Addressing Hospital Malnutrition –
Where are We Now and Where are
We Headed?
Ainsley Malone,MS,RD,CNSC,FAND,FASPEN
Nutrition Support Dietitian
Mt. Carmel West Hospital
Clinical Practice Specialist
A.S.P.E.N.
Objectives
 Outline detailed evidence demonstrating
negative outcomes in malnourished
hospitalized patients
 Describe selected hospital activities in
improving malnutrition diagnosis and
documentation
 Describe efforts by the Academy and
A.S.P.E.N. in addressing hospital
malnutrition
Landmark Publication
“I suspect, as a matter of fact, that one of the largest
pockets of unrecognized malnutrition in America exists
not in rural slums or urban ghettos, but in the private
rooms and wards of big city hospitals.”
Nutr Today 1979; 9:4-8
Malnutrition Redefined
White J. JPEN 2012; 36:275-283
Severe Malnutrition in Adults
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
Grip Strength
Not Recommended in ICU
Reduced for Age/Gender
Reduced for Age/Gender
* 2012 ICD-9-CM Physician Volumes 1 and 2. American Medical Association
Non-Severe Malnutrition in Adults
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
Grip Strength
Not Applicable
Not Applicable
Not Applicable
* 2012 ICD-9-CM Physician Volumes 1 and 2. American Medical Association
Malnutrition Prevalence - 2013
 Nicolo, et al, 20131
• Two participating facilities
– Patients referred to RD for assessment
– Patients consulted for nutrition support
• Utilized Consensus Malnutrition Criteria2
JPEN 2014:38:954-59
Malnutrition Prevalence
Percentage Of Hospital Discharges With Malnutrition
Diagnoses, By Year, United States.
Corkins M R et al. JPEN 2013;38:186-195
Malnutrition and Outcomes
9
Table 5. Comorbid Conditions of Discharged Patients With and Without a Diagnosis of
Malnutrition, United States, 2010.
Corkins M R et al. JPEN J Parenter Enteral Nutr
2013;38:186-195
Copyright © by The American Society for Parenteral and Enteral Nutrition
Malnutrition in the ICU and Outcome
 57 patients
ventilated patients
 Mean APACHE II:
24±10
 Primary Dx:
• Resp failure – 63%
• Sepsis – 18%
• CVA – 16%
Sheehan P, Eur J Clin Nutr 2010;64:1358
Malnutrition in the ICU and
Outcome
 Overall
prevalence: 51%
Patients with “B” or
“C” SGA score had a
significantly longer
length of stay
Sheehan P, Eur J Clin Nutr 2010;64:1358
***P<0.001
Impact on Patient Outcomes
•
Patient Characteristics and the Occurrence of
Never Events
• US epidemiologic analysis of 887,189 surgery
cases from 1368 hospitals, using HCUP NIS data
from 2002-2005
• Malnutrition can dramatically increase the risk of
severe events
• 4X more likely to develop pressure ulcers
• 2X more likely to have SSI
• 5X more likely to have CAUTI
Fry et al, Arch Surg 2010;145(2):148-51
Impact on Patient Outcomes
14
Ben-Ishay O. Gastroenterol Res Pract 2011: 840512
Surgical Outcomes and Malnutrition
 Prospective cohort study
• Surgical GI cancer patients (n=694)
 Nutrition risk score 2002
 No pre-op nutrition support
 Complications measured
• Mortality, ventilator and ICU LOS
 Nutrition risk
• 152 patients (21%) with high nutrition risk
• NRS 2002 ≥3
Shpata V. Med Arh 2014;68:263-267
Nutrition Risk and Complications
 Malnutrition an
independent risk factor
 Total complications
ICU Length of Stay Per
Nutrition Risk
• OR = 6.07; p>0.0001
 Infectious complications
• OR = 3.14; p>0.0001
 Mortality
• OR = 2.08;p>0.0001
 Ventilator LOS
P<0.001
• F=29.96 p>0.001
Shpata V. Med Arh 2014;68:263-267
17
Impact on Patient Outcomes
•
Despite having the same disease severity,
malnourished patients had poorer outcomes
•
•
•
Significantly increased LOS (15d versus 10d)
Increased readmission rates (23% versus 18%)
2X greater risk of 90d mortality
Agarwal E et al, Clin Nutr 2013;32:737-45
Malnutrition and Mortality
 Pre-Liver Transplantation (n=861)
 Assessed via SGA
SGA Level
Well
Moderate
Severe
519 (60.3%)
290 (33.7%)
52 (6%)
Survival on Transplant Waiting List by SGA Category
P=0.001
Hasse J. CNW
15 Abstracts
Risk Factor for Readmission
 National Surgical Quality Improvement Program
• Parathyroidectomies and thyroidectomies (n=7069)
Mullen M.
