CONTINUOUS QUALITY IMPROVEMENT PROJECT

DIET 4470: Dietetics Seminar

Students will conduct a Continuous Quality Improvement (CQI) project at one of their
supervised practice sites that is a health care facility. If more than one student is located
at the same facility they may elect to do a joint project. During the Dietetics Seminar the
students will have the opportunity to share and discuss progress on the projects.

1. Identify an area within your facility for possible improvement, e.g. food temperatures,
nutrition assessment timeline, etc. The area is usually one involving an important aspect
of care that the department provides. Ideally this should be done in conjunction with
your preceptor and/or the chief clinical dietitian at the facility.

2. Problems or potential problems are identified utilizing measurable indicators

developed to monitor care, e.g., Standards of Care, Patient Satisfaction Surveys, etc.

3. Collect the data.

4. Assess the data by comparing it to standards.

5. Analyze/evaluate your results. This should include your method of data collection, an
analysis of the data, and your suggested actions to improve care or solve the
problem/potential problem.

6. Professional presentation of paper to include grammar, organization and spelling.

EVALUATION CRITERIA FOR PROJECT:

POINTS SCORE

Identification of problem & rationale for study 5

Use of appropriate measurable indicators 15

Data collection 20

Data analysis using standards 20

Discussion of results 20

Suggested actions to remedy the problem 10

Professional presentation of paper 10

TOTAL _____
 CONTINUOUS QUALITY IMPROVEMENT PROJECT
University of Connecticut Health Center, Farmington CT

Identification of Problem and Study Rationale

Malnutrition is known as a major contributor to increased

mortality, morbidity, and health care cost. Since 1995 the American
Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the Joint
Commission have mandated universal screening of acute care patients
for malnutrition. The Joint commission also mandates that nutrition
screening occurs within 24 hours in order to appropriately identify
patients at risk in a timely manner (Guenter, P et al. 2015). It is of the
utmost importance that the nutritional screening tools used are
effective in identifying at-risk patients.
The focus of this continuous quality improvement project is to
determine what proportion of high-risk patients are appropriately
identified by Nursing or a physician and referred to Dietary. This can
occur by the Nursing 24-hour screening tool or through a consult
ordered by an M.D. It has been noted by Dietitians at the facility that
occasionally high-risk patients have failed to be appropriately screened
and referred to Dietary staff. This issue may stem from the fact that
Nursing uses a screening tool that isnt validated. The tool in place was
developed approximately 5 to 6 years ago by a team of nursing staff
that collaborated with one Dietitian. This problem may not be facility specific,
as a recent study found that only 42% out of a sample of 545 nurses used a validated
screening tool (Chima, Dietz-Seher et al. 2008) . This brings into question the
effectiveness of such nutrition screenings.
It is Sodexos guidelines that 80% of initial assessments
completed should result a nursing screen or a physician consult. This
project strives to determine if this goal is being met and what
contribution is resulting from Nursings 24-hour screen. The results of
this project will provide insight towards the effectiveness of the 24-
Hour Screening Tool used by the nursing staff.

Measurable Indicator

To accurately determine what proportion of patients assessed at high risk were

appropriately screened and referred, assessment data from said patients were analyzed:

1.) Appropriate screening is occurring when 80% of 50 initial assessments are

resulting from a consult, as defined by Sodexos guidelines

Data Collection

It was determined by the facilitys Clinical Nutrition Manager that an appropriate

sample size of 50 high-risk patients should be analyzed. It was decided that the sample
would come from the month of December 2016. The assessments of patients seen during
this month were stored in a binder for easy access. On the assessments it was noted if a
consult was ordered by nursing. If a Physician made the referral, there was a consult
order stored with the assessment. If it wasnt noted that a nursing consult was ordered and
there was no physician consult order, it could then be determined that the high-risk
patient wasnt appropriately identified and referred to Dietary staff.

Data Analysis

Please see the Excel document that is attached, upon which data was collected.
Row one represents patients #1-50, of which were assessed as high risk. In row two a
number one was placed under all patients analyzed that had been assessed at high risk
without prompting a consult. Rows three and four represent patients that prompted either
MD or Nursing consults, respectively. In column AZ the total amount for each row is
represented. It demonstrates that 17 out of 60 high risk patients werent effectively
identified in the screening process and therefore didnt result in consult. It also showed
doctors identified twice as many high-risk patients as nursing, 22 patients as apposed to
11.
In column A, row 8 we see the percentage of high-risk patients that were
effectively screened and resulted in consult. The resulting 66% is well below Sodexos
guideline, which suggests the figure should be at least 80%.

