Standards of Practice

Standards of Practice Standards for Specialized Nutrition Support for Adult Residents of Long-Term Care Facilities American Society for Parenteral and Enteral Nutrition Board of Directors and Task Force on Standards for Specialized Nutrition Support for Adult Residents of Long Term Care Facilities: Sharon M. Durfee, RPh, BCNSP*; Charlette Gallagher-Allred, PhD, RD†; Jack A. Pasquale, MD§; and Joyce Stechmiller, ARNP, PhD‡ *Columbine Health Systems, Fort Collins, Colorado, Chair, Standards for Long-Term Care Residents Task Force; †Consultant, Columbus, Ohio; §Physician Nutrition Specialist, New York Hospital, Queens and Jamaica Hospitals, Queens, New York; ‡College of Nursing, University of Florida, Gainesville, FL

Introduction

This revision also addresses corresponding areas of current regulation published by the Centers for Medicare and Medicaid Services (CMS) for use in the long-term care survey process specifying requirements which must be met by long-term care facilities participating in Medicare and Medicaid. The standards are presented in the most generic terms possible. The details of specific tests, therapies, and protocols are left to the discretion of an interdisciplinary team of healthcare professionals who establish, implement and evaluate nutrition policies and procedures in each long-term care facility. Ideally, each long-term care facility should have a formal interdisciplinary team responsible for the provision of specialized nutrition support (SNS). It is recognized, however, that this is often not feasible in today’s medical economic climate. Each long-term care facility shall strive to provide the best nutrition structure that is possible given the resources of the facility to comply with CMS requirements. The standards aim to assure sound and efficient nutrition support in long-term care facilities for adult residents. These standards do not constitute medical or other professional advice, and should not be taken as such. To the extent that the information published herein may be used to assist in the care of residents, this is the result of the sole professional judgment of the attending healthcare professional whose judgment is the primary component of quality medical care. The information presented in these standards is not a substitute for the exercise of such judgment by the healthcare professional. These standards have been developed, reviewed, and approved by the A.S.P.E.N. Standards Committee and the A.S.P.E.N. Board of Directors.

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is a professional society of physicians, nurses, dietitians, pharmacists, allied health professionals, and researchers dedicated to assuring that every patient receives optimal nutrition care. A.S.P.E.N.’s mission is to serve as the preeminent, interdisciplinary nutrition society dedicated to patient-centered clinical practice worldwide through advocacy, education, and research in the field of specialized nutrition support. These Standards for Specialized Nutrition Support for Adult Residents of Long-Term Care Facilities are an update of the 1997 standards. These standards present a range of performance of competent care based on expert clinical opinion that should be subscribed to by any long-term care facility providing enteral or parenteral nutrition. A separate reference, Guidelines for the use of parenteral and enteral nutrition in adults and pediatric patients,1 provides evidence-based practice guidelines which are coded to reflect the strength of evidence supporting the guidelines to assist clinicians in their decision-making process in the development of nutrition care plans for patients. Use of the word “shall” within this document indicates standards strictly to be followed to conform to the standard; use of “should” indicates that among several possibilities, one is particularly suitable without mentioning or excluding others, or that a certain course of action is preferred but not necessarily required. “May” is used to indicate a course of action that is permissible within the limits of recommended practice. A list of definitions is included in the last chapter of this standard to assist the reader in understanding terms used in this standard.

Chapter I: Organization Standard 1. Interdisciplinary Approach An interdisciplinary team of appropriate healthcare professionals, including a registered dietitian,

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Figure 1. Nutrition care process.

registered nurse, physician, pharmacist, speech therapist, social worker and other healthcare professionals as appropriate shall be identified to establish, develop and implement policies and procedures for the provision of SNS.

3.3 The result of the nutrition screen shall be documented and appropriate intervention initiated within 7 days of admission. 3.4 A procedure for nutrition re-screening should be implemented no later than every 3 months.

Standard 2. Performance Improvement A team of healthcare professionals shall periodically review and evaluate the quality of nutrition care provided at the facility at least quarterly as required by CMS.