Surgery
2014;156:1423
Coding for Malnutrition Improvement
Needed
 Aim: to determine frequency of use of ICD9 codes in a population of malnourished
patients
 1371 patients
 SGA performed
 Discharge ICD-9 code assignment reviewed
 441 patients with SGA-B or C
• 32% malnourished
• 40 patients (9%) with malnutrition codes upon
discharge
Lach K. CNW Abstract 56, 2014
2
Coding for Malnutrition
Improvement Needed
ICD-9 Code
Code Detail
# of Patients
260
Kwashiorkor
0
261
Nutritional marasmus
3
262
Other severe malnutrition
0
263.0
Malnutrition of a moderate degree
0
263.1
Malnutrition of a mild degree
1
263.9
Unspecified protein calorie malnutrition
5
780.94
Early satiety
1
783.0
Anorexia
6
783.21
Loss of weight
23
783.22
Underweight
1
783.7
Adult Failure to Thrive
5
799.4
Cachexia
1
Lach K. CNW Abstract 56, 2014
Coding and Reimbursement
Phillips W. Pract Gastro; Sept 2014
23
Addressing Malnutrition as a
Healthcare System - Vision
 Develop a “Malnutrition Initiative”
 Create a culture where all stakeholders
value nutrition
• Empower organizations to create
multidisciplinary nutrition committees
– If not in place or if no equivalent
• A collaborative, interdisciplinary approach to
address aspects of malnutrition
• On admission, during hospital stay and
transition care
Malnutrition Initiative
 Empower organizations to develop best
practice opportunities/tactics to address
malnutrition
• More rapid nutrition intervention in malnourished
patients or those at risk
– Automatic intervention based upon selected “triggers”
– Collaborative efforts between RD and MD when
malnutrition diagnosed
– Peri-operative nutrition intervention
• Addressing altered diet schedules through
collaboration between health care team and
support systems
– An “alert” appears in the EMR when NPO/clear liquids
is ≥ 5 days
Malnutrition Initiative
 Empower organizations to develop best
practice opportunities/tactics to address
malnutrition
• Collaborative education for RN’s and PCA’s
– Monitor and maximize oral and supplement intake
– Educate patient and family
• Create a discharge nutrition plan of care for
malnourished or at risk patients
– Optimize oral intake with oral supplement
prescription post discharge
– Communication with alternate site care clinician
– Collaboration with home care agency and
automatic RD intervention
Malnutrition Initiative
 Create metrics to evaluate success
• Improved nutrition delivery (energy/protein) in ICU
patients
• Increased nutrient intake in nutritionally at risk
patients
• Increased nutrition intervention in patients identified
as malnourished upon admission
• Increased nutrient intake in patients post ICU care
• Increase in at risk patients discharged with active
nutrition intervention
• Increase in malnutrition discharge diagnosis (ICD-9
CM)
Malnutrition Process
New York-Presbyterian Hospital Process
Giannopoulos G. Nutr Clin Pract 2013;28:698-709
Mt. Carmel Malnutrition Process
Implementation
 Developed an “Implementation Team”
•
•
•
•
•
•
•
Clinical Nutrition
Medical Staff
Nursing
Finance
Documentation Specialists/Coders
Information System
Quality Management
Develop Implementation Plan
 Outlined nutrition assessment process
• Adult malnutrition characteristics are
standardized
 Formal and informal education of RDN’s
 Specify documentation nomenclature in
EMR
 Develop education plan
• Medical staff
• Documentation specialists
• Coders
Malnutrition Process Work Flow
 Nutrition Screening by Patient Care
Services upon admission
• MST – score of ≥ 2 generates referral
 RD assess patient
 RD reviews malnutrition findings with MD
• Collaborates on documentation and plan of
care
 RD enters “Dietary” malnutrition diagnosis
in EMR
Malnutrition Diagnosis
© 2013 CHE Trinity Health
Malnutrition Process Workflow
 MD is alerted and, if agrees, converts to
“Medical” Diagnosis
• Includes in progress notes
 Daily report generated from EMR of patients
with malnutrition documentation by RD
 Upon discharge, coders review medical
record and assign ICD-9 malnutrition code
Malnutrition Report
© 2013 CHE Trinity Health
Malnutrition and Reimbursement
 Aim: evaluate impact of documentation and
malnutrition coding on casemix funding
 SGA used for assessment
 658 patients screened with 105 (16%)
malnourished
 DRG changed in 24 of the 105 episodes
 Only 29 of the 105 malnourished patients
were coded and received increased
reimbursement
• Resulted in estimated lost revenue of
$US12,710
Raja R. Intern Med J 2004; 34: 176-181
Improvement in Malnutrition
Documentation
 German hospital
evaluated malnutrition
documentation
•
N=591
•
19% SGA B and C
 Used SGA for
assessment
 27% with malnutrition
resulted in improved
reimbursement
•
73% no change due to
existing co-morbidities
Ockenga J. Clin Nutr 2005;24:913
Effect of nutrition screening and
documentation on the number
of patients coded appropriately
Activities Addressing Malnutrition
AND
A.S.P.E.N.
