February 22, 2018

Initiative seeks to address malnutrition among adult patients

It is estimated that nearly one out of five pediatric patients and one of three adult patients age 60 and older are malnourished and will experience a decline in their nutritional status during their hospital stay.


It is estimated that nearly one out of five pediatric patients and one of three adult patients age 60 and older are malnourished and will experience a decline in their nutritional status during their hospital stay.

Recently, Vanderbilt University Medical Center (VUMC) participated in a novel study to address this issue directly by providing an education and training intervention with healthcare providers. From January to July 2016, VUMC was the primary test site for implementing the Malnutrition Quality Improvement Initiative (MQii) study led by principal investigator Heidi Silver, PhD, RD, MS, associate professor of Gastroenterology, Hepatology and Nutrition.

Heidi Silver, PhD, RD, MS

Vanderbilt and multiple hospitals nationwide implemented resources and tools developed by the Alliance to Advance Patient Nutrition to combat adult malnutrition. The Alliance is comprised of more than 60 stakeholders nationwide including the Academy of Nutrition and Dietetics, the Academy of Medical and Surgical Nurses, the American Society for Parenteral and Enteral Nutrition and the Society for Hospital Medicine.

“Nationwide, 30-50 percent of adult patients have malnutrition at admission or develop malnutrition while hospitalized. But only 5-10 percent actually have a medical diagnosis of malnutrition documented in the electronic medical record. It’s not a VUMC problem — it’s a pervasive and serious healthcare problem nationwide,” Silver said.

VUMC was the only hospital to study the effects of the intervention and analyze data. For three months, 45 healthcare professionals from the VUMC geriatric, general medicine, and general surgery units were trained and educated during numerous intervention sessions on ways to improve screening, assessment, diagnosis and treatment for malnutrition.

“We designed and implemented a program that was tailored to the specific roles of the 45 healthcare practitioners. We also tailored the intervention to enable providing education modules within the existing clinical and teaching workflow of our hospital,” Silver said. “In addition, we provided information in the form of presentations and handouts to all first- and second-year medical and surgical residents since these residents have such a substantial impact on the delivery of care.”

Resources — such as pocket-sized flip charts with pictures of the physical signs of malnutrition that include loss of muscle in the temporalis, scapula or clavicle area; loss of fat pad in the suborbital area; pitting edema at the ankle; skin turgor; and hair, nail and tongue changes — were provided to enable practitioners to quickly identify and diagnose malnutrition at a patient’s bedside. Emphasis was also placed on identifying the six key clinical symptoms of malnutrition in adult patients: weight loss, poor appetite, fat loss, muscle mass loss, edema and reduced handgrip strength.

At the same time as the intervention sessions were occurring, the Vanderbilt Institute for Clinical and Translational Research (VICTR) informatics department was collecting data from the back end of the electronic medical record to track the outcomes of the intervention.

“Data was collected on all patients in the three units targeted who were 65 years and older because they are at the highest risk for malnutrition,” Silver said. “Prior to the intervention, we administered a malnutrition knowledge questionnaire to the 45 healthcare practitioners. Over the course of the three-month intervention, we had a 14 percent improvement in malnutrition knowledge scores.”

The results of the study also showed a 12 percent improvement in the percentage of patients who had both a dietitian and a medical provider diagnosis of malnutrition in the electronic health record, and a 9 percent improvement in the percentage of patients with malnutrition who had malnutrition-specific care documented in their discharge plan.

While malnutrition is typically recognized in children, due to the substantial focus on growth and development during childhood, the adult patient population is underserved when it comes to recognizing, diagnosing and treating malnutrition.

“It is important to understand that malnutrition contributes to immune system compromise, infections, surgical complications, poor wound healing, development of pressure sores, physical frailty, falls and fractures and mortality,” explained Silver.

“The gaps in diagnosis and treatment of malnutrition also affect older adults and our healthcare system by promoting longer hospital stays, more ICU admissions, more hospital readmissions and admissions to assisted living and nursing homes.”

The study data showed that length of hospital stay was two-three days longer for patients with malnutrition and 30-day readmission rates were about 2 percent higher.

One positive outcome of the publishing of the study findings has been the creation of a National “Blueprint: Achieving Malnutrition Care for Older Adults” that is being used to encourage the Centers for Medicare and Medicaid Services (CMS) and other federal agencies to implement malnutrition quality measures and other programs to help the millions of Americans suffering from malnutrition by addressing malnutrition care policies across the continuum of acute, post-acute, community, and long-term healthcare settings.