The results of this study reveal two general areas of concern for clinical dietitians in the use of laboratory data--their lack of confidence in their own interpretive skills and the perceived resistance of physicians. Although clinical dietitians receive theoretical and applied training on the use of laboratory values in their undergraduate education and dietetic internship, clinical managers should be aware that they need support and continuing education to use their laboratory assessment skills to the fullest. Also, dietitians should demonstrate more clearly to physicians their knowledge, skill, and needs in this area. They should initiate and continue dialogue about the importance of laboratory analysis to nutrition care and improved patient outcome. Evidence-based data and clear documentation of improved medical outcomes should help overcome barriers to use of laboratory data by clinical dietitians.
As more health care facilities adopt computer-based patients records (CPR), dietitians will have the need to be trained in this technology. This descriptive survey examined supervised practice program directors’ expectations and current training of students on this topic and the barriers that might preclude such training. All program directors nationwide were surveyed with a response rate of 62.4%. Only 34.9% of respondents held any CPR expectations of students entering their programs, and 51.1% of the programs provided training on CPR. The predominant format used for recording electronic nutrition care notes was SOAP. Barriers noted to CPR training in descending order included lack of availability/accessibility of computers, lack of computer skills, lack of time and other resources, and lack of facility cooperation. When asked what they felt were the 3 most important computer skills for an entering supervised practice student to possess, respondents ranked word processing as number one followed by nutrient analysis and use of the Internet. The majority of directors rated their own computer skills to be at an intermediate level and assessed the majority of their students skills to be at that same level. Results have implications for curriculum development not only in supervised practice programs but in didactic programs as well.
Nutrition assessment performed as part of hospital admission protocol can significantly reduce length of stay, costs of care, and the incidence of readmission by efficiently identifying patients with malnutrition. As reported in more than 150 clinical studies, malnutrition is a health problem of huge magnitude, potentially affecting more than half of hospitalized patients in the United States. The laboratory director can optimize the use of visceral protein testing in nutrition assessment protocols to realize the greatest benefit for both patient and institution. The accurate identification of patients with protein calorie malnutrition allows the use of malnutrition ICD-9-CM codes to obtain higher reimbursement for the increased acuity of illness.
This study sought to determine the usefulness of lab data to clinical dietitians and perceptions of barriers to that use. A questionnaire was mailed to 2000 inpatient hospital dietitians (RD). A total of 969 RDs responded; analysis involved only those who indicated they were currently employed as clinical dietitians (N-969). The most frequent uses of lab data were for assessment of nutrition status (85%), improving nutrition care (73%), and understanding the illness/disease state (72%). Uses were not dependent on age, years of experience, route to registration, or whether one held an advanced degree. Certified Nutrition Support Dietitians (CNSD) were less likely to use lab results to avoid malpractice (P=.03). Top perceived barriers included physicians failing to routinely order labs necessary for nutrition assessment (45%), lab results not routinely available (38%), and unresponsive physicians to requests for certain lab tests (20%). RDs in the 45-54 yr range were least likely to identify lack of time as a barrier (P=.002). Those who became RDs through the grandfather clause were most likely to note they were unsure about discussing lab values with patient or family (P=.002). RDs with advanced degrees were less likely to view lack of knowledge as an obstacle (P=.0001); those at the baccalaureate-level were more likely to identify lab results not routinely available (P=.01) as problematic. Both CNSD RDs (P=.03) and RDs certified as diabetes educators (P=.004) were more likely to identify that the physician does not routinely order necessary labs for nutrition assessment than were RDs not certified in these specialties. Although the uses for lab data were not unexpected, barriers would appear to indicate that better communication with physicians is warranted.
This study sought to determine the usefulness of lab data to clinical dietitians and perceptions of barriers to that use. A questionnaire was mailed to 2000 inpatient hospital dietitians (RD). A total of 969 RDs responded; analysis involved only those who indicated they were currently employed as clinical dietitians (N-969). The most frequent uses of lab data were for assessment of nutrition status (85%), improving nutrition care (73%), and understanding the illness/disease state (72%). Uses were not dependent on age, years of experience, route to registration, or whether one held an advanced degree. Certified Nutrition Support Dietitians (CNSD) were less likely to use lab results to avoid malpractice (P=.03). Top perceived barriers included physicians failing to routinely order labs necessary for nutrition assessment (45%), lab results not routinely available (38%), and unresponsive physicians to requests for certain lab tests (20%). RDs in the 45-54 yr range were least likely to identify lack of time as a barrier (P=.002). Those who became RDs through the grandfather clause were most likely to note they were unsure about discussing lab values with patient or family (P=.002). RDs with advanced degrees were less likely to view lack of knowledge as an obstacle (P=.0001); those at the baccalaureate-level were more likely to identify lab results not routinely available (P=.01) as problematic. Both CNSD RDs (P=.03) and RDs certified as diabetes educators (P=.004) were more likely to identify that the physician does not routinely order necessary labs for nutrition assessment than were RDs not certified in these specialties. Although the uses for lab data were not unexpected, barriers would appear to indicate that better communication with physicians is warranted.
