Alleviating Hospital-based
Malnutrition: A Baseline
Progress Report
Improving patient outcomes, together
Introduction
Since the Institute of Medicine’s (IOM) landmark reports, To Err Is Human (2000) and
Crossing the Quality Chasm (2001), revealed widespread incidence of medical errors in
U.S. hospitals, an intensified effort has been underway to improve the quality and safety
of patient care. The result has been notable improvements, including the quality of care
provided to heart attack, pneumonia, surgical care, venous thromboembolism (VTE) and
stroke patients, according to composite accountability measures.1
Despite this progress, however, many challenges have yet to be solved. One of these
persistent challenges is hospital-based malnutrition—most simply defined as any
nutritional imbalance.2 According to a 2012 consensus statement by the Academy of
Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition, this
condition is associated with the presence of two or more of the following characteristics:
insufficient energy intake, weight loss, loss of muscle mass, loss of fat mass, localized
or generalized fluid accumulation, or decreased functional status.3 Occurring in both
overweight and underweight individuals2 and affecting patients of all ages—from
infants in the neonatal intensive care unit (ICU) to geriatric patients4—malnutrition
in hospitalized patients is not a new problem. In fact, since 1974 when Dr. Charles E.
Butterworth Jr’s landmark study brought recognition of the problem to the eyes of
hospital clinicians,5 patient malnutrition has been referred to as the “skeleton in the
hospital closet”,6,7 because it remains under-recognized and often untreated, despite
being associated with increased complication rates, length of hospital stay, readmission
rates, and mortality.8-14
Our alliance represents over 100,000 dietitians,
nurses, physicians, and other clinicians from
all 50 states, on a mission to transform
patient outcomes through nutrition.
2 | Alliance Year One Progress Report
The Impetus for Change
Forty years after Butterworth’s article called
for practices aimed at the proper diagnosis and
treatment of malnourished patients, a number of
factors are precipitating a real focus on addressing
this public health challenge. One of these factors
is the greying of America, described as one of the
most dramatic demographic shifts in the nation’s
history. According to the U.S. Census Bureau, the
number of Americans aged 65 and over will top
90 million by 2060,15 leading public health experts
to project a significant increase in age-related
chronic conditions and the demand for healthcare
and aging-related services. Since chronic disease is
often correlated with an increase in malnutrition,
this demographic shift underscores the need
for preventing and/or treating malnutrition and
reducing its associated complications.
At the same time, hospitals are responding to
major changes in Medicare and Medicaid programs
through implementation of the Patient Protection
and Affordable Care Act (ACA) in which malnutrition
plays a role. Two of these issues are hospital
infections, estimated to cost up to $33 billion
each year,16 and 30-day readmissions, which cost
the Medicare program approximately $26 billion
a year.17 To address these and other potentially
preventable costs, the Centers for Medicare and
Medicaid Services (CMS) has implemented new
Medicare rules that:
•
Withhold payment to hospitals for 11
recognized preventable conditions,18
including pressure ulcers,19 surgical site
infections,20 and falls21—all less likely
to occur when patients are adequately
nourished.8,22
•
Penalize hospitals with high rates of
avoidable readmissions for their heart
failure, heart attack, and pneumonia
patients. In 2013, 2,225 hospitals were
penalized $280 million through lower
Medicare payments due to their excess
readmissions.23
CMS has also set the stage for more hospitalized
malnourished patients to receive a formal diagnosis
of malnutrition by revising the severity level of
the diagnostics codes for moderate and mild
malnutrition. Collectively, these actions pave the way
for making malnutrition a public health priority and
working through stakeholders to ensure nutrition
therapy is a critical component of patient care.
Hospitals are responding to
broad changes in Medicare
and Medicaid programs
through implementation of
the Patient Protection and
Affordable Care Act (ACA)
Alliance Year One Progress Report | 3
Putting Hospital Malnutrition
on the Radar
The Burden of Hospital Malnutrition
In terms of its prevalence and cost, hospital
malnutrition is a serious threat to the improved
delivery of healthcare. According to research
findings:
•
At least 1/3 of patients are malnourished
upon admission to the hospital.24-26
•
If left untreated, approximately 2/3 of these
malnourished patients will experience a
further decline in their nutrition status
during their inpatient stay.27
•
•
Approximately 38 percent of well-nourished
patients will also experience a nutritional
decline during their hospital stay.27 The
reasons include dietary restrictions due to
diagnostic testing, prescribed treatments,
and symptoms of patients’ medical
conditions, including poor appetite and
gastrointestinal problems.
