Journal of Gerontological Nursing

Nursing Unit Meal Management Maintenance Program

Bernard Vincent Miceli, MS, CCC-SLP

Abstract

Continuation of Safe Swallowing and Feeding Beyond Skilled Therapeutic Intervention

Abstract

Continuation of Safe Swallowing and Feeding Beyond Skilled Therapeutic Intervention

Feeding, deglutition, and swallowing are the most natural means of alimentation. These means provide nutrition and hydration to the body. One study estimated that 12% of adult acute care inpatients had some type of swallowing disorder (Groher & Bukatman, 1986). Another study found that of 240 patients in a nursing center, 59% had symptoms of oropharyngeal swallowing dysfunction (Trupe, Siebens, & Siebens, 1984). However, 37% of these patients presented with cognitive deficits that interfered with deglutition (Trupe et al., 1984). Dysphagie patients are placed at risk for developing many problems including pulmonary disorders, nutrition deficits, dehydration, skin breakdown, cognitive decline, and psychosocial dysfunction. To prevent these problems, medical care facilities may need to develop organizational management programs that maintain safe and adequate alimentation. Specifically, nursing units may benefit from organizational protocols to structure the daily maintenance of safe and nutritional intake per os (i.e., by mouth).

Programmatically, therapeutic swallowing management may be viewed as a hierarchical step-down process seen in many aspects of medical practice. A similar model may be applied to the management of any physical disability. Specifically, swallowing impairments may be managed by using a stepdown model that includes:

* Medical-diagnostic assessment, aimed at explaining the dysphagia.

* Therapeutic-diagnostic assessment, aimed at identifying functional swallowing and feeding problems.

* Rehabilitation training.

* Nursing maintenance care.

The therapeutic-diagnostic assessment includes conducting and interpreting clinical bedside and specialized swallowing evaluations (e.g., videofluorography, endoscopy). Therapeutic management includes indirect swallowing treatment (i.e., without foods), direct swallowing treatment, group intervention, and nursing maintenance intervention for chronic cases. Variables such as severity of impairment, coexisting disorders, multitude of symptoms, learning ability, and recovery status are ingrethents that factor into moving patients through this continuum of care. For a review of normal swallowing physiology, dysphagia management, and feeding management, see Logemann (1996, 1998), Kohlmeyer (1992), Avery-Smith (1992), O'Sullivan (1990), and Cooper and Harrison (1994). The program described in this article is characteristic of a nursing maintenance intervention program.

This article provides solutions to problems encountered by gerontological nurses in daily management of patients with swallowing and feeding impairments. The geriatric population presents with various medical conditions that challenge gerontological nurses daily (e.g., malnutrition, dehydration, decreased appetite, reduced per os intake, aspiration). Many of these conditions are subsequent to swallowing and feeding disorders. Further, changes in executive functioning secondary to dementia potentially lead to changes in selfpreservation. As a result, patients who are cognitively impaired may become more dependent on external sources of help to maintain adequate nutrition, hydration, and pulmonary functioning. Gerontological nurses frequently are called on to provide care to patients with chronic disabilities, many oí whom manifest dysphagia (e.g., cerebral vascular accident, traumatic brain injury, spinal cord injury, developmental disability). Speech pathologists and occupational therapists are charged with the responsibility to rehabilitate patients who have swallowing and feeding impairments, but ultimately, gerontological nurses are responsible for the care of patients who reside on the unit, both during and after skilled therapeutic intervention. Additionally, gerontological nurses play a significant role in the management of long-term care residents who have living wills and do not desire artificial means of alimentation. Because many of these issues and conditions are central to the practice of gerontology, gerontological nurses may find the intervention program described in this article helpful in managing and monitoring patients with chronic dysphagia and feeding impairments.

DESCRIPTION

The Nursing Unit Meal Management Maintenance (NUMMM) program is an experimental swallowingfeeding intervention program that permits RNs to provide organized, reliable, and efficient nursing care to swallowing-impaired and feedingimpaired patients. The goal of the NUMMM program is to provide effective communication and reliable nursing care so patients maintain adequate nutrition and hydration. Dysphagie and feedingimpaired patients have special needs which the NUMMM program also factors into its design. These patients need to:

* Consume certain foods and liquids under certain circumstances safely and to prevent pulmonary compromise.

