nutritional support in the next millennium john p. grant, md director nss duke university medical...

Nutritional Support in the Nutritional Support in the Next MillenniumNext Millennium

John P. Grant, MDDirector NSSDuke University Medical Center

Executive Summary

Malnutrition contributes to:

Morbidity

Mortality

LOS

Hospital Cost

Executive Summary Malnutrition contributes to: increased

morbidity, mortality, LOS, hospital cost.

Appropriate nutrition support can treat and prevent malnutrition and reduce complications.

Executive Summary Malnutrition contributes to: increased

morbidity, mortality, LOS, hospital cost.

Appropriate nutrition support can treat and prevent malnutrition and reduce complications.

Malnutrition is common in hospitalized patients.

Executive Summary

On review, most medical centers, including DUMC, have inadequate systems for:

– Identifying patients at risk of malnutrition, and

– Ensuring provision of appropriate nutrition care when identified.

1997 JCAHO Standards

Nutrition care practices will be standardized throughout the hospital.

When indicated by patient’s needs:

– Nutrition status will be assessed.

– For patients at nutritional risk:

Nutrition care will be planned and implemented.

Response to nutrition care will be monitored.

Most hospitals are not meeting the new standards for nutrition care

Executive Summary

Hospitals are:

– Currently absorbing increased costs of care and yet not achieving optimal patient outcomes, and

Executive Summary

Hospitals are:

– Currently absorbing increased costs of care and yet not achieving optimal patient outcomes, and

– Not fulfilling requirements of JCAHO standards for nutrition care.

Therefore,

We need to revisit the way we provide nutrition care...

Does malnutrition contribute to increased morbidity, mortality, LOS, and hospital cost?

Morbidity and Malnutrition

Risk factors for clean wound infections in 23,649 surgical patients at Foothills Hospital in Calgary, Alberta, 1967-1972.

Risk IncreaseMalnutrition 9.2 xObesity 7.5 xDiabetes 5.9 xAge > 50 1.9 xSteroids 1.4 x

Cruse, Arch Surg 107:206,1973

Mortality and Albumin

Review of 509 veterans at Hines IL VAMC found a linear relationship between 30-day mortality and serum albumin concentration. Percent Mortality = 132 - 37.3 [Alb]

Mortality was decreased in 15 patients who received 5 or more days of TPN

Reinhardt, JPEN 4:357, 1980

Prognostic Nutrition Index

Complications Monitored

Death PhlebitisSepticemia CHFIntraabdominal SepsisMIFistula Formation Resp. FailureUTI AtelectasisPneumonia Pulm. EmbolusWound Infection CVAWound Dehiscence Shock

Buzby, Surg Clin North Am 61:465, 1981


Correlated standard nutrition assessment with patient outcome in 100 veterans undergoing elective abdominal surgery.

PNI(%) = 158 - 16.6 [Alb] - 0.78 [TSF] -

0.2 [TFN] - 5.8 (DTHR)



Prospective study in 161 elective abdominal surgery patients demonstrated:

% Complications % Death

PNI < 40 8.0 3.0

PNI 40-49 30.0* 4.3

PNI 50 46.0* 33*

*p<.01


Malnutrition and M&M

Nutrition status determined by:% UBW, % IBW, AMC, Albumin.

Compared outcome in 215 non-cancer patients undergoing major and minor vascular, and abdominal surgery.

Warnold, Ann Surg 199:299, 1984

Malnutrition and M&M

If two or more assessment parameters were abnormal:

Hospital stay was prolonged from 14 to 29 days (p<.01).

Overall frequency of complications increased from 23 to 48% (p<.01).

Serious complications increased from 9 to 31% (p<.01).

