Documentation Of Malnutrition Research Articles

What is the level of nutrition care provided to older adults attending emergency departments? A scoping review

BackgroundOlder adults often experience adverse health outcomes including malnutrition following discharge from emergency departments (ED). Discharge to community care is a transitionary time where nutritional vulnerability could be mitigated with the instigation of targeted nutrition care pathways in ED settings.Aims and objectivesThis scoping review aimed to establish and describe the level of nutrition care provided to older adults admitted and subsequently discharged from EDs.Research designSystematic searches of nine academic and grey literature databases (Medline (Ovid), Pubmed, CINAHL Complete (EBSCOhost), EMBASE, Cochrane Library and Scopus), grey literature sources (DART-Europe E-theses portal, Open Grey, and Trip Medical database) and four websites (Google, Google Scholar, NICE and LENUS) for relevant professional and organisational publications of research, policy, practice, and guidelines between January 2011 to 2023 were completed. Eligible studies included a population of older adults (≥ 65 years) with an ED attendance and subsequent community discharge, and where nutrition screening had identified malnutrition. Data were extracted on the level of nutrition and dietetic care initiated for older adults in the ED according to the Nutrition Care Process Model and summarised descriptively.ResultsOverall, 22 studies were included in the review. Nutrition status was screened on admission to the ED using validated tools: Mini Nutritional Assessment-Short Form (n = 13), Malnutrition Universal Screening Tool (n = 2), Short Nutritional Assessment Questionnaire (n = 2), NRS-2002 (n = 1) and the Mini Nutritional Assessment – Full Form (n = 1). A full nutrition assessment was reported by 5 studies. Only one study referred to documentation of malnutrition in healthcare records. Subsequent nutrition intervention after discharge from the ED for older adults was not described in any study.ConclusionWhile there is evidence to support malnutrition screening is taking place in EDs, there is a lack of information about subsequent nutrition care including assessment and therapy interventions. This points to the need for comprehensive exploration of nutrition care pathways, practice, policy, and research to inform models of integrated care for older persons.

Malnutrition risk assessment using a machine learning-based screening tool: A multicentre retrospective cohort.

Malnutrition is associated with increased morbidity, mortality, and healthcare costs. Early detection is important for timely intervention. This paper assesses the ability of a machine learning screening tool (MUST-Plus) implemented in registered dietitian (RD) workflow to identify malnourished patients early in the hospital stay and to improve the diagnosis and documentation rate of malnutrition. This retrospective cohort study was conducted in a large, urban health system in New York City comprising six hospitals serving a diverse patient population. The study included all patients aged ≥ 18 years, who were not admitted for COVID-19 and had a length of stay of ≤ 30 days. Of the 7736 hospitalisations that met the inclusion criteria, 1947 (25.2%) were identified as being malnourished by MUST-Plus-assisted RD evaluations. The lag between admission and diagnosis improved with MUST-Plus implementation. The usability of the tool output by RDs exceeded 90%, showing good acceptance by users. When compared pre-/post-implementation, the rate of both diagnoses and documentation of malnutrition showed improvement. MUST-Plus, a machine learning-based screening tool, shows great promise as a malnutrition screening tool for hospitalised patients when used in conjunction with adequate RD staffing and training about the tool. It performed well across multiple measures and settings. Other health systems can use their electronic health record data to develop, test and implement similar machine learning-based processes to improve malnutrition screening and facilitate timely intervention.

Academy for Quality and Safety Improvement (AQSI) project to improve diagnosis and documentation of malnutrition in a community hospital

BackgroundMalnutrition is a significant public health problem that affects many patients in inpatient settings. Timely identification and addressing malnutrition in an inpatient setting presents an opportunity to improve patient care...

Improving physician documentation for malnutrition: A sustainable quality improvement initiative.

