Practice audit of nutrition support certification.

The National Board of Nutrition Support Certification (NBNSC) is an independent credentialing board responsible for administering certification programs in nutrition support. The NBNSC conducted a study (practice audit) of Nutrition Support Professionals (NSP), with the purposes of defining the role of the nutrition support professional and determining the current elements (knowledge or functions) required for competent NSP practice. This article describes the development of the study, results of the study, and use of the information for future certification in nutrition support. A list of the elements required for competent practice was gleaned from a variety of sources. A rating scale was developed to measure the importance of elements required for competent practice and frequency of practice. From this, an online survey instrument was prepared. Surveys were sent to 5964 NSPs; a total of 891 surveys were completed (return rate of 16.8%). There was 98% agreement among the disciplines of the perceived importance of the elements required of competent entry-level NSP practice; that the survey either completely or adequately described these elements; and that it reflected practice by region as well as among various disciplines and work settings. The results of the practice audit demonstrate a common core of practice (95%) across the nutrition support disciplines as well as a universal core of elements believed to be important for competent nutrition support practice. As a result, the NBNSC has developed 1 examination for future nutrition support certification testing and will confer 1 credential, Certified Nutrition Support Clinician (CNSC), to those who pass the exam.     

Evaluating Evidence‐Based Nutrition Support Practice Among Healthcare Professionals With and Without the Certified Nutrition Support Clinician Credential

Background: The National Board of Nutrition Support Certification credentials healthcare professionals and certifies that holders of the Certified Nutrition Support Clinician (CNSC) credential have specialized knowledge of safe and effective nutrition support therapy. The purpose of this pilot study was to survey healthcare professionals affiliated with the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) regarding their approaches to nutrition support practice using a complex patient case scenario in accordance with established clinical guidelines. Materials and Methods: An electronic survey was emailed to individuals affiliated with A.S.P.E.N. Eight multiple‐choice knowledge questions addressed evidence‐based nutrition support practice issues for a patient with progressing pancreatitis. Demographic and clinical characteristic data were collected. Results: Of 48,093 email invitations sent, 4455 (9.1%) responded and met inclusion criteria. Most respondents were dietitians (70.8%) and in nutrition support practice for 10.3 years, and 29.3% held the CNSC credential. Respondents with the CNSC credential answered 6.18 questions correctly compared with 4.56 for non‐CNSC respondents (P < .001). For all 8 questions, CNSC respondents were significantly more likely to choose the correct answer compared with non‐CNSC respondents (P < .001). Conclusion: Professionals with the CNSC credential scored significantly higher on a complex case‐based knowledge assessment of guideline recommendations for the nutrition support treatment of pancreatitis compared with those without a credential.     

Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent,Proficient, and Expert) in Nutrition Support

Nutrition support is a therapy that crosses all ages, diseases, and conditions as health care practitioners strive to meet the nutritional requirements of individuals who are unable to meet nutritional and/or hydration needs with oral intake alone. Registered dietitian nutritionists (RDNs), as integral members of the nutrition support team provide needed information, such as identification of malnutrition risk, macro- and micronutrient requirements, and type of nutrition support therapy (eg, enteral or parenteral), including the route (eg, nasogastric vs nasojejunal or tunneled catheter vs port). The Dietitians in Nutrition Support Dietetic Practice Group, American Society for Parenteral and Enteral Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nutrition support. The SOP and SOPP for RDNs in Nutrition Support provide indicators that describe the following 3 levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for assuring competent practice in nutrition support and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.     

The value of audit and feedback reports in improving nutrition therapy in the intensive care unit: a multicenter observational study

