Please review article. Submit a 2 page summary on three take-aways from the article. Include how you will use nutrition in your career.

The Journal of the Academy of Nutrition and Dietetics, Journal of Parenteral and Enteral Nutrition, and MEDSURG Nursing Journal have arranged to publish this article simultaneously in their publica- tions. Minor differences in style may appear in each publication, but the article is substantially the same in each journal.

Copyright ª 2013 by the Academy of Nutrition and Dietetics, American Society for Parenteral and Enteral Nutrition, and Academy of Medical-Surgical Nurses.

2212-2672/$36.00 doi:10.1016/j.jand.2013.05.015 Available online 17 July 2013

JO

FROM THE ACADEMY

Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition Kelly A. Tappenden, PhD, RD, FASPEN; Beth Quatrara, DNP, RN, CMSRN; Melissa L. Parkhurst, MD; Ainsley M. Malone, MS, RD; Gary Fanjiang, MD; Thomas R. Ziegler, MD

ABSTRACT The current era of health care delivery, with its focus on providing high-quality, affordable care, presents many challenges to hospital- based health professionals. The prevention and treatment of hospital malnutrition offers a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and treat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute post-hospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reduce complication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patients who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following six principles: (1) create an institutional culture where all stakeholders value nutrition; (2) redefine clinicians’ roles to include nutrition care; (3) recognize and diagnose all malnourished patients and those at risk; (4) rapidly implement comprehensive nutrition interventions and continued monitoring; (5) communicate nutrition care plans; and (6) develop a comprehensive discharge nutrition care and education plan. J Acad Nutr Diet. 2013;113:1219-1237.

T HE UNITED STATES IS entering a new era of health care delivery in which changes in health care policy are driving

an increased focus on costs, quality, and transparency of care. This new focus on improving the quality and ef- ficiency of hospital care highlights an urgent need to revisit the long-standing challenge of hospital malnutrition and

elevate the role of nutrition care as a critical component of patient recovery. Malnutrition is common in the hospital setting and can adversely affect clinical outcomes and costs, but it is often overlooked. Although results of inter- vention studies vary, addressing hospi- tal malnutrition has the potential to improve quality of patient care and clinical outcomes and reduce costs.1

Today it is estimated that at least one third of patients arrive at the hos- pital malnourished1-5 and, if left un- treated, many of those patients will continue to decline nutritionally,5

which may adversely impact their re- covery and increase their risk of com- plications and readmission. Hospital malnutrition is not a new problem, but “the skeleton in the hospital closet,” was brought to light in Butter- worth’s call for practices aimed at proper diagnosis and treatment of malnourished patients.6 As we enter a new era of health care delivery, the time is now to implement a novel, comprehensive nutrition care model

URNAL OF THE ACADE

as part of improved quality standards and to leverage proven examples for success.

Effective management of malnutri- tion requires collaboration among multiple clinical disciplines. In many hospitals, malnutrition continues to be managed in silos, with knowledge and responsibility provided predominantly by the dietitian. However, the new era of quality care will require a deliber- ately more holistic and interdisci- plinary process to address this critical issue. All members of the clinical team must be involved, including nurses who perform initial nutrition screening and develop innovative strategies to facilitate patient compliance; dietitians who complete nutrition assessment/ diagnosis and develop evidence-based intervention(s); pharmacists who eval- uate drug�nutrient interactions; and physicians, including hospitalists, over- seeing the overall care plan and docu- mentation to support reimbursement for services. Recognition of this prob- lem and the opportunity to improve

MY OF NUTRITION AND DIETETICS 1219

FROM THE ACADEMY

patient care were the impetus behind creating the Alliance to Advance Patient Nutrition (Alliance). The Alli- ance brings together the Academy of Nutrition and Dietetics (AND), the Academy of Medical-Surgical Nurses (AMSN), the Society of Hospital Medi- cine (SHM), the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), and Abbott Nutrition. The Alliance is made possible with support from Abbott Nutrition. These health organizations are dedicated to the ad- vancement of effective hospital nutri- tion practices to help improve patients’ medical outcomes and support all clinicians in collaborating on hospital- wide nutrition procedures. The estab- lished charter of the Alliance is to champion improved hospital nutrition practices through identification of malnourished patients and patients at risk for malnutrition, early nutrition intervention and treatment, and in- clusion of nutrition as a standard component of all care processes. Nutrition intervention for malnour-

ished patients is a low-risk, cost-effec- tive strategy to improve quality of hospital care, but it requires interdisci- plinary collaboration. As representa- tives of the Alliance, we announce a call to action. We aspire to facilitate the institution of universal nutrition screening, rapid and appropriate nu- trition interventions utilizing effective interdisciplinary nutrition partner- ships, and integration of comprehen- sive strategies to prevent or treat hospital malnutrition. This paper is not intended to provide practice-based guidelines, but rather highlights avail- able data on the critical role nutrition plays in improving patient outcomes, outlines an innovative nutrition care model, underscores the importance of an interdisciplinary approach to address hospital malnutrition, and identifies challenges believed to impair optimal nutrition care. In addition, specific solutions that can be employed by dietitians, nurses, physicians, and other health care professionals, such as nurse practitioners, physician assis- tants, pharmacists, and dietetic techni- cians, registered, are provided.

BURDEN OF HOSPITAL MALNUTRITION Although estimates of the prevalence of malnutrition vary by setting,

1220 JOURNAL OF THE ACADEMY OF NUTRI

subgroup, and method of assessment, the prevalence of malnutrition in hos- pitals is particularly startling. It is estimated that at least one third of patients in developed countries have some degree of malnutrition upon admission to the hospital1-3,5 and, if left untreated, approximately two thirds of those patients will experience a further decline in their nutrition status during inpatient stay.5 Unfortu- nately, despite the availability of vali- dated screening tools, malnutrition continues to be under-recognized in many hospitals.7,8 Moreover, among patients who are not malnourished upon admission, approximately one third may become malnourished while in the hospital.9

Historically, a variety of tools and definitions have been used throughout the nutrition literature. For the pur- poses of this paper mild through severe malnutrition will be the focus and is the intent when the term malnutrition is used. Malnutrition is most simply defined as any nutrition imbalance10

that affects both overweight and underweight patients alike and is generally described as either “under- nutrition” or “overnutrition.”11 Hospi- talized patients, regardless of their body mass index (BMI), typically suffer from undernutrition because of their propensity for reduced food intake due to illness-induced poor appetite, gastrointestinal symptoms, reduced ability to chew or swallow, or nil per os (NPO) status for diagnostic and thera- peutic procedures. In addition, they may have increased energy, protein, and essential micronutrient needs because of inflammation, infection, or other catabolic conditions. A consensus statement by AND and A.S.P.E.N. pub- lished in May 2012 defines malnutri- tion as the presence of two or more of the following characteristics: insuffi- cient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumu- lation, or decreased functional status.11

The importance of identifying at-risk patients is highlighted by data showing that malnutrition is associated with many adverse outcomes, including an increased risk of pressure ulcers and impaired wound healing, immune sup- pression and increased infection rate, muscle wasting and functional loss increasing the risk of falls, longer length of hospital stay, higher readmission

TION AND DIETETICS

rates, higher treatment costs, and increased mortality.1 Therefore, malnu- trition places a heavy burden on the patient, clinician, and health care system.

Many of the adverse outcomes influ- enced by malnutrition are potentially preventable. Nosocomial infections are a prime example. Approximately 2 million nosocomial infections occur annually in the United States,12 and those patients are more likely to spend time in the intensive care unit, be readmitted, and die as a result.13 A retrospective study by Fry and col- leagues examined nearly 1 million sur- gical patients (N¼887,189) treated at 1,368 hospitals to determine the risk of nosocomial infections and better un- derstand the underlying patient char- acteristics influencing that risk.14 The analysis showed that patients with pre- existing malnutrition and/or weight loss had a two- to threefold increased risk of developing Clostridium difficile enterocolitis, surgical-site infection, or postoperative pneumonia, and a greater than fivefold higher risk ofmediastinitis after coronary artery bypass graft sur- gery or catheter-associated urinary tract infection. Malnutrition and/or weight loss also correlated with an approximate fourfold higher risk of developing a pressure ulcer. These data are further supported by a prospective multivariate analysis demonstrating that malnutrition is an independent risk factor for nosocomial infections.15

Impaired wound healing can signifi- cantly influence length of hospital stay, and the literature supports a strong correlation between nutrition and wound healing, wherein protein syn- thesis is necessary.16 Hospitalized pa- tients are at increased risk because loss of significant lean body mass (LBM) accelerates during bed rest.17,18 A 10% loss of LBM results in immune sup- pression and increases the risk of infection, and a loss of >15% to 20% of total LBM will impair wound heal- ing.16,19 A loss of �30% leads to the development of spontaneous wounds, such as pressure ulcers, an increased risk of pneumonia, and a complete lack of wound healing.16,19 These complica- tions are also associated with a sub- stantial mortality risk, particularly in older patients. A study evaluating the care processes for hospitalized Medi- care patients (N¼2,425; aged 65 years and older) at risk for pressure ulcer

September 2013 Volume 113 Number 9

FROM THE ACADEMY

development showed that 76% of pa- tients were malnourished, and esti- mated compliance with nutrition consultation was low (34%).20

