Transitioning the child fed by gastrostomy into school

Young children dependent on gastrostomy feeding are examples of special-needs children now eligible for expanded nutrition services in schools through Public Law 99-457. With the implementation of this law, nutritionists have an opportunity to expand their roles as consultants to special education teachers. A team approach involving nutrition, nursing, and special education was used to prepare a gastrostomy-fed preschool child and his family for school. The family of the multihandicapped child had been isolated by the child's feeding problems and viewed the problems as barriers to his entering school. Components of a nutrition care plan for an interdisciplinary team included oral feeding readiness, nutritional adequacy and timing of meals, and mechanical aspects of gastrostomy feeding in the classroom. Nutrition interventions were adjusted for the classroom from those used in the home or clinical setting. The major activity in the transition program was behavioral management of the child's rumination, which affected nutritional status and feeding. The major outcome of the transition program was enrollment of the child in school, with gastrostomy feeding as a routine activity. A transition program for a gastrostomy-fed child is an appropriate mechanism for expanding the role of the nutritionist into the classroom.     

An interdisciplinary nutrition assessment and intervention protocol for children with disabilities

Because of the multifactorial nature of the nutrition problems associated with developmental disabilities, a well-organized, interdisciplinary effort is necessary to deal with such problems. A team composed of professional and support staff, the client, and the family needs to be involved in an integrated approach to service. The team members share their knowledge and expertise in developing an individual program plan to meet identified needs. This article describes the development and implementation of a prototype for interdisciplinary nutritional evaluation and intervention in an outpatient setting. In 1987, a Regional Nutrition and Feeding Diagnosis and Evaluation Clinic was established through a contractual agreement between the University of Georgia University Affiliated Program and St. Mary's Hospital in Athens, GA. The purposes of the clinic are twofold: to offer direct services to developmentally disabled infants and children who require outpatient services and to provide a unique community-based interdisciplinary training experience for graduate students in nutrition and other health disciplines. The interdisciplinary treatment protocol is based on current knowledge in the treatment of developmental disabilities.     

Nutrition support in the morbidly obese, critically ill patient.

Nutrition support in the critically ill patient is challenging but is even more difficult in a morbidly obese patient. This case report chronicles the care of a 6-foot-tall, 256-kg male (body mass index 76.5 kg/m(2)) who spent over a month in the intensive care unit for respiratory failure, sepsis, and acute renal failure. Parenteral nutrition was provided throughout his critical care course. One of the major difficulties encountered was determining his nutritional needs. A hypocaloric nutritional regimen was used, along with moderate protein provisions. Numerous electrolyte imbalances occurred, including hypercalcemia that did not resolve by eliminating calcium from the parenteral nutrition solution. Enteral nutrition was desired but was not used initially because of a need for vasopressors, a diagnosis of pancreatitis, difficulty in documenting feeding tube placement because of diagnostic limitations secondary to the patient's large size, and concern about managing stools. Eventually, oral intake and supplemental enteral feeding were initiated. Nutrition support team members worked closely with the interdisciplinary care team to develop strategies to manage the nutritional problems related to his obesity. A discussion of the various nutritional issues encountered in the care of this patient is provided. Reasonable nutritional status was achieved, but this case reflects some of the challenges encountered in caring for the nutritional needs of select patient populations in clinical practice and the need for increased research and guidelines in this area.     

Crossing the quality chasm: building a safe nutrition system

Recent reports to Congress and the public from the Institute of Medicine underscore concern about the quality of healthcare in America. The nutrition community has focused most of its attention on the report titled The Role of Nutrition in Maintaining Health in the Nation's Elderly, which evaluated nutrition services coverage for the Medicare population. Of equal importance was the recent publication of two reports from the Committee on Quality of Health Care in America: To Err is Human--Building a Safer Health System and Crossing the Quality Chasm--A New Health System for the 21st Century. IV nutrition support was a breakthrough in medical care that has become a standard tool in treating patients who cannot eat for prolonged periods of time. It is also a medical treatment that can result in harm to patients. As problems with patient safety associated with the use of IV nutrition were documented, safer methods to deliver this life-saving form of treatment were developed and evaluated. Although an interdisciplinary team approach has been shown to be the safest way to administer IV nutrition, this system is costly and not universally used. Alternatives to the interdisciplinary team approach should be evaluated to assure that patients receive optimum nutrition care. The tools that can be used to improve patient safety include self-assessment of practitioners who routinely use nutrition support in their practice, curricular-based continuing education programs, board certification in nutrition support practice, and the use of clinical guidelines to assist in making clinical decisions. By developing and promoting these tools, A.S.P.E.N. is committed to building a safe nutrition system so every patient receives optimal nutrition care.     

