Global Malnutrition Composite Score for IQR

The Global Malnutrition Composite Score quality measure is now available for 2024 hospital reporting.

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The Malnutrition Quality Improvement Initiative
The MQii is designed to help your organization improve
malnutrition care and subsequently achieve better outcomes.

MQii Toolkit / Select Your Quality Improvement Focus

Identify and Select Your Clinical Improvement(s) to Implement

Once your existing workflow is well understood by team members, compare the recommended best practices for malnutrition care to the existing workflow processes you just mapped. Assessing where there are differences or gaps compared to your current workflow may help identify more specific areas to target for improvement. The recommended clinical workflow and related best practices presented in this section are based on existing consensus-based, clinical guidance documents from professional societies and research results at leading hospitals.

Example: Evaluate whether templates used for patient intake include a section for recording results of a malnutrition screening. If these documents are separate, it creates an additional step for nurses during patient intake and may decrease the likelihood that screening results get captured in the patient record. Addressing this documentation issue would be an improvement your care team can implement for this initiative.

Key Steps for Identifying your Quality Improvement Focus

  1. Create a workflow map of existing malnutrition care practices
  2. Compare your current malnutrition care workflow to recommended care practices to identify where improvement efforts would be most beneficial
  3. Identify an improvement activity to address gaps or optimize your facility’s malnutrition care workflow
You do not need to implement improvements for every component of the recommended malnutrition care workflow at once. Focus your initial efforts on areas that offer the biggest opportunity for change and are most feasible for your organization to implement. Once you have implemented one improvement, you can use your learnings to tackle the other components in an organized fashion.

Malnutrition Screening

  1. Responsible team member
    • Nurse or qualified care team member
  2. Definition
    • The systematic process of identifying an individual who is malnourished or who is at risk for malnutrition to establish whether the patient is in need of a nutrition assessment[20]. Initial patient screening should occur within 24 hours of hospital admission.
  3. Data sources/tools
    1. Validated screening tools such as the Malnutrition Screening Tool (see: List of Validated Malnutrition Screening Tools)[21], or some other valid and reliable screening tool
    2. Medical or health records
    3. Patient/family interviews to obtain additional history
    4. Attending physician referral form
  4. Data to collect and record
    1. Assessment of recent weight loss[21]
    2. Assessment of decreased appetite[22]
    3. Height
    4. Weight
  5. Malnutrition screening and follow-up steps
    • Screen patient with screening tool[22]
    • Score patient to determine risk[22]
    • Document results of patient screening in the EHR
    • For patients determined to be at risk for malnutrition refer immediately (within 24 hours) for nutrition consult and assessment[22]
    • For patients determined to be at risk for malnutrition during screening, expedite nutrition intervention within 24 hours with food and/or oral nutrition supplement per malnutrition-risk protocol to accelerate treatment, unless contraindicated
    • Consult patient and/or family caregiver, or refer to information in the patient’s medical record, regarding diet restrictions, difficulties swallowing, and preferences when issuing the malnutrition-risk diet order
  6. Decision points for continuation of care
    • If the patient is determined to be at risk for malnutrition from either the initial or a secondary screening test during hospital stay, a nutrition assessment is needed[21]

Best Practices

  1. Screening is recommended to be conducted by a qualified nurse but can be conducted by any qualified member of the care team vii
  2. Use a validated tool in the screening for malnutrition in a standardized way consistent with the recommendations from tool developers[23] 
  3. Establish a policy to order a nutrition consult and assessment for all patients at nutritional risk
  4. Establish policy and protocol to feed patients within 24 hours of malnutrition screen where patient is determined to be “at risk”
  5. Screen surgical patients upon admission for malnutrition who have not received a malnutrition screening (as evidenced by the medical record) within 7 days prior to admission
  6. Complete malnutrition screening 24 hours prior to surgery for patients who are NPO and screen again within 24 hours following surgery
  7. Rescreening patients
    • Within 72 hours, rescreen patients age 65+ years who are at high-risk for malnutrition due to chronic conditions including stroke, COPD, diabetes, and certain cancers
    • Rescreen every seven days if the overall length of stay allows for it[22]
  8. Leverage EHR to standardize malnutrition documentation, facilitate clinical flow, and build in advisory or reminders
    • Install a validated malnutrition screening tool into the nurses’ workflow and where other admission processes are housed

Examples of Validated Malnutrition Screening Tools

Birmingham Nutrition Risk (BNR)
Malnutrition Screening Tool (MST)[21]
Malnutrition Universal Screening Tool (MUST)
Mini Nutrition Assessment (MNA)
Nutrition Risk Classification (NRC)
Nutritional Risk Index (NRI)
Nutrition Risk Assessment (NRS-2022)
Short Nutrition Assessment Questionnaire (SNAQ)

Sample PDSA Cycle: Malnutrition Screening

Project: Elevating the Importance of Malnutrition Screening on the Surgical Unit

Objective of this PDSA cycle: Test an intervention to improve rates of completion of malnutrition screening using a validated tool for all admitted adult patients.

