Knowledge of the risks patient malnutrition poses to population health and to provider operations is widespread. In fact, this problem has been well-known, and studied in depth, since Dr. Charles Butterworth, Jr. published his article, The Skeleton in the Hospital Closet, some 45 years ago. What many providers may not know, however, is that malnutrition continues to plague hospitals around the country despite efforts to stem it.  

How big is this malnutrition problem?

Experts tend to agree that between 20 and 50 percent of hospitalized adult patients are malnourished, with some reports having this percentage topping 60 percent.  

Which patients are most impacted?  

Older adults, those already underweight, Black patients and those with a lower income.  

In 2013, nearly 2 million U.S. hospital stays involved malnutrition, according to the National Association of Clinical Nurse Specialists (NACNS).

(Malnutrition occurs when nutritional intake does not provide enough calories, minerals, vitamins and other nutrients for the body to take care of itself and to heal from surgeries or disease). Patients who do not have adequate key nutrients can end up having hospital stays that are twice as long as patients who are not malnourished. In addition, there is an almost five-fold increase in the risk of death. Malnutrition also increases the risk of poor wound healing, impaired immune systems, muscle wasting and infection.

Many patients already arrive at a medical facility with varying degrees of malnourishment due to whatever illness or injury caused their hospitalization in the first place. There is also evidence that almost a third of patients become malnourished during their hospital stay. And if malnourishment is not caught in time or is left untreated, two-thirds of malnourished patients will see a further decline in their nutritional status before discharge.

Independent of the cause of the malnutrition, what should be concerning to providers is that malnutrition is often significantly underdiagnosed and undertreated. For example, one study suggested that while almost half of a group of hospitalized patients were malnourished, the hospital’s electronic health record (EHR) documented a malnutrition diagnosis in only 11 percent of them. The implications of this level of underdiagnoses are clear.

The importance of adequate nutrition can be even more acute in critical treatment areas, such as the ICU, where being malnourished can literally make the difference between life and death for a patient. It is well-known that well-nourished patients recover faster and have better clinical outcomes than those that are malnourished. But unfortunately, up to one-half of patients in the ICU do not get adequate nutrition, with only about half getting the calories they need and about a third of the protein they need (GE Healthcare).

This malnourishment may have many causes. These include a general lack of appetite or interest in food after surgery or during the acute stage of a disease, physical limitations of the patient, taste changes, anxiety and pain, to name a few. Another contributing factor is that only around 10 percent of malnourished ICU patients are diagnosed as such (which is in line with the general trend of under diagnosing malnutrition). This situation can result in ICU patients requiring more time than they would need otherwise  to get back on their feet and enjoy a quality of life similar to the one they had before being hospitalized. This extra hospital time may, of course, translate into additional costs for providers, payors, patients and the general population. According to recent data, disease-related malnutrition costs the United States $15.5 billion annually.  

Impact of malnutrition on healthcare providers

The impact of malnutrition on providers is just as far-reaching as it is on the patient population. Nutrition is critical for good health and is even more important in a hospital setting since it literally can impact all aspects of a provider’s operation. These include readmission rates, clinical outcomes, mortality rates, post-discharge patient success as well as operational costs and profitability.  

And, as mentioned, the financial impact is not insignificant. To go into even more detail about the economic burden of this problem, several recent studies estimate that malnutrition creates a $42 billion burden on the healthcare system. This includes an estimated $11 billion annually for the direct treatment of malnutrition along

with the effects of malnutrition, including hospital acquired incidents such as falls, infections and pressure injuries. Other tangible and intangible costs include the impact of Medicare’s HRRP penalties for readmissions, an erosion in the public trust in the provider’s services, possible regulatory intervention and insurance claim denials and malpractice suits.

Solutions?

Broadly speaking, there are three things providers should be doing to help reduce the incidence of malnutrition among their patient populations:  

Nutritional Screenings

The first step is being diligent with conducting appropriate nutritional screenings for all patients. This step is very important. In fact, the Joint Commission mandates a nutritional screening within 48 hours of patient admission and the Academy of Nutrition and Dietetics has made a similar recommendation. This screening should include, at the minimum, information on weight and any recent weight changes, any GI symptoms, physical characteristics, functional capacity and symptoms of any nutrient deficiencies.

There are a variety of tools available for determining nutritional status and risk, including:

• Nutritional Risk Screening 2002
• Malnutrition Screening Tool
• Malnutrition Universal Screening Tool
• Nutrition Screening Tool

Unfortunately, there are many factors that can result in providers making cursory nutritional evaluations of patients if they even do so at all. Taking a casual approach to this important task unnecessarily increases health risks to patients.

Identify Reasons for Malnutrition and Address Them

There are tools, such as the Mealtime Audit Tool, developed by the University of Waterloo, which helps dieticians, doctors and nurses identify why patients may not eat their meals.  Almost a third of patients don’t eat all the food on their meal trays. Some possible solutions for providers include flexible meal times, minimized interruptions during meals and better temperature control.

Take a Multidisciplinary Approach

Taking a multidisciplinary approach to diagnosing and treating patient malnourishment has been shown to be quite effective. In fact, the Society of Critical Care Medicine recognizes it as a way to improve clinical outcomes. These teams addressing malnourishment and associated issues include dieticians, doctors, nurses, pharmacists, physical therapists, respiratory therapists and even speech pathologists. Provider policies and procedures should be designed to support both this approach and the team’s activities such as implementation of their recommendations, ongoing patient assessment, program successes and human/financial resource allocation.

Increase Education and Create a Culture of Nutrition Awareness

Another important step for providers is to take steps to move the issue of malnutrition to the forefront of medical and administrative staffs’ thinking and approach to patient management. Providers need to continue to shine a light on this issue through ongoing internal communications and training programs.

There is a direct benefit between this type of awareness and key operational metrics. One group of researchers found, for example, that hospitals that do a better job at identifying (and treating) malnutrition tend to have a higher volume of patients and better rankings. And for teaching hospitals associated with a medical school, administrators would do well to lobby for more inclusion of nutrition courses in their curricula, since one study revealed that fewer than 75 percent of U.S. medical schools have no required nutrition course and fewer than 15 percent of interviewed medical residents feel adequately versed in nutrition care.

Addressing patient malnutrition in a systematic, consistent and aggressive manner can reap many tangible benefits for providers and the communities they serve. For example, several studies have shown that addressing patient malnutrition can help reduce readmissions by almost 30 percent and reduce the length of hospital stays by an average of two days.  Ensuring that patients receive the nourishment they need benefits everyone.

(Sources for this article included the following: GE Healthcare, Academy of Nutrition and Dietetics, National Institutes of Health, Medical Xpress, The Conversation, Intensive Care Medicine, American Association of Critical-Care Nurses, Critical Care, American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine, The Association of UK Dieticians, European Journal of Anaesthesiology (EJA), American Association for Respiratory Care, University of Colorado, Denver School of Medicine, The Hospitalist, Today’s Dietitian, The Healthcare Cost and Utilization Project (HCUP), Baxter, Joint Commission).