Lecture 2

The CMTF stands for?

-the canadian malnutrition task force
-45% pts admitted to the hospital are malnourished based on SGA scale
-48% leaving malnourished

What is hospital malnutrition?

-state of malnt. where deficiency in energy causes measurable adverse effects
-inadequate intake-->increased requirements-->impaired absorption-->altered nutrient utilizatoin

Etiology-based definitions of malnutrition

Starvation-related- no infl. and chronic
Chronic disease related, mild-mod infl. and chronic
Acute-disease related, severe infl. and acute

What is required in acute illness?

-higher energy and protein needs in acute illness, due to catabolism
-nutrient support only partially reverses this catabolism

What is the importance of lean body mass?

-mobility, balance, generation of energy
-protein pool for skin
-survival during stress
-conservation of protein in vital organs

What are the implications of malnutrition?

-inc. mortality, inc. treatment, inc. length of stay, dec. quality of life and inc. cost 24%

Infection and malnutrition?

-2-3 fold increased risk of developing: C-diff colitis, surgical site infection, post-operative pneumonia
-5 fold increase risk of developing: mediastinitis after CABG surgery, catheter associated UTI
-4 fold increase of developing pressure ulcer

What is the length of stay in malnourished patients?

-Malnourished -hospitalized on average 2 days longer than those screened and treated with early nutrition intervention
-Severely malnourished -5 days longer than moderate and 7 days longer than well-nourished

What are the consequences of malnourished patients with COPD?

-worsened respiratory muscle strength
-decreased ventilatory drive
-altere immune function

What are the consequences of malnourished patients with CVA?

-inc. rates of respiratory and urinary tract infections
-inc. rates of pressure ulcers (high cal and pro helps heal wounds)
-longer length of stay
-inc. mortality

What are the functional outcomes of malnutrition?

-advanced malnutrition is associated with a loss of muscle mass and function resulting in reduction in strength and performance (hand grip strength, physical performance tests)
-implications for ADLs

What is the SGA?

-requires trained health professionals, disease stress, muscle wasting, fat mass wasting and edema examined

What is the mean prevalence of malnutrition in hospitals worldwide?

-41.7%

What does the CMTF do?

-create knowledge
-aggregate data on current rate, health impact and causes of malnutrition
-develop best practices
-culture change in nutrition care

Nutrition care in canadian hospitals study?

-patients followed during hospitalization +30 days post-discharge

Nutrition care in canadian hospitals study- admissions and hospital stay?

-SGA, weight, MAC, CRP, albumin, 3 day food record, hand grip strength
-mortality, antibiotic use, nutrition care, diet orders, weight

What types of malnutrition were present at admission?

-malnutrition + inflammation = 76%

What are the nutritional predictors of prolonged length of stay?

-SGA B/C, NPO>3d, on nutrition support, food intake<50%

What are the nutritional predictors of 30-day readmission?

-SGA B/C, handgrip strength

What are the nutritional predictors of mortality?

-SGA B/C

What are the effects of changes in nutritional status outcomes?

-worsening of nutritional status independently associated with LOS
-no association in nutritional status and LOS

Pre-admission CMTF

-relying on grocery shopping by adult children, living alone, number of diagnoses, charlson co-morbidity index>2
-increasing age, eating alone, weight change, F/V intake, chewing difficulty
-polypharmacy,l ow functional status

At admission

-health care professionals: shortage, perception, knowledge
-lack of clear protocols
-nurses only recognized malnutrition in 25% of actual cases

Is albumin a marker of malnutrition?

-poor specificity to nutrition status
-low levels prevalent in chronic- and acute- disease related malnutrition
-marker for severity of underlying disease
-remains in normal range in starvation-disease related malnutrition due to compensatory decrease in albumin breakdown

During hospital stay?

-food quality, variety, satisfaction
-pain
-patient cognition
-delayed nutrition care

Why might tray delivery increase risk of malnutrition?

-eating alone, not social so don't want to eat

What is the most common reason for not eating?

-poor appetite -69%

Nutrition care perspectives?

-lack of medical directive for changing diet orders
-un-necessary referrals
-ht and wt of pt
-food as an essential "tool" is not adequately budgeted and is not treated as an important factor in the care of patients
-lack of adequate dietitian staffing to properly address all patients
-unclear role of inter-professional team
-nurses not consistently included in nutrition care

What bout unnecessary NPO?

-hepatic glycogen depleted after 18-24 hours of fasting
-during first 3 days: fat loss minimal, deplete liver glycogen, Na and water loss, 500g muscle loss
-clinical repercussions: dec. in blood pressure and sugar, dizziness and muscle week, dec. energy

What are some strategies to address malnutrition?

1. create institutional culture
2. redefine clinicians roles to include nutrition
3. recognize and diagnose patients at risk
4. implement interventions and continued monitoring
5. communicate nutrition care plans
6. develop discharge nutrition care and education plan

1. Create and institution culture?

-make nutrition a priority
-nutrition champion
-educate clinicians
-mandate discussion
-financial benefits

2. Redefine clinicians role?

-nurses and physicians play a role
-under-consumed meals
-calorie counts
-body wt measurements

What are medical directives?

-delegations give the RDs the authority to perform tasks to support effective delivery of client-centered services
-order tx, diagnostic procedures, controlled outside of dietetic scope
-should have competencies to do so

3. Recognize and diagnose malnutrition

-nutrition screen completed on all patients

What does SIM stand for?

-screen
-intervene
-monitor

What is the CNST?

-canadian nutrition screening tool
-2 questions
-validated
-unintentional wt loss and food intake

What is MST?

-malnutrition screening tools
-MST can be used regardless of age and medical history

What is included in the systematic nutritional assessment?

-SGA
-RD full assessment
-history of pt
-ABCD

Medical nutrition care to improve QOL?

-mandatory screening tool
-malnutrition on the differential
-nutritional assessment and a care plan developed by an RD
-multidisciplinary team to evaluate effectiveness

What are the protein recommendations?

>65 yrs: healthy= 1.0-1.2
chronic diseases= 1.2-1.5
marked malnutrition= 2.0
-25-30g/meal pro
-2.5-2.8g leucine/meal

What is leucine?

-stimulate muscle growth and prevent deterioration of muscle with age
-cheese, soy, beef, chicken, pork