Plan:

Questions: What is the biggest reason that malnutrition screening isn’t completed within 24 hours of admission?

Predictions: Educating the nursing staff on the importance of malnutrition screening will improve the rates of completion.

Plan for change: In the baseline data collection and workflow assessment phase, the project team learned that the nurses on the surgical unit did not realize that completing the malnutrition screening was a required component of the admissions process. Further, the project team member from that unit reported that staff members were not aware that completion of the screening was the trigger in the EHR to automatically consult a dietician for a full nutrition assessment. This project will test the success of a nursing unit-based in-service educating the nursing teams on the importance of completing the malnutrition screening in the EHR upon admission to a unit.

Do:

Carry out the change: Develop education & training materials and train each nursing unit educator on the materials.

  • Develop a short PowerPoint presentation that can be used to train the nurse educators and also used by the educators to train the nursing staff. Also consider developing “reminder aids” such as flyers that can be posted in nursing unit staff break rooms or stickers that can be put on workstations where nurses complete their EHR documentation.
  • Keep a training log to track completion of the training by nursing staff
  • Track completion rates for malnutrition screening by unit, before and after the training intervention

Study:

Complete analysis of data

  • Debrief: Analyze the data to look for improvement between the pre- and post-training intervention. How much did the training impact results?  Were there commonalities between patients (e.g., patient types, hospital location, time of admission) who still did not receive the malnutrition screening?

Verify predictions

  • How closely did the results of this cycle match the prediction that was made earlier?
  • Summarize any new knowledge gained by completing this cycle. For example, once nurses were educated on the importance of the screening and that it wasn’t just trivial admission paperwork, rates went up dramatically. However, screening remained low for patients who were admitted via the emergency department with altered mental status that impacted their ability to respond to questions.

Act:

Identify actions

  • Consider actions to take as a result of this cycle
  • Continue and/or expand the successful components of this cycle – in this case, education the nursing staff.
  • Identify additional actions to take to address the other potential barriers to optimal screening rates

Nutrition Assessment

  1. Responsible team member
    • Dietitian
  2. Definition
    • Systematic approach to collect and interpret relevant data from patients and family caregivers, to determine a malnutrition diagnosis[1] and severity of malnutrition.
  3. Data sources/tools[24]
    1. Results from initial patient screening
    2. Standardized nutrition assessment tools such as the Subjective Global Assessment[22] (see Standardized Nutrition Assessment Tools for additional tools)
    3. Patient/family caregiver interviews to obtain additional history
    4. Medical or health records
  4. Data to collect and record[1]
    1. Review data collected for factors that affect nutrition and health status, including:
      1. Food and nutrition patient history
      2. Anthropometric measurements
      3. Biochemical data
      4. Physical exam information
      5. Patient history
  5. Nutrition Assessment Steps
    • Conduct nutrition assessment within 24 to 48 hours after malnutrition screening[24]
    • Review data that may impact nutrition or overall health status[1]
    • Consult with other members of the Care team[1]
    • Conduct interview with patient and family caregiver
    • Compare data to a predefined assessment scale
    • On the tool to allow for a determination of what is a healthy score[1]
  6. Decision points for continuation of care[1]
    1. Patients who are not determined to be malnourished do not warrant a malnutrition care plan
    2. Providers may need to consider patient/family decisions around seeking malnutrition treatment, particularly in end-of-life care

Best Practices

  1. Nutrition assessment is recommended to be completed by a dietitian
  2. Complete nutrition assessment for patients at risk of malnutrition within 24 to 48 hours after malnutrition screening[2]
  3. Consider completing a cognitive assessment during the assessment to inform whether a patient can remember and carry out aspects of the care plan
  4. Use a standardized tool to conduct a nutrition assessment in a standardized way consistent with recommendations from the tool developer[1]
  5. Current clinical standards do not recommend the use of serum albumin and prealbumin levels to inform whether a patient is diagnosed as malnourished, noting the limited relevance of laboratory tests of acute-phase protein levels to indicate malnutrition[25]
  6. Consider the patient and their family caregivers as an integral part of the assessment process
  7. Leverage EHR to standardize malnutrition documentation, facilitate clinical workflow, and build in advisory reminders
  8. Utilize a standardized nutrition assessment template for consistent assessment and ease of incorporation into electronic health records
    • Mark the nutrition data in the EHR so it can easily be queried

Standardized Nutrition Assessment Tools

Patient Population

Surgery, Geriatric, Oncology, Renal.

Nutrition Assessment Parameters

Includes medical history (weight, intake, GI symptoms, functional capacity) and physical examination.

