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.