Nurses can make a difference when it comes to malnutrition

After falling at home and sustaining a left hip fracture, Charlotte struggled to regain her lost independence.

As the pain medications led to constipation and nausea, Charlotte became less and less interested in eating. At 350 pounds, some of the staff commented that the unplanned weight loss of 20 pounds during the past two weeks might be good for her. But is it? The face of malnutrition isn't always what you would anticipate.

Unplanned weight loss and poor nutritional intake is never a benefit to healing or improved physical functioning.

What's behind the weight loss?

For many people who already have had a decline in muscle mass associated with aging, the addition of disease or injury leads to further loss of lean body mass and decline in functional abilities. Up to 50% of hospitalized patients are at risk for or already have malnutrition, but only 7% actually receive a diagnosis during their hospital stay, according to an article in Clinical Interventions in Aging and the Agency for Healthcare Research and Quality.

Malnutrition diagnoses can significantly impact Medicare reimbursement and the case mix index for a facility. Patients who are malnourished may not only have longer lengths of stay of up to four to six days, but also hospital costs twice as high for patients with malnutrition, according to the Agency for Healthcare Research and Quality and International Journal of Environmental Research and Public Health.

Terese Scollard, MBA, RDN, LD, FAND, a leading expert in malnutrition and a member of the Academy of Nutrition and Dietetics work group that designed and released the Consensus Statement on malnutrition in 2012, highlights guidelines you need to tackle this important condition. According to the Agency for Healthcare Research and Quality, malnutrition also can lead to:

An increased risk of adverse events and complications
A 54% higher likelihood of hospital 30-day readmission
Up to 5 times more likely to die in the hospital than a non-malnourished patient

It was difficult to diagnose malnutrition in the past as there were no widely accepted characteristics that clinicians could use to classify this condition consistently throughout all care settings.

But that all changed in 2012 with the publication of the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition Consensus Statement on identifying and diagnosing malnutrition.

From the ED to the ICU, it's important all healthcare providers document malnutrition characteristics accurately. When a physician automatically clicks "Appears well nourished," when the patient actually isn't, facilities risk ignoring a condition that increases costs, length of stay, and even the patient's chance of readmission. All clinicians should be aware of the guidelines and working as a team to treat malnutrition.

One study, which assessed the impact of an interdisciplinary malnutrition treatment program in several hospitals within a large accountable care organization, reduced 30-day readmission rates by 27% and the average length of stay in the hospital by almost two days for patients with malnutrition.

The impact of these interventions has the potential for significant savings for a healthcare system.

Another study from suburban Chicago-based Advocate Health Care resulted in a $4.8 million cost reduction after implementation of a nutrition-focused quality improvement program at four facilities. The savings of approximately $3,800 per patient was attributed to decreased readmission rates and shorter lengths of stay.

A successful malnutrition treatment program requires an interdisciplinary team to assess, document and prioritize interventions that improve the nutritional status of those under our care.

What can you do to help?

Recognize that malnutrition can have a significant impact on healing, length of stay and readmission rates.
Refer patients of concern to your registered dietitian nutritionist for a comprehensive nutrition assessment.
Avoid weight bias in identifying malnutrition. Patients of any size can become malnourished.
Ensure that accurate weights and meal percentages are documented.
Communicate your concerns with the primary care provider.

The medical diagnosis of protein-calorie malnutrition should be documented so all providers are aware of the client's condition. Providing a diagnosis alerts other practitioners to the situation so they can intervene and provide better interprofessional care. The diagnosis helps the client and family be prepared to discuss root causes.

Although the term "malnutrition" can be stigmatizing, the focus should be on the client's condition and on interventions that can lead to recovery and prevention of further problems. Malnutrition is no one's fault, but together we can work to find solutions.

Explore Nurse.com courses related to nutrition.

References

Wells JL, Dumbrell AC. Nutrition and Aging: Assessment and treatment of compromised nutritional status in frail elderly patients. Clin Interv Aging. 2006; 1(1):67-69.
Weiss AJ, Fingar KR, Barrett ML, et al. Characteristics of hospital stays involving malnutrition, 2013. HCUP Statistical Brief #210. Rockville, MD: Agency for Healthcare Research and Quality. Available at: http://www.hcup-us.ahrq. gov/reports/statbriefs/sb210-Malnutrition-Hospital-Stays-2013.pdf.
Barker LA, Gout BS, and Crowe TC. Hospital malnutrition: Prevalence, identification, and impact on patients and the healthcare system. Int J of Environ Res and Public Health. 2011;8:514-527.
Fingar KR, Weiss AJ, Barrett ML, et al. All-cause readmissions following hospital stays for patients with malnutrition, 2013. HCUP Statistical Brief #218. December 2016. Agency for Healthcare Research and Quality, Rockville, MD. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb218-Malnutrition-Readmissions-2013.pdf
White JV, Guenter P, Jensen G, et al; Academy of Nutrition and Dietetics Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.
Sriram K, Sulo S, VanDerBosch G, et al. A comprehensive nutrition-focused quality improvement program reduces 30-day readmissions and length of stay in hospitalized patients. JPEN J Parenter Enteral Nutr. 2017;41(3):384-391.
Sulo S, Feldstein J, Partridge J, et al. Budget impact of a comprehensive nutrition-focused quality improvement program for malnourished hospitalized patients. Am Health Drug Benefits. 017;10(5):262-270.