Malnutrition Quality Initiative MQII Optimizing Nutrition Care Accurate

Malnutrition Quality Initiative (MQII) Optimizing Nutrition Care • • Accurate diagnosis Appropriate treatment Improved outcome Reduce LOS Decrease readmission Improving quality of life Cost savings Intensive Malnutrition Intervention

Nutrition Focused Presentation (RDN) • Effect of malnutrition • chronic disease • hospitalization • elderly • Value of implementing a MQII • Procedure to implement a MQII • Value of Oral Nutrition Supplementation (ONS)

Contributor • Allison Rathje, Therapeutic Nutrition Specialist Acute Care Abbott Nutrition • • • Malnutrition initiative Education material Medical staff presentation Taste testing Staff training

Contributor • Gina Fernandez, RDN, LDN Oncology Dietitian Palos Health • • • Nutrition assessment Adequate intake Supplements Special menu Between meal nourishments

Johns Hopkins Bayview Medical Center “Malnutrition can increase the risk of hospitalacquired infections, increasing the patient’s length of stay and increasing their risk of morbidity and mortality. It can also interfere with the health care practitioner's ability to adequately and successfully treat the patient while he or she is in the hospital. " Carmen Roberts, MS, RD, LDN, a clinical dietitian specialist

Background • • RDN 30 years plus Clinical Dietitian Recognizing the value of nutrition Education Intervention Health care environment unaware

The Skeleton in the Hospital Closet Butterworth CE. Nutr Today 1974 “I am convinced that iatrogenic malnutrition has become a significant factor in determining disease outcomes in many patients” • Hospital Malnutrition Critical Evidence: • • Height not recorded 56% Weight not recorded 23% 61% of those weight was documented lost > 6 kg 37% albumin < 3. 0 g/dl

Malnutrition Treatment • • No universal approach No standard of care No best practice RD not authorized to diagnosis malnutrition

Areas of Focus Developing • Diabetes programs • Cardiac rehabilitation • Hospital based weight loss programs • Corporate wellness program Limited Activity • Diagnosis of malnutrition • Cancer nutrition care

Nutrition Care Process 2003 Established by the Academy of Nutrition and Dietetics. The NCP is designed to improve the consistency and quality of care for patients. The NCP establishes a standardized process for providing care.

Malnutrition Breakthrough • 2012 Academy of Nutrition and Dietetics & ASPEN defined malnutrition as two or more of the following characteristics: • • • Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Fluid accumulation Decrease functional status / diminished grip strength

Physically Focused Nutrition Assessment

Physically Focused Nutritional Assessment

History

Malnutrition Problem Quantified • 30% to 50% of hospitalized patients malnourished • 38% decline from normal nutrition during stay • 5% weight loss 30 days post-discharge significant risk factor for readmission • 45% of patients who fall are malnourished • 2 day increase in length of stay • 4 time increase in pressure ulcers • 5 time increase in infections

Impact on Malnutrition on Outcomes • • Length of Stay Infection Rate Wound Complications Pressure Ulcers Mortality Rate Readmission Rate Cost of Hospitalization

Six Characteristics of Malnutrition • • • Weight loss Insufficient energy Loss of subcutaneous fat Loss of muscle mass Fluid accumulation • Localized or generalized • Diminished functional status • Measured by hand grip-strength

Positive Outcome of Nutrition Intervention in Malnutrition • • 21% decrease in length of stay 21% decrease in episode cost 6. 7% reduction in readmissions Improved surgical outcome as measured by reduction in complications • Significant financial benefit

Goals of Malnutrition Intervention • Malnutrition moves to the forefront • Proper identification will promote improvements in nutritional intake • In a perfect world every patient eats well • Multiple factors prevent adequate intake • Appropriate nutrition intervention at time of admission through discharge and beyond is essential • Along with a healthy diet, oral nutrition supplementation (ONS) is a proven treatment for malnutrition

Assessment • Simple malnutrition screening tool to identify patients at risk • Early focus on the importance of promoting adequate nutrition

Malnutrition Screening Tool (MST)

ONS link Diet Order Coronary Diet Clear Liquid Diet Low Fat Diet High Fiber Diet Low Fiber Diet Full Liquid Diet General Diet Gluten Restricted ONS to be Provided Ensure High Protein Ensure Clear Ensure High Protein Ensure Enlive Ensure Enlive Frequency BID BID Meals Breakfast & Dinner Breakfast & Dinner GERD Diet No Concentrated Sweets Ensure Enlive Glucerna Shake BID One Daily Breakfast & Dinner Breakfast Calorie Controlled 1200 – 3000 calories Sodium Restricted Glucerna Shake One Daily Breakfast Ensure Enlive BID Breakfast Protein Restricted 40 -80 grams Renal Diet Pureed Diet Mechanical Soft Diet Vegetarian Diet Soft Diet Low Residue Diet Nectar Thick Liquids Honey Thick Liquids Pudding Thick Liquids Ensure High Protein One Daily Breakfast Ensure High Protein Magic Cup Ensure Enlive Magic Cup One Daily BID BID Breakfast Lunch & Dinner Breakfast & Dinner Lunch & Dinner

Intervention • Patients at risk of malnutrition are identified at admission • ONS is linked to the physician's diet order and provided immediately • RD consult for malnutrition risk at admission follow up within 48 hours • Accurate documentation of oral intake • LOW COST

RDN Changing Role • • • Diagnosis malnutrition Improve patient outcome Decrease length of stay Decrease readmission rate Promote improved continuum of care

Education • Everyone encourages patient to eat well and consume ONS • Multidisciplinary approach to education on benefit of adequate nutrition & ONS: • patient • family • care-giver • ONS is opened and provided to patient with encouragement to consume • Discharge plan includes education on healthy food selection & ONS: product, quantity, coupons

MQII Timeline • Nutrition Committee Presentation & Approval September 2016 • Nursing Practitioner & Teachers October 2016 • ICU Improvement Committee October 2016 • Medical Staff Introduction November 2016 • Information Systems MST & ONS link December 2016 • Staff taste testing / education March 2017 • Go-Live MQII March 20, 2017 • Nursing Education Workshop March 29, 2017

5/19/2021

Issues • MST being completed • Duplicate ONS • Learning curve • Safe to order ONS • Allergies • Compliance with order

Ensure Enlive

Hydroxymethyl butyrate (HMB) • • • Metabolite of leucine Regulates protein synthesis Helps maintain nitrogen balance Inhibits muscle breakdown Increased lean body mass in patient with stage IV cancer • Improves body composition and functionality • Improved muscle strength • Preserved muscle mass during prolonged bed rest

AMDR • Carbohydrate • 45 -65% • Energy Spares Protein • Protein • 10 -35% • Promotes Lean Body Mass • Can be used for energy • Fat • 25 -35% • Concentrated energy source

Protein Foods

Thank You Questions