Tappenden Critical Final

The Journal of the Academy of Nutritionand Dietetics, Journal of Parenteral andEnteral Nutrition, and MEDSURG NursingJournal have arranged to publish thisarticle simultaneously in their publica-tions. Minor differences in style mayappear in each publication, but the articleis substantially the same in each journal.

Copyright ª 2013 by the Academy ofNutrition and Dietetics, American Societyfor Parenteral and Enteral Nutrition, andAcademy of Medical-Surgical Nurses.

2212-2672/$36.00doi:10.1016/j.jand.2013.05.015Available online 17 July 2013

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FROM THE ACADEMY

Critical Role of Nutrition in Improving Quality of Care:An Interdisciplinary Call to Action to Address AdultHospital MalnutritionKelly A. Tappenden, PhD, RD, FASPEN; Beth Quatrara, DNP, RN, CMSRN; Melissa L. Parkhurst, MD; Ainsley M. Malone, MS, RD;Gary Fanjiang, MD; Thomas R. Ziegler, MD

ABSTRACTThe current era of health care delivery, with its focus on providing high-quality, affordable care, presents many challenges to hospital-based health professionals. The prevention and treatment of hospital malnutrition offers a tremendous opportunity to optimize theoverall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognizedand untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance PatientNutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose andtreat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach toaddressing malnutrition both in the hospital and in the acute post-hospital phase. It is well recognized that malnutrition is associatedwith adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reducecomplication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patientswho are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing thefollowing six principles: (1) create an institutional culture where all stakeholders value nutrition; (2) redefine clinicians’ roles to includenutrition care; (3) recognize and diagnose all malnourished patients and those at risk; (4) rapidly implement comprehensive nutritioninterventions and continued monitoring; (5) communicate nutrition care plans; and (6) develop a comprehensive discharge nutritioncare and education plan.J Acad Nutr Diet. 2013;113:1219-1237.

THE UNITED STATES ISentering a new era of healthcare delivery in which changesin health care policy are driving

an increased focus on costs, quality,and transparency of care. This newfocus on improving the quality and ef-ficiency of hospital care highlights anurgent need to revisit the long-standingchallenge of hospital malnutrition and

elevate the role of nutrition care as acritical component of patient recovery.Malnutrition is common in the hospitalsetting and can adversely affect clinicaloutcomes and costs, but it is oftenoverlooked. Although results of inter-vention studies vary, addressing hospi-tal malnutrition has the potential toimprove quality of patient care andclinical outcomes and reduce costs.1

Today it is estimated that at leastone third of patients arrive at the hos-pital malnourished1-5 and, if left un-treated, many of those patients willcontinue to decline nutritionally,5

which may adversely impact their re-covery and increase their risk of com-plications and readmission. Hospitalmalnutrition is not a new problem,but “the skeleton in the hospitalcloset,” was brought to light in Butter-worth’s call for practices aimed atproper diagnosis and treatment ofmalnourished patients.6 As we enter anew era of health care delivery, thetime is now to implement a novel,comprehensive nutrition care model

URNAL OF THE ACADE

as part of improved quality standardsand to leverage proven examples forsuccess.

Effective management of malnutri-tion requires collaboration amongmultiple clinical disciplines. In manyhospitals, malnutrition continues to bemanaged in silos, with knowledge andresponsibility provided predominantlyby the dietitian. However, the new eraof quality care will require a deliber-ately more holistic and interdisci-plinary process to address this criticalissue. All members of the clinical teammust be involved, including nurseswho perform initial nutrition screeningand develop innovative strategies tofacilitate patient compliance; dietitianswho complete nutrition assessment/diagnosis and develop evidence-basedintervention(s); pharmacists who eval-uate drug�nutrient interactions; andphysicians, including hospitalists, over-seeing the overall care plan and docu-mentation to support reimbursementfor services. Recognition of this prob-lem and the opportunity to improve

MY OF NUTRITION AND DIETETICS 1219

http://dx.doi.org/10.1016/j.jand.2013.05.015

FROM THE ACADEMY

patient care were the impetus behindcreating the Alliance to AdvancePatient Nutrition (Alliance). The Alli-ance brings together the Academy ofNutrition and Dietetics (AND), theAcademy of Medical-Surgical Nurses(AMSN), the Society of Hospital Medi-cine (SHM), the American Society forParenteral and Enteral Nutrition(A.S.P.E.N.), and Abbott Nutrition. TheAlliance is made possible with supportfrom Abbott Nutrition. These healthorganizations are dedicated to the ad-vancement of effective hospital nutri-tion practices to help improve patients’medical outcomes and support allclinicians in collaborating on hospital-wide nutrition procedures. The estab-lished charter of the Alliance is tochampion improved hospital nutritionpractices through identification ofmalnourished patients and patients atrisk for malnutrition, early nutritionintervention and treatment, and in-clusion of nutrition as a standardcomponent of all care processes.Nutrition intervention for malnour-

ished patients is a low-risk, cost-effec-tive strategy to improve quality ofhospital care, but it requires interdisci-plinary collaboration. As representa-tives of the Alliance, we announce acall to action. We aspire to facilitatethe institution of universal nutritionscreening, rapid and appropriate nu-trition interventions utilizing effectiveinterdisciplinary nutrition partner-ships, and integration of comprehen-sive strategies to prevent or treathospital malnutrition. This paper is notintended to provide practice-basedguidelines, but rather highlights avail-able data on the critical role nutritionplays in improving patient outcomes,outlines an innovative nutrition caremodel, underscores the importanceof an interdisciplinary approach toaddress hospital malnutrition, andidentifies challenges believed to impairoptimal nutrition care. In addition,specific solutions that can be employedby dietitians, nurses, physicians, andother health care professionals, such asnurse practitioners, physician assis-tants, pharmacists, and dietetic techni-cians, registered, are provided.

BURDEN OF HOSPITALMALNUTRITIONAlthough estimates of the prevalenceof malnutrition vary by setting,

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subgroup, and method of assessment,the prevalence of malnutrition in hos-pitals is particularly startling. It isestimated that at least one third ofpatients in developed countries havesome degree of malnutrition uponadmission to the hospital1-3,5 and, ifleft untreated, approximately twothirds of those patients will experiencea further decline in their nutritionstatus during inpatient stay.5 Unfortu-nately, despite the availability of vali-dated screening tools, malnutritioncontinues to be under-recognized inmany hospitals.7,8 Moreover, amongpatients who are not malnourishedupon admission, approximately onethird may become malnourished whilein the hospital.9

Historically, a variety of tools anddefinitions have been used throughoutthe nutrition literature. For the pur-poses of this paper mild through severemalnutrition will be the focus and isthe intent when the term malnutritionis used. Malnutrition is most simplydefined as any nutrition imbalance10

that affects both overweight andunderweight patients alike and isgenerally described as either “under-nutrition” or “overnutrition.”11 Hospi-talized patients, regardless of theirbody mass index (BMI), typically sufferfrom undernutrition because of theirpropensity for reduced food intakedue to illness-induced poor appetite,gastrointestinal symptoms, reducedability to chew or swallow, or nil per os(NPO) status for diagnostic and thera-peutic procedures. In addition, theymay have increased energy, protein,and essential micronutrient needsbecause of inflammation, infection, orother catabolic conditions. A consensusstatement by AND and A.S.P.E.N. pub-lished in May 2012 defines malnutri-tion as the presence of two or more ofthe following characteristics: insuffi-cient energy intake, weight loss, loss ofmuscle mass, loss of subcutaneous fat,localized or generalized fluid accumu-lation, or decreased functional status.11

The importance of identifying at-riskpatients is highlighted by data showingthat malnutrition is associated withmany adverse outcomes, including anincreased risk of pressure ulcers andimpaired wound healing, immune sup-pression and increased infection rate,muscle wasting and functional lossincreasing the risk of falls, longer lengthof hospital stay, higher readmission

TION AND DIETETICS

rates, higher treatment costs, andincreased mortality.1 Therefore, malnu-trition places a heavy burden on thepatient, clinician, and health caresystem.

