Current fellow of The Academy of Nutrition and Dietetics Foundation - PDF document

6/12/2019 A Study to Validate the Malnutrition Clinical Characteristics and Quantify Dietitian Staffing Levels to Improve Medical Outcomes Courtney Bliss, MS RDN CNSC June 7, 2019 AZAND Annual Conference “Together Towards Tomorrow” 1 / Disclosures Current fellow of The Academy of Nutrition and Dietetics Foundation • Supporting study execution 2 / 1

6/12/2019 Learning Outcomes Upon completion of this presentation, attendees will be able to describe current: • MCC/NFPE evidence • RD staffing metrics • AND malnutrition initiatives • needs in acute care nutrition assessment and diagnosis of malnutrition 3 Overview • About me • Malnutrition and Assessment • Outcomes • Staffing • MCC and Staffing Study • Advanced research training opportunities • Questions 4 2

6/12/2019 About Me 5 Current Status of Malnutrition Incidence • Approx 4% hospitalized pediatric patients are malnourished • An estimated 50% of adult hospitalized patients are at risk Underdiagnosed, undertreated in hospitalized patients Longer LOS and higher hospital costs No gold standard for diagnosis 6 / 3

6/12/2019 Current Nutrition Assessment Screening tools • STAMP, STRONGKids • MST 7 Current Nutrition Assessment Subjective Global Assessment Nutrition Focused Physical Exam (NFPE) • Fat & Muscle Wasting • Micronutrient Deficiencies Biochemical markers • Albumin, prealbumin, CRP 8 / 4

6/12/2019 Malnutrition Clinical Characteristics MCC for adults include insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, fluid accumulation, and diminished functional status (measured via hand grip strength) • The presence of two or more of the clinical characteristics can be used to establish the diagnosis of malnutrition Consensus decision – not validated measures or tools 9 / Malnutrition Clinical Characteristics MCC for pediatric patients, when only one data point is available, the recommended MCC include weight-for- height/length z-score, body mass index for age z-score, length/height-for-age z-score, and mid-upper arm circumference z-score. • When additional data points are available, recommended indicators include weight gain velocity for children <2 years old, weight loss for children 2-20 years of age, deceleration in weight- for-length/height z-score, and inadequate nutrient intake. Consensus decision – not validated measures or tools 10 5

6/12/2019 Current Staffing Metrics Varies by state and patient populations Presumed best practice vs legal protections 11 Current Needs Validation of MCC • No systematic, universally accepted method of diagnosing malnutrition Need for large scale data across populations and regions • Malnutrition prevalence in hospitalized patients Best practice for staffing 12 / 6

6/12/2019 MCC and Staffing Study Overview Goal is to validate MCC against medical outcomes Quantify RD care/time required to improve outcomes Results will inform staffing levels for inpatient 13 / Study Design 14 / 7

6/12/2019 Nutrition and Medical Outcomes Primary medical outcomes for study are Length of Stay (LOS), mortality/morbidity, and readmissions/ED visits after discharge DRG is a confounder/covariate 15 / Recruitment and Enrollment Goal • 60-120 facilities • 6 host sites • Approx 4800 subjects Current numbers • Working with ~65 adult facilities • Working with ~42 pediatric facilities Staggered training and enrollment Subject enrollment to begin in July 16 / 8

6/12/2019 Benefits Networking Continuing Education and Training Participation in national initiatives with framework and support staff FUN!! 17 / Current Experiences Networking Recruitment to non-Academy members Clinicians as researchers • Research experience • Generational differences Hospital systems Protected research time Host/Training Site Recruitment 18 / 9

6/12/2019 Advanced training • Non-traditional methods • Providing CEUs as part of research training • Participation in national initiatives • Fellowships • Improved practice, stronger teams, improved patient outcomes 19 / Fellowship • Collaborative effort • Advance skills • Unique educational opportunities • Expand practitioner expertise, including leadership skills • Demonstrate RDN value • Networking • Passion 20 / 10

6/12/2019 My Experience • Collaborative effort • Networking • Advance skills • Research • Leadership • Unique educational opportunities • Demonstrate RDN value 21 / Together Towards Tomorrow • MCC and NFPE as standard of care • Large scale nutrition research utilizing clinicians • Standardized recommendations • Diversified training opportunities • RDNs better situated to affect change 22 / 11

