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