A Systematized Interdisciplinary Nutritional Care Plan Results in

Improved Clinical Outcomes

Christopher Lee, BS, MS, James Rucinski, MD, Larry Bernstein, MD

Departments of Nutrition Services and Surgery,

New York, Methodist Hospital

Corresponding author:James Rucinski, MDSurgery, Surgical Education, and Surgical Nutrition SupportNew York Methodist Hospital- Cornell WeillSixth St at 7th AveBrooklyn, NY

Abstract

Objective: The nutritional care plan recommended by a registered

dietitian is often not followed. This study investigated medical

staff compliance with institutional guidelines for identification

and treatment of patients at-risk for malnutrition associated

complications as well as extended inpatient length of stay.

Design: Data were collected retrospectively from the medical

records for a period of six months. The records were reviewed

for: (1) adherence to RD recommendation, (2) decreasing serum

albumin during hospital stay, (3) length of hospital stay, (4)

readmission within 30 days, (5) age, (6) gender, (7) past medical

history, (8) primary and secondary diagnoses, (9) the presence or

absence of a diet order and (10) medications.

Subjects and participants: Medical records were reviewed after

ICD-9 coding for primary and secondary diagnoses associated with

a high-risk for nutrition-related complications. The patient's

records were excluded when the length of stay was less than four

days, or when the patient died during admission.

Hypothesis: The inpatient length of stay (LOS) for nutritionally

high-risk patients is significantly shorter when the advice of

the registered dietitian (RD) is followed.

Statistics: Basic standard statistical tests were carried out on

SPSS 15.0 software (Chicago, IL). Results: The mean LOS was 26

days when the RD’s recommendation was not followed and 16 days

when the RD’s recommendation was followed (p = 0.0074).

Conclusions: Patients categorized as high nutritional risk on

admission have a shorter LOS and are likely to have fewer

nutrition-related complications when the physician follows the

recommendation of the RD.

Key words: Registered dietitian, length of stay, nutritionally

high-risk, protein-energy malnutrition, coordinated nutritional

care-plan, early identification

Abbreviations: RN, registered nurse; RD, registered dietitian;

LOS, length of stay; PEM, protein-energy malnutrition; BMI,

body mass index; SGA, subjective global assessment; LBM, lean

body mass

Introduction

The World Health Organization (WHO) definition of

malnutrition is “the cellular imbalance between supply of

nutrients and energy and the body’s demand for them to ensure

growth, maintenance, and specific functions” (1). Protein-

energy malnutrition (PEM) in the clinical setting is typically

manifested as weight loss with diminished body fat reserves but

normal protein reserves (marasmus), or with diminution of protein

reserves (kwashiorkor) (2). Kwashiorkor requires PEM with edema,

and/or ascites, whereas marasmus is PEM without the presence of

edema. It must be noted that the presence of edema is related to

a low serum albumin (3). The catabolic state is associated with

a decline in plasma albumin, (from a decline in hepatic

synthesis), as well as muscle loss and weakness. Catabolic

individuals are at high risk for PEM. The incidence of

malnutrition in the clinical setting is 30 to 55 percent (4 - 6),

and remains problematic 25 years after the publication of

“Skeleton in the Closet”, which called attention to the

prevalence of malnutrition in North American hospitals (7, 8).

The effects of PEM are seen when a deficit of energy leads

to proteolysis to provide essential amino acids for

gluconeogenesis in support of repair, growth and immune function.

The consequences of malnutrition are related to the pre-morbid

condition of the patient, the extent and length of time nutrient

intake is inadequate, and the concurrent presence of other

comorbid conditions (8, 9). Nutrient depletion is associated with

increased mortality and morbidity (10). In the presence of

malnutrition wound healing is delayed, complication rates are

increased up to 20 times higher, length of hospital stay is

increased, there is an increased rate of re-hospitalization and

the direct variable costs are higher (10, 11-14). Factors

indicative of malnutrition include: involuntary loss or gain of >

10% of usual body weight within 6 months, > 5% of usual body

weight in 1 month, body weight of 20% over or under ideal body

weight (especially in the presence of chronic disease or

increased metabolic requirements) and inadequate nutrition intake

including an impaired ability to ingest or absorb food adequately

(1, 2, 8).