Data from several recent studies show that malnutrition can also influ- ence hospital readmission rates.21-23

These studies evaluated multiple fac- tors to identify individuals at increased risk of readmission. The largest of these studies, a retrospective observational analysis of >10,000 consecutive ad- missions (N¼6,805), reported a 30-day readmission rate of 17%.21 Comorbid- ities that significantly increased the risk of readmission included congestive heart failure, renal disease, cancer, weight loss (not defined), and iron- deficiency anemia. Weight loss corre- lated with a 26% increased risk of readmission (adjusted odds ratio¼ 1.26).21 In a large single-center study of 1,442 general surgery patients, the 30-day readmission rate was 11%.22 The most common reasons for readmission were gastrointestinal problems/com- plications (28% of readmissions), sur- gical infections (22%), and failure to thrive/malnutrition (10%). These find- ings are consistent with the hypothesis that poor nutrition contributes to post- hospital syndrome, which, together with a variety of other factors, such as sleep disturbance, pain, and discom- fort, can dramatically increase the risk of 30-day readmission, often for reasons other than the original diagnosis.24

Finally, poor clinical outcomes asso- ciated with malnutrition contribute to higher hospitalization costs. As out- lined above, malnourished patients have higher rates of infections, pres- sure ulcers, impaired wound healing, and other adverse outcomes requiring greater nursing care and more medi- cations. In turn, these complications can contribute to longer lengths of hospital stay and higher rates of read- mission, all of which indirectly con- tribute to higher hospital costs.1

Indeed, a study conducted in the United Kingdom estimated the annual expenditure for managing patients at medium or high risk of disease-related malnutrition to be EURV10.5 billion (US$11.3 billion, based on 2003 ex- change rates), more than half of which was directly related to hospital care.25

These studies strongly suggest that the consequences of unrecognized and untreated malnutrition are substantial,

September 2013 Volume 113 Number 9

not only for patients’ quality of care but also from a cost perspective. Malnutri- tion negatively affects clinical out- comes and results in higher costs and, with the changing health care land- scape, reimbursement for costs associ- ated with preventable events will be reduced. All clinicians must take action to address these concerns, improve patient quality of life, and increase the health care system value.

IMPACT OF NUTRITION INTERVENTION ON KEY OUTCOMES The benefits of nutrition intervention in terms of improving key clinical out- comes are well documented. Numerous studies, predominantly in patients 65 years of age and older with or at risk for malnutrition, have shown the potential of specific nutrition interventions to substantially reduce complication rates, length of hospital stay, readmission rates, cost of care, and, in some studies, mortality.5,26-36

Nutrition intervention strategies rep- resent a broad spectrum of options that can be organized into four categories: (1) food and/or nutrient delivery; (2) nutrition education; (3) nutrition counseling, and (4) coordination of nutrition care. Food and/or nutrient delivery requires an individualized approach that includes energy- and nutrient-dense food, complete oral nutrition supplements (ONS) that pro- vide macronutrients (from carbohy- drate, fat, and protein sources) combined with micronutrients (mix- tures of complete vitamins, minerals, and trace elements); enteral nutrition (EN), which in the context of this report refers to nutrients provided into the gastrointestinal tract via a tube; and/or parenteral nutrition (PN). Although the nutrition support litera- ture has generally featured smaller trials and observational studies rather than large, multicenter, randomized controlled trials, evidence strongly supports the importance of nutrition intervention. The value of EN and PN is well established in select patient pop- ulations but remains unclear in others. In addition, numerous studies have shown improved body weight, LBM, and grip strength with dietary coun- seling, with or without ONS.37 A growing number of studies have exam- ined the impact of ONS inmalnourished

JOURNAL OF THE ACADE

patients, providing the framework for our call to action. Evidence sup- porting intervention with EN and PN is beyond the scope of the current paper and will be addressed in subsequent reviews.

Clinical Complications Studies evaluating the efficacy of ONS delivery have generally shown a variety of metabolic improvements and, in many studies, a reduction in several clinical complications. One meta- analysis including seven studies (N¼284) indicates that patients re- ceiving ONS had reduced complication rates (eg, infections, gastrointestinal perforations, pressure ulcers, anemia and cardiac complications) compared with control patients.28More recently, a large Cochrane systematic review of 24 studies involving 6,225 patients 65 years of age and older at risk for malnutrition demonstrated fewer complications (eg, pressure sores, deep vein thrombosis, and respiratory and urinary infections) among patients re- ceiving ONS compared with routine care (relative risk [RR]¼0.86; 95% CI 0.75 to 0.99).27 Available evidence in- dicates high-protein ONS to be partic- ularly effective at reducing the risk of complications. A systematic review of elderly patients (older than 65 years of age) with hip fractures demonstrated a more effective reduction in the number of long-term medical complications with high-protein ONS (>20% total en- ergy from protein) than low-protein or nonprotein-containing supplements (RR¼0.78; 95% CI 0.65 to 0.95).26 A meta-analysis of four randomized trials (N¼1,224) also showed that, in patients with no pressure ulcers at baseline, high-protein ONS resulted in a signifi- cant 25% lower incidence of ulcers compared with routine care.38 In addi- tion, evidence indicates that nutrition intervention can reduce the risk of falls in frail and malnourished elderly pa- tients. In 210malnourished older adults newly admitted to an acute-care hos- pital, intervention with a protein- and energy-rich diet, ONS, calcium/vitamin D supplements, and counseling reduced the incidence of falls by approximately 60% comparedwith routine care (10% vs 23%).35 Avoidance of these preventable events can shorten length of hospital stay, decrease morbidity and mortality, and reduce liability for the hospital.

MY OF NUTRITION AND DIETETICS 1221

FROM THE ACADEMY

Length of Stay Consistent with evidence that nutrition intervention can reduce clinical com- plications, strong nutrition care can also reduce the length of hospital stay. In a prospective study conducted at The Johns Hopkins Hospital, nutrition screening involving a team approach to address malnutrition and earlier inter- vention reduced the length of hospital stay byan average of 3.2 days in severely malnourished patients,5 and this trans- lated into substantial cost savings of $1,514 per patient. Two meta-analyses have shown significantly reduced length of hospital stay in patients re- ceiving ONS compared with control patients. One analysis demonstrated a reduced average length of hospital stay ranging from2days for surgical patients to 33 days for orthopedic patients (P<0.004).28 In addition, patientswith a lower BMI (<20) received the greatest benefit from optimized food and/or nutrient delivery. Likewise, in a recent meta-analysis of nine randomized trials (N¼1,227), high-protein ONS signifi- cantly reduced length of stay by an average of 3.8 days (P¼0.040) compared with routine care.31 A recent retrospec- tive analysis utilized information from >1 million adult inpatient cases found in the 2000-2010 Premier Perspectives Database maintained by the Premier Healthcare Alliance—representing a to- tal of 44 million hospital episodes from across the United States or approxi- mately20%of all inpatient admissions in the United States. Within this sample, ONS reduced length of hospital stay by an average of 2.3 days or 21%, and the average cost savingswas $4,734 or 21.6% compared with routine care.36

Readmissions Hospital readmission rate is another important outcome that can be improved through nutrition interven- tion. Thirty-day readmission rates de- creased from 16.5% to 7.1% in a community hospital that implemented a comprehensive malnutrition clinical pathway program focused on identifi- cation of at-risk patients, nutrition care decisions, inpatient care, and discharge planning.30 A prospective randomized trial in acutely ill patients 65 to 92 years of age (N¼445) demonstrated a signifi- cantly lower 6-month readmission rate among those who received a normal hospital diet plus high-protein ONS

1222 JOURNAL OF THE ACADEMY OF NUTRI

compared with those patients who received only the normal hospital diet (29% vs 40%, respectively; hazard ratio¼0.68; 95% CI 0.49 to 0.94).32

Finally, analysis of the Premier Per- spectives Database showed that use of ONS reduced 30-day readmission rates by6.7%,36 indicating the significant real- world benefit of nutrition intervention on a key patient outcome.

Mortality Several meta-analyses have also demonstrated reduced mortality in patients receiving optimized nutri- ent care. An analysis of 11 studies (N¼1,965) found significantly lower mortality rates among hospitalized pa- tients receiving ONS (19%) compared with control patients (25%; P<0.001).28

This represented a 24% overall reduc- tion in mortality, and patients with lower average BMI (<20) receiving ONS had a greater reduction in mortality. Among elderly patients hospitalized for hip fracture, significantly fewer patients had an unfavorable combined outcome (mortality or medical complication) if they received ONS vs routine care (RR¼0.52; 95% CI 0.32 to 0.84).29

Another systematic review of 32 studies (N¼3,021) found that, in elderly patients, ONS significantly reduced mortality compared with routine care (RR¼0.74; 95% CI 0.59 to 0.92).33 Sub- group analyses from the original Cochrane review and two updates have consistently shown reduced mortality in undernourished patients receiving ONS compared with routine care.27,33,34

Collectively, these data provide solid evidence that nutrition intervention significantly contributes to improved clinical outcomes and reduced cost of care, primarily in patients 65 years of age and older and those with, or at risk for, malnutrition. However, it is important to note that isolated studies and meta-analyses have not demon- strated such significantly improved clinical outcomes with nutrition inter- vention.37,39-42 Additional research studies, particularly well-powered, randomized controlled clinical trials, are always beneficial to further explore the effects of nutrition intervention on clinical outcomes and to assess how those benefits can translate into cost savings. Nevertheless, given the impor- tance of adequate nutrition to cell and organ function, coupled with promising

TION AND DIETETICS

clinical data reported to date, the time is now to act on the evidence at hand and implement nutrition intervention strategies shown to be safe and efficacious.

