Implementing Nutritional Assessment Protocols: A Benchmarking Study

The most challenging element of incorporating a malnutrition program is its implementation because obtaining the cooperation of interdisciplinary faculty can be difficult. Many institutions lack sufficient lines of communication and coordination between departments.

One institution overcame these challenges and has reported on the results of a 5-year malnutrition treatment study, which was part of a nationwide benchmarking study. (Brugler/1999) The program was conducted at St. Francis Hospital in Delaware and included two outcome studies that documented its effectiveness in improving the well being of the patient, length of stay, and cost of care, as well as demonstrated how a small community hospital can implement and benefit from such a program.

Establishment of Need

Since 1974, more than 150 clinical studies have demonstrated a risk of malnutrition for 30% to 55% of hospitalized patients, with declining nutrition status during hospital stays being estimated at 69%. (Brugler/1999 - Bickford/2000) This problem translates into higher costs for patient care since malnutrition is associated with comorbidity along with poor wound healing, increases in lengths of stay and a high readmission rate. (Brugler/1999)

Gaining Support of the Pathway

Consensus to adopt a nutrition care program among the staff of St. Francis Hospital was largely gained after their participation in a benchmark study in 1993, which compared the timeliness of nutrition intervention and length of stay (LOS) between 12 participating hospitals. Results indicated that St. Francis Hospital needed improvement in identifying and initiating a nutrition care program.

A crucial phase in implementing a malnutrition pathway is coordinating the interdisciplinary team that will assess and provide the patients with nutrition care. St. Francis Hospital was also faced with the challenge of budgetary constraints, which eliminated the option of hiring additional staff. The design of the pathway cleared these two major hurdles by:

1. Allowing the clinicians working directly with the malnourished patients to establish a shared vision of care for the malnourished patient between departments.
2. Integrating new procedures into existing practices with the addition of only one 0.4 FTE.

The interdisciplinary team involved in designing and implementing this new program included nurses, registered dieticians, physicians (medical and surgical specialties), pharmacists, medical technologists, quality managers, social services, administrators and home care providers.

Implementation

The malnutrition pathway was implemented using the following stages to delineate the progression and timing of care (Brugler 2002).

Stage 1: Identification of the patient at high risk for malnutrition
A nutrition screening form was incorporated into the assessment as well as the medical records of medical/surgical patients newly admitted to the hospital. High-risk patients that satisfied certain criteria were referred to a registered dietician. It’s important to note that approximately 50% of high-risk patients experience malnutrition. For strategies on screening, click here.

Stage 2: Nutrition care decisions
Once a patient was identified, the appropriate course of treatment was decided and a plan for nourishment was formulated. Treatment was initiated immediately. To standardize treatment, St. Francis devised an algorithm of nutrition care. Click on the following link to view a PDF version of the nutrition care algorithm.

Stage 3: Treatment in progress
During the patient’s stay in the hospital, treatment continued according to their outcome goals, which were devised on achieving and maintaining a state of adequate nutrition. Monitoring progress was dependent on the method of nutrient intake, but generally included taking weights on Sundays and Thursdays, lab values (e.g., serum albumin and prealbumin), observing PO intake and I & O.

Stage 4: Discharge planning
Care is typically rerouted for many patients in the early stages of their malnutrition treatment, thus requiring instruction for the continuation of such treatments as supplementation, tube feeding or parenteral nutrition. This stage ensured that patients were discharged with a detailed plan of nutrition therapy as well as information on their current nutrition status for continued care by subsequent healthcare providers.

Results of This Program

Results from the 1996 outcome study (the first of two outcome studies) were released 2 years following the initiation of the malnutrition clinical pathway, demonstrating St. Francis Hospital’s success in identifying high-risk patients (25.9% to 86%), as well as a statistically significant association of serum albumin measurements on admission with (Brugler 2002):

• Length of stay (P<0.01)
• Major complications (P<0.01)
• Functional status at discharge (P<0.01)
• Type of nutrition intervention required (P<0.01)
• Number of dietician interventions needed (P<0.05)

The second outcome study, released in 1998, reflected revisions incorporated in the malnutrition pathway with more than optimal results (see table). These revisions included an eight-day LOS format (versus the four-stage LOS format) and a better-defined expected outcome timeline.

1996 and 1998 Outcome Studies Comparison

Source: Brugler 2002.

Both outcome studies demonstrated the potential cost savings and improved patient outcomes from initiating a malnutrition intervention program. The success of this program led St. Francis Hospital to standardize and implement a malnutrition program for all acute care patients and discharge planning. Because this study proved successful, it serves as a useful model for other institutions in designing and implementing a malnutrition program.

To learn more about implementing a Nutrition Assessment Program in your institution click here.