Many of the adverse outcomes influ-enced by malnutrition are potentiallypreventable. Nosocomial infections area prime example. Approximately2 million nosocomial infections occurannually in the United States,12 andthose patients are more likely to spendtime in the intensive care unit, bereadmitted, and die as a result.13 Aretrospective study by Fry and col-leagues examined nearly 1 million sur-gical patients (N¼887,189) treated at1,368 hospitals to determine the risk ofnosocomial infections and better un-derstand the underlying patient char-acteristics influencing that risk.14 Theanalysis showed that patients with pre-existing malnutrition and/or weightloss had a two- to threefold increasedrisk of developing Clostridium difficileenterocolitis, surgical-site infection, orpostoperative pneumonia, and a greaterthan fivefold higher risk ofmediastinitisafter coronary artery bypass graft sur-gery or catheter-associated urinarytract infection. Malnutrition and/orweight loss also correlated with anapproximate fourfold higher risk ofdeveloping a pressure ulcer. These dataare further supported by a prospectivemultivariate analysis demonstratingthat malnutrition is an independentrisk factor for nosocomial infections.15

Impaired wound healing can signifi-cantly influence length of hospital stay,and the literature supports a strongcorrelation between nutrition andwound healing, wherein protein syn-thesis is necessary.16 Hospitalized pa-tients are at increased risk because lossof significant lean body mass (LBM)accelerates during bed rest.17,18 A 10%loss of LBM results in immune sup-pression and increases the risk ofinfection, and a loss of >15% to 20% oftotal LBM will impair wound heal-ing.16,19 A loss of �30% leads to thedevelopment of spontaneous wounds,such as pressure ulcers, an increasedrisk of pneumonia, and a complete lackof wound healing.16,19 These complica-tions are also associated with a sub-stantial mortality risk, particularly inolder patients. A study evaluating thecare processes for hospitalized Medi-care patients (N¼2,425; aged 65 yearsand older) at risk for pressure ulcer

September 2013 Volume 113 Number 9

FROM THE ACADEMY

development showed that 76% of pa-tients were malnourished, and esti-mated compliance with nutritionconsultation was low (34%).20

Data from several recent studiesshow that malnutrition can also influ-ence hospital readmission rates.21-23

These studies evaluated multiple fac-tors to identify individuals at increasedrisk of readmission. The largest of thesestudies, a retrospective observationalanalysis of >10,000 consecutive ad-missions (N¼6,805), reported a 30-dayreadmission rate of 17%.21 Comorbid-ities that significantly increased therisk of readmission included congestiveheart failure, renal disease, cancer,weight loss (not defined), and iron-deficiency anemia. Weight loss corre-lated with a 26% increased risk ofreadmission (adjusted odds ratio¼1.26).21 In a large single-center study of1,442 general surgery patients, the30-day readmission rate was 11%.22 Themost common reasons for readmissionwere gastrointestinal problems/com-plications (28% of readmissions), sur-gical infections (22%), and failure tothrive/malnutrition (10%). These find-ings are consistent with the hypothesisthat poor nutrition contributes to post-hospital syndrome, which, togetherwith a variety of other factors, such assleep disturbance, pain, and discom-fort, can dramatically increase therisk of 30-day readmission, often forreasons other than the originaldiagnosis.24

Finally, poor clinical outcomes asso-ciated with malnutrition contribute tohigher hospitalization costs. As out-lined above, malnourished patientshave higher rates of infections, pres-sure ulcers, impaired wound healing,and other adverse outcomes requiringgreater nursing care and more medi-cations. In turn, these complicationscan contribute to longer lengths ofhospital stay and higher rates of read-mission, all of which indirectly con-tribute to higher hospital costs.1

Indeed, a study conducted in theUnited Kingdom estimated the annualexpenditure for managing patients atmedium or high risk of disease-relatedmalnutrition to be EURV10.5 billion(US$11.3 billion, based on 2003 ex-change rates), more than half of whichwas directly related to hospital care.25

These studies strongly suggest thatthe consequences of unrecognized anduntreated malnutrition are substantial,


not only for patients’ quality of care butalso from a cost perspective. Malnutri-tion negatively affects clinical out-comes and results in higher costs and,with the changing health care land-scape, reimbursement for costs associ-ated with preventable events will bereduced. All clinicians must take actionto address these concerns, improvepatient quality of life, and increase thehealth care system value.

IMPACT OF NUTRITIONINTERVENTION ON KEYOUTCOMESThe benefits of nutrition interventionin terms of improving key clinical out-comes are well documented. Numerousstudies, predominantly in patients65 years of age and older with or atrisk for malnutrition, have shownthe potential of specific nutritioninterventions to substantially reducecomplication rates, length of hospitalstay, readmission rates, cost of care,and, in some studies, mortality.5,26-36

Nutrition intervention strategies rep-resent a broad spectrum of options thatcan be organized into four categories:(1) food and/or nutrient delivery;(2) nutrition education; (3) nutritioncounseling, and (4) coordination ofnutrition care. Food and/or nutrientdelivery requires an individualizedapproach that includes energy- andnutrient-dense food, complete oralnutrition supplements (ONS) that pro-vide macronutrients (from carbohy-drate, fat, and protein sources)combined with micronutrients (mix-tures of complete vitamins, minerals,and trace elements); enteral nutrition(EN), which in the context of thisreport refers to nutrients provided intothe gastrointestinal tract via a tube;and/or parenteral nutrition (PN).Although the nutrition support litera-ture has generally featured smallertrials and observational studies ratherthan large, multicenter, randomizedcontrolled trials, evidence stronglysupports the importance of nutritionintervention. The value of EN and PN iswell established in select patient pop-ulations but remains unclear in others.In addition, numerous studies haveshown improved body weight, LBM,and grip strength with dietary coun-seling, with or without ONS.37 Agrowing number of studies have exam-ined the impact of ONS inmalnourished

JOURNAL OF THE ACADE

patients, providing the frameworkfor our call to action. Evidence sup-porting intervention with EN and PN isbeyond the scope of the current paperand will be addressed in subsequentreviews.

