Support Line August 2007 Volume 29 No.

Clinical Nutrition Quality Indicators and Patient Outcomes

Lisa McDowell, MS, RD

Abstract
In collaboration with medical and
surgical initiatives for quality improve-
ment, the nutrition support service
must identify relevant quality objectives
to advance performance improvement.
The success of these initiatives is largely
dependent on the ability of the nutrition
service to “hardwire” the process into
the nutrition care plan. Inpatient
registered dietitians (RDs) should
align their quality indicators to meet
the needs of their patient population
or specialty service. Developing safety
initiatives with quality care components
such as computerized order entry for
prescribing nutrition provides consistent
care delivery. Partnering with physician
champions allows for the implementa-
tion of hospital-wide policies, procedures,
protocols, privileges, and computerized
order entry pathways. Improving out-
comes and achieving defined metrics
creates essential staffing productivity
requirements within each service line,
providing justification for staffing
levels and resulting in overall quality
improvements.
teaching hospital. Specific initiatives
and their effects on clinical operations,
staff performance, and patient out-
comes are reviewed.
Quality Initiatives in
Nutrition Support
There are numerous opportunities
for the pursuit of quality initiatives
related to nutrition therapy based on
the IOM quality aims (Table). In our
teaching hospital, the nutrition service
partners with each area of surgical and
medical specialty (service lines) and
the RDs participate on various service-
line collaborative practice teams. In
addition, an RD represents nutrition
issues on various hospital committees
such as Pharmacy Medication Use,
Medication Safety, Formulary
Committees, Research Task Forces,
and Medical Staff Quality Groups.
Each RD is required to define metric
objectives during the performance
Figure 1. Institute of Medicine quality aims.
appraisal process that are determined
in collaboration with the service-line
goals. A few examples include appro-
priate use of therapy, complications
associated with nutrition treatment,
patient satisfaction, compliance with
protocols, and glycemic control.
Individual performance assessment
involves defining how the metric meets,
exceeds, or does not meet expectations,
with corresponding monetary com-
pensation to pay for performance. All
nutrition orders are entered electroni-
cally within nutrition care sets, which
allows the service to devise safe path-
ways for ordering enteral (EN) and
parenteral nutrition (PN) support.
Both National Safety Goals and Joint
Commission standards can be incorpo-
rated into the pathways. Compliance
with complete quality documents by
the RD is maximized when the initia-
tive is hardwired into the process.
(Continued on next page)

Introduction
Quality improvement has become
an integral component of health care.
Commercial insurers and the Centers
for Medicare & Medicaid Services offer
incentives and superior reimbursement
to hospitals that exceed best practice
benchmarks (1–9). The American
Hospital Association (AHA) Quality
Center™ provides access to resources
and tools that support hospital initia-
tives for quality improvement (10). In
2001, the Institute of Medicine (IOM)
described six quality aims that provide
a foundation for the implementation
of the AHA quality and patient safety
agenda (11). These include: patient
safety, patient-centeredness, efficiency,
effectiveness, timeliness, and equity
(Fig. 1). This article examines quality
initiatives that have been established
by the nutrition support service of one

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Support Line August 2007 Volume 29 No. 4
Table. Nutrition Indicators Related to the Six Institute of Medicine
Quality Aims
Indicator Sample Quality Monitor
Patient Safety • Correct permanent feeding tube selection
• Avoidance of central line placement if therapy duration
is less than 7 to 10 days
• Tight glycemic control (serum glucose: 90 to 140 mg/dL)
• Criteria for therapy use
Patient- • Home enteral nutrition patient satisfaction survey
Centeredness • Consideration of patient wishes and ethical issues prior
to permanent tube feeding placement
• Creation of patient-friendly schedules for specialized
nutrition support delivery
Effectiveness • Evidenced-based practice
• Glycemic protocols
• Criteria for enteral nutrition specialty formula use
Efficiency • Protocol pathways for providing specialized nutrition
support
• Order sets for multivitamin and trace element therapy
• Wound care protocols
Timeliness • Consult response time within 48 hours
• Early enteral feeding to prevent malnutrition
• Preoperative oral supplementation when poor
nutritional status identified by physician
Equity • Consistent care to all patients
• Age-specific competencies defined and measured
For example, the RD specializing in positively affects hospital-wide patient
glycemic control for patients receiving care by improving glycemic control
nutrition support collaborates with the when the metrics are reached. As each
diabetes section and collaborative staff member commits to meaningful
practice team to implement insulin- performance objectives, departmental
dosing strategies for patients receiving commitment to quality increases. Best
nutrition support therapy. The RD practices have been achieved at our
works within defined structures of the hospital when the objectives are
hospital for gathering data, including included in the collaborative service-
the Institutional Review Board (IRB) line quality plans. Further, aligning
and the Quality Institute. The data are RD performance improvement
analyzed, and protocols are developed, opportunities within specialties
implemented, and monitored for success improves employee engagement and
by the nutrition team via their partici- job satisfaction (12–16), thereby
pation on collaborative practice teams improving resource utilization and
as data relates to each practice area. decreasing staff turnover.
