[August 13, 2014]

New Report Quantifies the Scope of Hospital-Based Malnutrition in the U.S.; Charts Progress in Addressing This Public Health Threat

At a time when one in three Americans are malnourished upon admission to the hospital,^1,2,3 a new report from an interdisciplinary consortium representing 100,000 hospitalists, other physicians, nurses, registered dietitian nutritionists, and public health leaders finds growing recognition of this pervasive public health problem and a greater focus on instituting effective nutrition practices in hospitals.

The report, Alleviating Hospital-Based Malnutrition: A Baseline Progress Report, released in recognition of the one-year anniversary of the Alliance to Advance Patient Nutrition, provides an assessment of the state of hospital-based malnutrition in the U.S. It also charts recent progress in malnutrition screening and nutrition intervention in the nation's hospitals. The Alliance is comprised by four leading organizations: the Academy of Medical-Surgical Nurses (AMSN), the Academy of Nutrition and Dietetics (AND), the Society of Hospital Medicine (SHM), and Abbott Nutrition. The work of the Alliance is made possible through support from Abbott Nutrition.

Quantifying the scope of hospital-based malnutrition, the report finds malnutrition affects patients of all ages, and is prevalent among the medically underserved and older adults, especially those with chronic diseases, such as cancer and cardiovascular disease. Moreover, because the number of Americans aged 65 and over is estimated to top 90 million by 2060,⁴ the report projects a significant increase in malnutrition in the coming years, underscoring the need to ensure nutrition therapy is a critical component of quality care in the nation's hospitals.

"There is a malnutrition epidemic in our hospitals, and now is the time to address this widespread problem," said Kelly Tappenden, PhD, RDN, FASPEN, Alliance representative from the Academy of Nutrition and Dietetics, who also serves as a professor in the Department of Food Science and Human Nutrition at the University of Illinois at Urbana Champaign (UIUC). "Identifying and treating malnourished patients upon admission through discharge is a low-cost, effective strategy for hospitals to improve patient outcomes."

Quantifying the Impact of Malnutrition on Hospitalized Patients

Calling hospital malnutrition a "serious threat to the improved delivery of healthcare" the report cites a growing body of evidence that associates the effective treatment of malnutrition in the hospital with a 25 percent reduction in the incidence of pressure ulcers,⁵ 14 percent fewer overall complications,⁶ an average reduced length of hospital stay of approximately two days, ^7,8 and, perhaps, the most important given healthcare reform, a 28 percent drop in avoidable hospital readmissions.⁹

"There is a growing body of evidence supporting the positive impact nutrition has on improving patient outcomes," said Melissa Parkhurst, MD, FHM, and medical director of the Nutrition Support Service at the University of Kansas Hospital, and the Alliance representative for the Society of Hospital Medicine. "We are seeing that early intervention can make a significant difference. As physicians, we need to work with the entire clinician care team to ensure that nutrition is an integral part of our patients' treatment plans."

However, the report finds malnutrition remains largely untreated in U.S. hospitals due to numerous institutional factors, such as lack of awareness of the scope and costs of malnutrition and limited formal nutrition education among physicians and nurses. Also impeding progress is the lack of standard care pathways to ensure patients are screened within 24 hours of admission and that nutrition therapy is administered in a timely fashion.

Because untreated malnutrition can delay recovery and increase medical complications, the report calls for urgent action to address these barriers, cautioning the adverse outcomes associated with hospital-based malnutrition are substantial and place a significant burden on the healthcare system. Among the findings cited, malnourished surgical patients are 2-3 times more likely to develop a surgical-site infection or postoperative pneumonia¹⁰ and twice as likely to develop a pressure ulcer.¹¹ The result is longer lengths of hospital stay, higher readmission rates and treatment costs. One recent study cited found malnourished patients spent an average of 12.6 days in the hospital compared to 4.4 days for other patients, resulting in an almost three-fold increase in hospital costs ($26,944 versus $9,485).¹²

"Every nurse who cares for hospitalized adults is likely to encounter a malnourished patient, yet most of us are relatively unaware of the pervasiveness of this diagnosis," said Beth Quatrara, DNP, RN, ACNS-BC, CMRSN, the Alliance member of the Academy of Medical-Surgical Nurses, the only specialty nursing organization dedicated to the practice of medical-surgical nursing. "Appropriately addressing malnutrition takes a team and it is our duty as healthcare providers to make sure our patients get the nutrition they need throughout the entire continuum of care."

