Download Anna Graml, Registered Dietitian

Anna Graml
May 13, 2010
Management- Jessie Pavlinac
JCAHO and OHSU Department Standards
I.
Nutrition Screening
A.. Joint Commission Standard: The hospital defines, in writing:
1. Scope and content of screening, assessment, and reassessment information
collected;
2. Criteria identifying when additional, specialized, or more in-depth assessments are
performed; and
3. Criteria identifying when nutritional plans are developed. Based on the patient's
condition, information gathered in the initial assessment includes:
a. Physical, psychological, and social assessment;
b. Nutrition and hydration status;
c. Functional status; and
d. For patients receiving end-of-life care, social, spiritual, and cultural variables
that influence the patient’s and family members’ perception of grief.
B. OHSU HC-ADM-AMB-P013:
1. During the initial patient visit and as appropriate to the patient’s condition and reason
for visit, patients are screened for interdisciplinary needs including:
a. Psychosocial assessment and socioeconomic history;
b. Nutrition status and diet;
c. Functional status; and
d. Medical and drug data.
2. Referral to OHSU dietitians or other OHSU clinics REQUIRES preauthorization and
may not be covered by insurance plans.
3. Screening can be performed by any health care team member, including Medical
Assistants and Licensed Practical Nurses (LPNs).
II. Nutrition Assessment
A. Joint Commission Standard (PE.1.2) Criteria for assessment:
1. Adequacy of nutrient intake;
2. Anthropometric measurements and evaluations; and
3. Nutritional implications of:
a. Selected lab tests;
b. Physical examinations;
c. Medications; and
d. Conditions that may affect digestion;
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e. Religious/cultural/ethnic and personal food preferences;
f. Diet prescription; and
g. Number of days NPO.
B. OHSU HC-ADM-AMB-P013:
1. Physical assessment;
2. Nutrition care plan: wt. kcal, protein
3. Appropriate risk level based on assessment
4. Performed only by Registered Nurses, Nurse Practitioners, Physician Assistants,
Physicians, and other designated clinical disciplines.
III. Nutrition Counseling
A. Joint Commission Standard
1. PC: 02.02.01: Care, treatment, and services provided to patient according to
individualized plan of care
2. PC 02.03.01: Education and training based on patient needs and abilities
B. OHSU HC-ADM-PRS-P015:
1. Education of high-risk patients and family according to patient's individualized needs
and hospital care
2. Goals:
a. Expand patient and family knowledge about patient's illness; and
b. Enhance skills and behaviors to facilitate further recovery at home.
3. RD counsels patient/family in diet modification and refers patient/ family to
appropriate community health care agencies for necessary nutritional services.
IV. Standards of Nutrition Care: By Diagnosis
A. Joint Commission Standard PC.01.03.01
1. Plan patient’s care, treatment, and services based on needs identified by:
a. Assessment, reassessment, and results of diagnostic testing.
B. OHSU:
1.
Clinical staff has established a Continuous Quality Improvement Program
2.
Developed Suggested Guidelines +for Nutrition Care for +diagnoses and for
adult and pediatric patients.
a. Developed from review of the research, national practice guidelines, and
accepted practice at OHSU.
b. As indicated, members of specialty health care team have been consulted
in development of these guidelines.
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V. Standards of Nutrition Care: By Diet Order
A . Joint Commission: TX 5-5.2
1. Based on resident assessment and interviews;
2. Actions and interventions to meet defined goals and updated timely;
3. Residents are weighed monthly or when necessary; and
4. Criteria used to evaluate weight gain or loss to determine the need for further
assessment .
B. OHSU:
1. Write any menu that CBORD system is unable to generate; and
2. Write menu based on OHSU Nutrition Manual or training/expertise.
VI. Standards of Nutrition Care: By Method of Feeding
A. Joint Commission Standard: Therapeutic diet or nutrition product prescribed to support
optimal nutrition status.
B. OHSU: Assess patient nutritional status (if not previously done), evaluate formulation for
nutritional adequacy, macronutrient and micronutrient need.
VII. Nutrition Status Monitoring: Residents
A. Joint Commission Standard: TX 5.7
1. Staff monitors and documents food and fluid consumption;
2. Extra fluids offered to residents between meals and during activities;
3. Residents identified as high-risk for dehydration as those with poor oral intake, fed
enterally, or with individual catheters; and
4. Have a thickened-liquid policy.
5. Assessment (PE):
a. Collect and analyze data;
b. Decide care and treatment;
c. Conducted by a qualified dietitian, but not necessarily be a specialist.;
d. Conform to the facility's policies, procedures, scope of practices, state
licensure laws, applicable regulations, and certifications; and
e. Nutrition case assessment started by the dietary manager or dietetic technician,
registered within 24 hours, completed within 14 days by RD, gathered from the
interdisciplinary team, the resident, resident's family, the resident's medical history,
and laboratory data.