The metric of improvement is quanti- Each employee is held accountable
fied and examined in the individual RD for quality improvement outcomes
performance appraisal. Through this related to his or her skill set (17–19),
process, the RD becomes committed to and the clinical nutrition manager or
the objective and develops a sense of pharmacy director is held accountable
ownership in relation to the outcome. for knowing individual strengths and
For the original glycemic control aligning quality initiatives to support
initiative, the original individual the individual. Clear competency
performance appraisal objective measures form the basis for objective
–4–
skill assessments that are crucial to
quality care (20,21), and advanced-
level practice is achieved as clinical
skills are enhanced (22–25). Such
practice is defined by RD job descrip-
tions and pay grades associated with
advanced-level practice. Finally,
opportunities resulting from quality
initiatives include invitations to
conduct research, teach, publish,
and present.
Many nutrition services struggle with
the areas identified at our hospital. For
example, the literature provides limited
guidelines for managing patients
receiving nutrition support therapy
while achieving tight glycemic control.
As more patients are managed with a
basal/bolus insulin regimen while
receiving enteral support, the RD
must identify or anticipate potential
safety concerns. If the patient receives
long-acting insulin in the morning and
is scheduled for a test off the floor
later in the day, the tube feeding is put
on hold, and a plan must be devised to
protect the patient from hypoglycemia
if the test takes longer than anticipated.
One of the steps within the ordering
of the enteral feeding is to provide
intravenous replacement fluids when
tube feedings are interrupted beyond
2 hours without the requirement for a
separate order or call to the physician.
Institutional protocols not only
address quality initiatives, but also
provide opportunities for RDs to
expand their clinical responsibilities.
The Joint Commission requires all
patients to be screened for nutrition
risk within 24 hours of admission (26).
Patients identified at nutrition risk
must be assessed by nutrition services.
Not surprisingly, patients with compli-
cated hospitalizations routinely are
identified at risk using nutrition
screening criteria (27,28). Our patients
are screened by nursing upon admis-
sion to the hospital via a functional
assessment that addresses predetermined
questions. If a patient fails any part of
the assessment, a consult to our service
is generated. When the consult is
completed, the nutrition professional
can activate physician-approved
institutional protocols. Examples of
protocols include ordering supplements,

vitamins, and minerals; managing tube
feedings; and instituting PN. Obtaining
clinical privileges from physician lead-
ership that empower the RD to exceed
job expectations by implementing care
immediately and efficiently results in
improved outcomes (29). The RD can
focus all clinical interventions on the
patient, and no time is spent contacting
physicians to implement orders. Job
expectations change with clinical
privileges as the nutrition service
realizes their greatest impact in patient
care and outcomes. Examples of insti-
tutional protocols include processes
that improve utilization of therapy,
timeliness of interventions, and execu-
tion of specific service-line initiatives.
One interesting example includes the
ordering of permanent feeding tubes.
Educating physicians plus implementing
a standardized enteral tube formulary
with supporting computerized order
entry screens that contain clear enteral
access algorithms allows the physician
to choose the proper tube.
Enteral Nutrition
Safety of therapy is the first priority
for hospitalized patients requiring
nutrition support therapy. The RD is
an integral part of a safe EN program
that encompasses a comprehensive
multidisciplinary approach addressing
many variables. EN quality indicators
designed to yield data regarding safety,
efficacy, and patient-centeredness
provide crucial information for
improvement. Examples of quality
indicators in our institution follow.
