Defining and evaluating the role of dietitians in intensive care: State of play

Exploring the role of dietitians in mental health services and the perceived barriers and enablers to service delivery: A cross-sectional study

BACKGROUND

Mental health is a rapidly evolving area of practice for dietitians. The role of dietitians in supporting the physical health of consumers experiencing mental illness is becoming more widely recognised given the importance of lifestyle interventions for physical health. The present study aimed to explore the dietitian role in mental health services as well as identify barriers and enablers to service delivery.

METHODS

This was a cross-sectional survey of dietitians currently employed in any capacity in public and private mental health services. An online survey comprised of questions pertaining to four domains, including demographics, role and service provision, experience and supervision, barriers/challenges and drivers/enablers was completed and included closed and open-ended responses.

RESULTS

In total, 48 responses were included. The mean ± SD age of respondents was 36.1 ± 10.9 years (range 23-67 years) with the majority working in inpatient settings. The top three tasks respondents reported conducting were individual consultations (n = 47; 98%), group programs (n = 23; 48%) and multidisciplinary team meetings. Barriers included a lack of awareness from others regarding a dietitian's role in mental health, and a lack of specific tools for nutrition screening. More training, resources and increased evidence base to guide practice would enable better service provision.

CONCLUSIONS

The present study provides insights regarding the possible drivers and barriers to effective service provision for dietitians working in mental health services focusing on the local contexts of respondents. The findings highlight the importance and value of working collaboratively within a multidisciplinary team.

Association of Subjective Global Assessment with outcomes in the intensive care unit: A retrospective cohort study

AIMS

This retrospective audit was conducted to investigate the association between outcome and protein-energy malnutrition diagnosed using Subjective Global Assessment (SGA), to evaluate the predictive validity of Subjective Global Assessment in adults admitted to intensive care.

METHODS

The audit analysed the medical records of 1034 consecutive adult patients who had nutrition assessment on admission to the intensive care unit between January 2017 and July 2018. Extracted data included patient demographics, nutritional status, outcomes, and Acute Physiology and Chronic Health Evaluation II score. Regression was used to explore the association between Subjective Global Assessment and outcomes.

RESULTS

The prevalence of protein-energy malnutrition was 39.5% (342 patients SGA-B, and 75 patients SGA-C), and there was a significant independent association between Subjective Global Assessment and outcomes both in surgical and non-surgical patients. Compared with well-nourished patients, mortality was significantly higher in the malnourished, during the intensive care admission (p = 0.007), in hospital (p < 0.0001), at 90 days (p = 0.001) and at 180 days (p = 0.002). Pressure injuries were more common (p = 0.01). Length of stay was longer in intensive care (p = 0.001) and in hospital (p < 0.001), with increased readmission rate (p < 0.001).

CONCLUSION

Protein-energy malnutrition diagnosed by Subjective Global Assessment had a significant independent association with adverse clinical outcomes in critically ill patients. Subjective Global Assessment appears to have predictive validity in this patient population.

Dieticians' practices in intensive care: A national survey

BACKGROUND & AIMS

A real public health problem, namely, malnutrition in the hospital, also concerns intensive care patients. The diagnosis and prevention of malnutrition are major issues in the multidisciplinary management of patients hospitalized in the intensive care unit (ICU). To our knowledge, few data describe dietary management in French ICUs, and few international scientific publications mention professional practices or how dieticians are integrated in this type of specialized and technical sector. The objective of this study is to identify the practices of dieticians in the ICU at a national level.

METHODS

This study is based on the use of an electronic questionnaire distributed to registered dietician nutritionists practising in intensive care.

RESULTS

A total of 185 dieticians participated in this survey, which allowed us to describe the practices of 174 ICUs. Among the respondents (n = 185), 95% were women with a median age of 37 [31; 52]. The respondents graduated a median of 14 years ago [8.5; 30] and have been practising in intensive care for 5 years [2; 10]. With a median number of 12 beds [10; 18] (n = 174), the ICU has a median of 0.1 [0.05; 0.25] (n = 185) full-time equivalent dieticians. The solicitation of the dietitian is variable in different ICUs. Nevertheless, information from dietitians is frequently sought. Dietary initiatives mainly concern acts relating to oral nutrition and enteral nutrition. A nutrition protocol was present in 38% of the ICUs (n = 174). The integration felt by dieticians in the service is heterogeneous. Statistical analysis reveals that a dietitian who spends more than 4 h a week in the ICU, has a nutrition protocol in his or her department and does not encounter any obstacles, such as the absence of a doctor's prescription, is more likely to be integrated into an ICU.

