Putting Nutrition Guidelines into Practice: AHRQ Preventing Pressure Ulcers in Hospitals Toolkit

Putting Nutrition Guidelines into Practice: AHRQ Preventing Pressure Ulcers in Hospitals Toolkit

September 26, 2019 1 By Ewald Bahringer


Also, I just want to thank everyone for joining us today. This is a like we want to go back to the top of the Present we go this is the third webinar in our implementation sharing webinar program for the agency for Healthcare Research and quality pressure ulcer prevention program So they get for everyone who was able to join us today So to start things off we’ll just do a little bit of housekeeping Update on our upcoming webinar, and then we’re going to go straight into the Presentation that we have today putting the nutrition guidelines into practice for pressure injury prevention By dr. Mary littered. We’ll have a period of time for Question and discussion and wrap up Turn housekeeping just as a reminder to everyone When we get to the discussion section we hope that you’ll participate And there are several ways you can do that one is to click on the little hand icon And let us know that you actually have a question or comment you can also use the chat panel I like to just remind everyone if you use the chat panel You want to make sure that that little thin tool box says all? Participants, so you’ll need to use the little drop down On you and scroll down to find all participants that way everyone can see your comment and/or question We will be muting all the lines During the presentation portion, but when we open the line we ask that you keep the your phone muted If you have you know so we keep that background noise to a minimum In terms of updates from the Athiya team I just want to let everyone know that we will be going back to our Hospital updates next month and this will conclude the implementation updates, and we will hear from both, Fort Washington and Broward we’re looking forward to hearing about their implementation activity So let me just briefly introduce dr. Lich Ferg dr. Lich furred is an acclaimed speaker author medical legal expert and a consultant to health care providers she received her PhD in human dition from the University of North Carolina Greensboro Professional careers included clinical practice in university teaching and business consulting She is the president of taste software and books a professional educational resource company Also a member of the Academy of Nutrition and Dietetics and the academy of nutrition and was Spent on the Dietetics evidence analysis workgroup on wound care She’s a member of the board of directors of national pressure ulcer advisory panel and currently serves as the vice President so it’s my sure to turn the webinar presentation over to dr. Lynch Byrd Well very much. It’s my pleasure to come to this webinar to talk about Some fit one of my favorite topics and that is putting the nutrition guidelines into practice for pressure injury provision Now I said injury did the nomenclature change in April of? 2016 the National pressure ulcer advisory panel held a consensus conference Was on staging and at that meeting it was announced that the word ulcer was be changed to the word injury because pres injuries result in ulcers but facts skin you can have an injury without an ulcer so a stage one and There’s much more to the story than that Though the manuscript out to produce the science behind all of the changes that Have been implemented, so we’re talking about pressure injuries today So we were learning four objectives going to beef today Well, I’m going to talk about the steps to prepare for dialogue with the hospital medical staff the order writing privileges for the registered dietitian nutritionist in this webinar they did for you there were many questions about how to implement this and So I do have a section today on that We’re going to discuss streets to identify new admissions. Who are at risk? malnutrition and pressure injuries and to be given the role of nutrition and reducing readmission rates And then this plea to a blue trician guidelines for prevention of pressure injuries use a case study approach Look at our webinar today with a visualization exercise I want you to visualize Your work setting and I want to think about what what kind of things could we change To optimize the care that we’re fighting for our patients It may seem small it may be something big Doing use some suggestions just to get you thinking You have in mind may not be on my list, but let’s just look at the list for headway that nursing medicine and nutrition care services communicate with each other We hate for records so you Don’t remember those days before we had electronic Records, but if I old days we had handwritten notes You know medical records conceal that we use electronic records do we commute it any better Obstacles other obstacles and getting messages from one person to the other Anything about that system. You’d like to change change about the process of writing down orders in order Perhaps the tools used to screen new admissions for malnutrition The way nurses use the nutrition screening tools or the water person screening tool snow scores are disseminated to other