critical role of nutrition in improving quality of care...
TRANSCRIPT
May-June 2013 • Vol. 22/No. 3 147
Kelly A. Tappenden, PhD, RD, FASPEN, is Kraft Foods HumanNutrition Endowed Professor, Department of Food Science and HumanNutrition, University of Illinois at Urbana-Champaign, Urbana, IL. (TheAcademy of Nutrition and Dietetics).
Beth Quatrara, DNP, RN, CMSRN, ACNS-BC, is Clinical NurseSpecialist, University of Virginia Health System, Charlottesville, VA.(Academy of Medical-Surgical Nurses).
Melissa L. Parkhurst, MD, is Associate Professor of Medicine,University of Kansas Medical Center, Kansas City, KS. (Society ofHospital Medicine).
Ainsley M. Malone, MS, RD, CNSC, is Nutrition Support Dietitian, Mt.Carmel West Hospital, Columbus, OH. (American Society for Parenteraland Enteral Nutrition).
Gary Fanjiang, MD, is Vice President, Medical Affairs, Abbott Nutrition,Columbus, OH.
Thomas R. Ziegler, MD, is Professor of Medicine, Department ofMedicine, Emory University School of Medicine, Atlanta, GA. (Society ofHospital Medicine).
Notes: Kelly A. Tappenden, Beth Quatrara, Melissa L. Parkhurst, AinsleyM. Malone, and Thomas R. Ziegler are members of the SteeringCommittee of the Alliance to Advance Patient Nutrition who have beenchosen by the professional organizations they represent and reimbursedfor Alliance-related expenses. Abbott Nutrition has provided funding tothe member organizations of the Alliance and to Dr. Marithea Gobervilleof Science Author, Inc., for writing assistance.
The Journal of the Academy of Nutrition and Dietetics, Journal ofParenteral and Enteral Nutrition, and MEDSURG Nursing arranged topublish this article simultaneously in their publications. Minor differencesin style may appear in each publication but the article is substantially thesame in each journal.
Critical Role of Nutrition in ImprovingQuality of Care: An Interdisciplinary
Call to Action to Address AdultHospital Malnutrition
T he United States is entering anew era of health care deliv-ery in which changes in
health care policy are driving anincreased focus on costs, quality, andtransparency of care. This new focuson improving the quality and effi-ciency of hospital care highlights anurgent need to revisit the long-stand-ing challenge of hospital malnutri-tion and elevate the role of nutritioncare as a critical component ofpatient recovery. Malnutrition iscommon in the hospital setting andcan affect clinical outcomes andcosts adversely, but it often is over-looked. Although results of interven-tion studies vary, addressing hospitalmalnutrition has the potential toimprove quality of patient care andclinical outcomes, and reduce costs(Barker, Gout, & Crowe, 2011).Today, it is estimated at least one-third of patients arrive at the hospi-tal malnourished (Barker et al., 2011;Bistrian, Blackburn, Hallowell, &Heddle, 1974; Christensen &Gstundtner, 1985; Lim et al., 2012;
Kelly A. Tappenden, Beth Quatrara, Melissa L. Parkhurst, Ainsley M. Malone, Gary Fanjiang, and Thomas R. Ziegler
The current era of health care delivery, with its focus on providing high-quality, affordable care, presents many challenges to hospital-basedhealth professionals. The prevention and treatment of hospital malnu-trition offers a tremendous opportunity to optimize the overall quality ofpatient care, improve clinical outcomes, and reduce costs. Unfortunately,malnutrition continues to go unrecognized and untreated in many hos-pitalized patients. This article represents a call to action from the inter-disciplinary Alliance to Advance Patient Nutrition to highlight the criticalrole of nutrition intervention in clinical care and suggest practical waysfor prompt diagosis and treatment of malnourished patients and thoseat risk for malnutrition. We underscore the importance of an interdisci-plinary approach to addressing malnutrition both in the hospital and inthe acute post-hospital phase. It is well recognized that malnutrition isassociated with adverse clinical outcomes. Although data vary acrossstudies, available evidence shows early nutrition intervention can reducecomplication rates, length of hospital stay, re-admission rates, mortality,and cost of care. The key is to identify patients systematically who aremalnourished or at risk and to promptly intervene. We present a novelcare model to drive improvement, emphasizing the following six princi-ples: (1) create an institutional culture where all stakeholders valuenutrition; (2) redefine clinicians’ roles to include nutrition care; (3) rec-ognize and diagnose all malnourished patients and those at risk; (4)rapidly implement comprehensive nutrition interventions and continuedmonitoring; (5) communicate nutrition care plans; and (6) develop acomprehensive discharge nutrition care and education plan.
May-June 2013 • Vol. 22/No. 3148
Somanchi, Tao, & Mullin, 2011),and, if left untreated, many of thosepatients will continue to declinenutritionally (Somanchi et al., 2011),which may adversely impact theirrecovery and increase their risk ofcomplications and re-admission.
Hospital malnutrition is not anew problem but “The Skeleton inthe Hospital Closet” was brought tolight in Butterworth's call for prac-tices aimed at proper diagnosis andtreatment of malnourished patients(Butterworth, 1974). As we enter anew era of health care delivery, thetime is now to implement a novel,comprehensive nutrition care modelas part of improved quality stan-dards and leverage proven examplesfor success.
Effective management of malnu-trition requires collaboration amongmultiple clinical disciplines. In manyhospitals, malnutrition continues tobe managed in silos, with knowledgeand responsibility provided predomi-nantly by the dietitian. However, thenew era of quality care will require adeliberately more holistic and inter-disciplinary process to address thiscritical issue. All members of the clin-ical team must be involved, includ-ing nurses who perform initial nutri-tion screening and develop innova-tive strategies to facilitate patientcompliance, dietitians who completenutrition assessment/diagnosis anddevelop evidence-based interven-tions, pharmacists who evaluatedrug-nutrient interactions, and phy -sicians (including hospitalists), whooversee the overall care plan and doc-umentation to support reimburse-ment for services. Recognition of thisproblem and the opportunity toimprove patient care were the impe-tus behind creating the Alliance toAdvance Patient Nutrition (Alliance).The Alliance brings together theAcade my of Medical-Surgical Nurses(AMSN), the Academy of Nutrition
and Dietetics (AND), the AmericanSociety for Parenteral and EnteralNutrition (A.S.P.E.N.), the Society ofHospital Medicine (SHM), andAbbott Nutrition. The Alliance ismade possible with support fromAbbott Nutrition. These healthorganizations are dedicated to theadvancement of effective hospitalnutrition practices to help improvepatients’ medical outcomes and sup-port all clinicians in collaborating onhospital-wide nutrition procedures.The established charter of theAlliance is to champion improvedhospital nutrition practices throughidentification of malnourished andpatients at risk for malnutrition, earlynutrition intervention and treat-ment, and inclusion of nutrition as astandard component of all careprocesses.
Nutrition intervention for malnu-trition patients is a low-risk, cost-effective strategy to im prove qualityof hospital care, but it requires inter-disciplinary collaboration. As repre-sentatives of the Alliance, weannounce a call to action. We aspireto facilitate the institution of univer-sal nutrition screening, rapid andappropriate nutrition interventionsutilizing effective interdisciplinarynutrition partnerships, and integra-tion of comprehensive strategies toprevent or treat hospital malnutri-tion. This paper is not intended toprovide practice-based guidelines, butrather highlights available data onthe critical role nutrition plays inimproving patient outcomes, outlinesan innovative nutrition care model,underscores the importance of aninterdisciplinary approach to addresshospital malnutrition, and identifieschallenges believed to impair optimalnutrition care. In addition, specificsolutions that can be employed bydietitians, nurses, physicians, andother health care professionals, suchas nurse practitioners, physician assis-
tants, pharmacists, and diet techni-cians, registered, are provided.
Burden of HospitalMalnutrition
Although estimates of the preva-lence of malnutrition vary by setting,subgroup, and method of assess -ment, the prevalence of malnutri-tion in hospitals is particularly star-tling. At least one-third of patients indeveloped countries are malnour-ished upon admission to the hospi-tal (Barker et al., 2011; Bistrian et al.,1974; Christensen & Gstundtner,1985; Somanchi et al., 2011), and, ifleft untreated, approximately two-thirds of those patients will experi-ence a further decline in their nutri-tion status during inpatient stay(Somanchi et al., 2011). Unfor -tunately, despite the availability ofvalidated screening tools, malnutri-tion continues to be underrecog-nized in many hospitals (Kirkland,Kashiwagi, Brantley, Scheurer, &Varkey, 2013). Moreover, amongpatients who are not malnourishedupon admission, approximately one-third may become malnourishedwhile in the hospital (Braunschweig,Gomez, & Sheean, 2000).
Historically, a variety of tools anddefinitions have been used through-out the nutrition literature. For thepurposes of this paper, mild throughsevere malnutrition will be the focusand is the intent when the term“malnutrition” is used.
Malnutrition is de fined mostsimply as any nutrition imbalance(Dorland’s Illustrated Medical Dic -tionary, 2011) that affects bothover weight and underweight pa -tients alike and is described general-ly as either “undernutrition” or“overnutrition” (White, Guenter,Jensen, Malone, & Schofield, 2012).Hospitalized patients, regardless oftheir body mass index (BMI), typi-cally suffer from undernutritionbecause of their propensity forreduced food intake due to illness-induced poor appetite, gastroin-testinal symptoms, reduced abilityto chew or swallow, or nil per os(NPO) status for diagnostic andtherapeutic procedures. In addition,
Alliance to Advance Patient Nutrition
The time is now to implement a novel,comprehensive nutrition care model as part of
improved quality standards and leverage provenexamples for success.
May-June 2013 • Vol. 22/No. 3 149
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
they may have increased energy,protein, and essential micronutri-ent needs because of inflammation,infection, or other catabolic condi-tions. A consensus statement byAND and A.S.P.E.N. published inMay 2012 defines malnutrition asthe presence of two or more of thefollowing characteristics: insufficientenergy intake, weight loss, loss ofmuscle mass, loss of subcutaneousfat, localized or generalized fluidaccumulation, or de creased func-tional status (White et al., 2012).
The importance of identifying at-risk patients is highlighted by datashowing that malnutrition is associ-ated with many adverse outcomes,including an increased risk of pres-sure ulcers and impaired woundhealing, immune suppression andincreased infection rate, musclewasting and functional loss increas-ing the risk of falls, longer length ofhospital stay, higher re-admissionrates, higher treatment costs, andincreased mortality (Barker et al.,2011). Therefore, malnutrition placesa heavy burden on the pa tient, clini-cian, and health care system.
Many of the adverse outcomesinfluenced by malnutrition arepotentially preventable. Nosocomialinfections are a prime example.Approximately 2 million nosocomi-al infections occur annually in theUnited States (Jarvis, 1996), andthose patients are more likely tospend time in the intensive careunit, be re-admitted, and die as aresult (Kirkland, Briggs, Trivette,Wilkinson, & Sexton, 1999). A retro-spective study by Fry, Pine, Jones,and Meimban (2010) examinednearly 1 million surgical patients(N=887,189) treated at 1,368 hospi-tals to determine the risk of nosoco-mial infections and understand bet-ter the underlying patient character-istics influencing that risk. Theanalysis showed patients with pre-existing malnutrition and/or weightloss had a 2- to 3-fold increased riskof developing Clostridium difficileenterocolitis, surgical-site infection,or postoperative pneumonia, and agreater than 5-fold higher risk ofmediastinitis after coronary arterybypass graft surgery or catheter-asso-ciated urinary tract infection.
Malnutrition and/or weight loss alsocorrelated with an approximate fourfold higher risk of developing a pres-sure ulcer. These data are supportedfurther by a prospective multivariateanalysis demonstrating that malnu-trition is an independent risk factorfor nosocomial infections (Schneideret al., 2004).
Impaired wound healing can influ-ence length of hospital stay signifi-cantly, and the literature supports astrong correlation between nutritionand wound healing. Hospitalizedpatients are at increased risk becauseloss of significant lean body mass(LBM) accelerates during bed rest(Paddon-Jones et al., 2006; Paddon-Jones et al., 2004). A 10% loss of LBMresults in immune suppression andincreases the risk of infection, and aloss of more than 15% to 20% of totalLBM will impair wound healing(Demling, 2009; Moran, Custer, &Murphy, 1980). A loss of 30% or moreleads to the development of sponta-neous wounds such as pressure ulcers,an increased risk of pneumonia, and acomplete lack of wound healing(Demling, 2009; Moran et al., 1980).These complications also are associat-ed with a substantial mortality risk,particularly in older patients. A studyevaluating the care processes for hos-pitalized Medicare patients (N=2,425;age ≥65) at risk for pressure ulcerdevelopment showed that 76% ofpatients were malnourished, and esti-mated compliance with nutritionconsultation was low (34%) (Lyder etal., 2001).
