Statement of Need:
Understanding and Implementing the
New Definition of Malnutrition
Malnutrition is a major contributor to increased morbidity and mortality,
decreased function and quality of life, increased frequency and length of
hospital stay, and higher health care costs.
New guidelines have changed the nutritional assessment methods.
Terese Scollard MBA RDN LD FAND
The St. Charles Supervisor of Clinical Documentation Improvement
requested education to update physicians on the new guidelines, citing
a lack of understanding of the new criteria.
Medical Grand Rounds
St. Charles Medical Center
Bend, Oregon
January 17, 2014
This activity addresses competencies “medical knowledge”, “patient
care” and “systems-based practice”.
This education is also relevant to documentation improvement
specialists, medical coders, dietitians and nurses
Terese M Scollard MBA RDN LD
The views expressed herein are those of the presenter and do not necessarily represent St Charles Medical Center
views. The material herein is accurate as of the date it was presented, and is for educational purposes only and
not intended as a substitute for medical advice.
2
Learning Objectives
1.
2.
3.
4.
5.
Increase understanding to apply the (2012) international consensus
characteristics for adult disease-related malnutrition and their
application in patient care.
Examine updates on the relationship of inflammation, serum albumin
and relationship to adult disease-related malnutrition.
Demonstrate how consistent documentation enables clinicians to better
establish prevalence of malnutrition and in turn target cost effective
interventions.
Examine in-office and hospital tools to reduce incidence and identify
patients at risk for adult disease-related malnutrition.
Discuss future care models to prevent the negative economic impact of
adult disease-related malnutrition.
Note: we will be discussing adult malnutrition in light of energy balance and
protein anabolism and catabolism rather than micronutrients.
3
4
The Skeleton in the Hospital Closet
Dr. Butterworth’s list: 1974
•
Failure to record height/weight
•
Frequent staff rotation
•
Diffusion of patient care responsibility
•
Prolonged use of glucose/saline iv
•
Withholding meals due to tests
•
Inadequate tube feeding, unsanitary and
uncertain composition
•
Ignorance of composition of vitamin
mixtures and other nutritional products
•
Failure to recognize increased nutrition
needs for injury/illness
“I suspect that one of the largest pockets of unrecognized malnutrition in America, and in Canada, too, exists, not
in rural slums or urban ghettos, but in the private rooms and wards of our big city hospitals.”
“Many undesirable practices concerning the nutritional care of hospitalized patients have their
roots in long-standing neglect of nutrition in medical education and in health care delivery systems.”
Charles E. Butterworth, MD Nutrition Today, 1974
http://www.uab.edu/nutrition/about/history?start=1 accessed 3/6/2012
CL Krumdieck, In memoriam, Dr. Charles Edwin Butterworth, Jr. Am J Clin Nutr November 1998 68; 981-2.
5
•
Surgical procedures without first optimizing
nutrition; failure to give nutrition after
surgery
•
Failure to appreciate role of nutrition in
infection/overuse antibiotics
•
Lack of communication and interaction
between MD and RD
•
Lack of RD concern about every patient in
hospital
•
Delay of nutrition until advanced state of
depletion
•
Limited availability of laboratory tests to
assess nutrition status
•
Failure to use those that are available
6
1
Malnutrition:
“The Cinderella of Modern Medicine”?
What contributors to
malnutrition have you observed?
•
Viewed as “Old technology”
•
Failure to define in a way that engages physicians to cause it to be taken
seriously
•
Vague definitions and degree of it which requires interventions
•
Imprecise and perceived to disagree on how to diagnose and describe
prevalence
Stratton, R., Green, C.,Elia, M. Disease-Related Malnutrition: an Evidence-Based Approach to Treatment. CABI Publishing 2003.
7
http://www.fightmalnutrition.eu/fileadmin/images/malnutrition/Consequences_of_malnutrition.JPG accessed 2/28/13
9
8
http://www.bapen.org.uk/about-malnutrition/introduction-to-malnutrition?showall=&start=1
10
Disease-related Malnutrition
“…decline in lean body mass with the potential
for functional impairment” at multiple levels—
ie, molecular, physiologic, and/or gross motor.”
Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syndromes: A conundrum vs continuum. JPEN J Parenter Enteral Nutr. 2009;33(6):710-716.
