Malnutrition in Hospitalized Patients
Summary
TLDRThis video provides an overview of malnutrition in hospitalized patients, focusing on undernutrition. It explores the definition of malnutrition by the WHO and its impact on patient outcomes, including complications like infections, longer hospital stays, and higher mortality rates. The video traces the history of malnutrition awareness, from Dr. Butterworth's 1974 paper to the development of modern screening and assessment tools. It highlights the importance of early detection, nutrition interventions, and standardized assessment practices in ensuring proper care, as well as the financial implications for hospitals in diagnosing malnutrition.
Takeaways
- π Malnutrition includes both undernutrition and overnutrition, with the focus in hospitals primarily on undernutrition.
- π The World Health Organization defines malnutrition as deficiencies, excesses, or imbalances in a personβs intake of energy and/or nutrients.
- π₯ Undernutrition is a significant concern in hospitalized patients and can lead to worsened health outcomes and prolonged hospital stays.
- π Since 1996, hospitals in the U.S. have been required to screen all admitted patients for malnutrition within the first 24 hours.
- π οΈ Various screening tools like the Malnutrition Screening Tool (1999) and Nutrition Risk Screening (2002) have been developed to streamline early detection.
- π¬ A comprehensive assessment for malnutrition includes medical history, physical examination, anthropometrics, and lab data, typically performed by dietitians.
- π Malnutrition in hospitalized patients leads to muscle mass loss, impaired immune response, and delayed wound healing, increasing the risk of infections and complications.
- π° Accurate diagnosis and documentation of malnutrition can increase hospital reimbursement and justify the allocation of resources for better care.
- π Recent trends emphasize the standardization of malnutrition assessment tools to ensure consistency in diagnosis and facilitate better research and education.
- βοΈ The Malnutrition Screening Tool (1999) and the etiology-based assessment tool from the Academy and Aspen (2012) are recommended for consistent screening and diagnosis across hospitals.
Q & A
What is the World Health Organization's definition of malnutrition?
-The World Health Organization defines malnutrition as deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients. This includes overnutrition (such as overweight and obesity) and undernutrition (a lack of essential nutrients).
Why is undernutrition a focal point in the context of hospitalized patients?
-Undernutrition is common among hospitalized patients and can have devastating consequences, including worse health outcomes, longer hospital stays, increased risk of infection, and delayed recovery. As a result, addressing undernutrition is a priority in clinical nutrition.
What was the significance of Dr. Charles E. Butterworth's 1974 paper 'The Skeleton in the Hospital Closet'?
-Dr. Butterworth's paper highlighted the widespread presence of unrecognized malnutrition in hospitals. He argued that malnutrition was a common issue among hospitalized patients due to neglect of nutrition in medical education and healthcare systems.
What is the purpose of the subjective global assessment (SGA) tool created in the 1980s?
-The subjective global assessment (SGA) tool was developed to classify patients as well-nourished, moderately malnourished, or severely malnourished. It is recognized as a valid and reliable tool for assessing malnutrition.
What role does the Joint Commission play in addressing malnutrition in hospitals?
-In 1996, the Joint Commission mandated that all hospitalized patients undergo nutrition screening within the first 24 hours of admission. This ensures early identification of those at risk for malnutrition and enables them to receive specialized nutrition care.
What are some examples of screening tools used to identify malnutrition in hospitals?
-Examples of malnutrition screening tools include the Malnutrition Screening Tool (1999), Nutrition Risk Screening 2002 (2002), Malnutrition Universal Screening Tool (2003), and Short Nutrition Assessment Questionnaire (2005).
Why is it important to diagnose and document malnutrition in the hospital's electronic medical record (EMR)?
-Diagnosing and documenting malnutrition in the EMR ensures that patients receive appropriate care and helps hospitals receive higher reimbursement for treatment. It also contributes to better resource allocation for malnourished patients.
What impact does malnutrition have on patient outcomes and hospital resources?
-Malnourished patients experience worse outcomes, such as longer hospital stays, higher readmission rates, and increased mortality. They also require more resources, including nutrition support, wound care, additional medications, and life-saving therapies.
How does the Academy of Nutrition and Dietetics recommend screening and assessing for malnutrition?
-The Academy recommends using the Malnutrition Screening Tool within the first 24 hours of hospital admission. If the patient's score is 2 or higher, they should undergo a full nutrition assessment using criteria established by the Academy and ASPEN in 2012, which include six clinical characteristics like energy intake and muscle loss.
What are the six clinical characteristics used in the malnutrition assessment tool created by the Academy and ASPEN?