Data from several recent studiesshow that malnutrition also mayinfluence hospital re-admission rates(Allaudeen, Vidyarthi, Maselli, &Auerbach, 2011; Kassin et al., 2012;Mudge et al., 2011). These studiesevaluated multiple factors to identifyindividuals at increased risk of re-admission. The largest of these stud-ies, a retrospective observationalanalysis of more than 10,000 consec-utive admissions (N=6,805), reporteda 30-day re-admission rate of 17%(Allaudeen et al., 2011). Co-morbidi-ties that significantly increased therisk of re-admission included conges-tive heart failure, renal disease, can-cer, weight loss (not defined), andiron deficiency anemia. Weight loss
correlated with a 26% increase in riskof re-admission (adjusted oddsratio=1.26) (Allaudeen et al., 2011).In a large single-center study of1,442 general surgery patients, the30-day re-admission rate was 11%(Kassin et al., 2012). The most com-mon reasons for re-admission weregastrointestinal problems/complica-tions (28% of re-admissions), surgi-cal infections (22%), and failure tothrive/malnutrition (10%). Thesefindings are consistent with thehypothesis that poor nutrition con-tributes to post-hospital syndrome,which together with a variety ofother factors, such as sleep distur-bance, pain, and discomfort, canincrease the risk of 30-day re-admis-sion dramatically, often for reasonsother than the original diagnosis(Krumholz, 2013).
Finally, poor clinical outcomesassociated with malnutrition con-tribute to higher hospitalizationcosts. As outlined above, pa tientswho are malnourished have higherrates of infections, pressure ulcers,impaired wound healing, and otheradverse outcomes requiring greaternursing care and more medications.In turn, these complications cancontribute to longer lengths of hos-pital stay and higher rates of re-admission, all of which indirectlycontribute to higher hospital costs(Barker et al., 2011). Indeed, a studyconducted in the United Kingdomestimated the annual expenditure formanaging patients at medium orhigh risk of disease-related malnutri-tion to be €10.5 billion (Euro) ($11.3billion USD, based on 2003 exchangerates), more than half of which wasrelated directly to hospital care(Russell, 2007).
These studies strongly suggest theconsequences of unrecognized anduntreated malnutrition are substan-tial, not only for patients’ quality ofcare but also from a cost perspective.Malnutri tion negatively affects clini-cal outcomes and results in highercosts, and, with the changing healthcare landscape, reimbursement forcosts associated with preventableevents will be reduced. All cliniciansmust take action to address these con-cerns, improve patient quality of life,and increase health care system value.
May-June 2013 • Vol. 22/No. 3150
Impact of NutritionIntervention on KeyOutcomes
The benefits of nutrition inter-vention in terms of improving keyclinical outcomes are well docu-mented. Numerous studies, predom-inantly in patients age 65 and olderwith or at risk for malnutrition, haveshown the potential of specific nutri-tion interventions to reduce compli-cation rates, length of hospital stay,re-admission rates, cost of care signif-icantly, and, in some studies, mortal-ity (Avenell & Handoll, 2006, 2010;Brugler, DiPrinzio, & Bernstein,1999; Cawood, Elia, & Stratton,2012; Gariballa et al., 2006; Milne etal., 2009; Milne, Potter, & Avenell,2005; Milne, Avenell, & Potter, 2006;Neelemaat et al., 2012; Philipson etal., 2013; Somanchi Tao & Mullin,2011; Stratton Green & Elia, 2003).Nutrition intervention strategies rep-resent a broad spectrum of optionsthat can be organized into four cate-gories: (1) food and/or nutrientdelivery, (2) nutrition education, (3)nutrition counseling, and (4) coordi-nation of nutrition care. Food and/ornutrient delivery requires an individ-ualized approach that includes ener-gy- and nutrient-dense food, com-plete oral nutrition supplements(ONS) that provide macronutrients(from carbohydrate, fat, and proteinsources) combined with micronutri-ents (mixtures of complete vitamins,minerals, and trace elements); enter-al nutrition (EN), which in the con-text of this report refers to nutrientsprovided into the gastrointestinaltract via a tube; and/or parenteralnutrition (PN). Although the nutri-tion support literature generally hasfeatured smaller trials and observa-tional studies rather than large mul-ticenter randomized controlled tri-als, evidence strongly supports theimportance of nutrition interven-tion. The value of EN and PN is wellestablished in select patient popula-
tions but remains unclear in others.In addition, numerous studies haveshown improved body weight, LBM,and grip strength with dietary coun-seling, with or without ONS(Baldwin & Weekes, 2011). A grow-ing number of studies have exam-ined the impact of ONS in malnour-ished patients, providing the frame-work for our call to action. Evidencesupporting intervention with ENand PN is beyond the scope of thecurrent paper and will be addressedin subsequent reviews.
Clinical ComplicationsStudies evaluating the efficacy of
ONS consumption generally haveshown a variety of metabolic im -provement and, in many studies, areduction in several clinical complica-tions. One meta-analysis includingseven studies (N=284) indicates thatpatients receiving ONS had reducedcomplication rates (e.g., infections,gastrointestinal perforations, pressureulcers, anemia, and cardiac complica-tions) compared with control patients(Stratton, Green, & Elia, 2003). Morerecently, a large Cochrane systematicreview of 24 studies involving 6,225patients age 65 and older at risk formalnutrition demonstrated fewercomplications (e.g., pressure sores,deep vein thrombosis, and respiratoryand urinary infections) amongpatients receiving ONS compared withroutine care (relative risk [RR] 0.86;95% confidence interval [CI] 0.75-0.99) (Milne, Potter, Vivanti, &Avenell, 2009). Available evidenceindicates high-protein ONS to be par-ticularly effective at reducing the riskof complications. A systematic reviewof older adult patients (age 65 andolder) with hip fractures demonstrat-ed a more effective reduction in thenumber of long-term medical compli-cations with high-protein ONS (>20%total energy from protein) than low-protein or non-protein containingsupplements (RR 0.78; 95% CI 0.65-
0.95) (Avenell & Handoll, 2010). Ameta-analysis of four randomized tri-als (N=1,224) also showed that, inpatients with no pressure ulcers atbaseline, high-protein ONS resultedin a significant 25% lower incidenceof ulcers compared with routine care(Stratton et al., 2005). In addition,evidence indicates nutrition inter-vention can reduce the risk of falls infrail and malnourished older adultpatients. In 210 malnourished olderadults newly admitted to an acute-care hospital, intervention with aprotein- and energy-rich diet, ONS,calcium/ vitamin D supplements,and counseling reduced the inci-dence of falls by approximately 60%compared with routine care (10% vs.23%) (Neelemaat et al., 2012).Avoidance of these preventableevents can shorten length of hospi-tal stay, decrease morbidity and mor-tality, and reduce liability for thehospital.
Length of StayConsistent with evidence nutri-
tion intervention can reduce clinicalcomplications, providing strongnutrition care can also reduce thelength of hospital stay. In a prospec-tive study conducted at The JohnsHopkins Hospital, nutrition screen-ing involving a team approach toaddress malnutrition and earlierintervention reduced the length ofhospital stay by an average of3.2 days in severely malnourishedpatients (Somanchi et al., 2011), andthis translated into substantial costsavings of $1,514 per patient. Twometa-analyses have shown signifi-cantly reduced length of hospital stayin patients receiving ONS comparedwith control patients. One analysisdemonstrated a reduced averagelength of hospital stay ranging from2 days for surgical patients to 33 daysfor orthopedic patients (p<0.004)(Stratton et al., 2003). Additionally,patients with a lower BMI (<20)received the greatest benefit fromoptimized food and/or nutrientdelivery. Likewise, in a recent meta-analysis of nine randomized trials(N=1,227), high-protein ONS signifi-cantly reduced length of stay by anaverage of 3.8 days (p=0.040) com-pared with routine care (Cawood,
Alliance to Advance Patient Nutrition
The benefits of nutrition intervention in terms of improving key clinical outcomes
are well documented.
May-June 2013 • Vol. 22/No. 3 151
Elia, & Stratton, 2012). A recent ret-rospective analysis utilized informa-tion from more than one millionadult inpatient cases found in the2000-2010 Premier PerspectivesData base™, maintained by the Pre -mier Healthcare Alliance – repre-senting a total of 44 million hospi-tal episodes from across the UnitedStates or approximately 20% of allinpatient admissions in the UnitedStates. Within this sample, ONSreduced length of hospital stay byan average of 2.3 days or 21%, andthe average cost savings was $4,734or 21.6% compared with routinecare (Philipson, Thornton Snider,Lakdawalla, Stryckman, & Goldman,2013).
Re-AdmissionsHospital re-admission rate is
another important outcome that canbe improved through nutrition inter-vention. Thirty-day re-admissionrates decreased from 16.5% to 7.1%in a community hospital that imple-mented a comprehensive malnutri-tion clinical pathway programfocused on identification of at-riskpatients, nutrition care decisions,inpatient care, and discharge plan-ning (Brugler, DiPrinzio, & Bernstein,1999). A prospective randomizedtrial in acutely ill patients 65 to92 years of age (N=445) demonstrat-ed a significantly lower 6-month re-admission rate among those whoreceived a normal hospital diet plushigh-protein ONS compared withthose patients who received only thenormal hospital diet (29% vs. 40%,respectively; hazard ratio [HR] 0.68,95% CI 0.49-0.94) (Gariballa, Forster,Walters, & Powers, 2006). Finally,analysis of the Premier PerspectivesDatabase showed that use of ONSreduced 30-day re-admission rates by6.7% (Philipson et al., 2013), indicat-ing the significant real-world benefitof nutrition intervention on a keypatient outcome.
MortalitySeveral meta-analyses have also
demonstrated reduced mortality inpatients receiving optimized oralnutrition care. An analysis of 11studies (N=1,965) found significantlylower mortality rates among hospi-
talized patients receiving ONS (19%)compared with control patients(25%; p<0.001) (Stratton et al.,2003). This represented a 24% over-all reduction in mortality, andpatients with lower average BMI(<20) receiving ONS significantlyhad a greater reduction in mortality.Among elderly patients hospitalizedfor hip fracture, fewer patients hadan unfavorable combined outcome(mortality or medical complication)if they received ONS versus routinecare (RR 0.52; 95% CI 0.32-0.84)(Avenell & Handoll, 2006). Anothersystematic review of 32 studies(N=3,021) found that, in elderlypatients, ONS significantly reducedmortality compared with routinecare (RR 0.74; 95% CI 0.59-0.92)(Milne, Potter, & Avenell, 2005).Subgroup analyses from the originalCochrane review and two updateshave consistently shown reducedmortality in undernourished pa -tients receiving ONS compared withroutine care (Milne, Avenell, &Potter, 2006; Milne et al., 2009;Milne et al., 2005).
Collectively, these data providesolid evidence that nutrition inter-vention significantly contributes toimproved clinical outcomes andreduced cost of care, primarily inpatients 65 years of age and olderand those with or at risk for malnu-trition. However, it is important tonote that isolated studies and meta-analyses have not demonstratedsuch significantly improved clinicaloutcomes with nutrition interven-tion (Baldwin & Weekes, 2011; Beck,Holst, & Rasmussen, 2013; Burden,Todd, Hill, & Lal, 2012; Hendry et al.,2010; Langer et al., 2012). Thus,additional research studies, particu-larly well-powered, randomized con-trolled clinical trials, are always ben-eficial to further explore the effectsof nutrition intervention on clinicaloutcomes and to assess how thosebenefits may translate into cost sav-ings. Nevertheless, given the impor-tance of adequate nutrition to celland organ function, coupled withpromising clinical data reported todate, the time is now to act on theevidence at hand and implementnutrition intervention strategiesshown to be safe and efficacious.
