Health System Quality Improvement: Impact of Prompt Nutrition Care on Patient Outcomes and Health Care Costs

Survey of nutrition screening practices in pediatric hospitals across the United States

BACKGROUND

Nutrition screening on admission is critically important to systematically identify patients with undernutrition given the known relationship with deleterious clinical outcomes. Limited data exist regarding optimal processes and criteria for pediatric nutrition screening. Therefore, we sought to characterize nutrition screening practices in pediatric hospitals.

METHODS

A total of 365 inpatient pediatric hospitals in the United States were identified, eligible, and contacted. Eligible hospitals included general pediatric hospitals, adult hospitals with pediatric units, and specialty pediatric hospitals. One respondent at each eligible hospital was asked to complete a 33-question survey of admission nutrition screening practices.

RESULTS

Of 268 survey respondents, 37% represented pediatric units in adult hospitals, 35% general pediatric hospitals, and 28% pediatric specialty or psychiatric hospitals. A total of 98.5% endorsed the existence of a screening process on admission. Anthropometrics (eg, body mass index z score, 84%) and nutrition status (eg, change in intake, 67%) were the most common screening criteria applied. A nutrition screening instrument was used in 37% of institutions, and only 31% of institutions reported using pediatric-specific screening instruments. Pediatric units within adult hospitals were 1.38 times more likely to use a screening instrument validated in any population. Barriers to nutrition screening included the lack of a standard screening procedure and insufficient staff to conduct screening. Fifty-four percent of respondents reported a desire to change their hospital's nutrition screening process.

CONCLUSION

Most pediatric hospitals screen for nutrition risk on admission. However, methods and criteria varied widely across pediatric hospitals, highlighting the importance of standardized best practices.

The Global Malnutrition Composite Score: Impacting malnutrition care

The presence and impact of malnutrition in adult hospitalized patients has been well documented by a significant body of literature. However, current malnutrition care practices often vary widely and frequently lack standardization. The Global Malnutrition Composite Score (GMCS), the first nutrition-related electronic clinical quality measure, is intended to evaluate the quality of malnutrition care provided to inpatient adults. This measure aims to aid in standardizing malnutrition care through performance measurement. The four components of the measure (nutrition screening, nutrition assessment, malnutrition diagnosis, and nutrition care plans) follow the well-established Nutrition Care Process and encourage the use of standardized terminology. Facilities with high-performance scores on the GMCS are likely to experience improved outcomes associated with high-quality malnutrition care.

Preoperative nutritional status and postoperative health outcomes in older adults undergoing spine surgery: Electronic health records analysis

AIM

To examine whether a high nutritional risk status, assessed via the Geriatric Nutritional Risk Index (GNRI), is independently associated with postoperative health outcomes, including unplanned intensive care unit (ICU) admissions, infectious complications, and prolonged length of stay in older patients undergoing spine surgery.

METHODS

We conducted a retrospective descriptive study analyzing electronic health records from a tertiary hospital, including data from 1,014 patients aged ≥70 undergoing elective spine surgery between February 2013 and March 2023.

RESULTS

High nutritional risk patients had significantly higher odds of unplanned ICU admission, infectious complications, and prolonged length of stay compared to low-risk patients. For each one-point increase in GNRI, there was a significant 0.91- and 0.95-fold decrease in the odds of unplanned ICU admission and infectious complications, respectively.

CONCLUSION

GNRI screening in older patients before spine surgery may have potential to identify those at elevated risk for postoperative adverse outcomes.

Improving Administration and Documentation of Enteral Nutrition Support Therapy in a Veteran Affairs Health Care System: Use of Medication Administration Record and Bar Code Scanning Technology

OBJECTIVES

The goal of this project was to evaluate and improve the ordering, administration, documentation, and monitoring of enteral nutrition therapies within the inpatient setting in a Veteran's Health Administration system.

METHODS

An interdisciplinary team of clinicians reviewed the literature for best practices and revised the process for enteral nutrition support for hospitalized veterans. Interventions included training staff, revising workflows to include scanning patients and products, including enteral nutrition orders within the medication administration record (MAR), and using the existing bar code medication administration system for administration, documentation, and monitoring. Baseline and postprocess improvement outcomes over a year period were collected and analyzed for quality improvement opportunities.

RESULTS

Before process change, only 60% (33/55) of reviewed enteral nutrition orders were documented and 40% (22/55) were not documented in the intake flowsheet of the electronic health record. In the year after adding enteral nutrition therapies to the MAR and using bar code scanning, a total of 3807 enteral nutrition products were evaluated. One hundred percent of patients were bar code scanned, 3106/3807 (82%) products were documented as given, 447/3807 (12%) were documented as held (with comments), 12/3807 (<1%) were documented as missing/unavailable, and 242/3807 (6%) were documented as refused.

CONCLUSIONS

Inclusion of enteral nutrition order sets on the MAR and using bar code scanning technology resulted in sustained improvements in safety, administration, and documentation of enteral therapies for hospitalized veterans.