Standard 4. Nutrition Assessment Each resident shall undergo a nutrition assessment to determine the nutrition care needs and the type of nutrition care to be provided. The nutrition assessment shall be documented and available to all resident care providers. 4.1 The nutrition assessment shall be performed by or under the supervision of a registered dietitian or healthcare professional with training and expertise in SNS within the time frame specified by organization policy or as required by regulation. 4.2 The nutrition assessment shall include subjective, objective and psychosocial factors of the resident’s current nutrition status. 4.2.1 The subjective assessment of nutrition status should include information from the resident’s medical record. Elements that should be documented as part of the subjective assessment of nutrition status include the following: reported usual body weight; desirable body weight, recent change in body weight (quantified); recent changes in dietary intake (quantitative and qualitative); cultural, religious, or ethnic food preferences; mastication, swallowing, gastrointestinal, and elimination symptoms (including stomatitis, nau-

Chapter II: Nutrition Care Process Standard 3. Nutrition Screening The process of nutrition care and the administration of SNS require a series of steps with feedback loops.2 These steps include nutrition assessment, formulation of a nutrition care plan (NCP), implementation of the plan, monitoring, reassessment of the NCP, reevaluation of the care setting, and then either reformulation of the NCP or termination of therapy. The nutrition care process is outlined in Figure 1. Residents who are nutritionally-at-risk should be identified by nutrition screening. Criteria shall be established for identification by an initial nutrition screening of patients who are nutritionally-at-risk.2–7 3.1 The policy and procedure for nutrition screening shall be formalized and documented. 3.2 All patients admitted to the facility shall be screened for nutritional risk within 2–3 days of admission.

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A.S.P.E.N. BOARD OF DIRECTORS AND STANDARDS COMMITTEE

sea, vomiting, diarrhea, constipation, and anorexia); current status and recent changes in functional capacities (eg, activities of daily living, employment, recreation). 4.2.2 The objective assessment of nutrition status should include nutrition status data obtained from the physical examination, anthropometric and laboratory evaluations. Elements that should be documented as part of the objective assessment of nutrition status include the following: age; height; current body weight, ideal body weight, percent change over the past 30, 90, and 180 days and body mass index; admitting diagnosis and past medical history; concurrent medical and surgical problems that may effect nutritional requirements and nutrition support options (including allergies and medications); and laboratory data as available which may include but not be limited to complete blood count with red cell indices, total lymphocyte count, serum electrolytes, blood urea nitrogen, creatinine, serum glucose, serum albumin, serum cholesterol, serum triglycerides, liver function studies, and resident specific indices. Information from the physical examination relevant to nutrition status should be reviewed (eg, loss of subcutaneous fat, muscle wasting, edema, ascites, mucocutaneous lesions, hair changes, and condition of skin including presence of pressure ulcers or wounds). Other elements of an objective assessment of nutrition status that may be helpful but that are not routinely used at many institutions include arm muscle circumference, serum transferrin, prealbumin, and resting energy expenditure. 4.2.3 The nutrition assessment shall include an evaluation of psychosocial and socioeconomic factors and advance directives that may influence prescription and administration of nutrition support. 4.3 The subjective, objective, and psychosocial assessments of nutrition status shall be summarized and documented. A system may be used to classify nutrition risk.2,3 4.4 The resident’s nutritional requirements shall be summarized based on the findings of the subjective and objective nutrition assessments and should include protein, calorie, fluid, and may include electrolyte, and micronutrient requirements.2 4.5 Nutrition assessment shall include an assessment and documentation of factors relevant to the route of SNS administration. Relevant factors may include the following: ability to meet nutrient requirements, presence of gag reflex,

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functional status of the gastrointestinal tract, mental status, enteral and vascular access, and schedule of tests and invasive procedures. 4.6 For residents receiving SNS, the nutrition assessment shall include indication of medical necessity for SNS, caloric intake below or above CMS range in kcal/kg, or medical necessity for delivery of an enteral formula via a pump.8

Chapter III: Development of Nutrition Care Plan The NCP should be developed with an interdisciplinary approach involving the physician, registered nurse, registered dietitian, and other healthcare professionals as appropriate, and with the involvement of the resident and/or family whenever possible and is based on information from the Resident Assessment Instrument (RAI) and the nutrition assessment. The NCP information should be completed within 7 days after the completion of the RAI and incorporated into the overall plan of care. Standard 5. Objectives The NCP is the template for nutrition therapy and is created by analysis of information from many aspects of care, including consultations, therapies, and assessments. The NCP should include nutrient requirements and intake targets, route of SNS administration, and measurable short- and longterm objectives of care and intervention.1,2,6 Standard 6. Interdisciplinary Approach The discipline responsible for carrying out each planned approach will be designated on the NCP. Standard 7. Goals and Expectations The resident, family, and if the resident lacks competency, then the appropriate decision maker as designated by the law of the state in which the resident resides should be included as part of the NCP to receive education about goals and expectations of SNS, and the NCP should incorporate resident wishes. 7.1 Routes of administration appropriate for use shall be defined, and identification of requirements for nutrient intake shall be included.2 7.2 The resident, family, and if resident lacks competency, the appropriate decision maker as designated by the law of the state in which the resident resides shall be informed and knowledgeable about the rationale, therapeutic goals and options, and the risks and benefits of receiving PN or EN. Standard 8. Selection of Route of SNS The route selected to provide SNS shall be appropriate to the resident’s medical condition and goals