“Historic definitions for malnutrition syndromes have
promoted widespread confusion and misdiagnosis.
They also do not encompass a modern understanding
of the role of inflammatory response,”
Krause’s Food and the Nutrition Care Process 13th ed. L. Mahan, S. Escott Stump, J. Raymond. P 132
11
Gordon Jensen, MD, PhD, Past-President A.S.P.E.N., Professor and Head, Department of Nutritional Sciences, the Penn State University 2010
https://www.nutritioncare.org/Index.aspx?id=4792 accessed 5/16/2013
12
2
Modern Nutrition in Health and Disease, 6 th ed. Chapter 22 “Malnutrition in Hospital
Patients: Assessment and Treatment”
C.E. Butterworth, Jr. and Roland Weinsier
1978 Lea & Febiger, Philidelphia
Nutr Clin Pract October 2010
vol. 25 no. 5 548-554
13
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Words that Describe Malnutrition
Nutritional Anasarca
Athrepsia
Nutritional Atrophy
Severe Calorie Deficiency
Protein Deficiency
Multiple Deficiency Syndrome
Protein Deprivation
Arested Development due to Malnutrition
Wasting Disease
Nutritional Dwarfism
Famine Edema
Inanition Edema
Starvation Edema
Emaciation
Nutritional Hydrops
Hypoproteinosis
Inanition with edema
Inanition due to malnutrition
Malnutrition degree, 1st, 2nd, 3rd, mild, moderate, severe
Protein Calorie Malnutrition NEC
Protein Calorie Severe NEC
Protein Calorie due to specified underlying condition
Pediatrophia
Pluricarential syndrome of infancy
Plurideficiency syndrome of infancy
Polycarential syndrome of infancy
Prekwashiorkor
Growth retardation due to malnutrition
Physical retardation due to malnutrition
Kwashiorkor
Marasmus
Adult Kwashiorkor
Hypoalbuminemic Malnutrition
Hypoproteinemic malnutrition
15
Combined Malnutrition
14
A Vision for the Identification of Adult Malnutrition in All Settings
Wouldn’t it be amazing to have standardized
definitions/characteristics and to know the
prevalence of Adult Malnutrition in…
Our Health Delivery System
Our Country
Our
Our
World
World
©Terese Scollard, MBA, RD, LD
16
Etiology Based Malnutrition Definitions
Nutritional Risk Identified
Compromised intake or
loss of body mass.
+
=
International Consensus
Guideline Committee:
Inflammation present? No / Yes
Yes
No
Etiology – based approach that incorporates understanding of the inflammatory response.
https://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines/2010__Adult_St
17
arvation_and_Disease-Related_Malnutrition/
Jensen GL. JPEN 2009;33:710
Starvation Related
Malnutrition
(pure chronic starvation,
anorexia nervosa)
Mild to Moderate
Degree
Chronic Disease – Related
Malnutrition
(organ failure, pancreatic
cancer, rheumatoid arthritis,
sarcopenic
18 obesity)
Yes
Marked
Inflammatory
Response
Acute Disease or InjuryRelated Malnutrition
(major infection, burns,
trauma, closed head injury)
18
3
Nutrition Risk Screening
• Determines at-risk patients
•In all settings of care, or targeted patient
populations
•Multiple validated tools are available
•Compliance with Joint Commission and CMS
admission screening to hospital
20
19
Mini-Nutrition Assessment
Malnutrition Universal
Screening Tool
Short Nutritional
Assessment
Questionnaire
Etiology Based Malnutrition Definitions
Nutritional Risk Identified
Compromised intake or
loss of body mass.
