Should standardized language be used to write a nutrition diagnosis?

For most diagnoses all that is needed is an ounce of knowledge, an ounce of intelligence, and a pound of thoroughness. 

— Anonymous

Arabic Proverb. In Lancet (1951). In John Murtagh, General Practice (1998), 125. 

One question that was raised during the MEDNA pilot survey last year was "Should standardized language be used to write a nutrition diagnosis?"

You really can't make a nutrition diagnosis UNLESS you have a standardized language.  In order to make a diagnosis of any kind, you must first have a list of diagnosis with descriptions that can be used to select/assign a nutrition diagnosis.  

To explain this thinking, here is a bit of background on the definition and description of "diagnosis".    

In  the Journal of the American Medical Association, in 1967 LS King, MD, discussed three critical components that needed to be present for the diagnosis process:  
     1-A preexisting series of categories or classes to provide the framework for the diagnosis
     2-A particular entity/situation that is being evaluated (patient's situation)
     3-The deliberate judgement that the entity being evaluated belongs to THIS particular category (versus other categories)

In this article King referenced an older reference, The Principles of Sciences:  A Treatise in Logic and Scientific Method  by Jevons, WS that was originally published in the 1830's and again in 1913.  It described diagnosis as follows:   

 " Diagnosis consists in comparing the qualities of a certain object with the definition of a series of classes;  the absence in the object of any one quality stated in the definition excludes it from the class thus defined;  whereas, if we fine every point of a definition exactly fulfilled in the specimen, we may at once assign to the class in question."  

Webster dictionary states that the first known use of the word diagnosis was in 1655 and it's language origin is from the Greek words,  diagignōskein meaning to distinguish and gignōskein meaning to know (Miriam Webster Dictionary)

So Bottom line:  You need to have a list of categories of nutrition diagnoses and corresponding descriptions that will allow the dietitian to accurately determine whether the patient's signs and symptoms match a preexisting definition of a particular nutrition diagnosis.

References:

King, LS.  What is a Diagnosis?  Journal of American Medical Association.  1967;202(8):154-157.

Jevons, W S. The Principles of Sciences:  A Treatise in Logic and Scientific Method. Second ed.  London, Macmillan and Company, Ltd., 1913.

Current definitions of "Diagnosis" in dictionaries follow:

• The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.(The Free Dictionary)
• The process of determining by examination the nature and circumstances of a diseased condition. (Dictionary.com)
• The identification of the nature of an illness or other problem by examination of the symptoms: (Oxford Dictionary)

Comparative Standards...why are they part of nutrition assessment?

The Nutrition Assessment Terminology includes a domain called Comparative Standards as an additional resource.  To understand why they are included we can go back to the description of nutrition assessment itself.
The Nutrition Assessment Component Summary identifies the following three activities in Nutrition Assessment:

• Reviewing data collected for the purpose of identifying factors that influence nutritional status or health status
• Clustering the data collected to identify a nutrition diagnosis (using the signs and symptoms on the nutrition diagnosis reference sheets as a guide)
• Identifying which standard will be used to compare the data against to determine if it is "unusual", for example either higher than expected or lower than expected.

One type of critical thinking that takes place during the Nutrition Assessment step is to identify what standards should be used to compare the data against, e.g. what is the appropriate comparative standard. How much energy is too much?  to little?  How much Vitamin B6 is too much or too little for this patient?

To assist the dietitian in explaining the care that is being provided we have Comparative Standards.  The E-NCPT includes a sixth domain as an addendum to the Nutrition Assessment terminology that is to be used to document how the dietitian "evaluated" the data collected from the patient or medical record during the nutrition assessment data collection.  These terms allow the dietitian to enter data into fields in the following categories:

Class/Category	Each allows the dietitian to identify both the estimated need as well as method to measure of estimate the need/requirement
Energy Needs	Kcal Specify formula and activity/injury factors used
Macronutrient Needs	Daily intake in grams of fat, protein, carbohydrate (type and total quantity), or fiber Method of estimating (for example if national reference standards are used such as Dietary Reference Intakes or disease related standards)
Fluid Needs	Fluid Method of estimating
Micronutrient Needs	Vitamins (A, C, D, E, K, Thiamin, Riboflavin, Niacin, Folate, B6, B12, Pantothenic acid, Biotin) Minerals (Calcium, Chloride, Chromium, Cobalt, Copper, Fluoride, iodine, Iron, Magnesium, Manganese, Molybdenum, Phosphorus, Potassium, Selenium, Sodium Sulfate, Zinc) Method of estimating needs
Weight and Growth Recommendations	Ideal body weight parameters, BMI, or growth patterns for children (weight for age, length of age, head circumference or weight for stature, or BMI for age)

In addition the Comparative Standards includes additional reference material that addresses concerns that dietitians may have when using national reference standards that were developed for groups of "healthy" people and then applying these standards to individuals who may not be "healthy".

