The impact of computerization of the nutrition support process on the nutrition support program in a tertiary care hospital in the Philippines: report for the years 2000-2003

BACKGROUND & AIMS: To improve hospital health care delivery by identifying malnutrition in all admitted patients and following up those identified to be malnourished and "at risk of developing malnutrition" a hospital nutrition support program based on the JCAHO system was initiated in 1999. Two major problems were encountered: first, the inability to perform a nutrition surveillance process due to failure by the staff to implement existing nutrition screening tools and second, the lack of awareness and support from the medical staff in this initiative. Two solutions were implemented in 2000: computerization of the nutrition screening and nutrition support process and synchronizing this with the whole nutrition support program. METHODS: A computer program was developed which performs BMI-based nutrition screening, produces lists of all malnourished patients, and computes the different formulas for either nutritional requirement or parenteral and/or enteral formulation. It also generates patient status reports based on encoded data from the nutrition support team, which prioritized these patients for management based on the data output. RESULTS: From 2000 to 2003, improvement was seen in these areas: entry of height and weight in the patient record increased from 30% to 90%; nutrition surveillance shows nutritional status distribution to be: normal (58%), underweight (9%), overweight (25%), and obese (8%), referrals to the nutrition support team based on the screen notification increased from 37% to 100%, patient coverage by nutrition support services increased from 7374 (38.8%) in 2000 to 11,369 (83%) in 2003, and critical care patients seen increased from 10% in 2000 to 99% in 2003. More improvement is needed in physician response to nutrition support recommendations, which still remains low (11.2-24%). CONCLUSIONS: Computerization helps to improve nutrition support delivery in the hospital, but more cooperation and support from the medical staff is still needed for better results.     

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.     

Developing a standard of care for patients at risk for long-term hospitalization

At one hospital, during 1 month, charts of patients whose length of stay was greater than or equal to 60 days were reviewed to determine current dietetics practice. Several areas that affect overall nutrition care were identified: consistent follow-through on recommendations, continuity of care, consistent protocol for addition of supplements, communication of results of calorie counts, and assessment of nutritional status over the course of hospitalization vs documentation on a particular day. A protocol was developed to provide weekly information about patient weight for ongoing nutrition assessment. A profile of patients at risk for increased length of hospital stay was developed using historical information. Patient age and diagnosis at the time of admission were the basis of the profile, which was incorporated into the screening program. A standard of care was designed to provide early, aggressive nutrition intervention to patients at risk. Clinical managers can follow the steps outlined to develop consistent nutrition care standards. Such standards can be incorporated into a quality improvement program to assess the effectiveness of the nutrition care methods and improve the quality of care provided.     

Home artificial nutritional support: the value of the British Artificial Nutrition Survey

The British Artificial Nutrition Survey (BANS) was established in 1996 by the British Association for Enteral and Parenteral Nutrition to audit and research nutritional care in hospital and the community, with the overall aim of improving the quality of nutritional support in patients with disease-related malnutrition. In this article the following information emerging from BANS is presented: growth and prevalence of artificial nutrition (enteral tube feeding and parenteral nutrition), clinical outcome of a wide range of diagnoses receiving artificial nutrition in the community, an economic perspective on home artificial nutrition, and some ethical issues. This information is used to illustrate how BANS can be of value in a wide range of health care activities, including health planning, health economics, clinical practice and patient care.     

Standards of care: an innovative approach

Clinical nutrition services at the Henderson General Division of Hamilton Civic Hospitals has taken a unique approach to standards of care. The Henderson General Division Standards of Care (HGDSC) focus on important issues in the evaluation of care including the goals, intensity and outcome of care. The HGDSC are based on populations defined by the level of nutrition care required and can easily be applied to patients with multiple medical and nutritional concerns. The standards operate under the premise that the process and intensity of care are determined by the goals of care. Thus, the standards assist in the delivery of equitable care to patients of similar nutritional risk. The goal-oriented focus of the standards is a benefit as the impact of nutrition care can be measured using the goals of care as expected outcomes. Outcome measures are considered important in the measurement of quality care since they focus on the patient's health status after intervention. The changing focus of health care in hospitals makes the identification of valid process criteria a priority for clinical dietitians. The purpose of this article is to provide insight into the unique features of the HGDSC and to explore the benefits of standards that focus on the goals and outcomes of nutrition care.     