Clinical ComplicationsStudies evaluating the efficacy of ONSdelivery have generally shown a varietyof metabolic improvements and, inmany studies, a reduction in severalclinical complications. One meta-analysis including seven studies(N¼284) indicates that patients re-ceiving ONS had reduced complicationrates (eg, infections, gastrointestinalperforations, pressure ulcers, anemiaand cardiac complications) comparedwith control patients.28More recently, alarge Cochrane systematic review of24 studies involving 6,225 patients65 years of age and older at risk formalnutrition demonstrated fewercomplications (eg, pressure sores, deepvein thrombosis, and respiratory andurinary infections) among patients re-ceiving ONS compared with routinecare (relative risk [RR]¼0.86; 95% CI0.75 to 0.99).27 Available evidence in-dicates high-protein ONS to be partic-ularly effective at reducing the risk ofcomplications. A systematic review ofelderly patients (older than 65 years ofage) with hip fractures demonstrated amore effective reduction in the numberof long-term medical complicationswith high-protein ONS (>20% total en-ergy from protein) than low-proteinor nonprotein-containing supplements(RR¼0.78; 95% CI 0.65 to 0.95).26 Ameta-analysis of four randomized trials(N¼1,224) also showed that, in patientswith no pressure ulcers at baseline,high-protein ONS resulted in a signifi-cant 25% lower incidence of ulcerscompared with routine care.38 In addi-tion, evidence indicates that nutritionintervention can reduce the risk of fallsin frail and malnourished elderly pa-tients. In 210malnourished older adultsnewly admitted to an acute-care hos-pital, intervention with a protein- andenergy-rich diet, ONS, calcium/vitaminD supplements, and counseling reducedthe incidence of falls by approximately60% comparedwith routine care (10% vs23%).35 Avoidance of these preventableevents can shorten length of hospitalstay, decrease morbidity and mortality,and reduce liability for the hospital.


FROM THE ACADEMY

Length of StayConsistent with evidence that nutritionintervention can reduce clinical com-plications, strong nutrition care can alsoreduce the length of hospital stay. In aprospective study conducted at TheJohns Hopkins Hospital, nutritionscreening involving a team approach toaddress malnutrition and earlier inter-vention reduced the length of hospitalstay byan average of 3.2 days in severelymalnourished patients,5 and this trans-lated into substantial cost savings of$1,514 per patient. Two meta-analyseshave shown significantly reducedlength of hospital stay in patients re-ceiving ONS compared with controlpatients. One analysis demonstrated areduced average length of hospital stayranging from2days for surgical patientsto 33 days for orthopedic patients(P<0.004).28 In addition, patientswith alower BMI (<20) received the greatestbenefit from optimized food and/ornutrient delivery. Likewise, in a recentmeta-analysis of nine randomized trials(N¼1,227), high-protein ONS signifi-cantly reduced length of stay by anaverage of 3.8 days (P¼0.040) comparedwith routine care.31 A recent retrospec-tive analysis utilized information from>1 million adult inpatient cases foundin the 2000-2010 Premier PerspectivesDatabase maintained by the PremierHealthcare Alliance—representing a to-tal of 44 million hospital episodes fromacross the United States or approxi-mately20%of all inpatient admissions inthe United States. Within this sample,ONS reduced length of hospital stay byan average of 2.3 days or 21%, and theaverage cost savingswas $4,734 or 21.6%compared with routine care.36

ReadmissionsHospital readmission rate is anotherimportant outcome that can beimproved through nutrition interven-tion. Thirty-day readmission rates de-creased from 16.5% to 7.1% in acommunity hospital that implementeda comprehensive malnutrition clinicalpathway program focused on identifi-cation of at-risk patients, nutrition caredecisions, inpatient care, and dischargeplanning.30 A prospective randomizedtrial in acutely ill patients 65 to 92 yearsof age (N¼445) demonstrated a signifi-cantly lower 6-month readmission rateamong those who received a normalhospital diet plus high-protein ONS


compared with those patients whoreceived only the normal hospital diet(29% vs 40%, respectively; hazardratio¼0.68; 95% CI 0.49 to 0.94).32

Finally, analysis of the Premier Per-spectives Database showed that use ofONS reduced 30-day readmission ratesby6.7%,36 indicating the significant real-world benefit of nutrition interventionon a key patient outcome.

MortalitySeveral meta-analyses have alsodemonstrated reduced mortality inpatients receiving optimized nutri-ent care. An analysis of 11 studies(N¼1,965) found significantly lowermortality rates among hospitalized pa-tients receiving ONS (19%) comparedwith control patients (25%; P<0.001).28

This represented a 24% overall reduc-tion in mortality, and patients withlower average BMI (<20) receiving ONShad a greater reduction in mortality.Among elderly patients hospitalized forhip fracture, significantly fewer patientshad an unfavorable combined outcome(mortality or medical complication) ifthey received ONS vs routine care(RR¼0.52; 95% CI 0.32 to 0.84).29

Another systematic review of 32studies (N¼3,021) found that, in elderlypatients, ONS significantly reducedmortality compared with routine care(RR¼0.74; 95% CI 0.59 to 0.92).33 Sub-group analyses from the originalCochrane review and two updates haveconsistently shown reduced mortalityin undernourished patients receivingONS compared with routine care.27,33,34

Collectively, these data provide solidevidence that nutrition interventionsignificantly contributes to improvedclinical outcomes and reduced cost ofcare, primarily in patients 65 years ofage and older and those with, or atrisk for, malnutrition. However, it isimportant to note that isolated studiesand meta-analyses have not demon-strated such significantly improvedclinical outcomes with nutrition inter-vention.37,39-42 Additional researchstudies, particularly well-powered,randomized controlled clinical trials,are always beneficial to further explorethe effects of nutrition intervention onclinical outcomes and to assess howthose benefits can translate into costsavings. Nevertheless, given the impor-tance of adequate nutrition to cell andorgan function, coupled with promising

TION AND DIETETICS

clinical data reported to date, the timeis now to act on the evidence at handand implement nutrition interventionstrategies shown to be safe andefficacious.

ALLIANCE NUTRITION CARERECOMMENDATIONSIf we are to make progress towardimproving nutrition care practices thatguarantee every malnourished or at-risk patient is identified and treatedeffectively, we must proactively iden-tify barriers impacting the provision ofnutrition care. Toward this end, at leastsix key challenges must be overcome.First, despite at least one third of hos-pitalized patients being admittedmalnourished, a majority of these pa-tients continue to go unrecognized orare inadequately screened.43 Second,while the responsibility of patients’nutrition care is often placed on thedietitian many institutions lack ade-quate dietitian staffing to properlyaddress all patients. Third, nutritioncare is often delayed due to the pa-tient’s medical status, lack of diet order,and time to nutrition consult. In fact, astudy at Johns Hopkins found that timeto consultation from admission isnearly 5 days,5 which is similar to theaverage length of hospital stay.44

Fourth, nurses provide and overseepatient care 24/7, observe nutritionintake and tolerance, and interactcontinually with the patient and theirfamily/caregivers, yet they are rarelyincluded in nutrition care.45 Fifth, inmany care environments, physiciansign-off is required to implement anutrition care plan. Dietitian recom-mendations are implemented in only42% of cases.46 Finally, many patientsexperience difficulty consuming mealswithout assistance, contributing tomore than half of hospitalized patientsnot finishing their meals.47

To address these barriers and shiftthe paradigm of nutrition care, theAlliance Steering Committee, whosemembers possess broad-ranging ex-pertise and clinical experience, devel-oped several key principles foradvancing patient nutrition. Through aseries of meetings conducted over thepast year, the committee explored thefollowing topics: empowerment of allclinicians; recognition and diagnosisof all patients; same-day automaticintervention for all at-risk patients;


Figure 1. The Alliance’s Key Principles for Advancing Patient Nutrition. EHR¼electronic health record.

FROM THE ACADEMY

education and involvement of patientsin their nutrition care; and apprecia-tion of the value of nutrition by allhospital stakeholders. Six principlesdeemed essential elements of optimalpatient nutrition care were derivedfrom these topics (Figure 1). Attain-ment of these six ideals, however, willrequire processes and collaborationamong all hospital stakeholders, in-cluding dietitians, nurses, physicians,and administrators, each of whommust fulfill their role in this effort(Figure 2). Translation of these pro-cesses into a practical interdisciplinarynutrition care algorithm is illustrated inFigure 3.

