Increased Knowledge, Self-Reported Comfort, and Malnutrition Diagnosis and Reimbursement as a Result of the Nutrition-Focused Physical Exam Hands-On Training Workshop

Dietitian perspective and experience: Implementation of telenutrition in Indonesia and the challenge of performing the nutrition-focused physical examination (NFPE)

BACKGROUND

Nutrition assessment is the first step of the nutrition care process (NCP), which includes investigating physical status and malnutrition signs. With the widespread digitalization of healthcare in Indonesia, including telehealth in dietetic practice (telenutrition), evidence is required to address the barriers and improve the current practice of conducting remote physical assessments.

AIM

This study aimed to explore the adaptation of nutrition-focused physical examination (NFPE) using telenutrition in Indonesia.

METHODS

This qualitative study recruited Indonesian registered dietitians (RD) with experience in performing NCP using video conferences, phone calls, or other remote/online platforms. The search for participants was conducted until the information was considered sufficient. Data were collected using semistructured in-depth interviews. Thematic analysis was used to analyze the data.

RESULTS

Eleven RDs were interviewed via video conference. Three themes emerged from the analysis: (1) feasibility and practicality, (2) barriers, and (3) adaptations and pre-requisites of remote physical assessment. Remote physical assessment was considered not practical by the majority. Barriers were categorized into technological challenges, lack of NFPE training and practice, and challenges in involving patients. Pre-appointment preparations, guiding the patients through video calls, or asking patients to send images of their bodies are adaptations needed for remote physical assessment.

CONCLUSION

Challenges in remote physical assessment could be minimized by establishing protocols to deliver standardized care and ensure session efficiency. Additionally, strengthening the implementation and training of NFPE for dietitians in Indonesia is of paramount importance.

Predictive Validity of the Academy of Nutrition and Dietetics/American Society for Parental Nutrition Indicators to Diagnose Malnutrition and the Screening Tool for Risk on Nutritional Status and Growth among Hospitalized Children Relative to Medical Outcomes

OBJECTIVE

To evaluate predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Indicators to diagnose pediatric malnutrition (AAIMp) and the Screening Tool for Risk on Nutritional Status and Growth (STRONGkids) in regard to pediatric patient outcomes in US hospitals.

STUDY DESIGN

A prospective cohort study (Clinical Trial Registry: NCT03928548) was completed from August 2019 through January 2023 with 27 pediatric hospitals or units from 18 US states and Washington DC.

RESULTS

Three hundred and forty-five children were enrolled in the cohort (n = 188 in the AAIMp validation subgroup). There were no significant differences in the incidence of emergency department visits and hospital readmissions, hospital length of stay (LOS), or health care resource utilization for children diagnosed with mild, moderate, or severe malnutrition using the AAIMp tool compared with children with no malnutrition diagnosis. The STRONGkids tool significantly predicted more emergency department visits and hospital readmissions for children at moderate and high malnutrition risk (moderate risk - incidence rate ratio 1.65, 95% CI: 1.09, 2.49, P = .018; high risk - incidence rate ratio 1.64, 95% CI: 1.05, 2.56, P = .028) and longer LOS (43.8% longer LOS, 95% CI: 5.2%, 96.6%, P = .023) for children at high risk compared with children at low risk after adjusting for patient characteristics.

CONCLUSIONS

Malnutrition risk based on the STRONGkids tool predicted poor medical outcomes in hospitalized US children; the same relationship was not observed for a malnutrition diagnosis based on the AAIMp tool.

US neonatal intensive care unit registered dietitian nutritionists salary description and correlates: results of a survey

BACKGROUND

This survey described the compensation of neonatal intensive care unit (NICU) registered dietitian nutritionists (RDNs) in the United States and examined correlates of higher salaries within this group.

METHODS

A cross-sectional online survey was completed in 2021 by 143 NICU RDNs from 127 US hospitals who reported hourly wage in US dollars (USD). We used initial bivariate analyses to assess the relationship of selected institution-level and individual-level variables to hourly wage; the rank-sum test for binary variables; bivariate regression and Pearson correlation coefficients for continuous variables; the Kruskal-Wallis test for categorical variables. Variables with a compelling relationship to the hourly wage outcome were considered in model creation. Final model selection was based on comparisons of model fit.

RESULTS

Median hourly compensation was USD 33.24 (interquartile range [IQR] 29.81, 38.49). Seven variables had a compelling bivariate relationship with hourly wage: cost of living, employer facility with a paediatric residency, employer facility with a neonatal fellowship, NICU bed: full-time equivalents (FTE) RDN ratio, years in neonatal nutrition, having a certification and order writing privileges. In the final adjusted model (R2 = 0.42), three variables remained associated with increased hourly wage: higher cost of living, longer length of career in neonatal nutrition and fewer NICU beds per NICU RDN FTE.