Nutrition-Focused Care for Community-Living Adults: Healthcare Utilization and Economic Benefits

OBJECTIVES

We assessed the impact of a recently reported nutritional quality improvement program (QIP) on healthcare resource utilization and costs for older, community-living adults in Bogotá, Colombia.

METHODS

The study included 618 community-dwelling, older adults (> 60 years) who were at risk or malnourished and receiving outpatient clinical care. The intervention was a QIP that emphasized nutritional screening, dietary education, lifestyle counseling, 60-day consumption of oral nutritional supplements, and 90-day follow-up. For economic modeling, we performed 90-day budget impact and cost-effectiveness analyses from a Colombian third-party payer perspective. The base-case analysis quantified mean healthcare resource use in the QIP study population. Analysis was based on mean input values (deterministic) and distributions of input parameters (probabilistic). As the deterministic analysis provided a simple point estimate, the cost-effectiveness analysis focused on the probabilistic results informed by 1000 iterations of a Monte-Carlo simulation.

RESULTS

Results showed that the total use of healthcare resources over 90 days was significantly reduced by > 40% (hospitalizations were reduced by approximately 80%, emergency department visits by > 60%, and outpatient clinical visits by nearly 40%; P < .001). Based on economic modeling, total cost savings of $129 740 or per-patient cost savings of $210 over 90 days could be attributed to the use of nutritional QIP strategies. Total cost savings equated to nearly twice the initial investment for QIP intervention; that is, the per-dollar return on investment was $1.82.

CONCLUSIONS

For older adults living in the community in Colombia, the use of our nutritional QIP improved health outcomes while lowering costs of healthcare and was thus cost-effective.

Economic Evaluation of Individualized Nutritional Support for Hospitalized Patients with Chronic Heart Failure

Background Malnutrition is a highly prevalent risk factor in hospitalized patients with chronic heart failure (CHF). A recent randomized trial found lower mortality and improved health outcomes when CHF patients with nutritional risk received individualized nutritional treatment. Objective To estimate the cost-effectiveness of individualized nutritional support in hospitalized patients with CHF. Methods This analysis used data from CHF patients at risk of malnutrition (N = 645) who were part of the Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial (EFFORT). Study patients with CHF were randomized into (i) an intervention group (individualized nutritional support to reach energy, protein, and micronutrient goals) or (ii) a control group (receiving standard hospital food). We used a Markov model with daily cycles (over a 6-month interval) to estimate hospital costs and health outcomes in the comparator groups, thus modeling cost-effectiveness ratios of nutritional interventions. Results With nutritional support, the modeled total additional cost over the 6-month interval was 15,159 Swiss Francs (SF). With an additional 5.77 life days, the overall incremental cost-effectiveness ratio for nutritional support vs. no nutritional support was 2625 SF per life day gained. In terms of complications, patients receiving nutritional support had a cost savings of 6214 SF and an additional 4.11 life days without complications, yielding an incremental cost-effectiveness ratio for avoided complications of 1513 SF per life day gained. Conclusions On the basis of a Markov model, this economic analysis found that in-hospital nutritional support for CHF patients increased life expectancy at an acceptable incremental cost-effectiveness ratio.

The Case for Malnutrition Quality Measures and Nutrition-Focused Quality Improvement Programs (QIPs) in US Skilled Nursing Facilities

As skilled nursing in the United States moves to a value-based model, malnutrition care remains a critical gap area that is associated with multiple poor health outcomes, including hospital readmissions and declines in functional status, psychosocial well-being, and quality of life. Malnutrition is often undiagnosed/untreated, even though it impacts up to half of skilled nursing facility (SNF) residents, and COVID-19 infections/related symptoms have likely further increased this risk. In acute care, malnutrition quality measures have been both developed/tested, and nutrition-focused quality improvement programs (QIPs) have been shown to reduce costs and effectively improve care processes and patient outcomes. Less is known about such quality initiatives in SNF care. This perspective paper reviewed malnutrition-related quality measures and nutrition-focused QIPs in SNFs and nursing home care. It identified that although the Centers for Medicare & Medicaid Services (CMS) has had a nursing home Quality Assurance and Performance Improvement (QAPI) program for 10 years and has had SNF quality measures for nearly 20 years, there are no malnutrition-specific quality measures for SNFs and very few published nutrition-focused QIPs in SNFs. This represents an important care gap that should be addressed to improve resident health outcomes as SNFs more fully move to a value-based care model.

Prevalence of malnutrition risk and its association with mortality: nutritionDay Latin America survey results

BACKGROUND & AIMS

Across the globe, the prevalence of hospital malnutrition varies greatly depending on the population served and on local socioeconomic conditions. While malnutrition is widely recognized to worsen patient outcomes and add financial burdens to healthcare systems, recent data on hospital malnutrition in Latin America are limited. Our study objectives were: (1) to quantify the prevalence of malnutrition risk in Latin American hospital wards, and (2) to explore associations between nutritional risk status, in-hospital food intake, and health outcomes.