This study compares documentation and reimbursement rates before and after provider education in nutritional status documentation. Our study aimed to evaluate accurate documentation of nutrition status between registered dietitian nutritionists and licensed independent practitioners before and after the implementation of a dietitian-led Nutrition-Focused Physical Exam intervention at an academic medical center in the southeastern US. ICD-10 codes identified patients from 10/1/2016-1/31/2018 with malnutrition. The percentage of patients with an appropriate diagnosis of malnutrition and reimbursement outcomes attributed to malnutrition documentation were calculated up to 24 months post-intervention. 528 patients were analyzed. Pre-intervention, 8.64% of patients had accurate documentation compared to 46.3% post-intervention. Post-intervention, 68 encounters coded for malnutrition resulted in an estimated $571,281 of additional reimbursement, sustained at 6, 12, 18, and 24 months. A multidisciplinary intervention improved physician documentation accuracy of malnutrition status and increased reimbursement rates.

Characteristics of Hospitalized Pediatric Patients with a Malnutrition Diagnosis at Riley Hospital for Children

Background: A diagnosis of malnutrition in hospitalized patients has been shown to negatively affect clinical outcomes by impairing immune responses (a subsequently increasing infection and complication rates), increasing the average length of stay in the hospital, and increasing mortality. In the past, there have been efforts to study the characteristics and prevalence of pediatric populations diagnosed with malnutrition in a hospital setting, but until 2014, no universal standards were used for malnutrition diagnosis and documentation. In 2014, The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) introduced a recommendation for standardization of identification and documentation of pediatric malnutrition. These recommendations guided a series of malnutrition awareness initiatives at Riley Hospital for Children (Riley) with a focus on increasing malnutrition documentation efficiency and integrity. Subsequently, the number of malnutrition diagnoses at Riley has increased from 2016 when the initiative started through 2021. Objective: The purpose of this study is to identify characteristics of patient populations diagnosed with malnutrition that may benefit from early intervention. Methods: Individuals with a diagnosis of malnutrition at Riley Hospital for Children (excluding Obstetric patients) from the years 2019-2021 were included in this study. Patient level data was used to study average length of stay (LOS), 30-day readmission percentage, admitting service, primary diagnosis, and demographics of this population. Results: Preliminary data analysis suggests there is a decreasing trend in readmission within 30 days for patients diagnosed with malnutrition. A similar trend is seen in the entire population of patients treated at Riley Hospital for Children in the same period. Of note, the entire patient population of Riley has seen a decreasing average length of stay while the patient population with a malnutrition diagnosis have seen an increasing average LOS. These observations have not been evaluated for significance at this time.

Using Quality Improvement to Improve Identification and Documentation of Malnutrition in Hospitalized Pediatric Patients.

Introduction:Recent publications have highlighted the importance and impact of recognizing malnutrition in hospitalized children. After noting that patients with malnutrition frequently went unrecognized in our facility, we implemented an interprofessional intervention comprising hospital medicine physicians, dietitians, and the clinical documentation improvement team to improve recognition and documentation of malnutrition in these patients, thereby facilitating earlier intervention.Methods:We implemented three separate plan-do-study-act cycles to improve the identification and documentation of malnutrition among patients hospitalized at our facility. The cycles consisted of identifying malnutrition using z-scores, educating providers, and implementing smart text within the medical record to help with consistent documentation. In addition, real-time communication between the disciplines (nutrition services, clinical documentation improvement providers, and hospitalists) was also employed to improve documentation quality. After completing the plan-do-study-act cycles, charts were reviewed to evaluate the nutritional interventions received.Results:Baseline data revealed that only 13% of patients with z-scores indicative of malnutrition were identified as such in attending physicians’ documentation. Upon implementation of our plan-do-study-act cycles, documentation of these patients increased to greater than 64%. Patients with documented malnutrition received nutritional interventions at least 81% of the time, increasing from 35% at baseline.Conclusion:Our findings demonstrate that an interprofessional approach can dramatically enhance the identification and documentation of malnutrition in hospitalized children, leading to earlier intervention.

The effect of quality improvement interventions on inpatient cancer malnutrition documentation and coding in an academic medical center.