Enteral Tubes on Formulary
It is helpful to assess the number of
feeding tubes available by each service
that places tubes, such as surgery,
gastroenterology, and interventional
radiology. When each tube is identi-
fied as being on formulary, with care
directions and pictures provided on
the hospital infonet to which all care-
givers have access, sentinel events can
be avoided. The RD is responsible for
managing the entire enteral process at
our institution, which includes under-
standing how to care for all enteral
tubes on formulary. This also is neces-
sary for educating patients receiving
home enteral regimens. The RD is
Support Line August 2007 Volume 29 No. 4
uniquely poised to collect outcome
data on permanent feeding tube com-
plications because he or she is involved
in all enteral consults. Additionally,
this allows RDs to focus on procedures
related to enteral tube care to improve
the incidence of patient complications.
It also has been helpful for our hospital
to identify special scheduling require-
ments for the services placing tubes,
such as weekend availability, outpatient
tube placements, or short-stay admis-
sions, to manage patient expectations
with discharge planning. Simply put,
the enteral tube formulary includes
which specific feeding and/or decom-
pression tube will be placed by which
service. The RD can provide expert
guidance in establishing the system-wide
enteral tube formulary and educating
all users about specific tube indications,
placement requirements, and care of
the tube. Such education must be easily
accessible to all members of the health-
care team responsible for patients who
have enteral feeding tubes.
Many complications have been
reported due to the placement of non-
formulary tubes at our facility. The
presence of an enteral tube formulary
eliminates industry sample tubes from
the institution and allows for systematic
evaluation of new products through a
committee process. One example of a
positive benefit from implementation
of an enteral tube formulary and
accompanying enteral algorithms for
tube selection is decreasing the likeli-
hood of a physician ordering a jejunal
tube without an indication for small
bowel feedings. The patient receiving
this tube requires administration of the
feeding via pump, which increases the
time to deliver therapy compared with
syringe gastric feedings. This may affect
a patient’s quality of life if the amount
of time to deliver therapy is unneces-
sarily increased. Insurance coverage
related to tube feeding formula, pump,
and supplies must be verified prior to
tube placement to manage patient
expectations.
Clear Delineation of Services
Placing Tubes
To simplify the decision tree for
permanent feeding tube placement in
our institution, the gastroenterology
–5–
service places percutaneous endoscopic
gastrostomy (PEG) tubes and the
radiology service places percutaneous
gastrojejunostomy tubes (PG/J).
Exceptions are defined by all services
involved. For example, if a patient is
unable to tolerate an endoscope being
passed through the esophagus because
of an esophageal tumor or varices, the
gastroenterologist defers placement to
radiology, where an endoscope is not
needed for placement. For surgical
patients requiring permanent enteral
access and undergoing laparotomy,
the surgical service places gastric and
jejunal tubes. Quality outcome data for
every percutaneous permanent feeding
tube placed is assessed by each RD and
summarized quarterly to identify areas
for improvement. Data analysis for
minor and major complications associ-
ated with permanent feeding tubes for
each service placing tubes has allowed
us to benchmark our complications
with complications reported in the
literature. Each service (gastroenterol-
ogy, radiology, and surgery) approved
the definitions for minor and major
complications associated with perma-
nent feeding tube placements (Fig. 2).
These data are collected by the RD
and reviewed for improvement oppor-
tunities. For example, radiologic tube
dislodgement in obese patients appeared
common. To address this problem, the
interventional radiologists reviewed
the data and changed placement
procedures to increase the number
of stays placed during feeding tube
placement in obese patients.
Change in placement practices have
resulted from identifying certain trends
with permanent decompression tubes.
For example, many trauma patients in
our facility require acute decompression
and receive permanent tubes. After
careful study, it was determined that
many of the patients needed only
short-term decompression and could
have been managed adequately with a
nasogastric (NG) tube. The NG tube
now is used for decompression until a
decision regarding long-term nutrition
support needs can be made. Surgically
placed feeding tubes also are considered
during the time of operation.
(Continued on next page)
Support Line August 2007 Volume 29 No. 4
Figure 2. Sample data collection form for permanent enteral access
data collection completed by the RD.
