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Nov 01 2013
The Important Role Physicians Can Play in Combating Hospital Malnutrition
Melissa Parkhurst, MD, FHM

With the implementation of the Patient Protection and Affordable Care Act, an urgent emphasis is being placed on improving quality of care and reducing costs. This creates a unique opportunity for physicians, along with other hospital clinicians, to elevate the role nutrition plays in enhancing health outcomes for patients.

Actionable Recommendations for Physicians
One of the most critical aspects to comprehensively identify and treat malnutrition is to drive interdisciplinary collaboration among dietitians, nurses, hospitalists, and other physicians. That’s why my hospital, The University of Kansas Hospital formed a multidisciplinary, nutrition support team in 2001, including a nurse, pharmacists, dietitians and my role – a physician medical director.

The Alliance has created a Nutrition Care Model that offers practical ways for healthcare providers in hospitals to collaborate to promptly diagnose and treat malnourished patients and those at risk for malnutrition. The model emphasizes the following six principles with specific actions physicians can take to make an impact:

Principle 1: Create an institutional culture where all stakeholders value nutrition
The Alliance wants all stakeholders, including hospital clinicians and administrators, to fully understand the pervasiveness of malnutrition and the effect nutrition can have on overall patient outcomes and cost of care. Physicians can help achieve this goal by providing leadership underscoring nutrition care as an essential part of patient-centered care, knowing the evidence regarding impact of malnutrition and effectiveness of nutrition intervention, including dietitians in daily team huddles / rounds and incorporating nutrition into routine care checklists and processes.
The University of Kansas Hospital is nationally ranked by U.S. News & World Report in nine adult specialty areas and is ranked as the top hospital in the State of Kansas and in the Kansas City, Missouri metropolitan area. It has been successful in broadly systematizing these practices with the development of nutrition intervention protocols gradually phased in over the past few years.

Principle 2: Redefine clinicians’ role to include nutrition care
Our vision includes empowering all health care professionals to influence nutrition decisions for the improvement of their patients’ outcomes. Physicians can empower dietitians to cooperatively lead nutrition care as clinical team members and support the work process of nurses to include nutrition screening and intervention.
A significant accomplishment for my team has been empowering dietitians with ordering privileges for select orders, such as oral nutritional supplements (ONS), calorie counts and vitamin supplementation. Prior to receiving ordering privileges, dietitians’ recommendations would often go without action. Now the communications process is streamlined and the care is much more effective.

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. Physicians can help by considering nutrition status as an essential attribute of medical assessment, monitoring, and care plans.
One way to do this is to update nutrition screening tools. The Alliance recommends the Malnutrition Screening Tool (MST) available in the Alliance Nutrition Model and Toolkit. In addition to this, The University of Kansas Hospital’s Department of Clinical Nutrition Services is redoing its nutritional assessments to implement the 2012 A.S.P.E.N. standards.

Principle 4: Rapidly implement comprehensive nutrition intervention and continued monitoring
Physicians can ensure that patients identified as malnourished or at-risk receive immediate nutrition intervention, and all efforts are made to ensure consumption. This includes supporting policy that provides automated nutrition intervention within 24 hours in patients identified as “at risk” during nutrition screen while awaiting nutrition assessment, diagnosis, and care plan and minimizing NPO periods for your patient with scheduling of procedures/tests and remain mindful of “holds” on PO diets.

Principle 5: Communicate nutrition care plans
The Alliance recommends that every patient’s nutrition care plan is comprehensively documented in the electronic health record (EHR), regularly updated, and effectively communicated to all healthcare providers and future care settings. Physicians can help by reinforcing this expectation and if present, ensure mild, moderate, or severe malnutrition is included as a complicating condition in coding process.

Principle 6: Develop a comprehensive discharge nutrition care and education plan
To improve quality of care, the Alliance recommends developing a comprehensive, systematic approach to managing nutrition from admission through discharge and beyond. Physicians can include nutrition as a component of all clinician conversation with patients and their family members / caregivers.

It is important for hospitals to recognize that a ‘one-size-fits-all’ paradigm does not work effectively. Certainly, each hospital possesses unique attributes that necessitate tailored approaches. Hospital administrators will need to evaluate the costs associated with the allocation of staff and the requisite training. Importantly, every hospital should strive to develop programs that fit their needs, organizational culture, and personnel budget. While this can be challenging, it can provide critical benefits that enhance the quality of care, improve clinical outcomes and reduce costs.