Nutritional Support in the Next Millennium

1
Nutritional Support in the Next Millennium
John P. Grant, MD Director NSS Duke University
Medical Center
2
Executive Summary

• Malnutrition contributes to
• Morbidity
• Mortality
• LOS
• Hospital Cost

3
Executive Summary

• Malnutrition contributes to increased morbidity,
  mortality, LOS, hospital cost.
• Appropriate nutrition support can treat and
  prevent malnutrition and reduce complications.

4
Executive Summary

• Malnutrition contributes to increased morbidity,
  mortality, LOS, hospital cost.
• Appropriate nutrition support can treat and
  prevent malnutrition and reduce complications.
• Malnutrition is common in hospitalized patients.

5
Executive Summary

• On review, most medical centers, including DUMC,
  have inadequate systems for
• Identifying patients at risk of malnutrition, and
  
• Ensuring provision of appropriate nutrition care
  when identified.

6
1997 JCAHO Standards
Most hospitals are not meeting the new standards
for nutrition care

• Nutrition care practices will be standardized
  throughout the hospital.
• When indicated by patients needs
• Nutrition status will be assessed.
• For patients at nutritional risk
• Nutrition care will be planned and implemented.
• Response to nutrition care will be monitored.

7
Executive Summary

• Hospitals are
• Currently absorbing increased costs of care and
  yet not achieving optimal patient outcomes, and

8
Executive Summary

• Hospitals are
• Currently absorbing increased costs of care and
  yet not achieving optimal patient outcomes, and
• Not fulfilling requirements of JCAHO standards
  for nutrition care.

9
Therefore,

• We need to revisit the way
• we provide nutrition care...

10

• Does malnutrition contribute to increased
  morbidity, mortality, LOS, and hospital cost?

11
Morbidity and Malnutrition
Cruse, Arch Surg 107206,1973

• Risk factors for clean wound infections in 23,649
  surgical patients at Foothills Hospital in
  Calgary, Alberta, 1967-1972.
• Risk Increase
• Malnutrition 9.2 x
• Obesity 7.5 x
• Diabetes 5.9 x
• Age gt 50 1.9 x
• Steroids 1.4 x

12
Mortality and Albumin
Reinhardt, JPEN 4357, 1980

• Review of 509 veterans at Hines IL VAMC found a
  linear relationship between 30-day mortality and
  serum albumin concentration. Percent Mortality
  132 - 37.3 Alb

Mortality was decreased in 15 patients who
received 5 or more days of TPN
13
Prognostic Nutrition Index
Buzby, Surg Clin North Am 61465, 1981

• Complications Monitored
• Death Phlebitis
• Septicemia CHF
• Intraabdominal Sepsis MI
• Fistula Formation Resp. Failure
• UTI Atelectasis
• Pneumonia Pulm. Embolus
• Wound Infection CVA
• Wound Dehiscence Shock

14
Prognostic Nutrition Index
Buzby, Surg Clin North Am 61465, 1981

• Correlated standard nutrition assessment with
  patient outcome in 100 veterans undergoing
  elective abdominal surgery.
• PNI() 158 - 16.6 Alb - 0.78 TSF - 0.2
  TFN - 5.8 (DTHR)

15
Prognostic Nutrition Index
Buzby, Surg Clin North Am 61465, 1981

• Prospective study in 161 elective abdominal
  surgery patients demonstrated
• Complications Death
• PNI lt 40 8.0 3.0
• PNI 40-49 30.0 4.3
• PNI ³ 50 46.0 33
• plt.01

16
Malnutrition and MM
Warnold, Ann Surg 199299, 1984

• Nutrition status determined by UBW, IBW,
  AMC, Albumin.
• Compared outcome in 215 non-cancer patients
  undergoing major and minor vascular, and
  abdominal surgery.

17
Malnutrition and MM
Warnold, Ann Surg 199299, 1984

• If two or more assessment parameters were
  abnormal
• Hospital stay was prolonged from 14 to 29 days
  (plt.01).
• Overall frequency of complications increased from
  23 to 48 (plt.01).
• Serious complications increased from 9 to 31
  (plt.01).