CONCLUSIONS

This research work has made it possible to describe and make visible the role and involvement of dieticians working in ICUs in France and oversea departments and territories. Proposals to increase the involvement of dieticians in these sectors were reported at the end of this analysis.

Dietitians' opinions regarding refeeding syndrome, clinical guidelines and extended scope of practice

AIM

Refeeding syndrome (RFS) prevalence rates vary across studies depending on the criteria used for assessment and identification. For registered dietitians, the assessment and management of RFS is highly reliant on daily serum electrolyte values; however, registered dietitians working within Australia do not currently possess laboratory test ordering privileges. We aimed to examine the opinions of registered dietitians regarding RFS identification, management and guidelines and the option of using extended scope of practice to order electrolyte monitoring autonomously.

METHODS

A multi-method action research approach was used, incorporating two projects. The first was a survey examining Australian registered dietitians' (n = 187) opinions regarding RFS identification, management and guidelines, and autonomous electrolyte monitoring. To establish if results were similar internationally, an interview was conducted with 22 registered dietitians working within 10 different countries. Data were analysed using chi-square tests and thematic analysis.

RESULTS

Australian registered dietitians (75%) identify patients at risk of RFS at a high rate of more than once per fortnight, with 74% reporting that they have previously worked with a patient diagnosed with RFS. Results varied internationally, with respondents from eight countries reporting that RFS is a problem within acute care versus respondents from five countries having never treated a patient with RFS. The majority (≥89%) of registered dietitians desire new guidelines and the option to order patient electrolyte monitoring autonomously.

CONCLUSIONS

Our findings suggest that more stringent tools for the identification of RFS are necessary. There was limited uniformity across countries, and updated practice guidelines are needed.

Parenteral nutrition with standard solutions: not the best solution for everyone? A retrospective audit of 300 patients

An observational retrospective study audited the incidence of adverse events in 300 consecutive inpatients receiving a single, premade total nutrient admixture. No patient experienced critically high triglycerides; 16% of patients had a metabolic adverse event, including raised bilirubin, urea, creatinine, or liver enzymes. Line sepsis occurred on 30 occasions representing 0.67 infections per 1000 catheter days. Mortality was significantly higher in dialysis, nonsurgical, and intensive care unit patients. The use of a standard formulation for all parenterally nourished patients does not lead to an unacceptable incidence or severity of metabolic complications; however, it did not meet the protein requirements of surgical or critically ill patients.

Protein Requirements in the Critically Ill: A Randomized Controlled Trial Using Parenteral Nutrition

BACKGROUND

Current recommendations for higher protein/amino acid provision in the critically ill are based on weak evidence. This double-blinded randomized controlled trial aimed to compare standard amino acid intake with the higher level recommended as the minimum for critically ill patients.

METHODS

In total, 119 patients requiring parenteral nutrition (PN) in an intensive care unit (ICU) were randomized to receive blinded PN solutions containing amino acids at either 0.8 g/kg or 1.2 g/kg. Primary outcome was handgrip strength at ICU discharge. Secondary outcomes measured at study day 7 included handgrip strength, fatigue score (using the Chalder scale), and ultrasound measurements of muscle thickness at defined body sites. Analysis of covariance was used to control for age, sex, nutrition status (Subjective Global Assessment), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and baseline measurement.

RESULTS

Actual amino acid delivery to the 2 groups was 0.9 and 1.1 g/kg respectively, averaged over the first 7 days. Grip strength at ICU discharge was not significantly different between groups (P =054) despite being improved at study day 7 in the group receiving the higher level of amino acids (mean [SD], 22.1 [10.1] vs 18.5 [11.8] kg, P =025). These patients also had less fatigue (Chalder score, mean [SD], 5.4 [2.2] vs 6.2 [2.2], P = .045) and greater forearm muscle thickness on ultrasound (mean [SD], 3.2 [0.4] vs 2.8 [0.4] cm, P < .0001). Nitrogen balance was significantly better at study day 3 but not at day 7. There was no difference between groups in mortality or length-of-stay measures.

CONCLUSION

The higher level of amino acids was associated with small improvements in a number of different measures, supporting guideline recommendations for ICU patients. This trial was registered at Australian New Zealand Clinical Trials Registry (www.anzctr.org.au) as ACTRN12609000366257.