Criteria for Risk of Malnutrition

Categorizes patients as:

  • SGA A (well nourished)
  • SGA B (mild-moderate malnutrition)
  • SGA C (severe malnutrition)

More Info
Subjective Global Assessment (SGA)

Patient Population

Oncology, Renal, Stroke.

Nutrition Assessment Parameters

Includes medical history (weight, intake, GI symptoms, functional capacity) and physical examination.

Criteria for Risk of Malnutrition

Categorizes patients as:

  • SGA A (well nourished)
  • SGA B (mild-moderate malnutrition)
  • SGA C (severe malnutrition)

Also provides a numerical score for triaging. Global categories assessed as per SGA.

More Info
Patient Generated Subjective Global Assessment (PG-SGA)

Patient Population

Adult, Elderly, Pediatric.

Nutrition Assessment Parameters

  • Assesses muscle wasting and fat loss
  • Evaluates the presence of edema or fluid accumulation
  • Identifies clinical signs of micronutrient deficiencies and toxicities
  • Measures functional status using handgrip strength dynamometer

Criteria for Risk of Malnutrition

Used for comprehensive assessment especially for micronutrients as the SGA does not assess micronutrients.
Incorporate the assessment of fat and muscle loss.

More Info
Nutrition Focused Physical Exam (NFPE)viii

Sample PDSA Cycle: Nutrition Assessment

Project: Increase efficiency of the RDN workflow.

Objective of this PDSA cycle: Analysis of assessment completion data showed that some patients with short lengths of stay were being discharged prior to the completion of the nutrition assessment.  The objective of this cycle is to provide RDNs with better information on the patients needing a nutrition assessment so that they can prioritize which patients to see first to ensure all patients needing an assessment receive one prior to discharge.

Plan:

Questions: 1. Does providing RDNs with better, more timely information about the patients who need an assessment improve the efficiency of their workflow? 2. What are the key data points needed for RDNs to triage and assess ?

Predictions:Creating a report identifying key patient data that RDNs can run at the beginning of their shift will result in fewer patients discharged prior to the completion of a nutrition assessment.

Plan for change: Who, what, when, where

Collaborate with representatives from the RDN team and the hospital IT team to design the report and process.

  • Project team should include a member of the hospital quality team, an RDN, and an IT representative.
  • Team to design a report from the EHR that 1. RDNs can run on-demand, 2. Includes the key data points needed to identify which patients to see first, and 3. That the IT department can easily create and maintain
  • Team to design the process for how the RDN staff should use the report to order their workflow and educate the full RDN staff on use of the new report

Plan for data collection: Who, what, when, where

  • Track the rates of completion of nutrition assessments for patients identified as malnourished or at-risk
  • Collect feedback from RDNs on the usefulness of the report and any recommendations for improvement

Do:

Carry out the change: 

  • Build the “patients needing nutrition assessment” report
  • RDNs run the report at the beginning of their shift and prioritize patients and their workflow accordingly
  • Track performance results

Study:

Complete analysis of data

  • Debrief: Discuss the utility of the report. Were all necessary data elements on the report? Is the report formatted in an optimal way? How much did the report help in ordering your workday?
  • Verify predictions
  • How closely did the results of this cycle match the prediction that was made earlier?
  • Summarize any new knowledge gained by completing this cycle. For example, limitations in the EHR documentation template during nutrition assessment may prevent accurate capture of assessment completion rates.

Act:

Identify actions

  • List actions to take as a result of this cycle
  • Repeat this test again after making any modifications based on the findings. Plan for the next cycle (adapt change, another test, implementation cycle): Run a second PDSA

Malnutrition Diagnosis

  1. Responsible team member
    • Dietitian or qualified Care team member
  2. Definition
    • The identification of and labeling of a patient’s malnutrition problem that requires independent treatment that may be secondary to the patient’s index hospital admission[1]
  3. Data sources/tools
    1. Results from the most recently completed nutrition assessment[1]
    2. SNOMED, ICD-9, and ICD-10 codes recommended for use in diagnosing patients as malnourished or at risk for malnutrition.
  4. Data to collect and record
    1. There are three distinct components that should be included in determining and recording information in the medical record regarding a malnutrition diagnostic statement[1]:
      1. Description of alterations in a patient’s status
      2. Malnutrition signs and symptoms
      3. Malnutrition etiology
    2. The patient’s diagnosis code should also be captured in the medical record and the “problem list” for the facility to ensure the diagnosis is correctly documented
  5. Malnutrition Diagnosis Steps
    • Record diagnosis in the medical record and the “problem list”
    • Establish possible causes from the nutrition assessment and other patient data
    • Consider conditions unique to the patient that may impact malnutrition status and diagnosis
    • Communicate the diagnosis to the attending physician
    • Communicate the diagnosis to the patient and family or caregiver
    • Address patient and family or caregiver immediate questions
  6. Decision points for continuation of care
    1. Continuation of malnutrition care should only proceed if the provider identifies a malnutrition-related diagnosis[1] and if is in alignment with patient/family wishes, particularly for end-of-life care