On average, both patients who are
malnourished upon admission and those
who become malnourished during their
hospital stay have higher healthcare costs
during their hospitalizations.27-29
Compounding these problems, studies find the risk
of malnutrition is particularly high among older
adults,30 especially those who suffer from chronic
diseases and comorbidities, such as cancer and
cardiovascular disease.31 Other factors associated
with malnutrition include depression, bereavement
and living alone, all of which are prevalent among
older adults.32
4 | Alliance Year One Progress Report
The Consequences and Cost of Patient
Malnutrition
The adverse outcomes associated with hospitalbased malnutrition are substantial and place a
significant burden on the healthcare system.
A growing body of research correlates malnutrition
with a range of complications, including surgical
site infections (SSIs), pressure ulcers, falls and
deteriorating functional status across the continuum
of care. As reported in the literature:
•
Malnourished surgical patients are 2-3
times more likely to develop a surgical-site
infection or postoperative pneumonia.20
•
Malnourished patients are twice as likely
to develop a pressure ulcer.19
•
45 percent of patients who fall in the
hospital are malnourished.21
Since malnutrition can delay recovery and increase
medical complications, studies further document
the costs to the health system in terms of longer
lengths of hospital stay, higher readmission rates,
higher treatment costs, and increased mortality.22
For example, a recent study examining data from
the 2010 Healthcare Cost and Utilization Project
(HCUP), the most current nationally-representative
data describing U.S. hospital discharges, found
malnourished patients spent an average of 12.6
days in the hospital compared to 4.4 days for other
patients, resulting in an almost three-fold increase
in hospital costs ($26,944 versus $9,485).33
At the same time, studies demonstrate that treating
malnutrition in the hospital leads to better patient
outcomes. According to research findings, nutrition
intervention has been associated with:
A
reduction in the incidence of pressure ulcers8
fewer overall complications10
2 days
An average reduced length of
hospital stay of approximately
A
11,12
drop in avoidable hospital readmissions34
Decreased mortality
35-40
Improved quality of life
41-46
Elevating the role of patient nutrition in the hospital
must become a priority
These findings make clear that elevating the role
of patient nutrition in the hospital must become
a priority. Identifying and treating malnourished
patients and those at risk of malnutrition upon
admission through discharge is a low-cost, effective
strategy for hospitals to improve patient outcomes
(complication rates, readmission rates, and mortality)
while reducing costs and length of hospital stay.
Alliance Year One Progress Report | 5
Major Obstacles Impeding Progress
•
Given the overwhelming evidence documenting
the burden of patient malnutrition why does
this pervasive problem remain unrecognized
and untreated in so many hospitalized patients?
Healthcare experts have identified six key challenges
that are impeding progress:
Moreover, physician sign-off is generally
required to implement nutrition care, which
delays time and adds layers to the process.