Permanent Feeding Tube Quality Survey
Name ______________________________________________ Date ________________
Type of tube placed (please circle one below):
GI: PEG
PEG-J
Radiology: PG
PG-J, single lumen
PG-J, double lumen
Surgery: G-tube
GJ-tube
J-tube
Date of tube placement ______________________________________________________
Service/Attending who placed tube ____________________________________________
YES
Were you involved with the decision as to the
type of tube placed?
Was the type of tube placed appropriate given
the patient’s medical condition?
Were any ethical issues (e.g., end of life, futile care)
present? If so, how was it addressed?
Were there any complications associated with the
feeding tube? If yes, please circle from the list
below and provide comments.
Major complications
• Peritonitis
• Hemorrhage necessitating transfusion
• External catheter leak necessitating catheter removal
or repeat gastric puncture for new site
• Other complication necessitating catheter removal
(severe infection, ruptured viscus, repeat aspiration)
Minor complications
• Tube malfunction requiring catheter exchange
• Site infection – superficial stoma infection
• Bleeding from tube site – no transfusion required
• External leak requiring catheter exchange
• Pneumonia
• New-onset aspiration or worsening of aspiration
not requiring tube removal
Other
• Tube dislodgement with catheter revision not requiring
repeat gastric puncture (include reason for dislodgment)
• Clogged tube requiring revision with repeat
gastric puncture
Note: Confer with medical staff regarding determination
of tube-related complication(s).
Physician’s Name _________________________________
If there were complications associated with the tube, was it:
• Repositioned
• Replaced without new gastric puncture
• Replaced requiring new gastric puncture
–6–
Ethical issues related to tube
placement were identified as part
of the permanent feeding tube data
collection. Numerous surveys revealed
that sufficient time was not taken to
explain the option of deferring feeding
tube placement to provide nutrition
support therapy because physicians
perceived this as a lengthy and difficult
conversation. As part of a teaching
initiative with the palliative care team,
resources were developed to assist
physicians with the language used to
explain nutrition and hydration options
to patients and family members.
Automatic referrals for tracheotomy
and PEG feeding tube placements in
combination no longer are initiated.
Careful consideration for each therapy
NO COMMENTS
is discussed.
Competency and Procedure for
Bedside Nasoenteric Tubes Placement
Outcome data are assessed for every
bedside nasoenteric tube placement to
assess the success of the placement.
Data analysis revealed the need for a
different feeding tube for small bowel
placement and clear indications for
gastric versus small bowel nasoenteric
tube placement. In addition, the
requirement for competent staff to
use established methodology for tube
placement and confirmation has
resulted in improved proper tube
selection and tip location as well as
early initiation of feeding. A successful
bedside program has decreased the
number of fluoroscopy visits for tube
placement, resulting in significant cost
savings at our institution.
Early Enteral Access and Feeding
Early enteral feeding parameters,
which may vary by patient population,
are compared with national benchmarks
at our institution. For example, the
number of days until goal enteral
feedings are reached is monitored in
the neonatal population and compared
with a national database from Vermont-
Oxford Network, a nonprofit voluntary
collaboration of health-care profes-
sionals who care for newborn infants
(http://www.vtoxford.org/). In addition,
the concomitant use of PN is assessed
when enteral access is not successful.
All of our intensive care units strive for

early enteral access when indicated and
measure the success of their bedside
placement algorithms.
Enteral Tubing, Pump, and
Formulary Selections
All RDs at our institution contribute
to EN formulary decisions. The clinical
nutrition manager must navigate
corporate group purchasing organiza-
tion contracts and establish essential
requirements for the EN formulary.
Defining criteria for use of specialty
formulas is essential for both patient
safety (proper use) and the budget
process due to their expense compared
with standard formula. The RD also
collaborates with nursing and bio-
electronics on enteral tube feeding
delivery pump selections. Once the
products are selected, the quality
initiatives constantly provide data
elements for re-evaluation.
Order Set Safety
An electronic EN order set provides
effective guidance for safe enteral
orders. For example, generic formula
selection screens on the computer that
provide indications and descriptions
with appropriate progressions for
continuous, bolus, syringe, gravity,
or cycled feedings aid in safe energy,
nutrient, and fluid delivery, thereby
preventing potential complications
such as the refeeding syndrome and
hyperglycemia. Indications and restric-
tions for specialty formula use can
be built into the computer-ordering
pathway for enteral feedings. Further-
more, proper care of each feeding tube
selected from the formulary can be
built into the order set. For example,
flushing requirements for specific
tubes can be addressed, and normal
saline or free water can be provided as
flushing options if medically indicated.