healthcare professionals Who? Completed and the score and upon the medical record, but not disseminated perhaps to other people Anyway that decisions are made on Which refined foods and oral nutritional supplements are stocked or perhaps even tube feedings are stocked so? formula decisions now That’s report list But what Gus saying the process change to optimize nutrition care for your? patients and for function of pressure injuries, I want you to keep this thought in the back of your mind of What kinds of things? Would like to change in my setting Would help me be more successful in yes. Do you have a? Count you may have already checked off some of these items Or just perhaps made a mental note of them and what about them in at the end? Start with our dishes on order privileges for the rdn Rdn is the preferred credential from the Academy of Nutrition and Dietetics Rd is the older credential they are equivalent he registered dietitian rdn register dietician nutritionist The origin is for the rdn were in the Federal Register on May 12 2014 so that’s a little over two years ago and They were effective July 11th 2014 and this what? The first sense in the final rule is hospital registered dietitian privileges We are permitting registered dietitians and other clinically qualified nutrition professional To be pledged to order patient diets under the hospital conditions of participation Is a link the link takes you to the federal register for the rules and regulations About how you would develop a global action plan for all privileges for the rdn Does do your homework I Be a college professor, and I remember students saying to me. Oh I just cannot wait to get out of school I will never have to do homework again Well, that is not true. There is homework to do and implement a plan for ordering privileges for the ODN You need to read the rules and regs And craft an action plan, but be sure you’ve done your homework As ins and outs of those rules before you start this before you implement your plan Lay is begin with the end in mind The purpose of the rule of the final rule, and I’m not going to tell you what that is You read those regs do your homework? Know the purpose of the final rule because you always want to come back to What is the purpose of the rule why are we doing this? Surd Conant is to know the key provisions and identify the key players, and I’ve listed some of those on the slide Step is to let the money do the talking set the focus is on cost reducing cost and benefits to the patients Now once you’ve got the makers at in about ordering diets and changing diets What about them other order writing privileges that are? compensable trician assessment process labs or diagnostic tests Are specific to the nutrition gonna see this is opportunity? To effort owes as well Other resources that will be helpful for you The rules and regulations are called the mayor and Medicaid programs regulatory provisions to promote program efficiency transparency and burden reduction So that tells a little bit about what the purpose is The link that was on the slide two slides ago. That’s not a different link Atomy of nutrition and dietetics has two two sheets while hospital regulation ordering privileges for the rdn and Then as implementation steps, and the link is below on the slide as well are very useful resources for you again start with rules and regulations Go through Moto’s underhand What’s document and then the tip sheets will be more useful to you from the Academy of Nutrition and Dietetics So study look at putting the Line for nutrition into practice now when I take local guidelines, I’m referring to 2014 international guidelines and that were taught by the National pressure ulcer advisory panel European pressure advisory panel and a pan-pacific pressure injury alliance Are came Jed Jed is a 68 year old retired tobacco farmer his son He was found unresponsive in a smoke-filled room It appears that he set his hair on fire with the cigarette Men to the hospital with smoke inhalation he has three of hypertension pre-diabetes emphysema erosive mild cognitive impairment he He has a history of alcohol abuse He pneumonia four weeks ago, although that is resolved seventy inches tall and weighs 147 pounds so as bhai is a 21 so lower end of normal Aiming to the primary care physicians weight records. He’s lost eight pounds in the last three months and As he’s on furosemide a vast torrent and albuterol His reports that he eats all foods But he prefers ground meats and well cooked veggies So we like soft foods an appetite is very good, but What if we can find in the medical record Here’s vitals and some labs that I’ve pulled out his blood pressure was 100 over 73 and his heart rate was 108 His sodium was 147 so that’s been elevated and chloride was at 106 both of those are milliequivalents per liter His glucose was at 130 milligrams per declar. That’s elevated, but it is not a 50 glucose If he was seven point two which is elevated And in creatinine are 36 and 1.4 and those milligrams per deciliter We look at liver function tests all through those are elevated as well the ALP the ast and alt And those are all in units even in a man crit, or 16 and 48 percent and MCV is 97 Human