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Recommendations Summary

SCI: Nutrition Assessment in Acute Care, Rehabilitation, and Community Setting 2009

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    SCI: Nutrition Assessment in the Acute Care Setting

    If a patient is in the acute phase of spinal cord injury,  the registered dietitian should conduct a nutrition assessment within the first 48 hours post-injury, in order to determine nutrient needs, provide nutrition support recommendations and identify conditions that may predispose the patient to nutrition-related complications. Evidence suggests that early nutrition support is associated with improved patient outcomes.

    The nutrition assessment should include but is not limited to: 

    • Food- and nutrition-related history: Energy intake, diet order, food or beverage intake
    • Anthropometrics: Weight change 
    • Biochemical and medical tests and procedures: Swallow study, inflammatory profile, metabolic profile, albumin, prealbumin 
    • Nutrition-focused physical findings: Digestive system, cardiovascular and pulmonary systems
    • Client history: Treatment and therapy
    • Comparative standards: Energy needs, protein needs, ideal and reference body weight, fluid needs.

    Rating: Strong
    Conditional

    SCI: Nutrition Assessment in the Rehabilitation Setting

    If a patient is in the rehabilitation phase of spinal cord injury, the registered dietitian should conduct a nutrition assessment to develop and implement an individualized therapeutic nutrition plan for the patient. Evidence suggests that medical nutrition therapy by a registered dietitian may result in improved ability to participate in therapies and in an improved transition into the community setting.

    The nutrition assessment should include but is not limited to:

    • Food- and nutrition-related history: Energy intake, diet order, food beverage intake, fiber intake, medication and herbal supplement use, mealtime behavior, nutrition-related ADLs and IADLs, physical activity, weight change
    • Anthropometrics: Weight change
    • Biochemical and medical tests and procedures: Swallow study, inflammatory profile, metabolic profile, albumin
    • Nutrition-focused physical findings: Digestive system; cardiovascular-pulmonary system, skin
    • Client history: Social history
    • Comparative standards: Energy needs, protein needs, ideal or reference body weight, fluid needs, fiber needs.

    Rating: Fair
    Conditional

    SCI: Nutrition Assessment in the Community Setting

    If a person with spinal cord injury is living in the community setting,  the registered dietitian should conduct a nutrition assessment as part of the annual medical exam to develop and implement an individualized therapeutic nutrition plan.  

    The nutrition assessment should include but is not limited to: 

    • Food- and nutrition-related history (specifically knowledge deficits, beliefs and attitudes, body image,  mealtime behaviors, physical ability to self-feed, access to food- and nutrition-related supplies, meal preparation and food avoidances)
    • Anthropometric measurements (specifically body composition, weight)
    • Biochemical data, medical tests and procedures (specifically serum lipid and glucose levels)
    • Social history (specifically isolation)
    • Nutrition-focused physical findings (specifically bowel and bladder function). Evidence suggests that annual nutrition assessment by a registered dietitian is necessary to identify nutrition-related concerns that may affect the health and quality of life of persons with spinal cord injury. 

    Rating: Fair
    Conditional

    • Risks/Harms of Implementing This Recommendation

      No potential harm or risks are associated with the implementation of this recommendation.

    • Conditions of Application

      Nutrition care provided to spinal cord injured patients by a registered dietitian in the acute, rehabilitation and community settings should occur within the context of an interdisciplinary care team in order to ensure a comprehensive approach to care.

    • Potential Costs Associated with Application

      • There are staffing and organizational costs associated with providing individualized nutrition care by a registered dietitian to spinal cord-injured patients in the acute care, rehabilitation and community settings
      • Individualized nutrition care provided by a registered dietitian to spinal cord-injured patients may result in significant cost savings to organizations by reducing length of stay in acute care and rehabilitation settings, occurrence of pressure ulcers and other nutrition-related complications.

    • Recommendation Narrative

       SCI: Nutrition Assessment in the Acute Care Setting

      • One cohort study found that 24.6% of patients with spinal cord injuries require dietary modifications during the acute phase of injury, and that 8.2% of patients were discharged from acute care with feeding tubes (Abel et al, 2004)
      • One narrative review concluded that baseline nutrition assessment performed by a registered dietitian is essential, and should occur within the first 48 hours of the acute phase of spinal cord injury (Mitcho et al, 1998)
      • One non-randomized trial concluded that early nutrition intervention by registered dietitians should be part of the clinical pathway for treatment during the acute phase of spinal cord injury (Vitaz et al, 2001).
      SCI: Nutrition Assessment in the Rehabilitation Setting
      • One narrative review concluded that the registered dietitian should be part of the interdisciplinary team managing the rehabilitation phase of spinal cord injury and that optimal rehabilitation requires a multidisciplinary approach to all aspects of care, including nutrition care (Croes-Barone et al, 1998)
      • One narrative review found that during the rehabilitation phase of spinal cord injury, nutrition needs should be assessed by a registered dietitian. The paper also recommended that nutrition education be provided to the patient and patient's family by a registered dietitian (Murphy et al, 1999). 
       SCI: Nutrition Assessment in the Community Setting
      • Two studies (one non-comparative study, one single-group uncontrolled trial) found that health promotion and weight management interventions may improve health parameters and quality of life in patients with spinal cord injuries living in the community. The weight management intervention was led by a registered dietitian (Block et al, 2005; Chen et al, 2006).
      • One non-comparative case study found that a bowel protocol including a standardized fiber intake and fluid guidelines may result in improved bowel function and quality of life in spinal cord injured patients living in the community (Badiali et al, 1997)
      • One expert commentary concluded that evaluation by a registered dietitian should be part of every spinal cord-injured patient's annual medical exam (Barber, Foster,  Rogers, 2003)
      • One cohort study found that registered dietitians were able to use a tele-rehabilitation approach to provide nutrition care to community-dwelling spinal cord-injured patients and that tele-rehabilitation interventions conducted by an interdisciplinary team resulted in a reduced number of hospitalizations and decreased length of stay for patients (Galea et al, 2005)
      • One cross-sectional study found that nutrition interventions and nutrition education are needed to reduce dietary fat intakes and serum lipids, especially in men, with spinal cord injury (Moussavi et al, 2001)
      • One non-randomized prospective trial found that dietary intervention should be included in the treatment of individuals with SCI whose total cholesterol levels are more than 200mg per dL (5.2mmol per L), with the expectation that about 20% will favorably respond to dietary intervention. The researchers also recommended that a registered dietitian should provide dietary intervention, since an individualized diet plan may enhance patients' compliance with dietary treatment (Szlachic, 2001).
      • One non-randomized controlled trial found that comprehensive wellness programs for spinal cord-injured patients result in improvements in health behaviors in several important areas, and thus may improve long-term outcomes and quality of life (Zemper et al, 2003) 
      • One cross-sectional study found that spinal cord-injured patients' intake of key nutrients often did not meet guidelines and that clinicians should screen, counsel and treat patients in order to prevent chronic disease (Tomey et al, 2005).

    • Recommendation Strength Rationale

      • SCI: Nutrition Assessment in the Acute Care Setting:
        • Small number of studies
        • Studies were of weak design for answering the question; however, studies were in substantial agreement
        • Strong rating (Grade I conclusion statement) for starting enteral nutrition within 48 hours following injury or admission to reduce the incidence of infectious complications; conclusion statement is supported by several RCTs and three meta-analyses studies.
      • Nutrition Assessment in the Rehabilitation Setting:
        • Small number of studies
        • Studies were of weak design for answering the question.
      • Nutrition Assessment in the Community Setting: Several studies of strong design for answering the question.

       

    • Minority Opinions

      Consensus reached.