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Education, implementation, and barriers to clinical
dietitians’ use of nutrition-focused physical exams
Brooke Kuhn
Introduction ! Frequency of malnutrition depends on diagnostic criteria,
but it is rising
! 35-55% of patients admitted
! 25-30% develop while hospitalized (estimates)
Results in consequences to patient health, recurrent hospitalization, longer LOS, increased healthcare costs
! Connection with emerging trend: changing healthcare focus from disease treatment to prevention- new ways to monitor patients for early intervention needs
! Typically diagnosed w/any two of the following!
! Weight loss
! Subcutaneous fat loss
! Reduced functional status (grip strength)
! Decreased muscle mass
! Fluid accumulation
Introduction ! Previous studies on NFPAs:
! Mackle et al: evaluated use of assessments after training via a dietetic practice group/continuing education program-time constraints were a major barrier to use, and often only parts of assessment performed
! Esper et al: demonstration & simulation based training during a coordinated dietetics program, then surveyed students about likelihood to use in practice
! Stankorb et al: studied which portions of NFPA were used most frequently- only about 1/3 of RDs had received training and mostly used anthropometric measurements regularly
! Ionatta et al: reviewed use of exams in RDs in a practice group, only 35% had received training and used anthropometric measurements most frequently, citing barriers of time and lack of training
Research Objective
• Determine if/when dietitians receive training in nutrition focused physical exams
• How often exams are used in daily practice
• What barriers prevent their use?
Methodology
Results ! 55 recipients, 25 responses
! 64% had previous training ! 37.5% on the job ! 25% undergrad ! 25% dietetic internship ! Others in grad school,
conference/seminar
! Most commonly performed in suspected malnutrition, critically ill/ICU patient, or when a nutrition consult is received
Results % Age
20-29 11 44 30-39 7 28 40-49 4 16 50-59 3 12 60+ 0 0
Gender
Male 25 100 Female 0 0
Facility Acute care
hospital 15 60 Hospital 4 16
Outpatient clinic 2 8
Teaching hospital 1 4 Tertiary
care hospital 1 4 Acute
teaching hospital 1 4 Acute rehab
hospital 1 4
Results
Timing of NFPA Training
On the job
Undergraduate
Dietetic Internship
Graduate school
Other: conference and seminar
Results ! Top 5 most common barriers:
! Lack of knowledge to successfully perform
! Time constraints ! Assessment already
performed (by RN, SLP, PT/OT, etc)
! Uncomfortable with physical contact
! No identified need for assessment
! 12 reported never using NFPAs in practice ! 4 indicated not likely to use
NFPAs at all
! 9 reported daily use of NFPAs ! 5 reported use of NFPAs in
most, if not all of patient cases 0 2 4 6 8 10 12 14 16
Lack of knowledge to perform
Time constraints
Assessment performed by other professional
Uncomfortable with physical contact
No identified need for assessment
Not relevant to daily job duties
Other: need more education
Other: isolation precautions
Other: cannot perform in all settings
Other: limited resources
(dynomometer)
Barriers to Performance of NFPAs
Discussion/Conclusions • Limitations: small sample size, only Maryland RDs surveyed, brief
survey (to encourage more responses)- answers provided less detail
• Majority of subjects had received some training in NFPAs
• If it did occur, most training was on the job
• Most frequent barrier was lack of knowledge to perform
• Suggests that most training (on the job or otherwise) is not sufficient
• Assessments that are being performed may not be performed correctly or thoroughly enough
• Only one participant reported training at a conference and seminar
• Maybe this specialized education would help in increasing comfort levels & competency
• Future research could examine what types of training/education would increase knowledge/confidence and in turn, increase use
References ! White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus Statement: Academy of
Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Parenter Enteral Nutr. 2012; 36:275. http://pen.sagepub.com/content/36/3/275. Accessed November 12, 2014.
! The Impact of Clinical Dietitians on New Healthcare Delivery Models. Aramark Healthcare. http://www.aramarkhealthcare.com/docs/default-source/position-papers/the-impact-of-clinical-dietitians-on-new-healthcare-delivery-models.pdf?sfvrsn=4. Accessed December 4, 2014.
! Rhea M, Bettles C. Future Changes Driving Dietetics Workforce Supply and Demand: Future Scan 2012-2022. J Acad Nutr Diet. 2012;112:S10-S24.
! Mackle TJ, Touger-Decker R, O’Sullivan Maillet J, Holland BK. Registered dietitians’ use of physical assessment parameters in professional practice. J Am Diet Assoc. 2003;103:1632-1638. http://www.ncbi.nlm.nih.gov/pubmed/14647090. Accessed November 20, 2014.
! Esper DH, Converse A, Yacovone ML, Pohle-Krauza RJ. A Training Program in Nutrition-Focused Physical Assessment for Dietetics Students. J Acad Nutr Diet. 2012;112:A27. http://www.andjrnl.org/article/S2212-2672(12)00891-X/pdf. Accessed December 4, 2014.
! Stankorb SM, Rigassio-Radler D, Khan H, Touger-Decker R. Nutrition Focused Physical Examination Practices of Registered Dietitians. TICN 2010;335-344. http://journals.lww.com/topicsinclinicalnutrition/Abstract/2010/10000/Nutrition_Focused_Physical_Examination_Practices.6.aspx. Accessed December 4, 2014.
! Iannotta JA, Rigassio Radler D, Parrot JS, Huhmann MB, Touger-Decker R. Nutrition Focused Physical Examination Practices of RD Members of the Oncology Nutrition Dietetic Practice Group and Board Certified Specialists in Oncology Nutrition. J Acad Nutr Diet. 2012;110:A19. http://www.andjrnl.org/article/S0002-8223(10)00767-4/pdf. Accessed December 4, 2014.
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