Best Practices

  1. The recommendation to add a medical diagnosis should be made by a dietitian and entered into the record by the clinician on the care team with the appropriate qualifications (this will  vary according to state regulations for privileges to diagnose)
  2. The diagnosis should be clear, concise, utilize a standardized set of codes, and take into account the unique needs of the patient[1]
  3. The clinician should clearly state the Problem, Etiology, and Signs & Symptoms supporting the diagnosis.
  4. The diagnosis should be recorded in the patient medical record and the “problem list”
  5. Dietitian must communicate the findings and recommended diagnosis  to the attending physician and agree on a treatment plan.

Providers should select appropriate diagnosis codes to document a malnutrition-related diagnosis in patients’ medical records or in the EHR. The table below provides a list of codes providers can use to indicate a patient’s malnutrition status. However, this is not an exhaustive list and users should verify most recent diagnosis codes from available sources. To determine which codes will also satisfy requirements for the Global Malnutrition Composite Score eCQM, see the Commission on Dietetic Registration’s GMCS resource webpage.

Sample Diagnosis Codes and Code Descriptors to Document a Malnutrition-related Diagnosis in the EHR

SNOMEDCT

238107002Deficiency of macronutrients (disorder)
272588001Malnutrition (calorie)
190602008Moderate protein-calorie malnutrition (weight for age 60-74% of standard)
190603003Mild protein-calorie malnutrition (weight for age 75-89% of standard)
360549009Severe protein-calorie malnutrition (Gomez: less than 60% of standard weight)
190605005Mild protein energy malnutrition (disorder)
190606006Moderate protein energy malnutrition
65404009Undernutrition – Malnutrition
70241007Nutritional Deficiency – Malnutrition
238107002Deficiency of macronutrients (disorder)
665128014Malnutrition (calorie) (disorder)
407752010Malnutrition (Calorie)
2920802017Malnutrition, calorie

LOINC

54816-4

Protein or calorie malnutrition or at risk for malnutrition in last 7 days

75305-3

Nutrition status

ICD-9

260

Kwashiorkor

261

Nutritional marasmus

262

Other severe protein-calorie malnutrition

263

Malnutrition of moderate degree

263.8

Other protein-calorie malnutrition

263.9

Unspecified protein-calorie malnutrition

799.4

Cachexia

ICD-10

E40

Kwashiorkor

E41

Nutritional marasmus

E42

Marasmic kwashiorkor

E43

Unspecified severe protein-calorie malnutrition

E44.0

Moderate protein-calorie malnutrition

E44.1

Mild protein-calorie malnutrition

E46

Unspecified protein-calorie malnutrition

E64

Sequelae of protein-calorie malnutrition

Note: Bolded codes are those most commonly used to indicate a patient’s malnutrition status as they specify severity of illness. However, the selection of diagnosis codes is based on a dietitian or physician assessment of individual patients.

Sample PDSA Cycle: Malnutrition Diagnosis

Project: Malnutrition Quality Improvement Initiative

Objective of this PDSA cycle: Test whether a new process using an EHR communication feature will result in higher rates of malnourished patients receiving a formal malnutrition medical diagnosis.

Plan:

Questions: Will all patients age 65+ years identified as malnourished via a malnutrition assessment receive a malnutrition diagnosis?

Predictions: All patients age 65+ years identified as malnourished will receive a malnutrition diagnosis

Plan for change: Who, what, when, where

The project team will education dieticians on the process change.

  • When their assessments identify a malnourished patient, dieticians will be directed to send a message or task to the inbox of the attending physician requesting that a malnutrition diagnosis be added to the patient’s problem list.

Plan for data collection: Who, what, when, where

  • Document the training (who was training by what method)
  • Track the rates of dietician assessment findings indicating malnutrition
  • For those patients, track the rates of dieticians sending messages or tasks to the attending physician
  • Track overall rates of medical malnutrition diagnoses entered on patients’ problem lists

Do:

Carry out the change: Collect data and begin analysis

  • Dietitians will document the assessment findings and recommendation for malnutrition in the EHR including:
    • Description of alternations in a patient’s status
      • Malnutrition signs and symptoms
      • Malnutrition etiology
      • Other key findings supporting the malnutrition diagnosis
    • Dieticians then sends a message and/or task to the EHR inbox of the attending physician recommending the addition of a malnutrition diagnosis code to the patient’s problem list.
    • Record results of data collected (e.g., a complete diagnosis was not entered for 5 out of 15 patients)

Study:

Complete analysis of data

  • Debrief: Discuss how to modify diagnosis entry processes to support the capture of complete diagnostic For example, could EHR templates be modified to include more diagnosis codes or more clearly indicate information necessary to capture?