Directions for residual checks, if needed,
can be customized to specific tube types.
Controversy regarding gastrointestinal
tolerance to EN programs due to
“high-volume residuals” is attenuated
at our institution by providing instruc-
tions within the pathway not to hold
tube feedings if residuals resemble the
appearance of tube feeding. Guidelines
for physician notification criteria also
can be included.
Support Line August 2007 Volume 29 No. 4
We have incorporated other com-
ponents into the ordering pathway,
including directions to nursing for
monitoring parameters such as sched-
uled laboratory tests, fluid balance,
weight, directions for head of bed
elevation requirements, schedule
changes due to percussion and postural
drainage, and/or drug/nutrient inter-
actions with the tube feeding as well as
replacement fluid guidelines for inter-
ruptions in formula delivery. These
components were built into the pathway
to reduce delays in care and alleviate
potential problems that could occur if
specific care guidelines were not readily
available as part of the tube feeding
order.
Glycemic Control With Tube Feeding
An additional medication order set
specific to dose and type of insulin
needed for patients receiving EN assists
with safe glycemic management. EN
often is interrupted or held, and inter-
nal data from the hospital suggest that
patients receiving long-acting insulin
or insulin drip infusions when EN is
interrupted are at risk for hypoglycemia.
Replacement guidelines that are hard-
wired into the order set, as described
previously, allow immediate action by
nursing to administer intravenous
dextrose to prevent complications.
Computerized order entry yields safe
and efficient EN delivery and optimal
glycemic control by initiating enteral
feedings gradually and progressing
according to tolerance and glycemic
control.
Parenteral Nutrition
As with EN, a safe PN program
includes a comprehensive multidiscipli-
nary approach that addresses inpatient
management and guidelines for PN in
the home. PN management and survey/
data collection variables yielding valu-
able information from our institution
follow. The RD manages both inpatient
and home nutrition support patients to
provide continuity of service.
PN Use
Understanding utilization trends
and the duration of therapy within an
institution provides information for
improvement. PN survey information
–7–
may include: indication for therapy;
service initiating therapy; information
regarding EN trial, if appropriate;
duration of therapy; and type of line
placed for therapy.
Our PN utilization data revealed
frequent placement of peripherally
inserted central catheters only for PN
therapy and often for short duration.
Requiring the RD to determine if PN
meets established criteria prior to
initiation of therapy eliminates
inappropriate PN orders because the
RD discusses the questionable indication
with the ordering physician. Physicians
at our teaching hospital have the
privilege to order PN, but the RD is
consulted automatically per protocol
and determines if therapy is indicated
based on standards of care. The RD
contacts the physician when therapy is
not indicated to discontinue the order.
The nutrition support service physician
advisor rarely needs to intervene
because the RDs have established an
excellent rapport and competency at the
institution. Figure 3 provides a sample
PN quality survey that is completed by
the RD with each new PN start. This
information is collated quarterly and
reviewed by the Medical Staff Quality
Committee. The number of patients
who do not meet our standards for PN
therapy is less than 3%.
