In 2015, an older man in Fayetteville, N.C., made headlines when he called 911 in need of food. Just discharged from the hospital, the man had nothing to eat at home and was unable to leave his chair. The dispatch officer arranged for a sandwich to be delivered.
Moving away from acute and inpatient care is often a good sign for prognosis or patient quality of life. But the transition also carries a significant risk for malnutrition. In the move to home or new facilities, for example, patients can be without adequate nutrients for brief or even extended amounts of time. If nutrition falls short, so will healing, quality of life and a patient’s functional well-being.
Fortunately, the care team can take steps to prevent or at least mitigate these transition-related nutritional gaps, experts noted during a webinar hosted by the American Society for Parenteral and Enteral Nutrition (ASPEN) during Malnutrition Awareness Week in September.
“By 2035 there will be more Americans over 65 than under 18,” said Rose Ann DiMaria-Ghalili, PhD, RN, a professor of nursing at Drexel University, in Philadelphia. Not only will there be more aging adults, but they will be living longer, she said.
The aging population is already at the highest risk for malnutrition, and it often is worsened when they have a health complication. Malnutrition is tied to worse outcomes, hospital stays that are 1.9 times longer and more frequent readmissions. Thirty-day all-cause readmission is nearly 50% higher for patients with malnutrition (J Nutr Elder 2010;29[1]:4-41). A 2020 study found that malnutrition rates are particularly high at hospital admission (31%) and just before discharge (36%) (Nutrition 2020;77:110814).
Less than adequate nutrition, especially in aging patients, causes functional decline and can lead to disability and frailty, Dr. DiMaria-Ghalili said. Thus, malnutrition could prevent a significant part of the population from aging in place.
Adequate nutrition for this growing population is a critical hurdle in hospitals and health systems, Dr. DiMaria-Ghalili said. The resources required to care for malnourished patients are already estimated in the billions in annual costs, and that number will only grow as the aging population swells and people live longer.
“It’s really important that we try to break this cycle as much as possible,” Dr. DiMaria-Ghalili said. That will require prioritizing nutrition at every point in the care continuum, she said.
Discharge from one facility to another or from the hospital to home is where nutrition tends to fall between the cracks. Amid other care instructions and care team transitions, the risks for malnourishment often go unaddressed. In fact, nutrition is often not a part of discharge documentation, according to Dr. DiMaria-Ghalili.
Nutrition status gets overlooked because it’s left out of the paperwork, which leads to a lack of follow-up, added Nina Rocca, DCN, RDN, a dietitian in private practice and at BayCare Hospitals in Clearwater, Fla. Many facilities don’t even have a malnutrition policy, she said.
Nutrition screening gaps are also a problem at skilled nursing facilities, where malnourished patients are commonly admitted. In a 2017 survey, 86.6% of patients underwent nutrition screening upon arrival, but nutrition status was reevaluated at discharge in only 38% of patients (Nurs Res 2017;66[2]:E89-E89).
Even among patients who get nutrition counseling, the messaging isn’t always accurate, effective or personalized. A 2019 study reviewed nutrition instructions in patients’ electronic health records (EHRs) at discharge for 76 patients confirmed as malnourished within four months of leaving the hospital. Nearly half received nutrition counseling that didn’t mention malnutrition. Moreover, 45% received inappropriate advice telling them to restrict calories (J Hum Nutr Diet 2019;32[5]:659-666). “This really points to the fact that we think [EHRs] are helping us, but we really need to standardize and tailor the approaches to discharge care for those identified as malnourished,” Dr. DiMaria-Ghalili said.
“The discharge discussion should happen right from the day of admission,” added Kathleen Gura, PharmD, a pharmacist who specializes in parenteral nutrition at Boston Children’s Hospital, who was not part of the ASPEN webinar. “You should start discharge planning from the beginning, at the time of admission, keeping the lines of communication open and looking for the resources patients will need when they are discharged to home.”
Getting an Early Start
Starting sooner and getting the future care team involved as early as possible makes for the best transition, Dr. Gura said. That proactive approach also prioritizes a personalized discharge, which can help eliminate dangerous rote advice, such as calorie restriction.