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expressed by the resident, family, or if the resident lacks competency, the appropriate decision maker as designated by the law of the state in which the resident resides. 8.1 When selecting the route of nutrition therapy, the least invasive, most efficacious, and cost effective therapy is preferred. 8.2 Whenever possible, nutrition therapy is provided through oral diet with supplementation. If oral intake is not adequate but the gastrointestinal tract is functional and available, the gastrointestinal tract is the preferred route for nutrition support and should be used to administer SNS. 8.3 EN may be used in preference to PN to the greatest extent possible. 8.4 Residents with a nonfunctional or inaccessible gastrointestinal tract or those with nutrient needs in excess of those which can be met through the gastrointestinal tract may receive PN. 8.5 The mode of SNS shall be reassessed periodically for adequacy, appropriateness, and effectiveness at a minimum quarterly for EN and monthly for PN. Standard 9. Selection of Formulation The EN or PN formulation shall be appropriate for the resident’s disease process and compatible with the route of access.2 9.1 The EN or PN formulation shall be adjusted as appropriate in patients with organ dysfunction. 9.2 When similarly effective EN or PN formulations are available, the least costly should be selected. 9.3 When significant amounts of nutrients are provided through means other than the feeding formulation (eg, parenteral infusions, drugs, dialysis), the formulation should be adjusted accordingly.

Chapter IV: Implementation Standard 10. Ordering Process Implementation should commence following assessment and development of the NCP. 10.1 Prescriptions/orders for food or SNS shall be documented in the resident’s medical record before administration.2 10.2 Verbal prescriptions/orders for food or nutrition products shall be accepted only by personnel designated by institutional policy and should be signed by the prescribing/ordering practitioner.2 Standard 11. Nutrition Support Access Access for SNS shall be achieved and maintained in a manner that minimizes risk to the resident.1,2 11.1 Appropriate access devices shall be placed by or under the supervision of a physician, nurse, or

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specially trained healthcare professional who is competent and knowledgeable in recognizing and managing complications associated with the placement and maintenance of the device.2 11.2 Standard techniques and policies should be established and followed for access device insertion and routine care.2 11.3 Proper placement of vascular and enteral access devices shall be appropriately confirmed and documented before use.2 11.3.1 Central venous access shall be used for administration of PN. The catheter tip should be positioned in the superior vena cava or adjacent to the right atrium.1,9 11.4 Complications related to an access device and outcome of actions to manage the complication shall be clearly documented in the medical record.2 Standard 12. Formulation Preparation EN formulations shall be prepared accurately and safely as prescribed.2 PN formulations should be outsourced or obtained from a pharmacy which adheres to standard aseptic admixture technique.10 12.1 EN and PN formulations shall be prepared using current policies and procedures regarding compounding, compatibility, and stability. These procedures shall be supervised by a healthcare professional with appropriate credentials and experience.2 12.2 Pharmacies providing PN formulations to longterm care facilities shall develop and adhere to policies and procedures for the use of automated compounding devices for PN formulations that address responsibilities for operation and maintenance, staff training, and monitoring compounder performance at all times.2,9,10 12.2.1 Adequate training of personnel shall include use of computer software to assist in daily use and trouble-shooting of automated compounding equipment.2,9 12.2.2 Documents generated by the automated compounding device shall be compared with the PN formulation that is ordered.2,9 12.2.3 The operator shall monitor the equipment during the preparation process to assure the proper operation of the equipment.2,9 12.3 PN formulations shall be sterile.2,9,10 12.3.1 Aseptic technique shall be taught, used, and evaluated on a periodic basis.9,10 12.3.2 PN formulations shall be prepared in a class 100 laminar air flow hood by using aseptic technique and under the direction of a pharmacist.9,10 12.3.3 The compounding room should be a con-