Improving nutrition care for nursing home residents using the INRx process

The purpose of this article is to describe the Individual Nutrition Rx (INRx) assessment process and report findings on elder nutritional status, common nutrition problems identified by the INRx process, resolution outcomes from each problem, and the most efficacious approaches used to address the identified nutrition problems. The study used a two-group prospective quasi-experimental design with measures taken at baseline and at 6 months. Participants in the treatment group (n = 41) received the 6-month INRx assessment process, while residents in the comparison group (n = 40) received routine care specific to their nursing home. The most frequent nutritional problems identified were appetite change, poor positioning while eating, and problems with oral status. A total of 39 approaches were recommended by the interdisciplinary research team. Serum albumin and prealbumin, and depression scores were all significantly improved post intervention. The problems, approaches, and outcomes identified during the INRx process support the premise that interdisciplinary teams following the INRx process can assess complex nutritional problems and influence outcomes for older adults living in nursing homes.     

Are dietitians prepared to work with handicapped infants? PL 99-457 offers new opportunities

PL 99-457 mandates nutrition as one of eight disciplines to be included on the team providing services to handicapped infants (up to age 3) and their families. A case-managed range of services is required to enable the child to benefit from early interventions. Findings from a survey of a sample of entry-level Plan IV/V Programs, Coordinated Programs in Dietetics, and dietetic internships randomly selected from The American Dietetic Association's 1988 Directory of Dietetic Programs indicate that the growth and development of handicapped infants and their nutrition care are underexposed in most didactic and experiential components of the education of entry-level dietitians. A working group of nine nutritionists with expertise in both dietetic education and nutrition care of handicapped children met at a national conference and recommended competencies that they thought would enable entry-level registered dietitians to join interdisciplinary teams working with handicapped infants and their families. Registered dietitians on the team that prepares the Individualized Family Service Plan (IFSP) can strive to ensure that infants are well nourished and therefore more responsive to the other therapies proposed in the plan.     

Challenges of preparing allied health professionals for interdisciplinary practice in rural areas

Meeting the health needs of individuals in rural communities involves addressing the challenges of complex multifaceted health problems, limited local health resources and services, isolation, and distance. Interdisciplinary collaboration can create solutions to health care problems that transcend conventional, discipline-specific methods, procedures, and techniques. This paper reports on the four-pronged approach of the Western Maryland Area Health Education Center used to prepare allied health students to be interdisciplinary team members in rural areas. It describes the development of four interdisciplinary instructional team member training venues (in-class instruction, Web-based modules, service-learning programs, and faculty development workshops) that integrate opportunities to develop and practice interdisciplinary health promotion skills in rural communities. Challenges to implementing the model are described, including developing faculty and student training participation, integrating training venues into existing programs at participating institutions, and designing a unified program evaluation.     

Position of the American Dietetic Association: Providing Nutrition Services for People with Developmental Disabilities and Special Health Care Needs

It is the position of the American Dietetic Association that nutrition services provided by registered dietitians (RDs) and dietetic technicians, registered (DTRs), are essential components of comprehensive care for all people with developmental disabilities and special health care needs. Nutrition services should be provided throughout life in a manner that is interdisciplinary, family-centered, community-based, and culturally competent. People with developmental disabilities and special health care needs frequently have nutrition concerns, including growth alterations (failure to thrive, obesity, or growth retardation), metabolic disorders, poor feeding skills, medication-nutrient interactions, and sometimes partial or total dependence on enteral or parenteral nutrition. Individuals with special needs are also more likely to develop comorbid conditions such as obesity or endocrine disorders that require nutrition interventions. Poor health habits, limited access to services, and long-term use of multiple medications are considered health risk factors. Health maintenance and avoidance of complications can be promoted by timely and cost-effective nutrition interventions. Public policy for individuals with special needs has evolved over time, resulting in a transition from institutional facilities and programs to community living. The expansion of public access to technology and health information on the Internet challenges RDs and DTRs to provide accurate scientific information for those with developmental disabilities and special health care needs. Nationally credentialed RDs and DTRs are best prepared to provide appropriate nutrition information for wellness and quality of life.     