 While the E-NCPT includes the Dietary Reference Intakes (DRI) used in the United States and Canada, it also addresses using other country's national reference standard when they are available.

If you have access/subscription to the E-NCPT the following pages address the information summarized in this blog.

Nutrition Assessment Component Summary in ENCPT

Nutrition Assessment - Identify relevant data by comparing to standards in ENCPT

Guidance for interpreting national reference standards - both US and Internationally in ENCPT

Roadmap for Implementing NCP

"Good ideas are not adopted automatically. They must be driven into practice with courageous impatience. Once implemented they can be easily overturned or subverted through apathy or lack of follow-up, so a continuous effort is required.“
-- Admiral Hyman Rickover (1900-1986)
The Academy of Nutrition and Dietetics Nutrition Care Process and Standardized Language Committee reviewed change management literature from 2003 to 2008.  One reference used was the book Leading Change.  John Kotter of Harvard Business School published steps in implementing organizational change that have been used to guide teams of dietitians as they implemented the Nutrition Care Process and standardized language.  Kotter's eight stage process can easily apply to teams of dietitians implementing the nutrition care process in medical organizations.

Kotter's Eight Stage Process used to lead successful change is:

1-Establishing a Sense of Urgency

Examine the circumstances leading to the decisions to implement, identify and discuss crises, potential problems or major opportunities

2-Creating the Guiding Coalition

Put together a group with enough power to lead the change and get the group to work together as a team

3-Developing and Vision and Strategy

Create a vision to help direct the change effort and developing strategies for achieving that vision

4-Communicating the Change Vision

Use every way possible to communicate the new vision and strategies and have the leadership demonstrate the behavior expected of others in the organization,  

5-Empowering Employees for Broad-Based Actions

Eliminate obstacles, change structure or systems that undermine the vision and encourage risk taking, nontraditional ideas, activities and actions.  

6-Generating Short-Term Wins

Plan for visible improvements in performance, create those wins and visibly recognize and reward people who make the wins possible.

7-Consolidating Gains and Producing More Change

Use newly developed successful processes/products to change all systems, structures, and policies to be consistent with new vision.  Develop the capacity of people who CAN implement the vision and re-imagine the process with new projects, themes, and change agents.

8-Anchoring New Approaches in the Culture

Create better performance through focused, leadership, management; articulate the connections between the new behaviors and organizational successes, ensure leadership development and succession.

Read more examples of implementation through published journal articles.  For example, the Journal of the Academy of Nutrition and Dietetics has special feature called "collections".  One of the collections that have been gathered is a group of articles published on the Nutrition Care Process and standardized language.  If you log on to the Journal page, the "collections" tab is the second tab on the navigation bar.  You will find several articles that summarize various methods use to implement the NCP and standardized language.  

Kotter, J.P.  Leading Change, Harvard School Press 1996

Journal of Academy of Nutrition and Dietetics

Seems like the NCP and IDNT is for the dietitian....not the patient??

For Dietitian??  or  For Patient??  or BOTH??   It would seem that the process is for both.  While it is true that the dietitian is the professional that "uses" the process to provide high quality services, the patient really receives the benefit.

The model clearly recognizes the need to put the patient in the CENTER of  the dietitian's activities as shown in the model.  While the model describes the activities from the dietitians viewpoint, the words used are intended to describe a COLLABORATIVE process.

The words used in the 2008 NCPM article describing this are:  " The central core of the model depicts the essential and collaborative partnership with a patient/client. The model is intended to reflect the dynamic nature of relationships throughout the NCPM."

In the chapter/text describing the intervention the following is included: " It is most desirable to set goals jointly with the patient/client".

The Nutrition Counseling intervention is described as "a supportive process, characterized by a collaborative relationship between the counselor and the patient/client to establish food, nutrition and physical activity priorities, goals, and action plans that acknowledge and foster responsibility for self-care to treat an existing condition and promote health."

The IDNT or NCPT (Nutrition Care Process Terminology) is designed to concisely describe the elements and results of each step in the care process using terms familiar to healthcare professionals, not necessarily patients.  The goal of the terminology as stated in the 2008 article on the terminology is to  "provide a standardized set of terms used to describe the results of each step of the model".  The initial list of standardized terms was developed in the United States and heavily reflects the common healthcare language at the time of development.  The cultural and language differences are acknowledged during the "translation" process for the standardized language into other languages, e.g Swedish, French, or Norwegian.  The persons completing the translation have found situations when there are no comparable words that correspond directly to the meaning of the US term or when terms are used differently in different cultures.

