Combating hospital malnutrition: Dietitian-led quality improvement initiative

Malnutrition is serious but under-diagnosed problem among hospitalized patients as approximately one-third patients may become malnourished during their stay. We audited our clinical nutrition practice (CNP) to understand the gaps and planned quality improvement initiatives to strengthen CNP through early delivery of oral nutrition supplement (ONS) prescribed.

A prospective study was conducted in a tertiary care hospital in three phases between Dec'15 and Feb'17. Phase-1(P1): To assess the prevalence of malnutrition on admission and CNP; Phase-2(P2): Sensitization of Clinical Dietitians' to improve the nutrition care process; Phase-3(P3): Coalition of Multidisciplinary Team (MDT) to improve the timely delivery of ONS. Patients' demographics, baseline nutritional status (Subjective Global Assessment (SGA)), details of nutrition intervention and outcomes were recorded. Data were analyzed using SPSS version 20.0.

Out of 1443 patients (P1-500; P2-428; P3-515) enrolled, 63% were men and 37% women with mean age of 53.6 ± 15.49y. A significant improvement in the nutritional diagnosis as per SGA (0.031) and increasing trend in ONS prescription (P1:10(2%); P2:56(13%); P3:83(16%) (p = 0.000) was evident, which was attributed to the sensitization of Dietitians. Early delivery of ONS within 6 h from the time of prescription (EDONS) was progressively higher in P3 (P1:10%; P2:16.1%; P3:44.6%) and notable reversal of delayed delivery (>24 h) (P1:40%, P2:16%, P3:8.4%) (p = 0.000). Remarkable decline in the Length of Stay (LOS) was shown between the phases (P1:6.82 ± 10.3d; P2:5.68 ± 4.07d; P3:5.60 ± 4.74d) (p = 0.010). Vegetarians (6.54d) had a longer stay compared with non-vegetarians (5.88d) (p = 0.036). Lower BMI correlated negatively with LOS (p = 0.026). Univariant analysis showed a significant increase in LOS with admission history on weight loss (No weight loss = 5.52d, <10% loss = 7.74d, 10-15% = 7.51d, >15% = 8.32 d) (p = 0.001), severe malnutrition (12.67d) and EDONS in shortening the LOS (<6 h = 6.11, 6-12 h = 7.97, 12-24 h = 6.83, >24 h = 17.3 days) (p = 0.000). Multiple Linear regression analysis using ANOVA indicated that EDONS was the only major contributing factor in lowering the LOS (p = 0.002). Re-admission was higher in non ONS group (72%: non ONS; 26%: ONS group) (p = 0.000).

Dietitian-Led multi-professional inter-disciplinary Coalition, bridging the knowledge gap among MDT with regular sensitization about the importance of hospital malnutrition and EDONS, has led to the early identification and intervention of nutrition risk which enhanced progressive decrease in LOS and healthcare cost.