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trolled room with limited access to decrease the potential for contamination of sterile compounded products.9,10 12.4 The final PN formulation shall be checked visually by a pharmacist to assure appropriate volume and absence of particulate matter or phase separation in the intravenous fat emulsion (IVFE).2,9 12.5 All PN formulations shall be prepared in compatible containers and shall be administered with an in-line filter.2,9,10 A 0.22-micron filter is recommended for a 2-in-1 formulation. A 1.2-micron filter should be used for total nutrient admixtures (TNAs). A 1.2-micron filter may be used for all PN formulations. 12.6 EN formulations shall be prepared to prevent contamination and promote safety and accuracy. Commercially prepared EN formulations should be utilized. Due to high risk of microbial contamination, in-house prepared blenderized preparations are not recommended.11,12 12.6.1 Open-system feeding containers shall be filled with feeding formulation using clean technique. Policies and procedures shall be established regarding use of commercially-prepared ready-touse formula. 12.6.1.1 Policies and procedures shall be established regarding use of commercially available modular products (eg, MCT oil, protein additives). 12.6.2 Closed-system feeding containers may be used to diminish the risk of microbial contamination of the feeding formulation. Standard 13. Additives Additives to PN and EN formulations shall be appropriate and compatible with all ingredients. 13.1 Healthcare professionals responsible for the preparation and delivery of PN formulations shall employ methods for detection or prevention of formulation incompatibilities. 13.2 All additions to a PN formulation, such as multivitamins, shall be made in a designated clean area such as the medication room under the direction of the providing pharmacy. 13.3 Any additions to a PN formulation, other than multivitamins should be approved by the providing pharmacy. 13.4 All residents receiving PN should receive daily parenteral multivitamins in quantities established by the Food and Drug Administration (FDA) Center for Drug Evaluation and Research.13 13.5 All residents receiving PN should receive daily parenteral trace elements. Dosing may need to be adjusted for severe renal and hepatic dys-

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function, excessive losses, or in patients receiving long term PN.1 13.6 Policies and procedures shall be established regarding subsequent additions to EN formulations. To avoid contamination, additives to open or closed-system containers should not be made. 13.7 Colorants (food coloring or methylene blue) shall not be added to enteral feeding products.14,15 Standard 14. Packaging and Labeling PN and EN formulations shall be appropriately packaged and labeled.2,9,10 14.1 PN formulations shall be packaged in containers that can assure maintenance of sterility and allow visual inspection during preparation, storage, and administration.9,10 14.1.1 The formulation shall be inspected to identify signs of gross contamination particle formation, or phase separation during the preparation process, before hanging and during administration of the formulation to identify potential incompatibilities. 14.1.2 The formulation shall be labeled with the patient’s name, additives, rate of administration, Beyond-use or do not use after date and time, and composition. The content and format of a PN label shall follow the Standard Label Format for Adults as recommended by the Task Force for the Revision of Safe Practices for Parenteral Nutrition.9,10 14.1.3 The formulation should be stored at 4°C. 9,10 14.2 EN formulations shall be packaged in containers which assure cleanliness and accuracy of volume.2 14.2.1 EN formulations shall be labeled with the patient’s name, the product name, strength, additives, volume, and expiration date and time.2 Standard 15. Administration of SNS Formulations EN and PN formulations shall be administered accurately in accordance with the prescribed order and consistent with the patient’s tolerance.2 15.1 SNS formulations shall be administered by or under the supervision of trained personnel. Administration and tolerance shall be documented. 15.2 The label on the formulation shall be checked before administration of the formulation to assure the prescribed formulation is given to the appropriate resident. 15.3 The SNS label, Beyond-use or expiration date shall be checked before administration of the formulation.9