ALLIANCE NUTRITION CARE RECOMMENDATIONS If we are to make progress toward improving nutrition care practices that guarantee every malnourished or at- risk patient is identified and treated effectively, we must proactively iden- tify barriers impacting the provision of nutrition care. Toward this end, at least six key challenges must be overcome. First, despite at least one third of hos- pitalized patients being admitted malnourished, a majority of these pa- tients continue to go unrecognized or are inadequately screened.43 Second, while the responsibility of patients’ nutrition care is often placed on the dietitian many institutions lack ade- quate dietitian staffing to properly address all patients. Third, nutrition care is often delayed due to the pa- tient’s medical status, lack of diet order, and time to nutrition consult. In fact, a study at Johns Hopkins found that time to consultation from admission is nearly 5 days,5 which is similar to the average length of hospital stay.44

Fourth, nurses provide and oversee patient care 24/7, observe nutrition intake and tolerance, and interact continually with the patient and their family/caregivers, yet they are rarely included in nutrition care.45 Fifth, in many care environments, physician sign-off is required to implement a nutrition care plan. Dietitian recom- mendations are implemented in only 42% of cases.46 Finally, many patients experience difficulty consuming meals without assistance, contributing to more than half of hospitalized patients not finishing their meals.47

To address these barriers and shift the paradigm of nutrition care, the Alliance Steering Committee, whose members possess broad-ranging ex- pertise and clinical experience, devel- oped several key principles for advancing patient nutrition. Through a series of meetings conducted over the past year, the committee explored the following topics: empowerment of all clinicians; recognition and diagnosis of all patients; same-day automatic intervention for all at-risk patients;

September 2013 Volume 113 Number 9

Figure 1. The Alliance’s Key Principles for Advancing Patient Nutrition. EHR¼electronic health record.

FROM THE ACADEMY

education and involvement of patients in their nutrition care; and apprecia- tion of the value of nutrition by all hospital stakeholders. Six principles deemed essential elements of optimal patient nutrition care were derived from these topics (Figure 1). Attain- ment of these six ideals, however, will require processes and collaboration among all hospital stakeholders, in- cluding dietitians, nurses, physicians, and administrators, each of whom must fulfill their role in this effort (Figure 2). Translation of these pro- cesses into a practical interdisciplinary nutrition care algorithm is illustrated in Figure 3.

Principle 1: Create an Institutional Culture Where All Stakeholders Value Nutrition True progress requires that all hospital stakeholders, including clinicians and administrators, fully understand the

September 2013 Volume 113 Number 9

pervasiveness of hospital malnutrition and the effect patient nutrition caremay have on overall clinical outcomes. Cli- nicians and administrators often fail to prioritize understanding the extent of malnutrition in their institutions and its potential impact on cost and/or quality of care. Nurses and physicians receive limited formal nutrition education dur- ing training and often do not prioritize nutrition among the competing prior- ities within patient care. Failing to pri- oritize nutrition within an institution may limit available nutrition interven- tion options and human resources (eg, dietitian nutrition-focused nurses and physicians) required for optimal nutrition care. To be successful, in- stitutions need motivated nutrition champions at all levels of clinical care and administration. To ensure that clinicians and hospital

leaders understand the clinical and financial implications of malnutrition and take proper steps to address it,

JOURNAL OF THE ACADE

the Alliance offers the following recommendations:

� Clinicians must be educated on the recognition of malnourished patients and evidence-based nutrition interventions. Discus- sion of nutrition care plans should be a mandated compo- nent of daily team meetings (rounds or huddles).

� Malnutrition must be appropri- ately included as part of the pa- tient’s diagnosis and nutrition interventions must be viewed as a core component of a patient’s medical therapy. Nutrition treat- ment plans should be addressed with the same consistency and rigor as other therapies.

� Hospital administrators must recognize the financial benefit of optimal nutrition care. Institu- tional financial data must be reviewed to identify challenges

MY OF NUTRITION AND DIETETICS 1223

Principle Key Hospital Stakeholders

Dietitian Nurse Physician Hospital administrator

1. Create an Institutional Culture Where All Stakeholders Value Nutrition

� Serve as primary authority on “all things nutrition”

� Educate key hospital stakeholders on improved patient outcomes and reduced costs achieved with optimal nutrition care

� Host hospital-wide learning opportunities at regular intervals

� Recognize the essential role that nurses play in achieving enhanced patient outcomes through individualized nutrition care

� Incorporate nutrition into routine care checklists and processes

� Include patient dietary intake into team huddles

� Provide leadership under- scoring nutrition care as an essential part of patient- centered care

� Know evidence regarding impact of malnutrition and effectiveness of nutrition intervention

� Include dietitian in daily team huddles/rounds

� Incorporate nutrition into routine care checklists and processes

� Become a nutrition cham- pion and provide support for the development of effective nutrition care processes

� Share quality and eco- nomic gains to be made by investing in nutrition care with hospital leadership team

2. Redefine Clinicians’ Role to Include Nutrition Care

� Actively contribute nutri- tion expertise and engage other team members with assessment data on prog- ress made with nutrition care efforts

� Regularly participate in interdisciplinary rounds

� Ensure practices are in place to support imple- mentation of nutrition intervention

� Develop processes to ensure that nutrition screening and dietitian–prescribed inter- vention occurs within the targeted timeframes

� Facilitate nursing inter- ventions to treat patients who are malnourished or at risk

� Empower dietitian to cooperatively lead nutri- tion care as clinical team member

� Support nurse work pro- cesses to include nutrition screening and support nutrition intervention

� Support nutrition educa- tion of clinicians needing initial training and continuing education

� Provide ordering privi- leges to dietitian for issues relating to the nutrition care process

3. Recognize and Diagnose All Malnourished Patients and Those At Risk

� Utilize standard malnutri- tion characteristics set forth by ANDa and A.S.P.E.N.b guidelines

� Screen every hospitalized patient for malnutrition as part of regular workflow procedures

� Consider nutrition status as an essential attribute of medical assessment, moni- toring, and care plans

� Ensure EHRc captures screening data and malnutrition criteria with the appropriate triggers in place for initiating the

(continued on next page)

Figure 2. Summary of Alliance’s nutrition care recommendations for key hospital stakeholders.

FR O M

TH E A C A D EM

Y

1224 JO

U R N A L O F TH

E A C A D EM

Y O F N U TR

ITIO N

A N D

D IETETIC

S Septem

ber 2013

Volum e 113

N um

ber 9

Principle Key Hospital Stakeholders

Dietitian Nurse Physician Hospital administrator

� Establish competence in nutrition-focused physical assessment

� Communicate screening results through use of EHR

� Rescreen patients at least weekly during hospital stay

� Communicate changes in clinical condition indica- tive of nutrition risk

next steps when positive screens or diagnostic assessment are obtained

4. Rapidly Implement Comprehensive Nutrition Intervention and Continued Monitoring

� Establish procedures to support policy that patients identified as “at-risk” during nutrition screen receive automated nutrition inter- vention within 24 hours while awaiting assessment, diagnosis, and care plan

� Lead an interdisciplinary team to establish nutrition algorithms for use in various scenarios when positive screens or diag- nostic assessments are obtained

� Provide ENd formulary and micronutrient therapy options in written form as a pocket-sized document; make readily available to all staff to ensure fast intervention

� Work with nurses to estab- lish policies and

� Ensure that procedures allowing patients identi- fied as “at-risk” during nutrition screen receive automated nutrition inter- vention within 24 hours while awaiting assess- ment, diagnosis, and care plan

� Develop procedures to provide patients with meals at “off times” if pa- tient was not available or under a restricted diet at the time of meal delivery

� Avoid disconnecting EN or PNf forpatient repositioning, ambulation, travel, or procedures

� Work with interdisciplinary team dietitian to establish policies and interdisci- plinary practices to

� Support policy that - vides automated nutrit intervention within 24 hours in patients ident d as “at-risk” during nutr n screen, while awaiting nutrition assessment, d - nosis, and care plan

� Minimize nil per os - riods for patient with scheduling of procedu / tests and remain mind l of “holds” on POe diet

� Provide ordering privileges to dietitian for issues relating to the nutrition care process (eg, diet plans, ONSg, micronutrients, and calorie counts)

� Ensure EHR includes auto- matic triggers that initiate nutrition protocol mea- sures to be reviewed when positive screens are obtained

� Ensure EHR includes a module for recording food/ONS intake data and triggers dietitian consult if consumption is suboptimal

(continued on next page)

Figure 2. (continued) Summary of Alliance’s nutrition care recommendations for key hospital stakeholders.