METHODS

On nutritionDay (nDay), a specific day every year, hospital wards worldwide can participate in a one-day, cross-sectional audit. We analyzed nDay data collected in ten Latin American countries from 2009 to 2015, including demographic and nutrition-related findings for adult patients (≥18 years) from 582 hospital wards/units. Based on patient-reported responses to questions related to the Malnutrition Screening Tool, we determined the prevalence of malnutrition risk (MST score ≥2). We also summarized patient-reported food intake on nDay, and we analyzed staff-collected outcome data at 30 days post-nDay.

RESULTS

The prevalence of malnutrition risk in the Latin American nDay study population (N = 14,515) was 39.6%. More than 50% of studied patients ate one-half or less of their hospital meal, ate less than normal in the week before nDay, or experienced weight loss in the prior three months. The hospital-mortality hazard ratio was 3.63 (95% CI [2.71, 4.88]; P < 0.001) for patients eating one-quarter of their meal (compared with those who ate the full meal), increasing to 6.6 (95% CI [5.02, 8.7]; P < 0.0001) for patients who ate none of the food offered.

CONCLUSIONS

Based on compilation of nDay surveys throughout Latin America, 2 of every 5 hospitalized patients were at risk for malnutrition. The associated risk for hospital mortality was up to 6-fold higher among patients who ate little or none of their meal on nDay. This high prevalence showed scant improvement over rates two decades ago-a compelling rationale for new focus on nutrition education and training of professionals in acute care settings.

Community-Dwelling Adults at Nutrition Risk: Characteristics in Relation to the Consumption of Oral Nutritional Supplements

Purpose: Nutrition risk and utilization rate of simple but effective interventions such as oral nutritional supplementation (ONS) in community settings in the United States, particularly among older adults, has received little emphasis. We conducted a cross-sectional study of community-dwelling adults ≥55 years of age and living independently to assess their risk of poor nutrition and characteristics in relation to ONS consumption. Methods: Demographic characteristics, activities of daily living (ADL), and health care resource utilization in the past 6 months were also collected via telephone survey. Nutrition risk was assessed with the abridged Patient-Generated Subjective Global Assessment (abPG-SGA) and the DETERMINE Checklist. A logistic regression model tested possible predictors of ONS use. Results: Of 1001 participants surveyed, 996 provided data on ONS use and 11% (n = 114) reported consuming ONS during the past 6 months. ONS users were more likely to be at high nutrition risk than nonusers based on both abPG-SGA (43% vs 24%, P < .001) and DETERMINE Checklist (68% vs 48%, P < .001) scores. ONS users reported less functional independence based on ADL scores (86% vs 92%, P = .03), taking ≥3 medications/day (77% vs 53%, P < .001), and utilizing more health care services. Higher nutrition risk (per abPG-SGA), lower body mass index, hospitalization in the past 6 months, and ≥3 medications/day were each independently associated with ONS use (P < .05). Conclusions: Although one in four, urban community-dwelling adults (≥55 years of age) were classified as at high nutrition risk in our study, only 11% reported consuming ONS—a simple and effective nutrition intervention. Efforts to improve identification of nutrition risk and implement ONS interventions could benefit nutritionally vulnerable, community-dwelling adults.

Prevalence and Economic Burden of Malnutrition Diagnosis Among Patients Presenting to United States Emergency Departments

BACKGROUND

Malnutrition is a potentially remediable condition that when untreated contributes to poor health and economic outcomes. While assessment of malnutrition risk is improving, its identification rate and economic burden in emergency departments (EDs) is largely unknown. We sought to determine prevalence and economic burden of diagnosed malnutrition among patients presenting to U.S. EDs.

METHODS

This is a retrospective analysis of Healthcare Cost and Utilization Project Nationwide Emergency Department Sample data. Malnutrition prevalence was confirmed via International Classification of Diseases, 9th Edition, diagnosis codes. The economic burden was assessed by comparing probability of hospitalization and the average total charges between propensity-score matched visits with and without a malnutrition diagnosis.

RESULTS

Data from 238 million ED visits between 2006 and 2014 were analyzed. Over this period, the prevalence of diagnosed malnutrition increased for all demographic categories assessed. For older adults (≥65 years), the prevalence increased from 2.5% (2006) to 3.6% (2014). Older age, high-income community residence, Western region, urban areas, and Medicare coverage were associated with higher diagnosis prevalence. Malnutrition diagnosis was associated with a 4.23 (95% confidence interval [CI] = 3.93 to 4.55) times higher odds of hospitalization and $21,892 higher mean total charges (95% CI = $19,593 to $24,192).

CONCLUSIONS

While malnutrition is currently diagnosed at a low rate in U.S. EDs, the economic burden of malnutrition is substantial in this care setting. Given the potential for systematic malnutrition screening and treatment protocols to alleviate this burden, future research is warranted.

How a Malnutrition Quality Improvement Initiative Furthers Malnutrition Measurement and Care: Results From a Hospital Learning Collaborative

BACKGROUND

Malnutrition in hospitalized patients can adversely affect health outcomes and increase the cost of care. Real-world strategies are needed for prompt identification and treatment of patients at risk of malnutrition.