38 Background: Malnutrition (MN) is common yet underdiagnosed in hospitalized cancer patients. Effective assessments can identify those who need nutritional care and help plan intervention. We examined the effect of quality improvement (QI) interventions on the dietitian documented MN (DDMN) and physician coded malnutrition (PCMN). We also determined if the registered dietitian (RD) and physician assessments of MN agreed. Methods: Electronic medical records (EMR) were reviewed for a consecutive cohort of inpatients with a solid tumor diagnosis staged I-IV and admitted to Atrium Health’s Carolinas Medical Center at least once between 1/1/2016 to 5/31/2019. Data were collected from the first admission EMR encounter closest to the cancer diagnosis date. RD assessments were reviewed for DDMN. PCMN diagnosis was based on MN ICD-10 codes in the discharge summary. MN was graded as mild, moderate, and severe. Two QI interventions were implemented during the study period: 1) 8/2016: RD message via EMR to query MD approval for MN diagnosis; 2) 4/2018: Clinical Documentation Integrity Team query MD by sending ASPEN criteria via an alert integrated into MD workflow. Agreement in MN identification was defined as the absence or presence of both DDMN and PCMN; agreement in severity was defined as the absence of DDMN and PCMN or the agreement in presence and severity of DDMN and PCMN. Cochran-Armitage tests for trend assessed prevalence and agreement across the three periods (N1=652; N2=2858; N3=1622) defined by the two sequential QI interventions. Results: N=5143; 52% males. Median age 63 (range 18-102) years. 70% White; 24% Black, 3% Latino. Commonest cancer diagnostic groups: Upper Gastrointestinal 22%, Thoracic (19%), Genitourinary 18%. 28% had stage IV disease. 11% (N=557) met criteria for DDMN and/or PCMN. Of the 557, 40% (N=223) met criteria for both DDMN and PCMN. DDMN (N=420) was mild 2%, moderate 19%, and severe 79%. On discharge, PCMN (N=360) was mild in 10%, moderate in 21%, and severe in 69%. The RD and MD agreed on the presence or absence (94%) and severity (93%) of MN. Significant trends were observed as DDMN prevalence increased from 3.1%, 8.1%, to 10.3% (p<.001), and PCMN prevalence from 0.5%, 7.8%, to 8.2% (p<.001). While rates of mild, moderate, and severe MN varied across the periods, statistically significant change in these distributions was not identified in DDMN (p=0.62) or PCMN (p=0.20) after the second QI intervention. Conclusions: MN was under-diagnosed compared to nutrition intervention studies. When MN was identified, it was moderate or severe in the majority. Evaluations by RD and MD were highly congruent for MN prevalence and severity. Implementation of nutrition-focused QI interventions improved documentation and coding of MN. Improved communication between the RD and the MD could improve the recognition and diagnosis of MN.

Implementation Science and Nutrition: From Research to Practice.

Implementation science (IS) is a young field that seeks to minimize the gap between what we know and what we practice, otherwise known as the "know-do gap." Recently, IS has focused on research that expedites the dissemination of evidence-based knowledge, accelerates the translation of interventions to improve knowledge gaps, shrinks healthcare disparities, enhances care of complex medical conditions, and narrows variation in clinical practice and policy. This article seeks to review theoretical frameworks of IS and demonstrate how IS can be utilized to improve nutrition care. Specific examples in this article include implementation of initiatives to improve documentation of malnutrition, increase provision of oral nutrition supplements, increase use of Enhanced Recovery After Surgery protocols, and increase energy and protein delivery. Clinical nutrition is a growing field with more and more research findings pointing to new therapies. In implementing these new therapies, practitioners should recognize the complex system present in healthcare and lean on IS findings to speed implementation and more rapidly improve clinical outcomes.

Inconsistencies in Physician Documentation of Malnutrition in a Community Hospital

Inconsistencies in Physician Documentation of Malnutrition in a Community Hospital

A New Approach to Comprehensive Growth and Nutrition Assessment in Children.

A new approach to comprehensive growth and nutrition assessment of infants, children, and adolescents that is etiology based and relatively simple to implement is now available. It encompasses five domains: anthropometry (growth measurements), assessment of change in growth (growth dynamism), duration of the growth abnormalities, etiology of the nutritional imbalance, and impact of the nutritional state on functional outcomes. Its increased use will help to standardize the screening, diagnosis, and documentation of malnutrition in both ambulatory and hospitalized patients. [Pediatr Ann. 2019;48(11):e425-e433.].