FR O M

TH E A C A D EM

Y

Septem ber

2013 Volum

e 113

N um

ber 9

JO U R N A L O F TH

E A C A D EM

Y O F N U TR

ITIO N

A N D

D IETETIC

S 1225

pro ion

ifie itio

iag

pe

res fu s

Principle Key Hospital Stakeholders

Dietitian Nurse Physician Hospital administrator

interdisciplinarypractices to maximize nutrient con- sumption and monitoring needs

maximize food/ONS consumption

� Monitor food/ONS and communicate to dietitian/ physician via EHR

5. Communicate Nutrition Care Plans

� If present, ensure mild, moderate, or severe malnutrition is included as complicating condition in coding processes

� Assume responsibility for ensuring that a patient’s nutrition care plan is care- fully documented in the EHR, regularly updated, and effectively communi- cated to all healthcare providers, including post- acute facilities and primary care physicians

� Lead a interdisciplinary team to create and main- tain standardized policies, procedures, and EHR-auto- mated triggers relevant to nutrition, including order sets and protocols in the hospital’s EHR

� Consult dietitian regarding nutrient intake concerns

� If present, ensure mild, moderate, or severe malnutrition is included as complicating condition in coding processes

� Incorporate nutrition dis- cussions into handoff of care and nursing care plans

� Establish and reinforce expectation that a patient’s nutritioncareplan iscarefully documented in the EHR, regularly updated, and effectively communicated to all health care providers

� If present, ensure mild, moderate, or severe malnutrition is included as complicating condition in coding processes

� If present, ensure mild, moderate, or severe malnutrition is included as complicating condition in coding processes

� Ensure EHR is adapted to ensure nutrition diagnosis and complete care plan is included as a standard category of medical assessment in the central area of EHR

6. Develop a Comprehensive Discharge Nutrition Care and Education Plan

� Provide patients, family members, and caregivers with nutrition education and a comprehensive

� Include nutrition as a component of all clinician conversations with pa- tients and their family members/caregivers

� Include nutrition as a component of all clinician conversations with pa- tients and their family members/caregivers

� Provide expectation re- garding continuity of nutrition care, including discharge planning and patient education

(continued on next page)

Figure 2. (continued) Summary of Alliance’s nutrition care recommendations for key hospital stakeholders.

FR O M

TH E A C A D EM

Y

1226 JO

U R N A L O F TH

E A C A D EM

Y O F N U TR

ITIO N

A N D

D IETETIC

S Septem

ber 2013

Volum e 113

N um

ber 9

Pr in ci p le

K ey

H os p it al

St ak

eh ol d er s

D ie ti ti an

N ur se

Ph ys ic ia n

H os p it al

ad m in is tr at or

po st -h os pi ta liz at io n nu

tr i-

tio n ca re

pl an

� En

su re

pa tie

nt an

d ca re -

gi ve r un

de rs ta nd

th e

im po

rt an

ce of

fo llo w -u p

nu tr iti on

as se ss m en

t an

d ed

uc at io n

� Pr ov

id e

sp ec ifi c

in fo rm

a- tio

n fo r nu

tr iti on

fo llo w -u p

ap po

in tm

en ts

to pa

tie nt

an d ca re gi ve r

� Re

in fo rc e

th e

im po

rt an

ce of

nu tr iti on

ca re

an d

fo llo w -u p po

st -d is ch ar ge

to pa

tie nt

an d ca re gi ve r

� Re

in fo rc e

th e

im po

rt an

ce of

nu tr iti on

ca re

an d

fo llo w -u p po

st -d is ch ar ge

to pa

tie nt

an d ca re gi ve r

a A N D ¼A

ca de

m y of

N ut rit io n an

d D ie te tic s.

b A .S .P .E .N .¼ A m er ic an

So ci et y fo r Pa

re nt er al

an d En

te ra lN

ut rit io n.

c E H R¼

el ec tr on

ic he

al th

re co rd .

d EN

¼e nt er al

nu tr iti on

. e P O ¼p

er or al .

f P N ¼p

ar en

te ra l nu

tr iti on

. g O N S¼

or al

nu tr iti on

su pp

le m en

t.

Fi g ur e 2.

(c on

tin ue d)

Su m m ar y of

A lli an

ce ’s nu

tr iti on

ca re

re co m m en

da tio

ns fo r ke y ho

sp ita

ls ta ke ho

ld er s.

FROM THE ACADEMY

September 2013 Volume 113 Number 9 JOURNAL OF THE ACADEMY

to improving nutrition interven- tion, project cost savings with various nutrition interventions, and revise budgets to facilitate action. Budgets must support adequate and appropriate nutri- tion intervention as necessitated by dietitian, nursing, and physi- cian staff.

� Professional associations for di- etitians, nurses, physicians, and hospital administrators must address the widespread problem of hospital malnutrition. Disci- pline-specific resources such as toolkits and practice bundles, evidence-based publications, and continuing education opportu- nities must be established and widely available. Funding mech- anisms for nutrition-related re- search should be established to identify best practices to opti- mizing nutrition care.

Principle 2: Redefine Clinicians’ Roles to Include Nutrition Care Providing effective nutrition interven- tion requires a champion within and collaboration among all disciplines involved in patient care. All health care professionals involved in patient care must be empowered to influence nu- trition decisions. In many hospitals, however, the responsibility for nutri- tion recommendations almost always rest solely with the dietitian. Many in- stitutions lack nurse and physician leaders who champion nutrition care. Interdisciplinary leadership is essential to ensure that nutrition care is valued and carries a high priority. To ensure effective management of hospital malnutrition, nurses and physicians must also play a role.

In this regard, the Alliance recom- mends redefining clinicians’ roles to include responsibility for optimal nutrition care, which can be accom- plished as follows:

� Interdisciplinary teams must discuss potential barriers and solutions to recognize and treat malnourished or at-risk patients in their hospitals.

� Engage nurses to understand nutrition risk factors such as un- derconsumed meals and actions required on positive malnutri- tion screenings. Develop and

OF NUTRITION AND DIETETICS 1227

Figure 3. The Alliance’s Approach to Interdisciplinary Nutrition Care. AND¼Academy of Nutrition and Dietetics; A.S.P.E.N.¼American Society for Parenteral and Enteral Nutrition; EHR¼electronic health record; ONS¼oral nutrition supplement; PCP¼primary care physician.

FROM THE ACADEMY

12

implement policies that allow nurses to provide nutrition care, suchas returning low-riskpatients to previous established feeding orders following temporary de- lays, initiating calorie counts, and measuring body weight as indi- cated. Policies that inhibit nursing action inhibit optimal patient nutrition. Prompt nursing action can reduce malnutrition by creating focused meal times, managing meal-time environ- ments and staff meal times, inter- vening with nutrition therapies as appropriate, and designating a nutrition care nurse in each clin- ical area to monitor and evaluate implementation of the policy.48

� Given the extensive nutrition expertise of dietitians, hospital administrators, such as a chief medical officer, must grant them

28 JOURNAL OF THE ACADEMY OF NUTRITIO

ordering privileges for ordering diets, ONS, vitamins, and calorie counts to eliminate inefficiencies and prevent delays in food and/or nutrient delivery. For example, at the University of Kansas Hospital (KUH), when faced with delays in care because the dietitian’s recommendations were not being noted and or- dered by physician teams, the nutrition support team obtained ordering privileges for all di- etitians. These privileges include ordering ONS, calorie counts, patient weights, zinc, vitamin C and multivitamins, and select nutrition-related labs. This was an important step in advancing nutrition care at KUH by pro- moting timely gathering of assessment data and nimble

N AND DIETETICS

implementation and revision of optimal nutrition interventions.

� Hospitalistsmust add nutrition to their interdisciplinary approach to patient care and serve as nutrition champions among phy- sicians. In support of this effort, hospitalists should include a die- titian andnutrition-focusednurse in team huddles and nutrition should be included in the daily problem list.

Principle 3: Recognize and Diagnose All Malnourished Patients and Those at Risk Given the high prevalence of hospital malnutrition, each hospital- ized patient must receive proper nutri- tion screening, with findings effectively communicated to ensure immediate assessment and prompt nutrition

September 2013 Volume 113 Number 9

Table 1. Validated malnutrition screening tools for hospitalized patientsa

Screening tool Parameters/scoring Development Validation

Malnutrition Screening Tool (MST)53

Weight loss, appetite; at-risk score �2

408 inpatients (mean age¼58 y); standard for comparison: SGAb; sensitivity 93%; specificity 93%

SGA: sensitivity 92%, specificity 61%; MNAc: sensitivity 92%, specificity 72%62

Mini Nutritional Assessment- Short Form (MNA-SF)56

Weight change, recent intake, BMI,d acute disease, mobility, dementia/depression; at-risk score �11

155 community-dwelling elders (mean age¼79 y); standard for comparison: physician assessment of nutritional status; sensitivity 98%; specificity 100% (MNA-SFe cut point �10)

MNA: sensitivity 90%, specificity 88% (MNA-SF cut point �11)63

MNA: sensitivity 89%, specificity 82% (MNA-SF cut point �11)64

“Nutritional assessment”: sensitivity 100%, specificity 38% (MNA-SF cut point �10)65

Malnutrition Universal Screening Tool (MUST)52,66

Weight change, recent/ predicted intake, BMI, acute disease; high-risk score �2

8,944 inpatients, review of 128 trials (mean age not reported); standard for comparison: nutrition support trials demonstrating improved clinical outcomes; sensitivity 75%; specificity 55%

SGA: sensitivity 61%, specificity 79%67

SGA: sensitivity 72%, specificity 90%; MNA: k¼0.3968

MNA: k¼0.5569

Nutritional Risk Screening 2002 (NRS-2002)54

Weight change, recent intake, BMI, acute disease, age; at-risk score �3

Adapted from Malnutrition Advisory Group screening tool

SGA: sensitivity 74%, specificity 87%; MNA: k¼0.3968

SGA: sensitivity 62%, specificity 63%67

MNA: k¼1.0070

Short Nutritional Assessment Questionnaire (SNAQª)55

Weight change, appetite, supplements/tube feeding; at-risk score �2

291 inpatients (mean age¼58 y); standard for comparison: BMI <18.5 or weight loss >5%; sensitivity 86%; specificity 89%

BMI <18.5 or recent weight loss >5%: sensitivity 79%, specificity 83%71

aAdapted with permission from Young and colleagues.51 bSGA¼Subjective Global Assessment. cMNA¼Mini Nutritional Assessment. dBMI¼body mass index; calculated as kg/m2. eSF¼short-form.