CONCLUSIONS

US NICU RDNs earn similar or slightly higher wages than other US paediatric RDNs; they earn substantially less than other NICU healthcare team members. Employers need to improve compensation for NICU RDNs to incentivise their retention and recognise their additional non-clinical responsibilities.

Completion of a Nutrition-Focused Physical Exam with hospitalized adults and pediatric patients: Secondary analysis of a prospective cohort study

BACKGROUND

Nutrition-Focused Physical Exam (NFPE) feasibility is not well-studied. We describe registered dietitian nutritionist (RDN)-reported NFPE completion for hospitalized adult and pediatric patients overall and by assessment parameters.

METHODS

Trained RDNs systematically conducted NFPEs for hospitalized adult and pediatric patients during the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition Indicators to diagnose Malnutrition multisite cohort study (ClinicalTrials.gov: NCT03928548). RDNs reported their ability to evaluate assessment sites for subcutaneous fat and muscle loss, fluid accumulation, and micronutrient status and to complete handgrip strength (adults and children ≥6 years) and mid-upper arm circumference measurements (children). RDNs noted if they could complete the full NFPE; if not, they noted challenges. We descriptively summarized results and used multilevel logistic regression models to examine relationships between patient characteristics and NFPE completion.

RESULTS

RDNs from 39 adult and 29 pediatric US hospitals conducted NFPEs for 327 adults and 214 children aged 1 month to 17.9 years. RDNs reported completing the examination for 44% (n = 145) of adults and 15% (n = 33) of children. They successfully evaluated 25 of 27 and 19 of 26 unique NFPE components in >80% of adults and children, respectively. Common reasons the full NFPE was not completed were limited mobility in adults and patient refusal in children. RDNs had lower odds of completing NFPEs in adults with lower vs higher education levels or higher vs lower nutrition complexity and in younger vs older children.

CONCLUSION

RDNs evaluated NFPE components for a high proportion (>80%) of hospitalized patients.

Development of a bronchopulmonary dysplasia nutrition focused physical examination tool: A modified Delphi study

OBJECTIVE

The objectives of this study were to identify factors impacting nutrition needs in infants and children with bronchopulmonary dysplasia (BPD). A modified Delphi approach to obtain consensus among pediatric registered dietitian nutritionists (RDNs) was used to create a BPD-specific nutrition focused physical examination (NFPE) tool.

STUDY DESIGN

RDNs, recruited through pediatric nutrition professional associations, completed a survey rating proposed NFPE components on a Likert scale of 1-5 allowing open-ended responses in a two-round Delphi. Responses were analyzed, deidentified, and results were returned to panelists for in-round feedback. Consensus was defined a priori as 75% agreement for usefulness or relevance ± 1 standard deviation.

RESULTS

Six domains (anthropometrics, body composition, development, gastrointestinal, respiratory, and physical signs) and 38 components achieved consensus.

CONCLUSION

Components for an evidence-based tool to enhance nutrition assessment in infants and children with BPD were identified with consensus agreement by an expert panel of 19 pediatric RDNs.

Predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators to diagnose malnutrition tool in hospitalized adults: a cohort study

BACKGROUND

The lack of a widely accepted, broadly validated tool for diagnosing malnutrition in hospitalized patients limits the ability to assess the integral role of nutrition as an input and outcome of health, disease, and treatment.

OBJECTIVES

This study aimed to evaluate the predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (ASPEN) indicators to diagnose malnutrition (AAIM) tool and determine if it can be simplified.

METHODS

A prospective cohort study was conducted from August 2019 to September 2022 with 32 hospitals in United States. At baseline, 290 adult patients were evaluated for a diagnosis of malnutrition using the AAIM tool, which assesses weight loss, inadequate energy intake, subcutaneous fat and muscle loss, edema, and hand grip strength. Healthcare outcomes were extracted from the medical record: composite incidence of emergency department (ED) visits and hospital readmissions within 90 d postdischarge; length of hospital stay (LOS); and Medicare Severity Disease Related Group (MS-DRG) relative weight (i.e., healthcare resource utilization). We used multilevel, multivariable negative binomial or generalized linear regression models to evaluate relationships between malnutrition diagnosis and healthcare outcomes.

RESULTS

After adjusting for disease severity and acuity and sociodemographic characteristics, individuals diagnosed with severe malnutrition had a higher incidence rate of ED visits and hospital readmissions (incidence rate ratio: 1.89; 95% CI: 1.14, 3.13; P = 0.01), and individuals diagnosed with moderate malnutrition had a 25.2% longer LOS (95% CI: 2.0%, 53.7%; P = 0.03) and 15.1% greater healthcare resource utilization (95% CI: 1.6%, 31.9%; P = 0.03) compared with individuals with no malnutrition diagnosis. Observed relationships remained consistent when only considering malnutrition diagnoses supported by at least 2 of these indicators: weight loss, subcutaneous fat loss, muscle wasting, and inadequate energy intake.