* Maintain adequate nutrition and hydration.

* Maintain adequate feeding hygiene.

* Maintain their highest level of independent functioning.

* Have a means of socialization to facilitate acceptance of a chronic disability, to learn self-help management skills through observation and repetition, and to prevent social isolation.

Conceptualization of the NUMMM program came about through query into compliance issues related to consistent implementation of swallowing and feeding recommendations on the nursing unit. To gain better insight into this quality improvement issue, the author undertook the role of a nursing assistant for 1 week in a rehabilitation hospital. The occupational therapy and speech pathology evaluations were reviewed prior to supervising the patients on the unit. The following observations were made:

* The patients consumed their meals in their rooms.

* The dysphagic patients resided in different rooms, making it difficult to supervise all patients efficiently during the mealtime.

* There were numerous recommendations from both therapies.

* The nursing assistants did not have access to the medical records, and they received management instructions from the nurse or therapist through casual conversations.

* Information was not reported consistently across nursing shifts.

* The nursing assistants' schedules and assignments changed daily. The most striking insights gained from this learning activity were the lack of communication across shifts, the lack of spatial proximity of patients on the nursing unit, and the plethora of recommendations from the therapists on each patient.

The NUMMM program is designed to group patients together at a central dining location near the nursing station. Patients are assigned to a table, based on help level criteria, and a nursing assistant supervises their meal. The nursing assistant delivers the care which is posted on a large, communication board at the dining location. Five primary dysphagia management concepts are featured in the NUMMM program:

* Help level.

* Solid diet.

* Liquid diet.

* Swallowing strategy.

* Feeding condition.

The NUMMM program has specific application to settings that rehabilitate and care for patients who present with dysphagia and feeding impairments. Some examples of these settings include inpatient rehabilitation, skilled nursing, long-term care, assisted living facilities, and to a lesser extent, transitional rehabilitation units and acute care hospitals. The essential components of this program include:

* Role definition.

* Patient classification.

* Admission criteria.

* Central dining location assignment.

* Supervisory implementation.

Table

TABLE 1SUMMARY OF THE SWALLOW-FEED HELP LEVEL RATING SCALE CRITERIA AND ASSOCIATED NURSING CARE ASSISTANCE

TABLE 1

SUMMARY OF THE SWALLOW-FEED HELP LEVEL RATING SCALE CRITERIA AND ASSOCIATED NURSING CARE ASSISTANCE

Role Definition of Treatment Team Members

The management of swallowing and feeding impairments crosses boundaries of a variety of medical and rehabilitation disciplines (Ravich et al., 1985). Jones and Altschuler (1987) have discussed a specific team approach to the rehabilitation of dysphagia (i.e., a medical-rehabilitation team). Team members include staff from speech pathology, nursing, dietary, and dental hygiene. The role of occupational therapy staff, as it relates to feeding skills from plate to mouth and the use of adaptive feeding equipment, is a significant one in the medical-rehabilitation team model. The following is a description of the roles of various health care providers within the medical-rehabilitation team who are responsible for the management of dysphagic and feeding-impaired patients. The NUMMM program incorporates this model with some elaboration on the role of certified nursing assistants (CNAs) and the RN.

Physician. The physician is responsible for the evaluation and medical management of all conditions related to swallowing, nutrition, and pulmonary functioning, as well as other biologic systems.

Speech-Language Pathologist (SLP). The SLP is responsible for evaluating and managing swallowing and feeding skills. Specific to the NUMMM program, the SLP identifies safe solid and liquid diet consistencies, swallow-feed help level ratings, and safe swallowing strategies and feeding conditions on a communication tool for nursing staff.

Registered Nurse. The RN is responsible for:

* Identifying swallowing and feeding problems on nursing units and notifying the appropriate medical personnel.