-The six clinical characteristics are energy intake, weight loss, loss of subcutaneous fat, muscle loss, fluid accumulation, and reduced grip strength. A patient is diagnosed with malnutrition if they meet the criteria for at least two of these characteristics.
Outlines
π₯ Overview of Malnutrition in Hospitals
This paragraph introduces the topic of malnutrition within the hospital setting. It defines malnutrition as per the World Health Organization, encompassing both overnutrition and undernutrition. The focus is on undernutrition in hospitalized patients, which is common and can lead to severe health consequences. The historical context is provided, highlighting that malnutrition in hospitals was not widely recognized until Dr. Charles E. Butterworth's 1974 publication. The paragraph also outlines the evolution of malnutrition assessment tools, starting with the Subjective Global Assessment in the 1980s, followed by the Joint Commission's mandate for nutrition screening in 1996, and the development of various screening tools in the late 1990s and early 2000s. The paragraph concludes with the establishment of criteria for malnutrition assessment by professional organizations in the 2010s.
π The Process of Malnutrition Screening and Assessment
This paragraph delves into the processes of malnutrition screening and assessment in hospitals. Screening is described as a quick method to identify patients who are malnourished or at risk, typically performed by nursing staff within 24 hours of admission. Assessment, on the other hand, is a more comprehensive and detailed approach conducted by a registered dietitian. The paragraph emphasizes the importance of early identification and intervention for malnutrition, as it is linked to worse patient outcomes, including longer hospital stays, increased risk of readmission, and higher mortality rates. It also discusses the financial implications of malnutrition documentation, as it can affect the reimbursement hospitals receive and may lead to increased resources for patient care.
π Current Guidance for Malnutrition Screening and Assessment
The final paragraph discusses the current guidance from the Academy of Nutrition and Dietetics for malnutrition screening and assessment. It highlights the push for standardization across facilities to simplify education and research. The Academy recommends the use of the Malnutrition Screening Tool for all patients, regardless of age or medical history. This tool consists of three questions related to weight loss, appetite, and food intake, with scores indicating the risk of malnutrition. For a formal diagnosis, the Academy suggests using their assessment tool created with ASPEN in 2012, which is etiology-based and considers six clinical characteristics. The paragraph outlines the steps for using these tools, from initial screening to full assessment by a dietitian, and the importance of a formal diagnosis for hospital reimbursement.
Mindmap
Keywords
π‘Malnutrition
π‘Overnutrition
π‘Undernutrition
π‘Subjective Global Assessment (SGA)
π‘Nutrition Screening
π‘Malnutrition Screening Tool
π‘Nutrition Assessment
π‘Academy of Nutrition and Dietetics
π‘Malnutrition Universal Screening Tool
π‘Global Leadership Initiative on Malnutrition
π‘Etiology-based Classification System
Highlights
The World Health Organization defines malnutrition as deficiencies, excesses, or imbalances in a person's intake of energy and nutrients.
Overnutrition, including obesity, is a widespread problem in the U.S., but undernutrition is common among hospitalized patients, leading to severe consequences.
Malnutrition in hospitals gained attention in 1974 with Dr. Charles E. Butterworth's paper, which highlighted its prevalence in hospital settings.
In 1996, the Joint Commission mandated nutrition screening within 24 hours of hospital admission to identify at-risk patients.
Several malnutrition screening tools emerged between the late 1990s and early 2000s, including the Malnutrition Screening Tool (1999), Nutrition Risk Screening 2002, and the Malnutrition Universal Screening Tool (2003).
In 2012, the Academy of Nutrition and Dietetics and ASPEN established a new set of malnutrition assessment criteria, which was expanded upon by European and global clinical nutrition societies in 2015 and 2018.
Malnutrition screening is performed by nursing staff upon admission, while detailed nutrition assessments are conducted by registered dietitians for patients at risk.
Malnutrition results in a decline in functional status, poor immune response, and delayed recovery, often leading to increased hospital stays and readmissions.
A formal diagnosis of malnutrition can increase hospital reimbursements by documenting it as a secondary diagnosis, which helps secure additional resources for care.
Hospitals may see an increase in base rates if they consistently diagnose and document malnutrition, emphasizing its financial significance.
Diagnosing malnutrition not only improves patient care but also demonstrates the value of dietitians in healthcare systems.
Recent efforts aim to standardize malnutrition screening and assessment tools across all facilities, improving education, research, and patient outcomes.
The Academy of Nutrition and Dietetics published a position paper in 2020 recommending the use of the Malnutrition Screening Tool (MST) across all patient demographics.