Warnold, Ann Surg 199:299, 1984

Impact of Malnutrition on LOS and Cost

MN(40) Borderline(16) Normal(44)Actual LOS (days) Mean ± SEM 15.6 ± 2.2* 10.2 ± 1.7 8.2 ± 0.7Range 4-63 3-30 2-18

Allowed LOS (days) Mean ± SEM 10.7 ± 0.6 10.3 ± 1.0 10.0 ± 0.6Range 5.6-23.4 5.2-20.7 5.0-18.2

LOS > allowed 18 (45%) 6 (37%) 13 (30%)LOS < allowed 18 (45%) 7 (44%) 21 (61%)LOS = allowed 4 (10%) 3 (19%) 4 (9%)

100 Patients Albert Einstein, Philadelphia

Robinson et al., JPEN 11:49, 1987

*p<.01

Hospital Charges $16,691 $14,118 $7,692

Robinson, JPEN 11:49, 1987

Impact of Malnutrition on LOS, Total Charges, and Cost of Hospitalization

D ia g n o s is # P a t ie n ts (% ) A v e L O S (d ) C h a r g e s $ C o s t $

P n e u m o n ia M N 1 2 7 (6 3 ) 1 0 .9 ± 0 .0 * 7 9 0 2 ± 7 7 0 * 3 5 2 1 ± 3 8 0 * N o r m a l 7 8 (3 7 ) 8 .4 ± 0 .7 4 9 7 9 ± 5 0 5 2 1 4 0 ± 2 1 4

In f la m m a to r y B o w e l D is e a s e M N 5 2 (4 4 ) 8 .8 ± 1 .0 4 8 9 0 ± 4 5 2 * 1 8 8 6 ± 1 7 8 * N o r m a l 6 5 (5 6 ) 7 .0 ± 0 .6 3 6 7 2 ± 3 1 9 1 3 7 2 ± 11 2

F x H ip /P e lv is M N 1 8 (4 5 ) 1 5 .9 ± 2 .1 5 2 7 6 ± 11 7 0 2 6 4 9 ± 6 7 9 N o r m a l 2 2 (5 5 ) 1 4 .8 ± 2 .2 3 7 1 0 ± 7 7 8 1 5 8 7 ± 2 6 0

7 7 1 P a t ie n ts in Tw o A c u te C a r e H o s p ita ls

R e il ly e t a l . , J P E N 1 2 :3 7 1 , 1 9 8 8 .*p<.05

Reilly, JPEN 12:371, 1988


In tra -A b d o m in a l Va s c u la r S u rg e ry M N 6 (4 5 ) 2 5 .8 ± 11 .8 * 3 5 6 0 0 ± 1 0 0 5 9 * 1 8 0 0 5 ± 4 5 9 7 * N o rm a l 7 (5 5 ) 1 3 .0 ± 1 .1 1 3 9 1 7 ± 9 9 7 6 1 9 3 ± 3 2 8

B o w e l S u rg e ry M N 11 2 (6 1 ) 2 1 .5 ± 1 .2 * 1 8 8 9 6 ± 1 7 1 4 * 8 7 8 5 ± 8 0 3 * N o rm a l 7 3 (3 9 ) 1 6 .7 ± 1 .0 111 7 4 ± 7 5 4 5 0 6 2 ± 3 6 8

O rth o p e d ic S u rg e ry M N 8 5 (4 4 ) 1 8 .0 ± 1 .3 * 1 0 2 2 0 ± 7 0 2 4 6 5 9 ± 3 2 1 N o rm a l 11 0 (5 6 ) 1 3 .9 ± 1 .3 9 1 6 5 ± 3 1 6 4 0 7 1 ± 1 5 3

7 7 1 P a tie n ts in Tw o A c u te C a re H o s p ita ls

R e illy e t a l., J P E N 1 2 :3 7 1 , 1 9 8 8 .

D ia g n o s is # P a t ie n ts (% ) Av e L O S (d ) C h a rg e s $ C o s t $

*p<.05



For every DRG, the presence of malnutrition increased the mean LOS (1.1 to 12.8 excess days).