A multidisciplinary, malnutrition treatment program was developed and implemented at a 395-bed, community hospital to reduce delays in initiating and achieving a therapeutic level of nutrition care for patients identified to have a significant risk for malnutrition (13% of the adult patient population). The project contained a continuous quality improvement (CQI) plan that assessed the effectiveness of the treatment program to achieve these goals. An outcome study was designed to evaluate the impact of nutrition interventions on patient recovery and cost of care. To quantify the impact, the study compared the patient population at high risk for malnutrition both before and after implementation of a malnutrition clinical pathway. Albumin, functional status, and the use of nutrition support (enteral or parenteral) were the variables used to predict outcomes such as length of stay (LOS), discharge disposition and the number of complications. The study required the data sets to be examined and normalized for severity of illness using scaled values of serum albumin. The scaling produced three classes which identified the study population by serum albumin value: (1) >2.7g/dl, (2) 2.3-2.7g/dl, and (3) <2.3g/dl. A cost avoidance of $930,000 was calculated from the reduction of complications when comparable severity of illness between the study groups was considered. Similarly, a $1,008,000 cost avoidance was projected when calculations were made from the reduction in LOS. The application of CQI principles to nutrition care services improved clinical care and clinical effectiveness. The program established a model to effectively allocate existing resources to provide timely and therapeutic nutrition interventions to patients at high risk for malnutrition. A method for the ongoing collection of outcome data has been incorporated into the routine course of nutrition care. This allows for more efficient and frequent performance reviews and CQI.
The initial step in developing a clinical pathway for malnutrition at a 395-bed community hospital was to evaluate the nutrition screening method for sensitivity (appropriate identification of those at risk) and specificity (appropriate identification of those not at risk). The original tool used a simple point scoring system. Primary and co-existent diagnoses (e.g., cancer, renal disease) and conditions (e.g., fever, diarrhea) associated with an increased risk for malnutrition were complemented by lab (e.g., albumin, lymphocyte count) and anthropometric (weight for height) data. Nutrition risk was based on the number of indicators identified. Level I identified no indication of nutrition risk; levels II and III, mild and moderate risk, required further assessment; level IV, significant risk, required consideration for intervention. Every patient (N=683) admitted over a 2-month period was screened; data were analyzed using SPSSx statistical software. Data were categorized using ICD9CM parameters of malnutrition and compared with risk levels. Initially, the misclassification rate was 9%; the positive predictive value (probability that the individual is at nutrition risk) was 0.84. Although sensitivity was acceptable (0.97), specificity was not (0.87). The revised tool, which weighs indicators associated with nutrition risk (e.g. weight for height, albumin, lymphocyte count, hemoglobin) and assigns varying points according to severity, was applied to these same patient data. Misclassification rate dropped to 1%, sensitivity (0.99) and specificity (1.0) improved, and the positive predictive value increased (1.0). With improved accuracy in identifying those needing intervention versus those at less risk, nutrition care resources can be allocated more effectively and cycle time to intervention can be reduced.
The typical channels selected for nutrition education and research projects are schools, worksites, clinics and health care settings. In order to reach a diverse population in a brief time period, we chose to conduct a food labeling education and research project at the department of motor vehicles on the actual day and the day following license plate tag expirations in the month of March. As part of their National Nutrition Month project, 8 students in our Coordinated Dietetics Program surveyed almost 1000 customers in 2 eight-hour days. In addition to gathering data about food label awareness, usage, understanding, and demographics, the students also provided nutrition education while people waited in line to obtain or renew their licenses or tags. The Department of Motor Vehicles provides a unique opportunity to interact with a large population of wide age ranges, races, educational levels, and income brackets. Because of the long lines typically encountered at certain times of the month, the DMV is an ideal place to reach a large audience in a brief time period. The students, dressed in food label t-shirts bearing the logo “Are You Label-Able? Ask Me!”, provided an interesting distraction for long-line weary customers, most of whom were more than happy to participate in the project just to pass the time! The uniqueness of this project also attracted a great deal of television media attention and promoted university/community health partnerships.
