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Malnourished U.S. inpatients often go untreated



– Hospital staffs often fail to treat malnourished, recently admitted patients with supplemental nutrition.

A retrospective review of more than 150,000 patients admitted during a single year at any center within a large, multicenter U.S. hospital system found that even when patients receive oral nutritional supplementation, there is often a substantial delay to its onset.

The data also suggested potential benefits from treating malnutrition with oral nutritional supplementation (ONS). Patients who received ONS had a 10% relative reduction in their rate of 30-day readmission, compared with malnourished patients who did not receive supplements after adjusting for several baseline demographic and clinical variables, Gerard Mullin, MD, said at the annual Digestive Disease Week. His analysis also showed that every doubling of the time from hospital admission to an order for ONS significantly linked with a 6% rise in hospital length of stay.

Mitchel L. Zoler/MDedge News

Dr. Gerard Mullin

The findings “highlight the importance of malnutrition screening on admission, starting a nutrition intervention as soon as malnutrition is confirmed, and treating with appropriate ONS,” said Dr. Mullin, a gastroenterologist at Johns Hopkins Medicine in Baltimore and director of the Celiac Disease Clinic. A standard formulation of Ensure was the ONS routinely used at the Johns Hopkins hospitals

“We’re missing malnutrition,” Dr. Mullin said in an interview. The hospital accreditation standards of the Joint Commission call for assessment of the nutritional status of hospitalized patients within 24 hours of admission (Jt Comm J Qual Patient Saf. 2015 Oct;41[10]:469-73). Screening is “not uniformly done,” and when malnutrition is identified, the finding must usually pass through several layers of a hospital’s medico-bureaucratic process before treatment actually starts, he noted. Plus, there’s often dismissal of the importance of intervention. “It’s important to treat patients with ONS sooner than later,” he said.

Dr. Mullin and his associates studied hospital records for 153,161 people admitted to any of the Baltimore-area hospitals in the Johns Hopkins system during October 2016 through the end of September 2017. The hospital staff routinely assessed nutritional status of patients after admission with a two-question screen based on the Malnutrition Screening Tool (Nutrition. 1999 June;15[6]:458-64): Have you had unplanned weight loss of 10 pounds or more during the past 6 months? Have you had decreased oral intake over the past 5 days? This identified 30,284 (20%) who qualified as possibly malnourished by either criterion. The researchers also retrospectively applied a more detailed screen to the patient records using the criteria set by an international consensus guideline committee in 2010 (J Parenter Enteraal Nutr. 2010 Mar-Apr;34[2]:156-9). This identified 8,713 of the hospitalized patients (6%) as malnourished soon after admission. Despite these numbers a scant 274 patients among these 8,713 (3%) actually received ONS, Dr. Mullin reported. In addition, it took an average of 85 hours from the time of each malnourished patient’s admission to when the ONS order appeared in their record.

Dr. Mullin conceded that both the association his group found between treatment with ONS and a reduced rate of 30-day readmission to any of the hospitals in the Johns Hopkins system, and the association between a delay in the time to the start of ONS and length of stay may have been confounded by factors not accounted for in the adjustments they applied. But he maintained that the links are consistent with results from prior studies, and warrant running prospective, randomized studies to better document the impact of ONS on newly admitted patients identified as malnourished.

“We need more of these types of studies and interventional trials to show that ONS makes a difference,” Dr. Mullin said.

The study was sponsored by Abbott, which markets the oral nutritional supplement Ensure. Dr. Mullin had no additional disclosures.

On Twitter @mitchelzoler

SOURCE: Source: Mullin G et al. DDW 2018 presentation 883.

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