Etiology Intervention Link Predicts Resolution of Nutrition Diagnosis: A Nutrition Care Process Outcomes Study from a Veterans’ Health Care Facility

In this article, we evaluate relationships between Nutrition Care Process (NCP) chain links and improvement or resolution of the nutrition diagnosis. We conducted a retrospective record review for 12 months in a single Veterans Health Administration health care system using the Veterans Health Administration–specific monitoring and evaluation terms, NCP terminology, and its etiology categories to evaluate outcomes. Logistic regression analysis revealed that the strongest predictor for diagnosis improvement was the etiology–intervention link. The odds of improving the nutrition diagnosis were 51.43 times higher when the etiology–intervention link was present. The odds of improving the nutrition diagnosis were 19.74 times higher when the evidence–diagnosis link was present and 9.46 times higher when the intervention–goal link was present. For every added nutrition visit by the registered dietitian nutritionist, the odds of improving the nutrition diagnosis increased by 32.5%. For every increased point on the NCP audit score, the odds of resolving or improving the nutrition diagnosis increased by 37.7%. When applying the NCP, the presence of the etiology–intervention link significantly improves the odds of resolving the nutrition diagnosis in a Veterans Health Administration population. For the first time, we show evidence that the NCP works as designed. Also, we demonstrate that the quality of NCP documentation impacts resolution of the diagnosis, and we describe the methodology for how to evaluate NCP outcomes. Registered dietitian nutritionists are encouraged to critically evaluate links of the NCP chain, assess NCP documentation for quality, and pursue follow-up visits to improve resolution of nutrition problems.     

Academy of Nutrition and Dietetics Nutrition Research Network: Validation of a Novel Nutrition Informatics Tool to Assess Agreement Between Documented Nutrition Care and Evidence-Based Recommendations

More evidence regarding registered dietitian nutritionist implementation of evidence-based nutrition practice guidelines (EBNPGs) is needed. We assessed the utility of an automated informatics tool to evaluate congruence of documented nutrition care with 13 individual recommendations in the diabetes mellitus (DM) EBNPG and with the guideline overall. A concurrent validation study was conducted using Nutrition Care Process Terminology documentation entered in the Academy of Nutrition and Dietetics Health Informatics Infrastructure by registered dietitian nutritionists caring for patients with DM. A 15% subset (n = 115) of the 790 patient encounters recorded were selected randomly, and the documented care was evaluated using the automated DM Expected Care Plan (ECP) Analyzer and expert audit. Recommendation-level congruence, as determined by each method, was compared using Cohen’s κ analysis, and the accuracy, sensitivity, and specificity of the DM ECP Analyzer for assessing overall guideline-level congruence was calculated with expert audits as the “gold standard.” For recommendation-level congruence, the DM ECP Analyzer identified more instances of recommendation implementation in the patient encounters, and classified more encounters as including partial or full recommendation implementation for 10 of the 13 recommendations, compared with the expert audit. There was slight to fair agreement between the DM ECP and the expert audit for most individual recommendations, with a mean ± standard deviation level of agreement of κ = .17 ± .19 across all eligible recommendations. At the guideline level, the DM Analyzer had high accuracy (98.3%) and sensitivity (99.1%) and low specificity (0%; no true negatives detected). The DM ECP Analyzer is acceptable for conducting automated audits of nutrition documentation to assess congruence of documented care with recommendations for evidence-based care. Future changes to the EBNPG, Nutrition Care Process Terminology, Academy of Nutrition and Dietetics Health Informatics Infrastructure, and the DM ECP Analyzer could potentially improve recommendation-level performance. The DM ECP Analyzer can be modified for other EBNPGs to facilitate automated assessment of guideline implementation.     

Report of a nutritional screening audit

Background: Malnutrition in hospitals has been widely documented and nutritional screening forms part of the National Professional Standards for Dietitians. As a result of this concern, a nutrition screening tool has been incorporated into the nursing care plan documentation. Aims: To audit the use of the screening tool in nursing care plans for elderly patients and examine the communication methods concerning the need for individual nutritional care. Methods: A standard chart was used to audit patient notes. In addition, a short informal interview was conducted with nursing staff. Results: Use of the screening tool was variable and fewer than half of those identified by this tool as in need of nutritional care were referred to the dietitian. Conclusion: Ward staff are prioritizing patients referred for dietetic care, even when they have been identified by the screening tool, but this is not always done systematically. Improvements could be made in the relevant documentation. Further training of ward staff and a follow-up audit should be undertaken.     

Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care,Post-Acute Care,and Other Settings

It is the position of the Academy of Nutrition and Dietetics that the quality of life and nutritional status of older adults in long-term care, post-acute care, and other settings can be enhanced by individualized nutrition approaches. The Academy advocates that as part of the interprofessional team, registered dietitian nutritionists assess, evaluate, and recommend appropriate nutrition interventions according to each individual’s medical condition, desires, and rights to make health care choices. Nutrition and dietetic technicians, registered assist registered dietitian nutritionists in the implementation of individualized nutrition care, including the use of least restrictive diets. Health care practitioners must assess risks vs benefits of therapeutic diets, especially for frail older adults. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in malnutrition and related negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life.     

Clinical Competence Assessed Using Simulation: Development of a Standardized Tool to Assess Nutrition-Focused Physical Exam Skill Competence for Registered Dietitian Nutritionists

ObjectiveThis study details development and testing of a tool designed to evaluate clinical competence by registered dietitian nutritionists (RDNs) on the nutrition-focused physical exam (NFPE). The process demonstrated in this study can be adapted for assessment of other clinical skills in competency-based education programs, such as Accreditation Council on Education in Nutrition and Dietetics’ Future Model of Dietetics Education.Design and SettingThe tool was tested for content validity, then used to assess the videotaped performance of the NFPE with standardized patients in a simulated clinical environment.ParticipantsSeven expert raters assessed the relevance of the tool's items for content validity. For other tests, the tool was used by 3 dietetics faculty to score a group of 18 RDNs.Variables and AnalysisContent validity was tested using the item-level Content Validity Index. Interrater reliability and internal consistency of the tool were calculated and assessed.ResultsThe interrater reliability results indicated excellent agreement between raters, both overall (kappa statistic = 0.86; 95% confidence interval, 0.86–0.87; P < 0.001) and on individual items. Cronbach α statistic was calculated at α = .91, indicating excellent internal consistency.ConclusionsThe tool represents an instrument that can assess competence in the NFPE among RDNs and may be used as a template for development of other competency-based education assessment tools.     

Position of the Academy of Nutrition and Dietetics: Nutrition Informatics

It is the position of the Academy of Nutrition and Dietetics that nutrition informatics is a rapidly evolving area of practice for registered dietitian nutritionists and nutrition and dietetic technicians, registered; and that the knowledge and skills inherent to nutrition informatics permeate all areas of the dietetics profession. Further, nutrition and dietetics practitioners must continually learn and update their informatics knowledge and skills to remain at the forefront of nutrition practice. Nutrition informatics is the intersection of information, nutrition, and technology. However, informatics is not just using technology to do work. The essence of nutrition informatics is to manage nutrition data in combination with standards, processes, and technology to improve knowledge and practice that ultimately lead to improved quality of health care and work efficiency. Registered dietitian nutritionists and nutrition and dietetic technicians, registered, are already experts in using evidence to practice in all areas of nutrition and dietetics. To remain at the forefront of technological innovation, the profession must actively participate in the development of standards, processes, and technologies for providing nutrition care.     

The nutrition care profile: an aid to delivery of quality nutrition care in a small community hospital

In an effort to improve nutrition care in a small community hospital with one registered dietitian (R.D.), a system using a nutrition care profile (NCP) and a certified dietetic assistant (C.D.A.) was developed. The NCP includes criteria recognized in the literature or through clinical experience to be indicators of nutrition care needs. The profile is completed by the C.D.A. and reviewed by the R.D., who determines priorities for the patient's nutrition care needs. The NCP has proved to be an effective and efficient tool for prioritizing and systematizing follow-up of nutrition care needs. Indeed, because the NCP form is itself so effective as a follow-up tool for dietary records, the R.D. has found she must make a conscious effort to document nutrition care in the medical record.     