Analysis of Adult Inpatient Malnutrition at the University of Virginia Health System

The purpose of this study is to determine the effectiveness of the recent intervention on documentation of malnutrition, and, secondarily, to describe some characteristics of the patients identified as malnourished. Correct documentation and coding of malnutrition relies heavily on communication between registered dietitian nutritionists (RDN) and licensed independent practitioners (LIP). Oftentimes, the malnutrition diagnosis is not documented using the correct terminology for coding, is not documented at all by the LIP, and/or does not include adequate supporting evidence of malnutrition or a nutrition treatment plan. In hospitalized patients, malnutrition is associated with poor outcomes such as readmissions, increased length of stay (LOS), nosocomial infections, and increased healthcare costs. It is important to identify and address inpatient malnutrition in order to provide the best possible outcomes. Hospital reimbursement from the Centers for Medicare and Medicaid Services (CMS) for the treatment of malnourished patients is dependent upon correct documentation and coding, requiring adequate communication among members of the interdisciplinary team. A malnutrition note type in the electronic medical records was introduced in November 2018 to facilitate communication between RDNs and LIPs. Data were collected via Epic reports for adult inpatients admitted January-February of 2018 and 2019. Included in the reports were patients with malnutrition documented on the problem list or malnutrition on the discharge diagnosis. Analysis of variance (ANOVA) and post hoc Tukey test were used to determine significant differences in age and BMI between degrees of malnutrition. Chi square with post hoc analysis was used to determine changes in outcome measures from 2018 to 2019. A total of 724 adult inpatient admissions were analyzed: n(2018)=339, n(2019)=385. Documentation of malnutrition on the problem list increased from 136 to 252 times. There was a significant increase in the number of malnourished patients who were characterized has having malnutrition on admission (p=0.00003). RDN documentation on the problem list increased significantly from 88 times in 2018 to 217 times in 2019 (p=0.001). Service lines with the highest percent of malnourished patients were medical subspecialties and oncology at both time points. Primary discharge diagnosis categories with the highest percent of malnourished patients were oncology, infectious disease, and general medicine at both time points. Implementation of the malnutrition note type resulted in improved documentation of malnutrition at University of Virginia Health System (UVAHS). There were more patients with malnutrition documented on the problem list in 2019, specifically those with moderate and severe malnutrition. Of the patients identified as being malnourished, there was a significant increase in those identified as having malnutrition on admission.

Achievements in Improving Documentation to Depict a More Accurate Clinical Representation of Patients with Malnutrition While Increasing Visibility of the RDN