Jensen GL. JPEN 2009;33:710
Inflammation present? No / Yes
Yes
Marked
Inflammatory
Response
Yes
No
Mild to Moderate
Degree
http://www.mna-elderly.com/forms/MNA_english.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2964075/
http://www.bapen.org.uk/screening-for-malnutrition/must/must-toolkit/the-must-itself
Starvation Related
Malnutrition
(pure chronic starvation,
anorexia nervosa)
http://fightmalnutrition.eu /
Screening Needs Action/Intervention to be of Value
Chronic Disease – Related
Malnutrition
(organ failure, pancreatic
cancer, rheumatoid arthritis,
sarcopenic
22 obesity)
Acute Disease or InjuryRelated Malnutrition
(major infection, burns,
trauma, closed head injury)
21
22
Starvation-Related Malnutrition in Adults
(Malnutrition of social or environmental circumstances)
Classic: The Minnesota Semi-starvation Experiment
Colorado State University tape or DVD.
http://www.epi.umn.edu/cvdepi/video.asp?id=4047
Nutrition, Anabolism, and the Wound Healing Process: An Overview Robert H. Demling, MD ePlasty. 2009;9:65-94.
http://www.medscape.com/viewarticle/711879_print accessed 4/26/2013
23
24
4
• distinguish the effects of semistarvation on the body's strength,
composition, physiological status,
and mood from the confounding
effects of such underlying diseases
as cancer, intestinal malabsorption,
renal insufficiency, emphysema, etc.
– illnesses that often give rise to
conditioned PCM.
September 29, 1950 SCIENCE
“Even in times of comparative peace and prosperity man
suffers from malnutrition, including semi-starvation or
actual starvation, as a result of disease, injury, individual
poverty, nutritional ignorance, inequitable food
distribution, and crop failure. These factors are aggravated
in many parts of the world by population pressures that
tend to exceed the food production.”
• The Minnesota group showed
clearly that semi-starvation can be
independently responsible for an
array of psychological problems
such as anxiety, depression, and
hypochondria.
• From their studies, it is possible to
demonstrate a clear relationship
between a decline in fat-free mass
and PCM-associated morbidity.
Science 29 September 1950: 371-376. [DOI:10.1126/science.112.2909.371]
News and Notes The Residues of Malnutrition and Starvation
Laboratory of Physiological Hygiene, University of Minnesota, Minneapolis
September 29, 1950
Nutrition & Metabolism 2005, 2:4 VanItallie
http://www.nutritionandmetabolism.com/content/2/1/4 accessed
9/19/13
25
26
Hypothetical relationship –
Starvation Related Malnutrition w & w/o Nutritional Support
Starvation-Related Malnutrition
(pure chronic starvation, anorexia nervosa)
• Leaner person has a higher rate of weight loss than the
obese person during fasting
• Leaner person has a greater loss of lean tissue
• The rate of weight loss influences function during food
shortage
• Loss of body weight means fat and muscle loss
• Loss of body weight means organ mass loss
SRM = Starvation Related Malnutrition; NS = Nutritional Support
PSRM = Partial Starvation Related Malnutrition
• Shifts in body fluids
Figure 1. Hypothetical relationship of Starvation-related Malnutrition (top graph) and Disease-related Malnutrition (bottom graph) assuming the inflammatory
27
condition is relatively constant with changes in lean body mass. Jensen G L et al. JPEN J Parenter Enteral Nutr 2010;34:156-159
28
Stratton, Elia Disease-Related Malnutrition: an Evidence-Based Approach to Treatment p 114
Etiology Based Malnutrition Definitions
Chronic Disease-Related Malnutrition in Adults
Nutritional Risk Identified
Compromised intake or
loss of body mass.
&
Jensen GL. JPEN 2009;33:710
Inflammation present? No / Yes
Acute Disease or Injury-Related Malnutrition
Yes
No
Starvation Related
Malnutrition
(pure chronic starvation,
anorexia nervosa)
29
Mild to Moderate
Degree
Chronic Disease – Related
Malnutrition
(organ failure, pancreatic
cancer, rheumatoid arthritis,
sarcopenic
30 obesity)
Yes
Marked
Inflammatory
Response
Acute Disease or InjuryRelated Malnutrition
(major infection, burns,
trauma, closed head injury)
30
5
Hypothetical Relationship: Acute or Chronic Disease or Injury-Related Malnutrition
Inflammation
Promotes:
Can Blunt:
• Metabolic dysregulation Favorable responses to
• Hyperglycemia
nutrition intervention
• Decreased visceral
proteins
• Muscle catabolism
• Edema
• Anorexia
• Malaise / deconditioning
•
Gordon Jensen MD PhD 2011 ADA Food & Nutrition Conference and
Expo
31
Figure 1. Hypothetical relationship of Starvation-related Malnutrition (top graph) and
Disease-related Malnutrition (bottom graph) assuming the inflammatory condition is
relatively constant with changes in lean body mass. Jensen G L et al. JPEN J Parenter
Enteral Nutr 2010;34:156-159
32
Complications relative to loss of lean body mass*
Nutrition, Anabolism, and the Wound Healing Process: An Overview Robert H. Demling, MD ePlasty. 2009;9:65-94.
