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Improving Malnutrition in Hospitalized Older Adults: The Development, Optimization, and Use of a Supportive Toolkit

Published:August 22, 2019DOI:https://doi.org/10.1016/j.jand.2019.05.024

      Abstract

      Malnutrition is a leading cause of morbidity and mortality, especially among older adults. However, diagnosis and treatment of malnutrition in the hospital setting are often overlooked. In recent years, quality improvement (QI) initiatives to increase the assessment and treatment of malnutrition in hospital settings have been implemented and shown to improve both patient health and economic outcomes. The Malnutrition Quality Improvement Initiative (MQii) Toolkit was designed in an effort to support hospitals seeking to implement malnutrition QI initiatives. The Toolkit has been implemented, studied, and updated for optimization of content, adaptability, and usability over several cycles of improvement from 2016-2017 at more than 50 hospital centers in the United States. The result is an open access, customizable, and user-friendly MQii Toolkit that can facilitate the implementation of malnutrition QI initiatives in individual facilities. This article introduces the MQii Toolkit, describes the process by which it was designed and improved, and orients clinical care teams to its use.

      Funding/Support

      Publication of this supplement was supported by Abbott. The Academy of Nutrition and Dietetics does not receive funding for the MQii. Avalere Health's work to support the MQii was funded by Abbott.

      Keywords

      Statement of Potential Conflict of Interest: See page S31.
      Malnutrition, which has been defined through an etiology-based approach and can include individuals who are underweight or overweight,
      • Jensen G.L.
      • Mirtallo J.
      • Compher C.
      • et al.
      Adult starvation and disease-related malnutrition: A proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee.
      is a leading cause of morbidity and mortality, especially among older adults.
      • 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.
      • Lim S.L.
      • Ong K.C.
      • Chan Y.H.
      • Loke W.C.
      • Ferguson M.
      • Daniels L.
      Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality.
      As many as half of all patients are malnourished or are at risk of becoming malnourished at the time of hospital admission,
      • Allard J.P.
      • Keller H.
      • Jeejeebhoy K.N.
      • et al.
      Malnutrition at hospital admission-contributors and effect on length of stay: A prospective cohort study from the Canadian Malnutrition Task Force.
      • Correia M.
      • Perman M.I.
      • Pradelli L.
      • Omaralsaleh A.J.
      • Waitzberg D.L.
      Economic burden of hospital malnutrition and the cost-benefit of supplemental parenteral nutrition in critically ill patients in Latin America.
      • Sherry C.L.
      • Sauer A.C.
      • Thrush K.E.
      Assessment of the nutrition care process in US hospitals using a web-based tool demonstrates the need for quality improvement in malnutrition diagnosis and discharge care.
      with older adults especially at risk, often because of the health, physiologic, and functional changes associated with aging that can influence their nutritional status.
      • Bernstein M.
      • Munoz N.
      • Academy of Nutrition and Dietetics
      Position of the Academy of Nutrition and Dietetics: Food and nutrition for older adults: promoting health and wellness.
      • Porter Starr K.N.
      • McDonald S.R.
      • Bales C.W.
      Nutritional vulnerability in older adults: A continuum of concerns.
      Early identification and treatment of these patients is the most effective way to reduce malnutrition-associated safety and health outcome issues.
      • 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.
      • 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.
      • 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.
      • 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.
      However, the diagnosis and treatment of malnutrition are often overlooked when other care needs are given higher priority.
      In recent years, screening practices designed to detect patients at risk of malnutrition have become more widespread, and studies of their effectiveness have demonstrated that both patient health outcomes and hospital economic outcomes are improved when malnutrition is more effectively identified and treated.
      • Sherry C.L.
      • Sauer A.C.
      • Thrush K.E.
      Assessment of the nutrition care process in US hospitals using a web-based tool demonstrates the need for quality improvement in malnutrition diagnosis and discharge care.
      Such malnutrition quality improvement (QI) efforts have ranged from taking basic steps for improving patient nutrition to implementing wide-sweeping overhauls of the entire process, including medical record reviews, tracking of nutrition supplement administration, and provision of enteral and parenteral nutrition support.
      • Khan M.
      • Hui K.
      • McCauley S.M.
      What is a registered dietitian nutritionist’s role in addressing malnutrition?.
      • McCauley S.M.
      • Khan M.
      Elevating malnutrition care coordination for successful patient transitions.
      • Russell M.
      We’re part of the solution: Malnutrition prevention, treatment.
      In an effort to support hospitals seeking to implement malnutrition QI initiatives, the Malnutrition Quality Improvement Initiative (MQii) partners (Academy of Nutrition and Dietetics and Avalere Health) designed a toolkit (MQii Toolkit Team). The MQii Toolkit has been implemented, studied, and updated for optimization of content and usability in the clinical setting.
      • Silver H.J.
      • Pratt K.J.
      • Bruno M.
      • Lynch J.
      • Mitchell K.
      • McCauley S.M.
      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.
      This article introduces the MQii Toolkit, describes the systematic rapid-cycle process by which it was designed and improved, and encourages clinical care teams to tackle a malnutrition QI initiative using the MQii Toolkit as a guide.

