T.E.A.M. = Together Everyone Achieves More

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ne day last week, my office phone rang much earlier than usual. I picked it up and was fairly certain it was some sort of crank call because I heard muffled groans on the other end. I was just about to hang up when I heard someone faintly say, “Nancy, I just can’t work in this nursing home any more.” It turned out to be a tearful colleague at the end of her rope. The facility was in the midst of a state survey, and it appeared that several aspects of the nutrition program were under close scrutiny. The facility had many residents with fast weight loss, problems with meal intake documentation, improper food temperatures, and a pest control problem in the kitchen. The dietitian was being asked about each of these problems and felt she was unfairly carrying the burden of all aspects of the clinical nutrition department and food production area. She dealt with each of these problems by “dumping” them on other departments. In her mind, weight loss was the responsibility of the nurses who weigh the residents and physicians who write the orders. The meal intake records were completed by the nursing aides and were their problem. The dangerous food temperatures were the responsibility of the kitchen staff. And finally, the pest control problem was an issue for the maintenance department. This rationalization made her feel much better, and she was off the hook. Or so she thought.
       This type of situation is common. Each discipline aims to provide the best care it can in its special area. A typical facility has nearly a dozen disciplines interacting with each resident and several more working behind the scenes in supportive roles. It can be easy to forget that everyone is part of a larger team with responsibility for the resident from head to toe. Let us take a closer look at how the team approach can manage a common problem like unintended weight loss.

Identifying Involuntary Weight Loss

       Involuntary weight loss (IWL) is a pervasive problem in the long-term care industry. It is defined by a 5% loss of body weight in 30 days, a 7.5% loss in 90 days, or a 10% loss in 180 days. To determine the percentage of weight lost, the following formula is used: (Usual weight – current weight) ÷ (usual weight x 100). For example, if a resident usually weighs 130 pounds and currently weighs 120 pounds, this resident has lost 7.7% of his or her body weight. If this occurred over a month, it would be considered clinically significant weight requiring intervention and documentation. An effective program involves more than just the nutrition department. A commitment from every department in the facility is needed to form a multidisciplinary treatment team.

Administration’s Role

       The commitment must begin at the top of the corporate structure. The facility administrator must be willing to commit resources, typically in the form of personnel, to this team. Many long-term care facilities contract with consultant registered dietitians (RDs) for a certain number of hours per month. These hours are often inadequate to properly monitor all the residents at risk for nutritional decline. These residents include those with IWL, pressure ulcers, tube feedings, parenteral nutrition, and certain medical diagnoses (eg, uncontrolled diabetes or malabsorptive diseases). An evaluation of the adequacy and credentials of nutrition personnel should be conducted annually and adjusted as needed. (For a list of the types of nutrition professionals and their credentials, visit www.eatright.org or www.dmaonline.org.). Resources also include sufficient personnel to assist at mealtimes, including the evening meal and weekend meals, and adequate budgets for food supplies and kitchen operation and maintenance. Designated time for training and education must be provided. A facility culture emphasizing the importance of nutrition is paramount to the success of the team.

Nursing’s Commitment

       Many long-term care facilities rely on the nursing staff to distribute meals, assist with feeding, and document meal intake. Each meal must be treated as important. Missing even 1 or 2 meals can begin a downward spiral for an elderly resident. The nursing staff is on the front lines in the battle against malnutrition and dehydration, 21 meals and 21 snacks per week. It is understandable that meal duty may get tedious for the nursing staff, especially if mealtime is chaotic and stressful. A review of the system used to distribute and serve meals may be in order. Many creative approaches can be tried, including having the residents dine in shifts. Each facility is unique and should strive to find a solution that works for its specific population.
       Meal documentation is often left as the final task of the day and not viewed as a vital part of the nutrition program. This is certainly not the case, especially if your RD visits only once a week and, therefore, is not present at many meals. Accurate meal intake records provide valuable information for the nutrition staff. In addition, meal intake records are often stringently evaluated in nursing home litigation, as they are a part of the permanent medical record.
       The job of weighing residents often falls to the nursing staff. Training on proper scale usage is essential. There are many makes and models of scales, and each operates somewhat differently. Accurate weights are imperative. Nurses communicate with the doctors most frequently and relay any weight changes to the physician and follow up on nutritional recommendations. It is important to document these conversations so that other team members know what transpired. With these nutrition-related tasks, the nursing staff is critically important to the team. Creating a special nutrition team can foster team spirit and recognize nurses and aides who complete additional in-services or education in nutrition.

The Physician’s Position

       The medical staff may include a physician, a physician’s assistant, and/or a nurse practitioner. Diet and supplement orders must be given and nutrition recommendations acted upon expediently. It may be most efficient to create nutrition protocols that allow trials of different dietary supplements and food textures in order to arrive at the optimal diet order as quickly as possible. The physician should not hesitate to consult with the RD if necessary. Because it is the dietitian’s job to keep up with the latest nutritional products, a good rapport and open channels of communication is necessary to facilitate diet changes and recommendations.