Awaiting Publication
38
What is a National Patient Safety Goal?
 The National Patient Safety Goals (NPSGs)
were established in 2002 to help accredited
organizations address specific areas of
concern in regards to patient safety
 The first set of NPSGs was effective January
1, 2003
 The Patient Safety Advisory Group advises
The Joint Commission on the development
and updating of NPSGs
Current NPSG’s
 Improve the effectiveness of
communication among caregivers
 Improve the safety of using medications.
 Reduce the harm associated with clinical
alarm systems
 Reduce the risk of health care–associated
infections
Malnutrition – National Patient Safety
Goal
 Malnutrition in the hospitalized patient
cannot be eliminated
 How it is addressed by the clinician is the
key element
The absence of timely nutrition assessment,
diagnosis and implementation of a care plan in
patients at risk for malnutrition or with preexisting malnutrition should be a “never event”.
A.S.P.E.N - Malnutrition Strategy
42
Malnutrition Related Tools
 Nutrition Care Algorithm Update
• Adult and Pediatrics
• Interactive with links to additional documents
and impractical information
Update
in
Process
43
Malnutrition Related Tools
 Quality Performance Indicators
 Opportunities to assess malnutrition focused
practices
• Percentage of patients with nutrition screening
within 24 hours of admission
• Percentage of patients with malnutrition
diagnosis who receive nutrition intervention
within 48 hours
• Percentage of patients with nutrition diagnosis
of malnutrition who have a medical malnutrition
diagnosis
 Will be available in a spreadsheet format
44
AND – Avalere Health
45
Academy/A.S.P.E.N. Malnutrition
Characteristics Validation Study – Pilot
 Purpose: to determine reliable and valid
characteristics for diagnosing malnutrition
• Comparative study of 4 approaches
–
–
–
–
Consensus malnutrition criteria
SGA
Biochemical markers
Hybrid of above
 Outcomes
•
•
•
•
•
•
Death
Length of stay
Infections
Pressure ulcers
Falls
30 day readmissions
Academy/A.S.P.E.N. Malnutrition
Characteristics Validation Study - Pilot
 Recruited patients – n=27
• 19 positive nutrition risk
• 15% (n=4) with moderate malnutrition
• 33% (n=9) with severe malnutrition
 Conclusions
• Study protocol appears feasible for determining
validity
• Changes made to full study protocol for
reducing RD bias
Steiber A. CNW 15 Abstracts
Additional Malnutrition Related
Resources
 Nutrition Focused Physical Assessment
Workshops
 Nutrition Focused Physical Exam –
Malnutrition
• DNS – Cleveland Clinic Dietitians
• 15 minute video
 A.S.P.E.N. Clinical Nutrition Week 16
In Summary
 Malnutrition significantly increases risk of
negative clinical outcomes
 Recognition and treatment essential
• Malnutrition “programs” and processes are key
for improvement
 AND and A.S.P.E.N. leading malnutrition
related regulatory efforts
 Multiple malnutrition related tools to
become available
49
THANK YOU!!
Questions?
50