Verify predictions

  • Summarize any new knowledge gained by completing this For example, did physicians find the inbox messages helpful or overwhelming? Did dieticians consistently remember to send the messages or is a reminder tool in the EHR needed?

Act:

Identify actions

  • List actions to take as a result of this cycle
  • Plan for the next cycle (adapt change, another test, implementation cycle): Run a second PDSA cycle for another short time frame to test impact.

Malnutrition Care Plan Development

  1. Responsible team member
    • Dietitian
  2. Definition
    • Documentation outlining comprehensive planned actions with the intention of impacting malnutrition-related factors affecting patient health status[1]
  3. Data sources/tools
    1. Relevant clinical practice guidelines[1]
    2. Current literature evidence base[1]
    3. Local practice protocols
    4. Patient/family caregiver interviews from assessment stage
  4. Data to collect and record
    1. Description of malnutrition care plan in patient medical record
  5. Malnutrition Care Plan Steps
    • Confer with patient and family caregiver to develop a malnutrition care plan specific to the patient’s preferences (including food preferences), goals, needs, diagnosis, and values
    • Any malnutrition-risk diet order issued following a malnutrition screening determining the patient to be “at risk” should be reevaluated based on the result of the nutrition assessment
    • Work with all care providers and patient and family caregiver to formulate the malnutrition care plan Record the malnutrition care plan in the patient’s electronic medical record
    • Communicate malnutrition care plan to members of the patient’s clinical care team (e.g. the patient’s nursing team, occupational therapy, etc) via the most appropriate mechanism
    • For each element of the malnutrition care plan, identify the appropriate care team member to complete and document relevant tasks. For example, a nurse will monitor and document intake changes, facilitate adherence, and reinforce education. Physicians include malnutrition diagnosis and care plan in daily problem list and discuss in team huddles
    • Determine and document appropriate hand-off procedures among care team members and during changes in shifts
    • Communicate the malnutrition care plan to the patient/ family caregiver and ensure the care plan goals are well understood
    • Follow-up and monitor to ensure implementation of the malnutrition care plan, including coordination with primary care physicians and other providers who may interact with the patient following discharge from the hospital
  6. Decision points for continuation of care
    1. Actions outlined in the malnutrition care plan will be specific to provider types best positioned to carry out the actions.

Best Practices

  1. Malnutrition care plan should be developed by the dietitian 
  2. Recommend hospitals grant dietitians ordering privileges to facilitate efficient care and timely interventions, if in accordance with state law (Note: This may require a physician co-sign)
  3. Develop malnutrition care plan immediately following diagnosis (within 24 hours)
  4. Engage patients and their family caregivers throughout the development and implementation of the malnutrition care plan where appropriate; i.e., patient should understand the goal of the components of the malnutrition care plan and how these play a role in recovery and healing
  5. Design malnutrition care plan for execution by a multi-disciplinary team including dietitians, nurses, therapists, physicians, and caregivers[2]
  6. Consider assigning different intervention care levels depending on the malnutrition risk to maximize efficient use of resources.
  7. Leverage EHR to standardize malnutrition documentation, facilitate malnutrition care plan, and build in alerts
    • Consider including a prompt in the electronic health record to ask if a malnutrition care plan has been created when the patient malnutrition-related diagnosis is entered
    • Consider including a prompt (reminder) to reevaluate any malnutrition-risk diet order issued when developing the malnutrition care plan
  8. The malnutrition care plan should be incorporated into the overall patient care plans[1

The components highlighted below should be included in any malnutrition care plan developed by the dietitian. Users may print the table below to serve as a malnutrition care plan template or use the content to develop their own malnutrition care plans.

Recommended Malnutrition Care Plan Componentsix

Date and time stamp
Prioritization based on symptom severity
Clearly established goals developed in consultation with the patient and/or caregiver
Goals and prescription that consider a patient’s individualized recommended dietary intake

The prescribed treatment/intervention, which may include the following:

  1. Standard diet
  2. Specialized diet
  3. Oral nutrition supplement
  4. Liquid nutrition via tube feeding
  5. Parenteral nutrition
  6. Patient education
  7. Lab orders or culture assessments
  8. Physician consults or referrals
  9. Anthropometrics
  10. Physical activity (e.g., weight lifting)
  11. Suggested calorie counts
Identification of members of the care team
Timeline for patient follow-up, including recommendations for the attending physician regarding post-discharge planning
ix List of Recommended Malnutrition Care Plan Components provided by the Academy of Nutrition and Dietetics. Recommendations supplemented with findings from Avalere’s best practices research.

Sample PDSA Cycle: Malnutrition Care Plan Development and Implementation

Project: Malnutrition Quality Improvement Initiative

Objective of this PDSA cycle: Test the impact of a change in the EHR configuration to ensure that the malnutrition care plan carries through to orders for patient care.

