Fighting to end malnutrition in the hospital

Dr. Melissa Parkhurst, a hospitalist at the University of Kansas Hospital in Kansas City, is on a mission. She wants to get hospitalists around the country to pay more attention to patient malnutrition and to begin taking a systematic approach to recognizing and treating it.

An estimated one in three patients enters the hospital malnourished, and some only get worse during their inpatient stay, according to the Alliance to Advance Patient Nutrition. "Hospital malnutrition is a serious yet underappreciated problem," Dr. Parkhurst said. "It can delay recovery and increase a patient’s length of stay."

Dr. Parkhurst, who has been the medical director for the multidisciplinary Nutrition Support Service at the University of Kansas Hospital since 2002, is also part of a new organization focused on addressing nutrition and malnutrition in the hospital setting. She serves as the Society of Hospital Medicine’s representative to the Alliance to Advance Patient Nutrition. The organization, which formed in May, has released an online toolkit for health care providers. The Alliance is also introducing a nutrition care model designed to foster greater collaboration among clinicians and drive early nutrition screening, intervention, and discharge processes in hospitals.

In an interview with Hospitalist News, Dr. Parkhurst explained the hospitalist’s role in curbing patient malnutrition.

Question: Who is at risk? Should all patients be screened?

Dr. Parkhurst: In 1996, the Joint Commission required hospitals to have a program in place to provide nutrition screening within 24 hours of patient admissions. But they didn’t dictate how to perform the screen.

The screening can’t be simply a visual assessment of the patient. That’s not adequate. There are several simple, validated screening tools that health care providers can use. The Malnutrition Screening Tool, or MST, for example, is made up of just two simple questions that any health care provider can ask: Have you lost weight recently without trying? Have you been eating poorly because of a decreased appetite?

Obviously, many patients with both acute and chronic illnesses could screen positive, and then we need to perform a full assessment. But in particular, geriatric patients are often nutritionally fragile.

Question: What is the hospitalist’s role in this process?

Dr. Parkhurst: Hospitalists should always be aware of the nutritional status of their patient. They should know basic screening questions that they can incorporate into their history taking. They also need to know where to find the nutrition screening and assessments that are done on their patients in the hospital.

It is good to get to know the hospital’s dietitians and make them aware that you are reviewing their recommendations and that you would like their professional input on your patient. There’s also data gathering involved, such as calorie and protein count, keeping track of whether or not your patient is actually consuming the food and supplements that you ordered, and knowing if they are tolerating the tube feed that you ordered. Finally, hospitalists should be incorporating nutrition into daily rounds and notes and in conversations with patients and their families.

Question: You’re part of the Nutrition Support Service at your hospital. How does it work?

Dr. Parkhurst: Nutrition support teams can look very different from hospital to hospital. The main focus for our nutrition team at the University of Kansas is to provide safe and high-quality nutrition care to our parenteral nutrition patients. We also have a large presence in our intensive care units and take on the care of patients who have complex transitions from parenteral to enteral nutrition care.

Nutrition support teams are best when they are multidisciplinary. Our team has registered dietitians, myself as medical director, pharmacists, and a nurse. We have developed everything from parenteral nutrition hyperglycemia management protocols to proper flushing and declogging of feeding tubes to the placement of small bowel feeding tubes. These are system and quality improvement projects that we’ve been able to work on over the years because we are multidisciplinary. I personally oversee the daily parenteral nutrition care of the patients on the adult side, but our group gets together for patient care rounds and discussions twice a week.

Question: Should every hospital have a multidisciplinary nutrition support team?

Dr. Parkhurst:Our hospital works well with a nutrition support team because we have a very complex patient population. Multidisciplinary nutrition support teams like ours often exist at the larger academic centers. What’s most important for hospitals overall is to have multidisciplinary champions. It doesn’t necessarily need to be a formal team, but instead a champion physician, champion nurse, and champion dietitian to work together.