The MST comprises three simple questions about recent weight loss and decreased appetite, with a score of 2 or higher indicating the need for a full nutrition assessment.
The Academy and ASPEN's 2012 assessment tool uses six clinical characteristics, including energy intake, weight loss, muscle loss, and fluid accumulation, to diagnose malnutrition.
Transcripts
you're watching cnu where you can learn
everything you need to know to provide
excellent nutrition care and feel
confident doing it today i have an
overview of malnutrition in the hospital
for you let's get started
the world health organization defines
malnutrition as deficiencies excesses or
imbalances in a person's intake of
energy and or nutrients
this includes over nutrition such as
overweight and obesity and under
nutrition which involves an overall lack
of essential nutrients that can occur at
any body size
overnutrition is a more widespread
problem in the united states with over
40 percent of the adult population
considered to have obesity
nevertheless when it comes to those who
are sick and hospitalized undernutrition
is a common occurrence that can have
devastating consequences
addressing undernutrition has therefore
been an emphasis of research and policy
for clinical nutrition and will
therefore be the focal point of this
video from this point forward
malnutrition will be used to indicate
undernutrition only
malnutrition among sick and hospitalized
patients isn't a modern concept however
it wasn't brought to the forefront of
conversation in the medical community
until
1974 with the publication of the
skeleton in the hospital closet by dr
charles e butterworth
in this paper dr butterwear said i
suspect that one of the largest pockets
of unrecognized malnutrition in america
and canada too exists not in rural slums
or urban ghettos but in the private
rooms and wards of big city hospitals
he also described malnutrition as a
common accompaniment to the stress of
illness among hospitalized patients
that's rooted in long-standing neglect
of nutrition in medical education and in
health care delivery systems
since then major steps have been taken
to identify patients who are at risk of
malnutrition as well as those who
already have it in the 1980s the
subjective global assessment was created
this tool uses data collected during the
nutrition assessment to classify
patients as either well nourished
moderately malnourished or severely
malnourished and is widely recognized as
being both valid and reliable
then in 1996 a mandate for nutrition
screening was made by the joint
commission which is an organization that
provides accreditation to hospitals in
the united states
it requires that all hospitalized
patients undergo a nutrition screening
process within the first 24 hours of
admission so that those who require
specialized nutrition care will receive
it to streamline this process the
mandate was met with the production of a
number of screening tools in the late
1990s and early 2000s
examples include the malnutrition
screening tool in 1999
the nutrition risk screening 2002 in
2002
the malnutrition universal screening
tool in 2003
and the short nutrition assessment
questionnaire in 2005.
finally in the 2010s we saw an expansion
of malnutrition assessment and
diagnostic tools
in 2012 the academy of nutrition and
dietetics and the american society of
parenteral and enteral nutrition came
together to establish their own criteria
to assess for and diagnose malnutrition
this was followed by a set of criteria
published by the european society of
clinical nutrition and metabolism in
2015.
then both of these organizations came
together with other leading clinical
nutrition societies to create a third
set of criteria called the global
leadership initiative on malnutrition
this was done in 2018.
all of this is to show the
infrastructure that's now in place to
catch malnutrition early on
when a patient presents to the hospital
screening for malnutrition occurs right
away
screening is the process to identify an
individual who is malnourished or who is
at risk for malnutrition to determine if
a detailed nutrition assessment is
indicated screening tools are meant to
be quick and simple and are usually
performed by the nursing staff in the
first 24 hours of admission
assessment is the comprehensive approach
to defining nutrition status that uses
medical nutrition and medication
histories physical examination
anthropometric measurements and
laboratory data
compared to screening assessment is a
more in-depth process and is typically
performed by a registered dietitian
if the patient meets the criteria for
malnutrition that's specified in the
assessment tool being used then a formal
diagnosis of malnutrition can be made
even though there's a number of options
available medical institutions generally
choose just one screening tool and one
assessment tool to use
this way there's consistency in the
identification of malnutrition the
documentation of malnutrition in the
electronic medical record and the
training of hospital staff
identifying malnutrition early on and
applying nutrition interventions is
important because patients with
malnutrition experience worse outcomes
than patients without it
when inadequate energy and protein
intake results in loss of muscle mass it
can lead to a significant decline in
functional status making it difficult
for patients to get out of bed and
perform daily activities like shopping
for and preparing food
this serves as a barrier to discharging
the patient home and increases the risk
of pressure injuries
malnutrition will also contribute to an
impaired immune response and poor wound
healing which increases the risk of
infection and delays recovery from
surgery
overall compared to patients without
malnutrition patients with malnutrition
experience a longer length of stay are
more likely to be readmitted to the