Plan:

Questions: Will updating the EHR to remind providers to co-sign RDN orders for nutrition interventions positively impact the rate at which care plans are carried out?

Predictions: Automatically reminding providers to co-sign orders will result in orders flowing through to the task lists and care plans for the appropriate care team members, which will increase the rate at which interventions are carried out.

Plan for change: Who, what, when, where

In conversations with care team members, it was determined that nutrition interventions, though documented in the RDN notes, did not always flow over to the nursing, occupational therapy, or dietary team’s task lists.  This change will provide a prompt in the EHR for the attending physician/provider team to co-sign orders from the RDN so that those orders will flow onto those team’s tasks lists.

  • The IT department will work with an RDN, nursing, and physician informatics team member to design the prompt.
  • Prior to go-live of the prompt in the EHR, the training team will communicate the impending update to the impacted teams – physicians, nursing staff, RDNs, etc.

 

Plan for data collection: Who, what, when, where

  • Track before-and-after rates of RDN recommended interventions being entered as formal orders co-signed by an appropriate provider
  • Track completion of nutritional interventions before-and-after implementation of the prompt

Do:

Carry out the change: Collect data and begin analysis

  • Collect baseline data
  • Implement the plan for change
  • Collect data post-implementation to assess for impact

Study:

Complete analysis of data

  • Debrief: Discuss how well the prompt facilitated better communication to ensure all elements of the malnutrition care plan are implemented. Were there any unintended consequences?

Verify predictions

  • How closely did the results of this cycle match the prediction that was made earlier?
  • Summarize any new knowledge gained by completing this cycle. For example, finding that the physicians needed better guidance for specifically which orders to enter in the EHR
  • List actions to take as a result of this cycle
  • Repeat this test for another cycle after providing clearer instructions to the care team regarding care plan details to be captured or after appropriate modifications have been made in the data collection processes in the EHR. Plan for the next cycle (adapt change, another test, implementation cycle): Run a second PDSA

Act:

Identify actions

  • List actions to take as a result of this cycle
  • Once confirmed that the cycle has been a success, ensure that it is spread organization-wide.

Intervention Implementation

  • Carry out patient care as outlined by the malnutrition care plan
  • Continue ongoing communication of the malnutrition care plan to the patient/family/caregiver, and all members of the care team.

Best Practices

  1. Strive to begin implementation of the malnutrition care plan within 24 hours of diagnosis
  2. Deliver food, oral nutrition supplements, or other malnutrition support to patient as soon as is feasible
  3. Implementation of the malnutrition care plan should be a collaboration between all members of the care team
  4. Modify malnutrition care plan (with the patient, family, and/or caregiver’s input) as necessary depending on changes in condition and patient response to Document all modifications in the EHR.
  5. Include re-assessment in malnutrition care plan for patients who were diagnosed as “at risk” or malnourished at any point during their hospital stay if their last assessment did not occur within 24 hours prior to the discharge
  6. Leverage EHR to standardize malnutrition documentation, integrate malnutrition care plan into broader care plan and build in prompts or reminders
  7. Ensure patient safety, including communication of patient allergies, no conflicts between patient’s feeding schedule and medication administration
  8. Build nutrition intervention plan options into either the Diet line or Supplements line housed within the Diet Orders section of the EHR so clinician can select the most appropriate plan for the patient
  9.  

Malnutrition Monitoring and Evaluation

A) Responsible team member

  • All relevant Care team members

B) Definition

  • Identifies the amount of progress made since patient diagnosis and assesses whether outcomes relevant to the malnutrition diagnosis and treatment goals are being met[1]

c) Data sources/tools[1]

  1. Patient self-monitoring data (e.g., food diaries kept prior to admission, fatigue, appetite)
  2. Anthropometric measures (e.g., height and weight for body mass index calculation, body circumference, )
  3. Biochemical data and medical tests
  4. Patient and family caregiver interviews
  5. SNOMED codes to record implementation and evaluation of malnutrition care plan components in a standardized nomenclature
  6. Physical exam (e.g., Nutrition Focused Physical Exam) results
  7. Calorie counts
  8. Diet tolerance information
  9. Nutrient intake information
  10. Intake and output measurements

D) Data to collect and record

  • Changes in baseline from both biochemical and medical tests, anthropometric data, patient intake, and other relevant data points to malnutrition diagnosis[22]

E) Monitoring and evaluation Steps

  • Establish whether the malnutrition care plan is producing any positive or negative outcomes[1] through a reassessment completed after a recommended time frame
  • Receive feedback from patient and/or family caregiver as to the effect of the malnutrition care plan[1]
  • Document findings in the patient medical record
  • Perform follow-up and re-assessment by dietitian as necessary
  • Consider impact of any new patient diagnoses, treatments, or other clinical events
  • Adjust malnutrition care plan as necessary to ensure positive outcomes[1]