OBJECTIVES

The aim of this quality improvement (QI) study was to measure the impact of a nutrition-focused program on the malnutrition care processes of participating hospitals. Secondary objectives were to determine whether improvements in these nutrition-related processes reduced hospital readmissions and length of stay (LOS) in patients ≥65 years.

METHODS

A group of 27 US hospitals ("The Collaborative") implemented the Malnutrition Quality Improvement Initiative (MQii), as guided by a Malnutrition QI Toolkit and 4 electronic clinical quality measures (eCQMs), including (1) nutrition screening; (2) nutrition assessment following detection of malnutrition risk; (3) nutrition care plan for patients identified as malnourished after completed nutrition assessment; and (4) documentation of malnutrition diagnoses. Multivariate analyses identified the variables best correlated with patient outcomes.

RESULTS

Improvements were observed for all 4 eCQMs. The greatest improvements were achieved as a result of timely nutrition assessment (P = .06) and malnutrition diagnosis (P = .02). Patients ≥65 years with a malnutrition diagnosis and nutrition care plan had a 24% lower likelihood of 30-day readmission but a longer mean LOS than did those without a care plan.

CONCLUSIONS

In this study, the implementation of MQii practices significantly improved the identification of malnutrition. The prompt identification and treatment of patients at malnutrition risk can improve patient care and health, as well as reduce costly readmissions.

Association between early postoperative nutritional supplement utilisation and length of stay in malnourished hip fracture patients

BACKGROUND

Malnutrition in older hip fracture patients is associated with increased complication rates and mortality. As postoperative nutrition delivery is essential to surgical recovery, postoperative nutritional supplements including oral nutritional supplements or tube feeding formulas can improve postoperative outcomes in malnourished hip/femur fracture patients. The association between early postoperative nutritional supplements utilisation and hospital length of stay was assessed in malnourished hip/femur fracture patients.

METHODS

This is a retrospective cohort study of malnourished hip/femur fracture patients undergoing surgery from 2008 to 2018. Patients were identified through International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes and nutritional supplement utilisation via hospital charge codes. The primary outcome was hospital length of stay. Secondary outcomes included infectious complications, hospital mortality, ICU admission, and costs. Propensity matching (1:1) and univariable analysis were performed.

RESULTS

Overall, 160 151 hip/femur fracture surgeries were identified with a coded-malnutrition prevalence of 8.7%. Early postoperative nutritional supplementation (by hospital day 1) occurred in 1.9% of all patients and only 4.9% of malnourished patients. Propensity score matching demonstrated early nutritional supplements were associated with significantly shorter length of stay (5.8 [6.6] days vs 7.6 [5.8] days; P<0.001) without increasing hospital costs. No association was observed between early nutritional supplementation and secondary outcomes.

CONCLUSION

Malnutrition is underdiagnosed in hip/femur fracture patients, and nutritional supplementation is underutilised. Early nutritional supplementation was associated with a significantly shorter hospital stay without an increase in costs. Nutritional supplementation in malnourished hip/femur fracture patients could serve as a key target for perioperative quality improvement.

Nutrition Support Therapies on the Medication Administration Record: Impacts on Staff Perception of Nutrition Care

BACKGROUND

It has been reported that many hospitals in the United States have fragmented and ineffective ordering, administration, documentation, and evaluation/monitoring of nutrition therapies. This paper reports on a project to investigate if perceived hospital staff awareness and documentation of nutrition support therapies (NSTs) improves by including them as part of the medication administration record (MAR).

METHODS

Surveys were conducted with nursing staff, physicians, and dietitians before and after adding NSTs to the MAR to evaluate the perceived impact on the outcome of interest. The outcomes of interest include nurses' perception of ease of finding information, awareness of an order, and ability to assess administration and documentation and dietitian, nurse, and physician staff perceptions of impact of intervention on aspects of the nutrition care process.

RESULTS

After adding NST to the MAR, nursing staff perceived improvement in knowing that their patient had an oral nutritional supplement (ONS) order (P = .01), when and how much product was last administered (P = .01), and documentation of the type of product consumed (P = .01) and volume of product consumed (P = .01). The majority of dietitian and nurses surveyed reported perceived improvement in placing and finding ONS orders, in administration of ONS, in ability to evaluate patient nutrition status, and in ONS intake and a positive impact on clinical practice.

CONCLUSION

Inclusion of NST in the MAR presents an innovative solution to enhance staff awareness of ordered therapies and perception of improved documentation of nutrition interventions for hospitalized patients.

Nutrition Education on the Wards: A Self-Study Module for Improving Medical Student Knowledge of Nutrition Assessment and Interventions

INTRODUCTION

Nutrition plays a key role in the prevention and treatment of disease. Hospitalized patients are often malnourished, which is a major contributor to medical complications, decreased quality of life, lengthened medical stay, increased health care costs, and mortality. However, medical students continue to have inadequate education in nutrition and report feeling poorly trained in nutrition. We proposed an online module that could be used by medical students as a self-study activity to learn about key signs for the diagnosis of malnutrition and the nutrition interventions available in the hospital setting.