While hospitals and other skilled nursing facilities screen

for PEM using questionnaires, checklists, and laboratory

measures, there has not been a simple, reliable standardized

approach. Nutrition screening to identify individuals who are

malnourished or who are at risk for malnutrition may determine if

a comprehensive nutrition assessment is necessary and identify

changes in nutritional status by identifying risk factors that

are likely to lead to nutrition related problems (13-16). Data

that can facilitate early intervention, (including height,

weight, weight change, primary diagnosis, and presence of co-

morbid conditions), may be obtained easily, quickly, and

efficiently (17-20). The screening for malnutrition has received

considerable attention and is a requirement as a standard of care

by the Joint Commission for Accreditation of Health Care

Organizations (JCAHO) (21). Adult nutrition screening tools

designed for use by staff nurses have been tested for validity

and reproducibility, and evaluated for ease of use, cost-

effectiveness, and for validity, reliability, sensitivity, and

specificity (22-24). It may be particularly important to

aggressively screen elderly patients, because the elderly may

experience eating or swallowing difficulties, adverse drug-

nutrient interactions, alcohol abuse, depression, reduced

appetite, functional disabilities, impaired taste and smell,

and/or effects of poly-pharmacy (25-27).

The Malnutrition Advisory Group (MAG) in the United Kingdom

introduced the Malnutrition Universal Screening Tool (MUST) to

provide a consistent and reliable tool for malnutrition screening

(28). Other screening initiatives include a Mini Nutritional

Assessment (MNA)(29), Body Mass Index (BMI), percentage weight

loss (30), handgrip (31), serum albumin (32), and Malnutrition

Screening Tool (MST) (33). Most methods use recent unintended

weight loss and decreased recent appetite or food intake (34).

But an improved outcome may not be seen as a result of screening

if the information does not lead to a change in the clinical

management of the individual patient. In one study six

screening tools were evaluated for ease of use, cost-

effectiveness and reliability but none of them demonstrated an

associated improvement in clinical outcome or met all of the

criteria identified by the study (35).

The Registered Dietitian (RD) often oversees the feeding

plan for patients on hospital admission, but limited staff and

resource availability prohibits extensive evaluation of all

patients by an RD. Implementation of an effective tool is

essential to the identification of PEM in order to provide timely

and optimal nutritional intervention. The current process at

the study institution involves RN screening of each patient using

a standard tool. The process identifies an average of 49% of

all admissions as being at risk for or having malnutrition. Low

risk patients are re-screened by the RD 7 days after admission.

Twenty percent of the patients are identified with PEM upon re-

screen, an average of 90 patients per month.

Methods

The 37 patient sample population consisted of 24 men (37.8%)

and 23 women (62.2%), and the mean age was 68.1 years. A

retrospective analysis of medical records sought the following

data: age, gender, primary, secondary and past historical

diagnoses, length of stay, nursing nutrition screening

categorization, medications, time to first dietitian visit,

dietitian recommendation, the presence or absence of a

physician’s diet order, agreement or discord between diet

recommendation and physician prescription, serum albumin level,

albumin trending and readmission.

Inclusion criteria:

Adult patients (>18 years old) were selected using the

International Classification of Diseases Clinical Modification

(ICD-9-CM) coding (7) for the period of January 2005 – June 2005

and fulfilling one or more of the following nutritional high-risk

conditions: cachexia, cancer cachexia, intestinal obstruction,

pressure sores, dysphagia, chronic kidney disease (CKD),

cirrhosis, malabsorption, the need for mechanical ventilation,

multiple trauma, non-healing wounds, sepsis, end stage liver

disease, HIV, metastatic cancer, age over 80 years, dehydration.

Exclusion criteria: LOS <4 days and/or inpatient mortality.

Statistics: SPSS 15.0 was used for all the analyses, which

included the t-test, basic measures of central tendency, one-way

analysis of variance, and chi square analysis when needed.

Results

The mean LOS for patients with PEM that did not receive

dietary intervention as recommended by the RD (mean 26.4 days +

15.5) was significantly longer than the mean LOS for those

patients receiving the dietary information as recommended by the

RD (15.8 days + 6.9) (p=0.0074). The mean LOS for women was 28.8

days + 17.7 when the RD’s advice was not followed and 15.8 days +

5.78 when the advice was followed. The mean LOS (28.8 + 17.7 for

women was 15.0 days longer when the RD’s advice was not followed

(p = 0.04), whereas the mean LOS (21.6 + 8.4) for men was only

5.8 days longer when the RD’s advice was not followed (p =

0.16). The results are summarized in Tables 1-4, and Figure 1.

Discussion

This study highlights common problems in the management of a

nutritional support program in the acute care setting. The

results indicate that there is a strong positive correlation

between adherence to the advice of the clinical RD and a

significant reduction in LOS. The discordance between the

dietitian's notes and the physician's subsequent follow-up was

identified more than a decade before this study (36). The

discordance was found to be associated with either a failure in

direct communication or a failure in written communication, which

are factors amenable to correction (36). In most cases the

nursing staff is the first caregiver to evaluate the patient, and

in that case, knowledge, staffing, and the organization of the

work-flow can and may contribute to delays in timely and

effective intervention. A coordinated nutritional care-plan

requires a multidisciplinary approach in which the RN who first

sees the patient makes an efficient screening decision based on

information from a limited number of features. The RD uses the

screening information to provide the nutritional care plan. The

third step in the integrated system requires the translation of

the advice of the RD into the direct care of the patient with

PEM. Several studies indicate that the RD’s advice is often

ignored (36-38). When this link is severed there may be a

detrimental effect on the nutritional status and subsequent

clinical outcome of the patient.