      The MQii Toolkit: An Overview

      In 2015, the MQii was established by the Academy of Nutrition and Dietetics (Academy), Avalere Health, and other expert stakeholders as a program to advance the quality of malnutrition care for patients. One of several major outcomes of the MQii in 2016-2017 was to create a learning collaborative of hospitals across the country to develop and test a malnutrition QI-focused toolkit for clinicians, the MQii Toolkit.
      The MQii Toolkit is an evidence-based guide that directs hospital providers through the process of supporting malnutrition QI for older hospitalized patients. Although the MQii Toolkit is designed to facilitate the care of patients ages 65 and older, the best practices and core concepts it reflects are relevant to all adult patients (ages 18+) in the hospital setting. The MQii Toolkit helps clinicians identify and treat malnutrition in hospitalized patients by providing recommendations drawn from best-practice research, available literature, clinical practice guidelines developed by the Academy and the American Society for Parenteral and Enteral Nutrition, and the Academy’s Nutrition Care Process workflow elements.
      Providing start-to-finish guidance for optimal malnutrition care, the MQii Toolkit was built to be easily implemented and customizable to fit the unique needs of the implementing hospital. The MQii Toolkit provides interdisciplinary care teams (including registered dietitian nutritionists, nurses, physicians, pharmacists, patient advocates, and quality leaders) guidance for malnutrition screening, nutrition assessment, malnutrition diagnosis, care plan development, monitoring and evaluation, and discharge planning. These resources enable clinicians to identify care gaps and lead QI efforts at their hospitals, regardless of prior experience with QI processes. Information in the MQii Toolkit includes:
      • What “quality improvement” means and how to implement it
      • How to identify malnutrition care gaps
      • How to begin a hospital-based malnutrition QI project
      • Best practice recommendations for each step of the malnutrition clinical workflow
      • Implementation recommendations to address identified gaps
      • Tools and resources for clinicians
      • Other information such as key QI concepts, how to collect and monitor data for the evaluation of QI efforts, and more

      How Has the MQii Toolkit Been Optimized?