Often the dietitians at the hospital will know where the patient needs are, but what they need most are partners and a voice to the rest of the hospital. For example, at the University of Kansas Hospital, one of the important steps we took as a team was to get ordering privileges for our registered dietitians. This way they could order calorie counts, supplements, and multivitamins and move along the plan of care instead of leaving notes and waiting for orders to be implemented.

Question: What can be done to better treat patient malnutrition in the hospital?

Dr. Parkhurst: The Alliance to Advance Patient Nutrition is at its core a call to action. We’re trying to get the attention of physicians, dietitians, nurses, pharmacists, and hospital administrators. What we’re advocating for are more systemized nutrition care practices and more interdisciplinary collaboration.

There are three basic things that need to happen in order to drive real change in a hospital setting:

First, we need to make sure that all of our patients are getting screened for risk when they are admitted using a simple, validated screening tool.

Second, there needs to be a system in place so that when there’s a positive screen it prompts a timely, full nutrition assessment by a dietitian. And then that information and recommendations need to be effectively communicated back to the patient’s health care team so that there can be immediate interventions as indicated. Ongoing monitoring also needs to be part of that systemized approach.

Third, we need to integrate the nutrition care plan into the discharge plan. We need to ensure that the goals and improvements we make in the hospital don’t get lost in the transition of care.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected].

Dr. Melissa Parkhurst, a hospitalist at the University of Kansas Hospital in Kansas City, is on a mission. She wants to get hospitalists around the country to pay more attention to patient malnutrition and to begin taking a systematic approach to recognizing and treating it.

An estimated one in three patients enters the hospital malnourished, and some only get worse during their inpatient stay, according to the Alliance to Advance Patient Nutrition. "Hospital malnutrition is a serious yet underappreciated problem," Dr. Parkhurst said. "It can delay recovery and increase a patient’s length of stay."

Dr. Parkhurst, who has been the medical director for the multidisciplinary Nutrition Support Service at the University of Kansas Hospital since 2002, is also part of a new organization focused on addressing nutrition and malnutrition in the hospital setting. She serves as the Society of Hospital Medicine’s representative to the Alliance to Advance Patient Nutrition. The organization, which formed in May, has released an online toolkit for health care providers. The Alliance is also introducing a nutrition care model designed to foster greater collaboration among clinicians and drive early nutrition screening, intervention, and discharge processes in hospitals.

In an interview with Hospitalist News, Dr. Parkhurst explained the hospitalist’s role in curbing patient malnutrition.

Question: Who is at risk? Should all patients be screened?

Dr. Parkhurst: In 1996, the Joint Commission required hospitals to have a program in place to provide nutrition screening within 24 hours of patient admissions. But they didn’t dictate how to perform the screen.

The screening can’t be simply a visual assessment of the patient. That’s not adequate. There are several simple, validated screening tools that health care providers can use. The Malnutrition Screening Tool, or MST, for example, is made up of just two simple questions that any health care provider can ask: Have you lost weight recently without trying? Have you been eating poorly because of a decreased appetite?

Obviously, many patients with both acute and chronic illnesses could screen positive, and then we need to perform a full assessment. But in particular, geriatric patients are often nutritionally fragile.

Question: What is the hospitalist’s role in this process?

Dr. Parkhurst: Hospitalists should always be aware of the nutritional status of their patient. They should know basic screening questions that they can incorporate into their history taking. They also need to know where to find the nutrition screening and assessments that are done on their patients in the hospital.

It is good to get to know the hospital’s dietitians and make them aware that you are reviewing their recommendations and that you would like their professional input on your patient. There’s also data gathering involved, such as calorie and protein count, keeping track of whether or not your patient is actually consuming the food and supplements that you ordered, and knowing if they are tolerating the tube feed that you ordered. Finally, hospitalists should be incorporating nutrition into daily rounds and notes and in conversations with patients and their families.