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Impact of Malnutrition on LOS and Cost
Robinson, JPEN 1149, 1987
Hospital Charges 16,691
14,118 7,692
plt.01
19
Impact of Malnutrition on LOS, Total Charges, and
Cost of Hospitalization
Reilly, JPEN 12371, 1988
plt.05
20
Impact of Malnutrition on LOS, Total Charges, and
Cost of Hospitalization
Reilly, JPEN 12371, 1988
plt.05
21
Impact of Malnutrition on LOS, Total Charges, and
Cost of Hospitalization
Reilly, JPEN 12371, 1988

• For every DRG, the presence of malnutrition
  increased the mean LOS (1.1 to 12.8 excess days).
• Average hospital cost increased by 1,738 and
  charges by 3,557 per patient.
• A complication in a malnourished patient
  increased cost/charges by 2,996/6,157.

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Degree of Malnutrition and LOS
Messner, Gastroenterol Nurs 13202, 1991 COPD,
Cancer, Cardiovascular Disease, Alcoholism
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Degree of Malnutrition and LOS
Shaw-Stiffel, Nutrition 9140, 1993

• 245 general surgery patients, 131 were found
  malnourished by Alb lt 3.2 and recent weight loss
  gt 10 (53).
• Colon Ca, Perforated Diverticular Disease, SBO,
  Gastric or Eso Ca.
• LOS
• Normal 16.5 10.7
• Malnourished 23.5 16.5

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Degree of Malnutrition and LOS
Chima, J Am Diet Assoc 97975, 1997

• 173 medical patients in Metro Health Center,
  Cleveland, Ohio
• LOS Hosp cost Self care
• MN 6d 6,196 41
• Normal 4d 4,563 66
• p lt .05

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Impact of Malnutrition on LOS and Total
Hospitalization Charges
Lavernia et al., J Am Coll Nutr 18271, 1999
119 pts underwent hip or knee replacement

• LOS Hospital charges
• Alb lt3.4 8.6d 50,108
• Alb gt3.4 5.2d 33,720
• TLC lt1200 5.7d 42,098
• TLC gt 1200 5.4d 32,544

p lt 0.005
26

• Can appropriate nutrition support treat and
  prevent malnutrition and reduce complications?

27
Anorexia NervosaSerial Assessments
250
200
150
Albumin x 10
Transferrin mg
100
Weight pounds
50
0
1
3
5
7
9
11
13
Weeks
28
Crohns Disease
29
Enterocutaneous Fistulas
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Impact of Refeeding on MM
MacLean, Ann Surg 186241, 1977

• 204 patients tested for DTHR to common antigens
  preoperatively
• Pts Sepsis Death
• Anergic 12 17 33
• Normal 192 4 3

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Impact of Refeeding on MM
MacLean, Ann Surg 186241, 1977

• 60 anergic patients were given nutrition support
  preoperatively and re-tested for DTHR to common
  antigens.
• Pts Sepsis Death
• Anergic 30 63 67
• Normal 30 47 6.7

32
Impact of Refeeding on MM
Buzby, Surg Clin North Am 61465, 1981

• Prospective non-randomized study of 161 patients
  who, by physician preference, received 7-10 days
  of TPN prior to elective abdominal surgery or
  not.

33
Nutrition Support in Burn Patients
Weinsier, J Burn Care Rehab 6436, 1985

• Impact of nutrition support in 70 malnourished
  patients with 20 or more body surface burn.
• Wt loss LOS Cost
• 5 Dextrose 13 36 24,200
• Nutrition 3 29 17,800

plt.02
34
Postoperative Nutrition Support
Askanazi, Ann Surg 203236, 1986

• 35 non-malnourished patients after radical
  cystectomy for cancer were randomized to receive
  7 days 5 dextrose or 7 days TPN postoperatively.
• Ave. Hosp Days
• 5 Dextrose 24
• TPN 17 (plt.002)

35
VAMC Multicenter Study of Preoperative TPN
VA Trial, N Engl J Med 325525, 1991

• 395 malnourished GT patients were randomized to
  receive either 7-15 days of TPN or early surgery.
• Pts Complications
• TPN 130 19.2
• No TPN 265 36.6

p lt .0005
36

• How common is malnutrition in hospitalized
  patients?

37
Prevalence of Malnutrition

• Blackburn, JAMA 230858, 1974
• 50 incidence in New England Deaconess Hospital,
  Boston
• Mullen, JPEN 139, 1977
• 40 incidence in surgical patients at
  Philadelphia VAMC
• Willcutts, JPEN 125, 1977
• 65 incidence in community hospital, Mass
• Coats, J Am Diet Assoc 9327, 1989
• 46 of general medicine patients in teaching
  hospital

38
Prevalence of Malnutrition

• VA Clinical Trial, N Engl J Med 325525, 1991
• 34 GT surgery patients
• Shaw-Stiffel, Nutrition 9140, 1993
• 53 general surgery patients Bridgeport Hosp,
  Conn
• Guo, Br J Oral Maxillofac Surg 34325, 1996
• 35 in HN Cancer patients in Beijing, China
• Chima, J Am Diet Assoc 97975, 1997
• 32 of medical patients in Metro Health Center,
  Cleveland, Ohio

39
Duke Nutrition Service

• In a one month period in 1997
• Pts At Risk
• Medical 318 32
• Surgical 209 31
• Women/Peds 133 21
• 194 patients found at risk were recommend to
  undergo a full nutritional assessment.

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Progression of Malnutrition
Weinsier, Am J Clin Nutr 32418, 1979

• 134 consecutive admissions to general medicine
  service at University of Alabama, Birmingham,
  underwent initial nutrition assessment and again
  at 2 weeks, if still hospitalized.
• 48 were initially malnourished.
• 69 were malnourished at 2 weeks.

41
Progression of Malnutrition
Federer, Am Diet Assoc, 1968

• Up to 70 of patients transferred from hospitals
  to long-term care facilities have evidence of
  malnutrition.

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• Does your hospital have an effective system to
  identify malnourished patients?

43
Duke Nutrition Service

• Current method is an admission nutrition screen
  by the Nutrition Service (ward dietitians).
• Evaluated if a high risk diagnosis, high risk
  dietary order (cl liq, npo), or answer yes to
  any of the nutrition questions on the Universal
  Nursing Admission Form.

44
Duke Nutrition Service

• Assessment is primarily a global evaluation and
  chart review.
• Assessment is hit and miss depending on
  available chart data and dietitian time.

45
DRG Coding by Medical Records

• In 1996, of 25,961 discharges, only 81 patients
  were coded as malnourished at the time of
  discharge.

46
DRG Coding by Medical Records

• In 1996, of 25,961 discharges, only 81 patients
  were coded as malnourished at the time of
  discharge.
• In 1997, of 26,386 discharges, 105 patients were
  coded as malnourished at the time of discharge.

47
DRG Coding by Medical Records

• Assuming a 40 rate of malnutrition, DUMC fails
  to identify and report approximately 10,000
  cases/year of malnutrition present at the time of
  discharge.

48
DRG Coding by Medical Records

• Assuming a 40 rate of malnutrition, DUMC fails
  to identify and report approximately 10,000
  cases/year of malnutrition present at the time of
  discharge.
• When malnutrition is recorded as a comorbid
  condition, DRG reimbursement increases by an
  average of 2,436 per patient.

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DRG Coding by Medical Records

• Failure to recognize and document malnutrition at
  DUMC results in an loss in revenue of up to
• 10,000 Pts X 2,436/Pt
• 24,360,000 / year !
• Note Multiple comorbidities reduce individual
  payments.

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• Is there a system in place in your hospital to
  ensure provision of appropriate nutrition care if
  patients are identified as malnourished?

51
Duke Nutrition System

• There are over 51 different functional units
  providing nutrition care to DUMC patients.