Discussion

The results above clearly show a discrepancy between Sodexo guidelines and the
amount of high-risk patients, which are actually being identified and trigger a
consultation. It also appears that the 24-hour nursing screen has the greatest room for
improvement as it resulted in identification of half as many high-risk patients as the
indicators used by doctors.
The indicators that trigger an RD consult on the Nursing 24-hour screen are the
following: difficult chewing, difficulty swallowing, TPN, tube feeding, unintentional
weight loss, anorexia/bulimia, and binging/purging. It is interesting to note the tool
doesnt include specific diagnoses associated with malnutrition. It also lacks an indicator
of poor oral intake, which is used in 84% of screens out of a sample of 341 nation-wide
(Chima, Dietz-Seher et al. 2008) . Shortcomings in this tool have proven to translate into
a lack of effectiveness in the nursing screening process. This is a grave concern realizing
that nearly a third of patients admitted to hospitals in developed countries are
malnourished. Furthermore, when malnutrition is left untreated approximately two thirds
of those patients will see a further decline in nutrition status during hospitalization
(Guenter, P et al. 2015).

Suggested Remedies

Based on the data set, it is apparent that the biggest source of impact could stem
from an alteration in the Nursing 24-hour screening tool. Specifically, adding poor
intake as an indicator would put the tool more in line with what is used nationally. Such
indicator avoid scenarios playing out where a patient hasnt eaten anything for days prior
to admission and goes through screening without triggering a consult.
Another area for improvement could come through refining Nurses application of
the tool. As previously mention, there is a tendency for patients with significant weight
loss to be only identified upon assessment. Realizing weight loss is already an indicator
on the Nursing 24-hour screening tool, the issue may the Nurses use of the tool. The may
be ineffective in uncovering info about weight alterations in patients. This issue could
likely be addressed directly through an in-service on malnutrition. This in-service could
exaggerate the importance of nutritional intervention and the importance of identifying
those at risk. It could then exaggerate how crucial screening is to this process and focus
on the issue of failure to identify weight loss in patients. Through discussion, the source
of the issue could likely be uncovered and a remedy could be provided. Perhaps an issue
is getting a weight history from a confused or sedated patient. In such case it could be
suggested that a weight history is obtained through family members or the Electronic
Medical Record.
In addition to my CQI findings Ive begun to take a step further towards finding a
remedy for the issue identified. Out of interest toward the feasibility of adjusting the 24-
hour Nursing screening tool, the facilitys Clinical Nutrition Manager has prompted me to
conduct further research. The research being conducted involves going through every
nutrition assessment from December of 2016 and determining which criteria are being
met on an updated list of indicators. The list of criteria includes 16 indicators, as opposed
to only the seven previously mentioned. New additions to the list include low Albumin,
low BMI, NPO for five days, significant wounds, chemotherapy, poor intake, low
Braden, and relevant or newly determined diagnoses of Heart Failure, Diabetes,
Myocardial Infarction and Cancer. Data found could determine how indicators must be
altered in terms of criteria in hopes of being appropriately inclusive. For example the
indicator of poor intake may need a criteria for duration. A blanket term of poor intake
may include half the hospital simply due to the fact they are feeling sick and eating less.
However, a criterion including only those patients whom have consumed less than half
their normal intake for a week or longer may be deemed appropriate.
In conclusion, ongoing research discussed should lead to improvements in
Nutrition screening. Right now the facility is inefficient in screening and it is hopeful that
a multitude of solutions discussed could contribute to increased effectiveness. Like with
most things, there is no perfect solution, as there is no flawless screening tool for the
facility to adopt and make the issue instantly vanish. However, with the help of my
continued research along with contributions from future interns the facility will continue
on the right path to increasing the efficiency of its nutrition screening process and
ultimately benefit both its financial and patient care outcomes.
References

Guenter P, Jensen G, Patel V, Miller S, Mogensen KM, Malone A, Corkins

M, Hamilton C, DiMaria-Ghalili RA.Jt Comm J Qual Patient Saf. 2015
Oct;41(10):469-73.

CHIMA, C.S., DIETZ-SEHER, C. and KUSHNER-BENSON, S., 2008.

Nutrition Risk Screening in Acute Care: A Survey of Practice. Nutrition
in Clinical Practice, 23(4), pp. 417-423.