Dietitian recommendations have been
found to be implemented in only 42 percent
of cases.53
•
Finally, the inadequate food consumption of
many hospitalized patients can contribute to
malnutrition. There is documented evidence
that many patients experience difficulty
consuming food without assistance,
contributing to more than half of these
individuals not finishing their meals.54
•
Although The Joint Commission
recommends nutritional screening of
all at-risk patients within 24 hours of
hospital admission and at frequent
intervals throughout hospitalization,47
the vast majority of hospitalized patients
are inadequately screened and their
malnutrition risk goes unrecognized.48,49
•
While the responsibility for patients’
nutrition care in hospitals usually rests with
on-staff registered dietitian nutritionists
(RDNs), many institutions don’t employ
enough RDNs to address all patients’ needs
properly.50
•
Nurses, who are on the front lines in
observing patients, interacting with
caregivers and delivering patient care,
are not consistently included in patients’
nutrition care.51
•
Nutrition interventions are often delayed
due to the time required to obtain nutrition
consultations. In fact, research conducted by
Meena Somanchi, Ph.D. and colleagues at
the Johns Hopkins School of Medicine found
the time to consultation from admission is
nearly 5 days, which is similar to the average
length of hospital stay.52
•
Other factors delaying nutritional screening
and treatment for malnutrition include
lack of nursing protocols focused on
nutrition, lack of diet orders, and physician
uncertainty with specific nutrition
intervention options in their hospitals.50
6 | Alliance Year One Progress Report
Underlying these challenges are numerous
institutional factors, such as the lack of understanding
among hospital administrators and clinicians of the
scope and costs of untreated malnutrition and the
limited or nonexistent formal education in nutrition
among physicians and nurses. Also impeding progress
is the lack of formal policies and procedures in place
to ensure malnourished patients or patients at risk
for malnutrition are screened within 24 hours of
admission and treated with nutrition interventions
in a timely fashion. As such, these findings represent
a call-to-action for policymakers and clinicians to
improve the standards and best practice protocols
for diagnosing malnutrition in the hospital setting,
ensuring patients get timely and effective treatment.
Dietitian
recommendations
have been found to be
implemented in only
42% of cases53
Changing the Paradigm
Creating the Roadmap
Because the ramifications of hospital malnutrition
have wide-reaching consequences, addressing this
problem requires direct, systematic and sustained
intervention. Accordingly, a consortium of registered
dietitian nutritionists, nurses, hospitalists, other
physicians and public health leaders joined forces in
2013 to form the first interdisciplinary partnership
dedicated solely to overcoming the problem
of hospital malnutrition. Called the Alliance to
Advance Patient Nutrition, this stakeholder coalition
represents more than 100,000 health professionals
across the nation working collectively to advocate
for early nutrition screening, assessment and
intervention in hospitals.
Currently, the Alliance is managed by four leading
healthcare organizations: the Academy of MedicalSurgical Nurses (AMSN), the Academy of Nutrition
and Dietetics (AND), the Society of Hospital Medicine
(SHM), and Abbott Nutrition. The work of the Alliance
to Advance Patient Nutrition is made possible with
support from Abbott Nutrition.
Officially announced in May 2013, the Alliance is
already having a major impact in driving awareness
and systems change. Because no blueprint existed
that would drive systems change, on June 4, 2013
the Alliance published a pioneering consensus
paper, Critical Role of Nutrition in Improving Quality
of Care: An Interdisciplinary Call to Action to Address
Adult Hospital Malnutrition, in three leading peerreviewed journals.
Documenting the extent of undiagnosed and
untreated malnutrition in the nation’s hospitals
and the consequences for patients and the
healthcare system, the consensus paper provided
a renewed call to action to elevate hospital
malnutrition as a priority concern and presented a
novel Nutrition Care Model to drive improvement.
Specifically, the Nutrition Care Model emphasizes
the following 6 principles:
Principles to transform
hospital environment
Principles to guide
clinician action
Recognize and diagnose
ALL patients at risk
Create institutional culture
View nutrition as priority for
improving care, quality, and cost
Redefine clinicians’ roles
to include nutrition
Empower all clinicians to address
patients’ nutritional needs
Communicate nutrition
care plans
Leverage the electronic health record (EHR)
to standardize nutrition documentation
Screen, assess, and diagnose all
patients’ malnutrition risk
The Alliance
Nutrition
Care Model
Rapidly implement interventions
& continued monitoring
Establish and enforce policy to intervene
within 24 hours of at-risk screening
Develop discharge nutrition
care & education plan
Incorporate nutrition counseling
in the discharge plan
Alliance Year One Progress Report | 7
To drive widespread adoption of the Nutrition Care
Model, the consensus paper also lays out specific
recommendations for hospital administrators
and clinicians to institute effective nutrition
practices in the nation’s hospitals. Among these
recommendations are to:
Educate all clinicians to be able to
recognize and diagnose malnutrition,
and implement evidence-based nutrition
interventions.
Consider nutritional status an essential
part of the patient’s condition.
Make nutrition interventions a core
component of medical therapy.
Screen ALL patients within 24 hours
for malnutrition risk using a validated
screening tool and continually rescreen all patients at frequent intervals
throughout hospitalization.