* Identifying per os intake, hydration, and pulmonary problems.

* Monitoring per os intake data.

* Safely administering per os medications in conjunction with safe swallowing strategies.

* Instructing patients and CNAs on safe swallowing strategies and feeding conditions.

* Documenting patient status in the medical records.

Specific to the NUMMM program, the RN organizes the patient location assignment and monitors the implementation of the supervision provided to patients. The RN may be a staff nurse or a unit nurse manager. The key role for the RN is to assign patients requiring supervision to the central dining location and to have the communication tool available at that location.

Certified Nursing Assistants. The CNAs are responsible for implementing swallowing and feeding maintenance programs and recording per os intake data. Specific to the NUMMM program, the CNAs:

* Transport assigned patients to the central dining location.

* Prepare meal trays, according to the instructions posted on the large communication board.

* Review and coach patients on using safe swallowing strategies and feeding conditions.

* Record per os intake of solids and liquids.

* Report patient status changes to the RN.

The key role for individual CNAs is to supervise those specific patients assigned to one table and to review and implement the information on the communication board for those patients.

Occupational Therapist (QT). The OT is responsible for evaluating and managing safe feeding skills and positioning; prescribing and obtaining appropriate feeding utensils; and directly treating motor and perceptual feeding impairments, meal tray preparation skills, and feeding hygiene skills. Specific to the NUMMM program, the OT recommends safe feeding conditions in collaboration with the SLP.

Dietitian. The dietitian is responsible for evaluating and managing nutrition and hydration issues; determining appropriate per os or enteral diets; problem solving reduced per os and hydration intake; interpreting chemistry laboratory and calorie count data; and managing dietary and kitchen staff on appropriate meal tray preparation, patient food preferences, and feeding utensil sanitation.

Patient Classification

Patients on the nursing unit are classified according to a help level that identifies the amount and type of assistance required from the nursing staff. This classification process facilitates organization of patient and CNA assignment. Specifically, patients are classified according to a swallow-feed help level rating scale that permits an integrated consideration for safe swallowing and feeding. Swallowing includes all skills in deglutition, namely oral preparation, oral transit, pharyngeal transit, and esophageal transit. On the other hand, feeding skills include all the self-directed cognitive, motor, sensory, and perceptual abilities that permit the delivery of food or liquid from the table to the mouths of the patients.

The help level scale described in this article was developed to assist clinicians in identifying patients' self-preservation abilities, as defined as self-directed behaviors to maintain a status and to prevent deterioration or compromise. The SwallowFeed Help Level Rating Scale (SF Help Scale) is a 5-point ordinal, criterion-referenced behavioral measurement scale that accounts for:

* Severity of swallowing-feeding disability.

* Physiologic compensation contributing to dependency level.

* Hierarchy of cognitive functioning.

Patients are evaluated according to these three criteria and assigned a help level, which communicates to nursing staff the type, frequency, and intensity of care needed (Table 1).

The RN may complete classification of all patients at any time the patients remain on the nursing unit. However, the SLP tends to be the professional most likely to complete and update these ratings. The following describes the SF Help Scale.

Level 5: Complete Dependence. Patients present with profound dysphagia, characterized by absent to significantly delayed pharyngeal swallow onset and laryngeal penetration.* Sensorimotor and/or perceptual impairments may or may not be present. Moreover, the severity of dysphagia and decompensation are criteria enough to rate patients at this level (i.e., self-feeding skills are immaterial at this level). The patient is NPO (i.e., nothing by mouth) as a result of the severity of the dysphagia. Swallowing compensation techniques have shown no effectiveness at improving swallowing function (i.e., decompensation characterizes the swallow response). Patients either do not meet candidacy criteria for direct swallowing treatment or have shown poor responsiveness to indirect and/or direct swallowing treatment. Patients may or may not show any potential to participate in a swallow-feed task from a cognitive perspective. Complete dependence characterizes this help level. Tube feeding, as administered by the RN, is the patients' primary means of alimentation. The CNAs are not responsible for any per os intake care. However, patients require the specialized skills of RNs. Patients are not included in the central dining assignment on the nursing unit. Additionally, other patients who are classified at this level may include those who are in a coma state or present with a persistent vegetative state.