Alliance Nutrition CareRecommendations
If we are to make progress towardimproving nutrition care practicesthat guarantee every malnourishedor at-risk patient is identified andtreated effectively, we must proac-tively identify barriers impacting theprovision of nutrition care. Towardthis end, at least six key challengesmust be overcome. First, despite atleast one-third of hospitalizedpatients being admitted malnour-ished, a majority of these patientscontinue to go unrecognized or are inadequately screened (Elia,Zellipour, & Stratton, 2005). Second,while the responsibility of patients’nutrition care is often placed on thedietitian, many institutions lack ade-quate dietitian staffing to properlyaddress all patients. Third, nutritioncare is often delayed due to thepatient’s medical status, lack of dietorder, and time to nutrition consult.In fact, a study at Johns Hopkinsfound that time to consultationfrom admission is nearly 5 days(Somanchi et al., 2011), which issimilar to the average length of hos-pital stay (Centers for DiseaseControl and Prevention, 2009).Fourth, nurses provide and overseepatient care 24/7, observe nutritionintake and tolerance, and interactcontinually with the patient andfamily/caregivers, yet they are notconsistently included in nutritioncare (Willand & Luker, 2007). Fifth,in many care environments, physi-cian sign-off is required to imple-ment a nutrition care plan. Dietitianrecommendations are implementedin only 42% of cases (Skipper, Young,Rotman, & Nagl, 1994). Finally,many patients experience difficultyin consuming meals without assis-tance, contributing to more thanhalf of hospitalized patients not fin-ishing their meals (Hiesmayr et al.,2009).
To address these barriers and shiftthe paradigm of nutrition care, theAlliance Steering Committee, whosemembers possess broad-rangingexpertise and clinical experience,developed several key principles for advancing patient nutrition.Through a series of meetings con-
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
May-June 2013 • Vol. 22/No. 3152
ducted over the past year, the com-mittee explored the following topics:empowerment of all clinicians,recognition and diagnosis of allpatients, same-day automatic inter-vention for all at-risk patients, edu-cation and involvement of patientsin their nutrition care, and apprecia-tion of the value of nutrition by allhospital stakeholders. Six principlesdeemed essential elements of opti-mal patient nutrition care werederived from these topics (see Figure1). Attainment of these six ideals,however, will require processes andcollaboration among all hospitalstakeholders, including dietitians,
nurses, physicians, and administra-tors, each of whom must fulfill a rolein this effort (see Table 1). Translationof these processes into a practicalinterdisciplinary nutrition care algo-rithm is illustrated in Figure 2.
Principle 1: Create anInstitutional Culture WhereAll Stakeholders ValueNutrition
True progress requires that all hos-pital stakeholders, including clini-cians and administrators, fully un -derstand the pervasiveness of hospi-tal malnutrition and the effect pa -tient nutrition care may have on
overall clinical outcomes. Cliniciansand administrators often fail to prior-itize understanding the extent ofmalnutrition in their institutions andits potential impact on cost and/orquality of care. Nurses and physiciansreceive limited formal nutrition edu-cation during training and often donot prioritize nutrition among thecompeting priorities nutrition withinpatient care. Failing to prioritizenutrition within an institution maylimit available nutrition interventionoptions and human resources (e.g.,dietitians and nutrition-focused nurs-es and physicians) required for opti-mal nutrition care. To be successful,
Alliance to Advance Patient Nutrition
• Know the facts – nutrition improves patient outcomes• Support adequate and appropriate nutrition intervention• Identify motivated champions among hospital stakeholders
FIGURE 1.The Alliance’s Key Principles for Advancing Patient Nutrition
Principle 1: Create Institution Culture
• Assure accountability for malnutrition identification• Use valid screening tool and criteria to assess/diagnose malnutrition• Include fields for malnutrition characteristics in EHR
Principle 3: Recognize and Diagnose ALLPatients at Risk
• Establish policy to feed patients within 24 hours of “at-risk” screen• Create EHR prompt for diet order when “at-risk” screening data entered• Monitor patient’s food and oral nutrition supplement consumption
Principle 4: Rapidly Implement Inter ventionsand Continued Monitoring
• Leverage EHR to standardize nutrition documentation• When present, ensure coding of mild, moderate, or severe malnutrition as
complicating condition to primary diagnosis• Ensure care discussions include nutrition
Principle 5: Communicate Nutrition Care Plans
• Empower dietitians• Secure nurse and physician leadership• Engineer teamwork (e.g., daily team huddles) to include nutrition
Principle 2: Redefine Clinicians’ Roles toInclude Nutrition
• Ensure nutrition care plan incorporated into discharge plan• Educate patients and their family/caregivers• Communication with the patient’s health care providers
Principle 6: Develop Discharge NutritionCare and Education Plan
Abbreviation: EHR = electronic health record
May-June 2013 • Vol. 22/No. 3 153
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
Abb
revi
atio
ns:A
ND
= A
cade
my
of N
utrit
ion
and
Die
tetic
s; A
.S.P
.E.N
. = A
mer
ican
Soc
iety
for
Par
ente
ral a
nd E
nter
al N
utrit
ion;
EH
R =
ele
ctro
nic
heal
th r
ecor
d; E
N =
ent
eral
nutri
tion;
ON
S =
ora
l nut
ritio
n su
pple
men
t; P
N =
par
ente
ral n
utrit
ion;
PO
= o
ral
cont
inue
d on
nex
t pag
e
TAB
LE 1
.Su
mm
ary
of A
llian
ce’s
Nut
riti
on C
are
Reco
mm
end
atio
ns
for
Key
Hos
pit
al S
take
hol
der
s
Pri
ncip
le
Key
Hos
pita
l Sta
keho
lder
s
Die
titia
nN
urse
Phy
sici
anH
ospi
tal A
dmin
istr
ator
1.C
reat
e an
Inst
itutio
nal
Cul
ture
Whe
re A
llS
take
hold
ers
Valu
e N
utrit
ion
•S
erve
as
prim
ary
auth
ority
on
“all
thin
gs n
utrit
ion”
•E
duca
te k
ey h
ospi
tal
stak
ehol
ders
on
impr
oved
patie
nt o
utco
mes
and
red
uced
cost
s ac
hiev
ed w
ith o
ptim
alnu
tritio
n ca
re•
Hos
t hos
pita
l-wid
e le
arni
ngop
portu
nitie
s at
reg
ular
inte
rval
s
•R
ecog
nize
the
esse
ntia
l rol
enu
rses
pla
y in
ach
ievi
ngen
hanc
ed p
atie
nt o
utco
mes
thro
ugh
indi
vidu
aliz
ed n
utrit
ion
care
•In
corp
orat
e nu
tritio
n in
toro
utin
e ca
re c
heck
lists
and
proc
esse
s•
Incl
ude
patie
nt’s
nut
ritio
n in
take
into
team
hud
dles
•P
rovi
de le
ader
ship
unde
rsco
ring
nutri
tion
care
as
an e
ssen
tial p
art o
f pat
ient
-ce
nter
ed c
are
•K
now
evi
denc
e re
gard
ing
impa
ct o
f mal
nutri
tion
and
effe
ctiv
enes
s of
nut
ritio
nin
terv
entio
n•
Incl
ude
diet
itian
in d
aily
team
hudd
les/
roun
ds•
Inco
rpor
ate
nutri
tion
into
rout
ine
care
che
cklis
ts a
ndpr
oces
ses
•B
ecom
e a
nutri
tion
cham
pion
and
prov
ide
supp
ort f
or th
ede
velo
pmen
t of e
ffect
ive
nutri
tion
care
pro
cess
es•
Sha
re q
ualit
y an
d ec
onom
icga
ins
to b
e m
ade
by in
vest
ing
in n
utrit
ion
care
with
hos
pita
lle
ader
ship
team
2.R
edef
ine
Clin
icia
ns’ R
ole
toIn
clud
e N
utrit
ion
Car
e
•A
ctiv
ely
cont
ribut
e nu
tritio
nex
perti
se a
nd e
ngag
e ot
her
team
mem
bers
with
asse
ssm
ent d
ata
on p
rogr
ess
mad
e w
ith n
utrit
ion
care
effo
rts•
Reg
ular
ly p
artic
ipat
e in
inte
rdis
cipl
inar
y ro
unds
.
•E
nsur
e pr
actic
es a
re in
pla
ce to
supp
ort i
mpl
emen
tatio
n of
nutri
tion
inte
rven
tion
•D
evel
op p
roce
sses
to e
nsur
enu
tritio
n sc
reen
ing
and
diet
itian
-pr
escr
ibed
inte
rven
tion
occu
rsw
ithin
the
targ
eted
tim
efra
mes
•F
acili
tate
nur
sing
inte
rven
tions
to tr
eat p
atie
nts
who
are
mal
nour
ishe
d or
at r
isk
•E
mpo
wer
die
titia
n to
coop
erat
ivel
y le
ad n
utrit
ion
care
as
clin
ical
team
mem
ber
•S
uppo
rt nu
rse
wor
k pr
oces
ses
to in
clud
e nu
tritio
n sc
reen
ing
and
inte
rven
tion
•S
uppo
rt nu
tritio
n ed
ucat
ion
ofcl
inic
ians
nee
ding
initi
al tr
aini
ngan
d co
ntin
uing
edu
catio
n•
Pro
vide
ord
erin
g pr
ivile
ges
todi
etiti
an fo
r is
sues
rel
atin
g to
the
nutri
tion
care
pro
cess
3.R
ecog
nize
and
Dia
gnos
e A
llM
alno
uris
hed
Pat
ient
s an
dT
hose
at R
isk
•U
tiliz
e st
anda
rd m
alnu
tritio
nch
arac
teris
tics
set f
orth
by
AN
Dan
d A
.S.P
.E.N
. gui
delin
es•
Est
ablis
h co
mpe
tenc
e in
nutri
tion-
focu
sed
phys
ical
asse
ssm
ent
•S
cree
n ev
ery
hosp
italiz
edpa
tient
for
mal
nutri
tion
as p
art
of r
egul
ar w
orkf
low
pro
cedu
res
•C
omm
unic
ate
scre
enin
gre
sults
thro
ugh
use
of E
HR
•R
escr
een
patie
nts
at le
ast
wee
kly
durin
g ho
spita
l sta
y•
Com
mun
icat
e ch
ange
s in
clin
ical
con
ditio
n in
dica
tive
ofnu
tritio
n ris
k
•C
onsi
der
nutri
tion
stat
us a
s an
esse
ntia
l attr
ibut
e of
med
ical
asse
ssm
ent,
mon
itorin
g, a
ndca
re p
lans
•E
nsur
e E
HR
cap
ture
ssc
reen
ing
data
and
mal
nutri
tion
crite
ria w
ith th
e ap
prop
riate
trigg
ers
in p
lace
for
initi
atin
gth
e ne
xt s
teps
whe
n po
sitiv
esc
reen
s or
dia
gnos
ticas
sess
men
t are
obt
aine
d
May-June 2013 • Vol. 22/No. 3154
Alliance to Advance Patient Nutrition
Abb
revi
atio
ns:A
ND
= A
cade
my
of N
utrit
ion
and
Die
tetic
s; A
.S.P
.E.N
. = A
mer
ican
Soc
iety
for
Par
ente
ral a
nd E
nter
al N
utrit
ion;
EH
R =
ele
ctro
nic
heal
th r
ecor
d; E
N =
ent
eral
nutri
tion;
ON
S =
ora
l nut
ritio
n su
pple
men
t; P
N =
par
ente
ral n
utrit
ion;
PO
= o
ral
cont
inue
d on
nex
t pag
e
TAB
LE 1
. (co
ntin
ued)
Sum
mar
y of
Alli
ance
’s N
utri
tion
Car
e Re
com
men
dat
ion
s fo
r K
ey H
osp
ital
Sta
keh
old
ers
Pri
ncip
le
Key
Hos
pita
l Sta
keho
lder
s
Die
titia
nN
urse
Phy
sici
anH
ospi
tal A
dmin
istr
ator
4.R
apid
ly Im
plem
ent
Com
preh
ensi
veN
utrit
ion
Inte
rven
tion
and
Con
tinue
dM
onito
ring
•E
stab
lish
proc
edur
es to
supp
ort p
olic
y th
at p
atie
nts
iden
tifie
d as
“at
-ris
k” d
urin
gnu
tritio
n sc
reen
rec
eive
auto
mat
ed n
utrit
ion
inte
rven
tion
with
in 2
4 ho
urs
whi
le a
wai
ting
asse
ssm
ent,
diag
nosi
s, a
ndca
re p
lan
•Le
ad a
n in
terd
isci
plin
ary
team
to e