FROM THE ACADEMY

intervention. Using validated screening tools to identify at-risk patients is crucial because, for many health care professionals without nutrition train- ing, screening is currently a superficial observation wherein boxes are check- ed or unchecked without reliable

September 2013 Volume 113 Number 9

screening using a validated tool. Early identification of clinical criteria sup- porting malnutrition diagnosis and effective processes for communicating information related to the nutrition care process are often absent. Given these barriers, the Alliance is

JOURNAL OF THE ACADE

announcing this call to action to ensure prompt diagnosis and intervention of hospitalized patients who are malnourished or at risk for malnutri- tion. Every hospital must institute an interdisciplinary approach to nutrition care that is based on formal policies and

MY OF NUTRITION AND DIETETICS 1229

1. Have you lost weight recently without trying?

No 0

Unsure 2

If Yes, how much weight (kg) have you lost?

1 – 5 1

6 – 10 2

11 – 15 3

> 15 4

Unsure 2 Weight Loss Score:

2. Have you been eating poorly because of a decreased

appetite?

No 0

Yes 1 Appetite Score:

Total MST Score (weight loss + appetite scores)

Figure 4. Malnutrition Screening Tool (MST). Adapted with permission from Ferguson and colleagues.53

FROM THE ACADEMY

procedures ensuring the early identifi- cation of patients who are malnour- ished or at risk for malnutrition and implementation of comprehensive nutrition care plans.

Screening Comprehensive nutrition screening of all hospitalized patients is critical for both the timely identification of those at risk and to prioritize patients requiring nutrition assessment and intervention. The Alliance supports the Joint Commission’s recommendation for nutrition screening within 24 hours of admission to an acute-care hospital and at frequent intervals throughout hospitalization (Figure 3).49 Due to limited clinician time and nutrition knowledge, a simplified, practical, vali- dated screening tool must be used. Numerous tools exist to screen for malnutrition risk in hospitalized pa- tients.50,51 Although no universally accepted screening tool exists, it is important to select a tool that is prac- tical, easy to use, and has been validated in the patient population of interest. Currently, validated screening tools include theMalnutrition Screening Tool (MST), Mini Nutritional Assessment- Short Form (MNA-SF), Malnutrition

1230 JOURNAL OF THE ACADEMY OF NUTRI

Universal Screening Tool (MUST), Nutritional Risk Screening 2002 (NRS- 2002), and Short Nutritional Assess- ment Questionnaire (SNAQ)52-56

(Table 1). Important aspects of a nutri- tion screening tool include scientific validation, and easy administration requiring no specialized nutrition knowledge. For example, the advantage of the MST is that it is quick (takes <5 minutes) and straightforward, consists of two simple questions evaluating weight change and appetite (Figure 4) and was designed for use by busy health care professionals not neces- sarily trained in nutrition. These tools allow nutrition screening to become an integral part of routine clinical practice without being viewed as a burden or imposing a significant extra workload on hospital staff. Screening results must be docu-

mented within the electronic health record (EHR) to allow for prompt communication between the nursing staff and other health care team members. When a positive nutrition screen is obtained, the EHR should be configured to trigger a query for entry of a diet order or other appropriate intervention while the patient awaits further assessment and development of a nutrition care plan. Nurses must

TION AND DIETETICS

regularly rescreen patients with ade- quate nutrition status upon admission because many will become at risk for malnutrition during hospitalization. The MST can be easily completed while nurses interact with patients and their family/caregivers and while conducting regular assessments for patients at risk of pressure ulcers and falls.

Assessment and Diagnosis Nutrition assessment is a method of obtaining, verifying, and interpreting data needed to identify nutrition- related problems, their causes, and significance. The dietitian must per- form nutrition assessments in all pa- tients considered at risk based on nutrition screening to characterize and determine the cause of nutrition deficits. Traditionally, changes in acute- phase proteins, such as serum albumin and pre-albumin, were considered standard biomarkers for diagnosing malnutrition.11 However, it is now well documented that serum levels of these proteins are affected not only by nutrition status but also by inflamma- tion, fluid status, and other factors. Consequently, these are no longer considered reliable or specific bio- markers for malnutrition. Consistent with this evidence, as of 2012, the AND and A.S.P.E.N. no longer recommend using inflammatory biomarkers for diagnosis of malnutrition.

To address the need for guidance in this area, an International Guidelines group convened in 2009 and devel- oped an overarching etiology-based definition of malnutrition that takes into account the important relationship between disease and malnutrition.57

This broad definition describes three separate etiologies for malnutrition (Figure 5), two of which include the presence of disease (either acute or chronic). The AND and A.S.P.E.N. sub- sequently developed a standardized set of diagnostic criteria for adult malnu- trition in routine clinical practice using this new etiology-based definition.11

No single parameter is definitive for malnutrition; therefore, AND and A.S.P.E.N. proposed that malnutrition be diagnosed when at least two of the following six characteristics are iden- tified: (1) insufficient energy intake; (2) weight loss; (3) loss of subcutane- ous fat; (4) loss of muscle mass; (5) localized or generalized fluid

September 2013 Volume 113 Number 9

Figure 5. Etiology-based malnutrition definitions. Adapted with permission from White and colleagues.11

FROM THE ACADEMY

accumulation that may sometimes mask weight loss; and (6) diminished functional status. The magnitude and temporal aspects of change among these dynamic characteristics can be used to distinguish between nonsevere and severe malnutrition (Table 2). The Alliance recommends that all

clinicians become familiar with and use the AND and A.S.P.E.N. character- istics for identification and documen- tation of malnutrition (Figure 3).11 In patients with or at risk of malnutrition, development and initiation of a nutri- tion care plan must occur within 48 hours of admission. Several patient characteristics indicative of malnutri- tion (eg, weight loss, loss of muscle or fat, fluid retention, and cutaneous signs of micronutrient deficiencies, such as glossitis or cheliosis) can be identified during routine comprehensive assess- ments. As noted earlier, changes in acute-phase proteins should be inter- preted with caution and should not be used exclusively to diagnose malnutri- tion. These proteins are, however, good indicators of inflammation. In addition, other laboratory indicators of inflam- mation (eg, C-reactive protein, white blood cell count, and glucose levels) may be informative. A clear under- standing of the patient’s chief com- plaint and medical history is also important to appreciate the potential

September 2013 Volume 113 Number 9

for underlying inflammation, which can increase the risk of malnutrition by increasing metabolism. Conditions such as fever, infection, organ dys- function, and hyperglycemia may be indicative of underlying inflammation and contribute to an etiology-based diagnosis, including identification of currently well-nourished patients at risk for malnutrition. Obtaining adequate information

from the patient or caregiver regarding food and nutrient intake, body weight changes, and functional changes (eg, ability to purchase and cook food, and dental status) is essential to identify periods of insufficient intake. Changes in physical function (eg, ambulation, chewing ability, and mental status is- sues) must be assessed and monitored as appropriate based on individual pa- tient circumstances. Ensuring these various assessments are routinely and carefully performed is vital to an ac- curate diagnosis of malnutrition. In addition, specific fields for the AND and A.S.P.E.N. malnutrition characteristics must be completed so that system alerts are triggered when two of the six criteria are documented, thereby clearly communicating the malnutri- tion diagnosis to the health care team. Accurate coding of the malnutrition diagnosis as a complicating condition of the primary diagnosis is also critical

JOURNAL OF THE ACADE

to ensure adequate documentation to support appropriate reimbursement and tracking of costs to allow for a more accurate quantification of the burden of malnutrition in the future.

Principle 4: Rapidly Implement Comprehensive Nutrition Interventions and Continued Monitoring When a patient is identified as malnourished, appropriate nutrition intervention must be promptly ordered and fully implemented (Figure 3). Bar- riers to this ideal are varied, but often include: (1) NPO orders while patients await further assessment, (2) lack of nursing protocol orders focused on nutrition, (3) delay in assessment of nutrition status due to insufficient dietitian staffing, (4) dietitian recom- mendations unheeded due to the physician’s focus on other medical concerns, (5) physician uncertainty with product formulary and/or specific micronutrient therapy options in their hospitals, and (6) inadequate food consumption due to poor appetite, disease processes, and interruptions to mealtimes.

To overcome barriers to early and optimal nutrition intervention, the Alliance provides the following recommendations:

MY OF NUTRITION AND DIETETICS 1231

Table 2. Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition clinical characteristics that the clinician can obtain and document to support a diagnosis of malnutritiona

Clinical characteristicb

Malnutrition in the Context of Acute Illness or Injury

Malnutrition in the Context of Chronic Illness

Malnutrition in the Context of Social or

Environmental Circumstances

Moderatec Severed Moderate Severe Moderate Severe

(1) Energy intake: malnutrition is the result of inadequate food and nutrient intake or assimilation; thus, recent intake compared with estimated requirements is a primary criterion defining malnutrition. The clinician may obtain or review the food and nutrition history, estimate optimum energy needs, compare them with estimates of energy consumed, and report inadequate intake as a percentage of estimated energy requirements over time.

<75% of estimated energy requirement for >7 days

�50% of estimated energy requirement for �5 days

<75% of estimated energy requirement for �1 mo

�75% of estimated energy requirement for �1 mo

<75% of estimated energy requirement for �3 mo

�50% of estimated energy requirement for �1 mo

% Time % Time % Time % Time % Time % Time

(2) Interpretation of weight loss: The clinician may evaluate weight in light of other clinical findings, including the presence of under- or overhydration. The clinician may assess weight change over time reported as a percentage of weight lost from baseline. Physical findings Malnutrition typically results in changes to the physical examination. The clinician may perform a physical examination and document any one of the physical examination findings below as an indicator of malnutrition.

1-2 5 7.5

1 wk 1 mo 3 mo

>2 >5 >7.5

1 wk 1 mo 3 mo

5 7.5 10 20

1 mo 3 mo 6 mo 1 y

>5 >7.5 >10 >20

1 mo 3 mo 6 mo 1 y

5 7.5 10 20

1 mo 3 mo 6 mo 1 y

>5 >7.5 >10 >20

1 mo 3 mo 6 mo 1 y

(continued on next page)

FR O M

TH E A C A D EM

Y

1232 JO

U R N A L O F TH

E A C A D EM

Y O F N U TR

ITIO N

A N D

D IETETIC

S Septem

ber 2013

Volum e 113

N um

ber 9

Table 2. Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition clinical characteristics tha e clinician can obtain and document to support a diagnosis of malnutritiona (continued)

Clinical characteristicb

Malnutrition in the Context of Acute Illness or Injury

Malnutrition in the Context of Chronic Illness

Malnutrition in the Context of Social or

Environmental Circumstances

Moderatec Severed Moderate Severe M rate Severe

(3) Body fat: Loss of subcutaneous fat (eg, orbital, triceps, fat overlying the ribs).

Mild Moderate Mild Severe M Severe

(4) Muscle mass: Muscle loss (eg, wasting of the temples, clavicles, shoulders, interosseous muscles, scapula, thigh, and calf).

Mild Moderate Mild Severe M Severe

(5) Fluid accumulation: The clinician may evaluate generalized or localized fluid accumulation evident on examination (extremities, vulvar/ scrotal edema, or ascites). Weight loss is often masked by generalized fluid retention (edema), and weight gain may be observed.

Mild Moderate to severe Mild Severe M Severe

(6) Reduced grip strength: Consult normative standards supplied by the manufacturer of the measurement device.

NAe Measurably reduced NA Measurably reduced NA Measurably reduced

aAdapted with permission from White and colleagues.11 Height and weight should be measured rather than estimated to determine body mass index. Usual weight should be obtained to d ine the percentage and to determine the significance of weight loss. Basic indicators of nutrition status such as body weight, weight change, and appetite may improve substantively with refeeding in the absence of inflammation. Refeeding r nutrition support may stabilize but not significantly improve nutrition parameters in the presence of inflammation. The National Center for Health Statistics defines chronic as a disease/condition lasting �3 months. Serum proteins such as s albumin or prealbumin are not included as defining characteristics of malnutrition because recent evidence analysis shows that serum levels of these proteins do not change in response to changes in nutrient intake. bA minimum of 2 of the 6 characteristics is recommended for diagnosis of either severe or nonsevere malnutrition. cThe International Classification of Diseases, 9th Revision (ICD-9) code for moderate malnutrition is 263.0. dThe International Classification of Diseases, 9th Revision (ICD-9) code for severe malnutrition is 262.0. eNA¼not applicable.

FR O M

TH E A C A D EM

Y

Septem ber

2013 Volum

e 113

N um

ber 9

JO U R N A L O F TH

E A C A D EM

Y O F N U TR

ITIO N

A N D

D IETETIC

S 1233

t th

ode

ild

ild

ild

eterm and/o erum

Practices

1. Screen every admitted patient for malnutrition, regardless of physical appearance 2. Make every effort to ensure that patients receive all ENa or PNb as prescribed to maximize benefit 3. Develop procedures to provide ONSc in between meals or with medication administration to increase overall energy and

nutrient intake 4. Create a focused meal time and supportive meal-time environment 5. Take notice of patient meal consumption

� Be vigilant to the amount of food eaten � Sharing findings among the team (eg, during team huddles) facilitates development of a targeted nutritional plan

6. Stay alert to missed meals � Develop procedures to provide patients with meals at “off times” if patient was not available or under a restricted diet

at the time of meal delivery 7. Avoid disconnecting EN or PN for patient repositioning, ambulation, travel, or procedures

8. Consider managing symptoms of gastrointestinal distress while continuing to administer POd diet or EN � Nutrients may be administered while the source of distress is being identified and treated

9. Remain mindful of “holds” on PO diets or EN relative to procedures � Take action to reduce the amount of time that a patient’s intake is restricted

10. Identify medications and disease conditions that interfere with nutrient absorption � Develop plans to minimize the impact

aEN¼enteral nutrition by tube feeding methods. bPN¼parenteral nutrition. cONS¼oral nutrition supplements. dPO¼per oral.

Figure 6. Practices to support implementation of nutrition intervention.

FROM THE ACADEMY

12

� Unless specific contraindications exist, prompt nutrition interven- tion for all malnourished patients must be a high priority. Patients whose nutrition status is identi- fied as at risk through screening must be fed within 24 hours by nurses while awaiting a nutrition consult, unless contraindicated. Examples of immediate nutrition interventions can include modifi- cations to diet, assistance with ordering and eating meals, initia- tion of calorie counts, and/or addition of ONS. In many cases, establishing automated processes that trigger upon a positive screening will best accomplish rapid intervention (eg, prompting by the EHR to place a diet order).

� Standard practices to maximize nutrient consumption must be adopted. Figure 6 lists some practical approaches to support optimal nutrition. In some cases, it is as simple as staying alert to missed or poorly consumed meals and communicating such events to the dietitian so that

34 JOURNAL OF THE ACADEMY OF NUTRITIO

appropriate adjustments are made.

� Actual consumption must be monitored and intervention ad- justed as appropriate. Clinicians must adhere closely to the doc- umented nutrition care plan and document success or failure in the daily medical record. Results of watchful monitoring inform necessary changes to the nutrition care plan so that short- and long-term goals can be achieved. For example, incomplete con- sumption of items on the meal tray must prompt the nurse to have adiscussionwith the patient, and, depending on the severity of the intake deficit, underlying nutritional status, and other clin- ical issues, to call a nutrition huddle.

Principle 5: Communicate Nutrition Care Plans All aspects of a patient’s nutrition care plan, including serial assessment and treatment goals, must be carefully

N AND DIETETICS

documented in the EHR, regularly updated, and effectively communicated to all health care providers (Figure 3). This will allow informed engagement by all providers and continuity of treatment if the patient is transferred to another care setting. In addition, accurate and thorough documentation is essential for proper disease coding.58

For example, prior to 2012, only severe malnutrition could be coded as a complicating condition with a primary diagnosis. However, as of October 2012, mild or moderate malnutrition can now be coded as a complicating con- dition.59 In practice, however, proper documentation and communication do not always occur. Most often, nutrition status and progress are not adequately documented in the medical record, making it difficult to determine when and if patients are consuming food and supplements. In addition, nutrition standard operating procedures and EHR-triggered care are often lacking in the hospital, and nutrition care plans and medical conditions are poorly communicated to post-acute facilities and primary care physicians.

September 2013 Volume 113 Number 9

FROM THE ACADEMY

The Alliance recommends the following strategies to improve docu- mentation and communication of the patient’s nutrition care plan, including leveraging the various forms of EHR systems now routine in most hospitals.

� Nutrition care must be formally documented via the central area on the medical record or in the EHR with the following compo- nents: (1) nutrition screening results; (2) comprehensive nu- trition assessment data, including those obtained from a nutrition- focused physical assessment; (3) nutrition diagnosis; (4) nutrient�medication interactions and diagnosis-related alterations in requirements; (5) nutrition in- tervention(s) ordered and plan- ned goals; (6) dietary intake pattern, including percentage of food consumed with each meal and consumption of any ordered ONS; and (7) monitoring and evaluation plan with specific indices and timeframe for re- assessment.