is a frequent per dekaliter and a prealbumin was not ordered So the screening tools that nursing completed at the time of admission great Risk score for precious risk was 15 and that means he’s at risk But not particularly high risk If you see nutrition subscore this gave Jed a 3 That’s adequate the nur also did the many nutritional assessment Came up with a score seven so let me add n defied or he identified on that form Ma, and this is just one several valid nutrition screening tool But this the one I chose to use for this presentation and this question deals with Has food intake declined over the past three months due to a loss of appetite digestive problems chewing or suam difficulties gifs unreported no decrease in food intake, so that’s going to be a score of – What about lost during the last three months? Well, Jess lost eight pounds According to the records so that giving them a score of zero Jed is up and around and so he gets a score of two Question is has suffered psychological stress or acute disease in the past three months There is yeah, so that would be a score of zero because he had the pneumonia month gap Then no psychological problems he has a score of one because he has mild cognitive impairment The nation was that he had some mild dementia And then his BMI based on his height was twenty nine and so that gives him a score of two So our total score is seven so he come up malnourished But right at the top of that score range So let’s hike and see what if we have here He started on IV fluids when he was admitted to the hospital and the doctor ordered a regular diet with thin liquids So we kind of sent the dietician does not have Order writing privilege yes Else we can doubt about Jed’s first day in the hospital Mood he’s confused. He’s combative and he’s irritable at nine He’s only won in coffee and sedges and sweets. He reduced breakfast So they come in really early in the day and the uh He able to eat something, but he refused until later in the day He’s just too tired to eat, and he wants to go home, and he wants to know where his son is And does a nutrition assessment and that Cludes a nutrition focused physical assessment some of the dietitians observations the Dighton does an oral exam and Notes that Jed’s dentures are ill-fitting Nap are doing an oral exam the dietician could have heard The denture clicking in the background sometimes when dentures don’t fit well if you’re observant enough you can Hear them clicking because they’re loose But although once the person opes their mouth And you do an oral exam its prettiest if the ditches are ill-fitting because the person is lost weight over time This noted was moderate muscle wasting in the upper and lower body So it might be muscle wasting in the triceps the biceps could be the deltoids. It could be the pectoral muscles In terms lower money either the quadriceps or that’s straight aeneas muscle That would be the calf quadriceps would be define modern rustle wasting in the face That would be the temporalis muscle and a masseter muscle those your CIL’s of mastication for chewing Also some moderate muscle wasting in the hands, so that would be the interosseous and the CNR that’s going to affect their his ability to open things and Possibly to use utensils and cuts the food’s The dose the skin is very dry and the lips are filling Nice appear yellow and According to machine there’s a decrease urine output, and the color of urine is Amber and an is for labs to be ordered I Think about Jed’s nutrition risk factors based on what we know about Jed and the scores on Screening tools are there any nutrient risk indicators that increases risk for malnutrition and pressure injury That Will be at risk for up to injury from a nutrition standpoint the person must be at risk for malnutrition Or have malnutrition So, would you say Probably not that they didn’t Conclusive that Britta subscore was a three That’s adequate but the mission assessment was a seven. Well. That’s Mellish so inconclusive data or You’d say yes. That would be answer, and this is why? So he’s had a significant weight loss of about five percent in ninety days with a BMI in normal range Now he’s had an acute illness, but he had this stint in City weight loss Focus fiscal assessment identified moderate muscle wasting in four or more site Vettori diagnosis associated with increased energy requirements Meets the criteria for a nutrition diagnosis of malnutrition Labs his labs are consistent with dehydration he had the low blood pressure, but the elevate heart rate as well as the elevated serum sodium B u N and H and H if you have pre-diabetes and the glucose was fifteen that may be Also a red flag in terms of the D hydrogen Because well when you take the water out all the components and the blue are going to be more concentrated so everything increases Now bunnelby Neumann, but that doesn’t tell us anything about his protein status it only reflects his inflammatory stress, and it means due to The exo that he’s had with the smoking let me related to chronic conditions Nell scoffs as I said was non fastings that doesn’t really tell us you’re not but the NC is Troubling because it does reflect poor blood glucose control may be related