Average hospital cost increased by $1,738 and charges by $3,557 per patient.

A complication in a malnourished patient increased cost/charges by $2,996/$6,157.


Degree of Malnutrition and LOS

Status #Patients (%) Average LOS (days)

Normal 226 (45) 7.74Mild 94 (19) 8.18Moderate 45 (9) 9.71Severe 135 (27) 11.98

Messner et al. Society Gastroent Nurses & Assoc 202:205, 1981

500 Consecutive Patients Huntington VAMC

Messner, Gastroenterol Nurs 13:202, 1991 COPD, Cancer, Cardiovascular Disease, Alcoholism


245 general surgery patients, 131 were found malnourished by Alb < 3.2 and recent weight loss > 10% (53%).

Colon Ca, Perforated Diverticular Disease, SBO, Gastric or Eso Ca.

LOSNormal 16.5 ± 10.7Malnourished 23.5 ± 16.5

Shaw-Stiffel, Nutrition 9:140, 1993


173 medical patients in Metro Health Center, Cleveland, Ohio

LOS Hosp cost Self care

MN 6d* $6,196* 41%*

Normal 4d $4,563 66%

*p < .05

Chima, J Am Diet Assoc 97:975, 1997

Impact of Malnutrition on LOS and Total Hospitalization Charges

LOS Hospital charges

Alb <3.4 8.6d* $50,108*

Alb >3.4 5.2d $33,720

TLC <1200 5.7d* $42,098*

TLC > 1200 5.4d $32,544

Lavernia et al., J Am Coll Nutr 18:271, 1999

119 pts underwent hip or knee replacement

*p < 0.005

Can appropriate nutrition support treat and prevent malnutrition and reduce complications?

Anorexia NervosaSerial Assessments

0

50

100

150

200

250

1 3 5 7 9 11 13

Albumin x 10

Transferrin mg%

Weight pounds

Weeks

Crohn’s Disease

Enterocutaneous Fistulas

Impact of Refeeding on M&M

204 patients tested for DTHR to common antigens preoperatively

# Pts Sepsis Death

Anergic 12 17% 33%

Normal 192 4% 3%

MacLean, Ann Surg 186:241, 1977


60 anergic patients were given nutrition support preoperatively and re-tested for DTHR to common antigens.

# Pts Sepsis Death

Anergic 30 63% 67%

Normal 30 47% 6.7%

MacLean, Ann Surg 186:241, 1977


Prospective non-randomized study of 161 patients who, by physician preference, received 7-10 days of TPN prior to elective abdominal surgery or not.


Nutrition Support in Burn Patients

Impact of nutrition support in 70 malnourished patients with 20% or more body surface burn.

Wt loss LOS Cost5% Dextrose 13% 36 $24,200Nutrition 3%* 29* $17,800*

Weinsier, J Burn Care Rehab 6:436, 1985

*p<.02

Postoperative Nutrition Support

35 non-malnourished patients after radical cystectomy for cancer were randomized to receive 7 days 5% dextrose or 7 days TPN postoperatively.

Ave. Hosp Days5% Dextrose 24TPN 17 (p<.002)

Askanazi, Ann Surg 203:236, 1986

VAMC Multicenter Study of Preoperative TPN

395 malnourished G&T patients were randomized to receive either 7-15 days of TPN or early surgery.

#Pts Complications

TPN 130 19.2%*

No TPN 265 36.6%

VA Trial, N Engl J Med 325:525, 1991

*p < .0005

How common is malnutrition in hospitalized patients?