B. OHSU: RD rounds with the team 3 days/week to provide interdisciplinary care
for infants admitted to DNCC (consult only)
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VIII. Nutrition Status Monitoring: Intake
A. Joint Commission Standard: Staff monitors and documents food and fluid consumption.
B. OHSU: Monitor patient status based on risk level and calorie count.
IX. Enteral Feedings
A. Joint Commission Standard PC 02.02.03
1. Make food and nutrition products available to patients; and
2. Assigns responsibility for safe and accurate provision of food and nutrition products
B. OHSU:
1. Elevate head 30-40 degrees during feeding;
2. Check initial residuals every 4 hours when feeding into the stomach;
3. Hold feedings for residuals greater than 150-200cc;
4. Monitor for intolerance such as abdominal distention, nausea, vomiting, or aspiration;
5. Irrigate feeding tube with 50 cc water if feeding is interrupted or discontinued;
6. Check for formula and medication compatibility prior to administering medication
through the feeding tube or to the feeding bag;
7. Flush tube with water before and after medication;
8. Avoid adding crushed tablets whenever possible;
9. Record strict I &O=s;
10. Chart formula separately from other oral and IV intake;
11. Order SMAC daily until stable, then weekly;
12. Weigh patient daily; and
13. When receiving TPN/Enteral Feedings:
a. Perform nutritional assessment; OR
b. Refer to outpatient dietitian (adult 503-494-8636; pediatric 503-418-5257); OR
c. Refer to Home Health Agency providing enteral or parenteral product.
X. Parenteral Feedings
A. Joint Commission Standard: Medications are labeled
B. OHSU HC-CLN-MPI-P024; HC-CLN-MPI-R001: Administer intravenous (IV) medications
and fluids (IVF) using a parental infusion device. Inpatient orders must be written and scanned
to the pharmacy by 1500.
XI. Nutrient-Drug Interaction
A. Joint Commission Standard MM.07.01.03: Respond to actual/potential adverse drug
effects and significant drug reactions.
B. OHSU HC-CLN-MPI-P020:
1. Correctly document patient’s current medication.
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2. Create in-patient list within 24 hours of admit, except for trauma patients which is
required within 48 hours.
3. RD instructs patients being followed for nutritional interventions on the appropriate diet
for drug-food interaction and documents this in patient's medical record.
XII. Medical Record Documentation
A. Joint Commission Standard:
1. Maintain complete and accurate medical records for all patients.
2. Authenticate entries in medical record.
3. Document in a timely manner.
4. Audit and retain medical records.
5. Information reflects the patient’s care, treatment, and services.
6. Operative or other high-risk procedures and the use of moderate or deep sedation or
anesthesia are documented.
7. Create a summary list for each patient receiving ambulatory services.
8. Qualified staff receives and records verbal orders.
B. OHSU: HC-ADM-RPI-P003 and HC-ADM-PSB-P025:
1. Documented by the interdisciplinary health care team.
2. Identifies timeframe and key patient outcomes that should occur during care.
3. Specifies histories, physicals, and physical examinations.
4. Practitioners perform patient’s medical history and physical examination and updates.
5. Attending faculty may make original entries or co-sign resident/fellow/NP/PA History
and Physical documents.
6. Practitioners’ performance of documentation shall be measured periodically, included
in the determination for reappointment to the Professional Staff.
XIII. Discharge Planning
A. Joint Commission Standard
1. Describe the reason(s) for and conditions under which the patient is discharged or
transferred.
2. Describe the method for shifting responsibility for a patient’s care from one clinician,
hospital, program, or service to another.
3. Describe the mechanisms for external transfer of the patient.
4. Hospital and receiving organization agree with their roles to keep the patient safe
during transfer.
B. OHSU HC-CLN-ADT-P004:
1. Prepare a collaborated, developed care/discharge plan;
2. Complete preparations;
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3. Prepare discharge summary; and
4. Discharge follow-up must be completed within 48 hours.
XIV. Diet Order Processing
A.. Joint Commission Standard:
1. Assign responsibility for safe and accurate provision of food and nutrition products;
2. Prepare food and nutrition products using proper sanitation, temperature, light,
moisture, ventilation, and security;
.
3. Food and nutrition products are consistent with patient's care, treatment, and
services; and
4. Accommodate a patient's special diet and altered diet schedule, unless
contraindicated.
