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Future Dimensions in Clinical Nutrition Practice Fall 2017
Training Your Staff to Perform
Nutrition-Focused Physical Exams
By Kelsey Buecheler, RDN and Amanda Igel, MS, RDN, LD
An astonishing 30-50% of hospitalized adults are Identified”, “Malnourished”, or “Severely Malnour-
considered malnourished in the modern healthcare ished.”
system.1 This statistic is troubling because the nutri-
tional status of patients who do not receive appro- Methods for training clinicians on the NFPE may in-
priate and timely nutrition intervention will continue clude bedside practice, a webinar, or a live seminar.
to decline during their hospitalization. This may Ideally, there should be both a didactic component
often lead to worsened clinical outcomes such as as well as a hands-on component, which should in-
infectious complications, increased length of stay, clude supervised practice under the instruction of an
30-day readmissions, and even mortality. During experienced practitioner. Clinicians who learn the
hospitalization, these patients may be malnourished NFPE should be able to practice the NFPE on actual
due to one of the following reasons: a lack of ade- patients or patient actors so that their competence
quate nutrients such as protein and fat; increased in performing the exam and diagnosing malnutrition
energy requirements due to certain disease states; can be evaluated.
impaired nutrient transport, absorption or metabo-
2
lism. The collaboration between healthcare profes- Training clinicians to perform the NFPE can provide
sionals and RDNs to determine nutrition related risks many benefits, including an increase in the RDN’s
and implement timely interventions is crucial to a skill set and visibility in the clinical setting. When an
patient’s hospital associated outcomes. RDN competently performs the NFPE and diagnoses
malnutrition, they become a more influential pres-
The Academy of Nutrition and Dietetics and Ameri- ence on the interdisciplinary team caring for the pa-
can Society for Parenteral and Enteral Nutrition tient. NFPE training also standardizes malnutrition
(A.S.P.E.N.) created guidelines to identify and assess diagnosis, increases early interventions, and posi-
malnutrition in adult patients. In the past, it has tively impacts the hospital’s financial reimburse-
been difficult to diagnose malnutrition because ment. Mastering competency in the NFPE can help
there was no consensus on which parameters to use. RDNs become more skilled, qualified, and valuable in
The characteristics of these guidelines include: histo- the clinical setting. However, until recently, there
ry and clinical diagnosis, physical exam/clinical signs, were no standardized training programs offered by
anthropometric data, laboratory data, food/nutrient the Academy of A.S.P.E.N to learn these skills.
intake, and functional assessment.2 Although many
hospitals have adopted the criteria set forth by the The Cleveland Clinic Experience
Academy and A.S.P.E.N, it is important to note that Cleveland Clinic’s Center for Human Nutrition (CHN)
these guidelines have not yet been validated. created a comprehensive training program to teach
staff RDNs how to perform the NFPE and diagnose
The Nutrition Focused Physical Exam (NFPE) helps to malnutrition based on the Academy and A.S.P.E.N
identify the presence of any muscle wasting or fat guidelines. A Malnutrition Task Force was formed in
loss in the malnourished patient. It is a cost-effective 2011 to standardize the nutrition assessment pro-
and efficient way to evaluate a patient’s fat and cess. The task force, in conjunction with the Cleve-
muscle stores along with fluid gains (edema) and mi- land Clinic Simulation Center, designed an education
3
cronutrient deficiencies. Clinicians are trained to program for RDNs utilizing the Objective Structured
identify fat and muscle losses, which can then be Clinical Exam (OSCE) format. An OSCE is a perfor-
used to help categorize patients as “No Malnutrition mance-based test, which allows the standardization
Future Dimensions in Clinical Nutrition Practice Fall 2017
of clinical assessment skills and has been a staple of pare students for the simulation by demonstrating
medical education for years. It was originally creat- the physical exam techniques that will be used.
ed to “assess competency, based on objective Following the learning stations, the student then
testing through direct observation. It is precise, ob- completes three simulated OSCE sessions with ac-
jective, and reproducible allowing uniform testing tors and a written scenario. Students have five
of students for a wide range of clinical skills.”4 minutes to read the brief patient scenario that con-
tains medical history, lab values, and medications.
