An interdisciplinary approach to hospital malnutrition

Hendersonville, North Carolina may not have a Mayo Clinic that is known for medical innovation, but it is making waves in solving a stubborn problem in health care: malnutrition.

Pardee UNC Health Care is implementing a new nursing protocol that puts nutrition at the center of the care team and the locus for reducing readmissions, pressure ulcers and lengths of stay.

Pardee’s efforts come as more and more studies document the seriousness of the malnutrition problem: One in three Americans is malnourished upon admission to the hospital. And that may be an underestimate. A new study in the Annals of Emergency Medicine finds that nearly two-thirds of patients over 65 admitted to the emergency department at UNC Health Care are either malnourished or at risk for malnutrition.

What’s particularly insidious is that those most affected are our parents and grandparents as malnutrition most often afflicts older adults with cancer and debilitating chronic diseases. As a result, malnutrition delays recovery and is associated with a range of adverse outcomes, including surgical site infections, pressure ulcers and falls. The end result is more time in the hospital per patient, more patients who have to be readmitted after discharge and an almost three-fold increase in hospital costs.

Despite these consequences, malnutrition remains largely untreated in U.S. hospitals, which is why the Academy of Medical-Surgical Nurses, the Academy of Nutrition and Dietetics, the Society of Hospital Medicine and Abbott Nutrition came together to form an unprecedented consortium — the Alliance to Advance Patient Nutrition — to address the under-recognized and under-treated issue of malnutrition in hospitalized patients.

Mounting evidence finds that good hospital nutrition results in a 25 percent reduction in the incidence of pressure ulcers, 14 percent fewer overall complications, two fewer days in the hospital, and a 28 percent drop in avoidable hospital readmissions.

The Alliance recently issued its one year anniversary report — Alleviating Hospital-Based Malnutrition: A Baseline Progress Report— which documents a growing recognition of this pervasive public health problem and a greater focus on instituting effective nutrition practices in hospitals.

As untreated malnutrition can delay recovery and increase medical complications, the Alliance to Advance Patient Nutrition was formed in May 2013 to drive awareness and systemic change at the nation’s hospitals. The Alliance issued a consensus paper and published specific recommendations for hospital administrators and clinicians to institute effective nutrition practices along with the resources and tools to put these recommendations into practice.

A year later, qualitative results indicate that multidisciplinary care teams are implementing the Alliance’s recommendations across the country. In addition to Pardee, a number of hospitals are working to incorporate Alliance recommendations into their processes.

For instance, Mercy Health, a large system of 21 hospitals based in Cincinnati, Ohio, implemented a multidisciplinary approach to identify and treat malnourished patients. Mercy teams also provide standardized written instructions for nutrition care at discharge with the goal of reducing readmission risk.

In the Detroit area, TouchPoint Support Services at St. John Providence Health System is now screening 100 percent of its patients upon admission and providing ongoing assessment for every patient diagnosed as malnourished.

One Pardee nurse expressed astonishment that it has taken hospitals so long to address such a seemingly simple problem, but now teams provide medical nutrition therapy to those who are malnourished at the outset of their stays and include any necessary instructions for oral nutrition supplementation in the patient’s discharge orders.

There is a growing body of evidence supporting the positive impact nutrition has on improving patient outcomes. We are seeing that early intervention can make a significant difference. It is necessary to work with the entire team to ensure that nutrition is an integral part of our patients’ treatment plans.

Kelly A. Tappenden is a professor of nutrition and gastrointestinal physiology, University of Illinois, Urbana-Champaign and a clinical representative in the Alliance to Advance Patient Nutrition

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