http://www.medscape.com/viewarticle/711879_print accessed 4/26/2013
Nutrition, Anabolism, and the Wound Healing Process: An Overview Robert H. Demling, MD ePlasty. 2009;9:65-94.
http://www.medscape.com/viewarticle/711879_print accessed 4/26/2013
33
34
Chronic Disease-Related Malnutrition
Priority for Protein Intake vs % Loss of Lean Tissue
(organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity)
&
Acute Disease or Injury-Related Malnutrition
(major infection, burns, trauma, closed head injury)
• Immune changes, especially cellular immunity
• Muscle changes-reduction in mass and function
• GI changes
• Gut damaged by
• Decrease in mesenteric blood flow-operations, procedures
• Altered mucous
• Altered acid and bile secretion
• Altered gut motility
• Damaged villi
• Enzyme decrease
Nutrition, Anabolism, and the Wound Healing Process: An Overview Robert H. Demling, MD ePlasty. 2009;9:65-94.
http://www.medscape.com/viewarticle/711879_print accessed 4/26/2013
35
36
6
Why not serum albumin/visceral proteins?
Albumin/Pre-albumin
•Inflammatory disease / illness / injury elicit a cytokine-mediated
acute phase response
– Alters hormone secretion and target organ function
– Favors a catabolic state that results in metabolic alterations
• Over the short run the acute phase metabolic response with
resulting catabolism is likely an appropriate adaptive
response.
• If the underlying stressor is severe, protracted or repeated,
then adverse outcomes will result.
“Pre-albumin levels decreasing likely due to poor nutrition”
•Remains in textbooks and publications.
•Challenging to use other phrasing after so long a pattern
•A measure of morbidity and mortality
•Much used leverage for over 30 years to prompt treatment action
•See The Academy Evidence Analysis Library
Inflammation can blunt favorable responses to nutrition intervention.
...so what do we do now to get action?
Nutrition alone is ineffective in preventing muscle loss in inflammation.
Gordon
MD,
PhD Analysis Library: Albumin/Prealbumin
Academy of Nutrition
andJensen,
Dietetics
Evidence
The Time is NOW! Elevating the Role of Nutrition for Better Patient Outcomes 2012 Pre-FNCE Conference, Philadelphia PA. October 2012
37
14
38
Rationale for Developing Academy/A.S.P.E.N
Malnutrition Diagnoses/Markers
•
•
•
•
•
•
No standardization
Multiple Definitions
Multiple Diagnostic (ICD-9) Codes
Multiple characteristics used to diagnose
Limited evidence base
Emerging role of inflammation
– Influence on Assessment Parameters
– Influence on Response to Nutrition intervention
– Anti-inflammatory Interventions / Nutrition interventions outcomes
divergence
39
40
Task of Academy Malnutrition Work group
(Adults)
+
1. Convert these clinical conditions into
practical bedside clinical characteristics
• Starvation-Related Malnutrition and
• Disease/Injury Related Malnutrition
=
Malnutrition markers and
recommendations to National
Center of Vital and Health
Statistics (NCVHS) (determine
codes)
2. Propose additional detail to ICD-9 so they
would be meaningful codes
41
42
7
A Bridge to a Unified System
Consensus Statement:
Characteristics
Recommended for the
Identification and
Documentation of Adult
Malnutrition**
Adult Malnutrition
- Clinical presentation
- Will change
- Altered Metabolic Status
- Treatment specific to predisposing factors:
-Starvation
-Chronic disease
-Acute disease or injury
43
Tool to Bridge
- Academy & ASPEN Consensus
- Reasonable & reliable literature
and research-based criteria at
this time
- Will change with further clinical
understanding
- NOT the “be-all end-all’ criteria
for adult malnutrition
* 2012 ICD-9-CM Physician Volumes 1 and 2. American Medical Association
44
From Theory to Practice: Optimizing Recognition and Documentation of Adult Malnutrition. Academy of Nutrition and Dietetics 5/23/2012