The new webpage NCP 101 includes additional information and links to materials that may be helpful.

Link to 2008 NCPM Article
Link to 2008 IDNT  (terminology) Article
Link to NCP 101 webpage

Can NCP be implemented without government or organizations enforcing implementation?

"You've convinced me. Now go out and make me do it."  This statement was made by Franklin D Roosevelt, 32nd President of the United States (1933-1945) when he met with supporters and asked for their grassroots support for his government programs.  
Perhaps this quote applies to one of the questions posed by participants in the MEDNA survey which was about the need for "enforcement" in order to successfully implementation of the Nutrition Care Process and standardized terminology.  

The NCP Model diagram clearly acknowledges the importance of the healthcare environment as it impacts the NCP ( it is specified in an outer ring).  Certainly support from government ministries, agencies that regulate healthcare, and professional organizations is highly desirable and will greatly facilitate the speed with which the NCP implementation and use of the standardized terminology can occur. Dietitians must be knowledgeable of their healthcare environment to determine how to best approach the implementation so that it is consistent with existing regulations in their healthcare systems.  

But since the NCP is the thinking process that the dietitian uses as they provide care, this aspect of our profession practice is rarely completely controlled or enforced by a governmental agency or professional association.  The same is true of the words (standardized terminology) that is used in our documentation in the medical record to describe the nutrition care that we provided.  Governmental agencies and professional societies/organizations often do not have the authority or desire to control a practicing dietitian at this level of detail.  So while support is highly desirable, it is not likely that "enforcement" is required prior to starting implementation of  the NCP and standardized terminology.

For example in the United States, the Academy of Nutrition and Dietetics fully supports the NCP implementation, but  does not have any authority to actually "enforce" the actual implementation in daily practice.  Position papers, practice papers, books, publications, and evidence based guidelines provided by the Academy to assist dietitians in practice now reflect the Nutrition Care Process.  The Commission of Dietetics Registration includes it in the national registration examination along with the other topics.  ASCEND, the accrediting body for dietetics education programs, also includes it in the standards of education, but seeking accreditation is technically a voluntary process.  The incorporation of the NCP into these processes and documents has taken a decade.

In the United States, the use of the NCP and standardized terminology are not in conflict with governmental regulations or other healthcare standards.  In fact, the use of the NCP is helpful in meeting accreditation standards by The Joint Commission that require that a standard approach to nutrition care be followed.  

The Clinical Dietetics manager typically would have a key leadership role in directing the dialogue about how the NCP and standardized terminology should be used in their facility. However we have found that dietitians at all levels in the organization have taken the lead in learning about the NCP,   bringing up the topic,  educating others on the topic,  and being the ones that "experiment" with implementation.  One of our first implementation sites in the United States was started by a dietetic intern who was assigned to provide an "inservice" to the dietetics staff on the new concept of nutrition diagnosis.  Her inservice project provided the impetus for implementation and eventually the publication of the article that described their implementation process. (See article listed below)

In the end, it is up to the healthcare organization that actually hires and directs the work of the dietitian to set the job performance standards and "ensure" that the NCP and standardized terminology are implemented.  The hospital or healthcare organization develops the position descriptions, determines if they will audit the records for completeness and accuracy of nutrition care, and establishes the scope of practice for the dietitian in their organization.  

Bottom line:   the healthcare organization that employs the dietitian usually has the most influence on the actual implementation process.  

Mathieu, J, Foust, M, Oullette, Implementing Nutrition Diagnosis, Step Two in the Nutrition Care Process and Model: Challenges and Lessons Learned in Two Health Care Facilities.  J of Am Diet Assoc 105(10):  2005.  P 1636-1640  http://dx.doi.org/10.1016/j.jada.2005.07.015

“We are stuck with technology when what we really want is just stuff that works.” NCP & EHRs

“We are stuck with technology when what we really want is just stuff that works.”  quote from -- Douglas Adams, author of The Salmon of Doubt.
We have a love-hate relationship with technology...especially Electronic Health Records (EHR).  It would be nice if someone just came up with the perfect answer for how to incorporate NCP into an EHR.  But, there are almost as many ways to incorporate the Nutrition Care Process and terminology into the E H R as there are dietitians.  You can start incredibly simple or it may require extensive  programming by informatics specialists.  Your organization needs to determine what will best meet your needs.