Background: The objective of this study was to determine whether auditing practice and providing feedback in the form of benchmarked site reports is an effective strategy to improve adherence to nutrition guidelines. Methods: The authors conducted a multicenter observational study in Canadian intensive care units (ICUs). In January 2007, an audit of daily nutrition information was collected (type and amount of nutrition received and strategies to improve nutrition delivery). Each ICU was e‐mailed individualized benchmarked performance reports documenting their performance compared with the Canadian Critical Care Nutrition guidelines and in relation to the other ICUs. Nutrition practice was reaudited in May 2008 to evaluate changes in practice. Results: Twenty‐six ICUs in Canada participated, with 473 and 486 patients accrued in 2007 and 2008, respectively. The authors observed a significant increase in enteral nutrition (EN) adequacy (from 45.1% to 51.9% for calories, and from 44.8% to 51.5% for protein) and an increase in the percentage of patients receiving EN without parenteral nutrition (from 71.9% to 81.3%). They also observed trends toward improvements in the percentage of patients who had EN started within 48 hours (from 60.3% to 66.8%). There were no significant differences in the use of motility agents or small bowel feeding in patients who had high gastric residual volumes. Conclusion: Audit and feedback reports are associated with improvement in some nutrition practices in many ICUs; however, the magnitude of these effects is quite modest. More research is needed to determine the optimal methods of using audit and feedback to improve quality of nutrition care.     

Public nutrition: Why,What, How?

Public Nutrition is a field of professional study and practice that has existed for many years without being named as such. It encompasses the disciplines that deal with factors affecting the food consumption and nutritional outcomes of populations, and goes beyond the definition of Public Health Nutrition by including the study of public policy in areas outside of health and nutrition as traditionally defined, that nonetheless can have profound effects on nutrition. Career paths in Public Nutrition exist at a variety of professional levels, including practitioners and direct service providers; administrators and planners; policy makers; and researchers and educators. The professional preparation of those working in Public Nutrition typically combines education and experience in nutritional science, social science, and sometimes management and planning. The field of Public Nutrition is important in providing a critical link between advances in understanding biomedical determinants of nutrition and the application of such understanding in programs and policies. However, the study of Public Nutrition goes beyond this: it represents an agenda of research and practice in its own right. Public Nutrition includes the study of how specific policies, in varying contexts, affect food consumption and nutrition outcomes; it includes the study of determinants of program effectiveness in improving these outcomes. Specific training programs in Public Nutrition do exist; the elements of a curriculum in Public Nutrition include social science research skills (data collection, management, analysis and interpretation), an understanding of economic, social, political, and behavioral determinants of food consumption, health and nutrition; a grounding in nutritional science. Field experience is an essential part of the preparation of Public Nutrition professionals.     

American Society for Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent,Proficient, and Expert) in Nutrition Support

This 2014 revision of the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Nutrition Support represents an update of the 2007 Standards composed by content experts of the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics. The revision is based on the Revised 2012 SOP in Nutrition Care and SOPP for RDs, which incorporates the Nutrition Care Process and the following 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. These SOP and SOPP are designed to promote the provision of safe, effective, and efficient nutrition support services; facilitate evidence-based practice; and serve as a professional evaluation resource for RDNs who specialize in or wish to specialize in nutrition support therapy. These standards should be applied in all patient/client care settings in which RDNs in nutrition support provide care. These settings include, but are not limited to, acute care, ambulatory/outpatient care, and home and alternate site care. The standards highlight the value of the nutrition support RDN’s roles in quality management, regulatory compliance, research, teaching, consulting, and writing for peer-reviewed professional publications. The standards assist the RDN in nutrition support to distinguish his or her level of practice (competent, proficient, or expert) and would guide the RDN in creating a personal development plan to achieve increasing levels of knowledge, skill, and ability in nutrition support practice.     

Future Doctors' Perceptions about Incorporating Nutrition into Standard Care Practice

Objective: The increasing prevalence of chronic disease has been largely attributed to long-term poor nutrition and lifestyle choices. This study investigates the attitudes of our future physicians toward nutrition and the likelihood of incorporating nutrition principles into current treatment protocols.Methods: Setting: The setting of this study was an Australian university medical school. Subjects: Subjects including year 1–4 students (n = 928) in a 4-year medical bachelor, bachelor of surgery (MBBS) degree program. Students were invited to participate in a questionnaire based on an existing instrument, the Nutrition in Patient Care Attitude (NIPC) Questionnaire, to investigate their attitudes toward nutrition in health care practices.Results: Respondents indicated that “high risk patients should be routinely counseled on nutrition” (87%), “nutrition counseling should be routine practice” (70%), and “routine nutritional assessment and counseling should occur in general practice” (57%). However, despite overall student support of nutritional counseling (70%) and assessment (86%), students were reluctant to perform actual dietary assessments, with only 38% indicating that asking for a food diary or other measure of dietary intake was important.Conclusion: These findings demonstrate that future physicians are aware of the importance of considering nutrition counseling and assessment. However, students are unlikely to adequately integrate relevant nutritional information into their treatment protocols, evidenced by their limited use of a basic nutritional assessment. This is potentially the result of a lack of formal nutrition education within their basic training.     