** 2012 American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics 5/2012.
Characteristics to Diagnose
Adult Malnutrition**
ICD-9 Codes* – Two Levels of Severity:
262 - Other Severe Protein Calorie Malnutrition
263.0 – Malnutrition of a Moderate Degree
• Inadequate intake
Three Typical Etiologies:
Acute Illness/Injury – severe acute inflammation
Chronic Illness – mild to moderate chronic inflammation
Social/Environmental Circumstances – without inflammation

<50-75% estimated needs
– By History
– Observed
• Unintended weight loss 
Occurs at Any BMI
• Physical Exam 
Muscle Loss
Subcutaneous Fat Loss
Fluid Accumulation
Six Characteristics:
– Blackburn Criteria
– Localized
– Generalized
Weight Loss
Insufficient Energy Intake
Loss of Subcutaneous Fat
Loss of Muscle Mass
Localize or Generalized Fluid Accumulation
Diminished Functional Status - measured by hand grip strength
• Functional Status 
Hand Grip Strength
**Any 2 (or more) Characteristics Recommended for Diagnosis
J Acad Nutr Diet 2012;112(5):730-738
45
*2012 ICD-9-CM Physician Volumes 1 and 2. American Medical Association
Severe Malnutrition in Adults
ICD Classification *
- A system to
categorize and
communicate adult
malnutrition
- Allows for
benchmarking
prevalence
46
Malnutrition of Moderate Degree
J Acad Nutr Diet. 2012;112(5): 730-738
For Example:
ICD-9 Code 262*
Acute Illness/Injury
Chronic Illness
Social/Environmental
Weight Loss
>2%/1 week
>5%/1 month
>7.5%/3 months
>5%/1 month
>7.5%/3 months
>10%/6 months
> 20%/1 year
>5%/1 month
>7.5%/3 months
>10%/6 months
> 20%/1 year
Energy Intake
< 50% for > 5 days
< 75% for > 1 month
< 50% for > 1 month
Body Fat
Moderate Depletion
Severe Depletion
Severe Depletion
Muscle Mass
Moderate Depletion
Severe Depletion
Severe Depletion
Fluid Accumulation
Moderate  Severe
Severe
Severe
Hand Grip Strength
Not Recommended in ICU
Reduced for Age/Gender
Reduced for Age/Gender
J Acad Nutr Diet. 2012;112(5): 730-738
For Example:
ICD-9 Code 263.0 *
Acute Illness/Injury
Chronic Illness
Social/Environmental
Weight Loss
1-2%/1 week
5%/1 month
7.5%/3 months
5%/1 month
7.5%/3 months
10%/6 months
20%/1 year
5%/1 month
7.5%/3 months
10%/6 months
20%/1 year
Energy Intake
< 75% for > 7 days
< 75% for > 1 month
< 75% for > 3 months
Body Fat
Mild Depletion
Mild Depletion
Mild Depletion
Muscle Mass
Mild Depletion
Mild Depletion
Mild Depletion
Fluid Accumulation
Mild
Mild
Mild
Hand Grip Strength
Not Applicable
Not Applicable
Not Applicable
* 2012 ICD-9-CM Physician Volumes 1 and 2. American Medical Association
From Theory to Practice: Optimizing Recognition and Documentation of Adult Malnutrition. Academy of Nutrition and Dietetics 5/23/2012
* 2012 ICD-9-CM Physician Volumes 1 and 2. American Medical Association
47
From Theory to Practice: Optimizing Recognition and Documentation of Adult Malnutrition. Academy of Nutrition and Dietetics 5/23/2012
48
8
Muscle Mass and Function in Malnutrition
Obese and Malnourished? Yes!
“I think a lot of them
are compassionate and
don’t realize this is
going on,” Dr. Katz said.