On the simplest end of the continuum, a template can be developed with standard headings with "free text boxes" to prompt the dietitian as they write their progress note.  As shown below, the dietitian then simply types in the data and information just as he/she might write a note long-hand but uses the terminology as appropriate.  Sample headings shown below:

• Assessment/Re-Assessment
• Monitoring and Evaluation Data (Follow-up Note only)
• Nutrition Diagnosis
• Status of Previous Nutrition Diagnosis (Follow-up Note only)
• Nutrition Prescription
• Nutrition Intervention
• Plan for Monitoring and Evaluation

The purpose of this type of template would be to assist the dietitians in remembering to follow the process and document their care using the standardized terminology.  However it provides only extremely limited ability to capture data to use for reporting outcomes management or summarizing the type of nutrition care being provided in the institution.  It relies completely on the dietitian to remember and use the correct terms.  If you are able to recall reports, the "data files" will be the free text and someone will have to go through and create "countable data" from each file manually in order to summarize.  The types of things that might be useful would be the percent of patients where the Nutrition Diagnosis is improved or resolved, the frequency of nutrition diagnoses, frequency of nutrition interventions.  This is clearly not optimal and does not harness any of the benefits of the electronic health record!!

On the other end of the continuum would be the capability to program decision support prompts to help the dietitian enter patient care, similar to what the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) system does.  It automatically incorporates the data fields, data terms for Nutrition Diagnosis, Nutrition Intervention, and Monitoring and Evaluation.  And it "prompts" the dietitian with the most common etiologies, signs and symptoms and intervention to match the nutrition diagnosis/etiology.  This type of "smart" system will yield the most benefit in terms of saving time and allowing the users to create meaningful reports and analyze data to answer key questions about outcomes.   

The website contains a number of short videos that describe how the ANDHII works so a person can visualize the potential capabilities.  The best video to start with might be the overview of the Smart Visit.  When you see the demonstration of the Nutrition Diagnosis you will see that ANDHII automatically pre-populates suggestions for etiologies and signs and symptoms. 

The solution for your organization is likely somewhere in between these two extremes.   If you need help learning about how to work with electronic health records a toolkit (one per institution) was created for dietitians is available in the Academy "shop".

Please share your experiences in incorporating both NCP and the terminology into electronic health records!!

References:

Murphy, W, Steiber, A.  A New Breed of Evidence and the Tools to Generate It: Introducing ANDHII

Journal of the Academy of Nutrition and Dietetics, 2014:115(1)p 19-22  

DOI: http://dx.doi.org/10.1016/j.jand.2014.10.025

Like Hand in Glove...The Evidence-Based Nutrition Practice Guidelines and NCP go together!!

The Evidence Based Practice Guidelines published on the Evidence Analysis Library are organized by the steps in the Nutrition Care Process.  The specific project on the EAL that discusses critical care is called the Critical Illness project.  

On the introductory page to the project the Executive Summary is available to the public.  The recommendations are organized into Nutrition Assessment, Nutrition Intervention, and Nutrition Monitoring and Evaluation.  

Recommendations that are included in the Nutrition Assessment section include the following topics:

• Assessment for Critically Ill Patient (identifies the types of data to be collected and evaluated)
• Reassessment of Critically Ill Adults (identifies the data commonly used in re-assessments)
• Resting Metabolic Rate Predictive Equations for Non-obese Critically Ill Adults
• Resting Metabolic Rate Predictive Equations for Obese Critically Ill Adults

Recommendations that are included in the Nutrition intervention section include the following topics:

• Nutrition Prescription for Critically Ill Adults (identifies what should be included)
• Enteral vs Parenteral Nutrition (includes when indicated and contra indicated)
• Use of Promotility Agent (identifies when they are recommended)
• Enteral Formulas Containing Immune-Modulating Nutrients in Patients without ARDS or Acute Lung Injury
• Enteral Formulas Containing Immune-Modulating Nutrients in Patients with ARDS or Acute Lung Injury
• Addition of Fiber to Enteral Nutrition to Reduce Diarrhea
• Supplemental Enteral Glutamine (summarizes research and identifies one potential target population)

Recommendations that are included in the Nutrition Monitoring and Evaluation Section are: 

• Monitoring and Evaluation of Critically Ill Adults (includes data  to be used)

If  you are a member of the Academy of Nutrition and Dietetics or if you subscribe to the Evidence Analysis Library, the systematic reviews and other supporting materials are also available.  

BOTTOM LINE:  The Nutrition Care Process steps are used to organize the recommendations for care in the Evidence Based Nutrition Practice Guidelines for Critically Ill Patients.