Prevalence of Malnutrition

Blackburn, JAMA 230:858, 1974– 50% incidence in New England Deaconess Hospital,

Boston

Mullen, JPEN 1:39, 1977– 40% incidence in surgical patients at Philadelphia

VAMC Willcutts, JPEN 1:25, 1977

– 65% incidence in community hospital, Mass Coats, J Am Diet Assoc 93:27, 1989

– 46% of general medicine patients in teaching hospital

Prevalence of Malnutrition

VA Clinical Trial, N Engl J Med 325:525, 1991– 34% G&T surgery patients

Shaw-Stiffel, Nutrition 9:140, 1993– 53% general surgery patients Bridgeport Hosp, Conn

Guo, Br J Oral Maxillofac Surg 34:325, 1996– 35% in H&N Cancer patients in Beijing, China

Chima, J Am Diet Assoc 97:975, 1997– 32% of medical patients in Metro Health Center,

Cleveland, Ohio

Duke Nutrition Service In a one month period in 1997:

# Pts % At Risk

Medical 318 32

Surgical 209 31

Women/Peds 133 21

194 patients found at risk were recommend to undergo a full nutritional assessment.

Progression of Malnutrition

134 consecutive admissions to general medicine service at University of Alabama, Birmingham, underwent initial nutrition assessment and again at 2 weeks, if still hospitalized.

48% were initially malnourished.

69% were malnourished at 2 weeks.

Weinsier, Am J Clin Nutr 32:418, 1979

Progression of Malnutrition

Up to 70% of patients transferred from hospitals to long-term care facilities have evidence of malnutrition.

Federer, Am Diet Assoc, 1968

Does your hospital have an effective system to identify malnourished patients?

Duke Nutrition Service

Current method is an admission nutrition screen by the Nutrition Service (ward dietitians).

Evaluated if: a high risk diagnosis, high risk dietary order (cl liq, npo), or answer “yes” to any of the nutrition questions on the Universal Nursing Admission Form.

Duke Nutrition Service

Assessment is primarily a global evaluation and chart review.

Assessment is “hit and miss” depending on available chart data and dietitian time.

DRG Coding by Medical Records

In 1996, of 25,961 discharges, only 81 patients were coded as malnourished at the time of discharge.


In 1996, of 25,961 discharges, only 81 patients were coded as malnourished at the time of discharge.

In 1997, of 26,386 discharges, 105 patients were coded as malnourished at the time of discharge.


Assuming a 40% rate of malnutrition, DUMC fails to identify and report approximately 10,000 cases/year of malnutrition present at the time of discharge.


Assuming a 40% rate of malnutrition, DUMC fails to identify and report approximately 10,000 cases/year of malnutrition present at the time of discharge.

When malnutrition is recorded as a comorbid condition, DRG reimbursement increases by an average of $2,436 per patient.


Failure to recognize and document malnutrition at DUMC results in an loss in revenue of up to:*

10,000 Pts X $2,436/Pt =

$ 24,360,000 / year !

*Note: Multiple comorbidities reduce individual payments.

Is there a system in place in your hospital to ensure provision of appropriate nutrition care if patients are identified as malnourished?

Duke Nutrition “System”

There are over 51 different functional units providing nutrition care to DUMC patients.

Duke Nutrition Service (Dietary Services)Sarah W. Stedman Center for Nutritional StudiesGeriatric Research Education and Clinical CenterRice Diet Program/Heart Disease Reversal ClinicDuke Center for LivingDiet and Fitness CenterComprehensive Adult Diabetes ProgramComprehensive Cancer CenterEndocrinology ClinicMaternal-Fetal Medicine/High Risk ClinicCystic Fibrosis CenterLenox Baker Children’s HospitalRehabilitation CenterDialysis UnitClinical Research UnitPediatric Nutrition ServiceAdult Nutrition Service

Duke Nutrition System


There is no coordination between these units or between inpatient and outpatient nutrition care.

Duke Nutrition System


There is no coordination between these units or between inpatient and outpatient nutrition care.

There is no continuity of care, even during extended medical illnesses.

