LEADING ARTICLE

Treating malnutrition in hospitals: Dietitians in thedriving seat?ndi_1371 202..205

INTRODUCTION

Although the problem of malnutrition in hospitals is notnew,1,2 it is still a serious concern in Australian hospitals today.The population is ageing and patients are admitted withmultiple medical problems placing them at increased risk ofmalnutrition. Malnutrition prevalence rates in Australianhospitals have ranged from 6% to 53%.3–13 The wide variationis due to different study settings: the time between admissionand assessment, and the assessment tool used.

Malnutrition is a considerable problem that increases withage. Patients over 80 years have a higher odds risk of beingmalnourished compared with those between 61 and80 years.9 Chronically ill patients, many of whom are elderly,will be in and out of hospital regularly. Adequate flagging ofthese patients on admission is required, as is appropriatefollow up at discharge. Patients with a reduced energy intakethe month before hospitalisation have been shown to have areduced nutritional status compared with other patients.14

Further examination of malnutrition in medical patients hashighlighted a second group of patients, who while not mal-nourished on admission, are at high risk of becoming so.15

These patients need to be identified early and treated effec-tively to minimise a further decline in nutritional status.16

SYSTEMATIC ANDTIMELY NUTRITION SCREENING

Unfortunately, nutrition screening is not routine practice inAustralian hospitals, although it is used extensively in some.Nutrition screening is important for the timely identificationof patients who are ‘at risk’ and to prioritise those patientsrequiring referral to a dietitian for nutritional assessment andnutrition support.17,18 Routine nutritional screening, using avalidated tool, should be initiated for each patient soon afteradmission.19 A systematic approach to screening is requiredat each hospital, so that both responsibility and authority areheld by a particular position, and system-based approachescan be implemented. This would also assist in prioritisingthe important role of medical nutrition therapy.

Nutritional status can further decline throughout the hos-pital stay.9,16,20 Reasons for this decline may include poorappetite, medical condition, the variety of food options avail-able, difficulty with manipulating cutlery and accessingfood, lack of feeding assistance, food packaging, lack ofrecognition of malnutrition and referral for treatment.6,13,21

Weekly screening is therefore important for those not ini-tially found to be ‘at risk’.19

DIETITIANS DRIVING NUTRITIONASSESSMENT AND INTERVENTION

Nutrition assessment is a thorough process of determiningand evaluating the nutritional status of an individual viameasurable and validated methods.22 There are a number ofnutrition assessment tools in use today. Unfortunately, thereis no gold standard assessment tool and so it is important touse a tool that has been validated for use in the patient groupof interest.19 Subjective Global Assessment (SGA), PatientGenerated Subjective Global Assessment and the Mini Nutri-tion Assessment are three methods often used by Australiandietitians to determine the nutritional status of patients.3–13

Dietitians, as the nutrition experts, are well aware of theimportance of adequate recognition of malnutrition, nutri-tion during hospitalisation and the role of ‘food as medicine’.However, a recent study found less awareness in other hos-pital staff, reporting issues such as a lack of knowledge andtraining regarding nutritional status and assessment, com-munication issues, failure to recognise food and nutrition asa key part of care and no consistent team approach.23 Otherissues may include: the amount of available staff, timepressures and the priority of some other tasks, such asmedication rounds, which need to be signed off.21,24

Several recent Australian studies have indicated poor rec-ognition of malnutrition in hospitals. A prevalence rate of36% was reported when the SGA was applied to determinenutritional status of patients in two acute care Sydneyhospitals. The LOS of older, malnourished patients was sig-nificantly longer (17 vs. 11 days, P < 0.0005), mortality at12 months follow up significantly greater (P < 0.0005) andonly 36% of the malnourished patients had already beenreferred to a dietitian.4 A study at another Sydney hospitalreported a prevalence rate of 42.3% when using the SGA.The medical records indicated that 15.3% of the patients hadbeen referred for dietetic intervention, and only one mal-nourished patient had been documented as malnourished.This lack of documentation regarding malnutrition andresultant coding resulted in a shortfall of $125 311 for thehospital as the diagnostic related group (DRG) incorporatedmalnutrition for just one patient.6

A study of 777 patients at another Sydney hospitalreported that 51% of patients were malnourished. Theaverage LOS for the malnourished patients was significantlylonger at 30 days, versus 17 days for well-nourishedpatients. As with other studies, a large proportion of patientsidentified as being malnourished (43%) had not beenreferred to a dietitian.10 A recent Victorian study reported

Nutrition & Dietetics 2009; 66: 202–205 DOI: 10.1111/j.1747-0080.2009.01371.x

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30% of elderly patients (using the Mini Nutrition Assess-ment) to be malnourished on admission to hospital, with afurther 61% ‘at risk’. Patients were not often referred todietitians, reflecting the suboptimal recognition of malnutri-tion by doctors and nurses. Symptoms, such as a reducedappetite and recent weight loss, were not viewed as theimportant alarm bells that they would be to dietitians.13