F) Decision points for continuation of care

  1. Malnutrition care may continue if patient has not attained all treatment goals. This may include care following hospital discharge and should be coordinated with providers in the post-discharge setting
  2. Patients who do meet the goals of the malnutrition care plan should be monitored for a change in status [1]

Best Practices

  1. Multiple providers on the multi-disciplinary Care team may be responsible for ongoing malnutrition monitoring and evaluation depending on the care plan
  2. Monitor the care process
  3. Ensure patient/family caregiver understanding and compliance with malnutrition care plan
  4. Identify positive and negative outcomes and whether the intervention is or is not impacting patient malnutrition status
  5. Support findings with evidence and provide reasoning for improvement or lack of progress
  6. Measure outcomes by assessing progress, using outcome indicators relevant to the malnutrition diagnosis, symptoms, and malnutrition care plan goals
  7. Evaluate outcomes: compare current status with status at time of diagnosis and against treatment goals
    • Monitoring and evaluating results will inform modifications to the malnutrition care plan and implementation process

Discharge Planning

  1. Responsible team member
    • All relevant care team members
  2. Definition
    • Determines a patient’s appropriate post-hospital discharge destination, identifies what is required to facilitate a smooth and safe transition from the hospital to the discharge destination, and helps to identify services and/or care a patient may need post-discharge in alignment with their nutritional and medical needs[26]
  3. Data sources/tools
    1. Patient’s malnutrition diagnosis
    2. Patient’s malnutrition care plan details
    3. Documented progress towards goals of the malnutrition care plan
    4. Biochemical data and medical tests
    5. Post-discharge nutrition re-assessment
    6. Patient and family caregiver interviews
  4. Data to collect and record
    1. Note documentation of discharge
    2. Malnutrition-related components in discharge template
  5. Discharge Planning Steps
    Begin discharge planning 24 hours prior to the planned discharge

     

    • Include malnutrition-related components of a discharge plan (e.g., malnutrition status, diagnosis, patient education on importance of malnutrition in overall recovery)
    • Establish a follow-up appointment date and time for the patient
    • Support implementation of the malnutrition care plan beyond the inpatient setting by:
      1. Communicating the plan’s key components and goals to the patient/family caregiver, and any other post- discharge provider or caregiver
      2. Ensuring patient/caregiver has access to ongoing education to ensure understanding of malnutrition care plan
    • Document all malnutrition-related components in the discharge template
  6. Decision points for continuation of care
    1. The inclusion of nutrition-related components in the discharge plan is only necessary for those patients identified as at-risk or malnourished during the inpatient stay

Best Practices

  1. Create a designated space for nutrition information in the discharge planning template
  2. Tailor nutrition orders for discharge to the individual patient’s needs and obtain input from all members of the care team
    • Include take-home information including malnutrition education and malnutrition care plan instruction materials that are in the patient’s preferred language
    • Provide information directed to the patient and/or family caregiver related to best practices for self-management and links to community services; i.e., home delivered meals and Area Agency on Aging
    • Include a specific plan (e.g. specific appointment times for follow-up visits with the clinical Care team) for monitoring and evaluating the patient’s progress so that the patient’s malnutrition care plan can be adjusted as necessary
    • Encourage patients to continue to work with their dietitian and offer information to help facilitate this relationship (e.g. ensure patients have appropriate contact information, )
  3. Leverage EHR (when possible) to prepare discharge plan and coordinate care post-hospitalization
    • Include inpatient malnutrition diagnosis and nutrition intervention plan in the discharge If possible via EHR linking, allow for auto-population of diagnosis into discharge plan
    • Create a template in the discharge summary that includes the patient’s diet plan into the diet section of the summary
  4. Ensure appropriate policies and procedures are in place for patients lacking a support system outside of the hospital to facilitate effective and efficient discharge planning that is inclusive of malnutrition-related education and specific instruction

Sample PDSA Cycle: Discharge Planning

Project: Malnutrition Quality Improvement Initiative

Objective of this PDSA cycle: Test the inclusion of malnutrition related components in the discharge planning for all patients age 65+ years diagnosed as malnourished

Plan:

Questions: Will all patients age 65+ years with a malnutrition diagnosis have malnutrition related recommendations and orders included in their discharge plan?

Predictions: All patients age 65+ years with a malnutrition diagnosis will have malnutrition components included in their discharge plan

Plan for change: Who, what, when, where

Include malnutrition-specific discharge materials tailored to the individual patient in the patient’s overall discharge materials for all eligible patients age 65+ years with a malnutrition diagnosis

  • 24 hours prior to discharge, all members of the care team will provide input on the malnutrition components that should be included in the patient’s discharge plan for all eligible patients with a malnutrition diagnosis, including care transition documents for the provider in the post-discharge setting

Plan for data collection: Who, what, when, where

  • All members of the interdisciplinary care team are eligible to provide documentation in the discharge template of malnutrition components (i.e. education materials) that should be included in the discharge plan SAMPLE PDSA Cycle: Discharge Planning

Do:

Carry out the change: Collect data and begin analysis

  • Conduct the assessment during a 24 hour period prior to the discharge of patients with a malnutrition diagnosis
  • Review EHR records for 10 eligible patients identified as malnourished
  • Record results of data collected (e.g., malnutrition discharge planning materials were not provided for 2 out of 10 patients because there is no reminder system in place to alert the care team to the need to provide these materials)

Study:

Complete analysis of data

  • Debrief: Discuss what kinds of reminder systems could be employed to help ensure the care team provides malnutrition discharge materials for eligible patients. For example, could a reminder system be incorporated into the EHR system to alert providers 24 hours prior to discharge that malnutrition discharge materials should be prepared?

Verify predictions

  • How closely did the results of this cycle match the prediction that was made earlier?
  • Summarize any new knowledge gained by completing this cycle. For example, the lack of a designated reminder system to alert the care team 24 hours before patient discharge that malnutrition discharge planning materials should be prepared and provided decreases the likelihood that these components will be included in the discharge materials

Act:

Identify actions

  • List actions to take as a result of this cycle
  • Repeat this test for another 24 hours after providing modifications to the EHR Plan for the next cycle (adapt change, another test, implementation cycle): Run a second PDSA cycle for another 24 hour period

Malnutrition Considerations for Surgical Patients and/or Patients on NPO (nothing by mouth) Orders[27]

  • Providers should engage with patients around the decision to implement NPO orders as part of care shared decision-making processes[28,29]
  • All patients who have not received a malnutrition screening (as evidenced by the medical record) within 7 days prior to admission should be screened at admission[24,25]
  • Patients with an NPO order should be screened for malnutrition within 24-hours of beginning the NPO diet order[30]
  • Surgical patients who are NPO should have a completed malnutrition screening or nutrition assessment 24-hours prior to surgery[30]
  • The clinical workflow timeline for assessment and the malnutrition care plan implementation goes into effect following completed surgical/NPO patient screening[31]

Enhancing Care Efficiency Throughout the Episode of Care[27]

  • Hospitals are recommended to grant dietitians ordering privileges to facilitate efficient care and timely interventions, if in accordance with state law
    • This may require co-signing from a physician
  • Consider assigning different intervention care levels depending on the malnutrition risk of the patient to promote resource prioritization

Shared Decision-Making

  • Identify a staff liaison to work directly with patients or family caregivers
  • Patients and family caregivers should be made aware of the specific roles they play in implementing the malnutrition care plan, particularly as it relates to discharge planning
  • Patient engagement and shared decision-making should be supported through tools such as decision aids designed for a low level of health literacy and by encouraging patients and family caregivers to ask questions of their providers
  • Providers should ensure that not only do all adult patients have an advance care directive related to food preferences, but that malnutrition considerations (such as placement of a feeding tube) are included in the decision-making process
  • Providers should ensure that patient preference and feedback is incorporated into the malnutrition care plan (e.g., adjustments to meals for patient preferences, “protected” meal times, etc.), and that reasons for not incorporating any feedback be clearly explained to the patient or family caregiver

Patient Education

  • Throughout the clinical workflow patients and family caregivers should be provided with educational resources designed to enhance understanding of the patient diagnosis and malnutrition care plan goals
  • Patient education should include information on the benefits of proper nutrition and tips for maintaining good nutrition at home such as those available from the Alliance to Advance Patient Nutrition[32]
  • Patient education should focus on ensuring the patient and family caregiver understand the patient’s needs, available nutrition resources, and the importance of ongoing treatment
  • Patient education may include paper-based resources with reference to further electronic materials
  • Note: You can refer to CMS’s toolkit for Making Written Material Clear and Effective for more information on how to ensure patient education materials are clear and effective

Care Coordination

  • Consistent and accurate documentation of patient care in the EHR can help support team coordination
    • When considering how best to use the EHR to support patient care and team coordination, Project and care teams should consider mechanisms for reducing “alert fatigue”
  • Core care team members and other healthcare professionals involved in patient care must coordinate to ensure patient safety, including:
    • Communication of patient allergies
    • No conflicts between patient’s feeding schedule and medication administration
    • Effective transitions to care settings outside of the hospital

Additional Resources

If other information is needed or desired regarding any of the best practices highlighted on the previous pages, please refer to the clinical guidance documents for nutrition care listed below. They contain the relevant information on the most recent standards of nutrition care:

Last Updated on September 12, 2024

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These materials were developed by the Malnutrition Quality Improvement Initiative (MQii),
a project of the Academy of Nutrition and Dietetics, Avalere, and other stakeholders who
provided guidance and expertise through a collaborative partnership. Support provided by Abbott.

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