Dietetic Workforce Development Programme Webinars

1. Could you please give a PASS example for an intubated and ventilated ICU patient as we are struggling with PASS statements at present.

Answer: It depends on the problem and what you are trying to achieve – here are some examples below:

PASS statements could include some of the following:

(P) Enteral nutrition not optimised to requirements

OR At risk of malnutrition OR Predicted Malnutrition  

 related to (A) NBM status requiring enteral feeding

as evidenced by (SS) MUAC<10th centile, meeting 70% of energy requirements and 50% of protein requirements

2. Could inadequate insulin dosing in GDM with increased insulin resistance in pregnancy also be a nutrition-related medication problem like the renal example? If their diet has the recommended grams of carbohydrates at each meal and snack?

Answer: If Dietitians are supporting with advising on insulin dosing, then yes, we could have the problem related to inadequate nutrition related medication – particularly if there were no dietary changes required.

3. PASS statement examples for food allergies/intolerances:

Answer: Imbalance of nutrient intake related to allergy to food as evidenced by meeting 60% of protein requirements and weight loss of 3kg in 2 months

Incomplete food and nutrition knowledge related to specific food allergy to food as evidenced by eating foods high in cow’s milk protein

4. Students find it difficult to understand the example Model and Process for Nutrition and Dietetic Practice document. (Inadequate oral intake related to self-feeding difficulties and shortness of breath, as evidenced by consuming <50% of meals eaten and recent weight loss of 5.5%.) As dietitians we can't do anything about SOB or COPD but yet this is written in the PASS provided by the BDA.

Answer: You can’t always address the aetiology but you must be able to address the nutrition related problem (in this case the inadequate oral intake). You may be able to help resolve the self-feeding difficulties in the short term by providing softer foods, fortified foods and/or oral nutritional supplements.

5. I read somewhere that signs are objective data (biochemistry, weight, BMI etc.) and symptoms are subjective data (feelings, appetite etc.). Would you agree with this or do you just mix them together? Could signs be quantitative outcome indicators and symptoms be qualitative outcome indicators?

Answer: It is easier to compare objective data, but subjective data can still be valuable. You can use both objective and subjective outcome indicators for the same service user.

Yes, signs are often quantitative outcome indicators, but there are some validated tools for symptoms that can provide values too e.g., Bristol stool chart. Other subjective outcome indicators such as knowledge and motivation are still helpful, if more difficult to measure.

Likert scales to capture feelings / symptoms can be helpful and there are scales for readiness to change and for motivational interviewing. It may be worth linking in with specialist groups re any validated tools for use in their specialist areas.

6. How to do a PASS for a complex patient with multiple nutritional problems?

Answer: I would suggest writing a separate PASS statement for each problem. Then you will need to prioritise these problems to decide what should be tackled first. The patient may also have their own priorities which should be considered.

7. What are the signs and symptoms for a "predicted problem" as it doesn't currently exist?  Isn't it better to use inadequate oral intake over predicted malnutrition?

Answer: It depends on the situation – if they are likely to develop malnutrition due to their current signs and symptoms unless they receive dietetic input - I would suggest that predicted malnutrition is a helpful term.

8. If using malnutrition as a dietetic problem, should we all be using a standardised definition for the signs and symptoms to define this, such as GLIM ?

Answer: Yes, if one standard definition is used. There are several possible definitions of which GLIM can be very helpful.

9. Do you feel if 'Incomplete food and nutrition knowledge' or mentioning 'adherence' is acceptable to have on our clinic letters to our patients? We auto merge our clinic letters from our assessment we write in the patient records so don't want to cause offence to patients.

Answer: These are the recognised SNOMED terms – but I agree that some of the SNOMED language may not be how we would usually phrase our sentences. SNOMED terms can be updated – though this would take some time. The aim of our pilot project is to identify language / terms that we feel are missing and that we would like to add. Please be aware that this will take a little time to embed post completion of the project therefore please amend your clinical letters to what you feel is appropriate to communicate with your service users.

10. What about palliative patients- thinking mostly oncology or advanced dementia?  Losing weight due to inadequate intake/disease progression that we are unlikely to be able reverse and dietetic input is often regarded as QOL measure...should QOL be the outcome indicator?

Answer:

Palliative: The example of the patient with Head and Neck cancer should show this. You may not be able to resolve the problem but you can address it – the proposed outcome may well be ‘to minimise nutritional losses’ You could also add quality of life to the outcome by using a suitable measure to demonstrate this.

End of life: Yes, but we should ideally be more specific regarding the service user’s aim is – is the quality-of-life aspect more specific regarding food and nutrition e.g., food for comfort.

11. I have heard people use PASS statement and nutritional diagnosis as interchangeable terms. What is the key difference between the two?

Answer: The PASS statement is a structured sentence that describes the Nutrition and Dietetic Diagnosis (NDD) – so the two are very similar.

12. Who should I email to if I would like to discuss this NDD and PASS further?

Answer: Please direct questions to [email protected]