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15.4 The rate of prescribed administration shall be checked each time a new volume of formulation is ordered and periodically during its administration. 15.5 Inspection of the SNS formulation before administration for signs of gross contamination, particle formation, and phase separation of IVFE.9 15.6 Visual inspection of the resident’s enteral or parenteral access devices and insertion site to insure patency. 15.7 Protocols and procedures shall exist regarding techniques used to administer EN and PN formulations. 15.7.1 Protocols shall be written to prevent and manage vascular or enteral access device occlusion. 15.7.2 A protocol shall be written to prevent and manage patient infections caused by contamination of the formulation or the equipment used in its administration. 15.7.3 A protocol shall be written regarding the time within which a PN formulation shall be used before its contents become incompatible or pose an infectious risk to the resident. 15.7.3.1 Once started, the infusion of a PN formulation shall be completed within 24 hours or the remaining formulation shall be discarded.9,16 15.7.3.2 PN formulations shall be labeled with the Beyond-use or do not use after date and time and discard date and time.9,10 15.7.3.3 Infusion of IVFE as a separate infusion should be completed within 12 hours or discarded.9,16 15.7.4 A protocol shall be written regarding the maximal rate of administration for IVFE. Manufacturer’s recommendations should be considered in formulating this protocol. 15.7.5 A protocol shall be written to minimize the risk of microbial contamination of EN formulations. 15.7.5.1 EN formulations in open-system feeding containers at room temperature shall be used in 12 hours or as recommended by the manufacturer. 15.7.5.2 EN formulations in closed-system feeding containers at room temperature should be used within the time that is recommended by the manufacturer. 15.7.5.3 EN formulations shall be labeled with the expiration time and shall be discarded at the time of expiration.

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15.7.6 Protocols and procedures should be written to minimize the risk of regurgitation and aspiration of EN formulations. 15.7.6.1 Residents should be positioned upright at least 30 degrees during and 1 hour after receiving feeding. 15.7.6.2 Gastric residual volumes may be monitored to assess feeding tolerance. 15.7.6.3 Gastric decompression should be considered in patients receiving postpyloric feeding who must remain in a supine position or who develop gastric distention. 15.7.6.4 Protocols and procedures shall be written for medication administration to minimize adverse nutrient drug interactions.17 15.7.6.5 A protocol shall exist to prevent the inadvertent administration of an EN formulation through a vascular access device (VAD).18 Standard 16. Sentinel Event Management A sentinel event related to the administration of SNS shall be reported according to facility protocol to assure that the event is properly documented and that a corrective action plan can be instituted. This process reduces the risk of the development of a serious adverse outcome in the future.2

Chapter V: Monitoring and Re-evaluating the NCP Standard 17. Parameters and Frequency A plan for monitoring the effect of nutrition interventions should be stated in the NCP.1 Monitoring parameters are chosen relative to the goals of the NCP. The NCP shall be revised to optimize SNS and achieve predetermined outcomes for the patient.2 17.1 The frequency of monitoring should depend on severity of illness, degree of malnutrition, and level of metabolic stress.2 17.1.1 In stable residents, monitoring may occur as clinically indicated, monthly, or quarterly as specified by the Minimum Data Set (MDS). 17.1.2 Daily or more frequent monitoring should be required in residents who are critically ill, have unstable debilitating diseases or infection, are at risk for refeeding syndrome complications, are transitioning between PN or EN and oral diet, or have experienced complications associated with SNS.2

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17.2 Monitoring parameters may include but not be limited to the following2: physical assessment, including clinical signs of fluid and nutrient excess or deficiency; vital signs; actual nutrient intake (oral, enteral, and parenteral); weight; laboratory data [complete blood cell count, glucose, blood urea nitrogen, creatinine, electrolytes (Na, K, CL, CO2), calcium, magnesium, phosphorus, liver function tests, triglycerides, visceral proteins, or International Normalized Ratio]; review of medications; changes in gastrointestinal function. 17.3 Abnormalities in monitoring parameters shall be identified. Recommended changes in SNS formulation or route shall be made in writing and resulting outcomes shall be documented.2

use of clinical judgment in accordance with accepted standards of medical ethics, local practice standards, judicial decisions and local, state, and federal law.2 21.1 Competent residents or the appropriate decision maker as designated by law of the state in which the resident resides shall be involved in decisions regarding withholding or withdrawing of treatment. Wishes of residents who lack competency (as documented in advance directives) shall be considered in making decisions to withhold/withdraw SNS.2 21.2 Protocols shall provide latitude of clinical judgment in permitting the discontinuation of SNS.20

Standard 18. Re-evaluation of NCP The resident shall be monitored for progress toward short- and long-term objectives as defined in the NCP.1,2 18.1 Appropriate parameters should be measured serially during SNS and documented.1 Parameters may include weight change, adequacy of intake, ability to transition to oral diet, changes in laboratory data, functional status performance, and quality of life. 18.2 The monitoring parameters should be compared with the goals of the NCP. If goals are not being met or new problems/risks have arisen, the NCP should be modified or rewritten as appropriate. 18.3 The resident medication profile including prescription, over-the-counter medications, herbal and dietary supplements shall be reviewed for the following: potential effects on both nutrition and metabolic status and incompatibilities with SNS formulation.1