Everyone's problem but nobody's job: Staff perceptions and explanations for poor nutritional intake in older medical patients

Aim: Up to 60% of older medical patients are malnourished with further decline during hospital stay. There is limited evidence for effective nutrition intervention. Staff focus groups were conducted to improve understanding of potential contextual and cultural barriers to feeding older adults in hospital. Methods: Three focus groups involved 22 staff working on the acute medical wards of a large tertiary teaching hospital. Staff disciplines were nursing, dietetics, speech pathology, occupational therapy, physiotherapy, pharmacy. A semistructured topic guide was used by the same facilitator to prompt discussions on hospital nutrition care including barriers. Focus groups were tape‐recorded, transcribed and analysed thematically. Results: All staff recognised malnutrition to be an important problem in older patients during hospital stay and identified patient‐level barriers to nutrition care such as non‐compliance to feeding plans and hospital‐level barriers including nursing staff shortages. Differences between disciplines revealed a lack of a coordinated approach, including poor knowledge of nutrition care processes, poor interdisciplinary communication, and a lack of a sense of shared responsibility/coordinated approach to nutrition care. All staff talked about competing activities at meal times and felt disempowered to prioritise nutrition in the acute medical setting. Staff agreed education and ‘extra hands’ would address most barriers but did not consider organisational change. Conclusions: Redesigning the model of care to reprioritise meal‐time activities and redefine multidisciplinary roles and responsibilities would support coordinated nutrition care. However, effectiveness may also depend on hospital‐wide leadership and support to empower staff and increase accountability within a team‐led approach.     

A Night Without Stars (Book)

Children with disabilities need adequate nutritional intake to survive and thrive. Many are at risk and in need of nutritional intervention. In this study we evaluated the outcomes of nutrition services for children with disabilities and their families using an integrated model of feeding and nutrition. Thirty-five children and families who received nutrition intervention services participated in the study. Children with disabilities and inadequate nutrition significantly benefited from nutrition interven- tion services. Children increased in weight-for-height ratios. Families reported in- creased alertness for their children with improved nutritional status. Families of children with greater feeding difficulties experienced increased stress and decreased social support. These findings can help families and professionals work in partnership to meet the nutrition needs of children with disabilities and chronic health care problems before a child becomes severely malnourished or a family becomes dys- functional.     

Helping Families Meet the Nutritional Needs of Children With Disabilities: An Integrated Model

Children with disabilities need adequate nutritional intake to survive and thrive. Many are at risk and in need of nutritional intervention. In this study we evaluated the outcomes of nutrition services for children with disabilities and their families using an integrated model of feeding and nutrition. Thirty-five children and families who received nutrition intervention services participated in the study. Children with disabilities and inadequate nutrition significantly benefited from nutrition interven- tion services. Children increased in weight-for-height ratios. Families reported in- creased alertness for their children with improved nutritional status. Families of children with greater feeding difficulties experienced increased stress and decreased social support. These findings can help families and professionals work in partnership to meet the nutrition needs of children with disabilities and chronic health care problems before a child becomes severely malnourished or a family becomes dys- functional.     

Principles for Developing Interdisciplinary School-based Primary Care Centers

ABSTRACT: A 50% increase has occurred in the number of school-based primary care centers (SBPCCs) in the United States since 1993-94. Public schools offer a well-established and respected community-based infrastructure within which health centers may feasibly be developed. SBPCCs have documented improved access to care for underserved children and some initial success in addressing the complex morbidities and associated behavioral risk factors of children and adolescents. This paper presents five working principles to help communities establish SBPCCs that link community health and social services with their educational system. The principles encompass community participation, early assessment of community needs, integration of health and human services with educational services through an interdisciplinary and interagency team approach, development of a business plan, and program evaluation. These principles reflect the experiences of 22 Texas communities which operate 76 SBPCCs. They should prove helpful to many other communities and states that propose to develop, finance, and evaluate school-based, interdisciplinary health care and prevention services.     

