Advertisement

Effectiveness of the Malnutrition Quality Improvement Initiative on Practitioner Malnutrition Knowledge and Screening, Diagnosis, and Timeliness of Malnutrition-Related Care Provided to Older Adults Admitted to a Tertiary Care Facility: A Pilot Study

Published:December 20, 2017DOI:https://doi.org/10.1016/j.jand.2017.08.111

      Abstract

      Background

      Malnutrition is present in 30% to 50% of hospitalized patients aged 60 years or older. As few as 3.2% of patients identified as high risk have a malnutrition diagnosis documented by medical providers. The Malnutrition Quality Improvement Initiative (MQii) aims to reduce the burden of hospital malnutrition by improving the process and delivery of care.

      Objective

      To evaluate implementing the MQii toolkit of best practice resources for screening, diagnosis, documentation, and timeliness of malnutrition care.

      Design

      This 6-month prospective pilot included a 3-month intervention with training and education modules tailored to type of practitioner and integrated into existing teaching and clinical workflow.

      Participants/setting

      Forty-five health care professionals from geriatric, general medicine, and general surgery units at Vanderbilt University Hospital during January to June 2016.

      Main outcome measures

      Malnutrition knowledge by 30-item questionnaire; electronic medical record (EMR) documentation; and timeliness of malnutrition screening, diagnosis, intervention, and discharge planning.

      Statistical analyses

      Analysis of variance was used to test change over time.

      Results

      Malnutrition knowledge score increased 14%, from 39% to 53% (P=0.009). All patients whose nutrition screen indicated they were malnourished/high risk had registered dietitian nutritionist diagnosis of malnutrition documented in the EMR. The proportion who had medical provider (physician, nurse practitioner, or physician assistant) malnutrition diagnosis documented in the EMR increased 11.6%, from 26.7% to 38.3% (P=0.08). About 95% of malnourished/high risk patients had a documented intervention addressing malnutrition. Inclusion of malnutrition care in the discharge plan increased 4.8%, from 70.0% to 74.8% (P=0.13).