The nutrition OSCE session involves training small After the written information has been reviewed,
groups about individualized applications of Acade- students enter the room and have 15 minutes to
my/A.S.P.E.N. adult malnutrition guidelines in a conduct the NFPE and ask the actor questions while
simulated setting with trained actors and observers. an observer is watching. The student is expected to
At Cleveland Clinic, the actors are their own dieti- determine the etiology, presence, and degree of
tians. Two weeks prior to the training, the actors malnutrition using the Academy/A.S.P.E.N. guide-
are provided a written script and trained for that lines. After 15 minutes is up, students have 10
specific scenario. minutes to collaborate with the observer.
Participants, which include dietitians, educators, Competency is measured as follows: competency
and interns, are provided with preparatory online met, needs improvement, did not attempt, or not
didactic modules to accompany a four-hour hands- applicable. In order for the learner to pass, they
on training at the Simulation Center. The modules must accurately diagnose if the “patient” has non-
include material presented in various formats, in- severe malnutrition, severe malnutrition, or is well
cluding voiceover PowerPoint presentations, jour- nourished. They also need to correctly identify the
nal articles, and a five-point quiz for each section. etiology of the malnutrition – social / behavioral /
These modules are intended to provide background environmental, chronic disease or acute disease /
knowledge for the learner, and are available to the injury.
students two weeks prior to the training. These
modules are divided into the following topics: In order for the actors to “simulate” fat and muscle
depletion, they are provided a script of how to re-
Introduction to the NFPE spond when the learner either asks a question, or
Nutrition Screening and Nutrition Assessment touches a specific body part. The actor is trained to
Malnutrition Etiology describe and verbalize the degree or presence of the
Malnutrition Severity fat or muscle loss. For example, if the learner
NFPE of Macronutrients, Edema and Fluid touched the actor’s temples, the actor would be in-
Accumulation structed to say, “My temples appear to be slightly
Assessment of Functional Capacity indented lately”. However, the actor does not volun-
Micronutrient Deficiencies teer information if the learner did not trigger a re-
sponse. As the student inspects the hair, mouth,
Students are required to complete each module skin, and nails the actor states if there is an abnor-
and take a post-module quiz. References for each mality present. At the end of the session, the ob-
module are also provided for the students to read. server (an RDN trained for that role) will discuss the
findings or provide feedback if the student missed
On the day of the OSCE, students spend the first an area on the NFPE.
hour going through training stations taught by the
Malnutrition Committee members. The stations in- CHN developed a malnutrition bedside competency
clude mini courses on identifying subcutaneous fat that needs to be completed annually for all inpatient
and muscle loss, micronutrient deficiencies, and RDNs, which is the same as the OSCE simulation.
fluid accumulation (edema). These stations are RDNs must pass the competency with 80% or higher
about 15-20 minutes in length and intended to pre- and have two observed opportunities to pass the
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Future Dimensions in Clinical Nutrition Practice Fall 2017
test. The same evaluation sheet is used for this an- Conclusion
nual competency as the OSCE training. Peer- Documentation of malnutrition and communication
reviewed NFPEs are completed annually by clinical with other disciplines is vital to the success of a com-
managers or members of the Malnutrition Task prehensive malnutrition program. In some facilities,
Force. dietitians have been granted privileges to add mal-
nutrition to the electronic health record (EHR) prob-
Barriers to Implementation lem list, which alerts physicians that the RDN has
Even with adequate training, however, barriers exist performed a comprehensive nutrition assessment
in implementing malnutrition assessment and diag- and the patient is malnourished. When malnutrition
nosis in the hospital setting. One roadblock is having is placed on the problem list and addressed in the
enough competent staff to train, monitor, and evalu- physician’s documentation, it becomes a medical
ate the dietitians’ success. The OSCEs require a mini- diagnosis, which can then be coded appropriately for
mum of three participants (i.e. student, observer, potential reimbursement. In this way, RDNs can pos-
and standardized patient). However, one individual itively impact reimbursement rates in the hospital or
may be able to serve as both the observer and clinical setting when a patient is diagnosed with mal-
standardized patient if necessary, which suggests nutrition.