Severe acute pancreatitis: nutritional management in the ICU.

Patients with acute pancreatitis have elevated nutritional needs due to increased energy expenditure and catabolism. It is a clinical challenge to provide adequate nutrition to these patients while maintaining gut function, preventing pancreatic stimulation, and minimizing the risk of septic and metabolic complications associated with nutritional support. We present the case of a patient who had severe acute pancreatitis and was initially given total parenteral nutrition. After a period of initial improvement, he developed hyperglycemia, bacteremia, and sepsis. Parenteral nutrition was discontinued and infection was treated with antibiotics. Subsequent nutritional support consisted of enteral feeding with an elemental diet infused via a nasojejunal feeding tube. His condition improved gradually and he made a full recovery. This case illustrates the difficulties encountered while managing a case of severe acute pancreatitis and provides an evidence based approach to the nutritional management of severe acute pancreatitis in the intensive care unit setting.     

Nutrition and dietetics in aged care

Aim: The global trends of rapid population ageing and increased risk of malnutrition among older people have a tremendous impact on nutrition care for the elderly. The present paper offers an overview of the challenging nutritional needs and problems of the elderly and explores strategies related to nutrition and dietetics to improve care for this particular segment of the population. Methods: A narrative review on monitoring malnutrition and improving food services was undertaken with reference to the literature and drawing on the experience of the author. Results: There is a wide range of problems associated with malnutrition in the elderly that have implications on strategies of intervention for addressing these problems. Conclusions: The current challenges for dietitians include identifying and monitoring the nutritional needs and malnutrition problems of the elderly, improving the quality of food services in health‐care facilities, and initiating innovative approaches to nutrition and dietetic services in the community.     

Reimbursement for clinical nutrition services

The process for achieving reimbursement for clinical nutrition services can be generalized into three steps--identification, documentation, and administrative framework. Even though factors involved in developing a system of reimbursement may vary from institution to institution, our experience suggests that these three steps will remain constant. First, billable services need to be distinguished from routine services. Second, a vigorous effort to document both the delivery of nutrition care and its benefit to the consumer must be undertaken. Third, administrative mechanisms that provide for appropriate allocation of costs and revenue from clinical nutrition services must be established. Using this process at Children's Memorial Hospital in Chicago, we itemize a number of inpatient nutrition services, for which we bill and are reimbursed as separate items independent of the bed charge.     

An approach to the provision of nutrition services in a cancer treatment centre

Nutritional care of the cancer patient has been the subject of extensive publications in recent years. Its importance, although generally recognized, has not led to universal availability of nutrition services to cancer patients and their families. Nutritional care can be supportive or palliative and must be coordinated with the care provided by other members of the multidisciplinary team. This article presents some of the important factors involved in the implementation of nutrition programs in a cancer treatment centre. The need for enthusiastic, competent, and human delivery of nutritional care is emphasized.     

Prenatal nutrition services: a cost analysis

The scarcity of information about program costs in relation to quality care prompted a cost analysis of prenatal nutrition services in two urban settings. This study examined prenatal nutrition services in terms of total costs, per client costs, per visit costs, and cost per successful outcome. Standard cost-accounting principles were used. Outcome measures, based on written quality assurance criteria, were audited using standard procedures. In the studied programs, nutrition services were delivered for a per client cost of $72 in a health department setting and $121 in a hospital-based prenatal care program. Further analysis illustrates that total and per client costs can be misleading and that costs related to successful outcomes are much higher. The three levels of cost analysis reported provide baseline data for quantifying the costs of providing prenatal nutrition services to healthy pregnant women. Cost information from these cost analysis procedures can be used to guide adjustments in service delivery to assure successful outcomes of nutrition care. Accurate cost and outcome data are necessary prerequisites to cost-effectiveness and cost-benefit studies.     