to the stress of the recent pneumonia, or dvd as full diabetes and Not aware of it at this point Doing our nutrition assessment we want to use our nutrition care process and the next step would be to write a PE s statement with pull nutrition diagnosis our PE s stands for problem etiology and signs and symptoms the best selection of possible PE s statements It’s not an exhaustive list We’ll give you some IDs first Club optimal energy and protein intake related to smoke inhalation Confusion and emotional state and it’s by moderate muscle wasting or more sign Looking at historical intuition as well in the hospital increased energy requirements related to respite to illness and Recents min elation is evidenced by a 5 percent weight loss in 90 days Thermal water intake related to recent illness and hospitalization is evidenced by abnormal labs consent with the addition And I’ve noted which ones and physical findings of very dry skin and cracked peeling lips Couplers that are possibilities would be chewing difficulty rated to ill-fitting dentures and soon as muscles of mastication That’s going to pin paralysis, and the master muscle as evidenced by nutrition focused physical findings of muscle wasting in face King sound of loose dentures and report from patient that dentures didn’t fit properly if chin did had estimate an all assessment and noted the dentures were Ill-fitting that could be included there as well, and then will nutrition indicators Related to multiple chronic conditions and Ilsan dentures as evidenced by moderate muscle wasting in four plus soft and a five percent weight loss in ninety days these are just some examples of P/es statements that you could use for Anoosh in diagnosis From our assessment of nutrition related pressure injury risk based global guidelines for prevention treatment of pressure injuries is consuming sufficient energy in protein to receive risk for pressure injury during hospitalization What voices probably not, and yes, he’s eating a sufficient amount That is within the current recommend ents There is probably not Let’s look at a little bit more here the global guidelines for prevention and treatment of pressure injuries and evidence-based Recommendations for older adults, would you mend a change in his diet order? Our diet order is a regular diet with thin liquids Hunt since he’s going home soon, or yes From Jed’s history that eats a soft diet at home yellow fitting dentures Answer to that would be yes. We change the diet The global guidelines the estimate is protein an energy requirement The pregnant recommendation is 1.25 to 1.5 grams Per kilo of actual body weight so we would use his admission weight which is 147 pounds That’s a range of 84 to 101 grams of protein If we with the energy requirements based on guideline it would be 30 to 35 calories per QM of actual body weight or you could use in rack Colima tree if that was available to you You 30 to 35 calories per kilo gives us a range of about? 2,000 calories to 23 50 calories per day Last question was our Previous slide was do you think he is consuming between 84 to 101 grams of protein? But tell us one in 20 350 calories I answer that as probably not Now in order to meet Jed’s protein and energy requirements we can do this with a lot of foreign approaches with diet we can use supplements we can use fortified foods and Can do med passes we can do a lot of different things in order to meet those numbers but optimize tissue synthesis Because you want to do is to maintain the skin and at the body Repair itself from whatever the reason is for the hospitalization So you want to Mai’s tissue synthesis if you look literature in sarcopenia what we have learned is that? to optimize tissue synthesis have 30 grams of protein at 3 to 4 meals per day a Britta Mises that Yes What’s your call about 30 grams of protein? Well a couple of things number Linea. Is it ought to be high quality protein so ear from whole muscle meat chicken beef chicken pork seafood extra dairy products or A complete source of dietary protein, that’s that’s a protein supplement there are different or additional supplements that are protein supplements on the market and To blend to a whole animal product for to synthesis There’s a bit more than just the 30 grams of protein Because the new acid that triggers tissue synthesis or the mTOR pathway Is leucine leucine is one of the branched-chain, amino? acids and a court of the studies you need at least two point five grams of leucine a deal with 30 grams of protein and so typically if you’re on a whey protein isolate for example For 30 grams of protein you have more than 2.5. Grams of leucine But not true for some of your other Products such as your soy products your budging products your hemp products They be complete pretty, but they don’t have the very high level of leucine that you see in the whey products embassy and Whole Foods at our animals sources of protein So you be sure that you are serving 30 grams of protein at a meal and I’ve given you some examples of weighted ways to do this with food These are not complete news. I only included on the slides ideas in terms of the pro rich foods, and if you notice the one the one at the bottom is a