      The MQii Toolkit was initially built following the model of successful QI tools from other initiatives focused on myocardial infarction,
      • American College of Cardiology
      Door-to-balloon 10 years later: successful model sets the stage for the next generation of ACC’s QI programs.
      bloodstream infections,
      Centers for Disease Control and Prevention
      Central Line-Associated Bloodstream Infections (CLABSI) in Non-Intensive Care Unit (non-ICU) Settings Toolkit.
      and asthma.
      National Jewish Health
      Asthma Toolkit Program.
      Following the MQii Toolkit’s initial development, a systematic QI process was undertaken to optimize the MQii Toolkit for clinical use.
      A number of QI frameworks can be implemented within a hospital to assess and improve clinical processes. One of the most widely used models is the plan-do-study-act (PDSA) cycle approach (Figure 1A). Through systematic, rapid cycles of change and improvement, QI teams evaluate the impact of improvement at regular intervals, determine whether initiatives have successfully resulted in change, and refine the process as necessary.
      Figure thumbnail gr1
      Figure 1Evaluating the effectiveness of the Malnutrition Quality Improvement Initiative (MQii) Toolkit. (A) Three complete cycles of the plan-do-study-act model were implemented to rapidly optimize the MQii Toolkit for clinical use. (B) In each cycle, the Toolkit content was assessed for and updated to improve its adaptability, usability, and functionality. QI=quality improvement.
      Three PDSA improvement cycles to rapidly test, evaluate, and revise the MQii Toolkit were implemented over an 18-month period (February 2016 through September 2017) across 55 participating hospitals. Each PDSA cycle comprised of implementing the MQii Toolkit, collecting and analyzing feedback from the hospitals, and revising the Toolkit to address limitations identified in the findings. Given that the adoption of innovative care processes into clinical practice can take up to 17 years,
      • Morris Z.S.
      • Wooding S.
      • Grant J.
      The answer is 17 years, what is the question: Understanding time lags in translational research.
      one goal of this undertaking was to produce a toolkit that could spur innovation by its ability to be rapidly customized to the unique needs, demographics, and resources of individual hospitals across the United States.
      Between each of the three PDSA cycles, qualitative data were collected to assess the utility of the MQii Toolkit across four domains: content, adaptability, usability, and functionality (Figure 1B). Recommendations within the MQii Toolkit were developed to be clinically relevant and comprehensive and to address the needs of patients and clinicians. Modifications and revisions to the MQii Toolkit related to the four domains were made after every cycle, in accordance with the principles of PDSA rapid-cycle improvement. The short turnaround time of the PDSA model allowed the MQii Toolkit Team to efficiently adapt and refine the Toolkit.

      PDSA Cycle 1

      PDSA cycle 1 consisted of an initial assessment of a paper-based toolkit by a single demonstration site during a preimplementation period. Initial feedback on the content, usability, functionality, and adaptability to the demonstration site’s unique circumstances was collected (Figure 2).
      Figure thumbnail gr2
      Figure 2Malnutrition Quality Improvement Initiative (MQii) Toolkit improvement cycles. QI=quality improvement.
      Feedback indicated that this first iteration of the MQii Toolkit was very difficult to navigate, that it was not always clear how the different sections should be used, and that it appeared to have limited adaptability to the unique implementation needs of the demonstration site. Thus, it was unclear whether the MQii Toolkit would be suitable for widespread uptake at other facilities.
      Modifications were made to the MQii Toolkit accordingly, in advance of the second PDSA cycle. Specifically, the document was reformatted to more clearly highlight the user learning objectives, clarifying to users how each section should be implemented, and helping users identify the sections most relevant to their unique QI project. These revisions were intended to enhance the usability and adaptability of the MQii Toolkit.

      PDSA Cycle 2

      The second PDSA assessment cycle occurred at the demonstration site and five additional hospitals, which received limited directions for their use of the MQii Toolkit to best approximate “real-world” circumstances.
      • Silver H.J.
      • Pratt K.J.
      • Bruno M.
      • Lynch J.
      • Mitchell K.
      • McCauley S.M.
      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.
      During the “plan” phase of the second PDSA cycle, sites identified opportunities for improvement in their malnutrition clinical workflow and modified available tools and resources (eg, educational training materials) within the MQii Toolkit to suit their hospitals’ needs. The “do” phase consisted of implementation of a QI project using these tools and resources. During the “study” phase of the cycle, the MQii Toolkit Team routinely collected insights from the sites.
      The MQii Toolkit had been improved after PDSA cycle 1, with users noting that it helped institutions identify and implement QI projects that uniquely addressed their specific nutrition challenges (Figure 2). However, feedback from PDSA cycle 2 suggested that resources supporting MQii Toolkit internal buy-in and adoption were lacking, and aspects of the MQii Toolkit’s usability and functionality still needed additional improvement. In response, several updates were made in advance of PDSA cycle 3 (Figure 2).
      Finally, the critical weakness of the MQii Toolkit was found to be its paper-based format. Therefore, an open access, web-based version of the MQii Toolkit incorporating cycle 2 modifications and stand-alone sections to increase navigability was developed.

