Malnutrition

Good Samaritan Hospital

Kerri Bivona
What is malnutrition?
! Inadequate intake of protein and/or energy over
prolonged periods of time resulting in loss of fat stores
and/or muscle wasting including starvation-related
malnutrition, chronic disease-related malnutrition, and
acute disease or injury-related malnutrition ~IDNT
! Can be associated with overnutrition & undernutrition
! Overweight & obese patients are at risk for malnutrition with
development of a severe acute illness or trauma
Impact on Hospitals
! One in three patients enter the hospital malnourished, yet
only ~3% of patients admitted are diagnosed as such
! Associated with increased morbidity, mortality and
healthcare costs
! Unfavorable outcomes include:
! Higher infection rates
! Poor wound healing
! Longer lengths of stay
! Higher readmission rates
! Nutrition intervention may help to
! Reduce hospital stay by an average of two days
! Reduce 30-day avoidable readmission rates by 28%
! Reduce patient hospitalization cost by 21.6% (~$4,700)/stay
Nutrition Screening
! Identifies risk of malnutrition
! Any trained health professional can perform, typically
completed by nursing, nutrition assistant
! Currently there is no single, universally accepted
approach
! Wide variations in malnutrition screening protocols
! Malnutrition Screening Tool (MST)
! General, surgical & oncology patients
! Malnutrition Universal Screening Tool (MUST)
! Under-nutrition & obesity in adults
! Screenings which include unintentional weight loss &
reduced appetite are the most useful
Nutrition Assessment Tools
! Ultimate goal is to determine if nutrient intake is adequate to
maintain or attain body composition & physiologic function that is
optimal for the health & long-term survival of the individual
! Mini Nutrition Assessment (MNA)
! Elderly patients, ! 65 years
! 18-item assessment considering anthropometrics, medical, lifestyle,
dietary and psychosocial factors
! Nutrition Risk Screening (NRS-2002)
! Possible initiation of nutrition support
! Unintentional weight loss, BMI, disease severity
! Subjective Global Assessment (SGA)
! Gold standard for validity
! Greater amount of time required to administer
! Based on features of medical history & physical examination
NUTRITION RISK
IDENTIFIED
Compromised intake
or loss of body mass
INFLAMMATION
PRESENT?
No / Yes
NO
ACUTE DISEASE
OR INJURY-
RELATED
YES
Mild to Moderate
Degree
CHRONIC
DISEASE-
RELATED
YES
Marked Inflammatory
Response
STARVATION-
RELATED/SOCIAL
OR
ENVIRONMENTAL
AND & ASPEN: Etiology-based approach to diagnose malnutrition
Etiology of Malnutrition
! Acute disease or injury-related
! Acute, severe inflammation
! Major infection, burn, trauma, closed head injury
! Chronic disease-related
! Chronic, mild to moderate inflammation
! Organ failure, pancreatic cancer, RA, sarcopenic obesity
! Starvation-related
! Without inflammation
! Anorexia nervosa, pure chronic starvation
Identifying Clinical Characteristics
! Allow RD to distinguish between severe & non-severe
malnutrition
! Insufficient energy intake
! Weight loss
! Loss of body fat
! Loss of muscle mass
! Fluid accumulation
! Reduced grip strength*
! Pt must present with 2 or more characteristics
Energy Intake
! Result of inadequate food & nutrient intake
! Recent intake compared to nutrition
requirements
! Primary criterion for Dx
ACUTE ILLNESS/INJURY CHRONIC ILLNESS
SOCIAL/
ENVIRONMENTAL
NON-SEVERE
(MODERATE)
SEVERE
NON-SEVERE
(MODERATE)
SEVERE
NON-SEVERE
(MODERATE)
SEVERE
< 75% EER x
> 7 days
" 50% EER x
! 5 days
< 75% EER x
! 1 month
< 75% EER x
! 1 month
< 75% EER x
! 3 month
" 50% EER x
! 1 month
Unintended Weight Loss
! Evaluate in the presence of under-hydration or over-
hydration
! Report wt change over time as a percentage of wt lost
from baseline
ACUTE ILLNESS/INJURY CHRONIC ILLNESS
SOCIAL/
ENVIRONMENTAL
NON-SEVERE
(MODERATE)
SEVERE
NON-SEVERE
(MODERATE)
SEVERE
NON-SEVERE
(MODERATE)
SEVERE
% Time
1-2 1 wk
5 1 mo
7.5 3 mo
% Time
>2 1 wk
>5 1 mo
>7.5 3 mo
% Time
5 1mo
7.5 3 mo
10 6 mo
20 1 yr
% Time
>5 1 mo
>7.5 3 mo
>10 6 mo
>20 1 yr
% Time
5 1 mo
7.5 3 mo
10 6 mo
20 1 yr
% Time
>5 1 mo
>7.5 3 mo
>10 6 mo
>20 1 yr
Nutrition-Focused Physical Examination
! Loss of subcutaneous fat
! Loss of muscle mass
! Fluid accumulation
Subcutaneous Fat Loss
! Three major areas to focus on
! Orbital region
! Upper arm region
! Thoracic and lumbar region
TIPS SEVERE MILD/MODERATE NOURISHED
!