Development of the New York State Nutrition Surveillance Program.

New York State established a Nutrition Surveillance Program (NSP) in 1984. Precedents for the program included the Pediatric Nutrition Surveillance System of the Public Health Service''s Centers for Disease Control and Prevention and periodic food and nutrition surveys conducted by the National Center for Health Statistics and the Human Nutrition Information Service, Department of Agriculture. The first phase of NSP was connected to a new program, the Supplemental Nutrition Assistance Program (SNAP), which established support for more than 1,000 emergency food programs across the State. SNAP also expanded the home delivered meal program for the frail elderly and the Special Supplemental Food Program for Women, Infants, and Children. NSP provided information on the extent of unmet nutrition needs that was used to establish funding requests and provided data describing the characteristics of SNAP participants that were used in developing new SNAP program components. The second phase of NSP began in 1988. It identified populations that were thought to be at nutrition risk and compiled information about the extent of unmet need, the characteristics of the population, and the status of current nutrition programs to meet the needs. As a result of this review, NSP added a nutrition component to the Dental Survey of School Children; conducted a dietary survey; developed an inventory of information sources in all State agencies; and established an annual work plan using department of health objectives. The third phase of NSP is the policy and planning phase, monitoring the Year 2000 Objectives and the Five-Year Plan of the New York State Food and Nutrition Policy Council.     

A Qualitative Study of the Perceived Value of Membership in The Oley Foundation by Home Parenteral and Enteral Nutrition Consumers

Background: Support and educational organizations have been shown to improve quality of life of consumers of home nutrition support. One such organization, The Oley Foundation, offers resources for the home parenteral and enteral nutrition (HPEN) consumer. While research has shown proven benefits to HPEN consumers affiliated with The Oley Foundation, no studies have investigated the perceived value of membership to the consumer or the way in which consumers are introduced to the organization. Methods: Qualitative methodology was used to gain a deeper understanding of the perceived value of membership in The Oley Foundation. Audiotaped, in‐depth, semistructured telephone interviews were conducted to explore participants' experiences with The Oley Foundation and HPEN. Inductive content analysis was used to analyze data and identify themes associated with membership value. Results: The value of The Oley Foundation lies in programs and resources and the competency, inspiration, normalcy, and advocacy gained from membership, helping individuals adjust to life with HPEN dependency. More than half of participants found the organization through self‐initiated Internet searches, but all participants clearly expressed the desire “I wish I knew about it sooner.” Conclusion: This study identifies the value of membership in The Oley Foundation and the important role the organization has in the lives of HPEN‐dependent consumers. Nutrition support clinicians should introduce the organization to patients when the need for HPEN is established and prior to hospital discharge.     

Safety and Efficacy of Subcutaneous Parenteral Nutrition in Older Patients: A Prospective Randomized Multicenter Clinical Trial

Background: Many patients who cannot tolerate adequate enteral nutrition could benefit from parenteral nutrition support but fail to receive it due to difficult intravenous (IV) access. The objective of this study was to compare the safety and efficacy of subcutaneous (SC) administration of parenteral nutrition with the peripheral IV route. Materials and Methods: This was a prospective randomized multicenter study of 121 older hospitalized patients. The primary outcome was the composite end point of major local side effects, defined as local edema, blistering, erythema, phlebitis, cellulitis, unbearable pain, or route failure requiring a switch in route. Secondary outcomes were nutrition parameters, biochemical parameters, clinical outcomes, and safety. Results: The SC route (n = 59) was noninferior to the IV route (n = 61) for major local side effects. Major local side effects trended higher in the IV group (P = .059). Local edema was more common in the SC group (P < .05), while route failure was more common in the IV group (P < .001). Nutrition and biochemical parameters, safety, and clinical outcomes were similar between groups. Conclusions: The SC route of nutrient administration was better tolerated than the peripheral IV route. SC administration of parenteral nutrition represents a safe alternative to IV nutrition.     

Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent,Proficient, and Expert) in Pediatric Nutrition

Pediatrics spans the first 2 decades of life and is a dynamic period with rapid changes in size and physical ability, cognitive development, behavior, and nutrient needs. Registered dietitian nutritionists (RDNs) who work with the pediatric population provide the nutrition knowledge and support needed to promote optimal health and nutrition during this time across a variety of settings. The Pediatric Nutrition Practice Group, along with the Academy of Nutrition and Dietetics Quality Management Committee, have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working with pediatric populations. The SOP and SOPP for RDNs in Pediatric Nutrition provide indicators that describe 3 levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP illustrate how these standards apply to practice. The SOP and SOPP are intended to be used as a self-evaluation tool for assuring competent practice in pediatric nutrition and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.     

Establishing an innovative model of nutrition and dietetic care for a mental health service through collaboration with non-nutrition healthcare workers

Aim:  To describe the process of the development of the Web-based resources to extend nutrition care to mental health patients through existing non-nutrition mental healthcare professionals (case-managers).
Methods:  A formative approach was used to identify nutrition-related issues faced by both patients and staff through a synthesis of literature review, professional experience and clinical observations. Decision-making tools to assist case-managers in selecting resources were developed to guide case-managers' choice of effective evidence-based health education materials on the hospital intranet. Practical training was provided for case-managers during their orientation to the new website and the tools and resources it housed.
Results:  A Web-based nutrition site was created on the Royal Brisbane and Women's Hospital intranet. The website consisted of a Nutrition Referral Action Plan (a patient support triaging flowchart), a Nutrition Support Action Plan (action-based nutrition support tool to guide resource selection) and thirteen action-based nutrition education resources.
Conclusion:  By maximising established patient contact through existing health professionals, a Web-based approach to nutrition service delivery was an innovative method for delivering patient information. This collaborative action-based strategy has the potential to raise the nutrition profile in mental health and extend nutrition services to at-risk patients not previously receiving nutrition care.     

Implementation of a best-practice guideline: Early enteral nutrition in a neuroscience intensive care unit

Current evidence suggests that early enteral nutrition is a best practice and leads to improved clinical outcomes. An evidence-based practice project was implemented in a busy neurointensive care unit in a midwestern tertiary care facility that was designed to improve care by implementing the early nutrition portion of Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine and the American Society for Enteral and Parenteral Nutrition. The Registered Nurses’ Association of Ontario's (RNAO) Toolkit: Implementation of Best Practice Guidelines (BPGs) was selected and followed to guide implementation and achieve optimal results. During a 90-day implementation period, this project resulted in a 100% improvement in early nutrition. Interventions included the use of a series of cards that reminded the team to order enteral nutrition and prepacked bundles of nasogastric tube supplies. The RNAO toolkit served as a structured and effective step-by-step methodology for the implementation of a BPG.     

Audit in clinical practice: evaluating use of a nutrition screening tool developed for trauma nurses

Background: The Nutrition Checklist screening tool was developed by dietitians for the trauma nursing staff at the John Radcliffe Hospital, Oxford. Its purpose was to identify those at nutritional risk so that dietetic assessment and intervention could be implemented. This paper focuses on a single day audit that was devised 5 months post-initiation of the Nutrition Checklist. Method: Data from 48 nursing care plans was used to measure compliance of recording a nutrition score (and re-scoring where applicable) alongside the timing of dietetic referral and intervention. Results: Sixty-seven per cent (32/48) of trauma patients had a nutrition score recorded, however only 75% (24/32) of these patients were scored within 24 h of admission. Of those due for reassessment, only 38% (11/29) were rescored. Eighty-eight per cent (23/26) of the patients who scored ≥ 3 (automatic referrals) were referred to the dietitian; the dietitian documented 100% (23/23) of referrals. Conclusion: The audit suggests limited use of the screening tool by nurses. Collaboration between the nursing team, dietitian, consultant team, catering and clinical auditors could improve compliance in the use of the Nutrition Checklist and ultimately lead to improved clinical practice in nutritional care delivery. Despite its limitations, the audit exercise was a valuable learning experience in the maintenance of a nursing Nutrition Checklist. Further research is needed to assess whether the introduction of such a screening tool improves patient outcomes by minimizing nutrition-related complications.     

