The Malnourished Patient Journey: Part 3 Discharge
By Samir Hussaini, MD
After being treated for an exacerbation of congestive heart failure, Part 3 of our patient journey blog series takes the patient through the discharge process. Here, we can see some common pitfalls that may occur when discharging patients who are experiencing malnutrition or at risk for malnutrition.
The Role of the Dietitian
Dietitians are invaluable healthcare providers and are essential members of the inpatient care team. They are experts in medical nutrition therapy and provide nutrition assessments and tailored nutrition interventions. Dietitians also act as an education resource for patients when it comes to information and advice for nutrition. Dietitians tailor nutrition treatment plans (e.g., oral, parenteral, and enteral nutrition) and modify diets for disease states like heart failure and renal disease.
Mr. Doe* was discharged with home health care, as well as instructions for a cane, and follow-up with an advanced heart failure clinic. On admission, the nurse did not recognize a 6.5% weight loss, and waited to perform the MST 24 hours before discharge, leaving little room for nutrition intervention in the hospital setting. As a result, the dietitian was not consulted and a nutrition assessment and nutrition focused physical exam (NFPE) was not performed. This led to a missed opportunity for both a nutrition and medical based diagnosis of malnutrition, and the patient leaving the hospital without a nutrition care plan including nutrition interventions to follow at home.
This patient most likely would have met criteria for a malnutrition diagnosis. Screening on admission would have identified this patient as already malnourished due to him suffering from an acute exacerbation of heart failure, a 6.5% weight loss within three months, and a BMI of 19.
Different organizations use different malnutrition classification criteria (e.g., the Academy/ASPEN, Merck, GLIM, etc.) and different malnutrition workflows leaving room for non-dietitian clinicians to not be properly trained or forced to use inefficient workflows or criteria. One way to identify and overcome gaps in malnutrition care includes, adoption of practices in the Malnutrition Quality Improvement Initiative (MQii) toolkit, a collection of evidence based best practice resources for malnutrition diagnosis, and optimizing the EHR to assist in the coordination of care. One study using the MQii toolkit led to a 100% RDN-based diagnosis of malnutrition when patients were screened and identified as malnourished or at high risk, and a 4.8% increase in documentation of malnutrition¹.
Once identified, communicating the diagnosis and nutrition interventions to the patient is vital. By doing this it increases the chance of patient buy-in that will lead to better adherence to treatment plans and carrying out medical recommendations from discharge in an outpatient capacity.
Malnourished older patients are often likely to reappear to the hospital for admission. Guenter et all found that 55% of malnourished patients that were readmitted within 30 days were older than 65². One large single center study of surgical patients saw that the third most common reason for readmission was failure to thrive/malnutrition³. Physicians that ignore malnutrition during the hospital admission are making patients susceptible to this concept of malnutrition medical frailty called Post-Hospital Syndrome leading to the high probability of readmission for these patients within 30 days⁴ Hopefully, we can continue the call-to-action as physicians to think about this demographic of older malnourished patients and ensure we are discharging them with some sort of nutrition care plan.
Identifying malnutrition and prescribing the correct nutritional intervention is vital. Even though this patient’s journey through this particular hospital stay did not result in correctly identifying the signs and symptoms of malnutrition, we will see in part 4, what it looks like when a malnourished patient is properly assessed and treated during a hospital visit.
What areas in this patient’s journey do you feel can be improved?
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*To protect the patient’s identity, names and initials have been changed.