One in three patients admitted to a hospital each year has a serious dietary lapse and yet isn't sufficiently fed as an inpatient, says a report funded by a maker of nutritional supplements.
There's a "skeleton in the hospital closet," says an alarming report from an interdisciplinary consortium whose focus is patient nutrition practices.
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The 16-page report is from the Alliance to Advance Patient Nutrition, which was formed last year. It says that one in three patients admitted to the hospital is malnourished, yet clinicians are failing to screen and treat a sizeable number of these patients.
Really? One in three, or 10 million of the 30 million patients a year admitted to a hospital has serious dietary lapses and yet isn't sufficiently fed as an inpatient? Are we to believe these patients are being ignored or left to starve?
Apparently, yes, according to this group.
It's an "epidemic in our hospitals," the authors say in a news release accompanying the release of the report. It's a serious "public health threat." The scope of malnourishment is "unrecognized," and "pervasive," and thus, "untreated," the authors say.
Normally a skeptic, I thought that was an awfully high number. So did Robert Wachter, MD, former president of the Society of Hospital Medicine, one of four organizations that last year formed the Alliance.
"In terms of clinically significant malnutrition, i.e., something that needs to be addressed by the care team in the hospital, one in three is way high," Wachter, chief of the Division of Hospital Medicine at UCSF, told me in an e-mail this week.
Abbott Nutrition, which makes dozens of inpatient nutrition supplement products, some of which cost hospitals hundreds of dollars per day per patient, is another member of the alliance, along with the Academy of Medical-Surgical Nurses and the Academy of Nutrition and Dietetics. Abbott supports the organization financially.
Are you raising your eyebrows yet?
Costly Nutritional Supplements to the Rescue
The gist of the report is that if these millions of malnourished patients received appropriate nutrition through higher calorie hospital food on their trays—or often through pharmaceutical products such as liquid oral or IV supplements, or nutrients fed through tubes to their stomachs—patient outcomes would dramatically improve.
Readmissions would drop. Length of stay would decrease. Hospital-acquired infections would be reduced or resolve more quickly. Pressure ulcers would not develop or would heal faster. And patients would be much less likely to fall because they wouldn't be so weak.
The organization makes quantified claims for each. "Oral nutrition supplements," it says, "decreased the probability of 30-day readmissions by 12% among Medicare patients" over 65 with AMI, and 10.1% among those with congestive heart failure, the report says, referring to papers that merely noted an association rather than a cause and effect.
There is no mention of how many of these patients are actively dying, for whom aggressive supplementation would not only be inappropriate, but harmful and possibly unethical.
"Expansive" Definition
Wachter added that the group appears to "be using a relatively expansive" definition of malnutrition to derive this astonishingly high statistic. Indeed, to meet the definition, a patient must have any two of the following six conditions, listed on this Abbott Nutrition fact sheet prepared by the Alliance:
- Insufficient food intake compared with nutrition requirements
- Weight loss over time
- Loss of muscle mass
- Loss of fat mass
- Fluid accumulation
- Measurably diminished grip strength.
Self-disclosure: I meet at least four of the above six, having recently gone on a two-month diet, and since duration or quantity is kept vague.
Melissa Parkhurst, MD, medical director of the Nutrition Support Service at the University of Kansas Hospital and the Alliance representative for the Society of Hospital Medicine, stands firmly behind the one-in-three statistic and points to several dated research papers that provide support.
Not only that, she says that 50% to 60% of hospitalized patients are "at risk" of malnutrition, meaning that they may have diseases or conditions which place them perilously close to being nutritionally deficient.
They may be on medications that make them nauseous or alter their taste buds so they don't want to eat, or they may have dementia and forget to eat, or they have been prohibited from eating because of tests or procedures they had to undergo. "People can go for long periods without being fed because of testing or because of their illness."
An Epidemic?
OK, that sounds reasonable. And maybe getting better fed will improve overall recovery and hinder complications. But is this really an epidemic?
Parkhurst says that nutrition experts have moved away from defining malnutrition on the basis of blood work lab results, like albumin or visceral protein levels, which can be misleading.
But the bigger problem is the lack of trained clinicians who understand what to look for.
The Joint Commission requires that hospitals screen at-risk patients within 24 hours of hospital admission and at frequent intervals during their stay, but "there's no mandate how that screening is done. They don't mandate that you need to use a validated screening tool, or who does it, or what you should do with the information. You can see right now that this sets us up for a problem."
Screening tools vary widely. They can be home grown, or a feature of an electronic medical record system, but Parkhurst's point is that they should be validated, and if they indicate malnourishment, they should prompt a rapid full nutritional assessment by a registered dietician.
There again is a problem. Hospitals often don't have registered dieticians, or at least enough of them for their census.
Parkhurst points to research from Johns Hopkins that found it took an average of five days for hospital personnel to conduct that assessment, way too long when one considers the average length of stay is about 4.8 days.
Adding to her case, the report says that when dieticians recommended that physicians write nutrition supplement orders, they were implemented only 42% of the time.
And there's the issue of how aggressively the hospital care team stresses to the patient's family and caregivers the need to maintain nutritional supplements.
I repeatedly asked Parkhurst and other Alliance representatives how many hospital emergency room or hospital inpatients who should be aren't getting supplements...
How Many Malnourished Patients Go Untreated?
The bottom line answer was that they don't know. Or won't say.
But the cost and use of resources to screen and treat for malnutrition is well worth it, Parkhurst says. Yes, some of the nutritional supplement products are expensive. Industry sources say they can cost several hundred dollars a day plus the price of administration. But when they prevent a readmission or an infection, or shorten a length of stay, they're well worth it, Parkhurst says.
I asked the American Hospital Association what it thought of the one-in-three statistic. I was told the AHA doesn't track that stat, and was referred back to the Academy of Nutrition and Dietetics and the Society of Hospital Medicine, the co-authors of the report.
I asked others in hospital medicine practice whether they too think the one-in-three estimate is exaggerated. The National Quality Forum has not endorsed a quality measure to assess appropriateness of malnutrition screening and treatment in hospitals but sees it as a "gap area," where more work is needed.
The Joint Commission did not respond to my question about whether the estimate that one in three hospitalized patients is malnourished is a realistic.
My skepticism may be unfounded and the problem of malnutrition very real and very huge, and very much overlooked. If so, how terrible, and really awful to only now be pointing to the problem, today, in 2014. I'm eager to hear what you think.