stab
lish
nutri
tion
algo
rithm
sfo
r us
e in
var
ious
sce
nario
sw
hen
posi
tive
scre
ens
ordi
agno
stic
ass
essm
ents
are
obta
ined
•P
rovi
de E
N fo
rmul
ary
and
mic
ronu
trien
t the
rapy
opt
ions
inw
ritte
n fo
rm a
s a
pock
et-s
ize
docu
men
t; m
ake
read
ilyav
aila
ble
to a
ll st
aff t
o en
sure
fast
inte
rven
tion
•W
ork
with
inte
rdis
cipl
inar
yte
am to
est
ablis
h po
licie
s an
din
terd
isci
plin
ary
prac
tices
tom
axim
ize
nutri
ent c
onsu
mpt
ion
and
mon
itorin
g ne
eds
•E
nsur
e pr
oced
ures
allo
win
gpa
tient
s id
entif
ied
as “
at-r
isk”
durin
g nu
tritio
n sc
reen
rec
eive
auto
mat
ed n
utrit
ion
inte
rven
tion
with
in 2
4 ho
urs
whi
le a
wai
ting
asse
ssm
ent,
diag
nosi
s, a
nd c
are
plan
•D
evel
op p
roce
dure
s to
pro
vide
patie
nts
with
mea
ls a
t “of
ftim
es”
if pa
tient
was
not
avai
labl
e or
und
er a
res
trict
eddi
et a
t the
tim
e of
mea
lde
liver
y•
Avo
id d
isco
nnec
ting
EN
or
PN
for
patie
nt r
epos
ition
ing,
ambu
latio
n, tr
avel
, or
proc
edur
es•
Wor
k w
ith in
terd
isci
plin
ary
prac
tices
to e
stab
lish
polic
ies
and
inte
rdis
cipl
inar
y pr
actic
esto
max
imiz
e fo
od/O
NS
cons
umpt
ion
•M
onito
r fo
od/O
NS
cons
umpt
ion
and
com
mun
icat
e to
diet
itian
/phy
sici
an v
ia E
HR
•S
uppo
rt po
licy
that
pro
vide
sau
tom
ated
nut
ritio
n in
terv
entio
nw
ithin
24
hour
s in
pat
ient
sid
entif
ied
as “
at-r
isk”
dur
ing
nutri
tion
scre
en, w
hile
aw
aitin
gnu
tritio
n as
sess
men
t,di
agno
sis,
and
car
e pl
an•
Min
imiz
e ni
l per
os
perio
ds fo
ryo
ur p
atie
nt w
ith s
ched
ulin
g of
proc
edur
es/te
sts
and
rem
ain
min
dful
of “
hold
s” o
n P
O d
iets
•P
rovi
de o
rder
ing
priv
ilege
s to
diet
itian
for
issu
es r
elat
ing
toth
e nu
tritio
n ca
re p
roce
ss
(e.g
., di
et p
lans
, ON
S,
mic
ronu
trien
ts, a
nd c
alor
ieco
unts
)•
Ens
ure
EH
R in
clud
esau
tom
atic
trig
gers
that
initi
ate
nutri
tion
prot
ocol
mea
sure
s to
be r
evie
wed
whe
n po
sitiv
esc
reen
s ar
e ob
tain
ed•
Ens
ure
EH
R in
clud
es a
mod
ule
for
reco
rdin
g fo
od/O
NS
inta
ke d
ata
and
trigg
ers
diet
itian
con
sult
if co
nsum
ptio
nis
sub
optim
al
May-June 2013 • Vol. 22/No. 3 155
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
Abb
revi
atio
ns:A
ND
= A
cade
my
of N
utrit
ion
and
Die
tetic
s; A
.S.P
.E.N
. = A
mer
ican
Soc
iety
for
Par
ente
ral a
nd E
nter
al N
utrit
ion;
EH
R =
ele
ctro
nic
heal
th r
ecor
d; E
N =
ent
eral
nutri
tion;
ON
S =
ora
l nut
ritio
n su
pple
men
t; P
N =
par
ente
ral n
utrit
ion;
PO
= o
ral
TAB
LE 1
. (co
ntin
ued)
Sum
mar
y of
Alli
ance
’s N
utri
tion
Car
e Re
com
men
dat
ion
s fo
r K
ey H
osp
ital
Sta
keh
old
ers
Pri
ncip
le
Key
Hos
pita
l Sta
keho
lder
s
Die
titia
nN
urse
Phy
sici
anH
ospi
tal A
dmin
istr
ator
5.C
omm
unic
ate
Nut
ritio
n C
are
Pla
ns
•If
pres
ent,
ensu
re m
ild, m
oder
-at
e, o
r sev
ere
mal
nu tri
tion
isin
clud
ed a
s co
mpl
i cat
ing
cond
ition
in c
odin
g pr
oces
ses
•A
ssum
e re
spon
sibi
lity
for
ensu
ring
a pa
tient
’s n
utrit
ion
care
plan
is d
ocum
ente
d ca
refu
lly in
the
EH
R, u
pdat
ed re
gula
rly, a
ndco
mm
unic
ated
effe
ctiv
ely
to a
llhe
alth
car
e pr
ovid
ers,
incl
udin
gpo
st-a
cute
faci
litie
s an
d pr
imar
yca
re p
hysi
cian
s•
Lead
an
inte
rdis
cipl
inar
y te
am to
crea
te a
nd m
aint
ain
stan
dard
ized
pol
icie
s,pr
oced
ures
, and
EH
R-
auto
mat
ed tr
igge
rs re
leva
nt to
nutri
tion,
incl
udin
g or
der s
ets
and
prot
ocol
s in
the
hosp
ital’s
EH
R
•C
onsu
lt di
etiti
an re
gard
ing
nutri
ent i
ntak
e co
ncer
ns•
If pr
esen
t, en
sure
mild
,m
oder
ate,
or s
ever
e m
alnu
tritio
nis
incl
uded
as
com
plic
atin
gco
nditi
on in
cod
ing
proc
esse
s•
Inco
rpor
ate
nutri
tion
disc
ussi
onin
to h
ando
ff of
car
e an
d nu
rsin
gca
re p
lans
•E
stab
lish
and
rein
forc
eex
pect
atio
n th
at a
pat
ient
’snu
tritio
n ca
re p
lan
isdo
cum
ente
d ca
refu
lly in
the
EH
R, u
pdat
ed r
egul
arly
, and
com
mun
icat
ed e
ffect
ivel
y to
all
heal
th c
are
prov
ider
s•
If pr
esen
t, en
sure
mild
,m
oder
ate,
or
seve
rem
alnu
tritio
n is
incl
uded
as
com
plic
atin
g co
nditi
on in
codi
ng p
roce
sses
•If
pres
ent,
ensu
re m
ild,
mod
erat
e, o
r se
vere
mal
nutri
tion
is in
clud
ed a
sco
mpl
icat
ing
cond
ition
inco
ding
pro
cess
es•
Ens
ure
EH
R is
ada
pted
toen
sure
nut
ritio
n di
agno
sis
and
com
plet
e ca
re p
lan
is in
clud
edas
a s
tand
ard
cate
gory
of
med
ical
ass
essm
ent i
n th
ece
ntra
l are
a of
EH
R
6.D
evel
op a
Com
preh
ensi
veD
isch
arge
Nut
ritio
n C
are
and
Edu
catio
n P
lan
•P
rovi
de p
atie
nts,
fam
ilym
embe
rs, a
nd c
areg
iver
s w
ith n
utrit
ion
educ
atio
n an
d a
com
preh
ensi
ve p
ost-
hosp
italiz
atio
n nu
tritio
n ca
repl
an•
Ens
ure
patie
nt a
nd c
areg
iver
unde
rsta
nd th
e im
porta
nce
offo
llow
-up
nutri
tion
asse
ssm
ent
and
educ
atio
n•
Pro
vide
spe
cific
info
rmat
ion
for
nutri
tion
follo
w-u
p ap
poin
tmen
tsto
pat
ient
and
car
egiv
er
•In
clud
e nu
tritio
n as
a c
ompo
nent
of a
ll cl
inic
ian
conv
ersa
tions
with
patie
nts
and
thei
r fam
ilym
embe
rs/c
areg
iver
s•
Rei
nfor
ce th
e im
porta
nce
ofnu
tritio
n ca
re a
nd fo
llow
-up
post
-di
scha
rge
to p
atie
nt a
ndca
regi
ver
•In
clud
e nu
tritio
n as
aco
mpo
nent
of a
ll cl
inic
ian
conv
ersa
tions
with
pat
ient
s an
d th
eir
fam
ily m
embe
rs/
care
give
rs
•P
rovi
de e
xpec
tatio
n re
gard
ing
cont
inui
ty o
f nut
ritio
n ca
re,
incl
udin
g di
scha
rge
plan
ning
and
patie
nt e
duca
tion
May-June 2013 • Vol. 22/No. 3156
institutions need motivated nutritionchampions at all levels of clinical careand administration.
To ensure clinicians and hospitalleaders understand the clinical andfinancial implications of malnutri-tion and take proper steps to addressit, the Alliance offers the followingrecommendations:• Clinicians must be educated on
the recognition of malnourished
patients and evidence-basednutrition interventions. Discus -sion of nutrition care plansshould be a mandated compo-nent of daily team meetings(rounds or huddles).
• Malnutrition must be includedappropriately as part of thepatient’s diagnosis and nutritioninterventions must be viewed asa core component of a patient’s
medical therapy. Nutrition treat-ment plans should be addressedwith the same consistency andrigor as other therapies.
• Hospital administrators must rec-ognize the financial benefit ofoptimal nutrition care. Insti -tutional financial data must bereviewed to identify challenges toimproving nutrition interven-tion, project cost savings with
Alliance to Advance Patient Nutrition
FIGURE 2.The Alliance’s Approach to Interdisciplinary Nutrition Care
Hospital admission
Nutrition screen
Malnourished or at riskIf not at risk, monitor,
then rescreen
Nutrition assessmentordered
Automatic interventiontriggered in EHR
Patient fed and consumption monitored*
If malnourished, diagnosis documented
Monitor and re-evaluate Discharge plan updated
Patient discharged onappropriate nutrition care
plan
Nutrition care plan trans-ferred to next care setting
and PCP
Nutrition assessment conducted
Custom nutrition careplan created/ordered
Patient and family education
Nurse• Every patient screened within 24
hours using validated tool• Results document in EHR
Nurse• Initiate food/ONS intake within
24 hours*• Manage environments to
maximize consumption
Dietitian• Assessment includes AND and
A.S.P.E.N. malnutrition charac-teristics
Interdisciplinary• Dietitian: Create nutrition care
plan, order intervention and document in EHR
• Nurse: Facilitate adherence • Physician: Nutrition included in
daily problems list/team huddles
Interdisciplinary• Dietitian: Adjust
nutrition care plan andorders, as needed; document in EHR
• Nurse: Monitor and document changes inintake, weight, and function
• Physician: Continuenutrition care discussion
Interdisciplinary• Dietitian: Conduct comprehensive
education/counseling• Nurse: Reinforce teachings and
respond to questions• Physician: Discuss nutrition
status/plan
Interdisciplinary• Nutrition care included
within discharge plan• Nutrition care follow-up
scheduled
Physician• Severity-coded diagnosis
documented in EHR
Interdisciplinary• Nutrition care included
within transition callsand evaluations
*Patient fed orally unless specific contraindications exist
Abbreviations: AND = Academy of Nutrition and Dietetics; A.S.P.E.N. = American Society for Parenteral and Enteral Nutrition; EHR = electronic health record; ONS = oral nutrition supplement; PCP = primary care physician
May-June 2013 • Vol. 22/No. 3 157
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
various nutrition interventions,and revise budgets to facilitateaction. Budgets must supportadequate and appropriate nutri-tion intervention as necessitatedby dietitian, nursing, and physi-cian staff.
• Professional associations for dieti-tians, nurses, physicians, and hos-pital administrators must ad dressthe widespread problem of hospi-tal malnutrition. Dis cipline-specific resources, such as toolkitsand practice bundles, evidence-based publications, and continu-ing education op por tunities,must be established and widelyavailable. Funding mechanismsfor nutrition-related re searchshould be established to identifybest practices for optimizingnutrition care.
Principle 2: RedefineClinicians’ Roles to IncludeNutrition Care
Providing effective nutritionintervention requires a championwithin and collaboration among alldisciplines involved in patient care.All health care professionals in -volved in patient care must beempowered to influence nutritiondecisions. In many hospitals, howev-er, the responsibility for nutritionrecommendations almost alwaysrests solely with the dietitian. Manyinstitutions lack nurse and physicianleaders who champion nutritioncare. Interdisciplinary leadership isessential to ensure nutrition care isvalued and carries a high priority. Toensure effective management of hos-pital malnutrition, nurses and physi-cians also must play a role.
In this regard, the Alliance recom-mends redefining clinicians’ roles toinclude responsibility for optimalnutrition care, which can be accom-plished as follows: • Interdisciplinary teams must
discuss potential barriers andsolutions to recognize and treatmalnourished or at-risk patientsin their hospitals.