Question: You’re part of the Nutrition Support Service at your hospital. How does it work?

Dr. Parkhurst: Nutrition support teams can look very different from hospital to hospital. The main focus for our nutrition team at the University of Kansas is to provide safe and high-quality nutrition care to our parenteral nutrition patients. We also have a large presence in our intensive care units and take on the care of patients who have complex transitions from parenteral to enteral nutrition care.

Nutrition support teams are best when they are multidisciplinary. Our team has registered dietitians, myself as medical director, pharmacists, and a nurse. We have developed everything from parenteral nutrition hyperglycemia management protocols to proper flushing and declogging of feeding tubes to the placement of small bowel feeding tubes. These are system and quality improvement projects that we’ve been able to work on over the years because we are multidisciplinary. I personally oversee the daily parenteral nutrition care of the patients on the adult side, but our group gets together for patient care rounds and discussions twice a week.

Question: Should every hospital have a multidisciplinary nutrition support team?

Dr. Parkhurst:Our hospital works well with a nutrition support team because we have a very complex patient population. Multidisciplinary nutrition support teams like ours often exist at the larger academic centers. What’s most important for hospitals overall is to have multidisciplinary champions. It doesn’t necessarily need to be a formal team, but instead a champion physician, champion nurse, and champion dietitian to work together.

Often the dietitians at the hospital will know where the patient needs are, but what they need most are partners and a voice to the rest of the hospital. For example, at the University of Kansas Hospital, one of the important steps we took as a team was to get ordering privileges for our registered dietitians. This way they could order calorie counts, supplements, and multivitamins and move along the plan of care instead of leaving notes and waiting for orders to be implemented.

Question: What can be done to better treat patient malnutrition in the hospital?

Dr. Parkhurst: The Alliance to Advance Patient Nutrition is at its core a call to action. We’re trying to get the attention of physicians, dietitians, nurses, pharmacists, and hospital administrators. What we’re advocating for are more systemized nutrition care practices and more interdisciplinary collaboration.

There are three basic things that need to happen in order to drive real change in a hospital setting:

First, we need to make sure that all of our patients are getting screened for risk when they are admitted using a simple, validated screening tool.

Second, there needs to be a system in place so that when there’s a positive screen it prompts a timely, full nutrition assessment by a dietitian. And then that information and recommendations need to be effectively communicated back to the patient’s health care team so that there can be immediate interventions as indicated. Ongoing monitoring also needs to be part of that systemized approach.

Third, we need to integrate the nutrition care plan into the discharge plan. We need to ensure that the goals and improvements we make in the hospital don’t get lost in the transition of care.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected].

Dr. Melissa Parkhurst, a hospitalist at the University of Kansas Hospital in Kansas City, is on a mission. She wants to get hospitalists around the country to pay more attention to patient malnutrition and to begin taking a systematic approach to recognizing and treating it.

An estimated one in three patients enters the hospital malnourished, and some only get worse during their inpatient stay, according to the Alliance to Advance Patient Nutrition. "Hospital malnutrition is a serious yet underappreciated problem," Dr. Parkhurst said. "It can delay recovery and increase a patient’s length of stay."

Dr. Parkhurst, who has been the medical director for the multidisciplinary Nutrition Support Service at the University of Kansas Hospital since 2002, is also part of a new organization focused on addressing nutrition and malnutrition in the hospital setting. She serves as the Society of Hospital Medicine’s representative to the Alliance to Advance Patient Nutrition. The organization, which formed in May, has released an online toolkit for health care providers. The Alliance is also introducing a nutrition care model designed to foster greater collaboration among clinicians and drive early nutrition screening, intervention, and discharge processes in hospitals.

In an interview with Hospitalist News, Dr. Parkhurst explained the hospitalist’s role in curbing patient malnutrition.

Question: Who is at risk? Should all patients be screened?