      Conclusions

      This pilot study demonstrated feasibility of implementing the MQii resources to improve malnutrition knowledge and professionals’ skills relevant to screening, diagnosis, intervention, and timeliness of malnutrition care. By optimizing the process and delivery of malnutrition care, it is expected that the quality of clinical care provided to older adults with malnutrition or at high malnutrition risk will improve.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Butterworth C.E.
        The skeleton in the hospital closet. 1974.
        Nutrition. 1994; 10 (discussion 435, 441): 435-441
        • White J.V.
        • Guenter P.
        • Jensen G.
        • et al.
        Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition).
        J Acad Nutr Diet. 2012; 112: 730-738
        • Gallagher-Allred C.R.
        • Voss A.C.
        • Finn S.C.
        • McCamish M.A.
        Malnutrition and clinical outcomes: The case for medical nutrition therapy.
        J Am Diet Assoc. 1996; 96 (369; quiz 367-368): 361-366
        • Volkert D.
        • Saeglitz C.
        • Gueldenzoph H.
        • Sieber C.C.
        • Stehle P.
        Undiagnosed malnutrition and nutrition-related problems in geriatric patients.
        J Nutr Health Aging. 2010; 14: 387-392
        • Bavelaar J.W.
        • Otter C.D.
        • van Bodegraven A.A.
        • Thijs A.
        • van Bokhorst-de van der Schueren M.A.
        Diagnosis and treatment of (disease-related) in-hospital malnutrition: Tthe performance of medical and nursing staff.
        Clin Nutr. 2008; 27: 431-438
        • Singh H.
        • Watt K.
        • Veitch R.
        • Cantor M.
        • Duerksen D.R.
        Malnutrition is prevalent in hospitalized medical patients: Are housestaff identifying the malnourished patient?.
        Nutrition. 2006; 22: 350-354
        • Correia M.I.
        • Waitzberg D.L.
        The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis.
        Clin Nutr. 2003; 22: 235-239
        • Soderstrom L.
        • Rosenblad A.
        • Thors Adolfsson E.
        • Bergkvist L.
        Malnutrition is associated with increased mortality in older adults regardless of the cause of death.
        Br J Nutr. 2017; 117: 532-540
        • Adams K.M.
        • Kohlmeier M.
        • Zeisel S.H.
        Nutrition education in U.S. medical schools: Latest update of a national survey.
        Acad Med. 2010; 85: 1537-1542
        • Hark L.A.
        • Iwamoto C.
        • Melnick D.E.
        • et al.
        Nutrition coverage on medical licensing examinations in the United States.
        Am J Clin Nutr. 1997; 65: 568-571
        • Devries S.
        • Dalen J.E.
        • Eisenberg D.M.
        • et al.
        A deficiency of nutrition education in medical training.
        Am J Med. 2014; 127: 804-806
        • DiMaria-Ghalili R.A.
        • Mirtallo J.M.
        • Tobin B.W.
        • Hark L.
        • Van Horn L.
        • Palmer C.A.
        Challenges and opportunities for nutrition education and training in the health care professions: Intraprofessional and interprofessional call to action.
        Am J Clin Nutr. 2014; 99: 1184S-1193S
        • Ng M.
        • Fleming T.
        • Robinson M.
        • et al.
        Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: A systematic analysis for the Global Burden of Disease Study 2013.
        Lancet. 2014; 384: 766-781
        • Kaidar-Person O.
        • Person B.
        • Szomstein S.
        • Rosenthal R.J.
        Nutritional deficiencies in morbidly obese patients: A new form of malnutrition? Part A: Vitamins.
        Obes Surg. 2008; 18: 870-876
        • Kaidar-Person O.
        • Person B.
        • Szomstein S.
        • Rosenthal R.J.
        Nutritional deficiencies in morbidly obese patients: A new form of malnutrition? Part B: Minerals.
        Obes Surg. 2008; 18: 1028-1034
        • Batsis J.A.
        • Mackenzie T.A.
        • Jones J.D.
        • Lopez-Jimenez F.
        • Bartels S.J.
        Sarcopenia, sarcopenic obesity and inflammation: Results from the 1999-2004 National Health and Nutrition Examination Survey.
        Clin Nutr. 2016; 35: 1472-1483
        • Prado C.M.
        • Cushen S.J.
        • Orsso C.E.
        • Ryan A.M.
        Sarcopenia and cachexia in the era of obesity: Clinical and nutritional impact.
        Proc Nutr Soc. 2016; 75: 188-198
        • McCauley S.M.
        Malnutrition care: Preparing for the next level of quality.
        J Acad Nutr Diet. 2016; 116: 852-855
        • Sriram K.
        • Sulo S.
        • VanDerBosch G.
        • et al.
        A comprehensive nutrition-focused quality improvement program reduces 30-day readmissions and length of stay in hospitalized patients.
        JPEN J Parenter Enteral Nutr. 2017; 41: 384-391
        • Locher J.L.
        • Wellman N.S.
        “Never the twain shall meet:” Dual systems exacerbate malnutrition in older adults recently discharged from hospitals.
        J Nutr Gerontol Geriatr. 2011; 30: 24-28
        • Yang Y.
        • Brown C.J.
        • Burgio K.L.
        • et al.
        Undernutrition at baseline and health services utilization and mortality over a 1-year period in older adults receiving Medicare home health services.
        J Am Med Dir Assoc. 2011; 12: 287-294
        • Patel V.
        • Romano M.
        • Corkins M.R.
        • et al.
        Nutrition screening and assessment in hospitalized patients: A survey of current practice in the United States.
        Nutr Clin Pract. 2014; 29: 483-490
        • Tappenden K.A.
        • Quatrara B.
        • Parkhurst M.L.
        • Malone A.M.
        • Fanjiang G.
        • Ziegler T.R.
        Critical role of nutrition in improving quality of care: An interdisciplinary call to action to address adult hospital malnutrition.
        JPEN J Parenter Enteral Nutr. 2013; 37: 482-497
        • Heinich R.
        • Russell J.D.
        • Smaldino S.E.
        Instructional Media and Technologies for Learning.
        6th ed. Merrill, Upper Saddle River, NJ1999
        • Hand R.K.
        • Murphy W.J.
        • Field L.B.
        • et al.
        Validation of the Academy/A.S.P.E.N. malnutrition clinical characteristics.
        J Acad Nutr Diet. 2016; 116: 856-864
      1. ICD10Data.com. http://www.icd10data.com/ICD10CM/Codes/E00-E89/E40-E46. Accessed August 3, 2017.

