Addressing Malnutrition in Healthcare
Would you run a marathon on an empty stomach? That makes no sense! But, that isn’t far off from what patients in hospitals do every single day across the country.
A major factor is the use of NPO status ("nothing by mouth") for hours before and after major surgeries. This can contribute to, and even make worse, the already poor nutrition status of patients. Similarly, trauma and critical illness raise calorie requirements and speed up protein breakdown. This can occur at levels similar to what happens when running a marathon. Only this lasts for weeks to months afterwards!
All these factors can lead to malnutrition which brings its own set of complications. Malnutrition can be defined as a nutrition imbalance. It can happen to very obese and underweight patients alike. Malnutrition becomes severe when accompanied by weight loss, loss of fat or muscle stores, and decreased functional ability. Causes of malnutrition include chronic disease, acute illness or injury, and simple starvation.
The problem of malnutrition in hospitals has been gaining increased awareness since the 1974 publication of “The Skeleton in the Hospital Closet,” by Charles Butterworth. It brought to light the alarming percentages of patients that enter the healthcare system in a compromised nutrition state and the lack of attention paid to how these patients are nourished. Almost one in three admissions to a hospital admit already malnourished. Many others are at-risk or become malnourished during their stay. The reach of malnutrition extends to almost all disciplines: poor nutrition can contribute to delayed wound healing, increased infection rates, decreased functional status, and longer length of stay. All these lead to increased cost and use of healthcare dollars.
So, now that the closet doors are open, and we know about this issue, what can we do about it?
As clinicians in a long-term acute care hospital setting (LTACH), we are uniquely positioned to make a significant impact on our patient’s nutrition status. Therefore, we can positively influence their overall recovery and health. The increased use of nutrition protocols in short-term acute care hospitals (STACH) can increase calorie and protein delivery to at-risk patients by identifying these patients and generating orders for high-calorie and high-protein supplements. But, the average length of stay for STACHs is only 4.5 days. In the LTACH setting, average length of stay is about 25 days, depending on the severity of the illness.
At the outset, LTACH patients are at a high risk for malnutrition. Some even arrive malnourished from the previous facility. Wounds, infections, and complicated surgery recoveries make these patients challenging to care for. Chronic diseases such as end-stage renal disease or diabetes further complicate treatment.
Clinical Dietitians, along with the Interdisciplinary Team, can have a huge impact on a patient’s nutrition status. The longer average length of stay allows ample time to individualize patient care. These plans include consideration of preferences and cultural differences. Weekly, the interdisciplinary team meets to collaborate on patient progress. This team includes professionals from Infection Control, Rehab, Speech, Wound Care, Nursing and Nutrition. As the patient's diet moves from tube feeds to puree to regular textures, we offer interventions to help patients meet their calorie and protein needs. We trend physical changes, such as weight and physical appearance, monitor wound healing progress and help to reduce infection risk through improved nutrition status.
What are some specific ways we can do this?
At Vibra Hospital of Denver (an LTACH), we have been working to improve patient nutrition status on multiple fronts. We are improving food quality and the amount of choices patients have at mealtimes. We are increasing the accuracy of weekly weights to spot and treat weight loss quickly. NPO times before surgeries are being reduced. We provide education and training to nursing staff on how to improve delivery of calories and protein to tube fed patients by holding tube feeds less frequently.
We are also setting up patients for improved tube feed tolerance at the outset. We do this by ensuring bowel regimens are in place, tolerating higher gastric residual volumes, maintaining blood glucose levels in target ranges, and assessing for other signs and symptoms of intolerance on a regular basis.
But there's so much more to addressing malnutrition in healthcare. We encourage both providers and patients to educate themselves on malnutrition, and to document malnutrition in the patient’s medical record when it occurs. The official website for Malnutrition Awareness Week has a great library of resources on the topic.
Kate Nelson, MS, RD, CNSC is a Clinical Dietitian at Vibra Hospital of Denver. She is passionate about clinical nutrition and recently passed her Certified Nutrition Support Clinician (CNSC) exam in April of this year. She has also worked in acute care and skilled nursing facilities, and had a previous career as a Park Ranger with Colorado State Parks. At home, she spends her time cooking delicious meals for family and friends, cheering on the Denver Broncos, and spending time with her husband and beloved Boxer pup, Nemo.Posted By Kate Nelson