May 19, 2016

VUMC to be site for national malnutrition study

Vanderbilt University Medical Center is the test site for a nationwide initiative to address the longstanding problem of malnutrition in hospital patients.

Vanderbilt University Medical Center is the test site for a nationwide initiative to address the longstanding problem of malnutrition in hospital patients.

In 1974, Harvard surgeon and nutrition specialist Charles Butterworth, M.D., wrote, “The Skeleton in the Hospital Closet,” one of the first reports detailing the widespread incidence of hospital-acquired malnutrition and the failure of identify and treat patients.

More than 40 years later hospitals nationwide are not doing much better.

“There remains a huge gap in clinical practice nationwide between the presence of malnutrition and actual diagnosing and treating of malnutrition,” said Heidi Silver, Ph.D., R.D., research associate professor of Medicine and director of the Vanderbilt Diet, Body Composition and Human Metabolism Core.

Heidi Silver, Ph.D., R.D.
Heidi Silver, Ph.D., R.D.

“Nationwide, 30-50 percent of patients hospitalized have or are at high risk for malnutrition, but only 5 percent actually receive a treatment plan to address their malnutrition. It’s not a VUMC problem; it’s a pervasive nationwide problem.”

Avalere Health and the Academy of Nutrition and Dietetics, with support provided by Abbott, established the MQII to raise awareness about malnutrition and improve coordinated, evidence-based and patient-driven malnutrition care for hospitalized older adults (65+) from admission thru discharge using an interdisciplinary care team toolkit.

Silver is the principal investigator for the Malnutrition Quality Improvement Initiative (MQII) Study.

The MQI study at VUMC began in January and will have ongoing intervention and data collection until mid-July. While other hospitals around the country are using the resources and tools provided by the Alliance at their website, only Vanderbilt is testing an intervention.

Silver’s research team is enrolling VUMC health care practitioners and providing training and education sessions to better prepare them to identify, diagnose and treat malnutrition.

Handy flip charts have been widely distributed to help health providers quickly identify physical signs of malnutrition such as loss of weight in the temple area, pitting edema, skin changes, hair loss and more. It also helps to identify the six key symptoms to identify malnutrition in patients: weight loss, poor appetite, fat loss, muscle mass loss, edema and loss of grip strength.

“The sessions have been well received and we have had much positive feedback,” she said.

At the same time as the intervention sessions, the Vanderbilt Institute for Clinical and Translational Research (VICTR) is collecting patient data to track outcomes. Data is being collected from patients 65 and older because they are at highest risk for malnutrition, Silver said.

Historically, malnutrition is believed to be a highly visible disorder identified mostly by extreme weight loss and having a starved appearance, but Silver said one of the biggest challenges has been identifying malnutrition in overweight and obese patients.

“In all health care settings, an obesity malnutrition paradox exists,” Silver said. “For example, in our studies with patients who have had surgical resection over the past 10 years, only 5-10 percent are underweight, but 40-50 percent meet the criteria for malnutrition. In today’s clinical environment, we have a new form of malnutrition, sarcopenic obesity, where patients with malnutrition have a high BMI (body mass index) but low muscle mass. This is the most common form of malnutrition today.”

The adverse outcomes of hospital malnutrition include impairment of the immune system, infections, delayed wound healing, skin breakdown, development of fistulas and pressure sores and even falls.

Malnutrition is associated with longer lengths of hospital stay, increased admissions to the ICU, longer ICU stays, higher 30-day readmission rates, increased mortality and higher health care costs. All of these outcomes could be linked to the acute illness or injury, and thus be overlooked as consequences of malnutrition. Yet malnutrition compounds the acute problems, Silver said.

The goal of the study at VUMC is to help health care practitioners across the country by creating a model for better diagnosing and intervening to treat malnutrition in patients. In addition, there is a great need for nutrition care, especially malnutrition care, to be part of the discharge planning process and post-hospital discharge care to improve health outcomes and reduce costs, Silver said.

“There needs to be a more holistic approach and a greater understanding of the role of malnutrition in patient and health care outcomes, and it should be addressed in hospital practice,” Silver said.