Principle 1: Create anInstitutional Culture Where AllStakeholders Value NutritionTrue progress requires that all hospitalstakeholders, including clinicians andadministrators, fully understand the


pervasiveness of hospital malnutritionand the effect patient nutrition caremayhave on overall clinical outcomes. Cli-nicians and administrators often fail toprioritize understanding the extent ofmalnutrition in their institutions and itspotential impact on cost and/or qualityof care. Nurses and physicians receivelimited formal nutrition education dur-ing training and often do not prioritizenutrition among the competing prior-ities within patient care. Failing to pri-oritize nutrition within an institutionmay limit available nutrition interven-tion options and human resources(eg, dietitian nutrition-focused nursesand physicians) required for optimalnutrition care. To be successful, in-stitutions need motivated nutritionchampions at all levels of clinical careand administration.To ensure that clinicians and hospital

leaders understand the clinical andfinancial implications of malnutritionand take proper steps to address it,


the Alliance offers the followingrecommendations:

� Clinicians must be educated onthe recognition of malnourishedpatients and evidence-basednutrition interventions. Discus-sion of nutrition care plansshould be a mandated compo-nent of daily team meetings(rounds or huddles).

� Malnutrition must be appropri-ately included as part of the pa-tient’s diagnosis and nutritioninterventions must be viewed asa core component of a patient’smedical therapy. Nutrition treat-ment plans should be addressedwith the same consistency andrigor as other therapies.

� Hospital administrators mustrecognize the financial benefit ofoptimal nutrition care. Institu-tional financial data must bereviewed to identify challenges


Principle Key Hospital Stakeholders

Dietitian Nurse Physician Hospital administrator

1. Create an InstitutionalCulture Where AllStakeholders ValueNutrition

� Serve as primary authorityon “all things nutrition”

� Educate key hospitalstakeholders on improvedpatient outcomes andreduced costs achievedwith optimal nutrition care

� Host hospital-wide learningopportunities at regularintervals

� Recognize the essential rolethat nurses play inachieving enhancedpatient outcomes throughindividualized nutritioncare

� Incorporate nutrition intoroutine care checklists andprocesses

� Include patient dietaryintake into team huddles

� Provide leadership under-scoring nutrition care as anessential part of patient-centered care

� Know evidence regardingimpact of malnutrition andeffectiveness of nutritionintervention

� Include dietitian in dailyteam huddles/rounds

� Incorporate nutrition intoroutine care checklists andprocesses

� Become a nutrition cham-pion and provide supportfor the development ofeffective nutrition careprocesses

� Share quality and eco-nomic gains to be made byinvesting in nutrition carewith hospital leadershipteam

2. Redefine Clinicians’Role to IncludeNutrition Care

� Actively contribute nutri-tion expertise and engageother team members withassessment data on prog-ress made with nutritioncare efforts

� Regularly participate ininterdisciplinary rounds

� Ensure practices are inplace to support imple-mentation of nutritionintervention

� Develop processes to ensurethat nutrition screening anddietitian–prescribed inter-vention occurs within thetargeted timeframes

� Facilitate nursing inter-ventions to treat patientswho are malnourishedor at risk

� Empower dietitian tocooperatively lead nutri-tion care as clinical teammember

� Support nurse work pro-cesses to include nutritionscreening and supportnutrition intervention

� Support nutrition educa-tion of clinicians needinginitial training andcontinuing education

� Provide ordering privi-leges to dietitian for issuesrelating to the nutritioncare process

3. Recognize andDiagnose AllMalnourished Patientsand ThoseAt Risk

� Utilize standard malnutri-tion characteristics setforth by ANDa andA.S.P.E.N.b guidelines

� Screen every hospitalizedpatient for malnutrition aspart of regular workflowprocedures

� Consider nutrition status asan essential attribute ofmedical assessment, moni-toring, and care plans

� Ensure EHRc capturesscreening data andmalnutrition criteria withthe appropriate triggers inplace for initiating the

(continued on next page)

Figure 2. Summary of Alliance’s nutrition care recommendations for key hospital stakeholders.

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� Establish competence innutrition-focused physicalassessment

� Communicate screeningresults through use of EHR

� Rescreen patients at leastweekly during hospital stay

� Communicate changes inclinical condition indica-tive of nutrition risk

next steps when positivescreens or diagnosticassessment are obtained

4. Rapidly ImplementComprehensiveNutrition Interventionand ContinuedMonitoring

� Establish procedures tosupport policy that patientsidentified as “at-risk” duringnutrition screen receiveautomated nutrition inter-vention within 24 hourswhile awaiting assessment,diagnosis, and care plan

� Lead an interdisciplinaryteam to establish nutritionalgorithms for use invarious scenarios whenpositive screens or diag-nostic assessments areobtained

� Provide ENd formulary andmicronutrient therapyoptions in written form asa pocket-sized document;make readily available toall staff to ensure fastintervention

� Work with nurses to estab-lish policies and

� Ensure that proceduresallowing patients identi-fied as “at-risk” duringnutrition screen receiveautomated nutrition inter-vention within 24 hourswhile awaiting assess-ment, diagnosis, and careplan

� Develop procedures toprovide patients withmeals at “off times” if pa-tient was not available orunder a restricted diet atthe time of meal delivery

� Avoid disconnecting EN orPNf forpatient repositioning,ambulation, travel, orprocedures

� Work with interdisciplinaryteam dietitian to establishpolicies and interdisci-plinary practices to

� Support policy that -vides automated nutritintervention within 24hours in patients ident das “at-risk” during nutr nscreen, while awaitingnutrition assessment, d -nosis, and care plan

� Minimize nil per os -riods for patient withscheduling of procedu /tests and remain mind lof “holds” on POe diet

� Provide ordering privilegesto dietitian for issuesrelating to the nutritioncare process (eg, diet plans,ONSg, micronutrients, andcalorie counts)

� Ensure EHR includes auto-matic triggers that initiatenutrition protocol mea-sures to be reviewedwhen positive screens areobtained

� Ensure EHR includes amodule for recordingfood/ONS intake data andtriggers dietitian consult ifconsumption issuboptimal


Figure 2. (continued) Summary of Alliance’s nutrition care recommendations for key hospital stakeholders.

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interdisciplinarypractices tomaximize nutrient con-sumption and monitoringneeds

maximize food/ONSconsumption

� Monitor food/ONS andcommunicate to dietitian/physician via EHR

5. CommunicateNutrition Care Plans

� If present, ensure mild,moderate, or severemalnutrition is included ascomplicating condition incoding processes

� Assume responsibility forensuring that a patient’snutrition care plan is care-fully documented in theEHR, regularly updated,and effectively communi-cated to all healthcareproviders, including post-acute facilities and primarycare physicians

� Lead a interdisciplinaryteam to create and main-tain standardized policies,procedures, and EHR-auto-mated triggers relevant tonutrition, including ordersets and protocols in thehospital’s EHR

� Consult dietitian regardingnutrient intake concerns


� Incorporate nutrition dis-cussions into handoff ofcare and nursing careplans

� Establish and reinforceexpectation that a patient’snutritioncareplan iscarefullydocumented in the EHR,regularly updated, andeffectively communicated toall health care providers



� Ensure EHR is adapted toensure nutrition diagnosisand complete care plan isincluded as a standardcategory of medicalassessment in the centralarea of EHR

6. Develop aComprehensiveDischarge NutritionCare and Education Plan

� Provide patients, familymembers, and caregiverswith nutrition educationand a comprehensive

� Include nutrition as acomponent of all clinicianconversations with pa-tients and their familymembers/caregivers

� Include nutrition as acomponent of all clinicianconversations with pa-tients and their familymembers/caregivers

� Provide expectation re-garding continuity ofnutrition care, includingdischarge planning andpatient education


Figure 2. (continued) Summary of Alliance’s nutrition care recommendations for key hospital stakeholders.

