Destination Nutrition

The Calorie Count Process

Importance of Adequate Calories and Protein

The body needs adequate calories and protein to supply the body with energy

This prevents malnutrition, muscle wasting, and helps the healing process

Malnutrition in the Hospital

On average 1 in 3 patients admitted to the hospital are malnourished1

Malnourished patients are 2-times more likely to develop a pressure ulcer in the hospital2

Pressure ulcers can increase length of stay by 4.3 days3

Nutrition care has been shown to reduce pressure ulcer incidence by 25%4

1Allaudeen N, et al. J Hosp Med. 2011;6:54-60. 2Banks M et al. Nutrition 2010;26:896–901. 3Fry DE, et al. Arch Surg. 2010;145:148-151. 4Bauer, JD et al. J Hum Nutr Diet. 2007:20:558-564.

Malnutrition in the Hospital

If a patient is not meeting their recommended calorie and protein needs, further nutrition intervention may be required TPN, PPN, Tube Feeding

Oral Nutrition Supplements such Ensure Plus shakes can be sent with meals for added nutrition

What is a Calorie Count?

Policy: “Calorie Counts are conducted when ordered by a patient’s physician or other health care team member, or at the discretion of the dietitian.”

Purpose: “To document the patient’s calorie count and protein intake and need for additional nutrition intervention.”

Who is Involved?

Who Orders the Calorie Count? Physician, Registered Nurse, or Registered Dietitian

Who Implements the Calorie Count? RD or Diet Tech displays the materials

Who Records the Data? RN or Nursing Assistant records % on tickets RD or Diet Tech documents the information in the

medical record

Calorie Count Process Prior to 2012 Tape 3 papers to door

Nursing would manually write each food item and % consumed by the patient

Compliance was poor Too time consuming to

record meals

New Process as of 2012

A purple Calorie Count sign is hung outside the patient’s room

A yellow Calorie Count envelope is hung on the door

“Calorie Count” will be written on the patient’s white board

New Processas of 2012

Nursing will document the % eaten on the patient’s meal ticket and place it in the envelope

A dietitian or diet technician will total the calorie and protein intake and document it in Sorian Clinicals

Barriers to Compliance

Patients on calorie counts are low volume, high risk

There are many different shifts for nursing staff (i.e. day, night, weekend, per diem) making communication challenging

Kitchen staff may be removing trays from rooms prior to calorie counts being recorded

Diet Office may not be tagging every ticket with Calorie Count tray message

Steps to Further Improve Compliance

These green tags will be delivered to the nursing station by the Tray Passer when a Calorie Count Tray has been delivered to a patient’s room

This will notify the patient’s RN that a Calorie Count needs to be documented

This step was implemented as of March 1st

Calorie Countwas just delivered to Room # _________

PLEASE NOTIFY THE NURSEDo not discard tray until percentages are recorded

Compliance: One Patient

Meals Ordered

Meals Recorded

% Compliance

Oct 10 3 3 100%

Oct 11 3 2 67%

Oct 12 3 3 100%

Oct 13 3 2 67%

Oct 14 3 2 67%

Oct 15 3 2 67%

Oct 16 3 3 100%

Overall 21 17 81%

Compliance by Month

Meals Ordered Meals Recorded

% Compliance

September 54 28 52%

October 83 56 67%

November 43 18 42%

December 12 8 67%

January 17 9 53%

February 44 30 68%

March 35 21 60%

Overall 288 170 59%

Compliance by Month

% Compliance By Month

40%

45%

50%

55%

60%

65%

70%

September October November December January February March

Month

% C

om

plia

nce

Arrow indicates month where new step was added to the process in an attempt to increase compliance

Data Analysis

Having the green calorie count tray tags sent to the nursing station when a calorie count tray has been delivered resulted in a 60% compliance for the month of March

There were 2 patients on Calorie Counts in the month of March

In 90 days a re-review of compliance will be completed and further steps to increase compliance will be discussed

Process Improvement SummaryCalorie Count Process

October 2012 – February 2014

Goal StatementGoal Statement Data and TrendingData and Trending Lessons LearnedLessons Learned

Rationale/Previous ConditionRationale/Previous Condition

Food & Nutrition Services and Nursing will collaborate in achieving a 90% or higher compliance rate with documentation of Calorie Count Assessments.

Changes being Tested (T), Changes being Tested (T), Implemented (I) or Spread (S)Implemented (I) or Spread (S)

Recommendations and Next Recommendations and Next StepsSteps

1. Add Calorie Counts to the nursing electronic work list

2. 90 day follow-up to determine compliance improvement

Team MembersTeam Members

Carol Bergin, Melanie Wheeland, Caitlin Morgan

In accordance with NH RSA 151:13-A This Hospital Quality Improvement Document shall be confidential and privileged.

Our preferred standard of compliance wasn’t being met for the following reasons

• A low volume of calorie counts per month can make it difficult for staff to remember to complete the calorie count

• There are many different shifts for nursing (i.e. day, night, weekend, per diem) making communication challenging

• Kitchen staff may be removing trays from rooms prior to calorie counts being recorded

1. There was poor compliance for documentation of Calorie Count Assessments

2. Accurate depictions of patients calorie and protein intake were not being recorded

1. Food & Nutrition Services will put a green calorie count ticket on each calorie count tray to be dropped off at the nursing station as a reminder for nursing to complete the calorie count.

Data AnalysisData Analysis

% Compliance By Month

40%

45%

50%

55%

60%

65%

70%

September October November December January February March

Month

% C

om

pli

an

ce

A new step of the process which consists of adding a green calorie count ticket to each tray to be dropped off at the nursing station was implemented as of March 1st. Compliance for the month of March was 60% so it does not appear to have increased with the new step added.