SERIES: NUTRITION ISSUES IN LONG-TERM CARE
Using Evidence-Based Organizational Strategies to Prevent Weight Loss in Frail Elders : Page 2 of 4
Care Planning Strategies
To meet individual resident needs, care planning requires critical thinking by RNs and DONs. Numerous care planning strategies are available to these healthcare professionals to prevent weight loss in frail elders, including diet modification, protocol implementation, and care conferences, all of which are discussed in the section that follows.
Try diet modification. Modifying a resident’s diet refers to the adjustment of meals based on individualized nutritional requirements per resident.27 In a 3-month intervention program conducted by Christensson and associates,27 11 residents received individualized diets to meet their calculated energy requirements. Ten residents met their calculated energy requirements over a 3-month period of time and showed increased nutritional status and improved functional capacity.27 Increased nutrient intake, or diet modification, can also include enhanced or fortified foods. Castellanos and colleagues28 reported that bigger eaters consumed more calories when breakfast foods were enhanced (with energy and protein fortifiers), although this increase in calorie consumption did not occur with enhanced lunch foods; smaller eaters consumed more calories when either breakfast or lunch foods were enhanced. Since smaller eaters are at greater risk of weight loss, enhancing several foods at more than one meal is recommended. Additionally, flavor enhancers have been found to increase food consumption by stimulating appetite, subsequently boosting immune system status and handgrip strength.29
Nutritional supplements are often prescribed to nursing home residents for a variety of reasons, including decreased intake of food, unintentional weight loss, and wound healing.30 However, while the addition of dietary supplements has shown varying degrees of success in maintaining healthy weight, there are also problems. In a randomized controlled trial that compared the effectiveness of oral liquid nutrition supplements to food snacks, Simmons and colleagues31 found that supplements were associated with a higher cost, higher refusal rate, decreased meal intake, and more care time. Moreover, delivery of supplements to residents is not always provided as ordered. In a descriptive study involving 132 long-stay residents of six skilled nursing homes, Simmons and Patel32 reported that staff spent minimal time promoting supplement intake either during or between meals. These findings show that evidence-based guidelines for supplement prescribing and monitoring are not well developed, thus a “food first” strategy prior to supplement use is recommended.30 Clearly, diet modification with individual adjustment of meals, enhanced foods, and supplements should be implemented with the interdisciplinary strategy of working with a dietitian.
Implement and enforce standardized protocols. In general, when standardized protocols are implemented into daily care routines, there are better outcomes for residents.16 Nonstandardized protocols or observations lead to subjective results and thus difficulty in replication by other independent observers and unreliable quality improvement efforts.33 One intervention study found that when a standardized weighing procedure or protocol was used, there was better identification and assessment of residents with weight loss when compared with usual nutrition care without a protocol.34 The protocol involved assessment; intervention, including weighing frequency; facilitation of communication with staff, physicians, families, and residents; and reassessment. Simmons33 emphasized the importance of a meal rounds protocol, which would define when to observe eating, who is being observed (ie, at-risk patients), and what to observe (ie, amount of food eaten, food refusal). Meal rounds are discussed in more detail in the Leadership and Supervisory Strategies section.
Hold regular care conferences. Biweekly care conferences about residents with weight loss and/or eating problems can assist the facility in being proactive in preventing weight loss.9 These conferences provide an opportunity to implement both clinical and organizational strategies and provide opportunities for discussion among interdisciplinary team members. In addition, DONs need to include NAs in care planning discussions as they give direct care and can individualize care for residents.9
Leadership and Supervisory Strategies
Nursing leadership is important for ensuring nursing home care quality, as lack of leadership leads to poor resident outcomes.35,36 In a comparative case study, researchers found that DONs who facilitated open communication and teamwork among their staff achieved quality improvement, whereas leaders who impeded communication and teamwork did not.36 Leadership skills need to be implemented in conjunction with supervisory strategies for weight loss prevention, such as dining room rounds, medication pass scheduling, and quality improvement.
Perform meal rounds. Dining room rounds, also known as meal rounds, involve taking brief, informal observations of residents and staff in the dining environment. The purpose is to identify, document, and correct feeding and nutrition problems before significant weight change occurs.37 Direct observation is important in nursing home quality improvement programs due to the minimal or inaccurate documentation often found in nursing home charts.38
In a study of long-term care residents from two special care units, Keller and colleagues37 observed the usefulness of two standardized measurement instruments—the Edinburgh Feeding Evaluation in Dementia Scale (EdFed) and the Eating Behavior Scale (EBS)—which were administered by dietitians during meal rounds. The EdFed and the EBS revealed 32% of residents to be at moderate nutrition risk and 40% to be at high nutrition risk. The common problems observed during meal rounds were inappropriate consistency of food for residents and difficulties with eating and swallowing.
Another benefit of administrative involvement in the dining room is that it creates an informal dining setting that encourages socialization and allows the DON and residents to become better acquainted. Leadership in the dining room may be demonstrated through observation, socialization, and role modeling of appropriate behaviors for staff. Licensed nurses, either RNs or LPNs, also need to be in the dining room during mealtime in case of choking or aspiration.
Be mindful of medication pass times. The DON can choose to schedule medication passes before, after, or during mealtimes. As Dyck9 found in a pilot study that outlined administrative strategies, if the medication passes occur during mealtimes, then the nurses are focused on medication administration and not on dining activities. If the medication passes occur before or after meals, the nurses are more available to assist with feeding residents who are more difficult to feed, and because they are more qualified than NAs, they can role-model feeding assistance skills.
Arrange quality improvement activities. Quality improvement activities are particularly important with the problem of weight loss. Routine audits can help the DON track processes of care related to weight loss.39 Audits might include tracking residents with weight loss,40 monitoring use of a weight loss protocol, and monitoring feeding assistance. Simmons41 developed quality indicators (QIs) for feeding assistance. These QIs include the following:
• Identifying residents with low oral food and fluid intake during meals;
• Providing assistance to at-risk residents;
• Assisting residents identified during their MDS assessment as requiring staff assistance to eat;
• Prompting residents verbally who receive physical assistance at mealtimes;
• Interacting socially with all residents during mealtimes; and
• Assisting residents who receive an oral liquid nutritional supplement during mealtimes.
These QIs can be used for standardized assessment of feeding assistance quality, in addition to the QI on prevalence of weight loss based on the MDS. These quality improvement strategies need to be integrated into a facility-wide quality improvement program.
In a 2000 study, Feilmann42 outlined a model for determining whether a resident has experienced significant weight loss, which was successfully implemented in an Iowa veterans’ home. The procedural model involves weighing all residents twice per month and using a dietician to assess the occurrence of significant weight change (5% in
1 month, or 10% in 6 months). The dietician is then actively involved in making necessary alterations to the resident’s care plan and meals, and he or she is responsible for reporting changes to the resident’s physician, primary RN, and the entire care planning team. The Feilmann42 study also includes a sample questionnaire for ensuring accurate weight-taking procedures.