Table

TABLE 2NURSING UNIT MEAL MANAGEMENT MAINTANENCE (NUMMM) GLOSSARY FOR SAFE SWALLOWING STRATEGIES

TABLE 2

NURSING UNIT MEAL MANAGEMENT MAINTANENCE (NUMMM) GLOSSARY FOR SAFE SWALLOWING STRATEGIES

Table

TABLE 3NURSING UNIT MEAL MANAGEMENT MAINTANENCE (NUMMM) GLOSSARY FOR SAFE SELF-FEEDING CONDITIONS

TABLE 3

NURSING UNIT MEAL MANAGEMENT MAINTANENCE (NUMMM) GLOSSARY FOR SAFE SELF-FEEDING CONDITIONS

Level 4: Direct Feeding. Patients present with severe dysphagia, characterized by laryngeal penetration. Also, patients presenting with sensorimotor and/or perceptual impairments that preclude adequate delivery of food or liquid to the mouth are classified at this level. These patients evidence some tolerance for safe per os intake under specified conditions. Swallowing compensation techniques have shown some potential for minimally influencing safe swallowing of some specified bolus. Cognitively, patients have the potential to participate in swallowing tasks when completely controlled by trained staff but do not participate in self-feeding, as it relates to initiation, endurance, perseverance, self-monitoring, and selfpreservation. Direct feeding characterizes this help level. The CNAs prepare the meal trays and implement therapeutic techniques consistently by feeding each bolus to the patients. Patients may be receiving tube feedings as a supplement or as primary alimentation. Patients classified at this level may include those who manifest severe dysphagia. However, patients who present with cognitive limitations and demonstrate safe automatic or "reflexive" swallowing may be indicated in their care plans to receive some per os feedings under specified conditions. Additionally, other patients presenting with conditions that preclude self-feeding may be classified at this level, including visual-sensorially impaired, severely visual-perceptualIy impaired (e.g., homonymous hemianopsia), and bilaterally limb impaired (e.g., amputations, paralyses, movement disorders, skeletal conditions).

Level 3: Constant Supervision. Patients present with moderate dysphagia, characterized by laryngeal penetration on some items or under some circumstances. Also, these patients present with sensorimotor and/or perceptual skills that permit some delivery of food or liquid to the mouth. Swallowing compensation techniques lessen the risk of laryngeal penetration, and self-feeding compensation techniques improve delivery of some food or liquid. Cognitively, patients participate in self-feeding at some level. Some self-help management skills are present and evidenced by basic functional abilities in attention, concentration, imitation, and following directions. However, recalling and implementing compensation techniques may be reduced, and limitations in executive functioning may prevent independent, goal-directed, self-help management of per os nutrition. Constant supervision characterizes this help level. The CNAs provide:

* Meal tray preparation.

* Individualized review of, and instruction on, safe swallowing strategies and feeding conditions.

* Demonstration of these strategies and conditions.

* Feedback statements regarding performance.

* Frequent verbal reminding about implementing these strategies and conditions.

* Encouragement to complete the full meal.

In addition to dysphagic patients, other patients classified at this level may include visual-sensorially impaired, visual-perceptually impaired, and limb impaired. These patients generally require restricted diet consistencies, specialized feeding delivery sequences, specialized feeding utensils or enablers, or specific spatial tray arrangements.

Level 2: Monitoring. Patients present with mild dysphagia, characterized by potential laryngeal penetration and decreased oral deglutition efficiency (e.g., reduced bolus clearance). Also, these patients may have mild sensorimotor and/or perceptual impairments that reduce self-feeding efficiency. Swallowing and feeding compensations are effective. Basic cognitive skills are within functional limits. However, higher-level executive functioning may be limited and prevents independent, goal-directed, self-help management of per os nutrition. The CNAs provide meal tray preparation and occasional reminders to implement swallowing strategies and feeding conditions and to complete the full meal.