• Engage nurses to understandnu trition risk factors, such asunder-consumed meals andactions required on positivemalnutrition screenings. De -
velop and implement policiesthat allow nurses to providecomplete nutrition care, such asreturning low-risk patients toprevious established feedingorders following temporarydelays, initiating calorie counts,and measuring body weight asindicated. Policies that inhibitnursing action inhibit optimalpatient nutrition. Prompt nurs-ing action can reduce malnutri-tion by creating focused meal-times, managing mealtime envi-ronments and staff mealtimes,intervening with nutrition ther-apies as appropriate, and desig-nating a nutrition care nurse ineach clinical area to monitorand evaluate implementation ofthe policy (Jefferies, Johnson, &Ravens, 2011).
• Given the extensive nutritionexpertise of dietitians, hospitaladministrators such as a chiefmedical officer must grant themprivileges for ordering diets,ONS, vitamins, and caloriecounts to eliminate inefficien-cies and prevent delays in foodand/or nutrient delivery. Forexample, at the University ofKansas Hospital (KUH), whenfaced with delays in care becausethe dietitian’s recommendationswere not being noted andordered by physician teams, thenutrition support team obtainedordering privileges for all dieti-tians. These privileges includeordering ONS, calorie counts,patient weights, zinc, vitamin Cand multivitamins, and selectnutrition-related labs. This wasan important step in advancingnutrition care at KUH by pro-moting timely gathering ofassessment data and nimbleimplementation and revision ofoptimal nutrition interventions.
• Hospitalists must add nutritionto their interdisciplinary ap -proach to patient care and serveas nutrition champions amongphysicians. In support of thiseffort, hospitalists should in -clude a dietitian and nutrition-focused nurse in team huddles,and nutrition should be includ-ed in the daily problem list.
Principle 3: Recognize andDiagnose All MalnourishedPatients and Those at Risk
Given the high prevalence of hos-pital malnutrition, each hospitalizedpatient must receive proper nutri-tion screening, with findings effec-tively communicated to ensureimmediate assessment and promptnutrition intervention. Using vali-dated screening tools to identify at-risk patients is crucial because, formany health care professionals with-out nutrition training, screening iscurrently superficial observationwherein boxes are checked orunchecked without reliable screen-ing using a validated tool. Early iden-tification of clinical criteria support-ing a malnutrition diagnosis andeffective processes for communicat-ing information related to the nutri-tion care process are often absent.Given these barriers, the Alliance isannouncing this call to action toensure prompt diagnosis and inter-vention of hospitalized patients whoare malnourished or at risk for mal-nutrition. Every hospital must insti-tute an interdisciplinary approach tonutrition care that is based on formalpolicies and procedures ensuring theearly identification of patients whoare malnourished or at risk for mal-nutrition, and implementation of acomprehensive nutrition care plan.
Screening. Comprehensive nutri-tion screening of all hospitalizedpatients is critical for both the time-ly identification of those at risk andto prioritize patients requiring nutri-tion assessment and intervention.The Alliance supports the JointCommission’s recommendation fornutrition screening within 24 hoursof admission to an acute care hospi-tal and at frequent intervalsthroughout hospitalization (JointCommission on Accreditation ofHealthcare Organizations, 2007) (seeFigure 2). Due to limited cliniciantime and nutrition knowledge, a simplified, practical, validatedscreening tool must be used.Numerous tools exist to screen formalnutrition risk in hospitalizedpatients (Anthony, 2008; Young,Kidston, Banks, Mudge, & Isenring,2013). Although no universallyaccepted screening tool exists, it is
May-June 2013 • Vol. 22/No. 3158
important to select a tool that ispractical and easy to use, and hasbeen validated in the patient popula-tion of interest. Currently validatedscreening tools include the Mal -nutrition Screening Tool (MST), MiniNutritional Assessment-Short Form(MNA-SF), Malnutrition Uni versalScreening Tool (MUST), NutritionalRisk Screening 2002 (NRS-2002), andShort Nutritional Assessment Ques -tionnaire (SNAQ©) (see Table 2) (Elia,2003; Ferguson, Capra, Bauer, &Banks, 1999; Kondrup, Rasmussen,Hamberg, & Stanga, 2003; Krui -zenga, Van Tulder et al., 2005;Rubenstein, Harker, Salva, Guigoz, &Vellas, 2001). Important aspects ofnutrition screening tools include sci-
Alliance to Advance Patient Nutrition
TABLE 2.Validated Malnutrition Screening Tools for Hospitalized Patients
Screening Tool Parameters/Scoring Development Validation
Malnutrition ScreeningTool (MST) (Fergusonet al., 1999)
Weight loss, appetite; at-risk score ≥2
408 inpatients (mean age, 58years); standard forcomparison: SGA; sensitivity93%; specificity 93%
SGA: sensitivity 92%, specificity 61%;MNA: sensitivity 92%, specificity 72%(Correia et al., 2003)
Mini NutritionalAssessment-ShortForm (MNA-SF)(Rubenstein et al.,2001)
Weight change, recentintake, BMI, acute dis-ease, mobility,dementia/depression;at-risk score £11
155 community-dwellingelders (mean age, 79 years);standard for comparison:physician assessment ofnutritional status;sensitivity98%; specificity 100% (MNA-SF cutpoint £10)
MNA: sensitivity 90%, specificity 88%(MNA-SF cutpoint £11) (Lei et al., 2009) MNA: sensitivity 89%, specificity 82%(MNA-SF cutpoint £11) (Kaiser et al.,2009) “Nutritional assessment”: sensitivity100%, specificity 38% (MNA-SF cutpoint£10) (Ranhoff et al., 2005)
Malnutrition UniversalScreening Tool (MUST)(Elia, 2003)
Weight change,recent/predicted intake,BMI, acute disease;high-risk score ≥2
8,944 inpatients, review of 128trials (mean age not reported);standard for comparison:nutrition support trialsdemonstrating improvedclinical outcomes; sensitivity75%; specificity 55%
SGA: sensitivity 61%, specificity 79%(Kyle et al., 2006) SGA: sensitivity 72%, specificity 90%;MNA: κ = 0.39 (Velasco et al., 2011) MNA: κ = 0.55 (Stratton et al., 2004)
Nutritional RiskScreening 2002 (NRS-2002) (Kondrup et al.,2003)
Weight change, recentintake, BMI, acute disease, age; at-risk score ≥3
Adapted from MalnutritionAdvisory Group screening tool
SGA: sensitivity 74%, specificity87%;MNA: κ = 0.39 (Velasco et al.,2011) SGA: sensitivity 62%, specificity 63%(Kyle et al., 2006)MNA: κ = 1.00 (Martins et al., 2005)
Short NutritionalAssessmentQuestionnaire (SNAQ©)(Kruizenga, Van Tulderet al., 2005)
Weight change, appetite,supplements/tube feeding;at-risk score ≥2
291 inpatients (mean age, 58years); standard forcomparison: BMI <18.5 orweight loss >5%; sensitivity86%; specificity 89%
BMI <18.5 or recent weight loss >5%:sensitivity 79%, specificity 83%(Kruizenga et al., 2005)
Abbreviations: BMI = body mass index; MNA = Mini Nutritional Assessment; SGA = Subjective Global AssessmentNote: Adapted from Young et al. (2013).
FIGURE 3.Malnutrition Screening Tool (MST)
1. Have you lost weight recently without trying?No 0Unsure 2If Yes, how much weight (kg) have you lost?
1-5 16-10 211-15 3>15 4Unsure 2 Weight Loss Score:
2. Have you been eating poorly because of a decreased appetite?No 0Yes 1 Appetite Score:
Total MST Score (weight loss + appetite scores)
Note: Adapted from Ferguson et al. (1999).
May-June 2013 • Vol. 22/No. 3 159
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
entific validation and easy adminis-tration requiring no specializednutrition knowledge. For example,the advantage of the MST is that it isquick (takes <5 minutes) andstraightforward, consists of two sim-ple questions evaluating weightchange and appetite (see Figure 3),and was designed for use by busyhealth care professionals not neces-sarily trained in nutrition. Thesetools allow nutrition screening tobecome an integral part of routineclinical practice without beingviewed as a burden or imposing asignificant extra workload on hospi-tal staff.
Screening results must be docu-mented within the electronic healthrecord (EHR) to allow for promptcommunication between the nurs-ing staff and other health care teammembers. When a positive nutritionscreen is obtained, the EHR shouldbe configured to trigger a query forentry of a diet order or other appro-priate intervention while the patientawaits further assessment and devel-opment of a nutrition care plan.
Nurses must rescreen patients regu-larly with adequate nutrition statusupon admission because many willbecome at risk for malnutrition dur-ing hospitalization. The MST can becompleted easily while nurses inter-act with patients and their family/caregivers and while conducting reg-ular assessments for patients at riskof pressure ulcers and falls.
Assessment and Diagnosis. Nutri -tion assessment is a method ofobtaining, verifying, and interpret-ing data needed to identify nutri-tion-related problems, their causes,and significance. The dietitian mustperform nutrition assessments in allpatients considered at risk based onnutrition screening to characterizeand determine the cause of nutritiondeficits. Traditionally, changes inacute-phase proteins, such as serumalbumin and prealbumin, were con-sidered standard biomarkers for diag-nosing malnutrition (White et al.,2012). However, it is now well docu-mented that serum levels of theseproteins are affected not only bynutrition status but also by inflam-
mation, fluid status, and other fac-tors. Consequently, these are nolonger considered reliable or specificbiomarkers for malnutrition. Consis -tent with this evidence, as of 2012,the AND and A.S.P.E.N. no longerrecommend using inflammatorybiomarkers for diagnosis of malnu-trition.
To address the need for guidancein this area, an InternationalGuidelines group convened in 2009and developed an overarching etiolo-gy-based definition of malnutritionthat takes into account the impor-tant relationship between diseaseand malnutrition (Jensen et al.,2010). This broad definition de -scribes three separate etiologies formalnutrition (see Figure 4), two ofwhich include the presence of disease(either acute or chronic). The ANDand A.S.P.E.N. subsequently devel-oped a standardized set of diagnosticcriteria for adult malnutrition in rou-tine clinical practice using this newetiology-based definition (White etal., 2012). No single parameter isdefinitive for malnutrition; therefore,
FIGURE 4.Etiology-Based Malnutrition Definitions
Nutrition Risk IdentifiedCompromised intake or
loss of body mass
Starvation-RelatedMalnutrition
(pure chronic starvation,anorexia nervosa)
Acute Disease- or Injury-Related Malnutrition(major infection, burns,
trauma, closed head injury)
Chronic Disease-RelatedMalnutrition
(organ failure, pancreaticcancer, rheumatoid arthritis,
sarcopenic obesity)
No Yes
Mild to moderate Marked inflammatory response
Inflammation Present?
Note: Adapted with permission from White et al. (2012).
May-June 2013 • Vol. 22/No. 3160
Alliance to Advance Patient Nutrition
Abb
revi
atio
ns:A
ND
= A
cade
my
of N
utrit
ion
and
Die
tetic
s; A
.S.P
.E.N
. = A
mer
ican
Soc
iety
for
Par
ente
ral a
nd E
nter
al N
utrit
ion;
NA
= n
ot a
pplic
able
Not
es:
aT
he IC
D-9
cod
e fo
r m
oder
ate
mal
nutri
tion
is 2
63.0
.b
The
ICD
-9 c
ode
for
seve
re m
alnu
tritio
n is
262
.0.
A m
inim
um o
f tw
o of
the
six
char
acte
ristic
s ab
ove
is r
ecom
men
ded
for
diag
nosi
s of
eith
er s
ever
e or
non
seve
re m
alnu
tritio
n.H
eigh
t and
wei
ght s
houl
d be
mea
sure
d ra
ther
than
est
imat
ed to
det
erm
ine
body
mas
s in
dex
(BM
I).U
sual
wei
ght s
houl
d be
obt
aine
d to
det
erm
ine
the
perc
enta
ge a
nd th
e si
gnifi
canc
e of
wei
ght l
oss.
Bas
ic in
dica
tors
of n
utrit
ion
stat
us, s
uch
as b
ody
wei
ght,
wei
ght c
hang
e, a
nd a
ppet
ite, m
ay s
ubst
antiv
ely
impr
ove
with
ref
eedi
ng in
the
abse
nce
of in
flam
mat
ion.
Ref
eedi
ng a
nd/o
r nu
tritio
n su
ppor
t may
sta
biliz
e bu
t not
sig
nific
antly
impr
ove
nutri
tion
para
met
ers
in th
e pr
esen
ce o
f inf
lam
mat
ion.