CONCLUSIONS

Findings from this multihospital study confirm the predictive validity of the original or simplified AAIM tool and support its routine use for hospitalized adult patients. This trial was registered at clinicaltrials.gov as NCT03928548 (https://classic.

CLINICALTRIALS

gov/ct2/show/NCT03928548).

Item-Level Analysis of a Newly Developed Interactive Nutrition Specific Physical Exam Competency Tool (INSPECT) Using the Rasch Measurement Model

The Interactive Nutrition Specific Physical Exam Competency Tool (INSPECT) is a tool designed specifically to observe and measure registered dietitian nutritionists' (RDNs) nutrition-focused physical exam (NFPE) competence in authentic acute care settings. The initial INSPECT items were generated and tested for content and face validity using expert RDNs' input. The INSPECT was further examined for inter-rater, intra-rater, and internal consistency using clinical supervisor observations of RDNs performing NFPE on patients in real-life acute care settings. These previous studies showed the INSPECT to have excellent content validity, acceptable face validity, good inter-rater reliability, moderate to strong intra-rater reliability, and excellent internal consistency. In the current study, the Rasch measurement model was applied to examine the item-level properties of the INSPECT. Results confirm that the INSPECT measured a single construct. All items fit the established criteria for clinical observations of >0.5 and <1.7, had positive point measure correlations, met the Wright Unidimensionality Index criteria of ≥0.9, exhibited one latent construct with >40% variance explained by the Rasch dimension as well as a sub-dimension based on item difficulty from the principal component analysis of the first contrast Rasch residuals. Rasch rating scale analysis revealed that the rating scale and majority of the items (39/41) fit the Rasch model. Rasch item hierarchy analysis matched the a priori hypothesized hierarchy for the top-most and bottom-most items. Ceiling effects were seen for three items (hand hygiene, personal protective equipment, and patient position) and one item (handgrip using hand dynamometer) reached the floor effect. Rasch reliability assessment demonstrated high person reliability (0.86), high item reliability (0.96), and person separation of 3.56 ability levels. The principal component analysis of residuals revealed two factors based on item difficulty, one for micronutrient exam and another for macronutrient exam, initial steps, and bedside manner. The resulting two factors may likely be due to a sub-dimension of the latent NFPE trait. Overall, the INSPECT items were found to have good item-level psychometrics. Continued testing of the INSPECT with RDNs at different ability levels will help to determine cut-off scores ranging from novice to expert. Establishing cut-off scores for the INSPECT will further enhance the utility of the tool.

Inter-Rater and Intra-Rater Reliability of the INSPECT (Interactive Nutrition Specific Physical Exam Competency Tool) Measured in Multi-Site Acute Care Settings

Even as new medical modalities, diagnostics, and technologies are rapidly changing healthcare, providing patients with safe, high-quality care remains the central focus. To provide safe patient care, healthcare providers are obligated to demonstrate and maintain the necessary competence. As more healthcare disciplines move toward a competency-based education model, it is essential to extend the competence verification from the academic educational level to the patient’s bedside. The nutrition-focused physical exam (NFPE) is a competency recently adopted by registered dietitian nutritionists (RDNs) for assessing patients’ nutritional status. Being a newly acquired skill, validated tools are required to measure NFPE competence during routine clinical practice. The Interactive Nutrition Specific Physical Exam Competency Tool (INSPECT) is a new tool developed specifically to observe and measure RDNs’ NFPE competence in clinical settings. The INSPECT was designed and validated for content using expert RDNs’ input in the first and second phases of the study. This current study aimed to assess the reliability of the INSPECT through multi-site observations by clinical supervisors evaluating RDNs’ NFPE competency during patient assessment. The INSPECT exhibited good inter-rater reliability (ICC = 0.78 for the first assessment and ICC = 0.68 for the second assessment), moderate to strong intra-rater reliability for 37 of 41 items (Spearman rho = 0.54 to 1.0), and excellent internal consistency (Cronbach’s α = 0.86 for the first assessment and α = 0.92 for the second assessment). In total, 10 out of the 11 INSPECT subsets showed good to excellent internal consistency (α ranging from 0.70 to 0.98). The results demonstrate that the INSPECT is a reliable tool, is stable over time, and has good agreement and excellent consistency between raters. The INSPECT can be a valuable tool to measure, promote and maintain RDNs’ NFPE competence in authentic acute care settings.