Figure 1. Nursing Unit Meal Management Maintenance Worksheet.

Figure 1. Nursing Unit Meal Management Maintenance Worksheet.

Level 1: Independent. Patients' swallowing and feeding skills are within functional limits and may be characterized by little or no risk of laryngeal penetration and slightly impaired deglutition efficiency. Also, patients may have slightly impaired sensorimotor and/or perceptual functioning, but the impact on safe swallowing and feeding are insignificant. Patients who present with normal swallowing and feeding skills are classified at this level. Compensation techniques, if applicable, are completely effective. Patients show functional executive skills, favorable treatment generalization potential, and functional self-help management skills that facilitate self-preservation of nutrition and hydration. Patients may have mild signs of dysphagia and/or feeding impairment, but these mild deficits are managed completely and safely by the patients. This help level is characterized by the lack of help required by CNAs and is properly named independent. Maximally, the CNAs prepare the meal trays. The CNAs do not need to monitor the patients. These patients are encouraged to attend the dining room meal program or to have a private dining condition. Patients are not assigned to the central dining location on the nursing unit.

NUMMiM Admission Criteria

Admission to the NUMMM program may occur from a variety of sources. Primarily, the criterion for admission to this program is the rating on the SF Help Scale. Patients functioning at Levels 2, 3, and 4 are candidates for admission to the program. These patients may be receiving individual dysphagia and/or feeding treatment and may attend only some of the mealtimes on the nursing unit. Also, these patients may have shown a plateau in skilled treatment and attend the NTJMMM program for all mealtimes. Other criteria resulting in admission to the program may include recommendation from the RN, SLP, physician, OT, and dietitian, as well as positive weight loss from the monthly weight variance report. In fact, the monthly weight variance report may be used as the measure to admit and discharge patients from the NUMMM program. This will be discussed later in the article as the outcome measure for continuous quality improvement (CQI) monitoring.

Centralized Patient Dining Location Assignment

The central dining location is designed to maximize efficiency of care on the unit. This will allow CNAs to manage all the patients in one location. It also allows supervision by the RN because of the close proximity of this location to the nursing station. The rationale behind classifying and grouping patients at mealtimes is to allow CNAs to focus their attention on assisting the patients who need care for swallowing and feeding. During mealtimes, CNAs report to the central dining location. Each CNA is assigned a given number of patients to supervise. The CNAs assist those patients to the central dining location and seat them at the designated tables. For easy reference, each table is numbered to correspond to the table number on the assignment worksheet. Generally, each CNA is assigned to one table with four patients: a Level 4 patient (i.e., direct feeding) and three other patients rated Levels 3 or 2 on the SF Help Scale. This assignment may vary depending on the number of patients at each rating level and the number of CNAs scheduled on the unit. Patients functioning at Levels 1 and 5 remain in their rooms for their meals, but Level 1 patients may attend mealtime in the facility's dining room. After all patients are organized at the central dining location, the CNAs begin the supervisory process of the NUMMM program.

Supervisory Implementation

This level of intervention includes standard meal tray preparation and patient instruction. Standard meal tray preparation includes providing appropriate utensils, inspecting the correctness of foods and liquids, and preparing foods (e.g., cutting, seasoning, placement) for feeding, deglutition, and swallowing. The CNAs review supervisory instructions with the patients. These instructions specify solid and liquid diet consistency prescriptions, help level, swallowing strategies, and feeding conditions. Dysphagia-sensitive diets are a form of compensatory intervention. For some patients, this compensation may be the only maintenance intervention required. However, for other patients, further supervision may be warranted. Swallowing strategies are physiological modifications applied during the swallowing act that promote safe bolus transit to the esophagus, free of laryngeal penetration or aspiration. On the other hand, feeding conditions are limb and trunk positions and utensil and tray placement modifications that promote safe food and liquid delivery to the oral cavity by patients during eating. Glossaries for swallowing strategies and feeding conditions are provided in Table 2 and Table 3, respectively. These glossaries were developed by the author based on the literature (Cooper & Harrison, 1994; Kohlmeyer, 1992; Logemann, 1996) to aid clarification of terms and instructions for the CNAs, and they provide standard terminology which may influence the reliability of instructing patients. Throughout the meal, CNAs provide supervisory feedback statements to patients regarding their performance in addition to encouraging them to complete the full meal.