Food banks typically use process evaluation tools to measure their productivity because outcome measures that demonstrate impact have been hard to define in this setting. Some of the process indicators have included pounds of food distributed and the dollar value of those distributions. This type of measure does not provide any assessment of what impact a food bank may be having on hunger or malnutrition in the community it serves. We developed an outcome evaluation measure to determine the potential nutritional impact of the Food Bank of Delaware. We determined the number of people who could potentially be provided with the minimum recommended servings per day for each food group from the Food Guide Pyramid. The 169 different food items totaling more than 300,000 pounds which were distributed by the food bank for a one month period were assigned to a food group and portion sizes were calculated. Total portions were then divided by minimum Pyramid recommendations for each food group. Results indicated that, on a given day, 6509 persons could receive adequate bread/grains, 3729 persons could receive adequate fruit, 2051 persons could receive adequate meat, 1645 adequate vegetables, and 478 adequate milk. The evaluation also showed that sweet foods and fats were the second and third largest quantities of food being distributed by the food bank. Areas were identified for nutrition education and improved menu planning for the organizations who actually dispense these foods to clients.
Coordinated Program (CP) students gain knowledge and experience in nutrition counseling through their supervised practice course, Clinical Nutrition. Until recently, Didactic Program in Dietetic (DPD) students in the course Nutrition Counseling utilized the University Nutrition Clinic as the basis for their laboratory observations and experiences. When budget cuts limited the client pool and available services of the clinic, and demand for the course continued to increase, alternative strategies were sought to teach DPD students nutrition counseling skills. A video-based nutrition counseling program ("Nutrition Counselor", Nutrition Concepts, Inc.) served as the core of a major curriculum revision. At the end of the semester, individual videotaped counseling sessions of DPD and CP students were evaluated to assess differences in skills of the two groups. Instructors from both programs independently scored 60 skills on a scale of 0(absent) to 3 (outstanding). Broad areas reviewed included interpersonal skills, presentation skills, adherence promotion strategies, behavioral techniques, and essential teaching functions. Spearman rho was applied to assess correlation of instructors' ratings (r=0.79). DPD students' interpersonal skills were good (mean=2.1), but not significantly different from those of CP students (1.8); t=1.89; p<0.18). However, in all other areas, DPD students performed better than CP students. Plans are to emphasize behavioral techniques and adherence promotions skills in both programs, and to consider Nutrition Counseling as a required course for CP students.
Older adults have been identified as one of the largest groups at risk of malnutrition in America and represent the target population of the Nutrition Screening Initiative. At the University of Delaware Adult Day Care Center, nutrition screening is an integral component of basic services provided to clients and their caregivers. To determine the extent of current nutrition screening practices in other adult day care centers, centers across the United States were surveyed. A total of 160 centers (53%) responded; 101 indicated nutrition screening was an on-going service. A number of differences and similarities in nutrition screening parameters was evident. Most centers responding assessed the following parameters: food intolerance, medical history, weight, height, swallowing difficulties, and bowel habits. Hematological parameters and other anthropometric measurements were evaluated with least frequency. Interest in nutrition screening appeared great. Further research should examine relationships between nutrition screening and other factors such as staffing patterns, center settings, and funding sources.
Eleven student dietitians attempted to comply with a calorie-controlled, diabetic diet for 1 week. Pre- and posttest questionnaires, as well as food diaries, were used to assess projected versus actual compliance, obstacles to adherence, and thoughts and feelings about following a prescribed medical regimen. Scores of deviation from the meal plan and food exchanges were calculated to describe dietary compliance. Only one student indicated she was able to adhere to the diet for the entire week. Twenty-seven percent of the students complied with their meal plan 90 % of the time. All students felt they would be more empathetic in their relationships with patients and involve patients to a greater extent in planning their diets.
Facility preceptors contribute greatly to the education of students in health professions by serving as role models, mentors, and instructors. Helping to educate students means added responsibilities to an already busy schedule, while rewards are often intangible. The authors describe usual preceptor benefits and explore possibilities for more tangible rewards which can be cost efficient and stimulate preceptor interest and enthusiasm. Suggestions are applicable in any allied health program.
Student dietitians, in our experience, have demonstrated a very narrow perspective in using professional literature. The limited scope of reference journals used and the lack of ability to critically review the literature and abstract the essentials of a study were identified as problem areas. An assignment designed to address those inadequacies was developed, implemented, and evaluated. Following scientific guidelines, 11 students from the coordinated program in dietetics each reviewed three to five non-nutrition-specific journals and abstracted all nutrition-related articles published for the current 16-month period. The resulting 339 abstracts were compiled and distributed to faculty and facility preceptors. Improvement was evident in students' ability to critically evaluate and abstract an article. Faculty members, facility preceptors, and students evaluated the project as being worthwhile.