Free Nutrition Screening Tool Integrated Into Health Record
Over the last eight years, Mayo Clinic, in collaboration with Epic Systems, has been building a nutritional screening tool into its electronic health record (EHR) system to help providers better assess and track nutrition, according to Joy Heimgartner, MS, RDN, a clinical dietitian at Mayo in Rochester, Minn.
The new tool integrates the Patient-Generated Subjective Global Assessment (PG-SGA) score into Epic. The Mayo/Epic-built PG-SGA offers providers a way to gather, score and track nutrition status over time and across multiple care settings. Best of all, it’s completely free for any institution that uses Epic.
The team at Mayo chose the PG-SGA because “the MST [Malnutrition Screening Tool] wasn’t providing a lot of meaningful information for us, and we wanted something that worked better for outpatients,” Ms. Heimgartner said.
Together, teams from Mayo and Epic integrated the screening portion of the PG-SGA, also known as the short-form PG-SGA, into Epic’s EHR system. The screening tool is sent to patients directly as an Epic Questionnaire that they can complete on their own device or on arrival to their visit. They’re asked about four different nutritional factors in the form: 1) weight over a given time frame; 2) factors affecting eating and drinking; 3) types and amounts of foods eaten; and 4) their activity.
“What’s really interesting about the PG-SGA is that it [yields] really detailed data that is leveraged into a scored tool,” Ms. Heimgartner said. That score reflects the patient’s anabolic competence—whether a patient is in a decline or a state of building up. The scoring is extremely complex, but the patient’s responses go directly into the Epic PG-SGA flow sheet, where calculations are done automatically.
In Epic, the questionnaire can be assigned to specific patients, specific visit types or a designated provider. Patients can be assigned a one-time questionnaire or a series of questionnaires so they can be monitored over time.
“It’s really important not just to initially assess and screen for malnutrition, but to also provide ongoing screening and assessment,” Ms. Heimgartner said. “The PG-SGA tool makes that easy.”
—D.C.
Dr. Gura said pharmacists can play an integral role in these moments of transition. They are uniquely able to bridge the gap between facilities because of their expertise in compounding, supply chain issues, logistics and anything that could cause a variation in the resources used for care, she said. It can be as simple as telling the new pharmacist where to get a product or sharing a drug code so that it can be ordered from the wholesaler. But that pharmacist-to-pharmacist conversation also is a great way to prioritize the patient’s nutritional status and ensure continuity of the nutritional care plan.
Possible Interventions
In her presentation, Dr. Rocca shared data on a strategy that mitigated nutrition transition care gaps. The strategy uses four contact points over five weeks carried out by a registered dietitian. The first step is an in-person interview and nutritional plan before discharge, followed by a phone call one, three and five weeks after discharge. Dr. Rocca tested the intervention in 21 patients who were an average age of 67 years.
Participants who received the intervention showed significantly better food intake and Patient-Generated Subjective Global Assessment scores than the comparison group. The strategy’s effect on readmission rates was more difficult to measure because there is no standard rate of readmission for patients with malnutrition, Dr. Rocca said. However, the intervention did not appear to affect readmission rates, she noted (UNF Graduate Theses and Dissertations 2022;1145:1-24).
The study also confirmed that the need for food resources and dietetic support extends well beyond acute care. Many patients in the study were food insecure and needed food banks or meal delivery. Clinicians must work collaboratively to get these resources lined up before discharge.
Stratifying Nutrition Risk
Ideally, dietitians would be part of every patient’s transition team, Dr. Rocca said. But the reality is there aren’t enough dietitians to manage the nutritional needs of every patient through every transition. To make the best use of dietitians and help every provider prioritize nutrition, care teams need better information. “We need to think about nutrition risk assessment and how that impacts post-discharge care,” Dr. DiMaria-Ghalili said.
Better assessments could help stratify patients by malnutrition risk and get them the right support. Dietitians could prioritize high-risk patients, Dr. DiMaria-Ghalili said. Interventions for moderate-risk malnutrition potentially could be delivered by a nurse, and low-risk interventions could be managed by a social worker.
—Donavyn Coffey
Dr. Gura reported financial relationships with Alcresta, B Braun, Baxter, Fresenius Kabi, Lexicomp, Mead Johnson/Reckitt, NorthSea Therapeutics, Otsuka, Takeda and UpToDate. The other sources reported no relevant financial disclosures.
This article is from the January 2024 print issue.