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID‐19) in Australia and New Zealand

Coronavirus disease 2019 (COVID‐19) results from severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID‐19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID‐19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID‐19 and general nutrition and intensive care. Patients hospitalised with COVID‐19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5–7 days in lower‐nutritional‐risk patients and individualised care for high‐nutritional‐risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosol exposure and therefore infection risk to healthcare providers. Use of a volume‐controlled, higher‐protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS‐CoV‐2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS‐CoV‐2 pandemic.     

Management of severe acute malnutrition in an urban nutritional rehabilitation center in Burkina Faso

BACKGROUND: Management of acute severe malnutrition greatly contributes to the reduction of childhood mortality rate. In developing countries, where malnutrition is common, number of acute severe malnutrition cases exceeds inpatient treatment capacity. Recent success of community-based therapeutic care put back on agenda the management of acute severe malnutrition. We analysed key issues of inpatient management of severe malnutrition to suggest appropriate global approach. METHODS: Data of 1322 malnourished children, admitted in an urban nutritional rehabilitation center, in Burkina Faso, from 1999 to 2003 were analyzed. The nutritional status was assessed using anthropometrics indexes. Association between mortality and variables was measured by relative risks. Kaplan-Meier survival curves and Cox model were used. RESULTS: From the 1322 hospitalized children, 8.5% dropped out. Daily weight gain was 10.18 (+/-7.05) g/kg/d. Among hospitalized malnourished children, 16% died. Patients were at high risk of early death, as 80% of deaths occurred during the first week. The risk of dying was highest among the severely malnourished: weight-for-height<-4 standard deviation (SD), RR=2.55 P<0,001; low MUAC-for-age, RR=2.05 P<0.001. Kaplan-Meier survival curves and Cox model showed that the variables most strongly associated with mortality were weight-for-height and MUAC-for-age. Among children discharged from the nutritional rehabilitation centre, 10.9% had weight-for-height<-3 SD. CONCLUSION: The nutrition rehabilitation centre is confronted with extremely ill children with high risk of death. There is need to support those units for appropriate management of acute severe malnutrition. It is also important to implement community-based therapeutic care for management of children still malnourished at discharge from nutritional rehabilitation centre. These programs will contribute to reduce mortality rate and number of severely malnourished children attending inpatient nutrition rehabilitation centers, by prevention and early management.     

Digital disruption of dietetics: are we ready?

Digital health is transforming the delivery of health care around the world to meet the growing challenges presented by ageing populations with multiple chronic conditions. Digital health technologies can support the delivery of personalised nutrition care through the standardised Nutrition Care Process (NCP) by using personal data and technology‐supported delivery modalities. The digital disruption of traditional dietetic services is occurring worldwide, supporting responsive and high‐quality nutrition care. These disruptive technologies include integrated electronic and personal health records, mobile apps, wearables, artificial intelligence and machine learning, conversation agents, chatbots, and social robots. Here, we outline how digital health is disrupting the traditional model of nutrition care delivery and outline the potential for dietitians to not only embrace digital disruption, but also take ownership in shaping it, aiming to enhance patient care. An overview is provided of digital health concepts and disruptive technologies according to the four steps in the NCP: nutrition assessment, diagnosis, intervention, and monitoring and evaluation. It is imperative that dietitians stay abreast of these technological developments and be the leaders of the disruption, not simply subject to it. By doing so, dietitians now, as well as in the future, will maximise their impact and continue to champion evidence‐based nutrition practice.     