that this training may be done on a smaller scale. At
Cleveland Clinic, and other larger facilities where the The clinical and financial benefits of training staff to
NFPE is standard protocol, there may be multiple perform the NFPE are significant. RDNs who are pro-
RDNs who have expertise in performing the NFPE. ficient in this skill can be valuable assets to their in-
However, this is not always the case at smaller hos- stitution. The institution will benefit financially from
pitals. In this case, RDNs should seek out the assis- RDNs diagnosing malnutrition through increased re-
tance of members of the interdisciplinary team such imbursement. The challenges for developing a sus-
as nurses, physicians, and physician assistants who tainable training program for RDNs include signifi-
perform physical exams as part of their normal du- cant time and planning methods. Program goals and
ties. resources should be evaluated such as location,
equipment, and labor hours. RDNs should be in-
Performing the NFPE with ICU patients who have formed on their roles and responsibilities with the
mobility restrictions is another challenge for some project so expectations are clear. Overall, training
RDNs, and should be addressed in comprehensive your staff to complete the NFPE is a realistic and im-
training. Many patients in the ICU are intubated, portant component in the development of registered
which provides some difficulty in obtaining correct dietitian nutritionists.
information from the patient in the absence of fami-
ly. When family is available, information about the Resources for Malnutrition Workshops
patient should be obtained to complete a full assess- Cleveland Clinic:
ment. Compression socks are also highly utilized in http://www.clevelandclinicmeded.com/live/courses/
the ICU and can be a barrier to assessing the lower- malnutrition/
extremity areas for edema and fat/muscle loss. Academy of Nutrition and Dietetics:
Some clinical managers may fear that the addition of http://www.eatrightpro.org/resource/career/profes
the NFPE to diagnose malnutrition may adversely sional-development/face-to-face-learning/nfpe-
affect the RDN’s daily schedule. Staffing and produc- workshop
tivity should not be significantly affected due to the Rutgers:
small amount of time it takes to complete the NFPE http://shp.rutgers.edu/dept/nutr/INI/cpe.html
once it is mastered. Productivity tools can be used to Abbott: http://anhi.org/malnutrition-ce
track the time spent with each patient, and these
can be monitored by the CNM to assess changes in References
productivity. 1. Jensen GL, Compher C, Sullivan DH, Mullin GE.
Recognizing Malnutrition in Adults: Definitions
3
Future Dimensions in Clinical Nutrition Practice Fall 2017
4. Zayyan, M. (2011). Objective Structured Clinical
and Characteristics, Screening, Assessment, and
Examination: The Assessment of Choice. Oman
Team Approach. Journal of Parenteral and Enter-
al Nutrition 2013;37(6):802–807. Medical journal,219-222.
2. White JV, Guenter P, Jensen G, Malone A, doi:10.5001/omj.2011.55
Schofield M. Consensus Statement of the Acade-
Kelsey Buecheler is a Clinical Dietitian at St. Ann's
my of Nutrition and Dietetics/American Society
Community in Rochester, NY. She completed her un-
for Parenteral and Enteral Nutrition: Characteris-
dergraduate degree from Rochester Institute of
tics Recommended for the Identification and
Technology in Rochester, NY and a dietetic intern-
Documentation of Adult Malnutrition
ship at Cleveland Clinic in Cleveland, Ohio.
(Undernutrition). Journal of the Academy of Nu-
trition and Dietetics 2012;112(5):730–738.
3. Fischer M, Jevenn A, Hipskind P. Evaluation of Amanda Igel is an inpatient Registered Dietitian at
the Cleveland Clinic’s Center for Human Nutrition,
Muscle and Fat Loss as Diagnostic Criteria for
Digestive Disease and Surgery Institute.
Malnutrition. Nutrition in Clinical Practice
2015;30(2):239–248.
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