Did you know that the percentage of malnutrition cases among hospital patients ranges from 20 to 50 percent? And another one-third of patients can become malnourished while admitted? A variety of controllable and uncontrollable factors may contribute to this, including a patient’s condition, length of stay, unfamiliar surroundings and/or food offerings. All totaled, up to two-thirds of patients can be affected by poor nutritional status when they are discharged.
Malnutrition has been associated with poorer outcomes, increased length of stay and higher mortality rates. Nutritional deficits can also lead to muscle weakness and/or loss, which increase patients’ risks of falling, pressure injuries, infections, delays in wound-healing and hospital readmissions. With all of these connections, how is it that malnutrition is seldom recognized as a patient-safety issue?
March is National Nutrition Month. It’s a perfect time to consider if your organization is doing all that it can to identify, document and assist patients with malnutrition. A good place to start is by defining the problem—literally. Surprising, isn’t it? There is not a universally accepted definition of malnutrition. The Academy of Nutrition and Dietetics and The American Society for Parenteral and Enteral Nutrition (ASPEN) offered this definition in a 2012 Consensus Statement related to adult malnutrition:
“[Malnutrition is] an acute, sub-acute or chronic state of nutrition, in which a combination of varying degrees of over-nutrition or under-nutrition with or without inflammatory activity has led to a change in body composition and diminished function.”
Free resources can aid hospitals
Because disagreement exists about malnutrition’s definition, hospitals need to develop their own definitions using evidence-based guidelines. The consensus statement above is one example. By convening an interdisciplinary group to write a definition, followed by a malnutrition policy, hospitals are establishing a framework for more consistent malnutrition diagnoses. At a minimum, this group should include physicians, dietitians, nurses, pharmacists and other care team members. Bringing in other experts is also vital, including hospital executives, documentation specialists, EMR representatives and legal and billing specialists.
Free resources, such as the Malnutrition Change Package from the Health Research & Educational Trust and the Malnutrition Quality Improvement Initiative toolkit, are available online. A validated (tested) screening tool, described in the toolkit (page 29) should be implemented, along with trackable performance indicators to accurately measure progress.
While an indispensable foundation, your hospital’s definition and policy must then be correctly interpreted and applied. For example, guidelines recommend the diagnosis of adult malnutrition to be based on the presence of two or more of the following characteristics:
- Insufficient food and nutrient intake
- Weight loss over time
- Loss of muscle mass
- Loss of fat mass
- Fluid accumulation
- Diminished functional status
Treatment and documentation for the double win
The positive impacts of recognizing in-hospital malnutrition are twofold. First, identifying and treating malnutrition plays a key role in improving patient outcomes. At a high level, this involves administering a malnutrition screening within 24 hours of admission. For the patient identified as at-risk, a nutritional assessment is recommended, followed by a nutrition care plan if indicated, based on the assessment results.
Secondly, correct documentation, coding and billing of a malnutrition diagnosis are critical to appropriate reimbursement. Longer lengths of stay, more frequent readmissions, higher acuity of care and greater resource consumption are not uncommon. A 2016 analysis of patients discharged from U.S. hospitals showed that the average malnutrition-related stay cost $25,200, compared to the average hospital stay of $12,500 (excluding maternal and neonatal data). This supports a 2003 study by Correia, et al, which reported an associated cost increase of up to 300 percent due to malnutrition.
With an interdisciplinary team in place, all consistently striving for screening, identification, documentation and treatment, the negative impact of malnutrition can be reduced. It can improve outcomes and capture reimbursement for the additional care provided—certainly a win-win.
To learn more about addressing malnutrition in your organization, click here to listen to previous webcast recordings from the Vizient Hospital Improvement Innovation Network (HIIN) Community Knowledge Network series.
About the author. Juli Hermanson is a registered dietitian nutritionist with 20 years of experience in the field of nutrition and dietetics, including health care, food industry, public health and corporate wellness. Her expertise is providing continuing education programs and educational resources on the topics of health and nutrition for health care professionals. She has been a professional presenter to both state and national professional audiences, including the National Academy of Sciences. She currently manages the Vizient Hospital Improvement Innovation Network (HIIN) Community Knowledge Network series.