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to improving nutrition interven-tion, project cost savings withvarious nutrition interventions,and revise budgets to facilitateaction. Budgets must supportadequate and appropriate nutri-tion intervention as necessitatedby dietitian, nursing, and physi-cian staff.

� Professional associations for di-etitians, nurses, physicians, andhospital administrators mustaddress the widespread problemof hospital malnutrition. Disci-pline-specific resources such astoolkits and practice bundles,evidence-based publications, andcontinuing education opportu-nities must be established andwidely available. Funding mech-anisms for nutrition-related re-search should be established toidentify best practices to opti-mizing nutrition care.

Principle 2: Redefine Clinicians’Roles to Include Nutrition CareProviding effective nutrition interven-tion requires a champion within andcollaboration among all disciplinesinvolved in patient care. All health careprofessionals involved in patient caremust be empowered to influence nu-trition decisions. In many hospitals,however, the responsibility for nutri-tion recommendations almost alwaysrest solely with the dietitian. Many in-stitutions lack nurse and physicianleaders who champion nutrition care.Interdisciplinary leadership is essentialto ensure that nutrition care is valuedand carries a high priority. To ensureeffective management of hospitalmalnutrition, nurses and physiciansmust also play a role.

In this regard, the Alliance recom-mends redefining clinicians’ roles toinclude responsibility for optimalnutrition care, which can be accom-plished as follows:

� Interdisciplinary teams mustdiscuss potential barriers andsolutions to recognize and treatmalnourished or at-risk patientsin their hospitals.

� Engage nurses to understandnutrition risk factors such as un-derconsumed meals and actionsrequired on positive malnutri-tion screenings. Develop and

OF NUTRITION AND DIETETICS 1227

Figure 3. The Alliance’s Approach to Interdisciplinary Nutrition Care. AND¼Academy of Nutrition and Dietetics; A.S.P.E.N.¼AmericanSociety for Parenteral and Enteral Nutrition; EHR¼electronic health record; ONS¼oral nutrition supplement; PCP¼primary carephysician.

FROM THE ACADEMY

12

implement policies that allownurses to provide nutrition care,suchas returning low-riskpatientsto previous established feedingorders following temporary de-lays, initiating calorie counts, andmeasuring body weight as indi-cated. Policies that inhibit nursingaction inhibit optimal patientnutrition. Prompt nursing actioncan reduce malnutrition bycreating focused meal times,managing meal-time environ-ments and staff meal times, inter-vening with nutrition therapies asappropriate, and designating anutrition care nurse in each clin-ical area to monitor and evaluateimplementation of the policy.48

� Given the extensive nutritionexpertise of dietitians, hospitaladministrators, such as a chiefmedical officer, must grant them

28 JOURNAL OF THE ACADEMY OF NUTRITIO

ordering privileges for orderingdiets, ONS, vitamins, and caloriecounts to eliminate inefficienciesand prevent delays in foodand/or nutrient delivery. Forexample, at the University ofKansas Hospital (KUH), whenfaced with delays in care becausethe dietitian’s recommendationswere not being noted and or-dered by physician teams, thenutrition support team obtainedordering privileges for all di-etitians. These privileges includeordering ONS, calorie counts,patient weights, zinc, vitamin Cand multivitamins, and selectnutrition-related labs. This wasan important step in advancingnutrition care at KUH by pro-moting timely gathering ofassessment data and nimble

N AND DIETETICS

implementation and revision ofoptimal nutrition interventions.

� Hospitalistsmust add nutrition totheir interdisciplinary approachto patient care and serve asnutrition champions among phy-sicians. In support of this effort,hospitalists should include a die-titian andnutrition-focusednursein team huddles and nutritionshould be included in the dailyproblem list.

Principle 3: Recognize andDiagnose All MalnourishedPatients and Those at RiskGiven the high prevalence ofhospital malnutrition, each hospital-ized patient must receive proper nutri-tion screening, with findings effectivelycommunicated to ensure immediateassessment and prompt nutrition


Table 1. Validated malnutrition screening tools for hospitalized patientsa

Screening tool Parameters/scoring Development Validation

Malnutrition ScreeningTool (MST)53

Weight loss, appetite; at-riskscore �2

408 inpatients (meanage¼58 y);standard for comparison:SGAb; sensitivity 93%;specificity 93%

SGA: sensitivity 92%,specificity 61%;MNAc: sensitivity 92%,specificity 72%62

Mini Nutritional Assessment-ShortForm (MNA-SF)56

Weight change, recentintake, BMI,d acutedisease, mobility,dementia/depression;at-risk score �11

155 community-dwellingelders (mean age¼79 y);standard for comparison:physician assessment ofnutritional status;sensitivity 98%; specificity100% (MNA-SFe cut point�10)

MNA: sensitivity 90%,specificity 88% (MNA-SFcut point �11)63

MNA: sensitivity 89%,specificity 82% (MNA-SFcut point �11)64

“Nutritional assessment”:sensitivity 100%,specificity 38% (MNA-SFcut point �10)65

Malnutrition UniversalScreening Tool(MUST)52,66

Weight change, recent/predicted intake, BMI,acute disease; high-riskscore �2

8,944 inpatients, review of128 trials (mean age notreported);standard for comparison:nutrition support trialsdemonstrating improvedclinical outcomes;sensitivity 75%; specificity55%

SGA: sensitivity 61%,specificity 79%67

SGA: sensitivity 72%,specificity 90%;MNA: k¼0.3968

MNA: k¼0.5569

Nutritional Risk Screening2002 (NRS-2002)54

Weight change, recentintake, BMI, acute disease,age; at-risk score �3

Adapted from MalnutritionAdvisory Group screeningtool

SGA: sensitivity 74%,specificity 87%;MNA: k¼0.3968

SGA: sensitivity 62%,specificity 63%67

MNA: k¼1.0070

Short NutritionalAssessment Questionnaire(SNAQª)55

Weight change, appetite,supplements/tubefeeding;at-risk score �2

291 inpatients (meanage¼58 y);standard for comparison:BMI <18.5 or weight loss>5%;sensitivity 86%; specificity89%

BMI <18.5 or recent weightloss >5%: sensitivity 79%,specificity 83%71

aAdapted with permission from Young and colleagues.51bSGA¼Subjective Global Assessment.cMNA¼Mini Nutritional Assessment.dBMI¼body mass index; calculated as kg/m2.eSF¼short-form.

FROM THE ACADEMY

intervention. Using validated screeningtools to identify at-risk patients iscrucial because, for many health careprofessionals without nutrition train-ing, screening is currently a superficialobservation wherein boxes are check-ed or unchecked without reliable


screening using a validated tool. Earlyidentification of clinical criteria sup-porting malnutrition diagnosis andeffective processes for communicatinginformation related to the nutritioncare process are often absent. Giventhese barriers, the Alliance is


announcing this call to action to ensureprompt diagnosis and intervention ofhospitalized patients who aremalnourished or at risk for malnutri-tion. Every hospital must institute aninterdisciplinary approach to nutritioncare that is based on formal policies and


1. Have you lost weight recently without trying?

No 0

Unsure 2

If Yes, how much weight (kg) have you lost?

