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Recognizing malnutrition

Recognizing malnutrition

The time is now to raise awareness about the prevalence of malnutrition in hospitalized adults and to address the critical need for healthcare providers to proactively incorporate nutrition practices throughout all aspects of hospital care.

Malnutrition is a state of nutrition in which a deficiency, excess, or imbalance of energy, protein, and other nutrients causes measurable adverse effects on body function and clinical outcome.1

Read the research studies below to learn how malnutrition is defined, recognized and measured in the hospital setting.

This article was simultaneously published in the May 2012 issues of the Journal of the Academy of Nutrition and Dietetics and the Journal of Parenteral and Enteral Nutrition

The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend that a standardized set of diagnostic characteristics be used to identify and document adult malnutrition in routine clinical practice. An etiologically based diagnostic nomenclature that incorporates a current understanding of the role of the inflammatory response on malnutrition’s incidence, progression, and resolution is proposed. Universal use of a single set of diagnostic characteristics will facilitate malnutrition’s recognition, contribute to more valid estimates of its prevalence and incidence, guide interventions, and influence expected outcomes.

Since there is no single parameter that is definitive for adult malnutrition, identification of two or more of the following six characteristics is recommended for diagnosis:
  • Insufficient energy intake
  • Weight loss
  • Loss of muscle
  • Loss of subcutaneous fat
  • Localized or generalized fluid accumulation that may sometimes mask weight loss and diminished functional status as measured by hand grip strength

Incorporation of the assessment and documentation of the characteristics into standard clinical practice is highlighted within. Clinicians and healthcare team members should begin to consider how to implement use of the recommended characteristics by bringing key members of the healthcare team (e.g., physicians, dietetics practitioners, nurses, pharmacists, coders) together to develop an implementation strategy compatible with institutional practices and needs. This standardized approach will also help to more accurately predict the human and financial burdens and costs associated with malnutrition’s prevention and treatment and further ensure the provision of high-quality, cost-effective nutrition care.

White JV, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition).JPEN. 2012;36(3):275–283.

Background
This study aims to determine the prevalence of malnutrition in a tertiary hospital in Singapore and its impact on hospitalization outcomes and costs, controlling for diagnosis-related groups (DRG).

Methods
This prospective cohort study included participants who were patients newly admitted to National University Hospital (NUH), which is a 987-bed acute tertiary hospital, with a comprehensive range of medical and surgical specialties. Subjective Global Assessment was used to assess the nutritional status on admission of 818 adults. Hospitalization outcomes over three years were adjusted for gender, age, ethnicity, and matched for DRG. 

Results
  • Malnourished patients (29%) had longer hospital stays (6.9 ± 7.3 days vs. 4.6 ± 5.6 days,  p < 0.001) and were more likely to be readmitted within 15 days (p =  0.025).
  • Within a DRG, the mean difference between actual cost of hospitalization and the average cost for malnourished patients was greater than well-nourished patients (p =0.014).
  • Mortality was higher in malnourished patients at 1 year (34% vs. 4.1 %), 2 years (42.6% vs. 6.7%) and 3 years (48.5% vs. 9.9%); p < 0.001 for all.
  • Overall, malnutrition was a significant predictor of mortality (p < 0.001).

Conclusions
Malnutrition was evident in up to one third of the inpatients and led to poor hospitalization outcomes and survival as well as increased costs of care, even after matching for DRG. Strategies to prevent and treat malnutrition in the hospital and post-discharge are needed.

Lim S et al.  Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality.  Clinical Nutrition. 2012;31:345-350.

Background
Researchers from Johns Hopkins Hospital in Baltimore, Maryland conducted this study to estimate the percentage and severity of malnutrition, length of stay (LOS), and delays in implementing nutrition support, as well as ascertain the diagnosis-related groups (DRG) coding of malnutrition cases.  Secondly, this study evaluated the role of nutrition intervention on LOS, to reduce delays in implementing nutrition support, and to calculate the potential financial benefits of DRG coding and nutrition intervention.

Methods
The study was conducted in adult patients in two medical wards (ward A and ward B) in two phases. Phase 1 collected baseline data on approximately 200 patients in ward A and B. Phase 2 involved using a new screening tool, which was completed by nursing upon admission, and an increased focus on time to nutrition intervention for patients from ward A. Additionally, on ward A, the clinical nutrition department consultation was initiated by the nurse manager, who sent a list of malnourished patients via the physician-order entry (POE) method.  Ward B served as the control group, where the clinical nutrition department used the existing nutrition screening tool.

Results
  • The overall prevalence of malnutrition was similar in phase 1 and phase 2, 53.1% and 55.8% respectively.
  • Nutrition intervention significantly decreased LOS in malnourished patients. The LOS in the total malnourished group with nutrition intervention decreased significantly by 2.6 days vs. the historical control. The LOS in the severely malnourished group with nutrition intervention decreased significantly by almost 5 days vs. the historical control.
  • Nutrition intervention also resulted in cost savings. For patients with severe malnutrition, $1,514 in hospital costs was saved ($473/day x 3.2 days) due to the decrease in LOS. The new nutrition screen process decreased the time to nutrition consultation.  In phase 1 in ward A, only 20% of malnourished patients had a nutrition consultation, and the time to consultation was 4.90 ± 7.34 days from admission. In phase 2 of the study with nutrition intervention, 44% of malnourished patients had a nutrition consultation, and the time to consultation was 47% shorter at 2.63 ± 1.82 days from admission.

Conclusions
Malnutrition in acute care remains a significant issue and must be identified and addressed early in the patient’s stay. Nutrition intervention has been shown to result in numerous benefits including decreased length of stay.

Somanchi M, Tao X, Mullin GE. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition.  J Parenter Enteral Nutr. 2011;35(2):209–216.

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1Elia M, ed. Guidelines for Detection and Management of Malnutrition: A Report of the Malnutrition Advisory Group. Maidenhead, UK: British Association for Parenteral and Enteral Nutrition (BAPEN); 2000.