The
Nat
iona
l Cen
ter
for
Hea
lth S
tatis
tics
defin
es c
hron
ic a
s a
dise
ase/
cond
ition
last
ing ≥
3 m
onth
s.S
erum
pro
tein
s, s
uch
as s
erum
alb
umin
or
prea
lbum
in, a
re n
ot in
clud
ed a
s de
finin
g ch
arac
teris
tics
of m
alnu
tritio
n be
caus
e re
cent
evi
denc
e an
alys
is s
how
s se
rum
leve
ls o
fth
ese
prot
eins
do
not c
hang
e in
res
pons
e to
cha
nges
in n
utrie
nt in
take
.A
dapt
ed w
ith p
erm
issi
on fr
om W
hite
et a
l. (2
012)
.
TAB
LE 3
.A
ND
/A.S
.P.E
.N. C
linic
al C
har
acte
rist
ics
the
Clin
icia
n C
an O
bta
in a
nd
Doc
umen
t to
Sup
por
t a
Dia
gn
osis
of
Mal
nut
riti
on
Clin
ical
Cha
ract
eris
tic
Mal
nutr
ition
in th
e C
onte
xt
of A
cute
Illn
ess
or In
jury
Mal
nutr
ition
in th
e C
onte
xt
of C
hron
ic Il
lnes
sM
alnu
triti
on in
the
Con
text
of S
ocia
lor
Env
iron
men
tal C
ircu
mst
ance
s
Mod
erat
eaS
ever
ebM
oder
atea
Sev
ereb
Mod
erat
eaS
ever
eb
Ene
rgy
inta
ke:M
alnu
tritio
n is
the
resu
lt of
inad
equa
te fo
od a
ndnu
trien
t int
ake
or a
ssim
ilatio
n; th
us, r
ecen
t int
ake
com
pare
d w
ithes
timat
ed r
equi
rem
ents
is a
prim
ary
crite
rion
defin
ing
mal
nutri
tion.
The
clin
icia
n m
ay o
btai
n or
rev
iew
the
food
and
nut
ritio
n hi
stor
y,es
timat
e op
timum
ene
rgy
need
s, c
ompa
re th
em w
ith e
stim
ates
of
ener
gy c
onsu
med
, and
rep
ort i
nade
quat
e in
take
as
a pe
rcen
tage
of
estim
ated
ene
rgy
requ
irem
ents
ove
r tim
e.
< 75
% o
f es
timat
ed
ener
gy
requ
irem
ent
for
> 7
days
≤ 50
% o
f es
timat
ed
ener
gy
requ
irem
ent
for ≥
5 da
ys
< 75
% o
f es
timat
ed
ener
gy
requ
irem
ent
for ≥
1 m
onth
≤ 75
% o
f es
timat
ed
ener
gy
requ
irem
ent
for ≥
1 m
onth
< 75
% o
f es
timat
ed
ener
gy
requ
irem
ent
for ≥
3 m
onth
s
≤ 50
% o
f es
timat
ed
ener
gy
requ
irem
ent
for ≥
1 m
onth
Inte
rpre
tatio
n of
wei
ght l
oss:
The
clin
icia
n m
ay e
valu
ate
wei
ght i
nlig
ht o
f oth
er c
linic
al fi
ndin
gs, i
nclu
ding
the
pres
ence
of u
nder
- or
over
-hyd
ratio
n. T
he c
linic
ian
may
ass
ess
wei
ght c
hang
e ov
er ti
me
repo
rted
as a
per
cent
age
of w
eigh
t los
t fro
m b
asel
ine.
% 1-2
5 7.5
Tim
e1
wee
k1
mon
th3
mon
th
% > 2
> 5
> 7.
5
Tim
e1
wee
k1
mon
th3
mon
th
% 5 7.5
10 20
Tim
e1
mon
th3
mon
th6
mon
th1
year
% > 5
> 7.
5>
10>
20
Tim
e1
mon
th3
mon
th6
mon
th1
year
% 5 7.5
10 20
Tim
e1
mon
th3
mon
th6
mon
th1
year
% > 5
> 7.
5>
10>
20
Tim
e1
mon
th3
mon
th6
mon
th1
year
Phy
sica
l fin
ding
s:M
alnu
tritio
n ty
pica
lly r
esul
ts in
cha
nges
to th
eph
ysic
al e
xam
. The
clin
icia
n m
ay p
erfo
rm a
phy
sica
l exa
m a
nddo
cum
ent a
ny o
ne o
f the
phy
sica
l exa
m fi
ndin
gs b
elow
as
anin
dica
tor
of m
alnu
tritio
n.
Bod
y fa
t:Lo
ss o
f sub
cuta
neou
s fa
t (e.
g., o
rbita
l, tri
ceps
, fat
ove
rlyin
g th
e rib
s).
Mild
Mod
erat
eM
ildS
ever
eM
ildS
ever
e
Mus
cle
mas
s:M
uscl
e lo
ss (
e.g.
, was
ting
of th
e te
mpl
es, c
lavi
cles
,sh
ould
ers,
inte
ross
eous
mus
cles
, sca
pula
, thi
gh, a
nd c
alf).
Mild
Mod
erat
eM
ildS
ever
eM
ildS
ever
e
Flui
d ac
cum
ulat
ion:
The
clin
icia
n m
ay e
valu
ate
gene
raliz
ed o
rlo
caliz
ed fl
uid
accu
mul
atio
n ev
iden
t on
exam
(ex
trem
ities
, vul
var/
scro
tal e
dem
a, o
r as
cite
s). W
eigh
t los
s is
ofte
n m
aske
d by
gen
eral
-iz
ed fl
uid
rete
ntio
n (e
dem
a), a
nd w
eigh
t gai
n m
ay b
e ob
serv
ed.
Mild
Mod
erat
e to
sev
ere
Mild
Sev
ere
Mild
Sev
ere
Red
uced
gri
p st
reng
th:C
onsu
lt no
rmat
ive
stan
dard
s su
pplie
d by
the
man
ufac
ture
r of
the
mea
sure
men
t dev
ice.
NA
Mea
sura
bly
redu
ced
NA
Mea
sura
bly
redu
ced
NA
Mea
sura
bly
redu
ced
May-June 2013 • Vol. 22/No. 3 161
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
AND and A.S.P.E.N. proposed thatmalnutrition be diagnosed when atleast two of the following six charac-teristics are identified: (1) insufficientenergy intake, (2) weight loss, (3) lossof subcutaneous fat, (4) loss of mus-cle mass, (5) localized or generalizedfluid accumulation that may some-times mask weight loss, and (6)diminished functional status. Themagnitude and temporal aspects ofchange among these dynamic char-acteristics can be used to distinguishbetween nonsevere and severe mal-nutrition (see Table 3).
The Alliance recommends all cli-nicians become familiar with anduse the AND and A.S.P.E.N. charac-teristics for identification and docu-mentation of malnutrition (White etal., 2012) (see Figure 2). In patientswith or at risk of malnutrition, devel-opment and initiation of a nutritioncare plan must occur within 48hours of admission. Several patientcharacteristics indicative of malnu-trition (e.g., weight loss, loss of mus-cle or fat, fluid retention, and cuta-neous signs of micronutrient defi-ciencies such as glossitis or cheliosis)can be identified during routinecomprehensive assessments. Asnoted earlier, changes in acute-phaseproteins should be interpreted withcaution and should not be usedexclusively to diagnose malnutri-tion. These proteins are, however,good indicators of inflammation. Inaddition, other laboratory indicatorsof inflammation (e.g., C-reactiveprotein, white blood cell count, andglucose levels) may be informative. Aclear understanding of the patient’schief complaint and medical historyis also important to appreciate thepotential for underlying inflamma-tion, which can increase the risk ofmalnutrition by increasing metabo-lism. Con ditions, such as fever,infection, organ dysfunction, andhyperglycemia, may be indicative ofunderlying inflammation and con-tribute to an etiology-based diagno-sis, including identification of cur-rently well-nourished patients at riskfor malnutrition.
Obtaining adequate informationfrom the patient or caregiver regard-ing food and nutrient intake, body
weight changes, and functionalchanges (e.g., ability to purchase andcook food, and dental status) isessential to identify periods of insuf-ficient intake. Changes in physicalfunction (e.g., ambulation, chewingability, and mental status issues)must be assessed and monitored asappropriate based on individualpatient circumstances. Ensuring thatthese various assessments are per-formed routinely and carefully isvital to an accurate diagnosis of mal-nutrition. In addition, specific EHRfields for the AND and A.S.P.E.N.malnutrition characteristics must becompleted so that system alerts aretriggered when two of the six criteriaare documented, thereby clearlycommunicating the malnutritiondiagnosis to the health care team.Accurate coding of the malnutritiondiagnosis as a complicating condi-tion of the primary diagnosis is alsocritical to ensure adequate documen-tation to support appropriate reim-bursement and tracking of costs toallow for a more accurate quantifica-tion of the burden of malnutrition inthe future.
Principle 4: RapidlyImplement ComprehensiveNutrition Interventions andContinued Monitoring
When a patient is identified asmalnourished, appropriate nutritionintervention must be promptlyordered and implemented (seeFigure 2). Barriers to this ideal arevaried, but often include (1) NPOorders while patients await furtherassessment, (2) lack of nursing proto-col orders focused on nutrition, (3)delay in assessment of nutrition sta-tus due to insufficient dietitianstaffing, (4) dietitian recommenda-tions unheeded due to the physi-cian’s focus on other medical con-cerns, (5) physician uncertainty withproduct formulary and/or specificmicronutrient therapy options intheir hospitals, and (6) inadequatefood consumption due to poorappetite, disease processes, and inter-ruptions to meal times.
To overcome barriers to early andoptimal nutrition intervention, theAlliance provides the following rec-ommendations:• Unless specific contraindica-
tions exist, prompt nutritionintervention for all malnour-ished patients must be a highpriority. Patients whose nutri-tion status is identified as at-riskthrough screening must be fedwithin 24 hours by nurses whileawaiting a nutrition consult,unless contraindicated. Exam -ples of immediate nutritioninterventions may include mod-ifications to diet, assistance withordering and eating meals, initi-ation of calorie counts, and/oraddition of ONS. In many cases,establishing automated process-es that trigger upon a positivescreening will accomplish rapidintervention best (e.g., prompt-ing by the EHR to place a dietorder).
• Standard practices to maximizenutrient consumption must beadopted. Table 4 lists some prac-tical approaches to support opti-mal nutrition. In some cases it isas simple as staying alert tomissed or poorly consumedmeals and communicating suchevents to the dietitian so thatappropriate adjustments aremade.
• Actual consumption must bemonitored and interventionadjusted as appropriate. Clini -cians must adhere closely to thedocumented nutrition care planand document success or failurein the daily medical record.Results of watchful monitoringinform necessary changes to thenutrition care plan so that short-and long-term goals can beachieved. For example, incom-plete consumption of items onthe meal tray must prompt thenurse to have a discussion withthe patient and, depending onthe severity of the intake deficit,underlying nutritional status,and other clinical issues, to call anutrition huddle.
May-June 2013 • Vol. 22/No. 3162
Alliance to Advance Patient Nutrition
Principle 5: CommunicateNutrition Care Plans
All aspects of a patient’s nutritioncare plan, including serial assess-ment and treatment goals, must becarefully documented in the EHR,regularly updated, and effectivelycommunicated to all health careproviders (see Figure 2). This willallow informed engagement by allproviders and continuity of treat-ment if the patient is transferred toanother care setting. In addition,accurate and thorough documenta-tion is essential for proper diseasecoding (Funk & Ayton, 1995). Forexample, prior to 2012, only severemalnutrition could be coded as acomplicating condition with a pri-mary diagnosis. However, as ofOctober 2012, mild or moderatemalnutrition can now be coded as acomplicating condition (Depart -ment of Health and Human Services,2012). In practice, however, properdocumentation and communication
do not always occur. Most often,nutrition status and progress are notadequately documented in the med-ical record, making it difficult todetermine when and if patients areconsuming food and supplements.In addition, nutrition standard oper-ating procedures and EHR-triggeredcare are often lacking in the hospital,and nutrition care plans and medicalconditions are poorly communicat-ed to post-acute facilities and pri-mary care physicians.
The Alliance recommends the fol-lowing strategies to improve docu-mentation and communication ofthe patient’s nutrition care plan,including leveraging the variousforms of EHR systems now routine
in most hospitals:• Nutrition care must be formally
documented via the central areaon the medical record or in theEHR with the following compo-nents: (1) nutrition screeningresults; (2) comprehensive nutri-tion assessment data, includingthose obtained from a nutrition-focused physical assessment; (3)nutrition diagnosis; (4) nutrient-medication interactions anddiagnosis-related alterations inrequirements; (5) nutrition inter-vention(s) ordered and plannedgoals; (6) dietary intake pattern,including percentage of foodconsumed with each meal andconsumption of any orderedONS; and (7) monitoring andevaluation plan with specificindices and timeframe for re-assessment.