Initiate a nutrition care plan within 48
hours of admission for patients with or at
risk of malnutrition.
Engage nurses in understanding
malnutrition risk factors and develop/
implement policies that allow nurses to
provide nutrition care.
Allow registered dietitian nutritionists
ordering privileges for diet plans, oral
nutritional supplements, vitamins, and
calorie counts to prevent delays in food
and/or nutrient delivery.
Communicate malnutrition diagnosis
and care plans to the healthcare team.
Develop nutrition care plans and formally
document them in a central area on the
medical record or in the electronic health
record (EHR).
Develop clear, standardized written
instructions for nutrition care at home,
including the rationale for and details on diet
instructions, along with any recommended
oral nutritional supplementation (ONS),
vitamin and/or mineral supplements.
8 | Alliance Year One Progress Report
To equip the hospital community with the
resources to advocate for effective nutrition
practices in different institutions, the Alliance
also launched a comprehensive website—
www.malnutrition.com—as a national resource
on hospital malnutrition. The website makes
available a robust toolkit with validated
screening tools, feeding tips, fact sheets, case
studies, patient discharge materials and patient
education handouts. Malnutrition.com further
offers an evidence library of research data on
nutrition intervention in clinical settings, study
overviews vetted by specialists in hospital-based
malnutrition, and nursing education models.
Moving the Needle
With the consensus paper and website as the
foundation, the Alliance has begun a multi-year
initiative to elevate nutrition intervention as a
critical component of patient care in U.S. hospitals
through education, policy change, best practice
Our new, comprehensive website, www.malnutrition.com,
offers an evidence library of research data.
Alliance Year One Progress Report | 9
sharing and new research. This includes a national
public awareness effort using the mass media and
a more targeted communications program directed
specifically at hospitalists, nurses and registered
dietitian nutritionists. In this area, the Alliance has
not only succeeded in elevating awareness of patient
malnutrition within the hospital community but
qualitative results indicate the Alliance’s message is
being received and implemented by interdisciplinary
care teams in the hospital setting.
Among the results are the following:
•
•
•
Extensive coverage of hospital
malnutrition by the mass media. This
included 42 news articles reaching more
than 30 million readers and viewers and
over 2,500 views of national press releases.
All media coverage and communications
has included critical messaging about the
impact of malnutrition, the benefits of
nutrition intervention, and the need for
interdisciplinary clinical collaboration.
Reaching clinicians directly through
Alliance communications. Information
from the Alliance has generated 130-plus
Alliance-member articles, e-blasts and
social media posts targeted directly at
hospital administrators, clinicians
and policymakers.
A growing presence for the Alliance
website. As of March 31, 2014,
www.malnutrition.com had more than
125,000 page views, with 1,054 clinicians
choosing to register for ongoing information.
Moreover, the average visit duration on
the site is just under three minutes (2:55)
—about 50 percent longer than many sites
targeted to health professionals, due to
the large amount of relevant content and
informational tools available.
10 | Alliance Year One Progress Report
At the same time, the Alliance is spearheading
national malnutrition education programs for
hospital-based clinicians, providing hands-on,
skills-based information through teaching modules,
webinars, workshops, lectures and an interactive
exhibit booth at professional meetings and
conferences. Some of the 2013 highlights include:
•A Patient Nutrition section in the Practice
Resources made available to all nurses on
the AMSN website along with a “Nutrition
Stories” microsite to facilitate the sharing
of nutrition care ideas and practices. The
organization also distributes a regular
nutrition column in the AMSN newsletter
MEDSURG Matters!
• The recently published Critical Illness
Evidence-Based Nutrition Practice
Guidelines, which was made available to
registered dietitian nutritionists in over
200 countries as part of the Academy of
Nutrition and Dietetics Evidence Analysis
Library (EAL). The EAL houses more than
5,000 research article references, evidencebased practice toolkits, educator modules,
presentations and mobile apps.
• An updated version of the Malnutrition
Resource Center website, which was
launched in May 2014 by the Journal of
the Academy of Nutrition and Dietetics to
provide registered dietitian nutritionists,
nurses, and health practitioners a variety
of educational tools, self-study courses and
data on malnutrition from peer-reviewed
journal articles.