METHODS

Third- and fourth-year medical students at Rutgers Robert Wood Johnson Medical School in medicine, surgery, and critical care clerkships were given access to an online nutrition education module discussing the signs of malnutrition in hospitalized patients and the interventions available in the inpatient setting. A premodule and postmodule survey was given via email at the beginning and at the end of the clerkship. A one-sample t test was used to assess the relationship between the mean scores of the pre- and postmodule surveys.

RESULTS

One hundred nine out of 255 students responded to the premodule survey. Thirty-two students completed the module and postmodule survey. There was a significant difference in mean scores between students who completed the module and postmodule survey compared to the overall student population prior to having access to the module.

DISCUSSION

Medical students have limited training in nutrition education, and our findings show that a self-study online module can improve students' knowledge.

Impact of an interdisciplinary malnutrition quality improvement project at a large metropolitan hospital

As many as 50% of hospitalised patients are estimated to be malnourished or at risk of malnutrition on hospital admission, but this condition often goes unrecognised, undiagnosed and untreated. Malnutrition is associated with an elevated need for continued medical interventions, higher costs of care and increased patient safety risks. Tampa General Hospital (TGH), a large teaching hospital in the southeastern USA, initiated a project to improve the quality of patient care at its institution. They did this first by focusing on improving the care quality for their malnourished patients (or patients who were at risk of malnourishment) and by using elements of the national Malnutrition Quality Improvement Initiative (MQii) Toolkit as a mechanism to measure and improve quality. The aim of this study was to evaluate the impact of quality improvement interventions on patient length of stay (LOS), infection rates and readmissions, particularly for malnourished patients. The structure of the MQii and the use of the MQii Toolkit helped staff members identify problems and systematically engage in quality improvement processes. Using the MQii Toolkit, TGH implemented a multipronged approach to improving the treatment of malnourished patients that involved creating interdisciplinary teams of staff and identifying gaps in care that could be improved through a series of changes to hospital-wide clinical workflows. They enhanced interdisciplinary coordination through increased dietitian engagement, the use of electronic health record alerts and new surgical protocols. These interventions lasted 8 months in 2016 and data reported here were collected from 985 patients before the interventions (2015) and 1046 patients after the interventions (2017). The study examines how these process changes affected LOS, infection rates and readmissions at TGH. Following implementation of these quality improvement processes, patients who were malnourished or at risk of malnutrition had a 25% reduction in LOS (from 8 to 6 days, p<0.01) and a 35.7% reduction in infection rates (from 14% to 9%, p<0.01). No statistically significant changes in readmission rates were observed. This study adds to a growing body of literature on quality improvement processes hospitals can undertake to better identify and treat malnourished patients. Hospitals and health systems can benefit from adopting similar institution-wide, quality improvement projects, while policy-makers' support for such programmes can spur more rapid uptake of nutrition-focused initiatives across care delivery settings.

Clinical and Economic Value of Nutrition in Healthcare: A Nurse's Perspective

In the US healthcare system, malnutrition is a common condition, yet it remains underreported and underdiagnosed. The financial costs of disease-associated malnutrition are substantial; hospital-acquired conditions, readmissions, and prolonged lengths of stay are reported to cost as much as $150 billion per year. By contrast, nutrition-focused quality improvement programs for inpatients can help reduce the negative impact of disease-associated malnutrition. Such programs include systematic screening for malnutrition risk on admission, timely malnutrition diagnoses, and prompt nutrition interventions, which have been shown to lower rates of hospital-acquired infections, shorten lengths of stay, reduce readmissions, and lessen costs of care. Nurses are ideally positioned to play critical roles in nutrition-related care-screening for malnutrition on admission, monitoring for and addressing conditions that impede nutrition intake, and ensuring that prescribed nutrition interventions are delivered and administered or consumed. Such nursing support of multidisciplinary nutrition care contributes to better patient outcomes at lower costs.

Extending the Reach of Hospital-Based Nutrition: A Registered Dietitian Nutritionist's Perspective on the Malnutrition Quality Improvement Initiative and Improving Patient Recovery

Registered dietitian nutritionists (RDNs) at Legacy Salmon Creek Medical Center (Washington) recognized a need to use nutrition to help patients recover faster and stay independent longer. With the goal of decreasing 30-day hospital readmission rates, the RDNs at Legacy Salmon Creek developed a program for posthospital nutrition care. The intervention was a pilot program designed to provide palatable and nutritious meals to patients at home during a 4-week, postdischarge interval. The RDNs obtained approval from hospital administrators and received buy-in from nursing staff who participated in RDN-led training on malnutrition awareness and risk screening. Results of the pilot program indicated a high level of patient satisfaction and a decrease in the rate of readmissions. 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.

Reducing Hospitalizations and Costs: A Home Health Nutrition-Focused Quality Improvement Program

Background

Identification and treatment of malnutrition across the care continuum can help prevent illness onset or relapse and maximize the effectiveness of other medical treatments. This study aimed to evaluate the effect of a nutrition‐focused quality improvement program (QIP) conducted in a home health agency (HHA) on hospitalization rates and healthcare costs incurred over 90 days.