A s employers' interest and commitfiment to well ness programs for their employees grow, the need to identify cost-effective risk factor reduction interventions grows. Packaged interventions are an attractive programming altemative. A guide for assessing various characteristics of a packaged intervention can help the purchaser see through slick marketing techniques and point out the strengths and weaknesses of an intervention. One of the newest and fastest growing enterprises is workplace wellness (Behrens, 1987). Growth of this industry has been fueled by concern over rising health care costs, an increased understanding that lifestyle contributes to premature morbidity and mortality, and a heightened awareness of the real and potential benefits that a wellness program offers. Managers, who only a few years ago wanted to see unequivocal evidence of the contribution of health promotion to the company's "bottom line" before making a commitment, are now connecting with numerous providers of workplace wellness products and services. The person responsible for developing or coordinating a wellness program may have little formal training in health education or program administration. For this person, initial investigation soon reveals that there are a variety of approaches that may be taken. Basically, the person must choose between having interventions offered in-house by staff or contracting for services through an outside qualified vendor. Some combination of the two is another alternative. The company that contracts with an outside vendor relies on that vendor's expertise to offer a quality intervention. Intervention is defined as an activity concentrated on a specific content area-such as smoking cessation or weight loss-and that may be part of a more comprehensive ongoing wellness program. Whereas contracting with outside vendors adds variety and helps build community relations, particularly with nonprofit voluntary health agencies, a company that develops the capability to offer interventions gains certain advantages. The main advantages may include: • Lower costs. • Creation of a sense of ownership. • Greater flexibility in scheduling. • The ability to modify the intervention. A company's real disadvantage in offering its own risk reduction intervention (eg, smoking cessation, stress management, weight reduction) is that it takes a considerable amount of time and expertise to develop such an intervention. The time to research, develop, test, and refine an intervention aimed at longterm behavior change may take six months to a year, depending on the number of people assigned to the project and their abilities. An attractive alternative to developing one's own intervention is the purchasing of a ready-made or "packaged" intervention. The growth in employer interest for workplace wellness programs has been accompanied by an increase in the number of vendors interested in selling wellness products and services, such as packaged interventions (Harris, 1986). A packaged program consists of all, or nearly all, of the necessary ingredients to deliver an intervention, usually a series of education classes with a health behavior change implicitly or explicitly understood as one of the main objectives. A packaged intervention might include: • A facilitator's guide. • Lesson plans. • Audio-visual teaching aids. • Promotional material. • Participant workbooks, handouts, and evaluation tools. Despite a packaged intervention's attractiveness, buyers should be fully aware of what they are committing themselves to. As with any product or service, certain characteristics make the product or service more or less attractive/valuable to any given purchaser (Bills, 1985; Powell, 1985). Furthermore, marketing techniques can make the poorer products or services often appear more attractive or effective than the. truly good ones. The guide for assessing packaged wellness interventions is designed to encourage the potential buyer to consider many important characteristics associated with a quality packaged intervention, and the questions listed are designed to stimulate the potential purchaser's thinking about an intervention's value. No attempt is made to devise a scoring system, since the importance attached to each characteristic will vary from person to person. Whether greater importance is placed on overall cost, proven effectiveness, materials' completeness, or prior use by a well-known company, the guide will facilitate assessment of the overall worth of an intervention. A decision to purchase will be more a consequence of thoughtful consideration, rather than a result of fancy marketing techniques.
Compliance has long been an area of concern in medical therapies. As efforts toward health promotion and wellness grow, compliance also must be addressed in the context of health promotional lifestyle changes. Research has focused on direct and indirect methods useful in measuring compliance. Results, however, are inconclusive as to which method offers the most useful data. Studies have found related factors of compliance that may help the health-care provider to determine or predict compliance: lack of knowledge, sociodemographic variables, and practitioner-client relationship. Through research on measurement and determinants of compliance, a number of successful strategies for enhancing compliance have surfaced.
The needfor nutrition education programsfor the elderly is now accepted without debate. Messages must be meaningful and relevant for this population who confront unique physiological and psychosocial changes. The nutrition educator also faces challenges when confronting resistance to change and apathy displayed by some elderly persons. A number of programs have been developed and evaluated. Varying degrees of success have been noted. Significant points addressed here include problems related to the aging process, the need for nutrition education, and methods and approaches.
