Rose Ann DiMaria-Ghalili

Malnutrition Diagnoses in Hospitalized Patients United States, 2010

Malnutrition is common among hospitalized patients in the United States, and its coded prevalence is increasing. Malnutrition is known to be associated with increased morbidity, mortality and healthcare costs. Although national data indicate that the number of malnutrition diagnoses among hospital discharges has been steadily rising, an in-depth examination of the demographic and clinical characteristics of these patients has not been conducted. We examined data from the 2010 Healthcare Cost and Utilization Project (HCUP), the most recent nationally-representative data describing U.S. hospital discharges. Using ICD-9 codes, we constructed a composite variable indicating a diagnosis of malnutrition. Based on our definition, 3.2% of all U.S. hospital discharges in 2010 had this diagnosis. Relative to patients without a malnutrition diagnosis, those with the diagnosis were older, had longer lengths of stay and incurred higher costs. These patients were more likely to have 27 of 29 comorbidities assessed in HCUP. Finally, discharge to home care was twice as common among malnourished patients, and a discharge of death was more than 5 times as common among patients with a malnutrition diagnosis. Taken together, these nationally representative, cross-sectional data indicate that hospitalized patients discharged with a diagnosis of malnutrition are older and sicker and their inpatient care is more expensive than their counterparts without this diagnosis.

Undernutrition in Hospitalized Older Adults: Patterns and Correlates, Outcomes, and Opportunities for Intervention with a Focus on Processes of Care

Undernutrition in hospitalized older adults is increasingly being recognized as a serious problem with implications for both patient care and outcomes and health service utilization and costs. This article presents an overview of research that has been conducted examining undernutrition in hospitalized older adults. First, findings from observational studies examining patterns and predictors of undernutrition in hospitalized older adults will be described, with a focus on methodological challenges. Second, clinical outcomes and costs associated with undernutrition in hospitalized older adults will be presented, both while in the hospital and subsequent to discharge. Third, a description of interventions that have already been implemented in hospitalized older adults will be described. Finally, future areas of inquiry and opportunities for evidence-based nutritional interventions targeted at older adults during and following hospitalization will be suggested. The emphasis of the discussion on interventions will focus on processes of care and the hospital environment.

Nutrition Screening and Assessment in Hospitalized Patients A Survey of Current Practice in the United States

Background: The Joint Commission has mandated universal screening and assessment of hospitalized patients for malnutrition since 1995. Although various validated and nonvalidated tools are available, implementation of this mandate has not been well characterized. We report results of a survey of hospital-based professionals in the United States describing their perspective on the current range of nutrition screening and assessment practices as well as associated gaps in knowledge. Methods and Materials: Data from a 2012-2013 cross-sectional, web-based survey targeting members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), the Academy of Medical-Surgical Nurses, and the Society of Hospital Medicine were collected with non-hospital-based members excluded. Descriptive statistical analysis was performed. Results: Survey data from 1777 unique email addresses are included in this report. A majority of respondents were dietitians, nearly half were A.S.P.E.N. members, and 69.4% reported caring for a mix of adult and pediatric patients. Most respondents answered affirmatively about nutrition screening being performed in alignment with The Joint Commission mandate, but only 50% were familiar with the 2012 Consensus Statement from the Academy of Nutrition and Dietetics/A.S.P.E.N. on adult malnutrition. In most cases, nurses were primarily responsible for nutrition screening, while dietitians had primary responsibility for assessment. No one specific assessment tool or International Classification of Diseases, Ninth Revision code was identified as being used a majority of the time in assessing or coding a patient for malnutrition. Conclusions: The survey findings affirmed compliance with accreditation standards in completing a nutrition screen within 24 hours of admission, and most hospitals appear to have a process to perform a nutrition assessment once a screen is completed. However, there is considerable heterogeneity in both use of tools and mechanisms for coding capture. Opportunities exist to improve education around nutrition screening and assessment and to identify ideal practices for these processes in hospitalized patients.

Capacity building in nutrition science: Revisiting the curricula for medical professionals

The current nutrition education curricula for students in U.S. medical schools, and schools of other health professions, such as nursing and oral health, do not provide enough opportunity to gain knowledge of the interactions among micro‐ and macronutrients, their role in maintaining optimal body functions, factors that interfere with these interactions, or, importantly, how to integrate this knowledge into medical practice. There is a need to better prepare healthcare professionals for identifying nutrition risk and managing hospitalized patients, especially those with chronic conditions, using an interprofessional, team‐based approach. A major goal of this report is to revisit current nutrition training programs for physicians and other healthcare professionals in order to explore opportunities for providing healthcare providers with the essential tools of preventative and therapeutic nutrition intervention strategies. The issues addressed include whether a consensus exists on how to integrate basic and applied nutrition into the general healthcare professional curriculum, and if so, at which stages of training and at what depth should these integrations occur; how nutrition education is dealt with and achieved throughout all the health professions; and whether current nutrition education models are sufficient. To help address these issues, the report will review current nutrition education practices—their strengths and weaknesses—as well as evaluate promising new initiatives, and offer proposals for new directions for nutrition education training of future generation of medical practitioners.