� Hospitals must create and maintain standardized policies, procedures, and EHR-automated triggers relevant to nutrition, including nutrition-related and specific diet order sets and pro- tocols in the hospital’s EHR (eg, algorithms for initiating ONS, EN and PN orders).

� Nutrition care plan documenta- tion must be included in the discharge summary to ensure that post-acute facilities/clini- cians fully understand all aspects of the nutrition care plan, including goals, intervention, necessary resources, monitoring, and evaluation.

Principle 6: Develop a Comprehensive Discharge Nutrition Care and Education Plan A comprehensive, systematic approach to managing nutrition from admission through discharge and beyond is needed to consistently improve quality of care (Figure 3). The risk always ex- ists that nutrition goals achieved in the inpatient setting may be lost if the continuity of care is not adequately addressed at the time of discharge.7,60

In practice, patients and family

September 2013 Volume 113 Number 9

members/caregivers are rarely edu- cated adequately on nutrition care by the hospital team.61 Moreover, patient adherence to nutrition orders during and following a hospital stay is often poor, and not all physicians are familiar with the proper elements of a dis- charge nutrition care plan. Failing to address these challenges could result in nutrition care shortcomings at one of the most vulnerable stages in a pa- tient’s recovery. To ensure continuity of care, systems

must be put in place to provide pa- tients, family members, and caregivers with nutrition education and a com- prehensive post-hospitalization nutri- tion care plan. Toward this end, the Alliance makes the following recommendations:

� Nutrition must be a component of all clinicians’ conversations with patients and their family/ caregivers.

� The patient’s nutrition status, nutrition recommendations and other interventions (eg, ONS, vitamin and mineral supple- ments, and access to food), and the post-discharge nutrition care plan must be explained by the clinical care team throughout the inpatient stay and docu- mented in the EHR.

� Follow-up nutrition assessment and education, combined with specific follow-up appointment information must be provided to the patient and/or caregiver at time of discharge.

� Hospitals must develop clear, standardized, written instruc- tions for nutrition care at home, including the rationale for and details on diet instruction and any recommended ONS, vitamin and/or mineral supplements that can be given to the patient and his or her caregiver upon hospi- tal discharge.

� Nurses who manage patient transitions at discharge must prioritize nutrition within the care plan. Post-hospitalization phone calls must be adapted to include questions about dietary intake, weight change, and ac- cess to food with concerns brought to the dietitian’s atten- tion. Dietitians should be used to manage post-hospital transitions

JOURNAL OF THE ACADEMY

for patients that have malnutri- tion as a primary or secondary diagnosis. Ensuring nutrition care is part of the transition to home is a key step in reducing hospital readmissions.

CONCLUSIONS With the changing health care envi- ronment, quality patient care and cost containment are of utmost importance. Early and automated nutrition inter- vention coupled with clinician collab- oration is critical in remediating the issue of malnutrition in hospitals and has a strong potential to improve pa- tient care and reduce hospital costs. Successful management of hospital malnutrition requires an interdisci- plinary team approach and leadership that fosters open communication among disciplines. To be successful, all members of the health care team must understand the importance of nutrition care in improving patient outcomes and the financial impact of failing to address this problem. Processes must be put into place to ensure that appropriate nutrition intervention is provided and patients’ nutrition status is routinely monitored. Finally, addi- tional evidence quantifying the value of nutrition care must be assessed through broad research efforts, ranging from outcomes research to prospective randomized controlled clinical trials. Funding for these initiatives is needed from institutional, federal, foundation, and industry sources. Without ques- tion, nutrition care must be made a high priority and systematized in US hospitals.

This article is a call to action from the Alliance, challenging hospital-based clinicians to incorporate the proposed principles to evoke meaningful im- provement in nutrition care within their institutions. This call marks a step change in efforts to date to improve nutrition among hospitalized patients. For the first time, it unites professional organizations in a common pursuit to raise awareness about the problem of hospital malnutrition and make meaningful progress toward early nutrition intervention and improved hospital treatment practices with the ultimate goal of improving quality of care and reducing costs. To accomplish this will require interdisciplinary collaboration by dietitians, nurses, and

OF NUTRITION AND DIETETICS 1235

FROM THE ACADEMY

physicians throughout the continuum of care so that patients receive excel- lent nutrition care in the hospital and after discharge.

References 1. Barker LA, Gout BS, Crowe TC. Hospital

malnutrition: Prevalence, identification and impact on patients and the health- care system. Int J Environ Res Public Health. 2011;8(2):514-527.

2. Bistrian BR, Blackburn GL, Hallowell E, Heddle R. Protein status of general surgi- cal patients. JAMA. 1974;230(6):858-860.

3. Christensen KS, Gstundtner KM. Hospital- wide screening improves basis for nutri- tion intervention. J Am Diet Assoc. 1985;85(6):704-706.

4. Lim SL, Ong KC, Chan YH, et al. Malnu- trition and its impact on cost of hospi- talization, length of stay, readmission and 3-year mortality. Clin Nutr. 2012;31(3): 345-350.

5. Somanchi M, Tao X, Mullin GE. The facil- itated early enteral and dietary manage- ment effectiveness trial in hospitalized patients with malnutrition. JPEN J Parenter Enteral Nutr. 2011;35(2):209-216.

6. Butterworth C. The skeleton in the hos- pital closet. Nutrition Today. 1974;9(2): 4-8.

7. Kirkland LL, Kashiwagi DT, Brantley S, Scheurer D, Varkey P. Nutrition in the hospitalized patient. J Hosp Med. 2013;8(1):52-58.

8. Singh H, Watt K, Veitch R, Cantor M, Duerksen DR. Malnutrition is prevalent in hospitalized medical patients: Are housestaff identifying the malnourished patient? Nutrition. 2006;22(4):350-354.

9. Braunschweig C, Gomez S, Sheean PM. Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. J Am Diet Assoc. 2000;100(11):1316-1322. quiz 1323-1314.

10. Dorland’s Illustrated Medical Dictionary. 32nd ed. New York, NY: Elsevier Health Sciences; 2011.

11. White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement of the Academy of Nutrition and Dietetics/ American Society for Parenteral and Enteral Nutrition: Characteristics re- commended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.

12. Jarvis WR. Selected aspects of the socio- economic impact of nosocomial in- fections: Morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol. 1996;17(8):552-557.

13. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: Attributable mortality, excess length of hospitalization, and extra costs. Infect Con- trol Hosp Epidemiol. 1999;20(11):725-730.

14. Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg. 2010;145(2): 148-151.

15. Schneider SM, Veyres P, Pivot X, et al. Malnutrition is an independent factor

1236 JOURNAL OF THE ACADEMY OF NUTRI

associated with nosocomial infections. Br J Nutr. 2004;92(1):105-111.

16. Demling RH. Nutrition, anabolism, and wound healing proces: An overview. EPlasty. 2009;9:65-94.

17. Paddon-Jones D, Sheffield-Moore M, Cree MG, et al. Atrophy and impaired muscle protein synthesis during pro- longed inactivity and stress. J Clin Endo- crinol Metab. 2006;91(12):4836-4841.

18. Paddon-Jones D, Sheffield-Moore M, Urban RJ, et al. Essential amino acid and carbohydrate supplementation amelio- rates muscle protein loss in humans during 28 days bedrest. J Clin Endocrinol Metab. 2004;89(9):4351-4358.

19. Moran L, Custer P, Murphy G. Nutritional assessment of lean body mass. JPEN J Parenter Enteral Nutr. 1980;4:595.

20. Lyder CH, Preston J, Grady JN, et al. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med. 2001;161(12):1549-1554.

21. Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011;6(2):54-60.

22. Kassin MT, Owen RM, Perez SD, et al. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg. 2012;215(3):322-330.

23. Mudge AM, Kasper K, Clair A, et al. Recurrent readmissions in medical pa- tients: A prospective study. J Hosp Med. 2011;6(2):61-67.

24. Krumholz HM. Post-hospital syndrome— An acquired, transient condition of generalized risk. N Engl J Med. 2013; 368(2):100-102.

25. Russell C. The impact of malnutrition on healthcare costs and economic consider- ations for the use of oral nutritional sup- plements. Clin Nutr Suppl. 2007;2:25-32.

26. Avenell A, Handoll HH. Nutritional sup- plementation for hip fracture after care in older people. Cochrane Database Syst Rev 2010 Jan 20;(1):CD001880.

27. Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev. 2009 Apr 18;(2):CD003288.

28. Stratton RJ, Green CJ, Elia M. Disease- Related Malnutrition: An Evidence-Based Approach to Treatment. Wallingford, UK: CABI Publishing; 2003.

29. Avenell A, Handoll HH. Nutritional sup- plementation for hip fracture aftercare in older people. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001880.

30. Brugler L, DiPrinzio MJ, Bernstein L. The five-year evolution of a malnutrition treatment program in a community hos- pital. Jt Comm J Qual Improv. 1999;25(4): 191-206.

31. Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev. 2012;11(2):278-296.

