Malnutrition in Hospitalized Patients

Summary

This 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

• 📊 Malnutrition includes both undernutrition and overnutrition, with the focus in hospitals primarily on undernutrition.
• 🌍 The World Health Organization defines malnutrition as deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients.
• 🏥 Undernutrition is a significant concern in hospitalized patients and can lead to worsened health outcomes and prolonged hospital stays.
• 📅 Since 1996, hospitals in the U.S. have been required to screen all admitted patients for malnutrition within the first 24 hours.
• 🛠️ Various screening tools like the Malnutrition Screening Tool (1999) and Nutrition Risk Screening (2002) have been developed to streamline early detection.
• 🔬 A comprehensive assessment for malnutrition includes medical history, physical examination, anthropometrics, and lab data, typically performed by dietitians.
• 📉 Malnutrition in hospitalized patients leads to muscle mass loss, impaired immune response, and delayed wound healing, increasing the risk of infections and complications.
• 💰 Accurate diagnosis and documentation of malnutrition can increase hospital reimbursement and justify the allocation of resources for better care.
• 📋 Recent trends emphasize the standardization of malnutrition assessment tools to ensure consistency in diagnosis and facilitate better research and education.
• ✔️ 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

00:00

🏥 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.

05:01

📊 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.

10:02

📚 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.

Keywords

💡Malnutrition

Malnutrition refers to deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients. In the context of the video, it specifically denotes undernutrition, which is a common issue among hospitalized patients and can lead to severe health consequences. The video emphasizes the importance of identifying and addressing malnutrition in clinical settings to improve patient outcomes.

💡Overnutrition

Overnutrition is a type of malnutrition characterized by an excessive intake of nutrients, leading to conditions like overweight and obesity. The video mentions that overnutrition is more widespread in the United States, affecting over 40% of the adult population, but the focus of the video is on undernutrition in hospitalized patients.

💡Undernutrition

Undernutrition is a state where an individual lacks essential nutrients, which can occur at any body size. The video discusses undernutrition as a prevalent issue among sick and hospitalized patients, which can have devastating health consequences if not addressed.

💡Subjective Global Assessment (SGA)

The Subjective Global Assessment is a tool created in the 1980s to classify patients as well nourished, moderately malnourished, or severely malnourished based on nutrition assessment data. It is highlighted in the video as a significant step towards identifying patients at risk of malnutrition.

💡Nutrition Screening

Nutrition screening is a process to identify individuals who are malnourished or at risk of malnutrition, determining if a detailed nutrition assessment is needed. The video explains that all hospitalized patients in the U.S. must undergo nutrition screening within the first 24 hours of admission.

💡Malnutrition Screening Tool

The Malnutrition Screening Tool is one of the tools mentioned in the video, used to identify patients at risk of malnutrition. It is part of the suite of tools developed in response to the joint commission's mandate for nutrition screening.

💡Nutrition Assessment

Nutrition assessment is a comprehensive approach to defining a patient's nutrition status, involving medical nutrition and medication histories, physical examination, anthropometric measurements, and laboratory data. It is a more in-depth process than screening and is typically performed by a registered dietitian.

💡Academy of Nutrition and Dietetics

The Academy of Nutrition and Dietetics is a professional organization that plays a significant role in establishing criteria for assessing and diagnosing malnutrition. In the video, it is noted for its collaboration with other societies to create standardized criteria and its recommendation of specific tools for malnutrition screening and assessment.

💡Malnutrition Universal Screening Tool

The Malnutrition Universal Screening Tool (MUST) is one of the tools developed in the late 1990s and early 2000s to streamline the nutrition screening process in hospitals. It is an example of how the medical community has responded to the need for efficient and effective malnutrition identification.

💡Global Leadership Initiative on Malnutrition

The Global Leadership Initiative on Malnutrition is a collaborative effort between leading clinical nutrition societies, including the Academy of Nutrition and Dietetics, to create a unified set of criteria for malnutrition assessment. This initiative is mentioned in the video as part of the push for more consistency in malnutrition care.

💡Etiology-based Classification System

An etiology-based classification system seeks to identify the cause of malnutrition or the context in which it has occurred. The video describes how this system, established by the Academy and ASPEN in 2012, guides the assessment process by categorizing patients into groups based on factors like acute illness, chronic disease, or social/environmental circumstances.

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