6/12/2019 Thank you ! Questions ? Study Email: MCC@eatright.org My Email: feedingbliss@gmail.com 23 References Lakdawalla DN, Mascarenhas M, Jena AB, et al. Impact of Oral Nutrition Supplements on Hospital Outcomes in Pediatric Patients. J Parenter Enter Nutr . 2014;38(2_suppl):42S-49S. doi:10.1177/0148607114549769 Abdelhadi RA, Bouma S, Bairdain S, et al. Characteristics of Hospitalized Children With a Diagnosis of Malnutrition. J Parenter Enter Nutr . 2016;40(5):623-635. doi:10.1177/0148607116633800 Carvalho-Salemi J, Salemi JL, Wong-Vega MR, et al. Malnutrition among Hospitalized Children in the United States: Changing Prevalence, Clinical Correlates, and Practice Patterns between 2002 and 2011. J Acad Nutr Diet . 2018;118(1):40-51.e7. doi:10.1016/j.jand.2017.02.015 Somanchi M, Tao X, Mullin GE. The Facilitated Early Enteral and Dietary Management Effectiveness Trial in Hospitalized Patients With Malnutrition. J Parenter Enter Nutr . 2011;35(2):209-216. doi:10.1177/0148607110392234 Agarwal E, Ferguson M, Banks M, et al. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: Results from the Nutrition Care Day Survey 2010. Clin Nutr . 2013;32(5):737-745. doi:10.1016/J.CLNU.2012.11.021 Lim SL, Ong KCB, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr . 2012;31(3):345-350. doi:10.1016/J.CLNU.2011.11.001 Keller H, Allard JP, Laporte M, et al. Predictors of dietitian consult on medical and surgical wards. Clin Nutr . 2015;34(6):1141-1145. doi:10.1016/J.CLNU.2014.11.011 24 / 12

6/12/2019 References Raslan M, Gonzalez MC, Torrinhas RSMM, Ravacci GR, Pereira JCR, Waitzberg DL. Complementarity of Subjective Global Assessment (SGA) and Nutritional Risk Screening 2002 (NRS 2002) for predicting poor clinical outcomes in hospitalized patients. Clin Nutr . 2011;30(1):49-53. doi:10.1016/J.CLNU.2010.07.002 Philipson T, Snider J, Lakdawalla, DN Stryckman B, Goldman B. Impact of oral nutritional supplementation on hospital outcomes. Am J Manag Care . 2013;19(2):121-128. Becker PJ, Nieman Carney L, Corkins MR, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition). J Acad Nutr Diet . 2014;114(12):1988-2000. doi:10.1016/j.jand.2014.08.026 White J V, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet . 2012;112(5):730-738. doi:10.1016/j.jand.2012.03.012 Hand RK, Jordan B, DeHoog S, Pavlinac J, Abram JK, Parrott JS. Inpatient Staffing Needs for Registered Dietitian Nutritionists in 21st Century Acute Care Facilities. J Acad Nutr Diet . 2015;115(6):985-1000. doi:10.1016/J.JAND.2015.01.013 Phillips W. Clinical nutrition staffing benchmarks for acute care hospitals. J Acad Nutr Diet . 2015;115(7):1054-1056. doi:10.1016/j.jand.2015.03.020 Corkins MR, Guenter P, DiMaria-Ghalili RA, et al. Malnutrition Diagnoses in Hospitalized Patients. J Parenter Enter Nutr . 2014;38(2):186-195. doi:10.1177/0148607113512154 25 / Study Aims Assess the interrater reliability of the MCC. Determine the predictive validity of the adult and pediatric MCC relative to a portfolio of patient medical outcomes. Determine the relationship between the adult and pediatric MCC and body composition measurements conducted via bioelectrical impedance analysis (BIA) in a subset of patients. 26 / 13

6/12/2019 Study Aims Identify the utility of BIA for body composition analysis in clinical settings. Estimate the level of RDN care necessary to improve patient outcomes within the portfolio of outcomes. Specifically: quantify the dose (minutes of care and frequency of encounters) of RDN care that is associated with improved medical outcomes in patients already identified as requiring nutrition care, after adjusting for disease severity and other potential confounders. Identify the additional level of RDN care necessary to improve the medical outcomes in patients who have been identified as malnourished using the MCC. 27 / 14