32. Gariballa S, Forster S, Walters S, Powers H. A randomized, double-blind, placebo- controlled trial of nutritional supple- mentation during acute illness. Am J Med. 2006;119(8):693-699.

TION AND DIETETICS

33. Milne AC, Potter J, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Data- base Syst Rev 2005 Apr 19;(2):CD003288.

34. Milne AC, Avenell A, Potter J. Meta-anal- ysis: Protein and energy supplementation in older people. Ann Intern Med. 2006; 144(1):37-48.

35. Neelemaat F, Lips P, Bosmans JE, et al. Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older adults. J Am Geriatr Soc. 2012;60(4):691-699.

36. Philipson TJ, Snider JT, Lakdawalla DN, Stryckman B, Goldman DP. Impact of oral nutritional supplementation on hospital outcomes. Am J Manag Care. 2013;19(2): 121-128.

37. Baldwin C, Weekes CE. Dietary advice with or without oral nutritional supple- ments for disease-related malnutrition in adults. Cochrane Database Syst Rev. 2011 Sept 7;(9):CD002008.

38. Stratton RJ, Ek AC, Engfer M, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: A system- atic review and meta-analysis. Ageing Res Rev. 2005;4(3):422-450.

39. Beck AM, Holst M, Rasmussen HH. Oral nutritional support of older (65 yearsþ) medical and surgical patients after discharge from hospital: Systematic re- view and meta-analysis of randomized controlled trials. Clin Rehabil. 2013;27(1): 19-27.

40. Burden S, Todd C, Hill J, Lal S. Pre-opera- tive nutrition support in patients under- going gastrointestinal surgery. Cochrane Database Syst Rev. 2012 Nov 14;11: CD008879.

41. Hendry PO, van Dam RM, Bukkems SF, et al. Randomized clinical trial of laxatives and oral nutritional supplements within an enhanced recovery after surgery pro- tocol following liver resection. Br J Surg. 2010;97(8):1198-1206.

42. Langer G, Grossmann K, Fleischer S, et al. Nutritional interventions for liver- transplanted patients. Cochrane Database Syst Rev. 2012 Aug 15;8:CD007605.

43. Elia M, Zellipour L, Stratton RJ. To screen or not to screen for adult malnutrition? Clin Nutr. 2005;24(6):867-884.

44. National Hospital Discharge Survey: 2009 Table, number and rate of hospital discharges. www.cdc.gov/nchs/fastats/ hospital.htm. Accessed February 24, 2013.

45. Willard C, Luker K.Workingwith the team: Strategies employed by hospital cancer nurse specialists to implement their role. J Clin Nurs. 2007;16(4):716-724.

46. Skipper A, Young M, Rotman N, Nagl H. Physicians’ implementation of dietitians’ recommendations: A study of the effec- tiveness of dietitians. J Am Diet Assoc. 1994;94(1):45-49.

47. Hiesmayr M, Schindler K, Pernicka E, et al. Decreased food intake is a risk factor for mortality in hospitalised patients: The NutritionDay survey 2006. Clin Nutr. 2009;28(5):484-491.

48. Jefferies D, Johnson M, Ravens J. Nurturing and nourishing: The nurses’ role in nutritional care. J Clin Nurs. 2011;20(3-4):317-330.

September 2013 Volume 113 Number 9

FROM THE ACADEMY

49. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation for Hospitals. Chicago, IL: Joint Commission on Accreditation for Healthcare Organizations; 2007.

50. Anthony PS. Nutrition screening tools for hospitalized patients. Nutr Clin Pract. 2008;23(4):373-382.

51. Young AM, Kidston S, Banks MD, Mudge AM, Isenring EA. Malnutrition screening tools: Comparison against two validated nutrition assessment methods in older medical inpatients. Nutrition. 2013;29(1):101-106.

52. Elia M, ed. The "MUST" report. Nutritional Screening of Adults: A Multidisciplinary Responsibility. Redditch: BAPEN; 2003.

53. Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition. 1999;15(6): 458-464.

54. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z. Nutritional risk screening (NRS 2002): A new method based on an anal- ysis of controlled clinical trials. Clin Nutr. 2003;22(3):321-336.

55. Kruizenga HM, Van Tulder MW, Seidell JC, et al. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr. 2005;82(5):1082-1089.

56. Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for under- nutrition in geriatric practice: Developing the short-form mini-nutritional assess- ment (MNA-SF). J Gerontol A Biol Sci Med Sci. 2001;56(6):M366-M372.

57. Jensen GL, Mirtallo J, Compher C, et al. Adult starvation and disease-related

September 2013 Volume 113 Number 9

malnutrition: A proposal for etiology- based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr. 2010;34(2):156-159.

58. Funk KL, Ayton CM. Improving malnutri- tion documentation enhances reim- bursement. J Am Diet Assoc. 1995;95(4): 468-475.

59. Department of Health and Human Ser- vices. Centers for Medicare & Medicaid Services. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Pro- spective Payment System and Fiscal Year 2013 rates (CMS-1588-P). Fed Reg. 2012;77(92):27870-28192. http://www. gpo.gov/fdsys/pkg/FR-2012-05-11/pdf/ 2012-9985.pdf. Accessed December 25, 2012.

60. Ukleja A, Freeman KL, Gilbert K, et al. Standards for nutrition support: Adult hospitalized patients. Nutr Clin Pract. 2010;25(4):403-414.

61. Murphy JL, Girot EA. The importance of nutrition, diet and lifestyle advice for cancer survivors—The role of nursing staff and interprofessional workers. J Clin Nurs. 2013;22(11-12):1539-1549.

62. Correia JR, Martins CA, Amaral TF. Effi- ciency of MST—Malnutrition Screening Tool—in elderly hospitalised patients. Clin Nutr. 2003;22:S10-S11.

63. Lei Z, Qingyi D, Feng G, et al. Clinical study of mini-nutritional assessment for older Chinese inpatients. J Nutr Health Aging. 2009;13(10):871-875.

64. Kaiser MJ, Bauer JM, Ramsch C, et al. Validation of the Mini Nutritional Assessment short-form (MNA-SF): A

JOURNAL OF THE ACADE

practical tool for identification of nutri- tional status. J Nutr Health Aging. 2009;13(9):782-788.

65. Ranhoff AH, Gjoen AU, Mowe M. Screening for malnutrition in elderly acute medical patients: The usefulness of MNA-SF. J Nutr Health Aging. 2005;9(4): 221-225.

66. Malnutrition Universal Screening Tool. www.bapen.org.uk/musttoolkit.html. Accessed November 30, 2012.

67. Kyle UG, Kossovsky MP, Karsegard VL, Pichard C. Comparison of tools for nutri- tional assessment and screening at hos- pital admission: A population study. Clin Nutr. 2006;25(3):409-417.

68. Velasco C, Garcia E, Rodriguez V, et al. Comparison of four nutritional screen- ing tools to detect nutritional risk in hospitalized patients: A multicentre study. Eur J Clin Nutr. 2011;65(2):269- 274.

69. Stratton RJ, Hackston AJ, Price S, Joseph K, Elia M. Concurrent validity of the newly developed Malnutrition Universal Screening Tool (‘MUST’) with Mini Nutritional Assessment and Subjective Global Assessment Tools. Proc Nutr Soc. 2004;63:17A.

70. Martins CP, Correia JR, do Amaral TF. Undernutrition risk screening and length of stay of hospitalized elderly. J Nutr Elder. 2005;25(2):5-21.

71. Kruizenga HM, Seidell JC, de Vet HC, Wierdsma NJ, van Bokhorst-de van der Schueren MA. Development and valida- tion of a hospital screening tool for malnutrition: The short nutritional assessment questionnaire (SNAQ). Clin Nutr. 2005;24(1):75-82.

AUTHOR INFORMATION K. A. Tappenden is Kraft Foods Human Nutrition Endowed Professor, Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, IL (The Academy of Nutrition and Dietetics). B. Quatrara is a clinical nurse specialist, University of Virginia Health System, Charlottesville, VA (Academy of Medical-Surgical Nurses). M. L. Parkhurst is an associate professor of medicine, University of Kansas Medical Center, Kansas City, KS (Society of Hospital Medicine). A. M. Malone is a nutrition support dietitian, Mt Carmel West Hospital, Columbus, OH (American Society for Parenteral and Enteral Nutrition). G. Fanjiang is Vice President, Medical Affairs, Abbott Nutrition, Columbus, OH. T. R. Ziegler is a professor of medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA (Society of Hospital Medicine).

Address correspondence to: Kelly A. Tappenden, PhD, RD, FASPEN, Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, 443 Bevier Hall, 905 South Goodwin Avenue, Urbana, IL 61801. E-mail: [email protected]

STATEMENT OF POTENTIAL CONFLICT OF INTEREST K. A. Tappenden, B. Quatrara, M. L. Parkhurst, T.R. Ziegler, and A. M. Malone are members of the Steering Committee of the Alliance to Advance Patient Nutrition who have been chosen by the professional organizations they represent and reimbursed for Alliance-related expenses. Abbott Nutrition has provided funding to the member organizations of the Alliance and to Marithea Goberville, PhD, of Science Author, Inc, for writing assistance.

FUNDING/SUPPORT There is no funding to disclose.

MY OF NUTRITION AND DIETETICS 1237