Understanding malnutrition for positive patient outcomes
Malnutrition has historically been an issue in facilities, mainly because before 2012, no standard criteria existed for adult or pediatric malnutrition. With a widespread lack of awareness of national best practice guidelines for malnutrition, identifying and diagnosing malnutrition is often still difficult for providers and CDI specialists.
Joannie Crotts, RN, BSN, CPC, and clinical documentation and revenue integrity manager at Sarasota Memorial Health Care System in Sarasota, Florida, explained in the ACDIS webcast “Improving Identification, Documentation, and Treatment of Malnutrition in the Acute Care Setting,” that the collaboration between their CDI department and the clinical nutrition department didn’t begin until 2012.
The initiative came to the forefront when CDI specialists on Crotts’ team noted variations in criteria and clinical indicators used to diagnose malnutrition by providers while reviewing the hospital’s medical records, said Crotts.
“Without defined industrywide criteria in place, it was difficult for clinicians to consistently document malnutrition and differentiate between the different severity levels,” said Crotts.
The CDI specialists turned to their team of registered dietitians, and discovered there were new evidence-based national guidelines that had been recently developed.
“CDI really wanted to get more involved and learn more about the new criteria and how we could incorporate it in to our daily practice,” said Crotts. “So, [our] CDI and clinical nutrition departments started talking about how we would standardize and implement these guidelines house-wide so we could all be on the same page.”
This was the beginning of the Sarasota Memorial Health Care System Malnutrition Initiative. The objectives of the initiative, Crotts said, are to create consistent documentation across the hospital, create ways for early identification and intervention for those identified with malnutrition, and establish prevalence and impact of malnutrition on patient outcomes, length of stay (LOS), readmissions, and quality reporting.
Identification
The first step in implementing a malnutrition program, said Szilvia Kovacs, MS, RD, LDN, and clinical nutrition manager for Sarasota Memorial Hospital, is identifying the symptoms and establishing the prevalence of malnutrition at a facility.
Kovacs noted the following nationwide statistics[i] for malnutrition prevalence, which represent a mix of patients’ age, gender, and location of malnutrition presence.
- Hospitals – 20%-50% prevalence
- Long-term care—21%-51% prevalence
- Outpatient and homecare—13%-30% prevalence
“In our research and program implementation, it was very vital for us to recognize that malnutrition is often developed prior to admission, but can also be developed with-in the health care setting once the patient is already there,” said Kovacs.
During the implementation process for the facility, Kovacs said, it was important to establish framework to help providers and CDI specialists in identifying malnutrition.
Kovacs stated that adopting the evidence-based malnutrition guidelines supported by The American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN) to standardize the criteria for adult malnutrition was an important step for their clinical nutrition team and the CDI specialists when they implemented facility-wide malnutrition identification program.
The Academy and ASPEN state that a patient must have at least two of the six characteristics of malnutrition below in order to correctly be identified and diagnosed with the condition:
- Insufficient food intake compared to nutrition requirements
- Localized or generalized fluid accumulation that may sometimes mask weight loss
- Loss of muscle mass
- Loss of subcutaneous fat mass
- Measurably diminished hand grip strength
- Weight loss over time
Along with those six characteristics, Kovacs said, the facility also looks for pressure ulcers and non-healing wounds in support of malnutrition diagnosis and identification.
Using the right methods for identifying malnutrition is important since malnutrition is a serious, often underappreciated condition, that can impact patient outcomes and overall healthcare costs, said Kovacs.
Diagnosing
An important step in correctly diagnosing and documenting malnutrition at the facility, said Crotts, was the development of an electronic communication tool that makes reporting as easy as possible for clinicians.
The tool presents the registered dietitian’s nutrition assessment, without physicians having to search through documentation for the information, said Crotts.
It allows the registered dietitian to essentially alert the physician of a nutritional diagnosis of protein calorie malnutrition and of the patient’s care plan. Having this tool allows for timely and efficient communication, saves documentation time, impacts severity of illness reporting, and enhances quality of care, said Crotts.
“We’ve had a great deal of positive feedback about the new tool from clinicians,” said Crotts. “It makes it easier for the physician to address patient’s nutritional status and complete the necessary documentation.”
Albumin/prealbumin in malnutrition
While many identifiers come into play when diagnosing a patient with malnutrition, albumin and prealbumin levels no longer do.
In the past, albumin and prealbumin were often used to determine nutritional status because they were thought to reflect a protein status, but, Kovacs said, “we now know that albumin and prealbumin are very poor bio markers to determine one’s nutritional status, because they are very easily influenced by the inflammatory process, which is often present in many of our patients, whether they are malnourished or not.”
The levels are considered unreliable since albumin and prealbumin are proteins that can be impacted by an acute illness, injury, or chronic illness, not necessarily just malnutrition, said Kovacs.
Kovacs gave an example of a healthy, athletic 30-year-old female patient with a prealbumin level of 28 grams per deciliter (g/dL) and albumin level of 4 g/dL before she is hit by a motor vehicle. The next day, after surgery in the emergency department, her prealbumin level is 9 g/dL and albumin level is 2 g/dL. Although her levels decreased, the patient is not malnourished, making these levels insufficient evidence for a diagnosis.
To increase awareness and understanding of why albumin and prealbumin levels are not used in evaluating malnutrition at the facility, Kovacs said it was helpful to provide physicians, nurses, and even coders with laminated cards defining and explaining albumin and prealbumin in the context of malnutrition.
Post-initiative implementation
After implementing the malnutrition initiative, Crotts said the facility has benefited from many successes from better identifying, diagnosing, and treating malnutrition.
“One of the most important benefits of the program was the enhanced patient care,” said Crotts. “We can provide earlier intervention with nutritionally compromised patients.”
Another lesson, Crotts said, was the importance of partnership within the facility. The interdisciplinary approach to malnutrition improved communication, collaboration, and appreciation among the teams.
The facility has also enhanced quality reporting by accurately capturing a patient’s severity of illness and risk of mortality, and by accurately identifying and diagnosing malnutrition as a whole.
While the hospital’s program has been in place for several years at the facility, there are still many opportunities for improvement, such as breaking the habit of using albumin and prealbumin as indicators for malnutrition, said Crotts.
Looking forward, Crotts said their next steps include the continued interdisciplinary education on prevalence, identification, and treatment of malnutrition.
“We’ve been also working toward improved documentation to support the plan of care by including supplements on the MAR [medication administration record]. That will provide more consistent documentation, and increase the nurses’ awareness of the nutritional status of the patient,” said Crotts.
Another positive outcome of the malnutrition initiative is that it showed the important role support staff can play in improving the patient experience, even if they are not directly involved in bedside care, Crotts said.
“This effort gave the CDI team an opportunity to impact patient outcomes and help our clinicians deliver the best possible care,” said Crotts.
Editor's Note: This article originally published on JustCoding.com.