protein isolate powder you would add to milk and You can see the range from 29 to 32 grams of protein I mean ii ago. I’ve got a slice of whole wheat bread for three grams of protein Typically a person has some other food items for breakfast other than what’s on the slide So they’re probably getting a little bit more protein from some of the other items that they’ll be consumed at that meal And the some ideas for lunch and dinner, I think as Americans we Do a job at getting 30 grams of protein May and in the evening, but breakfast is the oldest seems to be the hardest To get people to consume 30 grams of protein now I’ve looked at his total amount of protein per day as Any form maybe ninety to a hundred grams 30 grams per day would be 90 we went to our full 100 then we’d have about 10 grams of protein left, and so let us look at since ideas Tins of protein now for Jed the he has a diagnosis of pre-diabetes and He may benefit from having to a chess snack that’s high in protein Happens to jet He’s charged a home on a regular diet. So nothing was changed about his diet the dietician might have requested a change or Recommended a change, but without order writing privileges And was not implemented in Jed’s case discharge weight was a hundred and forty pounds Nurse arm if they’ve scheduled homecare nurse to come twice a week to assess his status kind of flood with dead This home and with home the home care nurse arrived Jesus to let him in he is doing just fine he doesn’t need a nurse to check on him Care suspect that JIT is intoxicated Sound things are going well at home? It sounded Jed is meeting his nutri needs to prevent skin injury Well he certainly was discharging the hospital with intact skin Things will different at home Three Jed’s still feel like he’s getting better each day, and he’s eating about two meals a day Most of his day watching TV and drinking beer and sitting in his recliner He started to claim that his bed is uncomfortable and decides to sleep in his recliner Unde I’ve Notice is that? The change in status that Jed is confused at times and sometimes his speech is garbled And he’s complaining of pain and his lower back You know he won’t that recliner. He’s sleepy minute and his son just that Jed’s food intake. It’s been good But now he’s sipping on liquids on day five Well son is concerned enough that is getting worse that he calls 911 G readmitted to the hospital So assessment by the nurse to skin assessment They die it upper entry a three point six two four two centimeter open area on the sacrum covered with slump and eschar Without some points to ponder to think about Jed’s nutrition status at the kind of discharged home His murder was a regular diet with thin liquid you weight was 155 pounds in the months prior to the Acute episode so Indy days prior to this first solution not the pneumonia one, but with the smoking and He had lost 5% or 8 pounds and Paul Hospital He lost another 7 pounds, so that’s going to be enough. I percent weight loss though He’s lost a total of 15 pounds in 3 to 4 months now. It is true that these weights were done different scales and We’ve Run the primary care physicians office. We’ve got Eight at admission and discharge those may not be on the same scale either But we know that Jed has lost weight through last 90 days and Now his intent That first question was Jed’s pressure injury avoidable So this webinar series is about preventing skin Threes Which the outcome have been different if yet had received a different diet and more nutrition support during hospitalization You know the importance of nutrition to descendents of nutrition and the risk that Djilas are having a problem skin breakdown and pressure injuries And come have been different if your DN had authority to Cheat its diet on day one of his initial Hospitalization they aren’t identified a number of issues with his diet on day one What’s he been different if their DN? Had had the authority to make that change immediately? I’d like to have ordered the original diet to begin with and Polly to order some supplements based on jazz preferences Dad’s readmission hitter injury is covered with sloth and eschar so that means it’s unstageable according to the 2016 still staging consensus One sloth and eschar are removed. It’s not likely going to be a stage three or four pressure injury to see Roman numerals with the stages We’ve gone to Arabic numerals, and so you will see these Arabic 3 1 through 4 for the Dages of pressure injuries Do problems he’s having some difficulties with speech and may require 2 feet or some oral nutritional supplement would recommend an immune modulating supplement Just from the global guidelines on in the protein intake section and the new literature is 2014 so it’s our old nomenclature With protein arginine and micronutrients for individuals with a pressure author category or stage three or four ultimate pressure ulcers when nutritional requirements cannot be met with tradition I Cal rate and protein supplements this new recommendation in the 2014 guideline and because JIT has a stage three or a stage four per injury Then this would certainly considered as the choice to healing if required especially to go to a tube feeding But