Validation study of the USDA's Data Quality Evaluation System

The Nutrient Data Laboratory (NDL) of USDA conducted a validation study of the USDA Data Quality Evaluation System (DQES). The system evaluates the quality of analytical data on nutrients by rating important documentation concerning the analytical method, analytical quality control, number of samples, sampling plan, and sample handling and creates a “Quality Index” (QI) and “confidence code” (CC) for each nutrient and food. Objectives of the study were: (1) to measure the variability of ratings assigned by different evaluators, (2) to assess the objectivity of the “critical” questions of the DQES categories and (3) to test the robustness of the rating scale. Out of 39 individuals who participated in the International Postgraduate Course for Food Composition and four nutritionists from NDL, 37 completed the evaluation of a research article containing analytical data on vitamin K in lettuce, 25 evaluated an article containing data on catechin in black grapes, and 16 evaluated an article containing data on riboflavin in portabella mushrooms using the DQES. The various rating scores assigned by the participants were analyzed to assess the success of above objectives. The maximum score for each category was 20. There was a greater variation among individuals in the ratings for “number of samples” and “analytical quality control” categories than the other three categories. Overall seventy five percent of the participants assigned a confidence code of “C” to the vitamin K in lettuce, while 70% and 100% assigned confidence codes of “B” and “C” to catechin in black grapes and riboflavin in mushrooms, respectively. The wide range of scores on individual categories by first time evaluators emphasizes the importance of training for evaluators who score analytical values for inclusion in a food composition database. Clear documentation by the authors and training for evaluators to understand basic concepts related to data quality evaluation will be helpful. Future work will assess the assignment of equal rating points for all the categories. Modifications in “sampling plan” category to accommodate country and population size are necessary. The USDA Data Quality Evaluation System represents one of the first efforts to standardize and harmonize the evaluation of analytical data quality across the international food composition network.     

Position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior: Food and Nutrition Programs for Community-Residing Older Adults

Given the increasing number and diversity of older adults and the transformation of health care services in the United States, it is the position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior that all older adults should have access to evidence-based food and nutrition programs that ensure the availability of safe and adequate food to promote optimal nutrition, health, functionality, and quality of life. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, in partnership with other practitioners and nutrition educators, should be actively involved in programs that provide coordinated services between the community and health care systems that include regular monitoring and evaluation of programming outcomes. The rapidly growing older population, increased demand for integrated continuous support systems, and rising cost of health care underscore the need for these programs. Programs must include food assistance and meal programs, nutritional screening and assessment, nutrition education, medical nutrition therapy, monitoring, evaluation, and documentation of evidence-based outcomes. Coordination with long-term care services and support systems is necessary to allow older adults to remain in their homes; improve or maintain their health and manage chronic disease; better navigate transitions of care; and reduce avoidable hospital, acute, or long-term care facility admissions. Funding of these programs requires evidence of their effectiveness, especially regarding health, functionality, and health care–related outcomes of interest to individuals, caregivers, payers, and policy makers. Targeting of food and nutrition programs involves addressing unmet needs for services, particularly among those at high risk for poor nutrition. Registered dietitian nutritionists and nutrition and dietetics technicians, registered must increase programmatic efforts to measure outcomes to evaluate community-based food and nutrition services.Position StatementIt is the position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior that older adults should have access to evidence-based food and nutrition programs that ensure the availability of safe and adequate food to promote optimal nutrition, health, functionality, and quality of life. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, in partnership with other practitioners and nutrition educators, should be actively involved in programs that provide coordinated services between the community and health care systems that include regular monitoring and evaluation of programming outcomes. The rapidly growing older population, increased demand for integrated continuous support systems, and rising cost of health care underscore the need for these programs.     

