10/31/18. Malnutrition risk screening. Start to finish: diagnosing malnutrition from preterm infants to adults

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1 Start to finish: diagnosing malnutrition from preterm infants to adults Patricia J Becker MS RDN CSP CNSC Dayton Children s Hospital Medical Center Learning objectives: at the conclusion of the session attendees will be able to: 1. describe quality pediatric malnutrition care 2. state the tools needed to provide quality pediatric malnutrition care 3. identify the benefits of using standardized indicators What it is Why we do it What come next Malnutrition risk screening 1

2 What is it? A screen(ing) is a test or a tool that identifies the risk of a problem or condition / diagnosis. Malnutrition screening determines the risk of malnutrition / assessment determines the presence of malnutrition and allows for the diagnosis and assignment of levels of acuityseverity There are as many types of screens as there are problems / conditions-diseases. So there is no overall best screening tool or test for all nutrition problems However, it is probable (in my opinion) that there could be on overall malnutrition screening for children that could be used in all settings Why do we do it? Malnutrition screening is a supportive task that triggers entry into the NCP It identifies children who need to be seen by the pediatric dietitian Pediatric Malnutrition Screening Nutrition Screening: A process to identify a child (0-18 years) who is at nutritional risk for nutrition related problems, and should be referred to an RDN for nutrition assessment. may be conducted in any practice setting. tools should be quick, easy to use, valid and reliable for the patient, population, setting. The nutrition screening process and parameters are established by the institution by a multidisciplinary team (including RDNs) Nutrition screening is carried out by medical professionals who have been trained in the screening process. Nutrition screening / rescreening should occur within a designated- appropriate timeframe. 2

3 Research Questions The Academy of Nutrition and Dietetic Association Evidence Analysis Library Pediatric Nutrition Screening Project RQ1. What is the validity and reliability of specific nutrition screening tools for identifying risk of malnutrition related to under- and over-nutrition in the pediatric population? RQ2. Is there a difference in validity and reliability among users of nutrition screening tools? Results for RQ1 and RQ2 After many months of research and evaluating articles, we found 14 screening tools 8 inpatient/hospital setting 3 outpatient or specialty clinic setting 3 community setting Inpatient/Hospital Setting 1. Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) Developed in the United Kingdom for hospitalized children 2-17 years old Screen includes anthropometrics, clinical diagnosis and nutrient intake 2. Screening Tool for Risk on Nutritional Status and Growth (STRONGKIDS) Developed in the Netherlands Screen includes anthropometrics, subjective global assessment, high risk disease and nutrient intake and losses 3. Paediatric Yorkhill Malnutrition Score (PYMS) Developed in the United Kingdom based on European Society of Clinical Nutrition and Metabolism screening guidelines Screen includes anthropometrics, changes in nutrient intake and the predicted effect of the current medical condition on nutritional status 3

4 Inpatient/Hospital Setting 4. Paediatric Malnutrition Screening Tool (PMST) Modified version of STAMP to include children <2 years of age Screen includes anthropometrics, clinical diagnosis and nutrient intake 5. Pediatric Nutrition Screening Tool (PNST) Developed in Australia Simple 4 question screen including anthropometrics and food intake What Does It Mean to Say a Tool Is Valid? Ability of nutrition screening tool to identify those at malnutrition risk versus those who are not at risk Compare results of screening tool with reference standard (criterion validity) Reference standard Anthropometric (growth parameters) at given time or changes overtime Pediatric Subjective Global Nutrition Assessment Dietitian Assessment STAMP 4

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6 STRONGKIDS Pediatric Yorkhill Malnutrition Score 6

7 Overview of Inpatient/Hospital Setting Tools OVERALL VALIDITY RELIABILITY AGREEMENT OVERALL GRADE, EVIDENCE STRENGTH STAMP MODERATE HIGH LOW I, GOOD/STRONG STRONGkids MODERATE MODERATE LOW II, FAIR PYMS MODERATE MODERATE LOW II, FAIR PMST MODERATE NR LOW II, FAIR PNST NR NR II, FAIR PNRS MODERATE NR LOW III, LIMITED IMCI Algorithm NR NR III, LIMITED How do I screen for malnutrition risk in my facility? Tools used to identify nutrition risk should be valid and reliable Moderate-High The tools that demonstrated the highest validity and reliability for in-patient setting 1. STAMP 2. STRONGKIDS 3. PYMS No tools demonstrated moderate-high validity and reliability for general population in the outpatient/community setting. 7