Development of Sustain™ A.S.P.E.N.’s National Patient Registry for Nutrition Care

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) developed a Web-based registry for nutrition care launched in early 2011, initially focusing on the home parenteral nutrition (HPN) patient population. The purpose of Sustain is to collect information regarding the patients and populations who require HPN in the United States, measure outcomes associated with HPN, allow institutional benchmarking against the aggregate data, and publish the findings to improve the quality of care for patients receiving HPN. The registry is open to all sites (hospital and home based) who care for new or existing HPN patients. Preliminary data should be available in early 2012.

Integrating Nutrition in the Comprehensive Geriatric Assessment.

Malnutrition continues to be a serious problem in older adults. Experts have suggested a mandatory integration of nutrition into the comprehensive geriatric assessment (CGA). The purpose of this article is to briefly review the components of the CGA and discuss the nutrition implications of each individual domain of the CGA. Any problem identified during the assessment (including positive findings on nutrition screening and assessment tools) should be addressed and interventions implemented in a timely fashion. Recommendations for interdisciplinary health professionals across the care continuum are provided.

Inflammation, functional status, and weight loss during recovery from cardiac surgery in older adults: A pilot study

Objective: To determine the nutritional, inflammatory, and functional aspects of unintentional weight loss after cardiac surgery that warrant further investigation. Research Methods and Procedures: Twenty community-dwelling adults > 65 years old undergoing cardiac surgery (coronary artery bypass graft [CABG] or CABG + valve) were recruited for this prospective longitudinal (preoperative and 4–6 weeks postdischarge) pilot study. Anthropometrics (weight, standing height, and mid-arm and calf circumference), nutritional status (Mini-Nutritional Assessment™ [MNA]), appetite, physical performance (timed chair stand), muscle strength (hand grip) and functional status (basic and instrumental activities of daily living), and inflammatory markers (plasma leptin, ghrelin, interleukin [IL]-6, high-sensitivity[hs] C-reactive protein, and serum albumin and prealbumin) were measured. Results: Participants who completed the study (n = 11 males, n = 3 females) had a mean age 70.21 ± 4.02 years. Of these, 12 lost 3.66 ± 1.44 kg over the study period. Weight, BMI, activities of daily living, and leptin decreased over time (p < .05). IL-6 increased over time (p < .05). Ghrelin, hs-CRP, and timed chair stand increased over time in those who underwent combined procedures (p < .05). Grip strength decreased in those who developed complications (p = .004). Complications, readmission status, and lowered grip strength were found in those with low preoperative MNA scores (p < .05). Conclusion: After cardiac surgery, postdischarge weight loss occurs during a continued inflammatory response accompanied by decreased physical functioning and may not be a positive outcome. The impacts of weight loss, functional impairment, and inflammation during recovery on disability and frailty warrant further study.

Benchmarking a Home-Delivered Meal Program's Annual Satisfaction Survey: A Metropolitan Area Neighborhood Nutrition Alliance (MANNA) Initiative in Philadelphia

The Metropolitan Area Neighborhood Nutrition Alliance (MANNA) is a community-based organization providing home-delivered meals in Philadelphia, Pennsylvania to individuals at acute nutritional risk and experiencing a life-threatening illness, independent of age or income. The challenge MANNA faces, like other community-based organizations, is to demonstrate effective services by benchmarking with other organizations. This article reports how MANNA benchmarked results of their annual satisfaction survey against the 2013 National Survey of Older Americans Act Program. Overall, MANNA recipients were more often satisfied with the taste and variety of food, and more MANNA recipients rated the program as excellent. However, more MANNA recipients reported not having enough money to buy food, skipping meals because of money, needing to choose between food and medications or food and utilities. MANNA is using these findings as an impetus to better understand the needs of their clients, especially as they transition off the meal program, and to identify additional resources to support transitional programming.

Nutrition and Hydration in Older Adults in Critical Care

Nutrition and hydration are vital components of critical care nursing. However, meeting the nutrition and hydration needs of the critically ill older adult is often complex, because of preexisting risk factors (malnutrition, unintentional weight loss, frailty, and dehydration); as well as intensive care unit-related challenges (catabolism, eating and feeding, end-of-life care). This article highlights the challenges of managing nutrition and hydration in the critically ill older adult, reviews assessment principles, and offers strategies for optimizing nutrition and hydration.

Nutrition education for the health care professions

1Department of Nutrition, School of Medicine and Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 800 Eastowne Drive, Suite 100, Chapel Hill, NC 27514, USA 2UNC Nutrition Research Institute, 500 Laureate Way, Kannapolis, NC 28081, USA 3Centre for Physical Activity and Nutrition Research, School of Exercise and Nutrition Sciences, Deakin University, Waurn Ponds Campus, Locked Bag 20000, Geelong, VIC 3220, Australia 4College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA 5UK Need for Nutrition Education/Innovation Programme in Partnership with MRC Human Nutrition Research in Cambridge and the British Dietetic Association, c/o Elsie Widdowson Laboratory, Cambridge CB1 9NL, UK 6Cambridge University Hospitals and School of Clinical Medicine, c/o Elsie Widdowson Laboratory, Cambridge CB1 9NL, UK