      2. Silver HJ. Malnutrition: YouTube; 2016. https://www.youtube.com/watch?v=Ykit5uS6Krs. Accessed August 12, 2017.

        • Fleiss J.L.
        Measuring nominal scale agreement among many raters.
        Psychol Bull. 1971; 76: 378-382
        • Lacey K.
        • Pritchett E.
        Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
        J Am Diet Assoc. 2003; 103: 1061-1072
        • Deutz N.E.
        • Matheson E.M.
        • Matarese L.E.
        • et al.
        Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial.
        Clin Nutr. 2016; 35: 18-26
        • Kaiser M.J.
        • Bauer J.M.
        • Ramsch C.
        • et al.
        Frequency of malnutrition in older adults: A multinational perspective using the mini nutritional assessment.
        J Am Geriatr Soc. 2010; 58: 1734-1738
        • Kwon Y.E.
        • Kee Y.K.
        • Yoon C.Y.
        • et al.
        Change of nutritional status assessed using subjective global assessment is associated with all-cause mortality in incident dialysis patients.
        Medicine (Baltimore). 2016; 95: e2714
      3. Hiller LD, Shaw RF, Fabri PJ. Difference in composite end point of readmission and death between malnourished and nonmalnourished veterans assessed using Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition clinical characteristics [published online ahead of print September 8, 2016]. JPEN J Parenter Enteral Nutr. http://dx.doi.org/10.1177/0148607116668523.

        • Meehan A.
        • Loose C.
        • Bell J.
        • Partridge J.
        • Nelson J.
        • Goates S.
        Health system quality improvement: Impact of prompt nutrition care on patient outcomes and health care costs.
        J Nurs Care Qual. 2016; 31: 217-223
        • Barker L.A.
        • Gout B.S.
        • Crowe T.C.
        Hospital malnutrition: Prevalence, identification and impact on patients and the healthcare system.
        Int J Environ Res Public Health. 2011; 8: 514-527
        • Danciu I.
        • Cowan J.D.
        • Basford M.
        • et al.
        Secondary use of clinical data: The Vanderbilt approach.
        J Biomed Inform. 2014; 52: 28-35
        • Seaton W.H.
        The Statistical Analysis System for program management.
        ASHA. 1983; 25: 37-40
        • Rosen B.S.
        • Maddox P.J.
        • Ray N.
        A position paper on how cost and quality reforms are changing healthcare in America: Focus on nutrition.
        JPEN J Parenter Enteral Nutr. 2013; 37: 796-801
        • Vetter M.L.
        • Herring S.J.
        • Sood M.
        • Shah N.R.
        • Kalet A.L.
        What do resident physicians know about nutrition? An evaluation of attitudes, self-perceived proficiency and knowledge.
        J Am Coll Nutr. 2008; 27: 287-298
        • Lenders C.M.
        • Deen D.D.
        • Bistrian B.
        • et al.
        Residency and specialties training in nutrition: A call for action.
        Am J Clin Nutr. 2014; 99: 1174S-1183S
        • Mihalynuk T.V.
        • Scott C.S.
        • Coombs J.B.
        Self-reported nutrition proficiency is positively correlated with the perceived quality of nutrition training of family physicians in Washington State.
        Am J Clin Nutr. 2003; 77: 1330-1336
        • Lindorff-Larsen K.
        • Hojgaard Rasmussen H.
        • Kondrup J.
        • Staun M.
        • Ladefoged K.
        Scandinavian Nutrition Group. Management and perception of hospital undernutrition—a positive change among Danish doctors and nurses.
        Clin Nutr. 2007; 26: 371-378
        • Mowe M.
        • Bosaeus I.
        • Rasmussen H.H.
        • et al.
        Insufficient nutritional knowledge among health care workers?.
        Clin Nutr. 2008; 27: 196-202
        • Tsoutsoulopoulou K.
        Implementation of a web-based intervention targeting health care professionals to increase their knowledge regarding the implementation of nutritional screening and detecting malnutrition in the elderly.
        Clin Nutr ESPEN. 2016; 13: e59
        • Kruizenga H.M.
        • Seidell J.C.
        • de Vet H.C.
        • Wierdsma N.J.
        • van Bokhorst-de van der Schueren M.A.
        Development and validation of a hospital screening tool for malnutrition: The Short Nutritional Assessment Questionnaire (SNAQ).
        Clin Nutr. 2005; 24: 75-82
        • Green S.M.
        • James E.P.
        Barriers and facilitators to undertaking nutritional screening of patients: A systematic review.
        J Hum Nutr Diet. 2013; 26: 211-221
        • Elia M.
        • Zellipour L.
        • Stratton R.J.
        To screen or not to screen for adult malnutrition?.
        Clin Nutr. 2005; 24: 867-884
        • Dougherty D.
        • Bankhead R.
        • Kushner R.
        • Mirtallo J.
        • Winkler M.
        Nutrition care given new importance in JCAHO standards.
        Nutr Clin Pract. 1995; 10: 26-31
      4. Weiss AJ, Fingar KR, Barrett ML, et al. Characteristics of hospital stays involving malnutrition, 2013: Healthcare Cost and Utilization Project Statistical Briefs. Rockville, MD; 2006. Statistical Brief #210.