      PDSA Cycle 3

      The third PDSA cycle comprised evaluations by 50 hospitals across 12 states. Facility registered dietitian nutritionists were interviewed by the MQii Toolkit Team to gather feedback about use of the Toolkit (Figure 2). Additional areas for improvement identified included difficulty regarding the recruitment of an interdisciplinary team and confusion about what was required vs recommended for team composition. The electronic medium produced mixed feedback: some portions of the MQii Toolkit were easier to use electronically, but the volume of information was found to be overwhelming, and it was not readily apparent how best to use the document when planning their intervention or communicating with specific frontline staff. Despite modifications and clear improvements following PDSA cycle 2, navigability of the MQii Toolkit remained the primary weakness (Figure 2).
      The use of the PDSA cycle approach to develop the MQii Toolkit allowed for rapid evaluation and improvement of the Toolkit to support its implementation. Although findings from the quantitative and qualitative research indicated that the navigability of the MQii Toolkit continues to be an area for improvement, users generally felt that the content of the Toolkit was clinically appropriate and that progress had been made in enhancing the usability and adaptability of the document.

      Next Generation

      A next generation of the MQii Toolkit has been developed and features streamlined content intended to reduce its overall size, reorganization of certain components to better align with recommended project steps, and consolidation of the resources deemed most beneficial to a site as it kicks off its QI initiative. These improvements were launched in 2018 by the MQii Toolkit Team, at which point the MQii had enrolled over 250 hospitals nationwide in the Learning Collaborative to implement malnutrition QI projects using the MQii Toolkit and, at some of the hospitals, a set of malnutrition-focused electronic clinical quality measures.

      How to Use the Latest Version of the MQii Toolkit

      The MQii Toolkit is accessible online at malnutritionquality.org, where the viewer is directed to a prominent maroon button labeled “Access the MQii Toolkit” (Figure 3A). For users unsure of how someone in their role within the hospital organizational structure can impact nutrition policies and practices, the welcome page also features drop-down tabs with more information for physicians, nurses, hospital executives, and patient advocates, to name a few (Figure 3B). If the user has interest in connecting with other hospitals engaged in QI or joining the Learning Collaborative, an orange and blue “learn more” arrow in the upper-right-hand corner of the screen redirects to a contact information form (Figure 3C). Furthermore, for users with limited experience in implementing clinical or malnutrition QI processes, the “MQii Principles and Models of Quality Improvement” section serves as a valuable primer before entering the Toolkit (Figure 3D).
      Figure thumbnail gr3
      Figure 3Navigating the Malnutrition Quality Improvement Initiative (MQii) Toolkit. Accessible online at malnutritionquality.org, the MQii Toolkit (A) is presented with background information for specific members of the quality improvement (QI) team (B), a link to engage with the MQii Learning Collaborative (C), a QI primer (D), readiness assessment tools (E), and links to short or long versions of the MQii Toolkit document in PDF format (F).
      For users who are unsure of their facility’s readiness for a QI initiative, the orange “Assess your Readiness” button in the left-hand menu bar will redirect to a self-administered readiness assessment survey comprising questions about the institution (Figure 3E). Points assigned for each of the 20 questions are tallied, and an assessment of the facility is provided for different score ranges.
      Once users are ready to prepare for their institution’s malnutrition QI initiative, follow the link to “Access the MQii Toolkit.” The Toolkit itself is organized into 10 navigable sections:
      • 1.
        About the MQii
      • 2.
        The MQii Toolkit
      • 3.
        Why implement the MQii in your facility
      • 4.
        Plan your initiative
      • 5.
        Select your QI focus
      • 6.
        Plan for data collection
      • 7.
        Begin implementation
      • 8.
        Keep it going
      • 9.
        Glossary of terms
      • 10.
        References
      • 11.
        Appendices
      Below this electronic workflow are orange buttons for downloading both the complete (78-page) and abbreviated (58-page) Toolkit documents in PDF format (Figure 3F). While navigating the Toolkit's supporting materials and preparing to implement the Toolkit at a facility, it may help to refer to the recommended malnutrition clinical workflow (Figure 4). This clinical workflow template delineates the steps that should be taken to assess and address malnutrition in patients, along with timeframes for implementing each step. The MQii Toolkit is designed to assist in the execution and improvement of this clinical workflow process.
      Figure thumbnail gr4
      Figure 4The recommended malnutrition clinical workflow. Guidelines for each step of the malnutrition assessment and treatment process are available on page 22 of the complete Malnutrition Quality Improvement Initiative Toolkit, found at malnutritionquality.org.

