P3D318: The Nutrition Action Plan: A Novel Clinical Decision Support Tool with Automated Formula Mixing Guides, Automatic Free Water & Calorie Calculators, and Embedded Guideline-concordant Care Features

Purpose/Objectives: Pediatric feeding disorder, cows milk protein intolerance, and malnutrition necessitating tube feeds are all examples of challenges to the feeding practices for the caregiver-child dyad. In rare instances, children require home parenteral nutrition which presents additional complexity to home self-management.
Clinical action plans with low health literacy enhancements have demonstrated improved caregiver health confidence and adherence to therapy in managing children at home with regards to functional constipation and asthma. There is evidence suggesting that the complex interplay of mixing formulas, selecting nutraceuticals, and adhering to pharmacotherapy presents high risk for mistakes to be made at home.
We aimed to develop a low health literacy, pictogram–enhanced nutrition action plan with both enteral and parenteral offerings that would facilitate transfer of knowledge for children with complex nutritional needs.

Design/Methods: We followed the NIH 5-step "Clear & Simple Campaign" process to develop this tool.
First, we incorporated a Green-Yellow-Red zone motif. We developed a Page 1 called the "Enteral Nutrition Action Plan" (Figure 1) and a Page 2, the "Parenteral Nutrition Action Plan" (Figure 2). We created Simple Mathematic Automated Recommendation (SMART) Tools that leverage embedded JavaScript coding to provide clinical decision support:
1. Automatic Formula Mixing Guides (for infant and child powder formulas taken from the Academy of Nutrition and Dietetics)
2. Automatic Calculators for Daily Total Volume, Total Free Water, and Total Calories
3. Automatic, Evidenced-based Safety Pop-up warnings (e.g., if selecting a thickener that is not FDA approved for infants)
4. Buttons to display guideline algorithms (e.g., the NASPGHAN Reflux guideline)
5. Ability to personalize central venous line care with parenteral nutrition
6. Clinical symptom, feeding tube, and pump pictograms
7. Automatic generation of a textual progress note for copy/paste into health record
We worked with the Pediatric Feeding Disorders Alliance organization "Feeding Matters" to enhance our implementation science through audience-based review.
Next, we measured readability- the ease with which a text can be read and understood. The team used the seven readability formulas to assess readability and a consensus score was generated. The goal was to generate a score of 6th grade or less. Later, 4 medical librarians measured the understandability and actionability of the nutrition action plan using the Patient Education Materials Assessment Tool.

Results: The Nutrition Action Plan successfully received an "Approved Resource" rating from Feeding Matters. The tool registered at a 6th grade level. The clinical action plan received 100% ratings for both understandability and actionability. The Nutrition Action Plan completed 12 months of safety testing for clinical implementation.

Conclusion/Discussion: The Nutrition Action Plan is poised to make an impact in general pediatrics, pediatric gastroenterology, and multi-disciplinary clinics by providing a rapid, safe mechanism for nutrition plan development while simultaneously packaging a child's complex care into one document.