just sure those nutrient requirements are met Let’s look at the study the Allegro element trial this was one of several trials Were used to support this recommendation There were two groups there was an intervention group that received one product and a control group received A separate product if you’ll notice the total premium is the same? the intervention group received arginine and the control group did not And a higher dose of zinc copper vitamin C and vitamin E Compared to the core group and they sieved These supplements daily Is their findings? about 80% in the intervention formula group had 40 percent or greater reduction in pressure injury size compared 54 percent in the control So special about these products well digits of efficacy of these Nutrients in wound healing is actually Synergistic is what the authors concluded because there’s no evidence to support an independent effect when go on so if you do the arginine you just gave more zinc We didn’t see kind of effect, but when the nutrients were all together Plus meeting the energy and protein requirements that’s that synergistic effect Nutritional information May help when added to optimize local wound care for the treat of pressure engine injuries and malnourished patients that was the conclusion of the authors in this particular study I Aren’t these products being ordered was in is called lost and based on how things are set up in your organization and cost may be Of great concern and Physician support for the mention of pressure injuries cost effective Well is a study that came out about To go in the advances in skin wound care, so that would be in in the middle of 2016 It was a young study in Australia comparing standard care with nutrition support care now the Difference with a standard care in the nutrition support care was that the patient received no patient education neutral setting and consumption of high protein supplements and Findings were that the nutrition support care But it’s substantial cost savings and that the probability of nutrition support being cost effective with a 7 percent Stable article to share with the decision makers in your hospital it cost-effectiveness of products and especially for the prevention of pressure injuries is Opik of discussion among your colleagues this will be a very interesting study It’s a number of citations. There’s some other studies that the authors Cite that provide supportive information as well, but this was the newest one that I found Now tu ap pressure injury prevention points provides prevention points for all aspects of care But these are the ones from nutrition Number wants to consider that hospitalized patients are going to be at risk for undernutrition or malnutrition Just from their illness or because been NPO for diagnostic testing Both come to us malnourished But others dub that way as a result of what happens to them due to illness surgery injury, whatever It is it to use a valid and reliable Screening tool to determine risk of nutrition too many nutritionists is just one example there are several Important to refer all individuals at risk pressure injury for malnutrition registered dietitian nutritionist Inputs the individual at meal times to increase oral intake To all individuals at risk for pressure injury to consider put fluids in a balanced diet Nets labs suggested that it was dehydrated upon admission and dehydration Increases the risk for skin breakdown because skin can become more fragile Weight changes over time assess adequacy of oral interval and parental intake and prevent additional supplements either between meals and risk or eliminations unless contraindicated The Riv the Incheon points are at the link noted on the slide Other sources are the clinical practice guide That’s what the Glo guidelines look like and you can order these from npuap org right here There are some other resources for pressure injuries as well Into AP has updated the pressure injury stages, and that’s the link on your lied And then the prevention points are here, then there are also some new staging illustrations and these All been put up on the website the last month or so Senator conference Think back to Hippocrates. We talked about him in our first webinar He’s that was credited for saying that him is a matter of time, but sometimes also a matter of opportunity, so are you taking advantage of all of those nutrition opportunities that been everyday in your hospital Let’s tack to our visualization exercise at the beginning our webinar Would you see change It may have been on this lesson it may be something that you’ve added to the list Owens to you is to see that How can we optimize nutrition care for the prevention of pressure injuries and? In to optimize what we’re doing will most likely require some changes So what are some changes that would positively improve our outcomes with our patients? And it’s for questions Jill do you have some questions for me? Let’s open it up to the group real quick, and thank you so much for that great presentation really informative That Deidre asked you to go ahead and be unmuting folks at But can ask any questions that they might have But you know I mean yes Just a couple of questions to sort of