Patient Journey Blog Part 2 - The Ward
By Samir Hussaini, MD
The Role of the Hospitalist
The hospitalist oversees the patient journey in the hospital ward. These physicians take detailed histories and physicals pulling information from previous inpatient and outpatient encounters and noting any changes in the patient’s medical and social history. Hospitalists can have anywhere from 15-25 patients. So unfortunately, hospitalists might not have the time to perform a detailed review for each patient. While nutritional status is a concern for the patient, improvements in nutritional status is not something that can be fully resolved in a hospitalized visit and may require significant effort in the outpatient setting. Outpatient care falls outside the purview of the hospitalist.
Mr. Doe* is admitted and is treated with 80mg of Lasix, three times a day for his congestive heart failure. The patient’s cardiac echo from this year shows an ejection fraction (EF) of 15%. The hospitalist notes decreased medication compliance and increased water intake, but does not include any more information about food intake. He recommends that Mr. Doe consider going to hospice due to his advanced congestive heart failure (CHF). The patient continues to get daily labs. A nutritional assessment is completed by the dietitian for “length of stay” three days after admission. The nutrition assessment note does not identify any indicators from the nutritional risk screen. The only anthropometric traits measured are temperature and weight, recorded by a bed scale. BMI is calculated to be 19.8. The patient was placed on a cardiac diet.
Takeaways from Treating Malnutrition in the Hospital
It is important to understand there are different etiologies of malnutrition that can be closely related to other common diagnoses treated in admitted patients. The top 5 ICD-10 diagnosis codes that are coded along with malnutrition are sepsis, acute kidney failure, pneumonia, pneumonitis, and hypertensive heart and renal disease with heart failure.¹ One would hope that the hospitalists’ clinical gestalt would ask more probing questions related to malnutrition and lead to a quicker consult to the dietitian. According to research in Austria, inpatient physician referrals to dietitians are only 16.8%.² Patients with medical issues such as cardiovascular disease and musculoskeletal disease were 2.2 times less likely to be referred to dietitians compared to patients with weight loss and low BMI.² With increasing awareness of different types of malnourished patients, the hope is this awareness will lead to improved physician referrals to dietitians in the inpatient setting. Documentation of malnutrition by dietitians can differ from documentation by clinicians. A healthcare system in Delaware found that out of the 291 cases of malnutrition diagnosed by dietitians, only 32% of these cases were diagnosed by clinicians.³
Hospital policy also matters. Per the Malnutrition Quality Improvement Initiative (MQii), a malnutrition toolkit devised by a national collective of dietitian nutritionists (RDNs) to help better diagnose malnutrition, hospitals should have a nutrition screening conducted on patients within 24 hours of admission.⁴ Additionally, nutritional screening policies can be structured to include as many cases as possible such as a borderline BMI, like this patient. While this patient did not have malnutrition diagnosed on this visit, you will see in Part 4 of this blog series, how diagnosis of malnutrition can differ between hospitals. It is important to note that after the diagnosis of malnutrition, care needs to be delivered in a timely manner. Gaps in care for malnutrition, whether that is communication, testing, or discharge related, leads to a 48% increase in length of stay.⁵
What areas in this patient’s journey do you feel can be improved on?
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*To protect the patient’s identity, names and initials have been changed.