1. Destination Nutrition The Calorie Count Process

2. 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

3. Malnutrition in the Hospital On average 1 in 3 patients admitted to the hospital are malnourished 1 Malnourished patients are 2-times more likely to develop a pressure ulcer in the hospital 2 Pressure ulcers can increase length of stay by 4.3 days 3 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.

4. 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

5. 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.”

6. 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

7. 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

8. 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

9. New Process as 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

10. 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

11. 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 Count was just delivered to Room # _________ PLEASE NOTIFY THE NURSE Do not discard tray until percentages are recorded

12. Compliance: One Patient Meals Ordered Meals Recorded % Compliance Oct 1033100% Oct 113267% Oct 1233100% Oct 133267% Oct 143267% Oct 153267% Oct 1633100% Overall211781%

13. Compliance by Month Meals OrderedMeals Recorded % Compliance September542852% October835667% November431842% December12867% January17953% February443068% March352160% Overall28817059%

14. Compliance by Month Arrow indicates month where new step was added to the process in an attempt to increase compliance

15. 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

16. Process Improvement Summary Calorie Count Process October 2012 – February 2014 Goal Statement Data and Trending Lessons Learned Rationale/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), Implemented (I) or Spread (S) Recommendations and Next Steps 1. Add Calorie Counts to the nursing electronic work list 2. 90 day follow-up to determine compliance improvement Team Members Carol Bergin, Melanie Wheeland, Caitlin Morgan 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 Analysis 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 1 st. Compliance for the month of March was 60% so it does not appear to have increased with the new step added.