PN Order Set Safety
As with EN, computerized physician
order entry for PN allows for safe
solution selection and administration
according to policy. Specifically,
pathways can be designed for neonates,
infants, children, and adults. Macro-
nutrients and micronutrients are
selected from age-appropriate safe ranges
that are defined by the Medication
Safety Committee. For example, we
have reduced the incidence of hyper-
glycemia and the refeeding syndrome
with slow macronutrient PN progres-
sions. Other compatible additives such as
insulin can be managed with embedded
guidelines within the PN computer
order. For example, RDs coordinate
the amount of regular insulin in the
PN bag with the entire daily insulin
regimen to account for all sources of
(Continued on next page)
Support Line August 2007 Volume 29 No. 4

insulin. Peripheral osmolarity restric- Additional Nutrition • Oral supplement protocols for
tions can be addressed with standard Quality Indicators specific diagnosis to provide
macronutrient and micronutrient The nutrition support team can affect adequate oral intake
guidelines that have been predetermined quality indicators within each service • Education for defined drug/
to be acceptable for peripheral infusion. line in addition to nutrition support nutrient interactions to prevent
Volume options can be built into the monitors. A few examples include: complications
pathway, allowing for cyclic regimens • Compliance with nutrition risk • Preoperative nutrition supple-
for home PN patients. In collaboration screening and consult to nutrition ments in patients identified at
with the patient, the RDs provide cycled support service to expedite nutrition risk to improve
infusion times for home PN patients nutrition therapy postoperative healing
to reduce the amount of infusion time. • Consult completion time and • Specialized renal protocols for
productivity measurements to nutrition and medication manage-
Glycemic Control With PN
justify staffing needs ment to expedite care
The optimal management of patients
with hyperglycemia while receiving • Percent of new mothers breast- Summary
PN is challenging. Improving outcome feeding upon discharge
• Neonatal weight gain velocities When the nutrition support service
variables for this population remains a
compared to birth size aligns quality initiatives within each
priority at our institution. Using IRB
• Incidence of necrotizing entero- service line, quality care is delivered
data analysis for this population, our
colitis in the neonatal population and nutrition therapy is maximized.
efforts continue to focus on the devel-
• Wound care protocol implementa- The six IOM quality aims provide a
opment of order sets and protocols.
tion to improve wound healing foundation for the implementation of
RDs are crucial to the success of an
and decrease length of stay specific indicators. Each RD must be
insulin program designed for EN and
• Success with ketogenic diet in held accountable for clinical compe-
PN at our institution because they
refractory seizure control to tency and contributions to patient
assist in the management of therapy. care. This can be accomplished by
decrease the incidence of seizures
participation in hospital quality struc-
tures, research programs, and specific
service-line committees. Physician-
Figure 3. Sample survey for PN use completed by the RD. approved policies, protocols, and order
PN QUALITY SURVEY sets provide opportunities to implement
consistent quality nutrition care. Finally,
RD ________________________________________ Date _________________________ each quality objective provides an
Service recommending PN ___________________________________________________ opportunity for the RD to publish and
present, which ultimately increases
1. PN is being started on ____________________________________________________ employee engagement and job
Therapy ended on ______________________ for a total duration of __________ days satisfaction.
2. PN is indicated because: Lisa McDowell, MS, RD, is a service
3. Was the enteral route tried? delivery leader in clinical nutrition and
pharmacy at St. Joseph Mercy Health
If yes, what happened?
System, Ann Arbor, Mich.
Oral versus stomach versus small bowel feeding?
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–9–
Guest Editor’s
Perspective
(Continued from page 2)
their thoughts, expertise, professional
goals and experiences, and the subse-
quent outcomes of those experiences.
Lisa McDowell describes hospital-
based quality initiatives in nutrition
support services that resulted in positive
effects not only in patient outcomes,
but also in clinical operations and staff
performance. Carol Rees Parrish and
Joe Krenitsky share the dedication,
determination, and steps taken to grow
adult nutrition support services at a
university-based medical center from
an inpatient consult service to an
enormous program encompassing
inpatient, outpatient, and home care
nutrition support services as well as
multidisciplinary educational programs
and clinical nutrition support research.
Pamela Charney deftly integrates the
Nutrition Care Process (NCP) into
nutrition support practice, skillfully
leading the nutrition support dietitian
into the murky world of NCP imple-
mentation in this specialized arena.
Last, but by no means least, Annalynn
Skipper elucidates the emerging vision
and concepts of advanced-level dietetics
practice in nutrition support, including
the rationale for its creation and the
construct of its practitioners.
To repeat Dr. Einstein’s (or my
dentist’s) words, “Only a fool would
expect different results from doing the
same thing.” The need to alter dietet-
ics education and practice has been
identified, and changes are occurring.
Visionaries and leaders in the dietetics
profession are grappling continuously
with the whats, hows, whens, and whys
of this professional makeover. A com-
mon theme appears to be spurring
change: Doing the same thing results
in the same outcome, and that out-
come is losing its value for both the
practitioner and the public. This is an
exciting, albeit confusing, time in the
dietetics profession. I’m game for a
change. How about you?