        • Corkins M.R.
        • Guenter P.
        • DiMaria-Ghalili R.A.
        • et al.
        Malnutrition diagnoses in hospitalized patients: United States, 2010.
        J Parenter Enteral Nutr. 2014; 38: 186-195
        • Jordan L.
        • Slover A.
        • Hisse L.
        • Nelson C.
        Interprofessional approach to improving malnutrition screening and diagnosis at a VA Medical Center.
        J Hosp Med. 2016; 11
        • Tangvik R.J.
        • Tell G.S.
        • Guttormsen A.B.
        • et al.
        Nutritional risk profile in a university hospital population.
        Clin Nutr. 2015; 34: 705-711
        • Allard J.P.
        • Keller H.
        • Teterina A.
        • et al.
        Factors associated with nutritional decline in hospitalised medical and surgical patients admitted for 7 d or more: A prospective cohort study.
        Br J Nutr. 2015; 114: 1612-1622
      5. Becker's Hospital Review. http://www.beckershospitalreview.com/finance/average-cost-per-inpatient-day-across-50-states-2016.html. Accessed July 16, 2017.

        • Phillips W.
        • Doley J.
        Granting order-writing privileges to registered dietitian nutritionists can decrease costs in acute care hospitals.
        J Acad Nutr Diet. 2017; 117: 840-847
        • Henke R.M.
        • Karaca Z.
        • Jackson P.
        • Marder W.D.
        • Wong H.S.
        Discharge planning and hospital readmission.
        Med Care Res Rev. 2016; ([published online ahead of print May 3, 2016])https://doi.org/10.7755/8716647652
        • Lindegaard Pedersen J.
        • Pedersen P.U.
        • Damsgaard E.M.
        Nutritional follow-up after discharge prevents readmission to hospital–a randomized clinical trial.
        J Nutr Health Aging. 2017; 21: 75-82
        • Goncalves-Bradley D.C.
        • Lannin N.A.
        • Clemson L.M.
        • Cameron I.D.
        • Shepperd S.
        Discharge planning from hospital.
        Cochrane Database Syst Rev. 2016; : CD000313

      Biography

      H. J. Silver is a research associate professor and director, Vanderbilt Diet, Body Composition, and Human Metabolism Core, Vanderbilt University Medical Center, Nashville, TN, and a health scientist, Tennessee Valley Healthcare System, Nashville.

      Biography

      K. J. Pratt is a director, Avalere Health, Washington, DC.

      Biography

      M. Bruno is a director, Avalere Health, Washington, DC.

      Biography

      J. Lynch is a director, Avalere Health, Washington, DC.

      Biography

      K. Mitchell is a senior vice president, Avalere Health, Washington, DC.

      Biography

      S. M. McCauley is a senior director, quality management, Academy of Nutrition and Dietetics, Chicago, IL.

      Linked Article

      • Malnutrition Intervention Implementation
        Journal of the Academy of Nutrition and DieteticsVol. 118Issue 5
        • Preview
          We read with great interest the article by Silver and colleagues entitled “Effectiveness of the Malnutrition Quality Improvement Initiative on Practitioner Malnutrition Knowledge and Screening, Diagnosis, and Timeliness of Malnutrition-Related Care Provided to Older Adults Admitted to a Tertiary Care Facility: A Pilot Study.”1 We would like to commend the authors for their work in evaluating the implementation of the Malnutrition Quality Improvement Initiative (MQii) toolkit on patients’ screening, diagnosis, documentation, and timeliness of malnutrition care.
        • Full-Text
        • PDF