Dining Practice Standards 101: Part 2 Contributed by Rose Hoenig, RD, CSG. LD, and Carol S. Casey,...
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Transcript of Dining Practice Standards 101: Part 2 Contributed by Rose Hoenig, RD, CSG. LD, and Carol S. Casey,...
Dining Practice
Standards 101: Part 2
Contributed by Rose Hoenig, RD, CSG. LD, and Carol S. Casey, RD, CDN, LDN, SFPM, FSM
Review Date 12/11G-1753
New Standards of Practice
These nationally agreed upon new food and dining standards
of practice support individualized care and self-directed living vs traditional
diagnosis-focused treatment for people living in nursing homes. The document includes the new
Standards of Practice.
Standards of PracticeIndividualized Nutrition Approaches/Diet Liberalization Individualized Diabetic/Calorie-Controlled Diet Individualized Low-Sodium Diet Individualized Cardiac Diet Individualized Altered Consistency Diet Individualized Tube Feeding Individualized Real Food First Individualized Honoring Choices Shifting Traditional Professional Control to Individualized Support of Self-Directed LivingNew Negative Outcome
10 Dining Practice Standards
Reflects current thinking and consensus, which are in advance of researchReflects evidence-based research available to dateThe current thinking portions of each of the new Dining Practice Standards represent a list of recommended future researchhttp://www.pioneernetwork.net/Providers/DiningPracticeStandards/
It Is All About F-Tag 281
F281 §483.20(k)(3) (3) The services provided or arranged by the facility must—
(i) Meet professional standards of quality and Intent §483.20(k)(3)(i): The intent of this regulation is to assure that services provided meet professional standards of quality, in accordance with a specific definition
F-Tag 281 (cont’d)
Interpretive Guidelines §483.20(k)(3)(i):
“Professional standards of quality” means services that are provided according to accepted standards of clinical practiceStandards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting
F-Tag 281 (cont’d)
A professional organization, licensing board, accreditation body, or other regulatory agency may publish standards regarding quality care practices. Recommended practices to achieve desired resident outcomes also are found in clinical literature.
F-Tag 281 Standards of Practice Standards are published by
professional organizations, such as: Academy of Nutrition and
Dietetics American Medical Association American Medical Directors
Association American Nurses Association National Association of Activity
Professionals National Association of Social
Work (Cont’d)
F-Tag 281 Standards of Practice
Current manuals or textbooks on nursing, social work, physical therapy, health care guidelines, etcClinical practice guidelines published by the Agency of Health Care Policy and ResearchCurrent professional journal articles
Based on:
Interpretive Guidelines §483.20(k)(3)(i):
If a negative resident outcome is determined to be related to the facility’s failure to meet professional standards and the team determines a deficiency has occurred, it should be cited under the appropriate quality of care or other relevant requirement
Elements of Each Dining Standard
Basis in current thinking/researchRelevant research trendsRecommended course of practiceReferences
“All Decisions Default to Personal
Choice”
Dining Practice Standard 1
Individualized Nutrition
Approaches:
Diet Liberalization
Liberalized Diets Research
Evidence-based research continues to support that therapeutic diets are detrimental at worst, neutral at best for the elderly
Liberalized Diets Research
Restrictive diets are a frequent cause of weight lossPhysicians are encouraged to liberalize dietsMedical needs are balanced with quality of lifePrevention of weight loss is viewed as a priorityResident’s goals and wishes are followed
Letting Go of Therapeutic Diets
Fear of regulations may fade over timeIndividualized and resident-informed choice frequently found in regulationsIt is our duty to educate residents of the consequences, good or bad, of their choices then allow them to make choices
Dining Practice Standard 2
Individualized Diabetic/
Calorie-Controlled Diet
Research on Diabetic Diets
Intensive treatment of diabetes sometimes is not appropriate for all individuals in the long-term care (LTC) settingNo evidence to support no-concentrated sweets, no-added-sugar diets for older adults in LTC—using medication rather than dietary changes can enhance the joy of eatingAMDA: Target of A1c 7–8 discourages use of sliding scale insulin
Dining Practice Standard 3
Individualized Low-Sodium Diet
Research on Low-Sodium Diets
May benefit some individuals, but in frail elderly more lenient blood pressure goals and more lenient diets are neededA liberal approach sometimes is needed to maintain nutritional statusTypical 2-gram sodium diet achieved only modest effect on blood pressure and is not shown to improve cardiovascular outcomes in LTC residents
Dining Practice Standard 4
Individualized Cardiac Diet
Research on Cardiac DietsDiets are not shown to improve control or affect symptoms
Dietary Guidelines for Americans and/or DASH diet can achieve goals
Important to balance restrictions with adequate nutrition
Aggressive lipid reduction in LTC is more effectively achieved through use of medications
Dining Practice Standard 5
Individualized Altered Consistency
Diet
Research on Altered Consistencies
Swallowing abnormalities do not necessarily require modified textureCollaborate with doctor, speech pathologist, registered dietitian, and other professionalsLook beyond symptoms to underlying causes to avoid excessive modification of food/fluidSometimes it is necessary to evaluate tolerance of aspiration risk, compared to the slow process of wasting away
Dining Practice Standard 6
Individualized Tube Feeding
Research on Tube Feedings
Is not an automatic step when other strategies have failedDoes not ensure patient’s comfort or eliminate aspiration risk (abdominal distention, diarrhea, and restricted movement)Is not always appropriate for advanced disease statesWhat does/did the patient want?
Research on Tube Feedings
Tube placement will not resolve oral secretions/gastric content issues Weight gain from tube feeding is not shown to correlate with improved clinical outcomesDecreased socialization and depravity of the social experience at mealtimes are strong considerations by many
(Cont’d)
Enteral Feeding Decisions
Patient Rights and Informed Consent/Refusal Across the Healthcare Continuum, 2005 Mayo Clinic ProceedingsSee pages 52–56 of Dining Practice Standards for Enteral Algorithm for Decision Making
Arguments for placing a tube for feeding include improving nutritional status. Studies in the elderly with dementia have shown little to no improvement in weight.
Tube feedings also are considered for wound care as a means to improve wound healing. Data over a 6-month follow-up have shown no impact on pressure ulcers or infections associated with wounds.
Feeding tubes do not improve quality of life.
An association with physical or psychosocial discomforts related to the tube feeding is a negative consideration.
Dining Practice Standard 7
Individualized Real Food First
Research on Real Food FirstProvide naturally soft, smooth texture before pureed foods when possible (yogurt, puddings, ice cream, and vegetable soufflés)Create meals comparable to homeSelect from approved sources from family and friends, gardensServe food before supplementsChoose homemade before commercialUse flavor enhancers
Flavor EnhancementTaste and smell losses occur with aging, which can decrease food enjoyment, reduce food consumption, and negatively influence nutritional status.Flavor enhancers can compensate for the diminished sensory function, which is a contributing factor to impaired appetite and decreased intake in the elderly.What are flavor enhancers? They are food additives commonly added to foods, designed to enhance the existing flavors of products. You can use commercially manufactured flavor enhancers, but the best flavor enhancers are those found in an ordinary spice rack or pantry.You can make bland, tasteless meals a thing of the past with the improvements of culture change and dining practices.
Examples of Flavor Enhancers
Spices and herbs: Basil, garlic, dill, rosemary, lavender, mint, pickling spices, thyme, sage, etcSeasonings or flavor enhancers: Ancho powder, chili powder, Accent® (monosodium glutamate [MSG]), Spike® (hydrolyzed vegetable protein), anchovies and anchovy paste, balsamic vinegar, Bon Appetit® Seasoning Salt, capers, Chef Paul Prudomme’s® Seasoning Blends®, Chile peppers, citrus fruits (juice and zests), grapes, molasses, Old Bay® Seasoning, onions, pepper, peppermint oils and extracts, sugar, date sugar, Tabasco®, tahini, truffle oil, cooking wine, etcResource: http://whatscookingamerica.net/herbs.htm
Staff Creativity CombinesWith Resident Choices
The standard cooking techniques, recipes, and bland foods are no longer the Gold StandardStaff must bring creativity to food preparation, trying new recipes, new cooking techniques and food combinations, and flavor enhancementsStaff and residents must form an alliance in menu choices and selections
Additional Factors to Assess for Decreased or Poor
Appetite
Diagnostic or assessment factors that could impair appetite Active diseases and conditions that have the potential to negatively affect appetite Potential food and drug implicationsSurgical interventions—anesthesia has
a tendency to interfere with appetite Environmental issues, including texture and appearance of food