• Hospitals must create and main-tain standardized policies, pro-cedures, and EHR-automatedtriggers relevant to nutrition,including nutrition-related andspecific diet order sets and pro-tocols in the hospital’s EHR (e.g.,algorithms for initiating ONS,EN, and PN orders).
• Nutrition care plan documenta-tion must be included in the dis-charge summary to ensure thatpost-acute facilities/cliniciansful ly understand all aspects ofthe nutrition care plan, includ-ing goals, interventions, neces-sary resources, monitoring, andevaluation.
Principle 6: Develop aComprehensive DischargeNutrition Care andEducation Plan
A comprehensive, systematic ap -proach to managing nutrition fromadmission through discharge andbeyond is needed to improve qualityof care consistently (see Figure 2).The risk always exists that nutritiongoals achieved in the inpatient set-
TABLE 4. Practices to Support Implementation of Nutrition Intervention
Practices
1. Screen every admitted patient for malnutrition, regardless of physical appearance.2. Make every effort to ensure patients receive all EN or PN as prescribed to maxi-
mize benefit.3. Develop procedures to provide ONS in between meals or with medication admin-
istration to increase overall energy and nutrient intake.4. Create a focused mealtime and supportive mealtime environment.5. Take notice of patient meal consumption.
• Be vigilant to the amount of food eaten.• Sharing findings among the team (e.g., during team huddles) facilitates devel-
opment of a targeted nutritional plan.6. Stay alert to missed meals.
• Develop procedures to provide patients with meals at “off times” if patient wasnot available or under a restricted diet at the time of meal delivery.
7. Avoid disconnecting EN or PN for patient repositioning, ambulation, travel, or pro-cedures.
8. Consider managing symptoms of gastrointestinal distress while continuing toadminister PO diet or EN.• Nutrients may be administered while the source of distress is being identified
and treated.9. Remain mindful of “holds” on PO diets or EN relative to procedures.
• Take action to reduce the amount of time that a patient’s intake is restricted.10. Identify medications and disease conditions that interfere with nutrient absorption.
• Develop plans to minimize the impact.
Abbreviations: EN = enteral nutrition; ONS = oral nutrition supplements; PN = par-enteral nutrition; PO = per oral
Successful management of hospital malnutritionrequires an interdisciplinary team approach and
leadership that fosters open communicationamong disciplines.
May-June 2013 • Vol. 22/No. 3 163
ting may be lost if the continuity ofcare is not adequately addressed atthe time of discharge (Kirkland et al.,2013; Ukleja et al., 2010). In practice,patients and family members/care-givers rarely are educated adequatelyon nutrition care by the hospitalteam (Murphy & Girot, 2013).Moreover, patient adherence tonutrition orders during and follow-ing a hospital stay is often poor, andnot all physicians are familiar withthe proper elements of a dischargenutrition care plan. Failing to ad -dress these challenges could result innutrition care shortcomings at oneof the most vulnerable stages in apatient’s recovery.
To ensure continuity of care, sys-tems must be put in place to providepatients, family members, and care-givers with nutrition education anda comprehensive post-hospitaliza-tion nutrition care plan. Toward thisend, the Alliance makes the follow-ing recommendations: • Nutrition must be a component
of all clinicians’ conversationswith patients and their families/caregivers.
• The patient’s nutrition status,nutrition recommendations, andother interventions (e.g., ONS,vitamin and mineral supple-ments, and access to food), andthe post-discharge nutrition careplan must be ex plained by theclinical care team throughout theinpatient stay and documentedin the EHR.
• Follow-up nutrition assessmentand education, combined withspecific follow-up appointmentinformation, must be providedto the patient and his or her care-giver at time of discharge.
• Hospitals must develop clear,standardized written instruc-tions for nutrition care at home,including the rationale for anddetails on diet instruction andany recommended ONS, vita-min and/or mineral supple-ments that can be given to thepatient and his or her caregiverupon hospital discharge.
• Nurses who manage patient tran-sitions at discharge must priori-tize nutrition within the careplan. Post-hospitalization phone
calls must be adapted to includequestions about dietary intake,weight change, and access tofood, with concerns brought tothe dietitian’s attention. Dieti -tians should be used to managepost-hospital transitions forpatients who have malnutritionas a primary or secondary diag-nosis. Ensuring nutrition care ispart of the transition to home is akey step in reducing hospital re-admissions.
ConclusionsWith the changing health care
environment, quality patient careand cost containment are of utmostimportance. Early and automatednutrition intervention coupled withclinician collaboration are critical inremediating the issue of malnutritionin hospitals and has a strong poten-tial to improve patient care andreduce hospital costs. Successfulmanagement of hospital malnutri-tion requires an interdisciplinaryteam approach and leadership thatfosters open communication amongdisciplines. To be successful, all mem-bers of the health care team mustunderstand the importance of nutri-tion care in improving patient out-comes and the financial impact offailing to address this problem.Processes must be put into place toensure that appropriate nutritionintervention is provided andpatients’ nutrition status is moni-tored routinely. Finally, additionalevidence quantifying the value ofnutrition care must be assessedthrough broad research efforts, rang-ing from outcomes research toprospective randomized controlledclinical trials. Funding for these ini-tiatives is needed from institutional,federal, foundation, and industrysources. Without question, nutritioncare must be made a high priority
and systematized in United Stateshospitals.
This article is a call to action fromthe Alliance, challenging hospital-based clinicians to incorporate theproposed principles to evoke mean-ingful improvement in nutrition carewithin their institutions. This callmarks a step change in efforts to dateto improve nutrition among hospi-talized patients. For the first time, itunites professional organizations in acommon pursuit, to raise awarenessabout the problem of hospital mal-nutrition and make meaningfulprogress toward early nutrition inter-vention and improved hospital treat-ment practices, with the ultimategoal of improving quality of care andreducing costs. To accomplish thiswill require interdisciplinary collabo-ration by dietitians, nurses, andphysicians throughout the continu-um of care so that patients receiveexcellent nutrition care in the hospi-tal and after discharge.
REFERENCESAllaudeen, N., Vidyarthi, A., Maselli, J., &
Auerbach, A. (2011). Redefining read-mission risk factors for general medicinepatients. Journal of Hospital Medicine,6(2), 54-60. doi:10.1002/jhm.805
Anthony, P.S. (2008). Nutrition screening toolsfor hospitalized patients. Nutrition inClinical Practice, 23(4), 373-382.doi:10.1177/0884533608321130
Avenell, A., & Handoll, H.H. (2010). Nutritionalsupplementation for hip fracture after-care in older people. CochraneDatabase of Systematic Reviews,(1):CD001880. doi:10.1002/14651858.CD001880.pub5.
Avenell, A., & Handoll, H.H. (2006). Nutritionalsupplementation for hip fracture after-care in older people. CochraneDatabase of Systematic Reviews,(18):CD001880.
Baldwin, C., & Weekes, C.E. (2011). Dietaryadvice with or without oral nutritionalsupplements for disease-related malnu-trition in adults. Cochrane Database ofSystematic Reviews, (9):CD002008.doi:10.1002/14651858.CD002008.pub4
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
Without question, nutrition care must be made a high priority and systematized in
United States hospitals.
May-June 2013 • Vol. 22/No. 3164
Barker, L.A., Gout, B.S., & Crowe, T.C. (2011).Hospital malnutrition: Prevalence, identi-fication and impact on patients and thehealthcare system. International Journalof Environmental Research and PublicHealth, 8(2), 514-527. doi:10.3390/ijerph8020514
Beck, A.M., Holst, M., & Rasmussen, H.H.(2013). Oral nutritional support of older(65 years+) medical and surgicalpatients after discharge from hospital:Systematic review and meta-analysis ofrandomized controlled trials. ClinicalRehabilitation, 27(1), 19-27. doi:10.1177/0269215512445396
Bistrian, B.R., Blackburn, G.L., Hallowell, E., &Heddle, R. (1974). Protein status of gen-eral surgical patients. Journal of theAmerican Medical Association, 230(6),858-860.
Braunschweig, C., Gomez, S., & Sheean, P.M.(2000). Impact of declines in nutritionalstatus on outcomes in adult patients hos-pitalized for more than 7 days. Journal ofthe American Dietary Association,100(11), 1316-1322; quiz 1323-1314.doi:10.1016/S0002-8223(00)00373-4
Brugler, L., DiPrinzio, M.J., & Bernstein, L.(1999). The five-year evolution of a mal-nutrition treatment program in a commu-nity hospital. Joint Commission Journalof Quality Improvement, 25(4), 191-206.
Burden, S., Todd, C., Hill, J., & Lal, S. (2012).Pre-operative nutrition support inpatients undergoing gastrointestinal sur-gery. Cochrane Database of SystematicReviews, 11, CD008879. doi:10.1002/14651858.CD008879.pub2
Butterworth, C. (1974). The skeleton in thehospital closet. Nutrition Today, 9(2), 4-8.
Cawood, A.L., Elia, M., & Stratton, R.J. (2012).Systematic review and meta-analysis ofthe effects of high protein oral nutritionalsupplements. Ageing Re searchReviews, 11(2), 278-296. doi:10.1016/j.arr.2011.12.008
Centers for Disease Control and Prevention.(2009). National hospital discharge sur-vey: Number and rate of hospital dis-charges from short-stay hospitals byage, region, and sex: United States,2009 (table). Retrieved from http://www.cdc.gov/nchs/data/nhds/1general/2009gen1_agesexalos.pdf
Christensen, K.S., & Gstundtner, K.M. (1985).Hospital-wide screening improves basisfor nutrition intervention. Journal of theAmerican Dietary Association, 85(6),704-706.
Correia, J.R., Martins, C.A., & Amaral, T.F.(2003). Efficiency of MST - MalnutritionScreening Tool - in elderly hospitalisedpatients. Clinical Nutrition, 22, S10-11.
Demling, R.H. (2009). Nutrition, anabolism,and wound healing proces: An overview.EPlasty, 9, 65-94.
Department of Health and Human Services.Centers for Medicare & MedicaidServices. (2012). Hospital inpatientprospective payment systems for acutecare hospitals and the long-term carehospital prospective payment systemand fiscal year 2013 rates (CMS-1588-
P). Federal Register, 77(92), 27870-28192. Retrieved from http://www.gpo.gov/ fdsys/pkg/FR-2012-05-11/pdf/2012-9985.pdf
Dorland’s Illustrated Medical Dictionary (32nded.). (2011). New York, NY: ElsevierHealth Sciences.
Elia, M. (2003). The ‘MUST’ report. Nutritionalscreening of adults: A multidisciplinaryresponsibility. Retrieved from http://www.bapen.org.uk/pdfs/must/must_exec_sum.pdf
Elia, M., Zellipour, L., & Stratton, R.J. (2005).To screen or not to screen for adult mal-nutrition? Clinical Nutrition, 24(6), 867-884. doi:10.1016/j.clnu.2005.03.004
Ferguson, M., Capra, S., Bauer, J., & Banks,M. (1999). Development of a valid andreliable malnutrition screening tool foradult acute hospital patients. Nutrition,15(6), 458-464. doi:10.1016/S0899-9007(99)00084-2
Fry, D.E., Pine, M., Jones, B.L., & Meimban,R.J. (2010). Patient characteristics andthe occurrence of never events. Archivesof Surgery, 145(2), 148-151. doi:10.1001/archsurg.2009.277
Funk, K.L., & Ayton, C.M. (1995). Improvingmalnutrition documentation enhancesreimbursement. Journal of the AmericanDietary Association, 95(4), 468-475.doi:10.1016/S0002-8223(95)00123-9
Gariballa, S., Forster, S., Walters, S., &Powers, H. (2006). A randomized, dou-ble-blind, placebo-controlled trial of nutri-tional supplementation during acute ill-ness. American Journal of Medicine,119(8), 693-699. doi:10.1016/j.amjmed.2005.12.006
Hendry, P.O., van Dam, R.M., Bukkems, S.F.,McKeown, D.W., Parks, R.W., Preston,T., … Fearon, K.C. (2010). Randomizedclinical trial of laxatives and oral nutrition-al supplements within an enhancedrecovery after surgery protocol followingliver resection. British Journal of Surgery,97(8), 1198-1206. doi:10.1002/bjs.7120
Hiesmayr, M., Schindler, K., Pernicka, E.,Schuh, C., Schoeniger-Hekele, A.,Bauer, P., … Ljungqvist, O. (2009).Decreased food intake is a risk factor formortality in hospitalised patients: TheNutritionDay survey 2006. ClinicalNutrition, 28(5), 484-491. doi:10.1016/j.clnu.2009.05.013
Jarvis, W.R. (1996). Selected aspects of thesocioeconomic impact of nosocomialinfections: Morbidity, mortality, cost, andprevention. Infection Control andHospital Epidemiology, 17(8), 552-557.
