With as many as one in three patients entering the hospital malnourished, physicians and other healthcare providers must understand the adverse effects malnutrition has on patient outcomes. It delays recovery from illness and increases complications as well as frequency of hospital admissions and length of stay.
Research has shown measurable and positive effects when malnourished patients receive nutritional treatment. For patients with at least one known subsequent readmission, oral nutrition supplementation provided during hospitalization has been associated with a significant reduction in the probability of 30-day readmission. Studies have also shown that nutrition interventions can significantly reduce the risk of pressure ulcers. For gastrointestinal surgery patients, nutrition interventions have led to substantial reductions in overall complications.
Nutrition Care Model
One of the most critical aspects to comprehensively identify and treat malnutrition is to drive interdisciplinary collaboration among dietitians, nurses, hospitalists, and other physicians. To address this issue, the Alliance to Advance Patient Nutrition published a consensus paper outlining the problem of malnutrition and recommended steps to improve outcomes. The alliance describes a nutrition care model that offers practical ways for healthcare providers in hospitals to collaborate to promptly diagnose and treat malnourished patients and those at risk for malnutrition. The model emphasizes the following six principles:
• Create an institutional culture where all stakeholders value nutrition.
• Redefine clinicians’ roles to include nutrition care.
• Recognize and diagnose all malnourished patients and those at risk.
• Rapidly implement comprehensive nutrition interventions and continued monitoring.
• Communicate nutrition care plans.
• Develop a comprehensive discharge nutrition care and education plan.
For each of these steps, there are specific actions physicians can take to make an impact, such as including dietitians in daily team rounds and reinforcing that nutrition care plans be carefully documented in patient records. As physicians, we can lead the way by reinforcing that nutrition care plans be visibly documented in patient records and discussing the nutrition plan and expectations with the patient and their care providers.
Nutritional Support Teams
Each institution possesses unique attributes that necessitate tailored approaches. When developing nutrition support teams, hospital administrators will need to evaluate costs associated with the allocation of staff and the requisite training. Developing a multidisciplinary nutritional support team requires an analysis of the hospital’s needs, organizational culture, and personnel budget. While this may be challenging, it can provide important benefits that enhance quality of care, improve clinical outcomes, and reduce costs.
Readings & Resources (click to view)
Coats, KG, Morgan S, Bartolucci AA, et al: Hospital-association malnutrition: a reevaluation 12 years later. J Am Diet Assoc. 1993;93:27-33.
Giner M, Laviano A, Meguid MM, et al. In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition. 1996;12:23-29.
Thomas DR, Zdrowski CD, Wilson MM, et al. Malnutrition in subacute-care. Am J Clin Nutr. 2002;75:308-313.
Philipson T, Snider J, Lakdawall D, Stryckman B, Goldman D. Impact of oral nutritional supplementation on hospital outcomes. Am J Managed Care. 2013;19:121-128.
Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr. 2008;27:5-15.
Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011;6:54-60.
Stratton R J, Ek A C, Engfer M, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Research Reviews. 2005;4:422-450.
Stratton RJ, Elia M. Who benefits from nutritional support: what is the evidence? Eur J Gastroenterol Hepatol. 2007;19:353-358.
Bauer JD, Isenring E, Torma J, Horsley P, Martineau J. Nutritional status of patients who have fallen in an acute care setting. J Hum Nutr Diet. 2007;20:558–564.