Figure 2. Swallowing Safety Instruction and Precaution Sheet Communication Board.

Figure 2. Swallowing Safety Instruction and Precaution Sheet Communication Board.

Figure 3. Monthly meal and fluid intake percentage record.

Figure 3. Monthly meal and fluid intake percentage record.

Figure 4. Nursing Unit Meal Management Maintenance continuous quality improvement monitor.

Figure 4. Nursing Unit Meal Management Maintenance continuous quality improvement monitor.

PROGRAM TOOLS

Essential NUAAMM Program Tools

Nursing Unit Meal Management Maintenance Worksheet. This worksheet is the primary organization tool of the NUMMM program which categorizes all patients on the nursing unit relative to help level (Figure 1). Specifically, the worksheet is organized to identify:

* Level 5 patients, who receive parenteral and enteral feedings.

* Levels 4, 3, and 2 patients, who receive seat and CNA assignments at the central dining location on the nursing unit.

* Level 1 patients, who are independent.

* Patients who are receiving swallowing and/or feeding treatment and may not necessarily receive supervision on the unit.

The RN processes the NTJMMM Worksheet and posts it, in a protected sheet, on the dietary cart, which is located at the central dining location. The CNAs review the worksheet and implement the patient seating assignments.

Swallowing Safety Instruction and Precaution Sheet (SSIPS) Communication Board. This communication tool is a summary board that contains information on help level, prescribed solid and liquid diet consistencies, safe swallowing strategies, and safe feeding conditions for each patient at the central dining location (Figure 2). The information is organized on a board within 1-inch rows. The size of the board is important for easy inspection by CNAs and patients when they are seated at assigned tables. The SSIPS Communication Board is the tool CNAs use to instruct each patient. It is a visual memory aid for CNAs to use during mealtimes. In certain nursing environments, posting a summary board such as the SSIPS Communication Board in a central dining location at mealtimes may violate confidentiality practices of that setting. In this case, the board may be attached to the back of the dietary cart which contains the meal trays. As CNAs collect the meal trays, the SSIPS Communication Board is reviewed. After mealtime, the SSIPS Communication Board may be secured in the medication room. For most purposes, temporary posting of such a communication tool may be justified in a facility's policy and procedure manual as medically necessary for reliable and efficient nursing care. Other facilities may choose to code patients according to abbreviations or room numbers. Another modification is to adapt the dietary kardex (i.e., dietary informational communication card that accompanies each patient's meal tray) system to include the organizational structure of the SSIPS Communication Board.

Ancillary NUMMM Program Tools

Monthly Meal and Fluid Intake Percentage Record. This form contains daily record-keeping data for 1 month on percentages of per os intake for all meals, liquids at each meal, and supplements provided throughout the day. This form conveniently contains data for four patients and corresponds to the patients assigned to the given tables at the central dining location (Figure 3). These data, along with monthly weight data, may be used to document program outcome. Many procedures for estimating percentages of per os intake are available (Simko, Cowell, & Gilbride, 1984). At the completion of each meal, a consumption percentage of that meal tray is recorded on the Monthly Meal and Fluid Intake Percentage Record. Using this intake record may facilitate goal-striving behavior in patients or CNAs, and it may yield higher intake percentages and, as a result, higher caloric intake. The best advantage to recording percentages daily is that it allows close monitoring of intake data before problems develop that warrant more significant medical attention.

NUMMM Program Data Binder. The nursing station may maintain a binder that contains all information regarding the NUMMM program. The NUMMM program data binder includes sections for:

* Program description.

* Monthly weight variance reports.

* Monthly meal and fluid intake percentage records with percentage calculation instructions.

* Completed NUMMM Worksheet.

* Working form for the SSIPS Communication Board.

* Glossary of safe swallowing strategies and safe feeding conditions.