Jefferies, D., Johnson, M., & Ravens, J.(2011). Nurturing and nourishing: Thenurses’ role in nutritional care. Journal ofClinical Nursing, 20(3-4), 317-330.doi:10.1111/j.1365-2702.2010.03502.x
Jensen, G.L., Mirtallo, J., Compher, C.,Dhaliwal, R., Forbes, A., Grijalba, R.F.,… Waitzberg, D. (2010). Adult starvationand disease-related malnutrition: A pro-posal for etiology-based diagnosis in theclinical practice setting from theInternational Consensus GuidelineCommittee. Journal of Parenteral and
Enteral Nutrition, 34(2), 156-159.doi:10.1177/0148607110361910
Joint Commission on Accreditation ofHealthcare Organizations. (2007).Comprehensive accreditation for hospi-tals. Chicago, IL: Author.
Kaiser, M.J., Bauer, J.M., Ramsch, C., Uter,W., Guigoz, Y., Cederholm, T., … Sieber,C.C. (2009). Validation of the MiniNutritional Assessment short-form(MNA-SF): A practical tool for identifica-tion of nutritional status. The Journal ofNutrition, Health & Aging, 13(9), 782-788.
Kassin, M.T., Owen, R.M., Perez, S.D., Leeds,I., Cox, J.C., Schnier, K., … Sweeney, J.F. (2012). Risk factors for 30-day hospitalreadmission among general surgerypatients. Journal of the AmericanCollege of Surgeons, 215(3), 322-330.doi:10.1016/j.jamcollsurg.2012.05.024
Kirkland, K.B., Briggs, J.P., Trivette, S.L.,Wilkinson, W.E., & Sexton, D.J. (1999).The impact of surgical-site infections inthe 1990s: Attributable mortality, excesslength of hospitalization, and extra costs.Infection Control and Hospital Epi -demiology, 20(11), 725-730. doi:10.1086/501572
Kirkland, L.L., Kashiwagi, D.T., Brantley, S.,Scheurer, D., & Varkey, P. (2013).Nutrition in the hospitalized patient.Journal of Hospital Medicine, 8(1), 52-58. doi:10.1002/jhm.1969
Kondrup, J., Rasmussen, H.H., Hamberg, O.,& Stanga, Z. (2003). Nutritional riskscreening (NRS 2002): A new methodbased on an analysis of controlled clini-cal trials. Clinical Nutrition, 22(3), 321-336. doi:10.1016/S0261-5614(02)00214-5
Kruizenga, H.M., Seidell, J.C., de Vet, H.C.,Wierdsma, N.J., & van Bokhorst-de vander Schueren, M.A. (2005). Developmentand validation of a hospital screening toolfor malnutrition: The short nutritionalassessment questionnaire (SNAQ©).Clinical Nutrition, 24(1), 75-82. doi:10.1016/j.clnu.2004.07.015
Kruizenga, H.M., Van Tulder, M.W., Seidell,J.C., Thijs, A., Ader, H.J., & VanBokhorst-de van der Schueren, M.A.(2005). Effectiveness and cost-effective-ness of early screening and treatment ofmalnourished patients. AmericanJournal of Clinical Nutrition, 82(5), 1082-1089.
Krumholz, H.M. (2013). Post-hospital syn-drome — an acquired, transient condi-tion of generalized risk. New EnglandJournal of Medicine, 368(2), 100-102.doi:10.1056/NEJMp1212324
Kyle, U.G., Kossovsky, M.P., Karsegard, V.L.,& Pichard, C. (2006). Comparison oftools for nutritional assessment andscreening at hospital admission: A popu-lation study. Clinical Nutrition, 25(3), 409-417. doi:10.1016/j.clnu.2005.11.001
Langer, G., Grossmann, K., Fleischer, S.,Berg, A., Grothues, D., Wienke, A., …Fink, A. (2012). Nutritional interventionsfor liver-transplanted patients. CochraneDatabase of Systematic Reviews, 8,
Alliance to Advance Patient Nutrition
May-June 2013 • Vol. 22/No. 3 165
CD007605. doi:10.1002/14651858.CD007605.pub2
Lei, Z., Qingyi, D., Feng, G., Chen, W., Hock,R.S., & Changli, W. (2009). Clinical studyof mini-nutritional assessment for olderChinese inpatients. Journal of Nutrition,Health & Aging, 13(10), 871-875.
Lim, S.L., Ong, K.C., Chan, Y.H., Loke, W.C.,Ferguson, M., & Daniels, L. (2012).Malnutrition and its impact on cost ofhospitalization, length of stay, readmis-sion and 3-year mortality. ClinicalNutrition, 31(3), 345-350.
Lyder, C.H., Preston, J., Grady, J.N., Scinto,J., Allman, R., Bergstrom, N., &Rodeheaver, G. (2001). Quality of carefor hospitalized medicare patients at riskfor pressure ulcers. Archives of InternalMedicine, 161(12), 1549-1554. doi:ioi00449 [pii]
Martins, C.P., Correia, J.R., & do Amaral, T.F.(2005). Undernutrition risk screening andlength of stay of hospitalized elderly.Journal of Nutrition for the Elderly, 25(2),5-21.
Milne, A.C., Avenell, A., & Potter, J. (2006).Meta-analysis: Protein and energy sup-plementation in older people. Annals ofInternal Medicine, 144, 37-48.
Milne, A.C., Potter, J., Vivanti, A., & Avenell, A.(2009). Protein and energy supplemen-tation in elderly people at risk from mal-nutrition. Cochrane Database ofSystematic Reviews, (2), CD003288.doi:10.1002/14651858.CD003288.pub3
Milne, A.C., Potter, J., & Avenell, A. (2005).Protein and energy supplementation inelderly people at risk from malnutrition.Cochrane Database of SystematicReviews 2005:CD003288.
Moran, L., Custer, P., & Murphy, G. (1980).Nutritional assessment of lean bodymass. Journal of Parenteral and EnteralNutrition, 4, 595.
Mudge, A.M., Kasper, K., Clair, A., Redfern,H., Bell, J.J., Barras, M.A., ... Pachana,N.A. (2011). Recurrent readmissions inmedical patients: A prospective study.Journal of Hospital Medicine, 6(2), 61-67. doi:10.1002/jhm.811
Murphy, J.L., & Girot, E.A. (2013). The impor-tance of nutrition, diet and lifestyle advicefor cancer survivors - the role of nursingstaff and interprofessional workers.Journal of Clinical Nursing, 22(11-12),1539-1549.
Neelemaat, F., Lips, P., Bosmans, J.E., Thijs,A., Seidell, J.C., & van Bokhorst-de vander Schueren, M.A. (2012). Short-termoral nutritional intervention with proteinand vitamin D decreases falls in mal-nourished older adults. Journal of theAmerican Geriatric Society, 60(4), 691-699. doi:10.1111/j.1532-5415.2011.03888.x
Paddon-Jones, D., Sheffield-Moore, M., Cree,M.G., Hewlings, S.J., Aarsland, A.,Wolfe, R.R., & Ferrando, A.A. (2006).Atrophy and impaired muscle proteinsynthesis during prolonged inactivity andstress. Journal of Clinical Endocrinology& Metabolism, 91(12), 4836-4841.doi:10.1210/jc.2006-0651
Paddon-Jones, D., Sheffield-Moore, M., Urban,R.J., Sanford, A.P., Aarsland, A., Wolfe,R.R., & Ferrando, A.A. (2004). Essentialamino acid and carbohydrate supplemen-tation ameliorates muscle protein loss inhumans during 28 days bedrest. Journalof Clinical Endocrinology & Metabolism,89(9), 4351-4358. doi:10.1210/jc.2003-032159
Philipson, T., Thornton Snider, J., Lakdawalla,D., Stryckman, B., & Goldman, D.(2013). Impact of oral nutritional supple-mentation on hospital outcomes.American Journal of Managed Care,19(2), 121-128.
Ranhoff, A.H., Gjoen, A.U., & Mowe, M.(2005). Screening for malnutrition in eld-erly acute medical patients: The useful-ness of MNA-SF. Journal of Nutrition,Health & Aging, 9(4), 221-225.
Rubenstein, L.Z., Harker, J.O., Salva, A.,Guigoz, Y., & Vellas, B. (2001).Screening for undernutrition in geriatricpractice: Developing the short-form mini-nutritional assessment (MNA-SF).Journal of Gerontology Series A:Biological Sciences and MedicalSciences, 56(6), M366-372.
Russell, C. (2007). The impact of malnutritionon healthcare costs and economic con-siderations for the use of oral nutritionalsupplements. Clinical NutritionSupplements, 2, 25-32.
Schneider, S.M., Veyres, P., Pivot, X.,Soummer, A.M., Jambou, P., Filippi, J., &Hebuterne, X. (2004). Malnutrition is anindependent factor associated withnosocomial infections. British Journal ofNutrition, 92(1), 105-111. doi:10.1079/BJN20041152
Skipper, A., Young, M., Rotman, N., & Nagl, H.(1994). Physicians’ implementation ofdietitians’ recommendations: A study ofthe effectiveness of dietitians. Journal ofthe American Dietary Association, 94(1),45-49. doi:0002-8223(94)92039-7 [pii]
Somanchi, M., Tao, X., & Mullin, G.E. (2011).The facilitated early enteral and dietarymanagement effectiveness trial in hospi-talized patients with malnutrition. Journalof Parenteral and Enteral Nutrition, 35(2),209-216. doi:10.1177/0148607110392234
Stratton, R.J., Ek, A.C., Engfer, M., Moore, Z.,Rigby, P., Wolfe, R., & Elia, M. (2005).Enteral nutritional support in preventionand treatment of pressure ulcers: A sys-
tematic review and meta-analysis.Ageing Research Reviews, 4(3), 422-450. doi:10.1016/j.arr.2005.03.005
Stratton, R.J., Green, C.J., & Elia, M. (2003).Disease-related malnutrition: An evi-dence-based approach to treatment.Cambridge, MA: CABI Publishing.
Stratton, R.J., Hackston, A.J., Price, S.,Joseph, K., & Elia, M. (2004). Concurrentvalidity of the newly developedMalnutrition Universal Screening Tool(‘MUST’) with Mini NutritionalAssessment and Subjective GlobalAssessment Tools. Proceedings of theNutrition Society, 63, 17A.
Ukleja, A., Freeman, K.L., Gilbert, K.,Kochevar, M., Kraft, M.D., Russell, M.K.,& Shuster, M.H. (2010). Standards fornutrition support: Adult hospitalizedpatients. Nutrition and Clinical Practice,25(4), 403-414. doi:10.1177/0884533610374200
Velasco, C., Garcia, E., Rodriguez, V., Frias,L., Garriga, R., Alvarez, J., ... Leon, M.(2011). Comparison of four nutritionalscreening tools to detect nutritional risk inhospitalized patients: A multicentre study.European Journal of Clinical Nutrition,65(2), 269-274. doi:10.1038/ejcn.2010.243
White, J.V., Guenter, P., Jensen, G., Malone,A., & Schofield, M. (2012). Consensusstatement: Academy of Nutrition andDietetics and American Society forParenteral and Enteral Nutrition:Characteristics recommended for theidentification and documentation of adultmalnutrition (undernutrition). Journal ofParenteral and Enteral Nutrition, 36(3),275-283. doi:10.1177/0148607112440285
Willard, C., & Luker, K. (2007). Working withthe team: Strategies employed by hospi-tal cancer nurse specialists to implementtheir role. Journal of Clinical Nursing,16(4), 716-724.
Young, A.M., Kidston, S., Banks, M.D.,Mudge, A.M., & Isenring, E.A. (2013).Malnutrition screening tools: Comparisonagainst two validated nutrition assess-ment methods in older medical inpa-tients. Nutrition, 29(1), 101-106. doi:10.1016/j.nut.2012.04.007
ADDITIONAL READINGSingh, H., Watt, K., Veitch, R., Cantor, M., &
Duerksen, D.R. (2006). Malnutrition isprevalent in hospitalized medicalpatients: Are housestaff identifying themalnourished patient? Nutrition, 22(4),350-354. doi:10.1016/j.nut.2005.08.009
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition