Want better wound care healing and outcomes? Add a dietary consult
Want better wound care healing and outcomes? Add a dietary consult
Kansas agency’s program targets chronic wounds
Including dietary consults is not a routine part of many home care wound programs, although the referrals could help improve outcomes. But Susan B. Allen Memorial Hospital Home Health Agency in El Dorado, KS, recently changed its routine chronic wound program to include a dietary consult that’s not just for patients who are considered at risk.
"Based on current research and workshops I’ve attended on wound care, it became apparent to me that the dietitian was a very integral part of our wound care team that we were not utilizing," says Melinda May, BHS, RN-RRT, director of the hospital-based home health agency that serves two large counties in south-central Kansas. "We as RNs and health care professionals could be going out and doing daily wound dressings and keeping the wound clean, but unless you changed a nutritional status, the patient’s care would be very long term and a costly endeavor."
Elderly patients who often have comorbidities sometimes have poor nutritional habits, which prevents the body from most effectively healing itself, May adds.
"The elderly usually have a comorbidity, whether it’s peripheral vascular disease, diabetes, decreased nutritional status, malnutrition, obesity, venal insufficiency, or others that are costly to home care agencies," May explains. "My RNs are very excellent assessors, but when you look at the issue of nutrition, there are a lot of things we would not know to catch."
The home care agency has implemented a policy to have a dietary consult for all chronic wound care patients. Acute wound care patients would receive the consult only when the patient appears to be at risk, May says.
The policy is too new to measure outcomes, but the agency will gather baseline and intervention data to see if patients are healing more quickly.
Here’s how the program works:
1. Initial assessment.
Within 24 hours of the agency receiving a referral, the initial assessment is done. If the clinician sees that the patient has a chronic wound, then the patient would be referred to a dietitian. The agency’s policy is to have the dietitian follow-up on the referral within 48 hours, May says.
"She’ll go through her nutritional assessment and come up with a plan, whether it involves meal planning, a change in diet or increasing protein intake," May says. "Then she writes her dietary plan for the patient and follows up as needed."
The agency submits a physician order for the dietary consultation and the dietitian is given flexibility in how many visits are necessary, since some patients will make the necessary changes after one visit and for others, three or four visits may be necessary, May adds.
2. Nutritional assessment and intervention.
During the nutritional assessment, the dietitian reviews dietary information and instructs the patient on changes needed to promote healing. Patients often do not understand how wounds heal and how the foods they eat could affect that healing process, May explains.
"We have them look at food as medicine for the wound itself and if they put the correct medicine in their bodies then they will heal that much faster," May says.
The patient receives written nutritional information that the dietitian will review with the patient. They include food and medicine guides developed by the American Heart Association of Dallas; the U.S. Department of Health and Human Services of Rockville, MD; Sandoz Pharmaceuticals Corp. of East Hanover, NJ; Krames Communica-tions of San Bruno, CA, and other pharmaceutical companies. (See handout about food and drug interaction, p. 87.)
However, the nutritional assessment and education are designed for a particular patient’s needs and preferences. For instance, if a patient has certain cultural preferences in meals, then the dietitian will take them into consideration when devising a diet. The dietitian also will check with the patient to learn what vitamins and supplements are being taken, and if there are none, the dietitian may educate the patient about the importance of vitamin and mineral supplements. Nurses also review with patients information about how to prevent medical errors, including those resulting from the use of over-the-counter food supplements. (See tips on preventing medical errors, p. 88.)
The dietitian then tells the nurse what dietary information has been reviewed and what needs to be reinforced.
3. Monitoring patient status.
Nurses and the dietitian discuss patients’ wound care and nutritional status at weekly case conferences. Sometimes these sessions result in the dietitian hearing about a particular case in which the dietitian needs to be involved, although a referral had not yet been made.
When the dietitian makes only one visit to a patient, the nurses will continue to monitor the patient’s progress, including nutritional status. Nurses ask patients questions to assess whether they are following the dietitian’s guidelines. When patients don’t comply, it’s noted in their chart.
May says this information will be collected and analyzed to see if wound outcomes are better for patients who receive the nutritional assessment and adhere to the dietitian’s recommendations when compared with patients who receive the information but do not adhere to the dietary plan.
4. Providing multiple visits.
If a nurse reports at a case conference that a patient is not adhering to the nutritional plan, then the dietitian may pay the patient another visit and reinforce the importance of nutritional status to both the patient and family caregivers.
"A lot of times they see the same nurse day after day, and it’s good to have a new face visiting them who will reiterate what we’re trying to accomplish," May says. "So if we feel like we need an extra push to make the patient more adherent, we’ll send the dietitian back out."
However, nurses and the dietitian cannot force a patient to improve his or her diet. "We stress that you don’t have to do this, but it will help you to become more independent and allow you to do the things you want to do in your life," May says.
Sometimes, it simply will not work. For example, the agency had a younger non-Medicare client who had renal disease and was an alcoholic. The patient was shuttled back and forth between dialysis, home care, and acute-care services. No matter how the dietitian and nurses explained to the patient that continued alcohol use would only keep the patient ill, the patient would not stop drinking and there was nothing they could do about the problem, May recalls.
In other instances, the dietitian may need to repeat the education because the patient has poor cognitive status and was unlikely to understand or remember the information after only one visit.
And, in at least one case, the dietitian had to meet again with a patient and family because interpersonal dynamics between the patient and a daughter were causing conflicts. The daughter was severely strict with her mother over what she could and could not eat. The mother thwarted her daughter’s efforts by asking a neighbor to sneak cookies to her. Finally, the dietitian had to meet with the daughter and explain that the patient has the right to eat the wrong foods and that the staff and family can only encourage her to adhere to her meal plan.
Selling nutrition is part of the dietitian’s duties, May notes. "Our dietitian loves to do this work and she loves home care with a passion, so this is something she really has a heart for."
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