The five-year evolution of a malnutrition treatment program in a community hospital

Studies suggest that 30%-55% of hospitalized patients are at risk for malnutrition, an avoidable comorbidity contributing to increases in hospitalization and readmission, length of stay, complications, and mortality. Yet a variety of issues have impeded many hospitals' implementation of effective nutrition intervention programs. BENCHMARKING STUDY: St Francis Hospital (SFH), a 395-bed community acute care facility in Wilmington, Delaware, participated in a nationwide benchmark study in fall 1993. In comparison with the 12-hospital means, data for SFH showed both delays in initiating a nutrition care plan for acutely ill patients and a significantly higher risk for malnutrition. NUTRITION SCREENING PILOT: A pilot study was implemented in 1994 to identify nutrition needs within 48 hours of admission as a first step in the improvement process. Although interventions occurred earlier for a greater number of high-risk patients, nutrition intervention was not being provided in a uniform and timely manner. THE MALNUTRITION CLINICAL PATHWAY: A free-standing hospital committee, the Nutrition Care Committee (NCC), with guidance from the care management department, began developing a malnutrition pathway that would serve as an integrated plan for providing nutrition care to high-risk patients. The original pathway was organized into four stages that outlined the progression and timing of care--identification of the patient at high risk for malnutrition, nutrition care decisions, treatment in progress (the remainder of the patient's hospitalization), and discharge planning. OUTCOME STUDIES: Outcome studies were conducted in 1996 and again in 1998 to assess the malnutrition treatment pathway's impact on patient health outcomes and the cost of care. The 1996 outcome study indicated significant improvements in the identification of high-risk patients (from 25.9% to 86%) and the timeliness of nutrition intervention (from 6.9 days to 2.4 days). A second outcome study was conducted in 1998, following revision of the pathway. Comparison of the 1996 after-pathway patient population with a matched study group in 1998 indicated reductions in average length of stay from 10.8 to 8.1 days; the incidence of major complications from 75.3% to 17.5%; and 30-day readmission rates from 16.5% to 7.1%.

The performance improvement project described in this article began with SHF's voluntary participation in an interdisciplinary benchmarking study and continued when it was apparent that SFH had an opportunity for performance improvement. Forming an NCC at SFH was the first step in a process that gained the administrative support necessary to fully develop the program.

SFH has developed and implemented a malnutrition treatment program that is integrated into the care plan of all acute care patients and is included in the discharge planning process. Outcome studies have demonstrated the effect of the malnutrition treatment program on patient recovery and cost of care.