• A dedicated web-based “resource center”
on diagnosing and treating malnutrition in
the hospital made available to hospitalists
as part of the Society of Hospital Medicine’s
online Center for Hospital Innovation
and Improvement. This “resource room”
on malnutrition provides hospital-based
physicians with links to resources and
clinical tools to improve inpatient care,
including order sets, guidelines, templates,
and worksheets.
• Increasing awareness of hospital nutrition
at professional meetings and conferences.
This included a keynote address on “The
New Malnutrition: Challenges of Changing
the Paradigm Globally” by Kelly Tappenden,
PhD, RDN , one of the authors of the
consensus paper, at a March 2014 policy
conference Clinical and Economic Outcomes
of Nutrition Interventions Across the
Continuum of Care. Jointly hosted by the
Abbott Nutrition Health Institute,
The Sackler Institute for Nutrition Science,
and the New York Academy of Sciences,
the forum focused on emerging research
on nutrition health economics and how
nutrition can affect healthcare costs.
• Educating clinicians through Alliance booths
at major meetings and interdisciplinary
panel discussions and/or platforms at
major nutrition, nursing and physician
conferences. Between May 2013 and
January 2014, the Alliance reached 15,000
clinicians with science-based information
on hospital malnutrition, including 3,600
hospitalists during the Society of Hospital
Medicine’s 2014 annual meeting.
Alliance Year One Progress Report | 11
Complementing the efforts of the Alliance, 2013 also
saw the release of a new health economics study
that documents the value of treating malnourished
patients with oral nutrition supplements (ONS)
as a strategy for reducing hospital readmissions.
Conducted by leading researchers at the University
of Southern California, Stanford University, The
Harris School at The University of Chicago and
Precision Health Economics, and supported with
a research grant from Abbott Nutrition, the study
analyzed 667,000 hospital episodes of Medicare
patients older than 65 in 460 hospitals between
2000 and 2010 to determine differences in length
of stay, episode cost and 30-day readmission rates
when Medicare patients aged 65 and older were
prescribed ONS versus those not receiving ONS.
The results are noteworthy: ONS decreased the
probability of 30-day readmission by 12 percent
among Medicare patients over 65 years old treated
for acute myocardial infarction (AMI) and 10.1
percent among those with congestive heart failure
(CHF). ONS also decreased the average hospital
length of stay by 16 percent and achieved a cost
saving per episode of $3,079 among Medicare
patients over 65 with any primary diagnosis.46
To ensure these new findings reached the hospital
community, the study results were presented in a
poster session at the 35th annual meeting of the
Society for Medical Decision Making (SMDM) in
October 2013, as well as at Hospital Medicine 2014,
SHM’s annual meeting held in March 2014.
Taken together, the first-year efforts of the Alliance
have had a significant impact. Already, there is
evidence that specific hospitals are implementing
the recommended nutrition intervention protocols
from the Alliance, such as Pardee UNC Healthcare
in Hendersonville, NC where the institution
implemented a comprehensive nursing protocol to
reduce the incidence of pressure ulcers, avoidable
readmissions, infections, and falls. Through
this protocol, registered nurses and nursing
assistants screen all patients for malnutrition,
treat malnourished patients with medical
nutrition therapy, and include oral nutrition
supplementation in the patient’s discharge orders.
Another example is TouchPoint Support Services
at St. John Providence Health System in Metro
Detroit, MI, which places great emphasis on
nutrition interventions to improve patient
outcomes. By utilizing a validated screening tool,
optimizing its electronic medical record system
to include mandatory nutrition screening, and
through hands on training and utilization of
nutrition-focused physical assessments by the
dietitians, St. John Providence Health System is
now screening 100% of its patients on admission
and providing ongoing assessment for every
patient diagnosed as malnourished.
In addition, the Alliance is aware of up to 10 other
large hospitals and health systems that are now
working Alliance protocols into their processes.