A TEAM APPROACH TONUTRITIONAL CARE

Back in 1996, a report in the Medical Journal of Australia(MJA) stated that ‘Despite a high prevalence of malnutritionamong hospitalised patients, recognition, treatment anddocumentation of malnutrition is often poor’.25 The lack of ateam approach to nutritional care is an opportunity forfurther nutrition policy development and interventionimprovements.26,27 Further researchers have also highlightedthe need to document malnutrition in order to obtain theappropriate financial reimbursements for the hospital, whichassists in aiding nutrition support, as well as advocating forthe essential role of dietetics as part of medical treatment. Aclear model has been outlined for screening and assessingpatients in hospital, documenting their nutritional status andpromoting nutritional support. The model clearly involvesdoctors, nurses and dietitians.28

The British Association for Parenteral and Enteral Nutri-tion report discussed the need for across-discipline workingso that hospital food can be used as part of patients’ treat-ment. It is suggested that missed meals should be reported inthe same fashion as missed medications.29 Improving nutri-tion and food service provision means a change of attitudeand routines, not just for nurses and doctors, but also forhospital management. Implementation of food policy thatsecures nutritional care and support is essential.30 Patientsoften stay longer than the ‘average’ figures reported. A recentstudy from Brisbane reported ~50% of bed days as occupiedby those staying �14 days or more, and approximately 34%being occupied by those staying �28 days.31 This makes itall the more important that patients are screened andassessed appropriately, follow up screening is managed andthat food service provision is adequate. In this fiscal envi-ronment, it is increasingly apparent that further cost–benefitstudies are needed to provide evidence for the role of ‘food asmedicine’, especially as many such studies are now dated.32

EVIDENCE-BASED PRACTICEGUIDELINES

While it is important to demonstrate the prevalence rates ofmalnutrition and problems with recognition, it is also impor-tant that dietitians, as the nutrition experts, lead the strategiccharge forward with action, because malnutrition can bereversed, even in older patients.33 As leading dietitians in thisarea have noted, malnutrition is a significant issue and‘Action must be taken to increase the recognition, preventionand appropriate treatment of malnutrition especially inhigher-risk groups’.9

In June 2009, The Dietitians Association of Australiareleased endorsed Evidence Based Practice Guidelines forNutritional Management of Malnutrition in Adult Patientsacross the Continuum of Care.19 They are timely and providea valuable, evidence-based framework to standardise prac-tice, which are based on a systematic review of the literature,stakeholder consultation and critique of the strength of theevidence. Six key outcomes are highlighted that relate to:improved access to patient-centred protocols; correct diagno-sis of malnutrition; an improved patient experience; dieteticsadvocacy in addressing malnutrition, appropriate food ser-vices and environments for eating; and building capacity forthe healthcare workforce to appreciate the causes, indicatorsand treatments for malnutrition. The section on nutritiongoals and practice tips aligns well with the ‘food as medicine’position. It promotes advocacy for food service systems thatsupport adequacy, such as food fortification, protected meal-times, feeding assistance, nourishing snacks and staff educa-tion, to support these programs.

The guidelines highlight the need to avoid missed fundingopportunities when malnutrition coding is not completedconsistently. Changes were made to the criteria for diagnosisof malnutrition in July 2008. In acute, clinical settings,medical records coders are now able to assign an appropriatecode for malnutrition if adequately documented by a dieti-tian. It is critical that dietitians ensure that their documen-tation will meet the diagnostic criteria for malnutrition.Liaison with clinical coders is encouraged to standardisepractice and the concept of a malnutrition sticker is sug-gested. In a number of Australian states, correct coding formalnutrition may increase the case complexity, which mayalter the DRG and increase the valuable casemix funding thehospital receives.

The guidelines also emphasise the need for adequatetraining, discuss the use of validated screening and assess-ment tools, documentation of malnutrition, appropriatetreatment goals and options, as well as communication.Interestingly, the review highlighted a gap in the evidencebase relating to the influence of nutrition education onmalnutrition for healthcare professionals, a future researchopportunity.

In this issue of Nutrition & Dietetics, Gout et al. provides atimely insight into a range of key issues surrounding theidentification of malnutrition in an acute care Melbournehospital. The authors discuss a lack of training and theperceived complacency by other staff towards malnutritionand emphasise the need to take action on this importantissue, the need for collaboration and correct coding ofmalnutrition as a diagnosis.

A useful case study is provided that estimates a loss of$27 617 to the hospital as a result of inadequate coding formalnutrition. Those who were malnourished, but who werenot identified before the study, or were not documented andcoded as such, were later coded that way. This resulted in anumber of patients changing DRG, which when extrapolatedover the year suggests that $1850 540 in financial reim-bursements were missed out on. This summary furtheremphasises the need to get to know and practise the new

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evidence-based guidelines, and to communicate with others,including medical coders, hospital management, doctors,nurses and allied health teams.

CONCLUSION

For many reasons, malnutrition in hospitals is still not wellrecognised, with implications for patient outcomes andheath dollars. Early detection and appropriate treatment areessential. A standard method of medical record documenta-tion is also required to facilitate appropriate hospital re-imbursement that may continually improve models ofnutritional care, particularly with the future demands of anageing population. Dietitians are in an ideal position toembrace the new guidelines. Collaboration with, and train-ing of others will assist in the bid to implement systems tobetter identify ‘at risk’ and malnourished patients so thatessential medical treatment in the form of nutrition supportcan be prescribed.

Karen Walton, PhD, APDLecturer, Smart Foods Centre and School of Health Sciences

University of WollongongWollongong, New South Wales, Australia

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