Results of Current System

Due to suboptimal recognition, recording, and treatment of malnutrition, the health system is: – Absorbing increased cost of care– Failing to receive appropriate

reimbursement– Not obtaining optimal patient

outcome

Proposal

Establish Clinical Nutritionas a well funded program

in most hospitals

Program StructureChairperson

Director, Adult NSSClinicalFaculty

Dietitian Coordinator

Adult NSS Team

TraumaCenter

DigestiveHealth

CysticFib/Pulm

Surgery Medicine RenalSolid Org

TransplantAdult BM

TransplantOncology

Tier 2RD's

ProgramDirector

Other

Tier 1RD's

NurseCoordinator

Clinical Nutrition Program Purpose

Nutrition care should be seen as a continuum.

Nutrition Care as a Continuum

Nutrition evaluation and care should begin with a patient’s initial contact with the health system.

– It should encompass outpatient management, inpatient care, and home based care, as needed.



Nutrition care should be patient centered.

Patient Centered Care

Care should focus on:

– Enhanced quality of life

– Complication avoidance

– Maximization of functional outcome

– Cost containment

– And patient/family satisfaction



Nutrition care should be patient centered.

Nutrition care should incorporate multidisciplinary expertise.

Multidisciplinary Expertise

Primary Care Physicians

Nurses

Pharmacists

Dietitians

Social Workers

Home Care Providers

Outpatient Activity

PatientScreening

PatientAssessment

Developmentof NutritionCare Plan

Implementationof NutritionCare Plan

Evaluation ofCare Setting

PatientMonitoring

PatientReassessmentand Updatingof NutritionCare Plan

OutpatientCare

Monitoring

Not at Risk

At Risk

AcuteInpatient

CareRequired

InpatientCare NotRequired

GoalsAchieved

Change inStatus

Monitor

Inpatient Activity

Admission

PatientScreening

PatientAssessment

Developmentof NutritionCare Plan

Implementationof NutritionCare Plan

Evaluation ofCare Setting

PatientMonitoring

PatientReassessmentand Updatingof NutritionCare Plan

DischargePlanning

Monitor

Not at RiskAt Risk

AcuteInpatient

CareRequired

InpatientCare NoLongerRequired

GoalsAchieved

Change inStatus

Monitor

Clinical Nutrition Program Activities

Develop and implement a program for nutritional screening of all patients in the health system.


Develop and implement a program for nutritional screening of all patients in the health system.

All malnourished patients should be appropriately coded in the medical record to achieve optimal DRG reimbursement.


Whenever possible, nutritional repletion should be undertaken early, especially prior to elective hospitalization.


Ensure that nutrition care is given in the most cost effective and risk-free manner:

Dietary Modifications

Nutrition Supplements

Enteral Nutrition (gastric vs jejunal)

Total Parenteral Nutrition


Work to minimize complications of nutrition support:

Sepsis

Nutrient Intolerance

Fluid and Electrolyte Imbalances

Nutrient Deficiencies

Mechanical Problems

Clinical Nutrition Program Activities Facilitate transition of patients into the

outpatient/home setting -- coordinate nursing, social work, physical therapy, and physician management with nutrition care.

To include:

– Home Total Parenteral Nutrition– and Home Enteral Nutrition

Conclusion

Craftsman Analogy

The Craftsman

A Portal to the Millennium

There is a major opportunity for a quantum jump in quality of health care if we more appropriately address and improve nutritional evaluation and status of our patients.

Clinical Nutrition Program

A Portal to the Millennium

We can be more effective health care providers if we can secure healthier patients to apply our judgment and skills.

The “new health care environment” will eventually force this move. We now have an opportunity to be the leaders and garner the benefits for our patients.

Clinical Nutrition Program

Nutritional Support in the Nutritional Support in the Next MillenniumNext Millennium

John P. Grant, MDDirector NSSDuke University Medical Center

nutritional support in the next millennium john p. grant, md director nss duke university medical...

Documents

nutrition care slide

nutrition care practices

nutrition status

appropriate nutrition

risk of malnutrition

executive summary

standard nutrition assessment

increased costs of care