6 Steps to Combating Malnutrition in the Hospital

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One in three patients admitted to the hospital is malnourished, according to several recent studies.

"It's a shockingly high number," says Beth Quatrara, DNP, RN, ACNS-BC, CMSRN, a clinical nurse specialist with the digestive health department at University of Virginia Health System in Charlottesville. "And if we don't intervene promptly, the number of malnourished patients in the hospital will only increase," she says.

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Dr. Quatrara is a representative from the Academy of Medical-Surgical Nurses to the Alliance to Advance Patient Nutrition. The Alliance is comprised of representatives like Dr. Quatrara from the Academy of Medical-Surgical Nurses, the Academy of Nutrition and Dietetics, the American Society for Parenteral and Enteral Nutrition, the Society of Hospital Medicine and Abbott Nutrition.

Representing over 100,000 healthcare professionals, the goal of the Alliance is to "raise awareness about malnutrition among hospital patients and encourage the adoption of early nutritional screenings and nutritional interventions for all patients through to discharge," says Drs. Quatrara.

Patients are admitted malnourished for a variety of reasons. An aging population and additional stresses put on the body by chronic illness are both contributing factors to malnutrition, says Dr. Quatrara.

Regardless of the reason, malnourished patients are at greater risk while in the hospital. "There's a greater risk for falls among weaker patients," says Dr. Quatrara. These patients are also at an increased risk for pressure ulcers as "they don't have the skin integrity, the fat and muscle tissue to prevent the skin breakdown," she says. Surgical site infections are also an increased risk — "these infections are less likely to heal well" among malnourished patients, she says.

All of this can add up to a longer (and costlier) hospital stay, she says.

To help reduce the risk of these complications, the Alliance has released its Consensus Paper, detailing six best practices to reduce both the prevalence and consequences of malnutrition in hospitals.

1. Create an institutional culture where nutrition is valued. According to the Alliance, the first step in combating malnutrition in hospitals is to establish a culture where all hospital stakeholders recognize both the high rates of malnutrition among admitted patients and the consequences of such prevalent malnutrition.

Not only does malnutrition threaten patient safety, the complications that arise can increase a hospital's costs. "Falls associated with malnutrition are costly, infections are costly, pressure ulcers are costly," says Dr. Quatrara. These complications, and costs, can be reduced "when malnutrition is identified and treated promptly," she says.

2. Redefine clinicians' roles to include nutrition. To fully and consistently address malnutrition, all members of the clinical staff should be engaged with patient nutrition.  

To this end, the Alliance recommends that nurses be allowed to provide complete nutrition care, including measuring body weight, initiating calorie counts and returning low-risk patients to a previous feeding schedule. The report states: "Policies that inhibit nursing action inhibit optimal patient nutrition."

The Alliance also recommends that dietitians have ordering privileges for diets, oral nutritional supplements, vitamins and calorie counts to avoid delays in malnutrition being treated.  

3. Recognize and diagnose all patients at risk. The Alliance advocates screening every patient thoroughly within 24 hours of admission for malnutrition using a validated screening assessment to identify as many cases of malnutrition as possible.

"At UVA we've embedded nutrition screening into our admission process; it became part of the checklist," says Dr. Quatrara. The new process has found success. "We're definitely identifying more patients with malnutrition at admission," she says.  

4. Rapidly implement interventions and continued monitoring. Once a malnourished patient has been identified, an intervention should be implemented "within hours," says Dr. Quatrara. "You need to have practices in place so you can intervene quickly," she says.

Resources for nutrition intervention can be found on the Alliance website.  

The patient should also be monitored throughout the hospital stay to ensure the patient's dietary intake needs are met.

5. Communicate nutrition care plans. A patient's nutrition care plan should be kept up-to-date and communicated to any other healthcare providers.

All relevant nutrition information should be put in the patient's electronic health record. This includes nutrition screening results, nutrition assessment data, nutrition diagnosis, nutrition-medication interactions if applicable, prescribed nutrition interventions and planned goals, dietary intake patterns and a monitoring and evaluation plan with timeframe for reassessment.  

6. Develop discharge nutrition care and education plans. All relevant nutrition information should be given, and explained, to the patient at discharge.

The Alliance recommends that the patient be educated about his or her nutritional plan throughout the inpatient stay, and that the patient's nutrition, along with specifics about a follow-up nutritional assessment, be a part of all discharge discussions. Follow-up calls from nurses should be tailored to help evaluate the patient's nutritional progress.

While the report from the Alliance is a major step toward combating malnutrition in the hospital, Dr. Quatrara realizes that there is still work to be done on this issue. "The Alliance remains committed," she says.

More Articles on Patient Nutrition:

5 Organizations Form Alliance to Advance Patient Nutrition
Hospitals Gradually Moving Toward Healthier Food Environments
Meals on Wheels in Kansas to Pilot Readmission Prevention Program

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