Academy of Nutrition and Dietetics Nutrition Research Network: Rationale and Protocol for a Study to Validate the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Consensus-Derived Diagnostic Indicators For Adult And Pediatric Malnutrition and to Determine Optimal Registered Dietitian Nutritionist Staffing in Acute Care Hospital Settings

No systematic, universally accepted method of diagnosing malnutrition in hospitalized patients exists, which may contribute to underdiagnosis, undertreatment, and poorer patient outcomes. To address this issue, the Academy of Nutrition and Dietetics is conducting a cohort study to: assess the predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators for the diagnosis of adult and pediatric malnutrition in hospital settings; assess the interrater reliability of the indicators for the diagnosis of adult and pediatric malnutrition; and quantify the level of registered dietitian nutritionist care needed to improve patient outcomes. Up to 60 adult and 60 pediatric hospital sites will collect data to estimate level of registered dietitian nutritionist care, along with patient medical history and Malnutrition Screening Tool (adult) or STRONGkids (pediatric) results. A subset of 600 adult and 600 pediatric patients (∼1:1 screened as high- or low-risk for malnutrition) will be randomly selected for the indicators for the diagnosis of adult and pediatric malnutrition and Nutrition Focused Physical Exam data collection; 100 adult and 100 pediatric patients in this group will also undergo a bioelectrical impedance analysis measurement. Additional nutrition care and medical outcomes (eg, mortality and length of stay) will be collected for a 3-month period after the initial nutrition encounter. Multilevel linear, logistic, Poisson, or Cox regression models will be used to assess indicators for the diagnosis of adult and pediatric malnutrition validity and registered dietitian nutritionist staffing levels as appropriate for each medical outcome. Validation results will allow US clinicians to standardize the way they diagnose malnutrition in hospitalized patients, and the staffing data will support advocacy for available registered dietitian nutritionist-delivered malnutrition treatment to improve patient outcomes.

Clinical Competence Assessed Using Simulation: Development of a Standardized Tool to Assess Nutrition-Focused Physical Exam Skill Competence for Registered Dietitian Nutritionists

OBJECTIVE

This study details development and testing of a tool designed to evaluate clinical competence by registered dietitian nutritionists (RDNs) on the nutrition-focused physical exam (NFPE). The process demonstrated in this study can be adapted for assessment of other clinical skills in competency-based education programs, such as Accreditation Council on Education in Nutrition and Dietetics' Future Model of Dietetics Education.

DESIGN AND SETTING

The tool was tested for content validity, then used to assess the videotaped performance of the NFPE with standardized patients in a simulated clinical environment.

PARTICIPANTS

Seven expert raters assessed the relevance of the tool's items for content validity. For other tests, the tool was used by 3 dietetics faculty to score a group of 18 RDNs.

VARIABLES AND ANALYSIS

Content validity was tested using the item-level Content Validity Index. Interrater reliability and internal consistency of the tool were calculated and assessed.

RESULTS

The interrater reliability results indicated excellent agreement between raters, both overall (kappa statistic = 0.86; 95% confidence interval, 0.86-0.87; P < 0.001) and on individual items. Cronbach α statistic was calculated at α = .91, indicating excellent internal consistency.

CONCLUSIONS

The tool represents an instrument that can assess competence in the NFPE among RDNs and may be used as a template for development of other competency-based education assessment tools.

Trends and Novel Research in Hospital Nutrition Care: A Narrative Review of Leading Clinical Nutrition Journals

Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.

Simulations for Teaching and Evaluating Nutrition-Focused Physical Exam Skills

OBJECTIVE

To develop, implement, and evaluate a patient simulation to assess Nutrition-Focused Physical Exam (NFPE) skills among dietetics students.

METHODS

Three student cohorts (n = 47) in a combined internship and master's program participated. Curricula included: (1) formal instruction with practice resources, (2) baseline NFPE evaluation performed on a classmate, and (3) final NFPE evaluation performed on a standardized patient. Trained observers evaluated students using the NFPE Skills Assessment tool. Self-rated performance was assessed by the 8-item survey completed at baseline and after the final evaluation. Paired t tests analyzed differences in observed NFPE skill, and 1-tailed Wilcoxon signed-rank test analyzed differences in survey responses.

RESULTS

Nutrition-Focused Physical Exam skill improvements were observed for each cohort (P < .05). Surveys demonstrated increased comfort touching patients (P < .001), and improved self-rated abilities to assess subcutaneous fat, muscle stores, fluid accumulation, and micronutrient deficiency (P < .001).

CONCLUSIONS AND IMPLICATIONS

Simulations were an effective method for increasing observed and perceived NFPE skills among dietetics students. These findings justify the investigation of these methods within a larger sample of students from multiple programs with rigorous study design.