Background:
Malnutrition affects up to 30% of inpatients, but is rarely diagnosed. This leads to under-treatment and poor patient outcomes including: infections, pressure ulcers, and poor wound healing. In the MS-DRG system, malnutrition is considered either a major complication/comorbidity (MCC) or a complication/comorbidity (CC), depending on specificity and severity. Therefore, missed diagnoses significantly impact patient case severity and reimbursement. Screening criteria from the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition (AND/ASPEN) can accurately identify patients with moderate and severe protein-calorie malnutrition.
Purpose:
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To increase the frequency with which inpatients with positive malnutrition screenings receive malnutrition diagnoses.
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To increase the frequency with which coded malnutrition diagnoses are concordant with the dietitian malnutrition screening.
Description:
Our institution created a team to improve diagnosis of inpatient malnutrition, led by a registered dietitian, and including dietitians, hospitalists, nurses, documentation improvement specialists, and information technology analysts. A successful dietitian malnutrition screening project had already been completed and focused on implementing a malnutrition screening process to be completed by dietitians. The team identified opportunities for improvement, including: resident and attending physician education on malnutrition screening and diagnosis; communication of positive screens between dietitian and physician; physician documentation of coding terminology; and improved queries from clinical documentation staff. The team then performed multiple Plan-Do-Study-Act (PDSA) cycles to address these areas. These cycles included creating educational materials, creating a physician note template tying the dietitian’s screening to the concordant diagnosis language, and having dietitians update patient problem lists and add attendings as co-signers to their notes. An automated report of patients with positive screens was distributed at a pre-existing twice-weekly coding “huddle,” which includes clinical documentation improvement specialists, attendings, and residents. Preliminary data shows that immediately prior to implementation of the automated report, 49.5% of medicine inpatients with positive dietitian malnutrition assessments had concordant ICD diagnoses, which improved to 70.5% post-implementation (p = 0.012, 95% CI for the difference 6.49 – 35.51).
Conclusions:
Malnutrition is a common and often undiagnosed co-morbidity in the inpatient population. We have shown that an interdisciplinary approach to improve the recognition and communication of malnutrition can have a significant impact on the rates of diagnosis. We believe that this will lead to improved treatment, patient outcomes, and hospital quality metrics.