Methods

This was a multisite, pre‐post QIP implemented at 2 branches of an Illinois‐based HHA. The QIP included 1546 patients who were (1) at‐risk or malnourished hospitalized patients discharged to the HHA, (2) referred by a physician during an outpatient visit, or (3) enrolled in the HHA through a skilled nursing facility. A historic (n = 7413 patients) and concurrent group (n = 5235) of patients were used for comparisons. Propensity score matching was used to account for imbalances in patient characteristics.

Results

The QIP led to reduced relative risk of hospitalization post‐enrollment to the QIP by 24.3%, 22.8%, and 18.3% at 30, 60, and 90 days, respectively, when compared with the historic group, and by 18.2%, 16.2%, and 12.1% when compared with the concurrent group. Total cost savings from reduced 90‐day healthcare resource utilization was $2,318,894, or $1500 per patient treated.

Conclusions

Rates of hospitalization and healthcare resources can be significantly reduced through the implementation of a nutrition‐focused QIP delivering oral nutritional supplements in home health settings for adults at‐risk/malnourished. These results highlight the importance of nutrition as a strategy for HHAs and other post‐acute care institutions to improve patients' health outcomes and generate cost savings.

Increasing HIV-Free Survival of Infants: Reorganizing Care Using Quality Improvement for the Optimal Health and Nutrition of HIV-Positive Women and Their Exposed Infants in Uganda

Reorganizing service delivery to integrate nutrition and infant and young child feeding (IYCF) with prevention of mother-to-child transmission (PMTCT) is important for improving outcomes of HIV-positive mothers and HIV-exposed infants (HEIs). Quality improvement (QI) strategies were implemented at 22 health facilities. The percentage of HIV-positive pregnant women and lactating mothers who received IYCF counseling at each visit improved (45%-100%; mean = 93.1%, standard deviation [SD] = 15.5). Adherence to IYCF practices improved (70%-96%; mean = 92.4%, SD = 8.5). Mother-baby pairs receiving the standard care package improved (0%-100%; mean = 98.6%, SD = 22.6). The HEIs alive at 18 months and infected decreased (mean = 6.2%, SD = 4.8). Statistical significance of change was estimated using Fisher exact test and magnitude of change over time by calculating the odds ratio. For all indicators, improvement was rapid and significant (P < .001), especially in the first 6 months of QI implementation. Using QI to integrate nutrition and ensure consistent and comprehensive PMTCT service delivery improved IYCF adherence and decreased transmission.

Improving the standard of nutrition care in hospital: Mealtime barriers reduced with implementation of the Integrated Nutrition Pathway for Acute Care

BACKGROUND

Poor food intake is common in hospital patients and is associated with adverse patient and healthcare outcomes; diverse mealtime barriers to intake often undermine clinical nutrition care.

AIM

This study determines whether implementation of locally adaptable nutrition care activities as part of uptake of the Integrated Nutrition Pathway for Acute Care (INPAC) reduced mealtime barriers and improved other patient outcomes (e.g. length of stay; LOS) when considering other covariates.

METHODS

1250 medical patients from 5 Canadian hospitals were recruited for this before-after time series design. Mealtime barriers were tallied with the Mealtime Audit Tool after a meal, while proportion of the meal consumed was assessed with the My Meal Intake Tool. Implementation of new standard care activities occurred over 12 months and three periods (pre-, early, and late) of implementation were compared. Regression analyses determined the effect of time period while adjusting for key covariates.

RESULTS

Mealtime barriers were reduced over time periods (Period 1 = 2.5 S.D. 2.1; Period 3 = 1.8 S.D. 1.7) and site differences were noted. This decrease was statistically significant in regression analyses (-0.28 per time period; 95% CI -0.44, -0.11). Within and across site changes were also observed over time in meal intake and LOS; however, after adjusting for covariates, time period of implementation was not significantly associated with these outcomes.

DISCUSSION

Mealtime barriers can be reduced and sustained by implementing improved standard care procedures for patients. The More-2-Eat study provides an example of how to implement changes in practice to support the prevention and treatment of malnutrition.

TRIAL REGISTRATION

Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.

Relationship between pressure ulcer risk based on Norton Scale and on the "Eating/Drinking" need assessment

AIM

To study the relationship between pressure ulcer risk evaluated by the Norton Scale and inadequate fulfilment of Need 2 (Eating/Drinking) from the 14-need classification designed by Virginia Henderson.

BACKGROUND

Assessing nutritional status and skin condition to implement preventive measures are important nursing interventions. Our hospital's standard procedure requires recording Norton Scale and Henderson Eating/Drinking Assessment results.

METHODS

This was a descriptive cross-sectional study, analysing case histories of 219 patients in medical/surgical wards for >24 hr with nursing care recorded in the GACELA Care computer application. Patient sociodemographic variables and evaluation concepts from the Norton Scale and Eating/Drinking were studied.

RESULTS

A statistically significant relationship (p < 0.05; 95% CI: 0.61, 2.83) was seen between inadequate Eating/Drinking need fulfilment and increased pressure ulcer risk. Pressure ulcer risk was generally low in the sample, with mainly no or minimum risk (77.3%); the oldest age group had the highest risk. Self-care autonomy was the most frequently assessed item in Eating/Drinking (42%).