Position of The Canadian Dietetic Association and The American Dietetic Association: nutrition intervention in the care of persons with human immunodeficiency virus infection

The goals of nutrition intervention in HIV disease include early assessment and treatment of nutrient deficiencies, the maintenance and restoration of lean body mass, and support for activities of daily living and quality of life. The maintenance and restoration of nutritional stores is closely interrelated and interdependent with each of the other recommended medical therapies. Therefore, it is vital to the health of persons with HIV/AIDS to have access to the services of a registered dietitian, who is the essential member of the health care team for providing nutrition care (48). The registered dietitian should take an active role in developing nutrition care protocols for HIV/AIDS in their practice setting. The dietetic professional must take responsibility for obtaining and maintaining current knowledge in this area and take the lead in translating current nutrition knowledge and research into practical and realistic nutrition guidelines for the individual with HIV/AIDS. Further research is needed in the area of HIV/AIDS and nutrition. Registered dietitians and other members of the health care team are encouraged to conduct nutrition research in the area of nutrition interventions and outcomes of nutrition therapy. Additionally, government health related agencies, national AIDS-related organizations, and private industry should be encouraged to provide funding sources and support to the issue of research in nutrition related problems and interventions in HIV/AIDS.     

An Interdisciplinary Health Team Training Program for School Staff in Minnesota

ABSTRACT: This paper describes an interdisciplinary health team training program for school-based clinic staff in Minnesota. The project sought to improve team functioning, level of practice, and health care services at the school sites. Participants were interdisciplinary staff members from clinics in senior high, middle, and elementary schools. The program consisted of further development in team training knowledge and skills and educational sessions on issues identified by participants. Evaluations indicated participants reported greater knowledge and improved team functioning experiences from the team training. Gains also were shown in knowledge and skills in specific school topic areas such as violence, resiliency, working with resistant families, and self-care. The program could serve as a model for other interdisciplinary school health team training.     

The physician-hospice partnership: expanding opportunities to improve end-of-life care

People living with a life-limiting illness require expert medical care to control often debilitating symptoms. Beyond physical care issues, people at the end of life also need emotional and spiritual support for themselves and their loved ones. Hospices offer a range of services via an interdisciplinary team to meet the specialized needs of people at the end of life. This article will explore the physician-hospice partnership and the benefits to patients, family caregivers, and physicians when hospice care is accessed early in the dying process. Benefits of interdisciplinary, patient/family-directed care will be discussed. The range of palliative services being offered by many hospices will also be presented as a mechanism to increase access to end-of-life services for patients and family caregivers.     

A day in the life: a case series of acute care palliative medicine--the Cleveland model

Palliative care in advanced disease is complex. Knowledge and experience of symptom control and management of multiple complications are essential. An interdisciplinary team is also required to meet the medical and psychosocial needs in life-limiting illness. Acute care palliative medicine is a new concept in the spectrum of palliative care services. Acute care palliative medicine, integrated into a tertiary academic medical center, provides expert medical management and specialized care as part of the spectrum of acute medical care services to this challenging patient population. The authors describe a case series to provide a snapshot of a typical day in an acute care inpatient palliative medicine unit. The cases illustrate the sophisticated medical care involved for each individual and the important skill sets of the palliative medicine specialist required to provide high-quality acute medical care for the very ill.     

Diagnosing and improving functioning in interdisciplinary health care teams

Interdisciplinary teams play a key role in the delivery of health care. Team functioning can positively or negatively impact the effective and efficient delivery of health care services as well as the personal well-being of group members. Additionally, teams must be able and willing to work together to achieve team goals within a climate that reflects commitment to team goals, accountability, respect, and trust. Not surprisingly, dysfunctional team functioning can limit the success of interdisciplinary health care teams. The first step in improving dysfunctional team function is to conduct an analysis based on criteria necessary for team success, and this article provides meaningful criteria for doing such an analysis. These are the following: a common team goal, the ability and willingness to work together to achieve team goals, decision making, communication, and team member relationships. High-functioning interdisciplinary teams must exhibit features of good team function in all key domains. If a team functions well in some domains and needs to improve in others, targeted strategies are described that can be used to improve team functioning.     

SOCIAL WORK IN HOME DIALYSIS

This paper describes the author's 2-year experience as a social worker in a home dialysis training center. The experience is reviewed in relation to current trends in health care: greater recognition of the patient's emotional response; more patient responsibility for treatment; increased communication among various professions and between the health care team and patients; rehabilitation of chronically ill patients; and decentralized delivery of services. It is concluded that the social worker can provide leadership in responding to these trends. The basis for this leadership lies in the development of good working relationships in the interdisciplinary team and between professionals and patients. For this purpose the social worker must acquire skills in dealing with the conflicts arising from these more complex relationships.