A Growing Movement for Systems Change

Recognizing the need for action, the Alliance to Advance Patient Nutrition was formed in May 2013 and published a pioneering consensus paper, Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition, on June 4, 2013. Creating the blueprint for systems change, the consensus paper introduced a novel Nutrition Care Model that emphasizes six principles:

With the consensus paper as the call to action, the Alliance published specific recommendations for hospital administrators and clinicians to institute effective nutrition practices in the nation's hospitals. The Alliance also launched a comprehensive website - www.malnutrition.com - with the resources and tools for clinicians to put these recommendations into practice, and began a multi-year initiative to elevate nutrition intervention as a critical component of patient care in U.S. hospitals through education, policy change, best practice sharing and new research.

A year later, qualitative results indicate the Alliance's recommendations are being implemented by interdisciplinary care teams across the country. As documented in the progress report, a number of hospitals are working to incorporate Alliance protocols into their processes. Success stories highlighted include Mercy Health, a large health system of 21 hospitals based in Cincinnati, OH, which implemented an interdisciplinary approach to identify and treat malnourished patients and provide standardized written instructions for nutrition care at discharge. In addition, the report singles out TouchPoint Support Services at St. John Providence Health System in metro Detroit, MI, which is now screening 100 percent of its patients on admission and providing ongoing assessment for every patient diagnosed as malnourished; and Pardee UNC Healthcare in Hendersonville, NC, which put in place a place a comprehensive nursing protocol to reduce the incidence of pressure ulcers, avoidable readmissions, infections, and falls by screening all patients for malnutrition, treating malnourished patients with medical nutrition therapy, and including oral nutrition supplementation in the patient's discharge orders.

Along with these positive developments in institutional settings, the report cites a national movement to provide hospital-based clinicians with hands-on, skills-based information through teaching modules, webinars, workshops, lectures and an interactive exhibit booth at professional meetings and conferences. Between May 2013 and January 2014, the Alliance reached 15,000 clinicians with science-based information on hospital malnutrition, including more than 3,600 hospitalists during the Society of Hospital Medicine's 2014 annual meeting.

With the release of the progress report, the Alliance will move into a new phase through a series of initiatives intended to move the organization from awareness building to driving systems change. This will entail building on existing efforts with new educational programs, research grants, public policy initiatives, and best practice sharing in recognition that instituting effective nutrition practices in the nation's hospitals requires changes in the knowledge, attitudes and skills of clinicians, hospital administrators and policymakers alike.

About the Alliance to Advance Patient Nutrition

The Alliance to Advance Patient Nutrition is an interdisciplinary partnership dedicated to raising awareness about malnutrition and championing for early nutrition screening, assessment and intervention in hospitals. Founded in May 2013, the Alliance to Advance Patient Nutrition is comprised of four leading healthcare organizations: the Academy of Medical-Surgical Nurses (AMSN), the Academy of Nutrition and Dietetics (AND), the Society of Hospital Medicine (SHM), and Abbott Nutrition. The work of the Alliance to Advance Patient Nutrition is made possible with support from Abbott Nutrition.

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¹² Corkins MR, Guenter R, Di-Maria-Ghalili RA, et al. Malnutrition diagnoses in hospitalized patients: United States, 2010. JPEN J Parenter Enteral Nutr. 2014;38:186-195.

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