get it started so in any benefit at all to using the oral supplementation Be Well HIV stands for Beta hydroxy the methyl butyrate and so you why we call it a GM b8 can be Sent a blight of leucine and leucine is that? essential amino acid that is given up to a certain level that sets off the mTOR pathway for tissue synthesis, so About 5% of leucine is metabolized into Hmb so it takes about 20 grams of leucine to produce one gram of hmb So what we have seen in the studies is that hmb? Supplementation is associated with increased lean body mass so your gain lean body mass without gaining weight or gaining fat and associated with improved physical function and assisting in wound healing Now there’s some products on the market that do contain hmb Some of them are amino acid therapy, so they have some amino acids added to them others are oral nutritional supplements that have them added to it a Look at the fitness products for bodybuilders and elite athletes These products contain hmb There’s an evidence that um that it is a negative I don’t know they need two feedings that include it But that is another tool that’s out there or another product that will help increase lean body mass And may be involved in assisting with wound healing hmb was not identified as recommission in the global guidelines in 2014 Okay, so if a hospital Service forced to use food rather than supplements and may be the case here and certainly I Encourage some of the hospitals to chime in here Is it realistic that you can actually meet the energy and protein needs of a patient just from the foods? That would be on the menu that Good question and quite challenging when you’re looking at 1.5 grams of protein per kilo of body weight 85 calories per kilo of body weight Some of this maybe need to be fortified So things being added to them there are some four type foods that are on the market that you can purchase So I think it’s important that we always start with food first Because that’s ristic what people are going to do once They get home is to consume regular foods and usually that’s people’s preference Focusing on food first and what is reasonable for them to consume The volume of the food is to meet these requirements Is such that it becomes limiting and so that one meal Having some type of a supplement May be the way that you can reach that 30 grams of protein to Remove that when a person in negative energy balance which are not consuming enough energy They’re urging requirements are higher, so they’re higher than 1.5. Grams per kilo and that because the bum’s using pain for energy instead of For tissue synthesis so when you have a person on a very low intake they’re going to need even more protein so It’s very important that you’re realistic about what is this person willing to do? What are they able to do in terms of consumption? There in the hospital as well as for discharge planning when they go home Okay So are there any questions from the hospitals at this point again? I encourage you to please feel free to chime in and ask some questions It made your hand, but we’ve also muted unmuted Deline so you’re welcome to Just step if your ear if you have a question that you’re interested in asking But ask a different question, so if spittle is using the the two Cal HN oral nutrition Supplement to get to increase energy and protein intake is that going to be an effective way to meet the energy and protein requirement Well cute is an Abbott product, and there are two similar products from other But typically it has two calories per arm milliliter and usually these products have about 20 grams of protein per ounce cans looking at about 75 calories and 20 grams of protein and we’ve recommended four years as our DS and our DNA Did you give two ounces of a prop like this that’s high nitrogen high protein? Count Lori with empath and so that’s going to give you about a hundred and twenty calories and 5 grams of protein That help meet energy requirements that 5 grams of protein will not help with tissue synthesis When we’re leading at meat our protein and energy Requirements I think we’ve done a better job with CDs, but we stopped the protein through the day And we’re not giving 30 grams of protein at a meal or at a time that These mini meals aren’t as effective in terms of triggering the tissue sent us this You’re not getting high enough leucine dose dessert to mTOR pathway so you need a med pass use any of the high calorie high nitrogen products if a Increased energy Requirements, but really doesn’t help in terms of meeting Protein requirements optimize tissue synthesis now. We’ll provide some nitrogen But it’s not going to be the subject as having 30 grams at a meal What’s the sugar free collagen base sup oh, I’m sorry did somebody have a question Don’t think I was just wondering about that those sugar free college and base supplements well halogen based supplements um Having to quality some of them are complete sources of protein some of them are not now collagen Naturally does not contain tryptophane, so it’s not a complete source of protein also some deficient amino acids them as well, so it’s not the same as the grant protein from an egg say Elixirs are very popular because in an ounce