Prevalence of malnutrition and use of nutritional support in Peterborough Primary Care Trust

Background: Recent NICE guidance recommends that people in care homes should be screened with a validated tool such as the Malnutrition Universal Screening Tool [MUST (Elia, 2003)] on admission and where there is clinical concern (NICE, 2006). Nutrition support should be used for those who are either malnourished or at risk of malnutrition (NICE 2006; Stratton & Elia, 2007). Before implementation of MUST in care homes within the Peterborough PCT area, a cross sectional survey was undertaken with the aim of determining documentation of nutrition information, current screening practices, prevalence of malnutrition risk and use of nutrition support. Methods: A cross sectional study of nutritional care in 703 care home residents [mean age 84 (27–104) years] across 19 care homes (54% residential; 46% nursing) in Peterborough PCT was carried out for 4 months in 2007. The survey of care home notes collected information on; equipment, documentation of nutritional information (e.g. weight, height, weight loss), use of screening tools, and use of nutritional support including food fortification, dietary advice, use of supplements, and seeing a dietitian. To establish the prevalence of malnutrition risk, available nutritional information (n = 566) from the notes was used to classify residents risk using the MUST criteria. Results: All care homes (n = 19) had weighing scales with 74% having sitting and/or hoist scales, and 21% having standing scales only. Stadiometers were unavailable in all homes. Most (91%) of the residents had a recent weight documented and 58% had a documented height. Eighty‐one per cent of residents had been screened, mostly monthly, but nine different tools were used across the care homes. Using available data to calculate MUST indicated that 32% of residents were at risk of malnutrition (13% medium; 19% high) with a higher prevalence in nursing compared to residential homes (38% versus 25%; P = 0.001 Chi squared). The majority (64%) of residents at high risk of malnutrition using MUST were not receiving any form of nutritional support; in contrast 9% at low risk of malnutrition were receiving support including food fortification, oral nutritional supplements, and dietetic care. Discussion: This survey suggests that using MUST more than a quarter of residents in care homes are at risk of malnutrition. However, inconsistency in screening practices (frequency, types of tools and equipment available) can impair the identification of at risk residents preventing the appropriate use of nutrition support. Conclusions: There is a need to improve the identification and treatment of malnutrition and reduce inappropriate use of nutritional support in care homes. Therefore a programme is planned to implement routine screening with MUST, use of evidence based care plans, followed by an audit to evaluate its effects on the nutritional care of residents. References National Institute for Health and Clinical Excellence (NICE). (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Clinical Guideline 32. Stratton, R.J. & Elia, M. (2007) A review of reviews: A new look at the evidence for oral nutritional supplements in clinical practice. Clin. Nutr. (Suppl. 2), 5–23. Elia, M. ed. The “MUST” report (2003). Nutritional Screening for Adults: A Multidisciplinary Responsibility. Vol. 2. Suppl. 1. Redditch, UK: BAPEN.     

The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition

Background: The prevalence of malnutrition in the hospitalized setting is 30% to 55%. Previous studies reported an association of malnutrition with an increased hospital length of stay (LOS), morbidity, and mortality of patients. This study evaluated the role of early nutrition intervention on LOS, diagnosis coding of malnutrition cases, calculating case mix index, and reducing delays in implementing nutrition support to patients. Methods: Demographic data, anthropometric measurements, LOS, and serum albumin levels were collected from 400 patients in 2 medical wards to determine the prevalence of malnutrition and potential delays in nutrition consultation. Based on these results, a nutrition intervention study was conducted in 1 ward; the other ward served as a control. Patients were classified as normally nourished or malnourished. Multivariate general linear regressions were used to reveal the impact of intervention on the change in LOS, controlling for other potential confounding factors on the cohort and a subset with severe malnutrition. Results: Of the 400 patients assessed, 53% had malnutrition. Multiple general linear regressions showed that nutrition intervention reduced LOS an average of 1.93 days in the cohort group and 3.2 days in the severe malnourished group. Case mix index and female gender were positively associated with LOS in the malnourished group. Nutrition intervention reduced the delays in implementing nutrition support to patients by 47%. Conclusions: Results highlight the positive impact of nutrition intervention in terms of reduced LOS in malnourished hospital patients. Reduction in LOS with diagnosis coding of malnutrition cases yielded substantial economic benefits.