8 Malnutrition Diagnosis Pediatric Recommended Indicators Preterm and Neonatal Recommended Indicators The Pediatric dietitians role in diagnosing malnutrition Identifying pediatric malnutrition The good, the bad and the ugly The good Screening to risk of pediatric malnutrition Food insecurity Co-morbidities that affect nutrient intake BMI for age or weight for length z score -1 or below. Chronic conditions that negatively affect nutritional status If none of these are present: the patient may not be at risk for pediatric malnutrition. 8

9 Single data point indicators Weight for length z score Length or height for age z score BMI for age z score Mid-upper arm circumference Weight for length / BMI for age Anthropometric data must be accurate Weight Length Height Mid-upper arm circumference Bottom Line: Anthropometric Data is Crucial Accurate anthropometric measurements At admission AND throughout hospital stay When multiple data points available: use serial weights and heights or lengths to document growth trends in the short term 9

10 2 or more data point indicators Weight gain velocity percentage of the norm Weight loss percentage of usual body weight Deceleration across z score lines Inadequate nutrient intake Weight gain velocity One month interval charts 0 to 2 weeks / weight loss and regain of birth weight in first 1-2 weeks of life Two month interval charts Four month interval charts Six month interval charts Weight loss percentage of usual body weight Nutritionally significant weight loss for adults is time dependent Nutritionally significant weight loss for children is not time dependent Usual body weight for growing children is a challenge. Most recent stable weight vs. highest weight. 10

11 Deceleration across z score (SDS) SDS = standard deviation scores decreased to = deceleration of 1 SDS decreased to 0.25 = deceleration of 2 SDS decreased to 1.25 = deceleration of 3 SDS The not-so-good Mild malnutrition There are no recommended indicators for mild malnutrition in adults Too difficult to standardize Purpose of the recommended indicators for pediatric malnutrition is to identify malnutrition as early as possible in children. To prevent poor growth during critical windows To reduce duration of malnutrition (acute vs. chronic) The bad Moderate malnutrition WHZ / BAZ: -2 to Weight loss of 7.5% UBW Inadequate energy protein intake: 26-50% measured or estimated REE Weight gain velocity at 26-50% norm. 11

12 The Ugly Severe pediatric malnutrition Bradycardia Hypotension Hypothermia Postural orthostatic tachycardia syndrome BAZ -3 or below HAZ 3 or below Weight loss of greater than or equal to 10% UBW Energy / protein intake less than 25% measured or estimated need Weight gain velocity less than or equal to 25% of the norm coding: pediatric malnutrition (undernutrition) Modifiers Indicators Severe malnutrition Duration: ICD-10 / E43 Moderate malnutrition ICD-10 / E44.0 Mild malnutrition ICD-10 / E 44.1 Weight for length - 3 Z score to to 2.99 Z score to Z score Acute 3 months Chronic > 3 months BMI for age - 3 Z score to to 2.99 Z score to Z score Length / height - 3 Z score No data available No data available Inflammatory state +/- Illness related Mid-upper arm circumference Weight gain velocity ( 2 years of age) Weight loss (2 to 20 years of age) - 3 Z score to to 2.99 Z score to Z score 25 % of norm * % of norm * % of the norm * 10 % of usual body weight 7.5 % UBW 5 % UBW Non-illness related: Behavioral Socioeconomic Deceleration in weight for Deceleration across Deceleration across Deceleration across length/height or BMI for age 3 Z score lines 2 Z score lines 1 Z score line Inadequate nutrient intake 25 % of estimated energy % of estimated energy % of estimated energy protein need protein need protein need malnutrition ICD-10 codes E44.0 E44.1 E46 Malnutrition of Moderate Degree Malnutrition of MILD degree Unspecified proteincalorie malnutrition Complicating Conditions (CC) E43 Other Severe Protein- Calorie Malnutrition Major Complicating Conditions (MCC) 12

13 coding accurately Case Study: Four year old with seizure disorder and failure to thrive has T 38.6, HR 158, RR 34, and WBC Nutrition note documents protein calorie malnutrition, severe. Sepsis Failure to thrive Seizure disorder Severity of Illness: Moderate Risk of Mortality: Minor Reimbursement: $8,440 Sepsis Protein calorie malnutrition Seizure disorder Severity of Illness: Major Risk of Mortality: Moderate Reimbursement: $14,487 Assessing Malnutrition Where Are We Now? PNPG Malnutrition Indicator User Survey Malnutrition Clinical Characteristic Validation and Staffing Study The PNPG Malnutrition Indicator User Survey The proposed PNPG Malnutrition Indicators User Survey is to support and promote the Academy s mission, vision, philosophy and current position to address malnutrition: To Have a global impact in eliminating all forms of malnutrition Reduce all forms of malnutrition (including pediatric) Collaborate to advance basic science research related to malnutrition The Link to the Survey: 13

14 The PNPG Malnutrition Indicator User Survey Purpose: The purpose of this survey is to evaluate current practices and the effectiveness of the recommended pediatric malnutrition indicators in diagnosing and documenting malnutrition in the preterm, neonatal, and 1 month to 18 years of age populations. About: This survey will take 15 minutes and will ask some basic questions based on what current malnutrition indicators are used and which peds RDs find to be most effective. Benefits: The responses will aid in determining the best practices for identifying pediatric malnutrition and help all members of the health care team better treat malnourished pediatric patients. Our goal is to provide back ground data on pediatric malnutrition indicator use and to support work in adapting the Malnutrition Quality Improvement Initiative information to pediatrics and to support the work and findings of the Malnutrition Clinical Characteristics Validation and Staffing Study. Malnutrition Clinical Characteristic (MCC) Validation & Staffing Optimization Study Study Objective: To validate the adult and pediatric malnutrition clinical characteristics, and establish the relationship between registered dietitian nutritionist (RDN) care and patient medical outcomes for those who receive inpatient nutrition care. The Academy of Nutrition & Dietetics, Nutrition Research Network 14

15 Site Selection Recruit 120 hospitals nationwide 60 pediatric facilities Rolling facility recruitment throughout 2019 Designated Research Dietitian at each site Research Dietitian responsibilities include Pre-training webinars 2 day in-person training Free of cost with opportunity to earn CPEUs Total time commitment 2 days in-person training 4 days inpatient data collection 3-4 days medical outcomes data abstraction The Academy of Nutrition & Dietetics, Nutrition Research Network Identifying preterm. neonatal malnutrition The Recommended Indicators for the Identification and Documentation of Preterm and Neonatal Malnutrition The recently published recommended indicators for the identification of malnutrition in preterm infants and neonates were authored by an expert panel of Neonatal Registered Dietitian from the Pediatric Nutrition Practice Group over a 2- year period. They are evidence informed and consensus driven. They are the first step in a process to establish criteria for the diagnosis of malnutrition in this population. 15

16 Primary Indicators of neonatal and preterm malnutrition Mild malnutrition Moderate malnutrition Severe malnutrition Use of indicator Indicators that require a single indicator: Decline in weight-for-age z- score Decline of SD Decline of SD Decline of >2.0 SD Not appropriate for the first 2 weeks of life Weight gain velocity <75% of expected rate of weight gain to maintain <50% of expected rate of weight gain to maintain <25% of expected rate of weight gain to maintain Not appropriate for the first 2 weeks of life growth rate growth rate growth rate Nutrient intake ³ 3-5 consecutive days of protein/energy intake 75% of estimated needs. ³ 5-7 consecutive days of protein/energy intake 75% of estimated needs. >7 consecutive days of protein/energy intake 75% of estimated needs. Preferred indicator for the first 2 weeks of life Primary Indicators of neonatal and preterm malnutrition Indicators that require 2 indicators: Days to regain birth weight days days >21 days Use in conjunctions with nutrient intake Linear growth velocity <75% of expected rate of linear gain to maintain growth rate <50% of expected rate of linear gain to maintain growth rate <25% of expected rate of linear gain to maintain growth rate Not appropriate for the first 2 weeks of life Decline in length-for-age z- score Decline of SD Decline of SD Decline of >2.0 SD Not appropriate for the first 2 weeks of life. Use in conjunction with another indicator. Ensure length measurement is accurate. Weight Indicators Decline in weight-for-age z-scores Weight gain velocity **Days to regain birth weight** ** Starred items require 2 or more positive indicators to confirm malnutrition diagnosis** 48 16