CONCLUSIONS

A relationship was found between Norton Scale risk results and Eating/Drinking need assessment results. The greater the pressure ulcer risk, the more likely was inadequate need satisfaction (poor nutritional status).

IMPLICATIONS

To help identify pressure ulcer risk, nurses should assess patients' eating independence. Safeguarding nutritional status and preventing pressure ulcers are nursing skills associated with quality nursing care.

Economic Evaluation of Nutrition Support in the Prevention and Treatment of Pressure Ulcers in Acute and Chronic Care Settings: A Systematic Review

BACKGROUND

Recent developments in nutrition intervention indicated clinical effectiveness for pressure ulcer (PU) prevention and treatment, but it is important to assess whether they are cost-effective. The aims of this systematic review are to determine the cost-effectiveness and clinical outcomes of nutrition support in PU prevention and treatment.

METHODS

A systematic search of randomized controlled trials, observational studies, and statistical models that investigated cost-effectiveness and economic outcomes for prevention and/or treatment of PUs were performed using standard literature and electronic databases.

RESULTS

Fourteen studies met the inclusion criteria, which included 3 randomized controlled trials with their companion economic evaluations, 4 model-based, 2 cohort, 1 pre and post, and 1 prospective controlled trial. Risk of bias assessment for all of the uncontrolled or observational trials revealed high or serious risk of bias. Interventions that incorporated specialized nursing care appeared to be more effective in prevention and treatment of PUs, compared with single intervention studies. There is a trend of improved PU healing when additional energy/protein are provided. PU prevention ($250-$9,800) was less expensive than treatment ($2,500-$16,000). Nutrition intervention for PU prevention was cost-effective in 87.0%-99.99% of the simulation models.

CONCLUSIONS

There is potential cost-saving and/or cost-effectiveness of nutrition support in the long term, as predicted by the model-based PU prevention studies in the review. Prevention of PU also appears to be more cost-effective than treatment. A multidisciplinary approach to managing PU is more likely to be cost-effective.

Project SITUP: An Interdisciplinary Quality Improvement Initiative to Reduce Aspiration Pneumonia

The purpose of this quality improvement initiative was to improve oropharyngeal dysphagia screening and reduce aspiration pneumonia rates on 3 inpatient hospital medical units. Guided by a Plan-Do-Study-Act methodology, an interdisciplinary health team developed and implemented a systematic process for oropharyngeal dysphagia screening and management. As a result, use of the screening protocol increased, timely initiation of speech language pathology consultations increased, and aspiration pneumonia rates decreased.

Multi-site implementation of nutrition screening and diagnosis in medical care units: Success of the More-2-Eat project

BACKGROUND

Improving the detection and treatment of malnourished patients in hospital is needed to promote recovery.

AIM

To describe the change in rates of detection and triaging of care for malnourished patients in 5 hospitals that were implementing an evidence-based nutrition care algorithm. To demonstrate that following this algorithm leads to increased detection of malnutrition and increased treatment to mitigate this condition.

METHODS

Sites worked towards implementing the Integrated Nutrition Pathway for Acute Care (INPAC), including screening (Canadian Nutrition Screening Tool) and triage (Subjective Global Assessment; SGA) to detect and diagnose malnourished patients. Implementation occurred over a 24-month period, including developmental (Period 1), implementation (Periods 2-5), and sustainability (Period 6) phases. Audits (n = 36) of patient health records (n = 5030) were conducted to identify nutrition care practices implemented with a variety of strategies and behaviour change techniques.

RESULTS

All sites increased nutrition screening from Period 1, with three achieving the goal of 75% of admitted patients being screened by Period 3, and the remainder achieving a rate of 70% by end of implementation. No sites were conducting SGA at Period 1, and sites reached the goal of a 75% completion rate or referral for those identified to be at nutrition risk, by Period 3 or 4. By Period 2, 100% of patients identified as SGA C (severely malnourished) were receiving a comprehensive nutritional assessment. In Period 1, the nutrition diagnosis and documentation by the dietitian of 'malnutrition' was a modest 0.37%, increasing to over 5% of all audited health records. The overall use of any Advanced Nutrition Care practices increased from 31% during Period 1 to 63% during Period 6.

CONCLUSION

The success of this multi-site study demonstrated that implementation of nutrition screening and diagnosis is feasible and leads to appropriate care. INPAC promotes efficiency in nutrition care while minimizing the risk of missing malnourished patients.

TRIAL REGISTRATION

Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.