Malnutrition Care During the COVID-19 Pandemic: Considerations for Registered Dietitian Nutritionists

Recent evidence examining adults infected with coronavirus disease 2019 (COVID-19) has indicated a significant impact of malnutrition on health outcomes. Individuals who have multiple comorbidities, are older adults, or who are malnourished, are at increased risk of being admitted to the intensive care unit and of mortality from COVID-19 infections. Therefore, nutrition care to identify and address malnutrition is critical in treating and preventing further adverse health outcomes from COVID-19 infection. This document provides guidance and practice considerations for registered dietitian nutritionists providing nutrition care for adults with suspected or confirmed COVID-19 infection in the hospital, outpatient, or home care settings. In addition, this document discusses and provides considerations for registered dietitian nutritionists working with individuals at risk of malnutrition secondary to food insecurity during the COVID-19 pandemic.     

Applying Contemporary Machine Learning Approaches to Nutrition Care Real-World Evidence: Findings From the National Quality Improvement Data Set

Using real-world data from the Academy of Nutrition and Dietetics Health Informatics Infrastructure, we use state-of-the-art clustering techniques to identify 2 phenotypes characterizing the episodes of nutrition care observed in the National Quality Improvement (NQI) registry data set. The 2 phenotypes identified from recorded Nutrition Care Process data in the NQI exhibit a strong correspondence with the clinical expertise of registered dietitian nutritionists. For one of these phenotypes, it was possible to implement state-of-the-art classification techniques to predict the nutrition problem-resolution status of an episode of care. Prediction results show that the assessment of nutrition history, number of recorded visits in the episode, and use of nutrition counseling interventions were significantly and positively correlated with problem resolution. Meanwhile, evaluations of nutrition history that were not within the desired ranges were significantly and negatively correlated with problem resolution. Finally, we assess the usefulness of the current NQI data set and data model for supporting the application of contemporary machine learning methods to the data set. We also suggest ways of enhancing the NQI since registered dietitian nutritionists are encouraged to continue to contribute patient cases in this and other registry nutrition studies.     

Academy of Nutrition and Dietetics: Revised 2014 Standards of Professional Performance for Registered Dietitian Nutritionists in Management of Food and Nutrition Systems

Management in food and nutrition systems is presented with an ever-challenging tension between effective utilization of manpower resources, mechanical equipment, financial management, material production, and time constraints to produce optimal products. Management drives opportunities for personal development for multiple levels of its employee workforce. Given an increasing need to deliver high-quality food and services to satisfied customers, the Management in Food and Nutrition Systems Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has developed the Revised 2014 Standards of Professional Performance, which replace the 2009 Standards, as a tool for registered dietitian nutritionists working in food and nutrition systems management within health care and non−health care organizations. These Standards of Professional Performance consist of six domains of professionalism: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements that illustrate how strong communication skills, attention to customer satisfaction, use of various resources, and application of personnel management principles can be applied to practice. The indicators describe three skill levels (ie, competent, proficient, and expert) for registered dietitian nutritionists managing food and nutrition systems.     

Position of the Academy of Nutrition and Dietetics: Benchmarks for Nutrition in Child Care

It is the position of the Academy of Nutrition and Dietetics that early care and education (ECE) programs should achieve recommended benchmarks to meet children’s nutrition needs and promote children’s optimal growth in safe and healthy environments. Children’s dietary intake is influenced by a number of factors within ECE, including the nutritional quality of the foods and beverages served, the mealtime environments, and the interactions that take place between children and their care providers. Other important and related health behaviors that may influence the development of obesity include children’s physical activity, sleep, and stress within child care. Recent efforts to promote healthy eating and improve other health behaviors in ECE include national, state, and local policy changes. In addition, a number of interventions have been developed in recent years to encourage healthy eating and help prevent obesity in young children in ECE. Members of the dietetics profession, including registered dietitian nutritionists and nutrition and dietetics technicians, registered, can work in partnership with ECE providers and parents to help promote healthy eating, increase physical activity, and address other important health behaviors of children in care. Providers and parents can serve as role models to support these healthy behaviors. This Position Paper presents current evidence and recommendations for nutrition in ECE and provides guidance for registered dietitian nutritionists; nutrition and dietetics technicians, registered; and other food and nutrition practitioners working with parents and child-care providers. This Position Paper targets children ages 2 to 5 years attending ECE programs and highlights opportunities to improve and enhance children’s healthy eating while in care.     

