Development of a nutritional care plan for diabetic patients

A nutritional care plan, encompassing all aspects of nutritional assessment, education, and follow-up was designed and implemented at the Victoria General Hospital in Halifax, Nova Scotia. The care plan was developed in response to the results of an audit on nutritional care of diabetic patients. It was designed to assure referral of all diabetic patients to clinical dietitians, set standards for care and its documentation, provide a teaching tool, and enhance communication between inpatient and outpatient nutrition services. The care plan was developed by the authors in committee and approved by the clinical dietitians and the medical staff at the Victoria General Hospital. The care plan format is described in detail. It has been in effect since March, 1982 with positive feedback reported by clinical dietitians. Reevaluation of care, charting, and referrals to outpatient nutrition services are planned. Additional care plans on other nutritional topics are planned for the future.     

The role of the clinical dietitian: II. Staffing patterns and job functions

On the basis of responses to a telephone questionnaire, this study evaluated--from the viewpoint of nutrition support dietitians, general clinical dietitians (dietitians who are not members of a nutrition support team and who provide general clinical dietetic services), and other health professionals--the current job functions that nutrition support and general clinical dietitians perform in hospitals. Anticipated staffing needs and desired job functions were also assessed. For the nutrition support and general clinical dietitians, as viewed by themselves and other health professionals, there was considerable overlap in many job activities. However, a significantly larger proportion of directors of nursing thought that nutrition support dietitians were more involved than general clinical dietitians in the evaluation of nutritional status (42% vs. 14%) and in contributing expertise to medical team discussions (48% vs. 12%). A significantly larger proportion of physicians viewed the nutrition support dietitian as more involved than the general clinical dietitian in in-service programs for medical and nursing staffs (32% vs. 6%). A large proportion of directors of nursing (62%), hospital administrators (34%), and physicians (56%) believed that dietetic involvement in the supervision of food preparation, especially by general clinical dietitians, was much greater than did the dietetic staff. The outlook for the future suggests a greater participation by both the nutrition support and the general clinical dietitian in direct patient care functions and less involvement in food preparation and clerical tasks.     

Nutrition care activities and DRGs

The recent passage and implementation of the prospective payment system (PPS) for Medicare inpatient services have had a strong impact on dietitians practicing in southern Florida. Because several local hospitals service regions in which 90% of the population is 65 years old or older, the annual revenues from Medicare have been reduced. The hospitals still have to meet basic overhead costs and profit margins. This has resulted in the elimination of several dietetic positions. Therefore, dietitians need to establish a cost-benefit justification for the nutrition care and support of patients. This study is the initial phase of a plan to define the nutrition care services the dietitian provides and to identify the most frequently occurring diagnosis related grouping (DRG) categories. For 3 weeks, 31 dietitians maintained logs that detailed dietetic intervention and treatment for each of the 3,827 patients seen. The nutrition care activities reported most frequently by dietitians were basic services, hospital visit and reassessment, initial consultation, and screening to rule out malnutrition. The mean time spent in all nutrition care activities ranged from 13 to 33 minutes. The most frequently occurring DRGs were those for diabetes, heart failure, circulatory disorders, specific cerebrovascular accident, and transient ischemic attacks. Overall, the type of nutrition care activities and the time spent in those activities were significantly different among the hospitals studied. The differences reflect the philosophies of each facility. The types of DRG categories observed reflect the age of the population served.     

Documentation of time expenditures of clinical dietitians: results of a statewide time study in Texas

The purpose of this study was to establish a profile of the amount of time expended by clinical dietitians in providing nutrition services. One hundred twenty-seven dietitians in 49 hospitals in Texas collected time data according to nutrition care activity, diet order classification, care level, and diagnosis. Frequency, mean time, standard deviation, and percentage of time were computed for each of the variables. Data were analyzed to ascertain relationships among the variables. The dietitians expended 50.7% of their time performing client-related activities, 9.8% in administrative/managerial functions, 1.0% in professional activities, 5.1% in non-professional activities, 14.0% in delay activities, and 19.5% in transit time. The diet order classification that required the largest amount of the dietitians' time according to selected components of the nutrition care process was the calorie-controlled diabetic diet. Among the four nutrition care levels, dietitians expended the greatest percentages of time providing services for patients requiring intermediate (35.4%) and advanced intermediate care (30.4%). Dietitians expended more time providing client-related activities to patients diagnosed with diseases and disorders of the endocrine and excretory systems than to other patients. Mean times provide the clinical manager with documentation for determining staffing needs and costs of services.     