1 – 5 1

6 – 10 2

11 – 15 3

> 15 4

Unsure 2 Weight Loss Score:

2. Have you been eating poorly because of a decreased

appetite?

No 0

Yes 1 Appetite Score:

Total MST Score (weight loss + appetite scores)

Figure 4. Malnutrition Screening Tool (MST). Adapted with permission from Fergusonand colleagues.53

FROM THE ACADEMY

procedures ensuring the early identifi-cation of patients who are malnour-ished or at risk for malnutrition andimplementation of comprehensivenutrition care plans.

ScreeningComprehensive nutrition screening ofall hospitalized patients is critical forboth the timely identification of thoseat risk and to prioritize patientsrequiring nutrition assessment andintervention. The Alliance supports theJoint Commission’s recommendationfor nutrition screening within 24 hoursof admission to an acute-care hospitaland at frequent intervals throughouthospitalization (Figure 3).49 Due tolimited clinician time and nutritionknowledge, a simplified, practical, vali-dated screening tool must be used.Numerous tools exist to screen formalnutrition risk in hospitalized pa-tients.50,51 Although no universallyaccepted screening tool exists, it isimportant to select a tool that is prac-tical, easy to use, and has been validatedin the patient population of interest.Currently, validated screening toolsinclude theMalnutrition Screening Tool(MST), Mini Nutritional Assessment-Short Form (MNA-SF), Malnutrition


Universal Screening Tool (MUST),Nutritional Risk Screening 2002 (NRS-2002), and Short Nutritional Assess-ment Questionnaire (SNAQ)52-56

(Table 1). Important aspects of a nutri-tion screening tool include scientificvalidation, and easy administrationrequiring no specialized nutritionknowledge. For example, the advantageof the MST is that it is quick (takes <5minutes) and straightforward, consistsof two simple questions evaluatingweight change and appetite (Figure 4)and was designed for use by busyhealth care professionals not neces-sarily trained in nutrition. These toolsallow nutrition screening to become anintegral part of routine clinical practicewithout being viewed as a burden orimposing a significant extra workloadon hospital staff.Screening results must be docu-

mented within the electronic healthrecord (EHR) to allow for promptcommunication between the nursingstaff and other health care teammembers. When a positive nutritionscreen is obtained, the EHR should beconfigured to trigger a query for entryof a diet order or other appropriateintervention while the patient awaitsfurther assessment and developmentof a nutrition care plan. Nurses must

TION AND DIETETICS

regularly rescreen patients with ade-quate nutrition status upon admissionbecause many will become at risk formalnutrition during hospitalization.The MST can be easily completed whilenurses interact with patients and theirfamily/caregivers and while conductingregular assessments for patients at riskof pressure ulcers and falls.

Assessment and DiagnosisNutrition assessment is a method ofobtaining, verifying, and interpretingdata needed to identify nutrition-related problems, their causes, andsignificance. The dietitian must per-form nutrition assessments in all pa-tients considered at risk based onnutrition screening to characterizeand determine the cause of nutritiondeficits. Traditionally, changes in acute-phase proteins, such as serum albuminand pre-albumin, were consideredstandard biomarkers for diagnosingmalnutrition.11 However, it is now welldocumented that serum levels of theseproteins are affected not only bynutrition status but also by inflamma-tion, fluid status, and other factors.Consequently, these are no longerconsidered reliable or specific bio-markers for malnutrition. Consistentwith this evidence, as of 2012, the ANDand A.S.P.E.N. no longer recommendusing inflammatory biomarkers fordiagnosis of malnutrition.

To address the need for guidance inthis area, an International Guidelinesgroup convened in 2009 and devel-oped an overarching etiology-baseddefinition of malnutrition that takesinto account the important relationshipbetween disease and malnutrition.57

This broad definition describes threeseparate etiologies for malnutrition(Figure 5), two of which include thepresence of disease (either acute orchronic). The AND and A.S.P.E.N. sub-sequently developed a standardized setof diagnostic criteria for adult malnu-trition in routine clinical practice usingthis new etiology-based definition.11

No single parameter is definitive formalnutrition; therefore, AND andA.S.P.E.N. proposed that malnutritionbe diagnosed when at least two of thefollowing six characteristics are iden-tified: (1) insufficient energy intake;(2) weight loss; (3) loss of subcutane-ous fat; (4) loss of muscle mass;(5) localized or generalized fluid


Figure 5. Etiology-based malnutrition definitions. Adapted with permission from White and colleagues.11

FROM THE ACADEMY

accumulation that may sometimesmask weight loss; and (6) diminishedfunctional status. The magnitude andtemporal aspects of change amongthese dynamic characteristics can beused to distinguish between nonsevereand severe malnutrition (Table 2).The Alliance recommends that all

clinicians become familiar with anduse the AND and A.S.P.E.N. character-istics for identification and documen-tation of malnutrition (Figure 3).11 Inpatients with or at risk of malnutrition,development and initiation of a nutri-tion care plan must occur within 48hours of admission. Several patientcharacteristics indicative of malnutri-tion (eg, weight loss, loss of muscle orfat, fluid retention, and cutaneous signsof micronutrient deficiencies, such asglossitis or cheliosis) can be identifiedduring routine comprehensive assess-ments. As noted earlier, changes inacute-phase proteins should be inter-preted with caution and should not beused exclusively to diagnose malnutri-tion. These proteins are, however, goodindicators of inflammation. In addition,other laboratory indicators of inflam-mation (eg, C-reactive protein, whiteblood cell count, and glucose levels)may be informative. A clear under-standing of the patient’s chief com-plaint and medical history is alsoimportant to appreciate the potential


for underlying inflammation, whichcan increase the risk of malnutritionby increasing metabolism. Conditionssuch as fever, infection, organ dys-function, and hyperglycemia may beindicative of underlying inflammationand contribute to an etiology-baseddiagnosis, including identification ofcurrently well-nourished patients atrisk for malnutrition.Obtaining adequate information

from the patient or caregiver regardingfood and nutrient intake, body weightchanges, and functional changes (eg,ability to purchase and cook food, anddental status) is essential to identifyperiods of insufficient intake. Changesin physical function (eg, ambulation,chewing ability, and mental status is-sues) must be assessed and monitoredas appropriate based on individual pa-tient circumstances. Ensuring thesevarious assessments are routinely andcarefully performed is vital to an ac-curate diagnosis of malnutrition. Inaddition, specific fields for the AND andA.S.P.E.N. malnutrition characteristicsmust be completed so that systemalerts are triggered when two of thesix criteria are documented, therebyclearly communicating the malnutri-tion diagnosis to the health care team.Accurate coding of the malnutritiondiagnosis as a complicating conditionof the primary diagnosis is also critical


to ensure adequate documentation tosupport appropriate reimbursementand tracking of costs to allow for amore accurate quantification of theburden of malnutrition in the future.

Principle 4: Rapidly ImplementComprehensive NutritionInterventions and ContinuedMonitoringWhen a patient is identified asmalnourished, appropriate nutritionintervention must be promptly orderedand fully implemented (Figure 3). Bar-riers to this ideal are varied, but ofteninclude: (1) NPO orders while patientsawait further assessment, (2) lack ofnursing protocol orders focused onnutrition, (3) delay in assessment ofnutrition status due to insufficientdietitian staffing, (4) dietitian recom-mendations unheeded due to thephysician’s focus on other medicalconcerns, (5) physician uncertaintywith product formulary and/or specificmicronutrient therapy options in theirhospitals, and (6) inadequate foodconsumption due to poor appetite,disease processes, and interruptions tomealtimes.