Medical Nutrition Therapy for Adults in Health Resources & Services Administration-Funded Health Centers: A Call to Action

Vulnerable adult populations’ access to cost-effective medical nutrition therapy (MNT) for improving outcomes in chronic disease is poor or unquantifiable in most Health Resources & Services Association (HRSA)-funded health centers. Nearly 50% of the patients served at Federally Qualified Health Centers are enrolled in Medicaid; the lack of benefits and coverage for MNT is a barrier to care. Because the delivery of MNT provided by registered dietitian nutritionists is largely uncompensated, health centers are less likely to offer these evidence-based services and strengthen team-based care. The expected outcomes of MNT for adults with diabetes, obesity, hypertension, and other conditions align with the intent of several clinical quality measures of the Uniform Data System and quality improvement goals of multiple stakeholders. HRSA should designate MNT as an expanded service in primary care, require reporting of MNT and registered dietitian nutritionists in utilization and staffing data, and evaluate outcomes. Modification to the Centers for Medicare & Medicaid Services Prospective Payment System rules are needed to put patients over paperwork: HRSA health centers should be compensated for MNT provided on the same day as other qualifying visits. Facilitating the routine delivery of care by qualified providers will require coordinated action by multiple stakeholders. State Medicaid programs, Medicaid Managed Care Organizations, and other payers should expand benefits and coverage of MNT for chronic conditions, factor the cost of providing MNT into adequate and predictable payment streams and payment models, and consider these actions as part of an overall strategy for achieving value-based care.     

Providers’ Note-Writing Practices for Post-traumatic Stress Disorder at Five United States Veterans Affairs Facilities

The capacity of electronic health records (EHRs) to capture desired information depends on the practices of health care providers. These practices have not been well studied in relation to post-traumatic stress disorder (PTSD). This qualitative study investigated how providers write EHR notes on PTSD through 38 interviews with providers working at five Veterans Affairs (VA) hospitals across the United States of America. Two overarching themes were prominent in the results. Providers used progress notes primarily to remember and access details for direct patient care, but only rarely for care coordination. Providers infrequently recorded information not judged to directly contribute to improved care, sometimes deliberately omitting information perceived to jeopardize patients’ access to, or quality of, care. Omitted information frequently included sexual or non-military trauma. Understanding providers’ thought processes can help clinicians be aware of the limitations of EHR notes as a tool for learning the histories of new patients. Similarly, researchers relying on EHR data for PTSD research should be aware of likely areas of missing data.     

Survey Response Rate and Quality in a Mental Health Clinic Population: Results from a Randomized Survey Comparison

Given the limited ability of informatics-based assessment technologies to reach individuals with serious mental health conditions, this study evaluated the feasibility and data quality of mail-out healthcare surveys in this population to assist in measure selection for a multi-site controlled implementation trial. Veterans were randomly selected from those who had received services at a mental health clinic in the Department of Veterans Affairs, and were randomly assigned to one of three questionnaire lengths. Survey length (48–127 items) was not associated with differences in response rate, percent of items missing, or data quality. However, internal consistency reliability was variable among scales and survey lengths. Additional analyses indicate the above measures of survey data quality may differ among respondents who are non-white and younger and have psychotic disorders. These results can inform survey protocols to ensure maximal representation of this vulnerable population in health planning and policy assessment.

     

Development of an audit instrument for nursing care plans in the patient record

Objectives—To develop, validate, and test the reliability of an audit instrument that measures the extent to which patient records describe important aspects of nursing care.

Material—Twenty records from each of three hospital wards were collected and audited. The auditors were registered nurses with a knowledge of nursing documentation in accordance with the VIPS model—a model designed to structure nursing documentation. (VIPS is an acronym formed from the Swedish words for wellbeing, integrity, prevention, and security.)

Methods—An audit instrument was developed by determining specific criteria to be met. The audit questions were aimed at revealing the content of the patient for nursing assessment, nursing diagnosis, planned interventions, and outcome. Each of the 60 records was reviewed by the three auditors independently and the reliability of the instrument was tested by calculating the inter-rater reliability coefficient. Content validity was tested by using an expert panel and calculating the content validity ratio. The criterion related validity was estimated by the correlation between the score of the Cat-ch-Ing instrument and the score of an earlier developed and used audit instrument. The results were then tested by using Pearson's correlation coefficient.

