The Geriatric Rehabilitation Unit (GRU) is a 30-bed Medicare-certified skilled nursing facility. Since its inception in 1969, a multidisciplinary team approach has been the cornerstone of its assessment and treatment program.

As part of the team's quality improvement efforts, a prospective sampling of the 730 GRU admissions in 1992-93 was conducted Admissions who had been living in the community prior to hospitalization and who were considered “at risk” for institutionalization were study candidates. Residents whose initial plan was to be discharged to a nursing home were excluded The selected residents (N=155) were assessed initially and again prior to dismissal for several factors predict Ambulation was found to be the single most important factor in predicting discharge disposition.

As a follow-up to this finding, each member of the interdisciplinary team was charged with the responsibility of contributing to the outcome goal of promoting increased ambulation. It was determined that the amount of tubes and extra equipment associated with receiving necessary enteral nutritional support interfered with residents’ ability to ambulate independently. Consequently, a program of “Least Restrictive Nutritional Treatment” was developed The goal of this approach was to improve the conditions for ambulation by transitioning tube fed residents to oral feeding. Steps in achieving this goal included a variety of techniques such as employing a nighttime feeding schedule, utilizing bolus feeding during the day as appropriate, and terminating feeding during therapies while still meeting nutritional needs.

During 1994, a total of 78 residents admitted to GRU (approximately 21% of total admissions) were selected for study using the previously stated criteria. Within this group, 24% (N=19) were on tube feeding. The Least Restrictive approach to nutritional therapy was applied to these residents resulting in 53% being transitioned off of tube feeding to adequate oral intake prior to dismissal Of special interest was the finding that 57% of residents who entered the unit on PEGs were dismissed on adequate oral intake as a result of the combined efforts of dietetics and speech therapy. The dietitian and speech therapists collaborated in improving residents’ swallowing to the extent that nutritional needs could be met through oral intake.

The results of this quality improvement project indicate that a Least Restrictive Nutritional Treatment Program can be used to transition over half of tube fed residents to adequate oral intake, thus enhancing conditions for ambulation and promoting improved functional outcome in a geriatric rehabilitation population.