The Malnourished Patient Journey: Part 4 The Readmission
By Samir Hussaini, MD
In the final part of our patient journey, the undiagnosed malnourished patient has unfortunately been hospitalized again, but now at a different hospital. Let us see how this encounter differs from the previous ones described.
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* presented to the emergency department for evaluation after a fall. The emergency physician noticed generalized weakness and ulceration over the sacral area. The x-ray of the sacrum and coccyx showed a possible fracture. Lab work revealed hypokalemia and hypomagnesemia. Intravenous (IV) antibiotics and electrolyte supplementation were administered. The patient was admitted for recovery.
During this admission, the hospitalist asked about the patient’s home situation. The patient mentioned he had been eating less and was relying on his daughter more for food preparation. The hospitalist noticed that he had been admitted for congestive heart failure (CHF) exacerbations five times in the past three months. The hospitalist also recognized that this patient was most likely malnourished and consulted the dietitian for assessment and recommendations. This consult to the dietitian was sent less than 24 hours after the patient was admitted.
The dietitian’s note included a malnutrition assessment that incorporated a nutrition-focused physical exam to identify any signs of depletion in different body regions, subcutaneous fat loss, and muscle loss. The dietitian’s recommended nutrition care plan included a cardiac diet and oral nutrition supplement prescription to be consumed twice a day. The oral food intake target was greater than 50% of all meals and oral nutrition supplements. The dietitian also provided diet education to the patient. The dietitian included in her note that she reviewed these recommendations with the nurse.
Subsequent progress notes by the hospitalist included a medical malnutrition diagnosis as well as tracking the nutrition interventions recommended by the dietitian. As the patient improved throughout his admission, the dietitian kept noting progress until discharge. The patient was counseled on nutritional goals to aim for after discharge.
This malnourished patient encounter shows a hospital better equipped at assessing and treating malnutrition. Nutrition interventions in the inpatient setting have been shown to reduce the length of stay by 2 days and reduce 30-day readmission rates by 27% (¹,²). The main issue in malnutrition care is the gap of patients that are malnourished but are not identified or have their needs fully addressed during their hospital admission.. The Malnutrition Quality Improvement Initiative (MQii), a proven toolkit for better identifying malnutrition, describes four electronic clinical quality measures (eCQMs) that are best practices for hospitals³. These eCQMs are the following:
- Completion of a malnutrition screening within 24 hours of admission
- Completion of a nutrition assessment for patients identified as at risk for malnutrition within 24 hours of a malnutrition screening
- Nutrition care plan for patients identified as malnourished after a completed nutrition assessment
- Appropriate documentation of a malnutrition diagnosis
Employing these practices have helped hospitals make malnutrition diagnosis and document nutrition interventions.
While it was unclear if this patient had a malnutrition screening on admission using a screening tool, this patient had a nutrition assessment completed by the dietitian within 24 hours of admission, a documented nutrition care plan, a medical malnutrition diagnosis in the progress notes, and nutrition intervention recommendations for post-discharge. All of these steps executed during this admission is setting this patient up for better overall outcomes and well-being.
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*To protect the patient’s identity, names and initials have been changed.References: