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MAKING THE BEST BETTER:
CONTINUOUS NCP
IMPROVEMENT
WEBINAR SPONSORED BY: MEDICAL NUTRITION PRACTICE GROUP Karen Lacey MS, RD, CD Dietetic Director Emeritus, UW- Green Bay Wednesday, November 20, 2013 Objectives Utilize critical thinking in the application of the Nutrition Care Process Evaluate the quality of PES statements Utilize the nutrition intervention standardized language Identify appropriate outcome measures and indicators for nutrition monitoring and evaluation Questions ????? How to write accurate PES statements (confusion between etiology and signs and symptoms) What to do if there are no nutrition problems How best to use when patients are hospitalized for a short period of time Questions about the use of the IDNT Charting How best to use the standardized language How/where to start Revised NCPM, 2008 Nationwide data results April 2013 Readex Survey Results Random sample of registered dietitians (over 3000 responded) = 95 % confidence level Questions: NCP is easy to understand; scale of 1-11; 1= very strongly disagree, 11= very strongly agree Are you familiar with the NCP?; yes or no Various stages of implementation of each step Change is fully institutionalized, Implemented, Training, Determining implementation plan, Aware of need, Not currently aware, Don't know Summary of Key Results NCP is easy to understand = mean of 7. (2013) NCP is easy to understand (% that responded 9,10,11) 2011; 31% 2013; 35% Familiar with NCP (% that responded yes) 2011; 45% 2013; 54%
Stages of Implementation Stage of Implantation Assessment Diagnosis Intervention Monitoring & Evaluation Fully institutionalized 22.32 % 25.22 % 22.3 % 21.26 % Implemented 37.61 % 39.05 % 37.98 % 37.38 % (subtotal) 59.93 % 64.27 % 60.28 % 58.64 % Training 4.84 % 5.43 % 5.96 % 6.42 % (total) 64.77% 69.7% 66.24% 65.06% Critical Thinking Nutrition Assessment
- Organize & cluster data according to possible diagnoses
- Determine appropriate data to collect
- Distinguish important & relevant data from unimportant and irrelevant data Nutrition Diagnoses - Find patterns and relationships among data and possible causes - Rule in/rule out specific diagnoses - State problem clearly and singularly Critical Thinking Nutrition Intervention
- Set and prioritize goals
- Match intervention strategies with client needs, diagnoses and values
- Specify the time and frequency of care Nutrition Monitoring & Evaluation
- Select appropriate indicators and measures
- Use appropriate reference standards for comparison
Nutrition Assessment/Monitoring
and Evaluation Domains
Food/Nutrition-Related History (FH) Food and Nutrient Intake Food and Nutrient Administration Medication and Complementary/Alternative Medicine Use Knowledge/Beliefs/Attitudes Behavior Factors Affecting Access to Food and Food/Nutrition Related Supplies Physical Activity and Function Nutrition-Related Patient/Client-Centered Measures
Nutrition Assessment/Monitoring
and Evaluation Domains
Anthropometric Measurements (AD) Biochemical Data, Medical Tests and Procedures (BD) Nutrition-Focused Physical Findings (PD) Client History (CH) Comparative Standards (CS) What’s New – Assessment?
- Academy Unique Identifier (used to track data EMR)
- US and metric measures
- More specific terms for vitamins/minerals
- New terms within physical activity and function
- Revised shading areas for assessment only
Nutrition Counseling:
Theoretical Basis/Approach (1)
Cognitive – Behavioral Theory Health Belief Model Social Learning Theory Transtheoretical Model/Stages of Change Other
Nutrition Counseling: Strategies (2)
Motivational interviewing Goal setting Self-monitoring Problem-solving Social support Stress management Stimulus control Cognitive restructuring Relapse prevention Rewards/contingency management
Coordination of Nutrition Care
Consultation with, referral to or coordination of nutrition care with other providers, institutions or agencies that can assist in treating or managing nutrition- related problems What’s New? – Intervention
- Terms that reflect the type of action taken: recommend, implement, order, initiate, modify or discontinue
- More specific terms for many of the food/nutrient classifications
Intervention – 2 parts
#1 Set goals Based on signs and symptoms The indicator that you will monitor and evaluate Nutrition Prescription or Goal/Expected Outcome Reference Standard (e.g. national, institutional and/or regulatory standard) #2 Implement intervention Based on etiology
Nutrition Monitoring and Evaluation
Measuring Select the nutrition care outcome indicator to measure the desired outcome (initial and subsequent) Monitoring Review the data at scheduled intervals Evaluate Systematic comparison of current findings with previous status, intervention goals or reference standard
Nutrition Monitoring & Evaluation
Terminology
Refer to Nutrition Assessment Terminology Additional Specific to Monitoring and Evaluation
Diagnosis Terminology Flow
Sheet
Nutrition Diagnostic Terminology Intake Clinical Behavioral/ Environmental Energy Balance Oral or Nutrition Support Intake Fluid Intake Bioactive Substances Nutrient Functional Biochemical Weight Knowledge and Beliefs Physical Activity and Function Food Safety and Access Fat and Cholesterol Mineral Vitamin Carbohydrate and Fiber Protein
What’s New? - Nutrition Diagnoses
- Additional terms for documenting vitamin/mineral intake
- Enteral/parenteral; now less than optimal composition or modality
- Inappropriate intake of fats (specify); now leas than optimal intake of types of fats
- Harmful beliefs/ attitudes…; now Unsupported beliefs/attitudes…. Other more recent
- Energy Balance Predicted suboptimal energy intake NI-1. Predicted extensive energy intake NI-1.
- Multi-nutrient Predicted suboptimal nutrient intake NI-5.11. Predicted excessive nutrient intake NI-5.11.
- Biochemical: Predicted food-medication interaction NC-2.
- No nutrition diagnosis at this time NO-1.
Using the Diagnostic Terminology
All the terms can/must be used as the “Problem” Some terms can also be used as the “Etiology” (can also be free text) Some terms can also be used as “Signs and Symptoms” as long as accompanied by actual data (can also be free text) Nutrition Nutrition Nutrition Nutrition Assessment Diagnosis Intervention Mon & Eval Problem Etiology Signs & Symptoms Nutrition Diagnosis Labels Intake Domain (excessive or inadequate intake of xx) Use of Nutrition Dx Terms
Evaluating your PES statement Problem (P) Can the nutrition professional resolve or improve the nutrition diagnosis? When all things are equal and you have a choice between stating the PES statement using two nutrition diagnosis labels from different domains, consider the intake nutrition diagnosis as the one most specific to the role of the RD. Evaluating your PES statement Etiology (E) Is the etiology listed the “root cause”? Ask “Why?” 5 times Can you envision an intervention that would address the etiology and thus resolve the problem? If you are unsure about resolving the problem by addressing the etiology, is your intervention targeted to reducing or eliminating the signs and symptoms?
Evaluating your PES statement
Signs & Symptoms (S) Will measuring the Signs and Symptoms tell you if the problem is resolved? Are the Signs and Symptoms specific enough that you can measure/evaluate changes at the next visit to document resolution of the nutrition diagnosis? PES Overall Does the nutrition assessment data support a particular nutrition diagnosis with a typical etiology and signs and symptoms? A Well-Written PES Statement Simple, clear and concise Specific to the patient/client or group Descriptive of a single nutrition – related problem Accurately related to an etiology Based on reliable and accurate nutrition assessment data Nutrition Nutrition Nutrition Nutrition Assessment Diagnosis Intervention Mon & Eval Problem Etiology Signs & Symptoms
Relationship of PES
Statements to NCP Steps
Example: Nutrition Support PES (P) Inadequate enteral nutrition infusion (E) related to: increased residuals and holding of TF for 2 hours (S) As evidenced: by 24 hour infusion less than goal by 500 ml Intervention: Nutrition Support Part 1: Nutrition Prescription and Goals Based on estimated nutrient needs using accurate reference standards Provide goal nutrients per estimated needs within 24 hours Part 2: Select Intervention Enteral Nutrition ND-2. Options of changing formula concentration or rate Medications ND-6. Review options of gastric motility medications as appropriate Nutrition Nutrition Nutrition Nutrition Assessment Diagnosis Intervention Mon & Eval Problem Etiology Signs & Symptoms
Relationship of PES
Statements to NCP Steps
Monitoring and Evaluation Calculate 24 nutrient infusion of enteral feedings Montior for tube feeding tolerance Nutrition Nutrition Nutrition Nutrition (re)Assessment Diagnosis Intervention Mon & Evaluation Problem Etiology Signs & Symptoms Relationship of PES Statements to NCP Steps
Case Example: ICU patient meeting current
nutrition goals with enteral or parenteral nutrition 32 y.o. male admitted to the ICU with traumatic brain injury after motor vehicle crash. 6'1" and 200 lbs Previously healthy and well nourished prior to admission Pt is on mechanical ventilation and tolerating tube feedings at goal rate.
Evaluation of intake PES BEFORE Inadequate oral intake related to clinical status/physiological causes increasing nutrient needs (wound healing), as evidenced by poor appetite/intake, clinically significant weight loss, h/o low pre-albumin, dependence on multiple nutrition supplements to meet increased nutrient needs, and stage IV pressure ulcers Critical Thinking Too much data; not singular The S/S includes some data that describe the etiology Difficult to establish measurable goals The etiology does not lend itself to a clear and logical nutrition intervention Evaluation of Intake PES P= Inadequate oral intake E= increased nutrient needs secondary to wound healing of stage IV pressure ulcer S= observed poor intake of nutritional supplements, patient c/o decreased appetite and unintended weight loss of …… (quantifiable amount) Implementation of NCP Nutrition prescription: estimated calorie and protein needs to support increased needs Goal: patient improve appetite and intake to meet needs; weight stable Intervention: Meals/Snacks: protein modified ND-1. Supplements: commercial beverage ND-3.1. Evaluation of Clinical PES BEFORE: Altered GI function related to small bowel obstruction as evidenced by ngt for suctioning
AFTER:
Inadequate oral intake related to altered GI function secondary to small bowel obstruction and ngt suctioning as evidenced by NPO status X 3 days. Implementation of NCP Intervention (2 parts) Goals: Meet nutrient needs within 24 hours bypassing GI route (clearly linked to S) Parenteral Nutrition/IV Fluids (2.2) Provide recommendations Composition and Rate ND-2.2.1 & ND 2.2.
Evaluation of Behavioral-Environmental PES BEFORE: Food/nutrition related knowledge deficit related to lack of prior exposure to information as evidenced by pt’s questions/concerns
AFTER:
Food/nutrition related knowledge deficit as evidenced by pt’s questions/concerns regarding ………. (specify examples of such questions) May not need E (redundant) Common Issues No apparent nutrition problems Document pertinent data from assessment and clearly state “no nutrition diagnosis at this time” Follow institution’s P & P for routine rescreening or reassessment as conditions might change ND 3rd^ Edition: Predicted suboptimal energy intake NI-1.6 and Predicted excessive energy intake NI-1.
Documentation of Assessment
Date and time of assessment Pertinent data collected Comparison with standards Documentation, cont Patient/client/groups’ Perception Values Motivation related to presenting problems Changes in patient/client/group’s Level of understanding Food-related behaviors Other clinical outcomes Reason for discharge and/or /discontinuation if appropriate Select Documentation Format Modified SOAP format PES statement at conclusion of A section ADI format Narrative with PES statement Discuss how to handle routine “screening” assessments where there is no problem Determine your guidelines for how much is enough, too much, just right Document only terms; not the codes or numbers Documentation PES statement (s) that reflect the intervention that you are making Alternative method of documenting the other problems identified during an assessment Progress notes in other places in chart M & E section to be addressed later Separate document: Kardex etc.