Review of specialist dietitian services in patients with inherited metabolic disease in the United Kingdom

INTRODUCTION: Dietary management forms the mainstay of treatment for many inherited metabolic diseases (IMDs) and specialist dietitians play a crucial role in the multi-disciplinary core team for these patients. Professional concerns have been expressed that the current clinical workforce is inadequate for meeting current and future service demands. The aim of this work was to describe the provision of specialist dietetics to patients with IMD as part of a national needs assessment and review. MATERIALS AND METHODS: The 24 main specialist providers and 27 specialist dietitians were surveyed by a questionnaire. A focus group of three specialist dietitians was also held to explore the roles of specialist dietitians in greater depth. RESULTS: Responses were received from all 24 specialist service providers and 63% of 27 specialist dietitians. The majority of service providers (92%) have specialist dietitians, but only eight services had more than one whole time equivalent (33%). Key roles were management of complex dietary regimens, prevention and management of metabolic crises, education, co-ordination of care, clinical audit and research. Although highly qualified, there is currently no clear formal career structure or training pathway for dietitians in IMDs. CONCLUSION: Specialist dietitians have important clinical and leadership roles in managing IMD but specialist services are thinly spread. There is a need for access to formal education, training and support programmes. The clinical workforce needs expansion to provide more comprehensive and equitable services.     

Is prospective payment inhibiting the use of nutrition support services? Discussion and research implications

Much concern has been generated about the impact of the diagnosis-related group (DRG) prospective payment system on a variety of medical treatments. In particular, high technology medical or surgical applications, such as enteral and parenteral nutrition support, are often perceived as cost-increasing rather than cost-reducing. The threat to the use of nutrition support services relates to the non-existence of an effective reimbursement scheme for recovery of labor costs for the services. High overhead and relatively expensive hard- and software may price nutrition services out of the health care system if an appropriate reimbursement plan is not developed. To address the obvious lack of provision for reimbursement of nutrition support services under the DRG system, several cost-benefit issues related to the provision of nutrition support must be addressed. Empirical data are necessary to determine the clinical significance of these procedures relative to severity and duration of illness and subsequent associated length-of-stay issues; and the cost-benefit justification of nutrition support for acute and chronically ill patients. The purpose of this discussion is not to propose such a system of reimbursement but rather to present a framework for the development and justification of a revised DRG reimbursement plan to cover adequately the cost of providing enteral and parenteral nutrition support services.     

Staffing patterns in hospital clinical dietetics and nutrition support: a survey conducted by the Dietitians in Nutrition Support dietetic practice group.

The Dietitians in Nutrition Support dietetic practice group of The American Dietetic Association administered a questionnaire to evaluate changes in nutrition support services provided to hospitalized patients and home patients in 1989 and compared the results with results of a survey administered in 1986. The 1986 survey documented an increase in tube feeding to inpatients during 1984 to 1986 and greater dietitian staffing in tertiary care hospitals than in primary care hospitals and in larger hospitals in 1986. The 1989 questionnaire was mailed to clinical nutrition managers from a nationwide random sample of 1,000 hospitals from American Hospital Association members; 271 responses were received. Full-time equivalent (FTE) registered dietitians (RDs)--including clinical RDs, nutrition support service RDs, and clinical nutrition managers--decreased 11% from 1986 to 1989. FTE dietetic technicians decreased 22%. The number of FTE nutrition support service RDs and clinical nutrition managers decreased significantly (P less than .05). The mean number of FTE clinical dietitians per 100 beds decreased from 1.4 to 1.0 from 1986 to 1989. These decreases in dietetics staffing occurred despite an overall increase in total hospital FTE staff of 2.9%. Reported daily provision of nutrition support modalities to inpatients was 3.5% for parenteral nutrition, 4.9% for enteral tube feeding, and 9.6% for oral supplements. Decreased dietetics staffing was accompanied by other factors that negatively affect productivity (and therefore ability to provide adequate patient care), including inadequate delegation of technical tasks to dietetic technicians, limited availability of secretarial and computer support, and minimal provision of pocket pagers. These trends may be evidence of inadequacy of dietetics staffing to meet the needs of the US population for nutrition care.     