This includes Mercy Health, a large health system
based in Cincinnati, OH, whose 21 hospitals meet
the healthcare needs of people in Ohio, Kentucky,
and contiguous states. Embracing the Alliance’s
principles, Mercy Health has implemented an
interdisciplinary approach to systematically
improve the quality of patient care through
the identification of malnourished and at-risk
patients, nutrition interventions and providing
12 | Alliance Year One Progress Report
patients clear, standardized written instructions
for nutrition care at discharge. Comprised of
registered dietitians, nurses, and specialists in
information technology and healthcare quality, the
interdisciplinary team is led by Tonya Burnett RD,
LD, System Director of Food and Nutrition Services
for Mercy Health, who has been instrumental in
educating hospital leaders and staff on the role
of identifying and treating malnutrition as a lowcost strategy for reducing the incidence of falls,
pressure ulcers and readmissions, decreasing
hospital length of stays and improving quality
outcomes data for physician and hospital profiles.
Also embracing nutrition therapy as a critical
component of patient care are the Chief Medical
Informatics Officers for two of Mercy Health’s
regions: Vince Vanek MD, FACS, FASPEN, General
Surgeon and Chief Medical Informatics Officer
for Humility of Mary Health Partners (HMHP) and
Michael Stark, MD, FACS, General Surgeon and Chief
Medical Informatics Officer, Northern Region. Both
regions are now developing nutrition protocols and
practices based on the Alliance’s principles.
Accelerating Progress in 2014
These actions provide a solid foundation for
beginning to overcome the problem of hospital
malnutrition in the US. Moving forward, the Alliance
will move beyond awareness-building to achieve
measurable change. This will entail focusing on
ongoing education, grant funded projects, policy
change, best practice sharing and new research with
the recognition that instituting effective nutrition
practices in the nation’s hospitals requires changes
in the knowledge, attitudes and skills of clinicians,
hospital administrators and policymakers alike.
While no single strategy will guarantee success,
the Alliance intends to be the catalyst for action
by aligning stakeholders to address hospital
malnutrition and provide evidence-based
information and practice-based solutions.
Therefore in 2014 and beyond, priorities for the
Alliance are to:
•
Measurably demonstrate the impact of
nutrition intervention on improved patient
outcomes and reduced health care costs.
•
Raise awareness of the clinical
characteristics of malnutrition so health
professionals will recognize the common
signs at hospital admission and during
hospitalization.
•
Communicate a sense of urgency around
screening, assessing and diagnosing every
patient’s nutritional status.
•
Drive widespread implementation of the
Alliance’s Nutrition Care Model and the
specific recommendations to institute
effective nutrition practices in hospitals
across the nation.
•
Advocate for policies that will facilitate
universal nutrition screening in hospitals
and acute care settings, require rapid,
appropriate nutrition intervention when
patients are either malnourished or at-risk
for malnutrition, and establish nutrition as a
standard component of all care processes.
Now is the time to improve patient outcomes,
recognizing that identifying and treating
malnourished patients upon admission through
discharge is a critical component of quality care,
and providing the resources and attention required
for success.
Now is the time
to improve patient
outcomes.
Alliance Year One Progress Report | 13
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Alliance Year One Progress Report | 15
Improving patient outcomes, together.
Principles to transform
hospital environment
Principles to guide
clinician action
Recognize and diagnose
ALL patients at risk
Create institutional culture
View nutrition as priority for
improving care, quality, and cost
Redefine clinicians’ roles
to include nutrition
Empower all clinicians to address
patients’ nutritional needs
Communicate nutrition
care plans
Leverage the electronic health record (EHR)
to standardize nutrition documentation
Screen, assess, and diagnose all
patients’ malnutrition risk
The Alliance
Nutrition
Care Model
Rapidly implement interventions
& continued monitoring
Establish and enforce policy to intervene
within 24 hours of at-risk screening
Develop discharge nutrition
care & education plan
Incorporate nutrition counseling
in the discharge plan
In 2013, the Alliance introduced a novel
Nutrition Care Model, the effects of which
are beginning to be felt in hospital systems
around the country.
© 2014 Alliance to Advance Patient Nutrition
90909/July 2014 LITHO IN USA
www.malnutrition.com
These health organizations are dedicated to the education of effective hospital nutrition practices to help
improve patients’ medical outcomes and support all clinicians in collaborating on hospital-wide nutrition
procedures. The Alliance to Advance Patient Nutrition is made possible with support from Abbott Nutrition.