The following terms which are used in these standards have been defined previously22 in or by other organizations as referenced. Admixture. The result of combining two or more fluids. Automated compounding device. A device used in the preparation of PN. It automates the transfer of dextrose, amino acids, fat emulsion, sterile water as well as small volume injectable, such as electrolytes and minerals to the final PN container. The device is driven by computer software. Beyond-use Date. The date established by healthcare professionals from the published literature or manufacturer-specific recommendations for intravenous sterile preparations beyond which the product should not be used. Care plan. Plan of professional clinical activities developed to implement the treatment plan. Clinical guidelines: Systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.21 Drug-drug interaction. An event that occurs when a drug’s activity, availability, or effect is altered by another drug. Drug-nutrient interaction. An event that occurs when nutrient availability is altered by a medication, or when a drug effect is altered or an adverse reaction caused by the intake of nutrients. Enteral Access Devices. Tubes placed directly into the gastrointestinal tract for the delivery of nutrients or drugs. Enteral Nutrition (EN). Nutrition provided through the gastrointestinal tract. -Oral. Enteral nutrition taken by mouth. -Tube. Enteral nutrition provided through a tube, catheter, or stoma that delivers nutrients distal to the oral cavity. Expiration date. The date established from scientific studies by the FDA to meet regulatory requirements for commercially manufactured drug products beyond which the product should not be used. Formulation. A ready-to-administer mixture of nutrients.

Chapter VI: Transition of Therapy Standard 19. Adequacy of Intake The transition from PN or EN to oral feeding shall be monitored and shall include documentation of adequacy of intake. Adequacy of energy and nutrient intake (approximately 60% of estimated requirements or based on clinical judgment) shall be assessed before discontinuing SNS.2,19 Standard 20. Continuity of Care There shall be continuity of care and active communication with all members of the resident care team, the resident, and significant others to develop a plan for transition of SNS to an alternate healthcare setting or to home care.2 Standard 21. Termination of Therapy Protocols to address the termination of SNS shall be developed. These protocols shall acknowledge the

Chapter VII: Deﬁnitions

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Hang time. The period of time beginning with the flow of fluid through an administration set and catheter or feeding tube and ending with the completion of the infusion. Indicators. Prospectively determined measures used as normative standards within a performance improvement process. Intravenous fat emulsion (IVFE). An intravenous oil-in-water emulsion of vegetable oil(s), egg phosphatides, and glycerin. Malnutrition. Any disorder of nutrition status including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or overnutrition. Minimum Data Set (MDS). A core of elements to use in performing comprehensive assessments. Nutrition assessment. A comprehensive approach to defining nutrition status that uses medical, nutrition, and medication histories; physical examination; anthropometric measurements; and laboratory data. A formal nutrition assessment should provide all of the information necessary to develop an appropriate NCP. Because of the inextricable relationship between malnutrition and severity of illness and the fact that tools of nutrition assessment reflect both nutrition status and severity of underlying disease, an assessed state of malnutrition or presence of specific indicators of malnutrition in fact refers to the consequences of a combination of an underlying illness and associated nutrition changes and deficits. Nutritionally-at-risk. Adults are considered at nutritional risk if they have any of the following: ● Actual or potential for developing malnutrition (involuntary loss or gain of ⱖ 10% of usual body weight within 6 months, or ⱖ 5% of usual body weight in 1 month, a weight of 20% over or under ideal body weight) presence of chronic disease, or increased metabolic requirements. ● Altered diets or diet schedules (receiving PN or EN, recent surgery, illness, or trauma). ● Inadequate nutrition intake, including not receiving food or nutrition products (impaired ability to ingest or absorb food adequately) for greater than 7 days. Nutrition care. Interventions and counseling of individuals on appropriate nutrition intake through the integration of information from the nutrition assessment. Nutrition care plan (NCP). A formal statement of the nutrition goals and interventions prescribed for an individual using the data obtained from a nutrition assessment. The plan, formulated by an interdisciplinary process, should include statements of nutrition goals and monitoring parameters, the most appropriate route of administration of SNS (oral, enteral, and/or parenteral) method of nutrition access, anticipated duration of therapy, and training and counseling goals and methods. Nutrition screening. A process to identify an individual who is malnourished or who is at risk of