A computer-assisted management information system for nutrition services

A computer-assisted management information system was created to facilitate effective management of clinical nutrition services and labor resources in a 330-bed teaching and research hospital. Standards were developed for the quality and quantity of nutrition care, time required to provide nutrition care, and utilization of dietitians' time. Computer software was developed to report the volume of services provided, the need for services, and the utilization of labor hours. Data were evaluated to determine whether services were consistent with standards and to calculate a recommended number of clinical dietitian full-time equivalents for the hospital. Furthermore, the management information system was instrumental in developing a fee-for-service structure, for evenly distributing work loads among dietitians, and for monitoring adherence to standards of care.     

Changes in nutrition support services between 1984 and 1986

Reports of the economic impact of diagnosis-related group funding on staffing and patient care in hospitals have varied from optimistic to bleak. The Dietitians in Nutrition Support Practice Group of The American Dietetic Association developed a questionnaire to evaluate changes in nutrition support services provided to inpatients and home patients between 1984 and 1986. The written survey instrument was mailed to clinical nutrition managers at a nationwide random selection of 1,000 hospital members of the American Hospital Association. Two hundred thirty-six responses were received. Respondents reported an increase in the use of enteral nutrition support for inpatients between 1984 and 1986. In 1986, tertiary-care hospitals also reported greater use of parenteral nutrition support and tube feeding for inpatients and home patients than did primary-care hospitals. Tertiary-care hospitals also reported higher staffing in 1986 than did primary-care hospitals in the following areas: clinical, nutrition support, and outpatient dietitians and dietetic technicians. Greater use of enteral and parenteral support for inpatients was noted by large hospitals as well as greater staffing in the following areas: clinical managers; nutrition support, clinical, outpatient, and home care dietitians; and dietetic technicians. However, the ratio of patients to RDs was greater in large than in small hospitals. There was no significant difference in patients:RD ratio between tertiary-care and primary-care hospitals. The only difference between responses from for-profit and nonprofit hospitals was in the number of nutrition support RD positions, which was larger in the nonprofit hospitals. Utilization of nutrition support for inpatients or home patients was not different for hospitals in different profit categories.     

Specialty practice in dietetics: Empirical models and results

This article, which is the second of a two-part series, presents results for the second and third objectives of The American Dietetic Association (ADA) 1991 Dietetic Practice Study: to distinguish the task activities among registered dietitians practicing in renal nutrition, pediatric nutrition, and metabolic nutrition care; and to investigate the relationship between advanced-level practice and specialty practice. A nationwide mail survey of advanced-level practice was conducted on a stratified random sample of 8,012 beyond-entry-level (registered before April 1988) registered dietitians who were members of ADA and of dietetic practice groups (DPGs). The sample was supplemented with two randomly selected control groups of 1,000 entry-level and 1,000 beyond-entry-level registered dietitians. The operational definition for specialty practice was met by 1,925 sample members who were also included in the survey on practice in the three specialty areas. The overall response rate was 63.1%, and the total number of usable returns was 5,852. The results from a discriminant analysis of 121 specialty job tasks, administered in common to practitioners in each specialty, found that 84 tasks could be used to construct a generic model of specialty practice from which specific task lists were derived that defined practice in renal nutrition, pediatric nutrition, and metabolic nutrition care. Validation analyses found the generic model to be a reliable means of distinguishing the job activities in renal nutrition and in pediatric nutrition; it was somewhat less reliable for metabolic nutrition care. A weak relationship was found between advanced-level practice and practice in the three specialty areas. This was explained by the finding that many specialists do not meet the master's degree requirement of the model of advanced-level practice. Overall, the results from all analyses conducted suggest that it is reasonable to accept the picture of specialty practice constructed by this research as valid. The findings, therefore, establish the empirical basis for a specialty practice credential in the three specialty areas investigated.     

