Malnutrition in the Hospital Overview

Overview of Malnutrition in the Hospital

• Definition of Malnutrition: The World Health Organization defines malnutrition as deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients. It includes:
  • Overnutrition: Excessive intake of nutrients, prevalent as obesity in the U.S. (over 40% of adults).
  • Undernutrition: Deficiency in essential nutrients, which can occur at any weight but is more impactful in hospitalized patients.
  • Focus of this discussion will be on undernutrition, particularly as it relates to hospitalized patients.

Historical Context

• 1974 Landmark Paper: Dr. Charles E. Butterworth published "The Skeleton in the Hospital Closet".

  • He highlighted unrecognized malnutrition as prevalent in hospitals, linked to stress from illness and gaps in nutrition education in healthcare.

• Increased Focus on Malnutrition: Since Butterworth’s publication, significant steps have been taken to:

  • Identify at-risk patients.
  • Address and document malnutrition actively in clinical settings.

Development of Screening Tools

• 1980s onwards: Development of tools for identifying malnutrition risks:
  • Subjective Global Assessment (SGA): Classifies patients as well-nourished, moderately malnourished, or severely malnourished; known for its validity and reliability.
  • Joint Commission Mandate (1996): Requires nutrition screening within 24 hours of admission to identify patients needing specialized nutrition care.
  • Examples of screening tools developed:
  • Malnutrition Screening Tool (1999)
  • Nutrition Risk Screening (2002)
  • Malnutrition Universal Screening Tool (2003)
  • Short Nutrition Assessment Questionnaire (2005)

Modern Assessment and Diagnosis (2010s)

• 2012 Collaboration: Academy of Nutrition and Dietetics and American Society of Parenteral and Enteral Nutrition developed new criteria for malnutrition assessment.

• 2015 and 2018 Advancements: The European Society of Clinical Nutrition and Metabolism provided additional criteria. Further collaboration led to the Global Leadership Initiative on Malnutrition.

• Early Identification Importance: Identifying malnutrition on admission is vital due to its impact on patients' outcomes:

  • Patients with malnutrition have worse health outcomes:
  • Increased length of stay
  • Higher readmission rates
  • Greater likelihood of poor recovery and infection

Nutritional Interventions and Cost Implications

• Resource Considerations: Malnutrition increases healthcare costs due to:

  • Need for nutrition support and supplements
  • Treatment for infections and complications like pressure injuries

• Proper documentation of malnutrition helps hospitals increase reimbursements:

  • Malnutrition often added as a secondary diagnosis.

• Financial Implications: Malnutrition diagnosis contributes to hospital reimbursements from Medicare/Medicaid, essential for resource allocation.

Current Guidance and Recommendations from the Academy

• Push for Standardized Practice: Emphasis on uniformity in screening and assessment tools to enhance education and research.
• Academy's Position (2020): Recommendations include using:
  • Malnutrition Screening Tool: Consists of three questions about weight loss and appetite. If a total score of 2 or higher is achieved, the patient is at risk of malnutrition.

Assessment Process for Malnutrition

• Recommended Steps:
  1. Malnutrition Screening: Use the Malnutrition Screening Tool at first admission.
  2. Assessment Tool: If score is >= 2, proceed for full assessment by a registered dietitian.
  3. Identify Etiology: Determine malnutrition cause (acute illness, chronic disease, social/environmental factors).
  4. Compare to Clinical Parameters: Evaluate energy intake, weight loss, muscle loss, etc. Formal diagnosis if criteria met for at least two parameters, classified as moderate or severe.

Conclusion

• Importance of Accurate Diagnosis: Addressing malnutrition through timely screening, assessment, and intervention is crucial for patient care and hospital efficiency.

• Stay tuned for further explorations into the Academy and ASPEN malnutrition assessment tools in future discussions.