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malnutrition to determine if a detailed nutrition assessment is indicated. Nutrition support service (or team). A multidisciplinary group of healthcare professionals including a physician, nurse, dietitian, and pharmacist with expertise in nutrition who manage the provision of SNS. Nutrition therapy. A component of medical treatment that includes oral, enteral, and parenteral nutrition. Outcome. The measured result of the performance of a system or process. Parenteral nutrition (PN). The administration of nutrients intravenously. -Central. Parenteral nutrition delivered into a large-diameter vein, usually the superior vena cava. -Peripheral. Parenteral nutrition delivered into a peripheral vein, usually of the hand or forearm. Resident Assessment Instrument (RAI). Designed by the CMS (formerly Health Care Financing Administration) to help nursing facility staff gather definitive information on a nursing home resident’s strengths and needs, which must be addressed in an individualized care plan. The RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident’s status. To accomplish these purposes, the RAI consists of three basic components: 1. Minimum Data Set (MDS) Version 2.0, 2. Resident Assessment Protocols (RAPs), and 3. Utilization Guidelines specified in State Operations Manual (SOM) Transmittal #272. Resident. The recipient of care from a long-term care provider. In this case, the term “resident” can be used interchangeably with “client,” “customer,” or “patient.” Sentinel Event. An unexpected death or serious injury that is not related to the natural course of the patient’s illness. Specialized nutrition support (SNS). Provision of nutrients orally, enterally, or parenterally with therapeutic intent. This includes, but is not limited to, provision of enteral or parenteral nutrition support to maintain or restore optimal nutrition status and health. Standard. Benchmark representing a range of performance of competent care that should be provided to assure safe and efficacious nutrition care. Total nutrient admixture (TNA). A parenteral nutrition formulation containing carbohydrate, amino acids, IVFE, vitamins, minerals, trace elements, water and other additives in a single container. Treatment plan. Orders established and signed by a clinician with prescriptive rights for the care of the patient (ie, the medical orders including nutrients, medications, activity orders, access site orders, etc). Vascular Access Device (VAD). A device inserted into a vein which permits administration of inter-

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mittent or continuous infusion of parenteral solutions or medications.

References 1. A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26(Suppl):1SA–138SA. Errata, 2002;26:144. 2. A.S.P.E.N. Board of Directors and Task Force on Standards for Specialized Nutrition Support for Hospitalized Adult Patients. Standards for Specialized Nutrition Support: Adult Hospitalized Patients. Nutr Clin Pract. 2002;17:384 –391. 3. Guigoz Y, Vellas B, Garry PJ. Mini Nutritional Assessment: A practical assessment tool for grading the nutritional state of elderly patients. Facts and Research in Gerontology. 1994;Supplement 2:15–59. 4. Consultant Dietitians in Health Care Facilities Dietetic Practice Group of The American Dietetic Association. Enteral and Parenteral Nutrition Support. In: Niedert K, Dorner B. Nutrition Care of the Older Adult: A Handbook for Dietetics Professionals Working Throughout the Continuum of Care. 2nd edition. Chicago, IL: The American Dietetic Association; 2004. 5. Consultant Dietitians in Health Care Facilities Dietetic Practice Group of the American Dietetic Association. Enteral and Parenteral Nutrition. In: Robinson GE, Leif BJ. Nutrition Management & Restorative Dining for Older Adults: Practical Interventions for Caregivers. Chicago, IL: The American Dietetic Assocoation; 2001: 363–388. 6. American Dietetic Association Board of Directors. Definitions for screening and nutritional assessment. J Am Diet Assoc. 1994;94: 838 – 839. 7. Shopbell J, Hopkins B, Shronts E. Nutrition screening and assessment. In: Gottschlich MM, ed. The Science and Practice of Nutrition Support. A Case-Based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing Company; 2001:107–140. 8. DMERC Supplier Manual, Chapter 62, Enteral Nutrition, pages 62.5– 62.6, chapter 63, Parenteral Nutrition, Autumn 2004, pp 63.2– 63.6. 9. A.S.P.E.N. Board of Directors and Task Force for the Revision of Safe Practices for Parenteral Nutrition. JPEN J Parenter Enteral Nutr. 2004;S39 –S70.

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