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Duke Nutrition Service (Dietary Services) Sarah
W. Stedman Center for Nutritional
Studies Geriatric Research Education and Clinical
Center Rice Diet Program/Heart Disease Reversal
Clinic Duke Center for Living Diet and Fitness
Center Comprehensive Adult Diabetes
Program Comprehensive Cancer Center Endocrinology
Clinic Maternal-Fetal Medicine/High Risk
Clinic Cystic Fibrosis Center Lenox Baker
Childrens Hospital Rehabilitation
Center Dialysis Unit Clinical Research
Unit Pediatric Nutrition Service Adult Nutrition
Service
53
Duke Nutrition System

• There are over 51 different functional units
  providing nutrition care to DUMC patients.
• There is no coordination between these units or
  between inpatient and outpatient nutrition care.

54
Duke Nutrition System

• There are over 51 different functional units
  providing nutrition care to DUMC patients.
• There is no coordination between these units or
  between inpatient and outpatient nutrition care.
• There is no continuity of care, even during
  extended medical illnesses.

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Results of Current System

• Due to suboptimal recognition, recording, and
  treatment of malnutrition, the health system is
• Absorbing increased cost of care
• Failing to receive appropriate reimbursement
• Not obtaining optimal patient outcome

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Proposal

• Establish Clinical Nutrition
• as a well funded programin most hospitals

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Program Structure
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Clinical Nutrition Program Purpose

• Nutrition care should be seen as a continuum.

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Nutrition Care as a Continuum

• Nutrition evaluation and care should begin with a
  patients initial contact with the health system.
• It should encompass outpatient management,
  inpatient care, and home based care, as needed.

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Clinical Nutrition Program Purpose

• Nutrition care should be seen as a continuum.
• Nutrition care should be patient centered.

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Patient Centered Care

• Care should focus on
• Enhanced quality of life
• Complication avoidance
• Maximization of functional outcome
• Cost containment
• And patient/family satisfaction

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Clinical Nutrition Program Purpose

• Nutrition care should be seen as a continuum.
• Nutrition care should be patient centered.
• Nutrition care should incorporate
  multidisciplinary expertise.

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Multidisciplinary Expertise

• Primary Care Physicians
• Nurses
• Pharmacists
• Dietitians
• Social Workers
• Home Care Providers

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Outpatient Activity
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Inpatient Activity
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Clinical Nutrition Program Activities

• Develop and implement a program for nutritional
  screening of all patients in the health system.

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Clinical Nutrition Program Activities

• Develop and implement a program for nutritional
  screening of all patients in the health system.
• All malnourished patients should be appropriately
  coded in the medical record to achieve optimal
  DRG reimbursement.

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Clinical Nutrition Program Activities

• Whenever possible, nutritional repletion should
  be undertaken early, especially prior to elective
  hospitalization.

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Clinical Nutrition Program Activities

• Ensure that nutrition care is given in the most
  cost effective and risk-free manner
• Dietary Modifications
• Nutrition Supplements
• Enteral Nutrition (gastric vs jejunal)
• Total Parenteral Nutrition

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Clinical Nutrition Program Activities

• Work to minimize complications of nutrition
  support
• Sepsis
• Nutrient Intolerance
• Fluid and Electrolyte Imbalances
• Nutrient Deficiencies
• Mechanical Problems

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Clinical Nutrition Program Activities

• Facilitate transition of patients into the
  outpatient/home setting -- coordinate nursing,
  social work, physical therapy, and physician
  management with nutrition care.
• To include
• Home Total Parenteral Nutrition
• and Home Enteral Nutrition

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Conclusion

• Craftsman Analogy

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The Craftsman
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A Portal to the Millennium
Clinical Nutrition Program

• There is a major opportunity for a quantum jump
  in quality of health care if we more
  appropriately address and improve nutritional
  evaluation and status of our patients.

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A Portal to the Millennium
Clinical Nutrition Program

• We can be more effective health care providers if
  we can secure healthier patients to apply our
  judgment and skills.
• The new health care environment will eventually
  force this move. We now have an opportunity to be
  the leaders and garner the benefits for our
  patients.

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Nutritional Support in the Next Millennium
John P. Grant, MD Director NSS Duke University
Medical Center