Acute Care

Medical Nutrition Therapy in the Acute Care Setting

I completed my acute care rotation at LVHN-Pocono Medical Center. This facility has a clinical nutrition manager and four clinical dietitians taking care of about 130-140 patients per day. This experience gave me an opportunity to work with many different types of cases, from renal, to COPD, to CHF and conduct malnutrition assessments and provide nutrition education for different disease processes. The role of the RDN is consult, provide nutrition support recommendations, evaluate malnutrition cases, provide nutrition education, perform nutrition assessments of wounds, length of stay patients, BMI less than 18.5 or BMI over 40, new diabetes diagnosis nutrition education, mechanically altered diets,  lung cancer, and others. My daily tasks involved helping to compile a list of appropriate patients to be seen, by looking at a daily census list and screening it for length of stay patients, those with low BMIs, those with mechanically altered diets and those with supplements. Also, another list was screened for patients with wounds or high BMIs that would need to be seen. Then the medical record was reviewed for the last 24 hrs for each floor of the hospital to determine what patients would need to be seen for the day, who did not show up on the previous two lists, such as those with ESRD with or without dialysis, those with cancer, or those with low appetites/poor intakes, significant weight loss, wounds or gangrene. After completing these tasks I would give my patient list to the dietitians and they compiled a master list and then assigned the patient caseload to each team member. The rest of the day was spent retrieving pertinent clinical data to perform nutrition assessments for each patient. After this, I would see each patient, speak with them, make my recommendations, chart my clinical notes and have them reviewed by a dietitian.

I was able to complete nutrition assessments for new admissions to the facility as well as follow up assessments and nutrition education for cardiac rehab and diabetes. I also conducted a PM/QI study on the new dysphagia diet recommendations and presented an in-depth case study on MNT and dwarfism. During this rotation, I completed the objectives detailed below in bold headings. (Hour reporting form and checklist).

Ethics and Professional Development

For this module I completed and submitted the Ethical Case Studies during acute care rotation orientation, submitted a copy of my Academy membership card, attended an Academy board meeting (enclosed meeting agenda below), participated in a professional organization, updated the student professional development plan, developed a health promotion program on Meditteranean Style Eating for National Nutrition Month with handouts and recipe, which can be found below.

I attended an Academy Board Meeting virtually on Saturday October 27, 2018. This meeting agenda included discussions of Pennsylvania licensure and updates in that process, including conversations with a firm specializing in lobbying and the legislative process because PA dietitians are introducing a scope of practice bill to expand their legal practice rights.

This meeting was very structured, accounting for members, review of last meetings, going over agenda, voting before moving on to next agenda items and adjourning the meeting. I learned that Board meetings are more formal and structured than general meetings and they follow a more strict agenda most likely because they address larger issues that affect the profession as a whole and are concerned with all dietitians, versus individuals.

This fall I acted as a student volunteer for the NEPAND Fall Seminar on November 2, 2018. I had the opportunity to serve by setting up and registering participants as well as meeting and greeting dietitians as they arrived. This was a good opportunity to give back to the dietetics community by being of service.


National Nutrition Month Health Promotion Project Tasting

Nutrition Screening and Assessment

The majority of the work for this rotation was reflected in the following objectives, which were met through daily EMR chart reviews, patient assessments, and medical record charting as well as through the summary encounter forms, which all represent meeting the following objectives: the objectives with no attached documents were completed as part of the 20 cases.

completed assigned documentation on nutrition-related problems or conditions

coordinated his/her caseload based on priority of need for patients residents assessed and ensure that appropriate follow up is achieved

completed documentation utilizing the Nutrition Care Process (NCP), including the development of the PES statements

completed a minimum of 5 cases/documentation using electronic data retrieval and storage

conducted monitoring activities

referred patients residents to other professional as the case required

participated in the development of the nutritional care plan for the multidisciplinary care meetings (detailed in the LTC rotation page)

has submitted acceptable encounter forms for 15 uncomplicated cases

has submitted acceptable encounter forms for 5 complicated cases

completed documentation as per institutions Policy and Procedures

reviewed coding and billing procedures (with my department manager, who explained that the dietitians do not manually enter any codes for billing inpatients. They do use CPT codes when billing outpatients, based on the hours they spent with the patients, and whether it is an initial or follow up sessions.)

Finally, I was able to observe a swallowing evaluation under the supervision of the speech therapist. This consisted of the speech therapist putting a tray together with various textured food items and drinks that contain barium. The patient was then taken to the x-ray room and sat in a chair in front of the x-ray machine. The speech therapist, radiologist, myself and another intern wore protective x-ray aprons. The speech therapist gave the patient different textures to swallow, as the radiologist took pictures of the swallowing in progress as seen in the image below. Once the patient swallowed all the textures the procedure was over. It was found that the patient passed all of the swallowing evaluations and would be upgraded to a regular diet. The speech therapist then wrote up her notes, which become part of the person’s medical record. Unfortunately, this patient was brought in outpatient, and therefore they were not part of our service. However, normally, if a speech consult is necessary, the speech therapist performs their evaluations bedsite and those records are immediately available in the EMR for our review. This is how we maintained communications with the speech therapist and were able to review their charting notes for each patient on our service.

Quality Management

For this module I participated in various committee meetings:

  1. Morning Huddle, Interdepartmental Meeting- where the managers from each department in the hospital give their stats about the number or patients at risk for various things, such as fall risks, etc. Departments heads also share upcoming events, meetings, changes etc.
  2. Q-meeting with dietary staff for general department information
  3. LTC morning meetings (detailed in full in the LTC rotation page)
  4. CHOP patient care meetings (similar to morning meetings at LTC)
  5. LTC Quality Assurance/Quality Improvement Meeting, where the nutrition department shares their findings from the CMS Casper Report, detailing the number of people who have excess weight loss.

Additionally, I participated in a PI/QM study on the IDDSI new texture regulations, presented results of the PI/QM monitor to my department manager, and presented data demonstrating the ability to create charts in MS Excel.


Education and Counseling

For this module I developed group education lessons plan including properly written behavioral objectives, provided group education, included a preceptor completed group education evaluation form and counseled patients, residents, using the Motivational Interviewing technique (preceptor signed Preceptor MI Evaluation form).

MNT Case Study

As part of this rotation, I was assigned a case study on dwarfism. I performed a full nutrition assessment, calculated needs, and created a powerpoint presentation and wrote a paper detailing this case in full and I received feedback from several dietitians in attendance.