The purpose of this quality project was to improve the documentation of malnutrition diagnoses in the electronic health record (EHR) to represent more accurate depictions of patients' clinical conditions. It is imperative to identify, prevent and treat hospital malnutrition in order to provide high quality care for patients. Malnutrition diagnoses are often missed and are commonly queried by coders. Compared to those who are not, malnourished patients are more likely to have adverse outcomes such as: pressure injuries, falls, and delayed healing leading to longer stays and readmissions. Registered dietitian nutritionists (RDNs) are the experts who can provide low-risk, cost-effective interventions and engage the care team in efforts to provide high quality care for these patients. Work began at Spectrum Health (SH) in 2015 with a pilot study aimed at improving physician malnutrition diagnosing and documentation. RDNs worked with physicians to improve the process of documenting malnutrition. In January 2016, using the Malnutrition Quality Improvement Initiative (MQii) Toolkit, an executive-sponsored Malnutrition Steering Committee was initiated. The initial goal was to further improve the documentation of malnutrition diagnoses by RDNs and physicians. This required raising awareness around hospital malnutrition and the critical role of RDNs. It also required improving RDN performance of the Nutrition Focused Physical Exam (NFPE). In November 2017, enhancements were implemented to malnutrition documentation while switching EHR software platforms. RDNs collaborated with informatics specialists, providers, coders, and analysts to improve documentation processes. Malnutrition specific flowsheet rows and a malnutrition note were added to the EHR. The RDN completes the flowsheet rows in the Nutrition Assessment Flowsheet to efficiently and completely document the criteria that supports a malnutrition diagnosis found upon assessment and physical exam. These are then pulled into a Malnutrition Note that is routed to the physician for cosign. This provider signature is required for coding malnutrition diagnoses. RDNs were also granted privileges to add malnutrition diagnoses to the Problem List. Concurrently, RDNs were further trained on the NFPE and raised awareness of expertise. The number of documented cases by RDNs and providers in 2018 were compared to the number in 2016 to determine the impact of these changes. The number of documented malnutrition cases by RDNs in 2018 was 3895, up 270% from 2016 (1440). Enhancing RDN NFPE skills improved identification and documentation of malnutrition. The number of documented malnutrition cases by providers in 2018 was 1594 (Jan-May 2018), which was 7.2% of discharged patients in that time. This was up 239% from 2016 (667 between Jan-May 2016). Awareness efforts and EHR enhancements improved provider agreement with RDN diagnoses. RDNs began adding malnutrition diagnoses to the Problem List in the EHR in November 2017. RDNs are the only disciple other than providers granted these privileges at SH. This allows the malnutrition diagnosis to be addressed at each health care encounter. Improved documentation to represent a more accurate depiction of the clinical condition of patients with malnutrition was achieved. RDNs built interdisciplinary relationships while collaborating with other departments, which have elevated the RDN role in care and in decision making throughout the organization.

Prevalence, trends, and correlates of malnutrition among hospitalized children with cerebral palsy.

This cross-sectional study characterized the prevalence, trends, sociodemographic factors, and clinical factors that are associated with a coded diagnosis of malnutrition (CDM) among hospitalized children with cerebral palsy (CP) in the USA. We used data from the 2002 to 2015 National Inpatient Sample database and restricted the analysis to hospitalized children with CP between 2 and 17 years of age. International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis codes for CP, malnutrition, and comorbidities associated with CP were used to characterize hospitalizations for this population. Logistic regression models were conducted to identify the sociodemographic factors and comorbidities associated with a diagnosis of malnutrition. The average documented rate of CDM among hospitalized children with CP was 7.9% and nearly doubled during the study period. The model suggests that younger age, non-white ethnicity, lower income, and non-private insurance/payer status were associated with increased odds of documented malnutrition. Concomitant inpatient diagnoses of epilepsy, dysphagia, scoliosis, reflux, and constipation were associated with higher rates of CDM. The rate of CDM in hospitalized patients with CP is well under the estimated clinical prevalence of 30% to 40%. Multiple sociodemographic, hospital, and clinical factors are associated with higher rates of CDM. The documented rate of malnutrition in hospitalized children with cerebral palsy (CP) averaged 7.9% yearly. For hospitalized children with CP, documentation of malnutrition nearly doubled between 2002 and 2015. Economically disadvantaged and minority ethnic groups had a greater likelihood of malnutrition documentation. Inpatient malnutrition documentation was more likely with some comorbidities indicative of greater impairments. Gastrointestinal disorders increased the likelihood of an inpatient-documented diagnosis of malnutrition.

Improving Recognition & Documentation of Malnutrition in Pediatric Oncology

Describe interventions and impact of a quality improvement project to improve recognition and documentation of malnutrition in pediatric oncology and stem cell transplant

Malnutrition Documentation by the RDN Increases Malnutrition Coding at Discharge

Malnutrition Documentation by the RDN Increases Malnutrition Coding at Discharge

Malnutrition Documentation: Accuracy and Areas for Improvement

Upon completion, participants will be able to demonstrate understanding behind the importance of accurately accepting and documenting best practice alerts (BPA).

