Multidisciplinary effort to improve the diagnosis of malnutrition in hospitalized patients

Malnutrition has been increasingly demonstrated to be common and underrecognized in hospitalized patients. Rates have been demonstrated as high as 55%, but the diagnosis of malnutrition has historically been made in only a minority of inpatients. Laboratory studies, including serum prealbumin level, have been shown to have poor predictive value of malnutrition. In 2014, our institution embarked on a system-wide effort to improve diagnosis of malnutrition in hospitalized patients. We adopted the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) Clinical Characteristics and implemented the Nutrition-Focused Physical Exam/Assessment into clinical practice. Dietitians recorded malnutrition diagnoses in a flow sheet in the electronic medical record (EMR) and alerted the primary team when a patient met criteria for malnutrition. An editable link to malnutrition diagnosis was created in the discharge summary templates in the EMR. Over 4 years, these efforts led to an increase in our rate of diagnosis of malnutrition from 6% to 12%, which was sustained over the last 2 years. We also found that the percentage of inpatients having serum prealbumin levels checked decreased from 13% to 8% over the study period. We found that a system-wide, stepwise approach to improving our diagnosis of inpatients with malnutrition was effective and appears sustainable over the period studied. We noted a behavior change for providers in both documenting the condition and decreasing their utilization of laboratory studies as part of their clinical diagnostic workup, thus avoiding unnecessary laboratory draws and leading to potential cost saving.