Delivery of Enteral Nutrition after the Introduction of Practice Guidelines and Participation of Dietitians in Pediatric Critical Care Clinical Teams

Provision of optimal nutrition is often difficult to achieve in the critically ill child, but can improve with better nutritional support practices. This study evaluated the joint impact of the introduction of enteral feeding practice guidelines and participation of dietitians in daily ward rounds on enteral nutrition (EN) intake and practices in children in intensive care. Nutritional intake and EN practices were audited before (period A) and after (period B) the introduction of enteral feeding practice guidelines and participation of dietitians in daily ward rounds in a pediatric intensive care unit. Information was collected on a daily basis and nutritional intake was compared with predefined targets and the United Kingdom dietary reference values. There were 65 patients and 477 nutritional support days in period A and 65 patients and 410 nutritional support days in period B. Basal metabolic rate (BMR) energy requirements were achieved in a larger proportion of nutritional support days in period B (BMR achieved [% nutritional support days]; period A: 27% vs period B: 48.9%; P<0.001). In patients admitted for nonsurgical reasons, median energy, protein, and micronutrient intake improved significantly. In the same group, the percentage of daily fluid intake delivered as EN increased post implementation (period A: median=66.8%; interquartile range=40.9 vs period B: median=79.6%; interquartile range=35.2; P<0.001). No significant changes were seen in patients admitted for corrective heart surgery. Implementation of better EN support practice can improve nutritional intake in some patients in critical care, but can have limited benefit for children admitted for corrective heart surgery.     

Nutrition support practice: a study of factors inherent in the delivery of nutrition support services

The purpose of this study was to determine the degree of intercorrelation among dietitian, physician, and team nutrition support functions. Eight hundred and eighty dietitians and physicians were asked to respond to a questionnaire describing nutrition support functions as reported in the literature and validated by a panel of nutrition support physicians and dietitians. Two hundred and fifty-four completed questionnaires were included in the study, 84 from physicians and 170 from dietitians. Intercorrelations among function statements were subjected to factor analysis. The magnitude and consistency of factor loadings suggest that nutrition support is not perceived as independent components, but as a comprehensive pattern or structure. However, there was one important difference in perception. The sample tended to have an "enteral" orientation to the dietitian role and a "parenteral" orientation to the physician and team roles. The data support the contention that all members of nutrition support teams need a common core of knowledge and a set of highly developed process skills which can best be attained through an integrated, rather than segmented, approach to team training.     

Nutrition Measures for Managed Care Report Cards

Health plan “report cards,” that is, published summaries of health plan performance, are a new way to help consumers select a health plan on the basis of cost and quality. The Health Plan Employer Data and Information Set (HEDIS) includes a set of health plan performance measures, standardized definitions, and methods for data collection. HEDIS is used as the basis for many report card initiatives and is the preferred tool of the managed care industry for measuring health plan performance. Nevertheless, the current list of HEDIS performance measures omits many health services, including medical nutrition therapy. Nutrition measures have the potential for wide appeal among health care stakeholders (ie, payers, consumers, and providers). Four measures related to medical nutrition therapy are proposed for managed care report cards: staffing for nutrition services and medical nutrition therapy for high cholesterol level, gestational diabetes, and cardiovascular disease. Barriers to adopting medical nutrition therapy measures in HEDIS include the need to address technical issues before considering new measures and competition from other potential measures. Steps to create support for medical nutrition therapy measures in HEDIS should focus on influencing representatives of health plans and employers to include these measures. The involvement of registered dietitians in the dynamic process of health plan evaluation is an important extension of ongoing efforts for strategic positioning in the managed care market. J Am Diet Assoc. 1996; 96:374-380.     

Current state of dietetic services for inflammatory bowel disease patients in New Zealand: an observational study

Aim

Nutritional therapies for inflammatory bowel disease are increasingly recommended. This study aimed to gain insight from patients, dietitians and gastroenterologists into inflammatory bowel disease dietetic care in New Zealand.

Methods

Mixed-methods surveys were developed and then distributed online to patients with inflammatory bowel disease and dietitians and gastroenterologists that care for patients with inflammatory bowel disease. Quantitative survey data were analysed using nonparametric statistical tests. Qualitative survey data were analysed using thematic analysis.