Childhood malnutrition and maltreatment are linked with personality disorder symptoms in adulthood: Results from a Barbados lifespan cohort

Both childhood malnutrition and maltreatment are associated with mental health problems that can persist into adulthood. Previously we reported that in Barbados, those with a history of infant malnutrition were more likely to report having experienced childhood maltreatment. Few studies, however, address the long-term outcomes of those who have been exposed to both. We assessed the unique and combined associations of a history of early malnutrition and childhood maltreatment with personality pathology in mid-adulthood in participants of the 47-year longitudinal Barbados Nutrition Study. We used the Structured Clinical Interview for DSM-IV-TR Axis II Personality Disorders Personality Questionnaire (SCID-II-PQ) and NEO Personality Inventory-Revised derived Five-Factor Model (NEO PI-R FFM) personality disorder (PD) scores to assess personality pathology, the Childhood Trauma Questionnaire-Short Form (CTQ-SF) to assess childhood maltreatment, and clinical documentation of malnutrition in infancy. We tested the associations of malnutrition and maltreatment with PD scores using linear regression models, unadjusted and adjusted for other childhood adversities. We found increased scores for paranoid, schizoid, avoidant, and dependent PDs among those who had been malnourished and increased scores for paranoid, schizoid, schizotypal, and avoidant PDs among those with higher childhood maltreatment scores. Overall, those exposed to both adversities had even greater PD scores.

Identification, Coding, and Reimbursement of Pediatric Malnutrition at an Urban Academic Medical Center.

The American Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition released a pediatric malnutrition consensus statement in 2014 recommending the use of z-scores as indicators for identification and documentation of malnutrition. A shift in focus is needed on standardizing pediatric malnutrition language at institutions nationwide to make study data comparable. With this standardized language, establishment of institutional baselines for identification, coding, and reimbursement of pediatric malnutrition is crucial to measure process improvements. The objectives of this study were to determine the prevalence of malnutrition among pediatric patients at an urban academic medical center, the frequency of malnutrition codes used, and the reimbursement impact of coding for malnutrition. Electronic medical records of pediatric patients admitted from January 2013 to December 2015 were reviewed. Malnutrition was identified based on registered dietitian identification and z-score. Patients given a malnutrition-related International Classification of Diseases code upon discharge were identified. A reimbursement calculation was performed: the malnutrition-related International Classification of Diseases code was removed to determine the difference in reimbursement with vs without the code. Of the 1,532 admissions included in this study, 464 (30%) were identified as malnourished. A total of 152 (33%) malnourished patients were given a malnutrition-related secondary diagnosis. The calculation revealed that coding for malnutrition resulted in an additional $27,665.70 to the medical center. Malnutrition coding may have a significant financial impact and processes improvement efforts can be made to improve malnutrition coding.

Accuracy of Malnutrition Documentation in the Hospitalized Adult: A Retrospective Analysis of Four Adult Patient Populations at the University of Virginia Health System

Accuracy of Malnutrition Documentation in the Hospitalized Adult: A Retrospective Analysis of Four Adult Patient Populations at the University of Virginia Health System

Missed Opportunities for Nutritional Rehabilitation in Children Admitted to Surgical Wards

Background. Malnutrition in children has serious health and economic consequences. We studied documentation of malnutrition, actual prevalence, and treatment given in children admitted to surgical wards. Methods. Retrospective study of 154 patients aged <5 yrs admitted to general surgical, orthopedic, and otorhinolaryngology wards. Records were evaluated for completeness of data, way of documentation, and data quality. Descriptive analysis was done. If malnutrition was not identified and/or proper action was not taken, it was defined as a “missed opportunity.” Results. Of 154 records audited, 100 (64.94%) were males, 108 (70.13%) were from general surgery ward, and 78 (50.65%) were residing in suburban area. The mean (SD) age of the study population was 2.32 (1.16) years whereas mean (SD) duration of stay was 5.84 (6.29) days. Weight and height were mentioned in 116 (75.32%) and 8 (5.19%) records, respectively, mostly by nonsurgical personnel. Documentation and treatment of malnutrition were poor. Out of 106 apparently correct weight records, 19 (17.93%) children were severely undernourished and 30 (28.30%) were moderately undernourished whereas 20 (18.87%) children were not undernourished but required nutritional attention. Conclusion. There is poor documentation of nutritional indicators of children admitted to surgical wards. From data that was available, it is apparent that malnutrition is at high levels. “Identification” and hence management of malnutrition need more attention.