To overcome barriers to early andoptimal nutrition intervention, theAlliance provides the followingrecommendations:


Table 2. Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition clinical characteristics that the clinician can obtain and documentto support a diagnosis of malnutritiona

Clinical characteristicb

Malnutrition in theContext of AcuteIllness or Injury

Malnutrition inthe Context ofChronic Illness

Malnutrition in theContext of Social or

EnvironmentalCircumstances

Moderatec Severed Moderate Severe Moderate Severe

(1) Energy intake: malnutrition is theresult of inadequate food andnutrient intake or assimilation; thus,recent intake compared withestimated requirements is a primarycriterion defining malnutrition. Theclinician may obtain or review thefood and nutrition history, estimateoptimum energy needs, comparethem with estimates of energyconsumed, and report inadequateintake as a percentage of estimatedenergy requirements over time.

<75% of estimatedenergyrequirement for>7 days

�50% of estimatedenergyrequirement for�5 days

<75% of estimatedenergyrequirement for�1 mo

�75% of estimatedenergyrequirement for�1 mo

<75% of estimatedenergyrequirement for�3 mo

�50% of estimatedenergyrequirement for�1 mo

% Time % Time % Time % Time % Time % Time

(2) Interpretation of weight loss: Theclinician may evaluate weight inlight of other clinical findings,including the presence of under- oroverhydration. The clinician mayassess weight change over timereported as a percentage of weightlost from baseline.Physical findingsMalnutrition typically results inchanges to the physicalexamination. The clinician mayperform a physical examination anddocument any one of the physicalexamination findings below as anindicator of malnutrition.

1-257.5

1 wk1 mo3 mo

>2>5>7.5

1 wk1 mo3 mo

57.51020

1 mo3 mo6 mo1 y

>5>7.5>10>20

1 mo3 mo6 mo1 y

57.51020

1 mo3 mo6 mo1 y

>5>7.5>10>20

1 mo3 mo6 mo1 y


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Table 2. Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition clinical characteristics tha e clinician can obtain and documentto support a diagnosis of malnutritiona (continued)

Clinical characteristicb

Malnutrition in theContext of AcuteIllness or Injury

Malnutrition inthe Context ofChronic Illness

Malnutrition in theContext of Social or

EnvironmentalCircumstances

Moderatec Severed Moderate Severe M rate Severe

(3) Body fat: Loss of subcutaneousfat (eg, orbital, triceps, fatoverlying the ribs).

Mild Moderate Mild Severe M Severe

(4) Muscle mass: Muscle loss (eg,wasting of the temples, clavicles,shoulders, interosseous muscles,scapula, thigh, and calf).

Mild Moderate Mild Severe M Severe

(5) Fluid accumulation: The clinicianmay evaluate generalized orlocalized fluid accumulation evidenton examination (extremities, vulvar/scrotal edema, or ascites). Weightloss is often masked by generalizedfluid retention (edema), and weightgain may be observed.

Mild Moderate to severe Mild Severe M Severe

(6) Reduced grip strength: Consultnormative standards supplied bythe manufacturer of themeasurement device.

NAe Measurably reduced NA Measurably reduced NA Measurably reduced

aAdapted with permission from White and colleagues.11 Height and weight should be measured rather than estimated to determine body mass index. Usual weight should be obtained to d ine the percentage and to determine the significanceof weight loss. Basic indicators of nutrition status such as body weight, weight change, and appetite may improve substantively with refeeding in the absence of inflammation. Refeeding r nutrition support may stabilize but not significantlyimprove nutrition parameters in the presence of inflammation. The National Center for Health Statistics defines chronic as a disease/condition lasting �3 months. Serum proteins such as s albumin or prealbumin are not included as definingcharacteristics of malnutrition because recent evidence analysis shows that serum levels of these proteins do not change in response to changes in nutrient intake.bA minimum of 2 of the 6 characteristics is recommended for diagnosis of either severe or nonsevere malnutrition.cThe International Classification of Diseases, 9th Revision (ICD-9) code for moderate malnutrition is 263.0.dThe International Classification of Diseases, 9th Revision (ICD-9) code for severe malnutrition is 262.0.eNA¼not applicable.

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1. Screen every admitted patient for malnutrition, regardless of physical appearance2. Make every effort to ensure that patients receive all ENa or PNb as prescribed to maximize benefit3. Develop procedures to provide ONSc in between meals or with medication administration to increase overall energy and

nutrient intake4. Create a focused meal time and supportive meal-time environment5. Take notice of patient meal consumption

� Be vigilant to the amount of food eaten� Sharing findings among the team (eg, during team huddles) facilitates development of a targeted nutritional plan

6. Stay alert to missed meals� Develop procedures to provide patients with meals at “off times” if patient was not available or under a restricted diet

at the time of meal delivery7. Avoid disconnecting EN or PN for patient repositioning, ambulation, travel, or procedures

8. Consider managing symptoms of gastrointestinal distress while continuing to administer POd diet or EN� Nutrients may be administered while the source of distress is being identified and treated

9. Remain mindful of “holds” on PO diets or EN relative to procedures� Take action to reduce the amount of time that a patient’s intake is restricted

10. Identify medications and disease conditions that interfere with nutrient absorption� Develop plans to minimize the impact

aEN¼enteral nutrition by tube feeding methods.bPN¼parenteral nutrition.cONS¼oral nutrition supplements.dPO¼per oral.

Figure 6. Practices to support implementation of nutrition intervention.

FROM THE ACADEMY

12

� Unless specific contraindicationsexist, prompt nutrition interven-tion for all malnourished patientsmust be a high priority. Patientswhose nutrition status is identi-fied as at risk through screeningmust be fed within 24 hours bynurses while awaiting a nutritionconsult, unless contraindicated.Examples of immediate nutritioninterventions can include modifi-cations to diet, assistance withordering and eating meals, initia-tion of calorie counts, and/oraddition of ONS. In many cases,establishing automated processesthat trigger upon a positivescreening will best accomplishrapid intervention (eg, promptingby the EHR to place a diet order).

� Standard practices to maximizenutrient consumption must beadopted. Figure 6 lists somepractical approaches to supportoptimal nutrition. In some cases,it is as simple as staying alertto missed or poorly consumedmeals and communicating suchevents to the dietitian so that

34 JOURNAL OF THE ACADEMY OF NUTRITIO

appropriate adjustments aremade.

� Actual consumption must bemonitored and intervention ad-justed as appropriate. Cliniciansmust adhere closely to the doc-umented nutrition care plan anddocument success or failure inthe daily medical record. Resultsof watchful monitoring informnecessary changes to the nutritioncare plan so that short- andlong-term goals can be achieved.For example, incomplete con-sumption of items on the mealtray must prompt the nurse tohave adiscussionwith the patient,and, depending on the severity ofthe intake deficit, underlyingnutritional status, and other clin-ical issues, to call a nutritionhuddle.