hospital within 30 days of discharge and
are more likely to die of any cause
while hospitalized
with these consequences in mind we can
see that malnutrition increases the
resources needed to provide excellent
patient care
patients with malnutrition often require
the provision of nutrition support and
or oral nutritional supplements
pressure injuries often require
specialized wound care
infections require additional
medications like antibiotics
and critical illness can require
life-saving therapies like mechanical
ventilation and hemodialysis
providing a formal diagnosis of
malnutrition and documenting it in the
electronic medical record is necessary
because it helps to address this cost
hospitals receive a reimbursement for
the care they provide which is paid for
by medicare medicaid a private insurance
company or by the patient themselves
the amount paid is based on a number of
factors such as the principal diagnosis
any secondary diagnoses and the base
rate of the hospital which is determined
by things like the demographics of the
patient population and the severity of
illness at the facility
while malnutrition is not a common
principle diagnosis in many cases it can
be added as a secondary diagnosis to the
patient's stay
when there's appropriate documentation
of it it will lead to a higher
reimbursement for the single admission
when this is done consistently a
hospital that has a lot of patience with
malnutrition may see an increase in the
base rate that's assigned to it
even though most clinicians are more
concerned with providing patient care
than they are the finances of the
hospital contributing to reimbursement
will help to ensure the hospital has the
resources it needs to function
for nutrition professionals diagnosing
malnutrition is one of the only ways to
demonstrate that their expertise adds
value in the form of dollar signs
this should serve as an incentive for
dietitians to master malnutrition
assessment and diagnosis because it's a
path to pay increases and or the hiring
of additional staff members
the final section of this video is going
to explore the current guidance from the
academy of nutrition and dietetics
in recent years there's been a push to
establish more consistency with the
screening and assessment tools that are
used
this isn't just within one facility as
was mentioned previously but across all
facilities to make diagnosis a more
standardized practice in the profession
one reason for this is to simplify
education not only for nutrition
students but for clinicians of all
disciplines who need to be aware of the
presence importance and consequences of
malnutrition in hospitals
another reason for the standardization
of malnutrition care is for research
purposes
when different screening and assessment
tools are used it's more difficult to
collect and analyze data which in turn
makes it more difficult to determine the
prevalence of malnutrition and monitor
the trends
in 2020 the academy published a formal
position paper that recommends the use
of the malnutrition screening tool
regardless of age medical history or
setting
this tool was created by ferguson at all
in 1999 and has since been validated in
both acute and long-term settings
it's composed of three simple questions
have you lost weight recently without
trying if yes how much weight have you
lost and finally have you been eating
poorly because of a decreased appetite
the possible responses to each question
have an associated score and if the
patient receives a total score of 2 or
higher then they're considered to be at
risk of malnutrition and should undergo
a full nutrition assessment
to complete the assessment for
malnutrition and see if a formal
diagnosis is warranted the academy
recommends using the assessment tool
they created with aspen in 2012.
this work established an etiology-based
classification system which means that
it seeks to identify the cause of
malnutrition or at least the context in
which it has occurred
when using it the first step is to
figure out which category the patient
belongs in
acute illness or injury chronic disease
or social or environmental circumstances
once the etiology is determined then the
information collected in the nutrition
assessment can be compared to parameters
set forth for six different clinical
characteristics
those characteristics are energy intake
weight loss
loss of subcutaneous fat muscle loss
fluid accumulation and reduced grip
strength
if the patient satisfies the criteria
that's outlined for at least two of the
characteristics then a formal diagnosis
of malnutrition can be made
malnutrition is classified as moderate
or severe depending on the objective and
subjective information that's obtained
during the assessment
looking at the recommendations from the
academy from a bird's eye view we can
see that when a patient presents to the
hospital they should undergo nutrition
screening using the malnutrition
screening tool in the first 24 hours of
their admission
if their score is less than 2 then
they're not at risk of malnutrition so
no nutrition assessment is automatically
necessary
but if their score is 2 or higher then
they are at risk of malnutrition and
should therefore undergo a full
nutrition assessment by a registered
dietitian
as part of the assessment consideration
should be given to the malnutrition
criteria that's outlined by the academy
and aspen starting with the etiology
then the data collected should be
compared to the parameters set forth for
the six clinical characteristics
if the patient satisfies the criteria
for at least two of those
characteristics then a formal diagnosis
should be made which contributes to the
reimbursement for the hospital
in the next video i'm gonna spend more
time digging into the academy and aspen
malnutrition assessment tool
thanks for watching and i'll see you
guys there
you
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