The Social Worker’s Job

       At first glance, the social worker may not think that he or she has a role on the IWL team, but he or she has a very important job. Living wills, powers of attorney, and do not resuscitate (DNR) declarations must be in order. The social worker should provide education to the other staff members to clarify exactly what the nutrition portion of a living will means and when it goes into effect. It is a fallacy that IWL is acceptable just because a resident has a living will indicating he or she does not want a feeding tube. End-of-life issues are complex, and the social worker may be asked to take the lead in assuring that they are handled with the proper respect, timeliness, and consideration. The social worker is often the connecting link to the family members and can ensure that proper information is being communicated to them as well as the resident. Again, documenting these discussions is vitally important.

The Pharmacist’s Role

       The long-term care consultant pharmacist is another nutrition team member who is often overlooked. But the pharmacist’s role is growing, as more pharmaceutical agents are being used to treat IWL. The advent of appetite stimulants and anabolic agents may raise questions that are best answered by a pharmacist. The pharmacist should educate the staff on proper dosing, proper timing of drug administration, and monitoring for adverse events. The pharmacist can provide useful recommendations on drug interactions that may cause anorexia, drugs that should be given with or without food, and information on all the latest pharmaceutical interventions to treat IWL.

The Activities Director’s Task

       Food and eating should be fun. Just look at how many people eat at restaurants and socialize over food. The activities director can be an important part of the IWL team in long-term care by providing enjoyable food-related activities. Holiday parties, theme parties, socials, and discussion groups can include food and beverages. The activities director may match suitable dining partners, introduce residents in the dining room, and encourage mealtime socialization. The activities department can decorate the dining areas and be in charge of making it a pleasant place to eat.

The Maintenance Staff’s Role

       Even the facility maintenance department is part of the IWL team. Scales are delicate instruments and should be properly maintained and calibrated. A successful weight-monitoring program cannot occur if the equipment malfunctions. A log documenting the scales’ preventative maintenance program and calibration may be useful; perhaps the first of each month can be declared the day to check on the scales. Kitchen equipment also malfunctions, making it difficult to serve food. Ovens break, sinks clog, and freezers defrost. Preventative maintenance and proper care of equipment should become a part of the nutrition program.

The Rehabilitation Department’s Role

       Physical, occupational, and speech therapists are all important IWL team members. Many residents grow tired while eating and may not have the necessary strength to complete meals. Others may benefit from special feeding equipment such as plate guards, “sippy” cups, or special utensils. Others may require a diet texture modification, such as mechanical soft or ground food. The therapists can provide both useful insights and workable solutions to impediments. Since properly nourished and hydrated residents may approach therapy with more zeal, nutrition is just as important to therapy as therapy is to nutrition.

Family Members in the Loop

       Family members also play a role in preventing and treating IWL. They can be trained to assist with feeding and encourage good meal intake. In our culturally diverse marketplace, many residents may enjoy favorite foods from home. Family members should be informed about the policy on bringing food from home and on safe food-handling procedures. Information regarding weight trends and nutritional indicators must be communicated to the family members regularly. Frank discussions about nutrition support should occur as soon as an IWL problem is identified. Family members should be provided with fair and balanced resource material in order to consider all available options. They may need support to understand that, despite optimal nutrition intervention, IWL may still occur and be a symptom of an end-stage disease. Thorough documentation is needed at every step, especially when several family members are involved or there are great geographical distances between the family and the resident.

So Who’s In the Kitchen?

       It takes every department’s cooperative effort to prevent, identify, treat, and document nutritional progress. Working together is the key to success. Each team member’s unique contribution is valuable and needed. So go ahead—be creative, feel renewed, think of clever training and incentive programs, form a new team, call a meeting complete with tasty treats, and challenge the old systems in order to usher in a new winning interdisciplinary team.
       Consider this case example. Mrs. Bock was a 79-year-old resident of Shady Manor. She had been in this facility for almost 2 years and suddenly started losing weight. She was upset by this weight loss but “just didn’t feel like eating.” Her doctor ordered a nutrition consultation to see if he could reverse this weight loss before it reached significant levels. Upon receipt of the consultation order, the RD visited Mrs. Bock to see if she could uncover any clues. The RD noticed that Mrs. Bock was on a few new medications and asked the pharmacist to review the list for any anorexic side effects or interactions. The RD also recommended a variety of high-calorie supplements to be tried over the next few days in search of the one Mrs. Bock preferred. The nursing aide weighed Mrs. Bock carefully to ensure an accurate weight in the documentation. The maintenance department recently calibrated the digital scale, but they weighed a 10-pound weight from the physical therapy department just to be sure the readings were correct. The activities director made a point to invite Mrs. Bock to the daily happy hour and encouraged her to eat more meals in the dining room by introducing her to other residents. Meanwhile, the social worker called Mrs. Bock’s son, who lives 3 states away, and informed him of his mother’s recent weight loss. The son then called a local cousin, who visited Mrs. Bock with a favorite homemade cake. After finding a medical nutrition supplement that Mrs. Bock enjoyed, the nurse called the physician an order. The speech therapist made sure that Mrs. Bock was swallowing safely, while the occupational therapist recommended a plate guard to help Mrs. Bock stay independent.
       As you can see, this case involved 11 disciplines: physician, nurse, nursing aide, dietitian, pharmacist, maintenance/engineer, recreation therapist, social worker, speech therapist, occupational therapist, resident, and family members. So who’s in the kitchen? Everyone who works in the facility.