Dr. Parkhurst: In 1996, the Joint Commission required hospitals to have a program in place to provide nutrition screening within 24 hours of patient admissions. But they didn’t dictate how to perform the screen.

The screening can’t be simply a visual assessment of the patient. That’s not adequate. There are several simple, validated screening tools that health care providers can use. The Malnutrition Screening Tool, or MST, for example, is made up of just two simple questions that any health care provider can ask: Have you lost weight recently without trying? Have you been eating poorly because of a decreased appetite?

Obviously, many patients with both acute and chronic illnesses could screen positive, and then we need to perform a full assessment. But in particular, geriatric patients are often nutritionally fragile.

Question: What is the hospitalist’s role in this process?

Dr. Parkhurst: Hospitalists should always be aware of the nutritional status of their patient. They should know basic screening questions that they can incorporate into their history taking. They also need to know where to find the nutrition screening and assessments that are done on their patients in the hospital.

It is good to get to know the hospital’s dietitians and make them aware that you are reviewing their recommendations and that you would like their professional input on your patient. There’s also data gathering involved, such as calorie and protein count, keeping track of whether or not your patient is actually consuming the food and supplements that you ordered, and knowing if they are tolerating the tube feed that you ordered. Finally, hospitalists should be incorporating nutrition into daily rounds and notes and in conversations with patients and their families.

Question: You’re part of the Nutrition Support Service at your hospital. How does it work?

Dr. Parkhurst: Nutrition support teams can look very different from hospital to hospital. The main focus for our nutrition team at the University of Kansas is to provide safe and high-quality nutrition care to our parenteral nutrition patients. We also have a large presence in our intensive care units and take on the care of patients who have complex transitions from parenteral to enteral nutrition care.

Nutrition support teams are best when they are multidisciplinary. Our team has registered dietitians, myself as medical director, pharmacists, and a nurse. We have developed everything from parenteral nutrition hyperglycemia management protocols to proper flushing and declogging of feeding tubes to the placement of small bowel feeding tubes. These are system and quality improvement projects that we’ve been able to work on over the years because we are multidisciplinary. I personally oversee the daily parenteral nutrition care of the patients on the adult side, but our group gets together for patient care rounds and discussions twice a week.

Question: Should every hospital have a multidisciplinary nutrition support team?

Dr. Parkhurst:Our hospital works well with a nutrition support team because we have a very complex patient population. Multidisciplinary nutrition support teams like ours often exist at the larger academic centers. What’s most important for hospitals overall is to have multidisciplinary champions. It doesn’t necessarily need to be a formal team, but instead a champion physician, champion nurse, and champion dietitian to work together.

Often the dietitians at the hospital will know where the patient needs are, but what they need most are partners and a voice to the rest of the hospital. For example, at the University of Kansas Hospital, one of the important steps we took as a team was to get ordering privileges for our registered dietitians. This way they could order calorie counts, supplements, and multivitamins and move along the plan of care instead of leaving notes and waiting for orders to be implemented.

Question: What can be done to better treat patient malnutrition in the hospital?

Dr. Parkhurst: The Alliance to Advance Patient Nutrition is at its core a call to action. We’re trying to get the attention of physicians, dietitians, nurses, pharmacists, and hospital administrators. What we’re advocating for are more systemized nutrition care practices and more interdisciplinary collaboration.

There are three basic things that need to happen in order to drive real change in a hospital setting:

First, we need to make sure that all of our patients are getting screened for risk when they are admitted using a simple, validated screening tool.

Second, there needs to be a system in place so that when there’s a positive screen it prompts a timely, full nutrition assessment by a dietitian. And then that information and recommendations need to be effectively communicated back to the patient’s health care team so that there can be immediate interventions as indicated. Ongoing monitoring also needs to be part of that systemized approach.

Third, we need to integrate the nutrition care plan into the discharge plan. We need to ensure that the goals and improvements we make in the hospital don’t get lost in the transition of care.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected].