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Courtney Bliss, MS RDN CNSC

June 7, 2019

AZAND Annual Conference

“Together Towards Tomorrow”

A Study to Validate the Malnutrition Clinical Characteristics and Quantify Dietitian Staffing Levels to Improve Medical Outcomes

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Disclosures

Current fellow of The Academy of Nutrition and

Dietetics Foundation • Supporting study execution

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Learning Outcomes

Upon completion of this presentation,

attendees will be able to describe current:

• MCC/NFPE evidence

• RD staffing metrics

• AND malnutrition initiatives

• needs in acute care nutrition assessment and

diagnosis of malnutrition

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Overview

• About me

• Malnutrition and Assessment

• Outcomes

• Staffing

• MCC and Staffing Study

• Advanced research training opportunities

• Questions

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About Me

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Current Status of Malnutrition

Incidence• Approx 4% hospitalized pediatric patients are

malnourished

• An estimated 50% of adult hospitalized patients

are at risk

Underdiagnosed, undertreated in hospitalized

patients

Longer LOS and higher hospital costs

No gold standard for diagnosis

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Current Nutrition Assessment

Screening tools

• STAMP, STRONGKids

• MST

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Current Nutrition Assessment

Subjective Global Assessment

Nutrition Focused Physical Exam (NFPE)

• Fat & Muscle Wasting

• Micronutrient Deficiencies

Biochemical markers

• Albumin, prealbumin, CRP

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Malnutrition Clinical Characteristics

MCC for adults include insufficient energy intake,

weight loss, loss of muscle mass, loss of

subcutaneous fat, fluid accumulation, and

diminished functional status (measured via hand

grip strength)

• The presence of two or more of the clinical

characteristics can be used to establish the

diagnosis of malnutrition

Consensus decision – not validated measures or

tools

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Malnutrition Clinical Characteristics

MCC for pediatric patients, when only one data point is

available, the recommended MCC include weight-for-

height/length z-score, body mass index for age z-score,

length/height-for-age z-score, and mid-upper arm

circumference z-score.

• When additional data points are available,

recommended indicators include weight gain

velocity for children <2 years old, weight loss for

children 2-20 years of age, deceleration in weight-

for-length/height z-score, and inadequate nutrient

intake.

Consensus decision – not validated measures or tools 10

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Current Staffing Metrics

Varies by state and patient populations

Presumed best practice vs legal protections

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Current Needs

Validation of MCC

• No systematic, universally accepted method of

diagnosing malnutrition

Need for large scale data across populations and

regions

• Malnutrition prevalence in hospitalized patients

Best practice for staffing

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MCC and Staffing Study Overview

Goal is to validate MCC against medical

outcomes

Quantify RD care/time required to improve

outcomes

Results will inform staffing levels for inpatient

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Study Design

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Nutrition and Medical Outcomes

Primary medical outcomes for study are Length

of Stay (LOS), mortality/morbidity, and

readmissions/ED visits after discharge

DRG is a confounder/covariate

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Recruitment and Enrollment

Goal• 60-120 facilities

• 6 host sites

• Approx 4800 subjects

Current numbers• Working with ~65 adult facilities

• Working with ~42 pediatric facilities

Staggered training and enrollment

Subject enrollment to begin in July

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Benefits

Networking

Continuing Education and Training

Participation in national initiatives withframework and support staff

FUN!!

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Current Experiences

Networking

Recruitment to non-Academy members

Clinicians as researchers• Research experience

• Generational differences

Hospital systems

Protected research time

Host/Training Site Recruitment

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Advanced training

• Non-traditional methods

• Providing CEUs as part of research training

• Participation in national initiatives

• Fellowships

• Improved practice, stronger teams,

improved patient outcomes

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Fellowship

• Collaborative effort

• Advance skills

• Unique educational opportunities

• Expand practitioner expertise, including

leadership skills

• Demonstrate RDN value

• Networking

• Passion

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My Experience

• Collaborative effort• Networking

• Advance skills • Research

• Leadership

• Unique educational opportunities

• Demonstrate RDN value

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Together Towards Tomorrow

• MCC and NFPE as standard of care

• Large scale nutrition research utilizing

clinicians

• Standardized recommendations

• Diversified training opportunities

• RDNs better situated to affect change

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Thank you!