* Continuous quality improvement monitors.

* Blank copies of program tools.

STAFF EDUCATION

Staff training on the NUMMM program consists of a four-phase process:

* Nurse training.

* CNA lecture series.

* Go-Live modeling week.

* Annual review lecture.

The SLP meets with the RN regarding the organizational components of the NUMMM program. This meeting includes a review of all the tools of the NUMMM program, a discussion of how to prepare for implementation of the program, and a discussion of how to monitor the implementation of the program. Next, the SLP meets with the CNAs on patient sensitivity issues and the contents of the program. Generally, the lecture series involves four 1hour sessions. First, patient sensitivity and help level descriptions are reviewed. Second, solid and liquid diet prescriptions, tray preparation, and generic safe swallowing and feeding practices are described and illustrated. Third, specific swallowing strategies and feeding conditions are thoroughly defined (Tables 2 and 3). Special attention is given to defining and modeling various safe swallowing strategies and safe feeding conditions because this is the focus of maintenance supervision. A glossary of these terms is provided to the CNAs, and instructional directions are provided for the CNAs to use during direct patient care. Fourth, program tools, per os intake recording procedures, and problem solving strategies are reviewed. At the conclusion of the lecture series, the SLP conducts demonstration training sessions on the unit regarding the use of the NUMMM program for a 1-week, Go-Live implementation training phase. This training models patient table assignment, meal tray preparation, patient supervision, and data recording procedures. At the completion of the training program, CNAs complete a cursory program knowledge mastery questionnaire that represents a comprehension measure of the key points of the NUMMM program. These questionnaire items are featured on the CQI monitor. Additionally, recently hired employees are provided with an orientation packet at the beginning of their employment and routine facilitywide inservices are provided annually.

CONTINUOUS QUALITY IMPROVEMENT MONITORING

Quality improvement monitoring is a continuous process that assesses the reliability of the implementation of an intervention program and its outcome. Different personnel may complete the CQI monitor on a quarterly or biannual basis. The SLP and the RN may complete the quality improvement monitor jointly (Figure 4). This team approach opens communication and allows for onsite problem solving and program modifications. The variables important to CQI monitoring of the NUMMM program include:

* Organizational compliance.

* Knowledge mastery.

* Implementation compliance.

Organizational compliance includes preparation and use of the NUMMM Worksheet and SSIPS Communication Board. The CQI evaluation assesses that these tools were processed by the RN and the SLP and that the tools were available and accurate with that observed at mealtimes. The program knowledge mastery component contains two questions on each of the following five target topics:

* Name and location of NUMMM Worksheet and SSIPS Communication Board.

* SF Help Scale.

* Solid and liquid diets.

* Swallowing strategies.

* Feeding conditions.

The CQI evaluator requests the information from the CNAs, usually in a verbal multiple-choice format, and the CNAs are allowed to use the program tools when answering the test questions. The NUMMM program requires that the CNAs know how to obtain the supervisory information rather than memorize the information. Memorization of information is contraindicated because changes may occur at any time. Implementation compliance focuses on observing the CNAs in the meal context. The objective is to observe the use of the NUMMM Worksheet and the SSIPS Communication Board regarding patient seating assignment, meal tray inspection and correction, provision of supervisory information with the patients before the meal, provision of intervention matched to the swallow-feed help level, and accurate per os intake data record keeping.

The CQI monitoring may include analysis of functional outcomes. Functional outcome may be defined as the overall effect an intervention program has on patient functioning. The key to analyzing functional outcome is defining the function that needs to show improvement. Three functional outcomes have been identified that relate to the program's goal (i.e., maintaining adequate per os nutrition and hydration):

* Body weight maintenance.

* Hydration balance.

* Adequate pulmonary functioning.