Principle 5: CommunicateNutrition Care PlansAll aspects of a patient’s nutrition careplan, including serial assessment andtreatment goals, must be carefully

N AND DIETETICS

documented in the EHR, regularlyupdated, and effectively communicatedto all health care providers (Figure 3).This will allow informed engagementby all providers and continuity oftreatment if the patient is transferredto another care setting. In addition,accurate and thorough documentationis essential for proper disease coding.58

For example, prior to 2012, only severemalnutrition could be coded as acomplicating condition with a primarydiagnosis. However, as of October 2012,mild or moderate malnutrition cannow be coded as a complicating con-dition.59 In practice, however, properdocumentation and communication donot always occur. Most often, nutritionstatus and progress are not adequatelydocumented in the medical record,making it difficult to determine whenand if patients are consuming food andsupplements. In addition, nutritionstandard operating procedures andEHR-triggered care are often lacking inthe hospital, and nutrition care plansand medical conditions are poorlycommunicated to post-acute facilitiesand primary care physicians.


FROM THE ACADEMY

The Alliance recommends thefollowing strategies to improve docu-mentation and communication of thepatient’s nutrition care plan, includingleveraging the various forms of EHRsystems now routine in most hospitals.

� Nutrition care must be formallydocumented via the central areaon the medical record or in theEHR with the following compo-nents: (1) nutrition screeningresults; (2) comprehensive nu-trition assessment data, includingthose obtained from a nutrition-focused physical assessment;(3) nutrition diagnosis; (4)nutrient�medication interactionsand diagnosis-related alterationsin requirements; (5) nutrition in-tervention(s) ordered and plan-ned goals; (6) dietary intakepattern, including percentage offood consumed with each mealand consumption of any orderedONS; and (7) monitoring andevaluation plan with specificindices and timeframe for re-assessment.

� Hospitals must create andmaintain standardized policies,procedures, and EHR-automatedtriggers relevant to nutrition,including nutrition-related andspecific diet order sets and pro-tocols in the hospital’s EHR (eg,algorithms for initiating ONS, ENand PN orders).

� Nutrition care plan documenta-tion must be included in thedischarge summary to ensurethat post-acute facilities/clini-cians fully understand all aspectsof the nutrition care plan,including goals, intervention,necessary resources, monitoring,and evaluation.

Principle 6: Develop aComprehensive DischargeNutrition Care and EducationPlanA comprehensive, systematic approachto managing nutrition from admissionthrough discharge and beyond isneeded to consistently improve qualityof care (Figure 3). The risk always ex-ists that nutrition goals achieved inthe inpatient setting may be lost ifthe continuity of care is not adequatelyaddressed at the time of discharge.7,60

In practice, patients and family


members/caregivers are rarely edu-cated adequately on nutrition care bythe hospital team.61 Moreover, patientadherence to nutrition orders duringand following a hospital stay is oftenpoor, and not all physicians are familiarwith the proper elements of a dis-charge nutrition care plan. Failing toaddress these challenges could resultin nutrition care shortcomings at oneof the most vulnerable stages in a pa-tient’s recovery.To ensure continuity of care, systems

must be put in place to provide pa-tients, family members, and caregiverswith nutrition education and a com-prehensive post-hospitalization nutri-tion care plan. Toward this end,the Alliance makes the followingrecommendations:

� Nutrition must be a componentof all clinicians’ conversationswith patients and their family/caregivers.

� The patient’s nutrition status,nutrition recommendations andother interventions (eg, ONS,vitamin and mineral supple-ments, and access to food), andthe post-discharge nutrition careplan must be explained by theclinical care team throughoutthe inpatient stay and docu-mented in the EHR.

� Follow-up nutrition assessmentand education, combined withspecific follow-up appointmentinformation must be provided tothe patient and/or caregiver attime of discharge.

� Hospitals must develop clear,standardized, written instruc-tions for nutrition care at home,including the rationale for anddetails on diet instruction andany recommended ONS, vitaminand/or mineral supplements thatcan be given to the patient andhis or her caregiver upon hospi-tal discharge.

� Nurses who manage patienttransitions at discharge mustprioritize nutrition within thecare plan. Post-hospitalizationphone calls must be adapted toinclude questions about dietaryintake, weight change, and ac-cess to food with concernsbrought to the dietitian’s atten-tion. Dietitians should be used tomanage post-hospital transitions

JOURNAL OF THE ACADEMY

for patients that have malnutri-tion as a primary or secondarydiagnosis. Ensuring nutritioncare is part of the transition tohome is a key step in reducinghospital readmissions.

CONCLUSIONSWith the changing health care envi-ronment, quality patient care and costcontainment are of utmost importance.Early and automated nutrition inter-vention coupled with clinician collab-oration is critical in remediating theissue of malnutrition in hospitals andhas a strong potential to improve pa-tient care and reduce hospital costs.Successful management of hospitalmalnutrition requires an interdisci-plinary team approach and leadershipthat fosters open communicationamong disciplines. To be successful, allmembers of the health care team mustunderstand the importance of nutritioncare in improving patient outcomesand the financial impact of failing toaddress this problem. Processes mustbe put into place to ensure thatappropriate nutrition intervention isprovided and patients’ nutrition statusis routinely monitored. Finally, addi-tional evidence quantifying the value ofnutrition care must be assessedthrough broad research efforts, rangingfrom outcomes research to prospectiverandomized controlled clinical trials.Funding for these initiatives is neededfrom institutional, federal, foundation,and industry sources. Without ques-tion, nutrition care must be made ahigh priority and systematized in UShospitals.

This article is a call to action from theAlliance, challenging hospital-basedclinicians to incorporate the proposedprinciples to evoke meaningful im-provement in nutrition care withintheir institutions. This call marks a stepchange in efforts to date to improvenutrition among hospitalized patients.For the first time, it unites professionalorganizations in a common pursuit toraise awareness about the problemof hospital malnutrition and makemeaningful progress toward earlynutrition intervention and improvedhospital treatment practices with theultimate goal of improving quality ofcare and reducing costs. To accomplishthis will require interdisciplinarycollaboration by dietitians, nurses, and

OF NUTRITION AND DIETETICS 1235

FROM THE ACADEMY

physicians throughout the continuumof care so that patients receive excel-lent nutrition care in the hospital andafter discharge.

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AUTHOR INFORMATIONK. A. Tappenden is Kraft Foods Human Nutrition Endowed Professor, Department of Food Science and Human Nutrition, University of Illinois atUrbana-Champaign, Urbana, IL (The Academy of Nutrition and Dietetics). B. Quatrara is a clinical nurse specialist, University of Virginia HealthSystem, Charlottesville, VA (Academy of Medical-Surgical Nurses). M. L. Parkhurst is an associate professor of medicine, University of KansasMedical Center, Kansas City, KS (Society of Hospital Medicine). A. M. Malone is a nutrition support dietitian, Mt Carmel West Hospital, Columbus,OH (American Society for Parenteral and Enteral Nutrition). G. Fanjiang is Vice President, Medical Affairs, Abbott Nutrition, Columbus, OH. T. R.Ziegler is a professor of medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA (Society of Hospital Medicine).

Address correspondence to: Kelly A. Tappenden, PhD, RD, FASPEN, Department of Food Science and Human Nutrition, University of Illinois atUrbana-Champaign, 443 Bevier Hall, 905 South Goodwin Avenue, Urbana, IL 61801. E-mail: [email protected]

STATEMENT OF POTENTIAL CONFLICT OF INTERESTK. A. Tappenden, B. Quatrara, M. L. Parkhurst, T.R. Ziegler, and A. M. Malone are members of the Steering Committee of the Alliance to AdvancePatient Nutrition who have been chosen by the professional organizations they represent and reimbursed for Alliance-related expenses. AbbottNutrition has provided funding to the member organizations of the Alliance and to Marithea Goberville, PhD, of Science Author, Inc, for writingassistance.

FUNDING/SUPPORTThere is no funding to disclose.



















































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