17 Weight Indicators Decline in weight-for-age z-score Mild malnutrition Decline of 0.8 to 1.2 SD Moderate malnutrition Decline of > 1.2 to 2 Severe malnutrition Decline of > 2 Decline in weight for age z-score is not appropriate for use during the first two weeks of life 49 Tools to determine weight for age indicators Weight for age based on Growth Charts specifically designed for preterm infants (Fenton 2013, Olsen 2010), Pedi-tools ( provides an easy tool to determine z-scores for preterm infants based on PMA, gender, and selected growth chart. 50 Weight Indicators Weight Gain Velocity (g/d) Mild <75% of expected rate of weight gains to maintain growth rate Moderate <75% of expected rate of weight gains to maintain growth rate Severe <25% of expected rate of weight gains to maintain growth rate Weight gain velocity is not appropriate for use during the first two weeks of life 51 17

18 Example: 27 2/7 wk gest male now DOL 32 (PMA 31 6/7 wk) with weight 1320 g, length 36.5 cm 27 2/7 wks male Value Imperial %ile Z-score Weekly* Weight (g) lb 14.6 oz 25% Length (cm) in 6% Weight gain goal = 188 g / 7 d = 27 g/d Weight Indicators **Days to Regain Birth Weight** Mild days Moderate days Severe > 21 days **Requires a second positive indicator to determine malnutrition** Use in conjunction with nutrient intakes Rochow N et al. Pediatr Res Jun;79(6): doi: /pr Epub 2016 Feb Length n**linear growth velocity** n**decline in length-for-age z-scores** n**requires a 2 nd positive indicator to determine malnutrition** 54 18

19 Length Indicators **Decline in length-for-age z-score** Mild Decline of SD Moderate Decline of SD Severe Decline of > 2 SD **Requires a second positive indicator to determine malnutrition** Use only when accurate length measurement available. Not appropriate for the first two weeks of life. May be deferred in critically ill or unstable infants 55 Length Indicators **Linear Growth Velocity (cm/wk)** Mild Moderate Severe <75% of expected rate of linear gain to maintain growth rate <50% of expected rate of linear gain to maintain growth rate <25% of expected rate of linear gain to maintain growth rate **Requires a second positive indicator to determine malnutrition** Use only when accurate length measurement available. Not appropriate for the first two weeks of life. May be deferred in critically ill or unstable infants 56 Nutrient Intake Indicator Nutrient Intake Mild 3-5 consecutive days of protein / energy intake < 75% of estimated protein-energy requirement Moderate 3-5 consecutive days of protein / energy intake < 50% of estimated protein-energy requirement Severe 3-5 consecutive days of protein / energy intake < 25% of estimated protein-energy requirement Preferred indicator for the first two weeks of life 57 19

20 Nutrition Focused Physical Exam The nutrition focused physical exam may be a useful adjunct to the malnutrition screening tool. Often information regarding the physical exam may be obtained from other healthcare providers (particularly the bedside RN) in order to limit the stress / stimulus to the infant. 58 The pediatric dietitian s role in diagnosing malnutrition. The big picture. How can we use the MQii information? The Role of the pediatric dietitian in malnutrition care The Academy through the Malnutrition Quality improvement initiative recommends several actions for us to take to support/facilitate the use of recommended criteria in our organizations. MQii was Developed to Address the Burden of Malnutrition The Malnutrition Quality Improvement Initiative (MQii) is a project of the Academy of Nutrition and Dietetics, Avalere Health, and other stakeholders who provided expert input through a collaborative partnership. This initiative aims to advance evidence-based, high- quality, patient-driven care for hospitalized older adults who are malnourished or at-risk for malnutrition. 20