      Practice Applications

      Hospitalized patients, especially older adults, are often at risk of malnutrition, and addressing malnutrition in these patients improves both health and economic outcomes. Hospitals embarking on QI initiatives to improve their malnutrition screening, assessment, diagnosis, and treatment procedures may benefit from the use of supportive materials. One such tool, the MQii Toolkit, can provide the necessary resources clinicians need to enhance patient safety and improve outcomes.
      The MQii Toolkit is customizable for individual hospitals and enables the implementation of local QI projects tailored to the unique needs and availability of resources at individual institutions. Use of the MQii Toolkit ensures the adoption of standardized best practice recommendations through the provision of a single, easy-to-reference resource.
      The MQii Toolkit was developed and improved using the PDSA cycle QI approach, which provided a rigorous, evidence-based method for its systematic and efficient development, implementation, and modification. The continuous feedback process greatly enhanced the overall content, adaptability, usability, and navigability of the MQii Toolkit.
      These findings add to the growing body of research and guidance on the development of QI and patient safety toolkits. Stakeholders seeking to develop QI toolkits in the future may use this model when considering how to test and refine similar toolkits over short periods of time using real-world input and practical experience from frontline staff, thereby supporting faster and more effective uptake of the highest quality clinical evidence.

      Acknowledgements

      We thank Albert Barrocas, MD, FACS, FASPEN, and Beth N. Ogata, MS, RDN, for their critical review of the manuscript and the medical writers of C. Hofmann & Associates (Western Springs, IL) for editorial assistance with this manuscript.

      Author Contributions

      While affiliated with Avalere Health, E. Fitall led development and optimization of the toolkit and the writing of the manuscript. K. J. Pratt, S. M. McCauley, and K. Mitchell contributed to the toolkit design and testing and practice application section of the manuscript. G. Astrauskas, T. Heck, B. Hernandez, J. Johnston, and H. J. Silver led toolkit testing in their facilities and provided insights into its further development and clinical use. All authors reviewed and commented on subsequent drafts of the manuscript.

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      Biography

      E. Fitall is a research associate, IMPAQ International, Washington, DC.
      K. J. Pratt is associate principal, Avalere Health, Washington, DC.
      K. Mitchell is practice director, Avalere Health, Washington, DC.
      S. M. McCauley is senior director, Quality Management, Academy of Nutrition and Dietetics, Chicago, IL.
      G. Astrauskas is a clinical dietitian, Spring Valley Hospital Medical Center, Las Vegas, NV.
      T. Heck is clinical nutrition manager, Spring Valley Hospital Medical Center, Las Vegas, NV.
      B. Hernandez is director, Clinical Nutrition Services, Tampa General Hospital, Tampa, FL.
      J. Johnston is clinical nutrition manager/dietetic internship director, WVU Medicine—J.W. Ruby Memorial Hospital, Morgantown, WV.
      H. J. Silver is research associate professor of medicine, and director, Vanderbilt Diet, Body Composition and Human Metabolism Core, and director, Vanderbilt Metabolic Kitchen Core, Vanderbilt University Medical Center, Nashville, TN.