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

Background: Malnutrition in hospitalized patients is a pervasive problem in the United States. To our knowledge, although malnutrition has been acknowledged as a concern for >40 y, it has not yet been well addressed with a systematic, process improvement approach. Objectives: We aimed to characterize the current nutrition care process in US hospitals to establish a baseline for improvements. We also aimed to demonstrate the application of a web-based quality improvement tool as a simple approach to address malnutrition in hospitalized patients. Methods: We established a web-based tool to measure and assess nutrition care practices from hospital electronic medical records. Individual institutions self-selected to participate and were assigned a unique identifier to input data. Aggregated patient data from registered institutions were assessed. Data from all institutions were combined and are presented as the totals for each variable. Results: Of 243 registered users, 97 provided data and 150 reports were included in the analysis, resulting in a total of 107,106 patients. Almost all patients (89.98%) were screened for malnutrition risk within 24 h of admission, and ∼30% were at risk for malnutrition. Of those at risk, ∼65% received a registered dietitian nutritionist consultation or an order for an oral nutrition supplement. The rate of malnutrition diagnosis for those at risk was ∼14%, and <10% of patients received a recommendation or prescription for an oral nutrition supplement at discharge. Conclusions: Malnutrition remains an issue for hospitalized patients, particularly the gap between those screened as at risk and those diagnosed with malnutrition. Moreover, discharge recommendations for patients who are screened as at risk for malnutrition are also lacking. These data demonstrate that a web-based quality improvement tool could be used to capture the nutrition care practice at an institution level to provide directed approaches for addressing hospital malnutrition and improving care of patients at risk for malnutrition.

Optimizing the electronic health record to standardize administration and documentation of nutritional supplements

Malnutrition in hospitalized patients is a major cause for hospital re-admission, pressure ulcers and increased hospital costs. Methods to improve the administration and documentation of nutritional supplements for hospitalized patients are needed to improve patient care, outcomes and resource utilization. Staff at a medium-sized academic health science center hospital in the southeastern United States noted that nutritional supplements ordered for patients at high risk for malnutrition were not offered or administered to patients in a standardized manner and/or not documented clearly in the electronic health record as per prescription. This paper reports on a process improvement project that redesigned the ordering, administration and documentation process of oral nutritional supplements in the electronic health record. By adding nutritional products to the medication order sets and adding an electronic nutrition administration record (ENAR) tab, the multidisciplinary team sought to standardize nutritional supplement ordering, documentation and administration at prescribed intervals. This process improvement project used a triangulated approach to evaluating pre- and post-process change including: medical record reviews, patient interviews, and nutrition formula room log reports. Staff education and training was carried out prior to initiation of the system changes. This process change resulted in an average decrease in the return of unused nutritional formula from 76% returned at baseline to 54% post-process change. The process change resulted in 100% of nutritional supplement orders having documentation about nutritional medication administration and/or reason for non-administration. Documentation in the ENAR showed that 41% of ONS orders were given and 59% were not given. Significantly more patients reported being offered the ONS product (p=0.0001) after process redesign and more patients (5% before ENAR and 86% after ENAR reported being offered the correct type, amount and frequency of nutritional products (p=0.0001). ENAR represented an effective strategy to improve administration and documentation of nutritional supplements for hospitalized patients.

Factors associated with the incidence of pressure ulcer during hospital stay

Abstract OBJECTIVE Estimating the incidence rate of pressure ulcers and verifying factors associated with this occurrence in a cohort of hospitalized patients. METHOD This is a cohort study in which the considered outcome was the time until pressure ulcer occurrence. Estimated effect of the variables on the cumulative incidence ratio of the outcome was performed using the Cox proportional hazards model. Variable selection occurred via the Logrank hypothesis test. RESULTS The sample consisted of 442 adults, with 25 incidents of pressure ulcers. Patients with high scores on the Braden scale presented a higher risk of pressure ulcer incidence when compared to those classified into the low score category. CONCLUSION These results reinforce the importance of using the Braden Scale to assist in identifying patients more likely to develop pressure ulcers.

Economic Burden of Disease-Associated Malnutrition at the State Level

Background

Disease-associated malnutrition has been identified as a prevalent condition, particularly for the elderly, which has often been overlooked in the U.S. healthcare system. The state-level burden of community-based disease-associated malnutrition is unknown and there have been limited efforts by state policy makers to identify, quantify, and address malnutrition. The objective of this study was to examine and quantify the state-level economic burden of disease-associated malnutrition.

Methods

Direct medical costs of disease-associated malnutrition were calculated for 8 diseases: Stroke, Chronic Obstructive Pulmonary Disease, Coronary Heart Failure, Breast Cancer, Dementia, Musculoskeletal Disorders, Depression, and Colorectal Cancer. National disease and malnutrition prevalence rates were estimated for subgroups defined by age, race, and sex using the National Health and Nutrition Examination Survey and the National Health Interview Survey. State prevalence of disease-associated malnutrition was estimated by combining national prevalence estimates with states’ demographic data from the U.S. Census. Direct medical cost for each state was estimated as the increased expenditures incurred as a result of malnutrition.

Principal Findings

Direct medical costs attributable to disease-associated malnutrition vary among states from an annual cost of $36 per capita in Utah to $65 per capita in Washington, D.C. Nationally the annual cost of disease-associated malnutrition is over $15.5 billion. The elderly bear a disproportionate share of this cost on both the state and national level.

Conclusions

Additional action is needed to reduce the economic impact of disease-associated malnutrition, particularly at the state level. Nutrition may be a cost-effective way to help address high health care costs.