Results

Responses were received from 406 inflammatory bowel disease patients, 79 dietitians and 40 gastroenterologists. Half of the patients (52%) had seen a dietitian for nutrition advice. Patients more likely to have seen a dietitian were/had: Crohn's disease (p = 0.001), previous bowel surgery (p < 0.001), younger (p < 0.001) or receiving biologic therapy (p = 0.005). Two-thirds (66%) of patients found the dietitian advice at least moderately useful. A common theme from patient comments was that dietitians needed better knowledge of inflammatory bowel disease. Almost all (97%) gastroenterologists reported that their inflammatory bowel disease patients ask about nutrition; 57% reported that there were inadequate dietitians to meet patient needs. Over 50% of dietitians saw inflammatory bowel disease patients infrequently and 39% were not confident that their knowledge of the nutritional management of inflammatory bowel disease was current. Dietitians desired greater links with the inflammatory bowel disease multidisciplinary team.

Conclusion

Current inflammatory bowel disease dietetic services in New Zealand are inadequate. Standardised care, increased resourcing, dietitian training in inflammatory bowel disease, and stronger links with the multidisciplinary team are suggested to improve services.     

Impact of gestational diabetes mellitus nutrition practice guidelines implemented by registered dietitians on pregnancy outcomes

Nutrition practice guidelines were developed for gestational diabetes mellitus by registered dietitians from the Diabetes Care and Education and the Women's Health and Reproductive Nutrition dietetic practice groups. To validate the guidelines, a clinical trial was designed with clinic sites randomly assigned to either nutrition practice guidelines care (12 sites) or usual nutrition care (13 sites), with diabetes, obstetric, and other clinic types represented in both groups. Volunteer dietitians served as study coordinators and recruited women diagnosed with gestational diabetes mellitus. The nutrition practice guidelines define medical nutrition therapy (MNT) for gestational diabetes and emphasize three areas-definition of MNT clinical goals with indexes to modify or advance MNT and criteria to start insulin; use of self-monitoring tools; and provision of three nutrition visits. Usual care sites provided prenatal nutrition care according to usual practice. The effect of nutrition care (sites following the nutrition care guidelines) and type of clinic site on changes in glycated hemoglobin and infant birth weight, adjusted for other covariates, were evaluated using linear regression. Differences in insulin use and other infant outcomes between treatment groups were evaluated using logistic regression. Generalized estimating equations were used to accommodate nonindependence within randomized clusters of patients within clinic sites. Data from 215 women indicated less insulin use at diabetes clinic sites in the nutrition practice guidelines groups and improved glycated hemoglobin control during the treatment period in diabetes clinics compared with obstetric or other clinics. A higher proportion of women in the usual care group had glycated hemoglobin levels that exceeded 6% at follow-up compared with women in the nutrition practice guidelines group (13.6% vs 8.1%), although not statistically significant (P=0.26). A significant clinic type and treatment group effect was found for birth weight. Nutrition practice guidelines for gestational diabetes mellitus reflected nutrition care already being provided by registered dietitians in diabetes clinics prior to this study because outcomes at these clinics were not impacted. Use of the guidelines by dietitians at obstetric and other clinics tended to improve outcomes at these sites.     

Home health care: A new worksite for dietitians monitoring nutrition support

Dietitians have been practicing in the home setting for many years. However, monitoring patients receiving home parenteral and enteral nutrition has been performed primarily on an outpatient basis by dietitians affiliated with hospital-based nutrition support teams. Changes in physician familiarity with these specialized therapies and expansion of the home infusion therapy industry have resulted in oppurtunities for dietitians to monitor nutrition support in a patient's home. This article describes the role of the home nutrition support dietitian, the work environment, and the training needed to prepare the practitioner for effective work in this field. Practical concerns of interest to the dietitian monitoring home nutrition support include equipment, resources, and communication tools. Home visits impart several benefits to dietetics practice by enriching the contact between patient and dietitian. A case study describes a dietitian's involvement in and potential cost-effectiveness of treatment of a patient whose parenteral nutrition therapy was initiated and completed without hospitalization. The home is emerging as a worksite for dietitians who monitor nutrition support. As providers of home infusion therapy continue to expand, widespread availability of dietitians' services for patients receiving parenteral and enteral support at home must be ensured.