Progress report cites awareness gaps among caregivers.
One in three Americans enters a hospital malnourished, which increases their risk for adverse events, such as surgical site infections, postoperative pneumonia and the development of pressure ulcers. So with the Centers for Medicare & Medicaid Services (CMS) withholding payment to hospitals for 11 of these preventable conditions, hospitals and long-term care facilities should be looking at malnutrition as a contributing factor—or so one would think.
Recent research shows that many facilities are missing an opportunity to address malnutrition, which is associated with increased rates of complications and readmission, prolonged hospital stays and greater mortality. In particular, malnourished patients are two to three times more likely to develop a surgical site infection or postoperative pneumonia (Arch Surg2010;145:148-151) and twice as likely to develop a pressure ulcer (Nutrition 2010;26:896-901). Nearly half (45%) of patients who fall in the hospital are malnourished (J Hum Nutr Diet2007;20:558-564).
“Malnutrition can increase the risk of hospital-acquired infections, increasing the patient’s length of stay and increasing their risk of morbidity and mortality. It can also interfere with the health care practitioner’s ability to adequately and successfully treat the patient while he or she is in the hospital,” explained Carmen Roberts, MS, RD, LDN, a clinical dietitian specialist at Johns Hopkins Bayview Medical Center, in Baltimore.
Also worrisome are the statistics showing that even well-nourished individuals will experience some type of nutritional decline when they enter the hospital because of their illness, poor appetite, dietary restrictions, gastrointestinal problems and other issues, according to Dr. Parkhurst.“Of course, there is never one thing that influences a patient’s stay in the hospital, but malnutrition can be a significant factor,” said Melissa Parkhurst, MD, associate professor in the Department of Internal Medicine at the University of Kansas Medical Center, in Kansas City, and medical director of Nutrition Support Services at the University of Kansas Hospital. “The data we have over a number of years consistently show that one in three patients enters the hospital already meeting the criteria for malnourishment,” said Dr. Parkhurst, who is also the clinical representative in the Alliance to Advance Patient Nutrition, an interdisciplinary partnership dedicated to raising awareness about malnutrition in hospitals. “We know that if left unattended, about two-thirds will experience further decline while they are in the hospital.”
“There are multiple reasons why malnutrition in the hospital is an issue,” she said. “The hospital care of a patient is a complex system with a lot of moving parts and a lot of things that are competing for the attention of the physician, nurses and administrators. Then on top of that, you add a lack of general understanding of the cost of malnutrition and lack of awareness and inaction.”
These factors make it easy for malnutrition to fall under the caregivers’ radar, she explained. Many patients are placed on NPO (nothing by mouth) orders for long periods, or they are taken for radiographs or other diagnostic tests or procedures during mealtimes and frequently miss meals. Others stop eating because they do not like the food, feel nauseated, are experiencing medication-related changes in taste, are depressed or in pain, or have another issue.
Patients’ lack of adequate caloric intake may go unnoticed over time and, if interventions are put into place, they are not always tracked to see if they are working. It happens every day in hospitals and long-term care facilities across the country, Dr. Parkhurst said.
The Skeleton in the Closet
Malnutrition in the hospital is not a new problem. In a landmark 1984 study, Charles E. Butterworth Jr., MD, referred to malnutrition as the “skeleton in the hospital closet” because it remains underrecognized and often goes untreated (Nutr Today 1974;9:4-8).
Because one in three people enters the hospital already meeting the criteria for malnourishment (Int J Environ Res Public Health 2011;8:514-527), and malnutrition has been linked to increased morbidity and mortality, the Joint Commission mandates that a nutrition assessment be done when a person enters the facility. However, the group does not provide any guidance about the management of the patient once he or she is identified, which is how that patient falls through the cracks, Dr. Parkhurst pointed out.
If a patient is identified as being malnourished, often he or she is discharged before a full nutritional assessment is performed because the average time for such an evaluation is five days after admission, which is also the average hospital length of stay (J Parenter Enteral Nutr2011;35:209-216).
“Dietitians need to do an assessment within a timely fashion of the screening coming back at risk,” Dr. Parkhurst said. “And the dietitian’s recommendations, which are only implemented about 40% of the time, need to be followed up by the physician-led team.”
The Alliance to Advance Patient Nutrition recently issued a progress report on alleviating hospital-based malnutrition (http://www.malnutrition.com/progressreport). The report highlights some of the obstacles impeding progress in recognizing and treating malnutrition, as well as recommends a roadmap for institutions to follow.
To change the paradigm will require direct, system-wide and sustained intervention, according to the report, released in August 2014. Among the recommendations are:
- Hospital administrators and staff must view nutrition as a priority for improving care, quality and cost.
- Clinicians’ roles must be redefined to include nutrition, giving them the power to address patient’s nutritional needs.
- The electronic health record (EHR) should be leveraged to standardize nutrition documentation and communicate nutrition care plans.
- Someone should take responsibility for the patient’s nutritional status.
The process begins with the screening, Dr. Parkhurst said. A simple, easy-to-use tool tied to the EHR should be used. Once a patient is identified as malnourished, the dietitian must quickly perform a full assessment and make recommendations. Someone on the care team must act on these recommendations and periodically check the patient’s nutritional status. Finally, during the huddle, nutritional status should be one of the issues discussed by the health care team.
All members of the health care team should be part of the screening and treatment of malnutrition, according to Johns Hopkins’ Ms. Roberts. Nurses and physicians can screen patients on admission and during history taking as well as do a physical for nutritional risk factors and to identify the need for nutritional intervention if needed, as well as educational requirements during the hospital stay. “Dietitians are experts at assessing the patient’s nutritional needs and providing appropriate nutritional interventions,” she said, which could include recommending therapeutic diets, providing education to the patient and caregivers, and making recommendations to the physician for supplemental nutrition if needed during the patient’s hospital stay.
Some malnutrition occurs because of nausea, vomiting, diarrhea and altered taste from medications. Pharmacists can conduct a medication reconciliation and side-effect profile, and make recommendations that might foster calorie intake. They also can assist with IV nutritional support if needed, Ms. Roberts said.
Even therapists can help recognize if patients are not eating properly and report that to the health care team. They also can recommend adaptive devices that might make eating easier for patients with handicaps.
Social workers can assist the patient in locating community resources if needed. “Providing the patient with community and outpatient resources is an essential part of treating nutritional problems and ultimately avoiding readmission for these conditions,” Ms. Roberts said. “The ultimate goal is to move the patient from the acute environment and to provide them with the resources in the community to ultimately treat any long-term nutritional problems.”
These efforts can pay off. Studies show a 25% reduction in the incidence of pressure ulcers (Ageing Res Rev 2005;4:422-450), 14% reduction in overall complications (Cochrane Database Syst Rev 2009;CD003288) and a 28% reduction in avoidable hospital readmissions (Arch Intern Med 2001;161:1549-1554) when adequate nutrition is maintained in hospitalized patients. Well-nourished patients also experience an average reduction in the hospital length of stay of about two days (Am J Med 2006;317:495-501).
“Let’s catch these patients who are already at risk, who are showing signs of malnutrition when they hit the door, and make sure we have a plan in place quickly to intervene and track [their progress],” Dr. Parkhurst said.