“The antipathy for
obesity is really rooted
in our culture. We
should expect better
from doctors and train
them better.”
http://well.blogs.nytimes.com/2013/04/29/overweight-patients-face-bias/?nl=health&emc=edit_hh_20130430&goback=.gde_1806863_member_236999858
Accessed 5/7/2013
Physicians build less rapport with obese patients K. Gudzune1,†,*,et al Obesity: A Research Journal : 10.1002/oby.20384 Copyright © 2013 The Obesity Society
49
• Reduction in Muscle Mass
• Reduction in Muscle Function
• Muscle function is sensitive to reduction in
nutritional intake even before any change in muscle
mass occurs
• Heart
• Respiratory muscle
• Hand grip strength
Stratton, Elia Disease-Related Malnutrition: an Evidence-Based Approach to Treatment p 116
The Health Risk of Obesity—Better Metrics Imperative Rexford S. Ahima and Mitchell A. Lazar
50
Science 23 August 2013: 856-858. The impact of a high BMI on mortality is in question, calling for a rethinking of how metabolic health is assessed. Accessed
Sept 23, 2013
Acute Care Disease-Related Malnutrition Work Flow
Upon admission, patients are screened by Nursing and MD Consults
to Nutrition

Documentation and Work Flow
Registered Dietitian (RD) assesses patients with nutrition risk factors

RD reviews malnutrition findings with MD/NP/PA; team collaborates
on plan of care with documentation

Upon discharge, Coders review medical records and assign ICD-9
codes which generate data to monitor population and provide
potential reimbursement to hospital for acuity and MD for patient
severity
From Theory to Practice: Optimizing Recognition and Documentation of Adult Malnutrition. Academy of Nutrition and Dietetics 5/23/2012
When Documenting Malnutrition: Remember
Quality Documentation
• Describe (succinctly, and descriptively) objective evidence and details supporting
malnutrition criteria and characteristics
• Documentation of additional data builds supporting evidence
• Subjective information is important too: Describe pertinent evidence and
associations to under nutrition
• Quantify data
• Time frames of deficits, actual weight change and percentages over time
• Intake percentages and estimates of intake compared to short term and long
term targets (especially calories and protein)
• Include nutrition physical assessment descriptions!
No single piece of information means a patient is malnourished:
• Use critical thinking
• Consider the whole patient situation
• Nutrition history
• Ongoing ability to access and consume food
• Weight history
• Food and liquids intake history
• Metabolism
Assessment of malnutrition occurs at this point in time, regardless of the
prognosis
Documentation does not replace care, advocacy, communication concerns,
questions and observations with other team members
• Avoid vernacular! Talk about nutrients, food, metabolism
• Describe ongoing nutritional needs and nutrient targets to stabilize or improve
nutritional status in the future.
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53
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9
Dr. Butterworth’s list 2013?
•
•
•
•
•
•
•
•
Failure to weigh/measure and
record height/weight
Frequent staff rotation
Diffusion of patient care
responsibility
Prolonged use of glucose/saline iv
Withholding meals due to tests
Inadequate tube feeding,
unsanitary and uncertain
composition
Ignorance of composition of
vitamin mixtures and other
nutritional products
Failure to recognize increased
nutrition needs for injury/illness
•
•
•
•
•
•
•
Surgical procedures without first
optimizing nutrition; failure to
give nutrition after surgery
Failure to appreciate role of
nutrition in infection/overuse
antibiotics
Lack of communication and
interaction between MD and RD
Lack of RD concern about every
patient in hospital
Delay of nutrition until advanced
state of depletion
Limited availability of laboratory
tests to assess nutrition status
Failure to use those that are
available
Challenges & Opportunities:
55
http://www.medicare.gov/hospitalcompare/?AspxAutoDetectCookieSupport=1
57
http://iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to58
Continuously-Learning-Health-Care-in-America.aspx
8
Nutrition Alert Portland
Transform the delivery of clinical care
Terese Scollard MBA RD LD, Manager Clinical Nutrition Services, Nutrition Services
OR Region Votes
121
2012 Investment
$4,850
Estimated ROI
$124,150
G8418 : CALCULATED BMI BELOW THE LOWER PARAMETER AND A
FOLLOW-UP PLAN WAS DOCUMENTED IN THE MEDICAL RECORD
Project summary: 20 to 25% of Providence acute care hospital admissions include patients with adult disease related malnutrition
(DRM). This proposal is to investigate and implement simple electronic triggers, work flow and basic resources for lower level
interventions so that physicians and nursing staff in PMG will be alerted to weight loss and other malnutrition risk factors early in order to
intervene and prevent nutritional compromise and hospital re-admission.
Affordable Services
High
Improve Population
Health
Simple and inexpensive first line
interventions cost much less than tube
feedings, hospital infections, non-healing
wounds, muscle function loss and
weakness. Ultimately preventing
infections, readmissions and morbidity.​
High
Recently released international standards
define characteristics of adult disease
related malnutrition. We will incorporate
many of these useful tools, including
connection with electronic health records
and early /ongoing patient tracking.​
Best Care Experience
High
Reduce and minimize trauma of
nutritional rescue attempts and reduce
or minimize hospitalization or rehospitalization​
http://www.hipaaspace.com/Medical_Billing/Coding/Healthcare.Common.Procedure.Coding.System/G8418
1Q 2013 Managing Execution & Results:
 Project Team: James Carlisle MD, Scott Gudger, Eric Bergstrom, Regis Peregrin, Kathy Phillips, Carolyn Bingham, Mike Phillips MD, Teresa Ballard
Jim Bradley
 Building Engagement: contacted above persons and then referred to persons who have access to data that might be helpful and who can obtain
data. Discussed nature of project and timing of availability of data, especially in light of complications with Epic data transfers into our data bases
for analysis. Included topic as part of regional medical nutrition committee work 12/12.
 Triple Aim Goal Setting: no changes; two phases are emerging; 1st is to obtain data , and a listing of data needs has been made; 2nd phase will
be to determine steps for action, based on the data results. Data examples: malnourished discharged to PMG, volume, visits, utilization of health
care services post dc, and utilization by Medicare and other populations, by zip code; weight tracking; in PMG, those at low BMI’s for age;
 Lessons Learned: Epic implementation slowed but did not delay setting up and organizing needs and determining questions for project.
 Upcoming Key Milestones: Locating a resource to obtain the data within the Analytics group.
59
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Community Education
and Video
Consumer- Education for Self Management
•
•
•
•
•
A culture of partnership with patients
Self management tools
Resources
Health Literacy attention
How to interact with health care providers
http://www.ahrq.gov/patients-consumers/index.html
http://www.nestle-nutrition.com/Clinical_Resources/tools.aspx
61
http://www.phsoregon.org/video/?view=d203426faaed7x480x293
local TV spot
55
62
Oregon AND: Public Policy Committee DRAFT Proposal to Health Share Oregon CCO
The first Strong for Surgery initiative addresses preoperative nutrition intervention, a priority topic identified
by SCOAP clinicians and quality leaders. Nutritional status is
a major determinant of outcome for the high-risk surgical
patient and is one of the most important pre-operative
predictors of outcome in any type of surgery.
Malnutrition Alert! Oregon
Purpose: To create accountability and value, and minimize the negative health and
economic impact of disease-related malnutrition for the adult population in Oregon.
1. The Consensus Statement of the Academy of Nutrition and Dietetics and the American
Society of Parenteral & Enteral Nutrition: Characteristics Recommended for the Identification
and Documentation of Adult Malnutrition (Undernutrition)1 is used as the characteristics
data set for the diagnosis of disease related malnutrition in adults.
2. Report prevalence of Adult Disease-Related Malnutrition for systems, economic and
outcomes analyses.
3. Create consumer value through education about self-management and by partnerships
with health care providers.
http://www.nestlenutrition-institute.org/resources/library/Free/nutrition-highlights/Nutrition-and-Enhanced-Recovery-inSurgery/Pages/Nutrition-and-Enhanced-Recovery-in-Surgery.aspx
63
64
Decreasing Malnutrition
Prevalence: the Dutch
Experience
http://www.fightmalnutrition.eu/fileadmin/images/fight_malnutrition/DUTCH_approach_MNI_Grant_Winner
_2010__hand-out_.pdf
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Opportunities to reduce morbidity
and save health care dollars
1.
Document malnutrition using Academy of Nutrition & Dietetics and American
Society of Enteral and Parenteral Nutrition Consensus Characteristics.
2.
Consider use of validated screening tools and referrals in all settings of care,
early and for high risk populations. Hospitals are only one location.
3.
From all care settings and home, refer at-risk and malnourished persons for
nutrition assessment, intervention, counseling and education by a registered
dietitian.
