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Malnutrition, Long Neglected, Needs Doctors' Attention

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   June 06, 2013

Relatively common among hospital patients, malnutrition is often overlooked by physicians. But improving nutrition intervention procedures not only raises quality of care, it can also reduce both hospital costs and readmissions.

The obesity epidemic in this country is rightly of deep concern to physicians and hospitals, but it obscures another deep-seated, but often less talked about problem: malnutrition.

Many people mistakenly believe that only exceedingly thin people are at risk of malnourishment. In fact, inadequate nutrition is an "invisible" condition. Malnutrition is relatively common among patients in hospitals, but is often overlooked by clinical staff.

At least one in three patients may enter a hospital malnourished, which increases their risk for complications and potential costly readmissions, Melissa Parkhurst, MD, FHM, an associate professor in the department of internal medicine at the University of Kansas Medical Center, tells me.  

Too often, the malnutrition goes unrecognized and unscreened, she says.

That's also the consensus of The Alliance to Advance Patient Nutrition, a partnership including five healthcare organizations that says it is working diligently to improve patient outcomes by improving nutrition intervention by physicians and hospitals.  

Parkhurst is a physician member of the alliance, which includes leaders from the Academy of Medical-Surgical Nurses (AMSN), the Academy of Nutrition and Dietetics (AND), the American Society for Parental and Enteral Nutrition (ASPEN), the Society of Hospital Medicine (SHN) and Abbott Nutrition.  

"There's been a lot of attention on the obesity epidemic in the country, but [an assessment of] malnutrition cannot be done visually," says Parkhurst, who is also medical director of the hospitalist section and medical director of the University of Kansas Hospital Nutrition Support Service. "You can have a patient that looks to be visually overnourished, but who could actually be malnourished. You can get caught missing the diagnosis."  

And that's the problem, she explains. Too many potential malnutrition diagnoses are being missed. That's why the alliance has issued a "wake-up call" in a report for providers to collaborate and improve nutritional care, Parkhurst says.  

For physicians and hospitals, dealing with patients' nutrition is important for improved patient care—and for the financial bottom-line of the healthcare providers themselves, Parkhurst adds.  

The alliance reports that malnutrition is "associated with many adverse outcomes," such as increased infection rates, muscle wasting, impaired wound healing and immune suppression. Malnutrition also can result in increased risk of patient falls and overall longer hospital stays.

Many of the adverse outcomes influenced by malnutrition are potentially preventable, the alliance states. Nosocomial infections are one example. About 2 million nosocomial infections occur annually in the U.S., and patients who have them are more likely to spend time in the intensive care unit, "be readmitted, and die as a result," the alliance states.

Hospitalized patients, regardless of body mass, can suffer from "undernutrition" because of their propensity for reduced food intake which could be the result of poor appetite from illnesses, gastrointestinal symptoms, or reduced ability to chew or swallow.

In 2012, physician and healthcare groups defined malnutrition as the presence of two or more of the following characteristics: "insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, or decreased functional status."

"Processes must be put into place to ensure that appropriate nutrition intervention is provided and patients' nutrition status is routinely monitored," the alliance's report notes. "Without question, nutrition care must be made a high priority and systematized in United States' hospitals."

The alliance is highly critical of nutritional care in hospitals, noting that too often physicians aren't as involved in monitoring nutrition care as they should be. Clinicians and hospital administrators "often fail to prioritize nutrition and fail to recognize" potential impacts.  

In addition, hospital oversight of nutrition programs is lagging because of a lack of nutrition education and training, and a dearth of coordination among staff. At many institutions, dietitians are solely responsible for nutrition, but hospitals lack staff or simply don't bother to coordinate the work of dietitians with physicians and nurses.

While nurses oversee patients 24/7, they are often not included in nutrition care because physician "sign-off" is required to implement a nutrition care plan... But physicians may neglect dietitian recommendations because they are focusing on other medical concerns. Doctors also may be uncertain about "specific micronutrient therapy options" in their hospitals.  

And while there often is the talk of forming multidisciplinary teams to improve healthcare, communication is lacking with dietitians to improve nutrition, the report adds.

Parkhurst says that hospitals and physicians can work together to improve efforts to dramatically improve nutritional care. The alliance's Nutrition Care Model offers guidelines in which physicians and hospitalists should collaborate with dietitians and nurses to better treat malnourished patients and those at risk for malnutrition.  

Physicians need to play a greater role in this important development by redefining clinicians' roles to include nutrition care, and recognize and diagnose all malnourished patients and those at risk, Parkhurst says.

Although nurses are on the front line of care, there is especially a need for physician champions to improve nutritional care by collaboration across disciplines, Parkhurst says.

"I know dietitians who are very well trained and know what needs to be done, but they don't have a voice within their hospital. Just having a physician champion can make a significant stride in improvements, by championing nutrition in their hospital and partnering with a dietitian."

The Joint Commission has recommended nutrition screening within 24 hours of a patient's admission to an acute-care hospital, and frequent intervals throughout hospitalization.

Although it appears that hospitals are conducting the screening, proper follow-up is lacking, Parkhurst says.

In its report, the alliance states that while screening is important to identify at-risk patients, it is often seen as a "superficial observation wherein boxes are checked or unchecked."

"Some hospitals have been more proactive in doing some sort of screening than others," she says. "After that it has become extremely variable from hospital to hospital. In a complex hospital environment, there is so much going on, with patients moving through a system."

While nurses and doctors may be outlining nutritional needs for patients, such as calorie counting, "so many notes are left in 24 hours on (each) patient's chart, the recommendations may get buried in pages of notes, and no one would see them, and the proper intervention doesn't happen," Parkhurst says.

Physicians should not only be involved in nutritional care in hospitals, but also when patients leave, ostensibly to prevent readmissions, Parkhurst says. There should be continued monitoring of patients, what vitamins they may need, or calorie counts or what kind of diet," she says. "It's very important that hospital summaries of a nutrition plan go to the primary care doctor and it's taken care of when patients are discharged from hospitals."

Generally, Parkhurst asserts, improving patient nutrition is another simple healthcare tool that can have a huge impact: on care and economic resources.

As the alliance notes: "Nutrition intervention is a low-risk, cost-effective strategy to help improve quality of hospital care and it's time to join forces to put better nutrition care plans in place."


Joe Cantlupe is a senior editor with HealthLeaders Media Online.

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