Questions?Study Email: MCC@eatright.org

My Email: feedingbliss@gmail.com

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References

Lakdawalla DN, Mascarenhas M, Jena AB, et al. Impact of Oral Nutrition Supplements on Hospital

Outcomes in Pediatric Patients. J Parenter Enter Nutr. 2014;38(2_suppl):42S-49S.

doi:10.1177/0148607114549769

Abdelhadi RA, Bouma S, Bairdain S, et al. Characteristics of Hospitalized Children With a Diagnosis

of Malnutrition. J Parenter Enter Nutr. 2016;40(5):623-635. doi:10.1177/0148607116633800

Carvalho-Salemi J, Salemi JL, Wong-Vega MR, et al. Malnutrition among Hospitalized Children in

the United States: Changing Prevalence, Clinical Correlates, and Practice Patterns between

2002 and 2011. J Acad Nutr Diet. 2018;118(1):40-51.e7. doi:10.1016/j.jand.2017.02.015

Somanchi M, Tao X, Mullin GE. The Facilitated Early Enteral and Dietary Management Effectiveness

Trial in Hospitalized Patients With Malnutrition. J Parenter Enter Nutr. 2011;35(2):209-216.

doi:10.1177/0148607110392234

Agarwal E, Ferguson M, Banks M, et al. Malnutrition and poor food intake are associated with

prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: Results from

the Nutrition Care Day Survey 2010. Clin Nutr. 2013;32(5):737-745.

doi:10.1016/J.CLNU.2012.11.021

Lim SL, Ong KCB, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of

hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr. 2012;31(3):345-350.

doi:10.1016/J.CLNU.2011.11.001

Keller H, Allard JP, Laporte M, et al. Predictors of dietitian consult on medical and surgical wards.

Clin Nutr. 2015;34(6):1141-1145. doi:10.1016/J.CLNU.2014.11.011

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References

Raslan M, Gonzalez MC, Torrinhas RSMM, Ravacci GR, Pereira JCR, Waitzberg DL.

Complementarity of Subjective Global Assessment (SGA) and Nutritional Risk Screening 2002

(NRS 2002) for predicting poor clinical outcomes in hospitalized patients. Clin Nutr.

2011;30(1):49-53. doi:10.1016/J.CLNU.2010.07.002

Philipson T, Snider J, Lakdawalla, DN Stryckman B, Goldman B. Impact of oral nutritional

supplementation on hospital outcomes. Am J Manag Care. 2013;19(2):121-128.

Becker PJ, Nieman Carney L, Corkins MR, et al. Consensus statement of the Academy of Nutrition

and Dietetics/American Society for Parenteral and Enteral Nutrition: indicators recommended for

the identification and documentation of pediatric malnutrition (undernutrition). J Acad Nutr Diet.

2014;114(12):1988-2000. doi:10.1016/j.jand.2014.08.026

White J V, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and

Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for

the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet.

2012;112(5):730-738. doi:10.1016/j.jand.2012.03.012

Hand RK, Jordan B, DeHoog S, Pavlinac J, Abram JK, Parrott JS. Inpatient Staffing Needs for

Registered Dietitian Nutritionists in 21st Century Acute Care Facilities. J Acad Nutr Diet.

2015;115(6):985-1000. doi:10.1016/J.JAND.2015.01.013

Phillips W. Clinical nutrition staffing benchmarks for acute care hospitals. J Acad Nutr Diet.

2015;115(7):1054-1056. doi:10.1016/j.jand.2015.03.020

Corkins MR, Guenter P, DiMaria-Ghalili RA, et al. Malnutrition Diagnoses in Hospitalized Patients. J

Parenter Enter Nutr. 2014;38(2):186-195. doi:10.1177/0148607113512154

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Study Aims

Assess the interrater reliability of the MCC.

Determine the predictive validity of the adult and

pediatric MCC relative to a portfolio of patient

medical outcomes.

Determine the relationship between the adult and

pediatric MCC and body composition

measurements conducted via bioelectrical

impedance analysis (BIA) in a subset of

patients.

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Study Aims

Identify the utility of BIA for body composition analysis in

clinical settings.

Estimate the level of RDN care necessary to improve patient

outcomes within the portfolio of outcomes. Specifically:

quantify the dose (minutes of care and frequency of

encounters) of RDN care that is associated with improved

medical outcomes in patients already identified as requiring

nutrition care, after adjusting for disease severity and other

potential confounders.

Identify the additional level of RDN care necessary to improve

the medical outcomes in patients who have been identified

as malnourished using the MCC.

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