When hospital patients are ill and malnourished/undernourished, the consequences are never good — patients suffer and so do facilities. That is unless clinicians take immediate action to address nutritional needs.
In September, the Agency for Healthcare Research and Quality (AHRQ) released a new statistical brief that showed nearly 2 million hospital stays in 2013 were related to disease-associated malnutrition (DAM).1 Authored by AHRQ, the American Society for Parenteral and Enteral Nutrition (ASPEN), and Baxter, the brief gives a snapshot of the characteristics of malnutrition reported during non-maternal and non-neonatal hospital inpatients stays, using information obtained from the AHRQ Healthcare Cost and Utilization (HCUP) database.
What the report indicates, unfortunately, is that DAM remains a lingering problem that often leads to increased mortality, longer hospital stays and billions of dollars in costs to the healthcare system. Yet, malnutrition — a problem that hits elderly, minority and low-income patients disproportionately — isn’t the only concern. What’s also troubling is that too many patients who would benefit from a dietary intervention end up falling through the cracks. When clinicians fail to recognize and flag malnutrition at the start, those patients are less likely to receive the appropriate, timely care they need to achieve optimal recovery.
“Malnutrition leads to weight loss, muscle weakness, apathy, immune deficiency, frequent infections and higher mortality. It can prolong illness and convalescence, hospitalization and treatment,” said Mary Hise Brown, PhD, RDN, CNSC, Senior Medical Director, Baxter. “The new AHRQ data helps us understand the impact of malnutrition in human and economic costs. For example, malnourished patients may end up staying in the hospital two times longer. Also, patients with a malnutrition diagnosis are at a five times higher risk of dying in the hospital. Longer hospital stays are also one of the contributors to an estimated $42 billion in cost to the healthcare system.”
Identification and coding
This year’s report showed that about 7 percent of patients received a malnutrition diagnosis upon admission. This is up from what the previous data shows but still not where it should be. “So while [the figure] is up from 2010 it is certainly not what we are seeing and measuring in observational clinical studies. There still remains a disconnect from what we see clinically to what is formally coded as malnutrition,” said Peggi Guenter, PhD, RN, FAAN, Senior Director of Clinical Practice, Quality, and Advocacy, ASPEN. “We would like to see this number grow and are working on various malnutrition awareness programs.”
“The data from AHRQ is another proof point that malnutrition continues to go undertreated in the hospital and community, and its impact in both direct and indirect costs,” said Refaat Hegazi, MD, PhD, MPH, Medical Director at Abbott, one of the five founding members of the Alliance to Advance Patient Nutrition.2 “While the value of nutrition is well established in the scientific community and we are seeing the cost implications for malnutrition, we are just beginning to scratch the surface of using that data to implement it into the healthcare setting.”
Small improvements matter
Ainsley Malone, MS, RD, LD, CNSC, FAND, FASPE, Clinical Practice Specialist at ASPEN and Nutrition Support Dietician at Mt. Carmel West Hospital, said momentum is building to get more patients identified and treated early. The latest data may represent just a small step forward but going forward nonetheless.
“I believe there is improvement in the documentation and thus coding for malnutrition. The statistical brief shows this with the malnutrition prevalence from 2013 of approximately 7 percent; this is an increase from the data of about 3 percent in 2010,” said Malone. “I attribute this to a number of things including increased awareness within hospitals especially by the documentation specialists and coders. Many hospitals are developing or have developed programs to address improvements in identification and documentation of malnutrition.”
Hise Brown added also that a timely diagnosis and intervention hinges on knowing what to look for. “Historically, there has not been a clear consensus on how malnutrition should be defined. Multiple definitions for adult malnutrition syndromes are found in the nutrition and medical literature, which can lead to confusion among practitioners and investigators alike,” Hise Brown said. “Simply said, there is no standard system implemented across all healthcare systems in the United States to screen and diagnose malnutrition because it requires measuring several factors, such as weight, body mass index, identification of muscle wasting and many other indicators.”
In October, Malone attended the Food and Nutrition Conference and Expo of the Academy of Nutrition and Dietetics in Boston. She said two sessions focused on the success some hospitals are having after implementing malnutrition identification and documentation programs.
