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Oct 01 2013
A Practical Guide for Nurses to Combat Hospital Malnutrition
Beth Quatrara, DNP, RN, ACNS-BC

Recently, the Alliance to Advance Patient Nutrition published a consensus paper that outlined a series of pragmatic recommendations for how hospitals can implement an effective Nutrition Care Model, and specific steps that nurses can take to drive institutional change in their hospitals.

Nutrition Care Model: Pragmatic Recommendations for Nurses

In order for patient malnutrition to be properly addressed and treated, a collaborative, interdisciplinary approach is necessary. At my hospital, the University of Virginia Health System, clinicians and hospital administrators are always working together to enhance our nutrition care. While each hospital possesses unique characteristics and requires carefully tailored approaches, the six principles outlined in the Alliance’s Nutrition Care Model offers hospitals, and nurses, a practical guide for how to deliver meaningful change to their patients:

Principle 1: Create an institutional culture where all stakeholders value nutrition
An important reason why widespread hospital malnutrition has gone largely unnoticed is because of inconsistent awareness and recognition of the problem at various institutions. Together, at UVA, nursing and nutrition teams are collaborating to enhance opportunities to identify and treat malnutrition.

By combining efforts with the nursing and nutrition teams, we are able to maximize institutional change at our hospital and communicate the importance of nutrition to all stakeholders.

Principle 2: Redefine clinicians’ role to include nutrition care
While clinician roles vary in treating patients, all clinicians need to integrate nutrition considerations to better address malnutrition. Nurses, in particular, can help to redefine and expand their roles by developing processes to ensure that nutrition screening and intervention occur within targeted timeframes. In addition, nurses, in collaboration with physicians and dietitians, should ascertain that practices are in place to support nutrition intervention efforts. As a way to begin redefining the roles of nurses, leaders at the UVA Health System are looking to raise awareness of at risk patients in every practice setting. This, in effect, will empower nurses to take on a leadership role relative to engaging in efforts to address hospital malnutrition.

Principle 3: Recognize and diagnose all malnourished patients and those at risk
The Alliance advocates for every hospital patient to be effectively screened and documented as nourished, malnourished, or at-risk, to guarantee effective assessment, intervention, and diagnosis. Nurses can play an important role by screening every hospitalized patient for malnutrition as part of regular workflow procedures. Also, nurses can further this effort by communicating screening results through the use of electronic health records (EHR).
In fact, the UVA Health System uses the malnutrition screening tool (MST), which is integrated into the electronic medical record as part of the admissions screening, so it is hardwired into the system. With the MST integrated into the EHR, more patients are being identified as malnourished by nurses with the MST upon admission, than were prior. This has made our screening process more accurate and rigorous.

Principle 4: Rapidly implement comprehensive nutrition intervention and continued monitoring
Once a patient is diagnosed as malnourished or at-risk, nurses can ensure that comprehensive nutrition interventions are promptly implemented and effective monitoring tactics are employed. Specific measures also include: making certain that patients identified as at-risk receive automated nutrition interventions within 24 hours while awaiting assessment, diagnosis and care plans; working with a dietitian to establish policies and interdisciplinary practices to maximize food / oral nutritional supplements (ONS) consumption; and communicating meal / oral nutritional supplements (ONS) consumption with clinician support team via EHR systems.

Principle 5: Communicate nutrition care plans
Communicating a course of action relative to a patient’s nutrition care plan is an indispensable aspect of the treatment process. This is not only important when communicating nutrition care plans to the patient’s immediate clinical support team, but also relative to implementing broader, systemized practices that better treat malnutrition.
One of the key actions we implemented at UVA was a system-wide evaluation of our patients’ overall nutrition status. This prompted collaborative discussion about what best practices are currently in place and what changes in protocols and policies can be made to ensure clinicians are more adequately addressing nutrition among their care teams.

Principle 6: Develop a comprehensive discharge nutrition care and education plan
When a patient is getting ready to leave the hospital, nurses can play a leading role in the discharge and education treatment plan by emphasizing the importance of including nutrition as a key component of all clinician conversations with patients and their family members / caregivers. In addition, nurses can reinforce the importance of nutrition care and follow-up post discharge to patients and caregivers to ensure that proper nutrition is being practiced.

While the examples and steps provided are not an exhaustive list of all the actions that nurses can implement at their respective hospitals, I hope the principles outlined serve as a useful framework to begin to drive substantive changes aimed at reducing patient malnutrition to improve patient outcomes.