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Implementation of malnutrition quality improvement reveals opportunities for better nutrition care delivery for hospitalized patients

Abstract Background Gaps in hospital‐based nutrition care practices and opportunities to improve care of patients at risk of malnutrition or malnourished have been demonstrated by several US hospitals implementing quality improvement (QI) projects. This study examined the impact of nutrition care process improvements focused on better documentation of identification and diagnosis of malnutrition in 5 hospital services and differences between nutritionally targeted vs nontargeted services. Methods Data on malnutrition risk screening, nutrition assessment, malnutrition diagnosis, and nutrition care plan delivery were collected from 32,723 hospital encounters for patients admitted to the intensive care unit, pulmonology, oncology, urology, and general medicine services (targeted) as well as the rest of the nontargeted hospital services between 2017 and 2019. Results Higher rates of morbidity in targeted service patients compared with those in the patient population admitted in the nontargeted services were observed, including higher rates of malnutrition risk (37.43% vs 19.16%, P < .001), higher rates of moderate and severe malnutrition first identified by a registered dietitian nutritionist (20.27% vs 9.67%, P < .001), and malnutrition diagnosis confirmed by an admitting physician (16.72% vs 6.74%, P < .001). Conclusions The findings suggest sustained improvements in confirmed rates of malnutrition identification and diagnosis are achievable. Targeting malnutrition QI efforts to hospital services with higher patient morbidity is an effective method for improving malnutrition diagnosis, in particular in hospitals with limited resources, which in turn can result in improved nutrition care delivery.


CLINICAL RELEVANCY STATEMENT
Malnutrition is a common and costly challenge in medical inpatients.
This study analyzed a quality improvement initiative to improve diagnosis of malnutrition. Improvements in the rate of diagnosis were achieved in targeted hospital services. The quality improvement initiative also improved communication as measured by agreement between physician diagnosis and dietitian assessment and improved the rate of nutrition care plan implementation.

BACKGROUND
Implementation of effective nutrition care processes for medical inpatients who are at risk of malnutrition or malnourished have been found to be cost-effective, 1 but such processes are often overlooked and underutilized. Gaps in nutrition care practice result in poor patient outcomes and increased costs. 2,3 A number of US hospitals have demonstrated that nutrition-focused quality improvement (QI) programs or initiatives can be effectively implemented to improve patient care while improving the health and economic outcomes of at-risk/malnourished patients. [4][5][6] Effective implementation of standardized metrics is key to measuring progress and assessing the impact of initiatives on both processes and patient outcomes. [5][6][7] Most reported data have focused on the impact of hospital-or subpopulation-level changes on practice and outcomes, with fewer studies examining QI projects targeted to certain services or subpopulations that may receive the greatest benefit from improved nutrition care.
The Malnutrition Quality Improvement Initiative (MQii) was developed to help hospitals in the US improve nutrition care for patients with malnutrition or at malnutrition risk. 8,9 MQii resources include (1) a toolkit to help hospitals implement best-practice malnutrition care 10 and (2) four malnutrition-focused electronic clinical quality measures (eCQMs). 6 The MQii Toolkit and eCQMs are being used by over 290 hospitals to implement best nutrition care practices as part of QI projects. 6 MQii hospitals collect, analyze, and share data on patient nutrition care and implementation of nutrition-focused QI projects.
UNC Medical Center (UNCMC) is a public, academic teaching hospital with >950 beds, noted for specialties in cardiology, trauma, gastroenterology, nephrology, pulmonology, cancer, neurology, and burn care. 7 As an MQii participant, UNCMC implemented a QI project from 2017 to 2019 focused on completion of nutrition-focused physical assessment of patients at malnutrition risk, improving physician alignment with registered dietitian nutritionist (RDN) assessment, and confirmation with malnutrition diagnosis. Emphasis on implementation of the QI project varied across services. This study evaluated how assessment and diagnosis of malnutrition varied across services.

METHODS
The UNCMC Clinical Nutrition Department partnered with clinical documentation specialists, nurses, and physician champions from across the hospital to assess nutrition care gaps. The team identified improving coordination between RDNs and physicians regarding the confirmation of malnutrition diagnosis when identified by RDNs as an opportunity to improve patient care.
The UNCMC QI team implemented a malnutrition diagnosis education intervention with resident physicians of 5 participating services (intensive care unit [ICU], pulmonology, oncology, urology, and general medicine). The remaining 48 nonparticipating services were categorized as nontargeted services (eg, cardiology, endocrinology).
Malnutrition documentation in the electronic health record (EHR) was modified to include RDN and physician documentation of nutrition status to facilitate better coordination between RDNs and physicians. Staff resources were reorganized and greater effort was made to communicate nutrition assessment results with physicians. No changes were made to UNCMC's process of screening patients by the admitting nurse or the manual nutrition consult request process. Data on malnutrition screening rate, assessment rate of patients at malnutrition risk, confirmation rate of malnutrition diagnosis by physicians, and overall malnutrition diagnosis rate in targeted services were collected via electronic extraction using a data query of the EHR to monitor progress.
The team also addressed nutrition assessment policies for clarity and efficient use of human resources. In 2018, the medical center

Analysis
Descriptive statistics are reported on all variables of interest. Differences across groups were evaluated using χ 2 tests. Results were considered statistically significant if P ≤ .05. All analyses were performed using SAS 9.4.

Indicator Pre-QI baseline (May to August 2017) Post-QI period (July to October 2018 and February to May 2019)
Targeted services 1964 3882 Nontargeted services 8728 18,080 Abbreviation: QI, quality improvement. Key nutrition indicators were also examined at the individual service level (Table 3). Oncology and ICU patients showed the highest nutrition risk before and after the QI project; pulmonology also had a high

DISCUSSION
This nutrition-focused QI project was successful in several aspects. Previous studies have linked early nutrition intervention to shorter hospital stays, reduced infection rates, and reduced unplanned readmission rates. 3,4,15 Effective care coordination between RDNs and physicians is only possible when medical teams have sufficient knowledge and training in nutrition care, a common understanding of the definition of malnutrition, and a mutually defined workflow and EHR functionality. 16 General nutrition education may be lacking among physicians, as studies have found that only 25% of US medical schools provide a dedicated nutrition course. 17 However, physician education in real-world clinical practice settings has been recognized as a feasible approach to improving patient nutrition care. 15 Abbreviations: MD, medical doctor; QI, quality improvement; RDN, registered dietitian nutritionist. *Statistically significant.