At this time, the CQI monitor has focused on body weight. Maintaining body weight is defined as evidencing stable weight within a range acceptable for a given patient, as determined by the dietitian. The dietitian may choose to use ideal body weight or usual body weight. In skilled nursing facilities, monthly weights typically are obtained on all patients during their residency, and the CQI monitor may examine those weights from the monthly weight variance report. Additionally, CQI monitoring may be analyzed best by integrating compliance and functional outcome. This analysis approach may permit an interpretation of the interaction of compliance and functional outcome. Four possible trends and consequential action plans may emerge:

* When compliance and functional outcome both measure low on the CQI monitor, the program may have implementation design problems and may require revision.

* When compliance and functional outcome both measure high, the program may be effective, and no major revisions are indicated.

* When compliance measures low and functional outcome measures high, the program may be unnecessary because the patients maintain adequate functioning.

* When compliance measures high and functional outcome measures low, the program may not be effective and may require revision, or the functional outcome measure may require redefinition.

Nonetheless, the CQI monitor may allow differential analysis of the components of the program and may direct program modifications.

NUMMM PROGRAM EVALUATION AND FUTURE RESEARCH INITIATIVES

The contribution of the NUMMM program to clinical practice may be evaluated initially by analyzing its strengths and limitations, its role with compliance and outcome performance, the reliability and validity of its tools, and the theoretical model on which it is based. Three primary strengths of this program are that it provides:

* A systematic approach to maintaining skill level performance in dysphagic and feeding-impaired patients.

* A means to promote reliable and efficient nursing maintenance care through the use of centralized dining and predictable tools.

* A CQI monitor that analyzes compliance relative to program organization, staff knowledge, and implementation.

The primary weaknesses of the NUMMM program are that it:

* Has no outcome or efficacy data from a large number of subjects.

* Has an experimental rating scale that currently does not have any reliability or validity data to support its use.

* Uses an intuitive application of executive functioning theory into the design of the SF Help Scale.

* May be perceived as violating confidentiality by state reviewing systems when the NUMMM program uses centralized, posted communication tools for promoting reliable and efficient care.

While the NUMMM program is a clinical nursing intervention, analyz1 ing its effect on maintaining safe and adequate per os intake becomes a research issue. A major concern regarding the effectiveness of the NUMMM program addresses compliance issues related to implementation of the program. The concept of compliance in medical research largely has addressed patient compliance with medical treatments (i.e., how well patients implement medical prescriptions and recommendations). Relating these issues to the NUMMM program may take a different focus (i.e., facility staff compliance rather than patient compliance may need to be explored). Typically, this program manages patients who have chronic swallowing and feeding disorders as part of medical conditions that manifest decreased mental functioning (e.g., cerebral vascular accident, dementia). Considering this population, compliance issues, as they relate to independent self-care and treatment generalization abilities, may be difficult to evaluate. However, investigations into staff compliance in implementing the NUMMM program may be more appropriate. The CQI monitor addresses three interrelated levels of assessment. For example, the implementation of the NUMMM program may be dependent on the CNAs' knowledge base, which may be dependent on the organization of the NUMMM program on the nursing unit. Investigations focusing on the development of CQI monitors such as the one proposed in this article may provide insight into the etiology of noncompliance.

Another area of research concerns beneficial outcomes of intervention programs. Well-implemented programs that do not yield favorable results will have little merit. Investigating the impact of a program on some practical outcome is paramount to clinical professions that provide interventions. Relevant outcome measures of the NUMMM program include per os intake percentage, weight maintenance, hydration, and pulmonary functioning. However, before useful information can be gathered on the effectiveness of the NUMMM program on any of these outcomes, it is important that some prerequisite research be completed on the reliability and validity of measures, such as the SFHeIp Scale.

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TABLE 1

SUMMARY OF THE SWALLOW-FEED HELP LEVEL RATING SCALE CRITERIA AND ASSOCIATED NURSING CARE ASSISTANCE

TABLE 2

NURSING UNIT MEAL MANAGEMENT MAINTANENCE (NUMMM) GLOSSARY FOR SAFE SWALLOWING STRATEGIES

TABLE 3

NURSING UNIT MEAL MANAGEMENT MAINTANENCE (NUMMM) GLOSSARY FOR SAFE SELF-FEEDING CONDITIONS

10.3928/0098-9134-19990801-06

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