Results—The new audit instrument, named Cat-ch-Ing, consists of 17 questions designed to judge the nursing documentation. Both quantity and quality variables are judged on a rating scale from zero to three, with a maximum score of 80. The inter-rater reliability coefficients were 0.98, 0.98, and 0.92, respectively for each group of 20 records, the content validity ratio ranged between 0.20 and 1.0 and the criterion related validity showed a significant correlation of r = 0.68 (p< 0.0001, 95% CI 0.57 to 0.76) between the two audit instruments.

Conclusion—The Cat-ch-Ing instrument has proved to be a valid and reliable audit instrument for nursing records when the VIPS model is used as the basis of the documentation.

(Quality in Health Care 2000;9:6–13)

Key Words: audit instrument; nursing care plans; quality assurance

     

Ensuring Quality Information for Patients: development and preliminary validation of a new instrument to improve the quality of written health care information

BACKGROUND: Despite the recent focus on improving the quality of patient information, there is no rigorous method of assessing quality of written patient information that is applicable to all information types and that prescribes the action that is required following evaluation. OBJECTIVE: The aims of this project were to develop a practical measure of the presentation quality for all types of written health care information and to provide preliminary validity and reliability of the measure in a paediatric setting. METHODS: The Ensuring Quality Information for Patients (EQIP) tool was developed through a process of item generation, testing for concurrent validity, inter-rater reliability and utility. Patient information managers and health care professionals tested EQIP in three annual audits of health care leaflets produced by a children's hospital. RESULTS: The final tool comprised 20 items. Kendall's tau B rank correlation between EQIP and DISCERN was 0.56 (P = 0.001). There was strong agreement between intuitive rating and the EQIP score (Kendall's tau B = 0.78, P = 0.009). Internal consistency using Cronbach's alpha was 0.80. There was good agreement between pairs of raters (mean kappa = 0.60; SD = 0.18) with no differences based on types of leaflets. Audits showed significant improvement in the number of leaflets achieving a higher quality EQIP rating over a 3-year period. CONCLUSIONS: EQIP demonstrated good preliminary validity, reliability and utility when used by patient information managers and healthcare professionals for a wide variety of written health care information. EQIP uniquely identifies actions to be taken as a result of the quality assessment. Use of EQIP improved the quality of written health care information in a children's hospital. Wider evaluation of EQIP with written information for other populations and settings is recommended.     

Construction and validation of the Outpatient Health Care Usability Profile (OHCUP)

BackgroundThe Americans with Disabilities Act (ADA) requires health care facilities to provide equal access to patents with disabilities. Yet, people with disabilities experience many access barriers.Objective/hypothesisTo develop a valid, reliable, and user-friendly tool that measures the physical and environmental features of outpatient health care facilities. Instead of addressing full compliance with the ADA, the tool measures the essential features of an outpatient health care facility.MethodsThe project included an online survey of people with disabilities (reported elsewhere), work groups of people with disabilities prioritizing ADA administrative guidelines (ADAAG), ADA expert review, measure development, pilot testing and re-testing. ADA experts' ratings were summarized as Content Validity Ratios (CVR). Retained ADAAG items were organized into a survey instrument and tested by raters at outpatient health clinics. Inter-rater reliability was assessed using Cohen's Kappa coefficient and Gwet's AC1 statistic. Refinement and re-testing of the instrument was conducted.ResultsThe work groups narrowed the ADAG items from over 400 to 154 items. CVR ratings from ADA subject-matter experts reduced the items to 129. Inter-rater reliability for the pilot version was 0.61 (Kappa) and 0.88 (AC1). After refinement, inter-rater reliability was 0.77 (Kappa) and 0.90 (AC1). The items with the lowest reliability scores were re-examined, revised, and re-tested. Inter-rater reliability for the final version of the OHCUP was 0.89 (Kappa) and 0.97 (AC1).ConclusionsThe OHCUP is a valid and reliable tool for measuring the usability of health care facilities.