In 1974, a groundbreaking article by Dr. Charles E. Butterworth, Jr. described malnutrition as “the skeleton in the hospital closet” because it so often went undetected and untreated. Sadly, more than 40 years later, contemporary authors similarly describe malnutrition as a silent epidemic. Reports today show that 20 to 50% of hospitalized patients are malnourished upon admission. A 2016 study by the Agency for Healthcare Research and Quality (AHRQ) substantiated this disturbing trend: nearly 2 million hospital stays are associated with malnutrition annually at a total annual cost of almost $42 billion.
The historical lack of a standardized approach to define, identify and treat malnutrition has largely contributed to its poor recognition, diagnosis and intervention. In 2012, the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (ASPEN) proposed standard malnutrition characteristics to facilitate more effective diagnosis. The standards also support the establishment of a culture where malnutrition care is valued.
Make awareness part of culture
Awareness of malnutrition should be interwoven into a hospital’s culture of improvement through everyday processes and practices. Dietitians play a key role by recognizing critical leadership initiatives and implementing procedures that connect malnutrition with those initiatives. Through leadership and interdisciplinary support, interventions may begin more promptly when malnourished patients are identified.
Prompt intervention is important. Malnourished patients have more comorbidities, longer hospital stays, higher readmission rates and substantially higher morbidity and mortality than patients who do not present with malnutrition. In spite of the known increase in nosocomial infections, pressure injuries and poor health outcomes, we remain challenged by malnutrition’s prevalence and devastating impact.
Given the multifactorial etiology of malnutrition, a multidisciplinary care process is imperative. Expert recommendations for more effective recognition and treatment of malnutrition include:
Standardize malnutrition documentation. Best practice based on the Academy of Nutrition and Dietetics is to ensure consistent use to the Academy/ASPEN consensus statement. Prior to the consensus statement, malnutrition was defined in several different ways, significantly affecting coding and reimbursement. Additionally, if one is not already in existence, consider establishing an interdisciplinary nutrition committee. This committee can assist and support development of policies and procedures for malnutrition diagnostic criteria, order writing privileges, and screening and assessment criteria. These combine to help provide clear definitions of clinicians’ roles in delivering nutrition care.
Utilize technologies. Add a validated instrument for malnutrition screening on admission using an electronic medical record (EMR) system. Validated instruments, such as the malnutrition screening tool, can be found on the Academy of Nutrition and Dietetics website. Building the following standard malnutrition diagnostic criteria into care plans within the EMR can also increase accuracy, efficiency and productivity. The criteria include:
- Characteristics, such as energy intake and interpretation of weight loss
- Severity, such as mild, moderate or severe malnutrition
- Context, e.g., acute/chronic, in which malnutrition occurs
The EMR can also be used to extract reports associated with malnutrition care. Some examples to consider are: patient supplement utilization, pressure ulcer risk patient report and malnourished patient report. These reports can be made electronically accessible to critical disciplines, including nursing, social work and dietetics.
Create electronic measuring tools and mechanisms. “You can’t improve what’s not measured.” Utilize Academy-endorsed electronic quality measures, which are bulleted for clarity below. These measures were created to promote appropriate screening, assessment and diagnosis of malnourished patients and support improved outcomes:
- Complete malnutrition screening within 24 hours of admission
- Assess patients identified as at-risk for malnutrition within 24 hours of a malnutrition screening
- Complete nutrition care plans for patients identified as malnourished
- Document appropriate malnutrition diagnosis
Multiple contemporary researchers aim to increase awareness of the prevalence and adverse consequences of malnutrition. Quality improvement programs within hospitals that include appropriate interdisciplinary protocols aimed at identifying and treating malnutrition are advised. Using standardized diagnostic criteria and established tracking and measuring mechanisms remain imperative as we grapple to outline a blueprint of care for malnourished patients.