Muscle Mass Loss
! Upper body
! Temple region
! Clavicle bone region
! Clavicle & acromion bone region
! Scapular bone region
! Dorsal hand
! Lower body
! Patellar region
! Anterior thigh region
! Posterior calf region
TIPS SEVERE MILD/MODERATE NOURISHED
Upper Body Muscle Mass Loss
Lower Body Muscle Mass Loss
TIPS SEVERE MILD/MODERATE NOURISHED
Edema
! Evaluate generalized or localized fluid accumulation
! Weight loss is often masked by generalized fluid retention
and weight gain may be observed
TIPS SEVERE MILD/MODERATE NOURISHED
Incorporating into Standard Clinical Practice
! History & Clinical Diagnosis
! Chief complaint & PMH
! Increased risk of malnutrition; presence/absence of inflammation
! Physical Exam/Clinical Signs
! Reveal characteristics of malnutrition
! Signs of specific macro- and/or micronutrient deficiencies
! Anthropometric Data
! Weight measured on admission & monitored frequently
! BMI at either extreme may increase risk of poor nutritional status
Incorporating into Standard Clinical Practice
! Laboratory Data
! Albumin, prealbumin affected by inflammation, fluid status
! Additional indicators of inflammation may include CRP, WBC
count
! Food/Nutrient Intake
! Evidence of inadequate intake may include 24-hour recall, calorie
counts
! Functional Assessment
! Hand-grip strength
Barriers to Improving Malnutrition
! NPO orders while patients await further assessment
! RDs recommendations unheeded due to the physicians
focus on other medical concerns
! Lack of nursing protocol orders focused on nutrition
! Physician uncertainty with specific MNT options, product
formulary
! Inadequate food consumption due to poor appetite,
disease processes, interruptions to mealtimes
Malnutrition Documentation
! Include the following components into (re)assessment
! Nutrition screening results
! Comprehensive nutrition assessment data
! Nutrition diagnosis
! Nutrient-medication interactions & diagnosis-related
alterations in requirements
! Nutrition intervention(s) ordered & planned goals
! Dietary intake pattern; include % food consumed, %
supplement consumed
! Monitoring & evaluation plan; include specific timeframe for
reassessment
Importance of Documentation
! Patient Protection & Affordable Care Act (PPACA)
! Addresses healthcare issues of cost and quality by promoting
expanded coverage & cost containment
! Creates financial incentives for well-coordinated, high-quality
care
! Healthcare providers are preferentially rewarded for value of
care rather than volume of care
! If not documented accurately & thoroughly, CMS will deny
claims of malnutrition
! CMS increases payments for the care of patients whose
physicians diagnosed their patients with severe
malnutrition
References
! Alliance to Advance Patient Nutrition. (2014). Approach to interdisciplinary nutrition care.
Malnutrition.com. Retrieved April 1, 2014, from http://static.abbottnutrition.com/cms-prod/
malnutrition.com/img/Patient%20Care%20Flow%20Chart_2014_v1.pdf
! Barker, L. A., Gout, B. S., & Crowe, T. C. (2011). Hospital malnutrition: prevalence,
identification and impact on patients and the healthcare system. International Journal of
Environmental Research and Public Health 8, pp. 514-527. doi: 10.3390/ijerph8020514
! Charney, P., & Marian, M. (2008). Nutrition screening and nutrition assessment. Journal of
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! Marcason, W. (2012). Malnutrition: where do we stand in acute care? Journal of the Academy of
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References
! Marino, M. J. & Patton, A. (2012). Cancer nutrition services: a practical guide for cancer
programs. Association of Community Cancer Centers, pp. 31-32.
! Rosen, B. S., Maddox, P. J., & Ray, N. (2013). A position paper on how cost and quality
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