Healthcare utilization among veterans undergoing chemotherapy: the impact of a cancer care coordination/home-telehealth program

The 2001 Institute of Medicine report indicted that the US healthcare system fails to provide high-quality care, and offered 6 aims of improvement that would redesign the delivery of care for the 21st century. This study compared the use of Department of Veterans Affairs (VA) inpatient and outpatient services of cancer patients enrolled in a Cancer Care Coordination/Home-Telehealth (CCHT) program that involved remote management of symptoms (eg, emotional distress, pain) via home-telehealth technologies to a control group of cancer patients receiving standard VA care. Using a matched case-control design, 2 control patients per case were selected, matched by tumor type and cancer stage. There were 43 Cancer CCHT patients and 82 control group patients. Based on a medical record review of each patient, the total number of cancer-related services (defined as visits that were expected given the patients' cancer diagnosis and treatment protocol) and preventable services (defined as visits needed outside of those expected given the cancer diagnosis and planned treatment) were calculated over a 6-month period. Poisson multivariate regression models were used to estimate the adjusted relative risks (RRs) for the effects of the Cancer CCHT program on the service use outcomes. Cancer CCHT patients had significantly fewer preventable services (clinic visits: RR = 0.03, 95% confidence interval [CI] = 0.00-0.24; bed days of care (BDOC) for hospitalization [all-cause]: RR = 0.50, 95% CI = 0.37-0.67; hospitalizations [chemotherapy related]: RR = 0.43, 95% CI = 0.21-0.91; and BDOC for hospitalizations [chemotherapy related]: RR = 0.49, 95% CI = 0.34-0.71) than the control group. This study offered some preliminary evidence that patients enrolled in a Cancer CCHT program can successfully manage multiple complex symptoms without utilizing inpatient and outpatient services.     

Position of the American Dietetic Association,American Society for Nutrition,and Society for Nutrition Education: Food and Nutrition Programs for Community-Residing Older Adults

Given the federal cost-containment policy to rebalance long-term care away from nursing homes to home- and community-based services, it is the position of the American Dietetic Association, the American Society for Nutrition, and the Society for Nutrition Education that all older adults should have access to food and nutrition programs that ensure the availability of safe, adequate food to promote optimal nutritional status. Appropriate food and nutrition programs include adequately funded food assistance and meal programs, nutrition education, screening, assessment, counseling, therapy, monitoring, evaluation, and outcomes documentation to ensure more healthful aging. The growing number of older adults, the health care focus on prevention, and the global economic situation accentuate the fundamental need for these programs. Yet far too often food and nutrition programs are disregarded or taken for granted. Growing older generally increases nutritional risk. Illnesses and chronic diseases; physical, cognitive, and social challenges; racial, ethnic, and linguistic differences; and low socioeconomic status can further complicate a situation. The beneficial effects of nutrition for health promotion, risk reduction, and disease management need emphasis. Although many older adults are enjoying longer and more healthful lives in their own homes, others, especially those with health disparities and poor nutritional status, would benefit from greater access to food and nutrition programs and services. Food and nutrition practitioners can play a major role in promoting universal access and integrating food and nutrition programs and nutrition services into home- and community-based services.     

Position of the American Dietetic Association, American Society for Nutrition, and Society for Nutrition Education: Food and Nutrition Programs for Community-Residing Older Adults

Given the federal cost-containment policy to rebalance long-term care away from nursing homes to home- and community-based services, it is the position of the American Dietetic Association, the American Society for Nutrition, and the Society for Nutrition Education that all older adults should have access to food and nutrition programs that ensure the availability of safe, adequate food to promote optimal nutritional status. Appropriate food and nutrition programs include adequately funded food assistance and meal programs, nutrition education, screening, assessment, counseling, therapy, monitoring, evaluation, and outcomes documentation to ensure more healthful aging. The growing number of older adults, the health care focus on prevention, and the global economic situation accentuate the fundamental need for these programs. Yet far too often food and nutrition programs are disregarded or taken for granted. Growing older generally increases nutritional risk. Illnesses and chronic diseases; physical, cognitive, and social challenges; racial, ethnic, and linguistic differences; and low socioeconomic status can further complicate a situation. The beneficial effects of nutrition for health promotion, risk reduction, and disease management need emphasis. Although many older adults are enjoying longer and more healthful lives in their own homes, others, especially those with health disparities and poor nutritional status, would benefit from greater access to food and nutrition programs and services. Food and nutrition practitioners can play a major role in promoting universal access and integrating food and nutrition programs and nutrition services into home- and community-based services.     

The impact of DRGs on the cost and quality of health care in the United States.