4.
Coordinate processes to capture and report adult malnutrition in populations.
5.
Educate the public and colleagues for awareness, and preventive action.
6.
Engage with Health Care Reform efforts to help your patients
Thank you!
Questions?
[email protected]
503.216.2496
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ICD-9
Additional Notes and
Resources
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ICD-10
ICD-10 NAMING
10/1/2014
Unspecified severe protein-calorie malnutrition
262
E43
263.0
E44.0
Moderate protein-calorie malnutrition
263.1
E44.1
Mild protein-calorie malnutrition
263.8
No Code
263.9
E46
278.01
E66.01
Morbid (severe) obesity due to excess calories
783.22
R63.6
Underweight
783.21
R63.4
Abnormal weight loss
799.4
R64
V85.4
Z68.4
260
E40
261
Applicable ToStarvation edema
converts approximately to:
2013 ICD-10-CM E46 Unspecified proteincalorie malnutrition
Unspecified protein-calorie malnutrition
Applicable To Malnutrition NOS
Protein-calorie imbalance NOS
Use Additional code to identify body mass index (BMI), if
known (Z68.-) Type 1 Excludes abnormal weight loss
(R63.4) anorexia nervosa (F50.0-) malnutrition (E40-E46)
Cachexia
Applicable To Wasting syndrome Code First underlying
condition, if known Type 1 Excludes abnormal weight loss
(R63.4) nutritional marasmus (E41)
Body mass index (BMI) 40 or greater, adult
Z68.41 goes to Z68.45 BY BMI 40.0 TO 70
Kwashiorkor
Peds
E41
Marasmus
Peds
E42
Marasmic Kwashiorkor
Peds
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http://www.icd10data.com accessed 5/16/13
Resources and Links to Efforts in Europe & North America
Malnutrition Resource sites: UK, EU, US, CA
The Minnesota Semi-Starvation Experiment
Euopean Society of Enteral & Parenteral Nutrition Video: http://www.espen.org/another-weight-problem-video
http://www.eufic.org/article/en/artid/Time-to-recognise-malnutrition-Europe/ European Food Information Council
http://www.youtube.com/watch?feature=youtu.be&hl=en-GB&v=Cqcc9bwi5tg
Video or DVD
http://malnutrition.andjrnl.org/
Malnutrition Resource site USA
Mark Cole
970-491-5920
[email protected]
Colorado State University
Academic Computing Network Services
Mail Stop 1018
Fort Collins, CO 80523
http://www.fightmalnutrition.eu/
The Netherlands and EU-excellent and well thought out
http://www.nice.org.uk/nicemedia/pdf/cg032fullguideline.pdf
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
UK Guidelines
http://www.nice.org.uk/CG032
UK: Nutrition Support in Adults: Oral nutrition support, enteral tube feeding and parenteral nutrition – Costing Report and
Excel Template
http://www.bapen.org.uk/ British professional resource site
http://www.wales.nhs.uk/sites3/Documents/814/GwentGuidelinesTreatmentUndernutrition%5BSept10%5D.pdf
Wales
http://nutritioncareincanada.ca/
Canada
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Additional Reading
http://malnutrition.andjrnl.org/
www.fightmalnutrition.eu
http://malnutrition.com/
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http://www.bapen.org.uk/about-malnutrition/introduction-tomalnutrition#
http://www.nestlenutritioninstitute.org/search/pages/advancedsearch.aspx?q=malnutr
ition
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Academy Evidence Analysis Library:
Validated Nutrition Risk Screening Tools
MNA- Mini Nutrition Assessment for the Elderly
http://www.mna-elderly.com/forms/MNA_english.pdf
an RN or trained aid would perform this >65 years old
http://mna-elderly.com/forms/Self_MNA.pdf
a patient could fill out most of this one >65 years old
http://mna-elderly.com/i-phone.html
NRS 2002:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2964075/ for “adults”
Malnutrition Universal Screening Tool (MUST)
http://www.bapen.org.uk/screening-for-malnutrition/must/must-toolkit/the-must-itself
http://www.bapen.org.uk/screening-for-malnutrition/must/must-app
http://www.bapen.org.uk/screening-for-malnutrition/must-calculator
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Patient Care Flow Chart
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