serving They advertise you can get 15 grams of protein so it may not be complete proteins It’s an elite then you don’t have all the amino acids you need for tissue synthesis And it is much lower in leucine than Playas and whole foods are and it’s not going to be getting that as well now Collagen is very high in nitrogen Does I do with some calories and though you know you could give chances and Even with the two ounces you’re still not getting 1.5. Grams of leucine that you need to start to mTOR pathway So then you want to look at the quality of the protein products you’re using if you are using Protein supplements see if we’re using Whole Foods We that we are getting a full Complement of amino acids the only of yot to that is that your grunt meat products Some MS. Are not complete sources of protein Because they’re fillers or there’s fat Or in them, and so sometimes those don’t come up with Amino acids core a PD cask or 100% But they’re still going to be other than some of the protein supplements on the market that have a lot of significant limiting no antacids, right So again anybody who has questions, please feel free to chime in Or kits about things you’d like to do. What would you like to change in your unit that would? optimize nutrition care We can go back to the action plan and the ordering privileges And I know that you suggested that you know it’s important to read those rules and regulations and then craft a plan I’m wondering if you have any suggestions especially for those hospitals, who? Who don’t have those ordering privileges and you know sucks on the line if if you’re one of those Hospitals that don’t have ordering privileges are there specific questions. You know that you want to kind of tap dr. Richford for right now what would be you know the best way to approach trying to get those And it’s going to be an issue with the state that you live in Anything items from you doctor later on on the you always have to look at your state license your plenty of– if you have licensure for dietitian nutritionist and There are different in each state Um some of the dates are Stating their licensure laws because they’ve been in on the books for twenty years the years ago. We weren’t talking about order privileges or during poojas for the onion So some of the states have Whis or lobbyists in their legislators to update the ordering privileges based on the CMS rule and is within the scope of practice a delegated responsibility And so the arm Hospital can delegate that Respond to you It’s the speech therapist rights died orders for consistency changes and That is a delegated order as well so you always want to be sure it is within your scope of practice and if your skill practice talks about nutrition assessment We base our diet order on is The nutrition assessment, so keep in mind as well So that way your first step, and then and we’ve got to consider your culture in your hospital and the politics and focus on you know What’s the purpose of the final rule and that’s to streamline things to reduce barriers and to? Reduce cost and have benefits for the patients and so focus of those I’m going to do for the patients and what is it going to do for the hospital? Cost-savings come in Well the costings come in and just like with Jay dead went home 8 3 and we pronated difference in his nutrient status In terms of provision of pressure injuries if his dive had been changed on day one did-did-did Some other made some other choices that weren’t very good either that increased to risk for skin breakdown But says nutrition status Deteriorated the three days. He was in the hospital it did not improve, and he went home not really knowing That he risked most likely and that he needed to do something different On and so patient education is very very important But you reduce off for readmissions The study that I hide it The Year law study in Australia found that this investment for the Concealments for the individuals because that’s what was commonly used in Australia That when the provided more nutrition and more nutrition support in other words counseling education products to patients That was 87 percent cost effective so that means it dramatically reduced the number of pressure injuries that they were seeing Right so it fit has pruned to be very cost Effective and that’s something that the American hospitals need to look at very closely if don’t have a plan in place at the moment Well, I think we’re going to have to conclude here and I’m wondering if you can put it advance it all the way to the last slide and Note for those of you Who are still on the line with us that there are some nice references? Listed at the end of the slide deck that you may want to look at some of these resources With that I just want to thank you again dr. Richard that was a great presentation love going through that case study And thank everyone for attending And just remind folks that we’re going to be hearing from Washington and Broward next month and If in mind completing the webinar evaluation we would very much appreciate that So at thank you again dr. Lynchburg. We do well. Thank you for the invitation right and The meeting is adjourned So say one have a good rest of the day