The prospective Payment System (PPS) represents a fundamental change in the way the United States government reimburses hospitals for medical services covered under Medicare, a federal health care insurance program for the elderly and disabled. PPS replaced the retrospective cost-based system of payment for Medicare services with a prospective payment system. Under PPS, a predetermined specific rate for each discharge dictates payment according to the diagnosis related group (DRG) in which the discharge is classified. The PPS was intended to create financial incentives that encourage hospitals to restrain the use of resources while providing high-quality inpatient care. Both objectives appear to have been met under PPS. Hospital utilization has declined, average length of stay has fallen, and the locus of care has shifted from the inpatient setting to less costly outpatient settings. The growth in inpatient hospital benefits has slowed and the impending insolvency of the Medicare trust fund has been forestalled. Studies have found no deterioration in the quality of care rendered to Medicare beneficiaries. Neither the mortality rate nor the rate of re-admission (presumably related to premature discharge) increased under PPS. Indeed, PPS appears to have enhanced the quality of inpatient care by discouraging unnecessary and potentially harmful procedures, and by encouraging the concentration of complex procedures in facilities in which the high frequency of these procedures promotes efficiency. Incentive-based reimbursement also appears to have contributed to the growth in alternative delivery systems, such as HMOs and PPOs, which contain costs by maintaining a high volume of a limited range of services. The success of the PPS/DRG system in controlling costs and promoting quality in this country suggests its application in other countries, either as a method of reimbursement or as a product line management tool.     

Arbre décisionnel du soin nutritionnel

Undernutrition is a frequent complication of acute and chronic diseases, and is correlated with disease prognosis and patients’ quality of life. Undernutrition has a major impact on health care costs. Screening of undernutrition and nutritional care are recommended in current clinical practice and the identification of undernutrition-related costs is of prime importance. The management of nutritional care depends on nutritional risk and status, protein and energy needs, and spontaneous oral intake. The goal of nutritional care is to avoid the onset of malnutrition in patients at risk, and in undernourished patients to prevent its worsening and to correct it. Three different levels of nutritional intervention do exist: dietary counseling and oral nutritional supplements, enteral nutrition, and in case of enteral nutrition's contra-indications, intolerance or insufficiency, total or supplemental parenteral nutrition. The choice of feeding routes depends mainly on the expected duration of nutrition support. In every case, nutritional strategy should be regularly re-evaluated and adapted according to nutritional efficacy and disease evolution.     

A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community

COVID-19 negatively impacts nutritional status and as such identification of nutritional risk and consideration of the need for nutrition support should be fundamental in this patient group. In recent months, clinical nutrition professional organisations across the world have published nutrition support recommendations for health care professionals. This review summarises key themes of those publications linked to nutrition support of adults with or recovering from COVID-19 outside of hospital. Using our search criteria, 15 publications were identified from electronic databases and websites of clinical nutrition professional organisations, worldwide up to 19th June 2020. The key themes across these publications included the importance in the community setting of: (i) screening for malnutrition, which can be achieved by remote consultation; (ii) care plans with appropriate nutrition support, which may include food based strategies, oral nutritional supplements and referral to a dietitian; (iii) continuity of nutritional care between settings including rapid communication at discharge of malnutrition risk and requirements for ongoing nutrition support. These themes, and indeed the importance of nutritional care, are fundamental and should be integrated into pathways for the rehabilitation of patients recovering from COVID-19.     

Critical Role of Nutrition in Improving Quality of Care

The current era of healthcare delivery, with its focus on providing high‐quality, affordable care, presents many challenges to hospital‐based health professionals. The prevention and treatment of hospital malnutrition offer a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and treat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute posthospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reduce complication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patients who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following 6 principles: (1) create an institutional culture where all stakeholders value nutrition, (2) redefine clinicians’ roles to include nutrition care, (3) recognize and diagnose all malnourished patients and those at risk, (4) rapidly implement comprehensive nutrition interventions and continued monitoring, (5) communicate nutrition care plans, and (6) develop a comprehensive discharge nutrition care and education plan.