B. OHSU:
1. Write any menu that CBORD system is unable to generate; and
2. Write menu based on OHSU Nutrition Manual or training/expertise.
3. OHSU Nutrition Manual:
a. Uses 1989 Recommended Daily Allowances of the Food and Nutrition Board
of the National Academy of Sciences.
b. Vitamin or mineral supplementation should be considered.
for any diet that does not meet all nutritional needs.
4. OHSU Guide to Prescription (Manual):
a. Physician-ordered diets should be written in the terminology of this manual.
b. Verbal orders accepted for one meal only and must be confirmed in writing.
c. Re-write complete diet order when modification is added or patient is
transferred.
d. RDs are available to assist in determining the appropriate diet prescription.
XV. Diet Manuel
A. Joint Commission Standard: PC 02.02.03:
1.
Responsible for the safe and accurate provision of food and nutrition products
2. Prepares food and nutrition products using proper sanitation, temperature, light,
moisture, ventilation, and security.
3. Products are consistent with each patient's care, treatment, and services
4. Accommodation for patients with special diet and altered diet schedule, unless
contraindicated.
B. OHSU:
1. The OHSU Nutrition Manual as a reference for dietetics and a teaching guide for all
members of the health care team.
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a. Represents current practices in nutrition and summary diets most commonly
used at University Hospital and Doernbecher Children’s Hospital.
2. Upon hospital admission, all patients are screened for individual management and
monitored by nutrition services.
a. Nutritional assessment and counseling are a necessary part to patient care.
Consultation with a clinical dietitian can be ordered for successful nutritional
treatment.
b. Uses 1989 Recommended Daily Allowances of the Food and Nutrition Board
of the National Academy of Sciences.
c. Vitamin or mineral supplementation should be considered.
3. All diets are ordered by physician. Verbal orders are accepted for one meal and
must be confirmed in writing.
4. Clinical dietitians are available to provide information and assistance in determining
appropriate diet prescription.
XVI. Nourishments
A. Joint Commission Standard PC.02.02.03:
1. Assign responsibility for the safe/accurate provision of food/nutrition products.
2. Food/nutrition products are consistent with patient's care, treatment, special diet, and
altered diet schedule unless contraindicated.
B. OHSU HC-ADM-PRS-P019 and HC-CLN-GPC-P021:
1. 10 AM: deliver tube feedings;
2. 2 PM: deliver baby formulas;
3. Mixed formulas must be refrigerated during delivery;
4. Tube feedings and formulas stored in refrigerators on the patient care unit;
5. Discard mixed tube feedings and formulas after 24 hours and inform Health Unit
Coordinator.
6. Formula preparation:
a. Order all infant formulas (except ready to feed 4 oz bottle of formula) and adult
and pediatric tube feeding from the Nutrition Office between 5am and 7:30 pm
and contact the patient transportation VIP system if Nutrition Office is closed.
b. Substitute the ready-to-feed product of the needed formula (closest calorie
level needed) until the Nutrition Office opens, if a mixed formula or tube feeding
is needed. Ready- to- feed 4oz bottles of infant formulas are obtained from
Logistics, stocked in 9N pantry.
c. If the infant formula is not available in any concentration as a ready-tofeed and must be mixed from the powder after the Nutrition Office closes, obtain
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a can of the powder formula by contacting the transportation VIP system and mix
the following products as a 20 calorie/oz formula by adding powder to a 4 oz
bottle of sterile water and shaking:
i. Neocate Infant - mix 1 level scoop of powder in 1 oz of sterile water (4
scoops with 4 oz sterile water)
ii. Portagen and PM 60/40 - mix 1 level scoop of powder in 2 oz of sterile
water (2 scoops with 2 oz sterile water)
iii.Read side of can for mixing directions for other formulas not listed
above
iv. Do not mix any formulas in a blender
XVII: Performance Improvement
A. Joint Commission Standard: PI.01-.03.01.01:
1. Collects data to monitor performance;
2. Analyze data to improve performance.
B. OHSU: HC-ADM-RPI-P014:
1. Coordinate the integration of patient care activities.
2. Establish measurements, assessment, and improvement of the healthcare systems.
3. Evaluate the need to re-prioritize improvement activities.
4. Communicate activities throughout the health system.
XVIII. Practitioner Competence
A. Joint Commission Standard HR. 01.07.01:
1. Establish system to process applications and verify credentials.
2. Medical staff reviews and evaluates the data collected.
3. Coordinate competence assessment with performance evaluation.
4. Performance evaluations include established expectations staff members.
B. OHSU:
1. Established policy of verification standards that include credentialing time frames and
verification of expirable credentials.
2. Ongoing monitoring of sanctions.
3. Maintain necessary records in permanent file in Food and Nutrition Service
Department (1 year).