“They all have utilized a team approach involving multiple disciplines including dietitians, physicians, documentation specialists, nursing leaders, information technology specialists, financial associates, etc.,” she said. “These hospitals evaluated their processes from nutrition screening effectiveness to frequency of adequate malnutrition documentation and made improvements in those areas that were deficient. The hospitals were all using the Academy of Nutrition and Dietetics/ASPEN Malnutrition Consensus Characteristics for malnutrition assessment. ASPEN has developed a resource guide that includes a nutrition care pathway and other tools to assist practitioners as they develop programs to improve their processes.”3
There is proof that progress is possible, but getting there requires consistent practice and commitment to the effort — and doing so is well worth it, said Hegazi,
pointing to a PLOS ONE study.4
“One area where reduction of DAM holds promise for dramatic cost reductions is hospital readmissions,” concluded the researchers. “Nutritional interventions have been shown to reduce readmission rates. Malnutrition is also a concern for transitions of care. The lack of standardized malnutrition screening means that there is not a consistent link to connect malnutrition care between hospitals, nursing homes, home, and community settings.”
Hegazi said Abbott is working with facilities to drive home the importance and benefits of catching and treating malnutrition as early as possible. “One example of a case study where Abbott collaborated with a hospital is Cleveland Clinic’s Akron General Medical Center,” Hegazi said. “In a recent study, published in the Journal of Nursing Care Quality, Cleveland Clinic Akron General saw reduced the hospital length of stays, readmissions and costs of care for patients after applying a nutritional quality improvement program.”5
In that study, nurses screened all patients for risk of malnutrition at admission, flagging vulnerable patients and administering oral supplements immediately, as part of their medication plan. The researchers said the plan was responsible for reducing pressure ulcer incidence, length of stay, 30-day readmissions and cost of care.
Strategies and solutions
Conferring with those who know the patient best — family, friends, and other caregivers — can also be extremely helpful in identifying patients at risk.
“Because caregivers can often be focused on a loved one’s chronic disease or illness, they have an opportunity to spot the signs of malnutrition. Symptoms can include loss of appetite, tiredness, lack of energy or strength among others,” suggested Hegazi. “Caregivers can also look for looser clothes or rings—sometimes these small signs can help facilitate a conversation with a healthcare provider on nutritional needs.
“This year, Abbott launched Ensure Enlive, our most scientifically-advanced nutrition drink that helps rebuild lost muscle and regain strength and energy after illness, injury or surgery,” he added. “For adults with a chronic illness when they are older, even short hospitalizations can cause loss of muscle and strength. Ensure Enlive is the first and only complete and balanced nutrition supplement with 20-grams of high-quality protein and the unique ingredient HMB (β-hydroxy β-methylbutyrate).”
Baxter, a leading global provider of parenteral nutrition products and services, works closely with ASPEN and other groups to expand the scientific exchange around malnutrition and deliver continuing education and other support to healthcare facilities. Hise Brown said Baxter partnered recently with the iCAN (International Conference for Advancement of Nutrition) project. “iCAN are Baxter-sponsored nutrition educational symposiums we’ve now launched in 20 countries, including the United States,” she said. “To date, the iCAN symposiums have sponsored international experts to train an approximately 700 healthcare providers on the importance of nutrition support to their patient’s outcomes.”
Baxter’s premixed CLINIMIX sulfite-free (Amino Acid in Dextrose) Injections and CLINIMIX E sulfite-free (Amino Acid with Electrolytes in Dextrose with Calcium) Injections options provide essential protein — up to 100 grams of protein per 2L bag — and are manufactured under cGMP processes to ensure the identity, strength, quality, and purity of the drug products in one container.
“Premixed PN therapy can be very helpful in a hospital setting as it is designed for activation and administration at the bedside, simplifying the preparation process for healthcare workers and helping reduce the potential risk to patients of infection and dosing errors,” said Hise Brown.
Read the related sidebar: www.hpnonline.com/connecting-with-gedsa
References
1. Characteristics of Hospital Stays Involving Malnutrition, 2013, AHRQ.
2. http://malnutrition.com/alliance
3. http://www.nutritioncare.org/Malnutrition/
4. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161833
Valerie J. Dimond | Managing Editor
Valerie J. Dimond was previously Managing Editor of Healthcare Purchasing News.
