The Malnourished Patient Journey: Part 1 The ED
By Samir Hussaini, MD
Join us on a four part blog series to explore a patient on his care journey and how malnutrition played an important role in his outcomes. Part 1 of our journey will walk you through the patient’s emergency department (ED) visit.
The Role of the ED Physician
The emergency department physician is the frontline provider of the patient care journey. These individuals are triaging patients based on their severity of illnesses and determining whether patient care needs to be upgraded to admission status. These physicians are primarily focused on making sure the patient does not deteriorate in an instant. Their time is limited and the patient’s nutritional status, while important to them, is a less prioritized concern. Below we will learn how nutrition taking a backseat in the ED can impact a patient.
Mr. Doe*, a 71 year old male with a history of congestive heart failure (CHF), coronary artery disease (CAD), hyperlipidemia(HLD), and hypertension (HTN), presents with shortness of breath. The patient’s vitals are borderline hypotensive and tachycardic. The ED physician completes a physical exam noting that he is a frail individual with crackles in his lungs and decreased breath sounds. The physician orders labs which show electrolyte derangement for sodium, potassium, and creatinine, and a brain natriuretic peptide (BNP) in the 3000s. The chest x-ray ordered shows an enlarged heart with congestion. The ED physician diagnoses Mr. Doe with an acute exacerbation of CHF needing admission and evaluation for heart failure.
The Missing Link: What happened in the ED?
As one can see above, there was no mention or review of the patient’s nutritional status in the ED physician’s workup of the patient. Furthermore, the diagnosis and treatment of malnutrition is a difficult process to be done in the ED, in some part due to the goal of expedient care or transition of care. ED physicians usually do not consult dietitians in the ED and nutritional intervention is usually not performed in this setting. Lanctin et al extracted data from 950 hospital EDs across the nation looking at the prevalence of malnutrition diagnosed. The diagnosis prevalence of malnutrition has ranged from 0.7% in 2006 to 1.15% in 2014.¹ This is unfortunately an under diagnosis of malnutrition, as the diagnosis is around 8.9% rate based on the latest data made available by ASPEN.² Within reason, this could be a potential area where physicians can do better in assessing for signs of nutrition risk. One area for improvement is additional physician education about the under diagnosis of malnutrition and how assessing for nutrition risk factors in the ED may help with early diagnoses and interventions that can improve patient outcomes. A pilot study in Australia successfully implemented a model of care with screening and nutritional intervention in the ED.³ Twelve weeks after intervention these participants had weight gain, increase in quality of life, and decreased depression.³ Another avenue is making the EHR streamline data gathering to look at previous documentation with concern for malnutrition and making it plainly available to physicians in the ED.
What would you have done differently to address malnutrition for this patient?
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*To protect the patient’s identity, names and initials have been changed.