If different screening methods correlate with each other

with respect to common metrics (39), then nutritional support

represents a systems management issue. Systematic care may be

associated with improved nutritional outcomes. One

interdisciplinary intervention of systematic nutritional patient

care found a 1.7 kg improvement in weight gain when compared to

unsystematic care (40). The number of nosocomial infections in

the intervention group was also less than in the group receiving

unsystematic care (33/140 versus 58/158, p = 0.01) (40). So

improved weight gain and decreased nosocomial infections can be

seen with systematic care.

Systematic care may also help to reduce other adverse

nutrition-associated outcomes. The association of malnutrition

with morbidity, mortality, increased LOS and higher hospital

costs has been shown in several studies of unsystematic

nutritional support systems. (41-43) In one study of patients

randomly screened for malnutrition risk and deemed to be at risk,

regular hospital screening identified only 60% and a significant

number did not have a nutritional care plan, while only 30% were

followed during their admission (41). But regardless of status

on admission, patients who experience a decline in nutritional

status have an increase in adverse outcomes that have been shown

to be averted by the systematic intervention of a nutritional

support team (42). Increased LOS appears to be a surrogate

marker for other adverse nutrition-associated outcomes that can

be reduced with systematic care in which the RDs input is

directly translated into patient care (21, 43-45).

The consequences of malnutrition persist beyond discharge.

At-risk patients are more likely to be discharged with home

health care support (p < 0.001)(44). Severely malnourished

patients are more likely to be dependent in activities of daily

living three months after discharge, to be resident in a nursing

home during the year after discharge and are more likely to die

within one year after hospital discharge. (44) Systematic

nutritional care during hospitalization may also help to reduce

these post-discharge adverse malnutrition- associated outcomes.

Conclusion

This study demonstrates that routine incorporation of the RDs

recommendations into the nutritional care plan is associated with

a decreased LOS. Since LOS may be seen as a surrogate marker for

other adverse malnutrition associated outcomes, then systematic

routine incorporation of RD recommendations appears to be

associated with improved clinical outcomes. A process for

improved nutrition-related outcomes, then, must include a simple

and rapid identification of the patients at risk for nutrition-

related complication (19, 20, 46) combined with systematic

routine incorporation of the RD’s recommendations into the

nutritional care of each patient. Key items for incorporating

this process are:

1. Utilize the smallest number of checklist items for

accurately identifying nutrition risk. (This has been identified,

and it can be incorporated into an automated EHR alarm (19, 20,

46).

2. Break down the silo that impairs the interaction between

the principle caregivers: RNs, RDs and physicians.

3. Systematically incorporate RD recommendations into the

nutritional care plan.

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Tables

Table 1-Summary of Screening ResultsTable 2-RD Advice not followedTable 3-RD Advice followedTable 4-Basic Statistics Summary

Table 1-Summary of Screening Results

Category Number PercentWomen 23 62.2RD advice followed

9 25

Declining albumin 19 51.4Wrong screen 13 35.1Delayed screen 28 75.7Readmission 5 13.5Total 37 100

Table 2-RD Advice not followed

Frequency Percent

ValidPercent

CumulativePercent

Valid 0 27 73.0 75.0 75.01 9 24.3 25.0 100.0Total 36 97.3 100.0

Missing

System 1 2.7

Total 37 100.0

Table 3-RD Advice followed

Frequency Percent

ValidPercent

CumulativePercent

Valid 0 9 24.3 25.0 25.01 27 73.0 75.0 100.0Total 36 97.3 100.0

Missing

System 1 2.7

Total 37 100.0

Table 4-Basic Statistics Summary

AGE LOS

LOS RDnot

followedLOS RDfollowed

N 37 37 27 90 0 10 28

Mean 68.14 23.14 26.41 15.78Median 71.00 19.00 22.00 14.00Std. Deviation 16.154 14.716 15.453 6.906Percentiles 25 57.00 11.00 18.00

50 71.00 19.00 22.0075 80.00 31.50 35.00

Figure 1. Composite graph of effect of RD advice on LOS

MeanStd.Dev. N

LOS 23.14 14.716 37

LOS RD not 26.41 15.453 27

LOS RD followed

15.78 6.906 9