.5. Results: The sample was primarily male, African American, and non-Hispanic, with a mean ± SD age of 55.4 ± 12.2 years, who reported being on MHD for an average of 62.4 ± 74.3 months. None of the mREE measures were significantly different from that of the 10-minute SS interval. Seventy-two percent of the participants were able to achieve SS at the 10-minute interval, 83.2% at 5 minutes, 87.2% at 4 minutes, and 89.6% for both 3 and 2 minutes. Conclusion: For patients on MHD, an abbreviated SS interval of <10 minutes (eg, 5 minutes) yielded valid mREE measurements.