21 The pediatric dietitian can: Regularly participate in interdisciplinary rounds 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 carefully documented in the EHR, regularly updated, and effectively communicated to all healthcare providers Lead an interdisciplinary team to create and maintain standardized policies, procedures, and EHR-automated triggers relevant to nutrition, including order sets and protocols in the hospital s EHR The pediatric dietitian can: Recognize and Diagnose All Malnourished Patients and Those at Risk Using a validated malnutrition screening tool Use standard malnutrition characteristics guidelines Establish competence in nutrition-focused physical assessment Rapidly Implement Comprehensive Nutrition Intervention and Continued Monitoring Work with interdisciplinary team to establish policies and interdisciplinary practices to maximize nutrient consumption on and monitoring needs Pediatric malnutrition algorithm: 1 24 months Malnutrition risk screen nutrition support / conditions with nutrition risk / reduced energy protein intake / WHZ >-1 RDN referral/consult at risk for pediatric malnutrition not at risk for PMN Identify and document PMN assess using all indicators for available data reassess every 14 days Assign acuity weight for lenght - HAZ adequacy of intake percentage of estimated or measure need weight gain velocity percentage of the norm mid-upper arm circumference Implement treatment protocol mild / moderate / severe PMN 21

22 Pediatric Malnutrition Algorithm: 2 18 years Malnutrition risk screen nutrition support / conditions with nutrition risk / reduced energy protein intake / BAZ >-1 RDN referral/consult at risk for pediatric malnutrition not at risk for PMN Identify and document PMN assess using all indicators for available data reassess every 14 days Assign acuity BMI for age z score - BAZ adequacy of intake percentage of estimated or measure need weig loss percentage of usual body weight mid-upper arm circumference Implement treatment protocol mild / moderate / severe PMN So what can a Peds RDN do? ü Know the definition of malnutrition ü Know the recommended indicators for children/preterm-neonatal/term infants ü Use the recommended indicators for children/preterm/neonatal/term infants to diagnosis and document malnutrition ü Support your diagnosis by stating the etiology (related to) and the signs and symptoms (as evidenced by) including the cause of the nutrition problem, medical, genetic, etc. the recommended indicator, any nutrition focused physical findings, etc. ü Communicate your findings and diagnosis to the team. ü Educate the team on the recommended indicators. ü Discuss with providers supporting the addition of the diagnosis to the patient problem list for coding purposes IDNT definition pediatric malnutrition Non-illness related pediatric malnutrition (undernutrition) (NC-4.1.4) Definition: inadequate nutrient intake due to environmental or behavioral factors which may negatively affect growth, development and/or other outcomes. Etiology: (cause/contributing risk factors) Factors gathered during the nutrition assessment process that contribute to the existence or the maintenance of pathophysiological, psychosocial, situational, developmental, cultural and or environmental problems, such as lack of or limited access to food, e.g. economic constraints, restricting food/feedings given to children, neglect or abuse, adoption/immigration/refugee from or in poorly resourced or conflict-torn countries. Interruption or intolerance to feedings. Social, economic, behavioral, cultural or religious practices that affect access to food. 22

23 IDNT definition pediatric malnutrition Illness related pediatric malnutrition (undernutrition) (NC-4.1.5) Definition: Nutrient deficit or imbalance due to disease or injury which may negatively affect growth, development and/or other outcomes. Etiology: (cause/contributing risk factors) Factors gathered during the nutrition assessment process that contribute to the existence or the maintenance of pathophysiological, psychosocial, situational, developmental, cultural and or environmental problems, Physiological causes increasing nutrient needs due to prematurity, genetic/congenital disorders, illness, injury, trauma. Inadequate intake related to anorexia or feeding intolerance. Alteration in gastrointestinal structure or function. Alterations in nutrient utilization. Food and nutrition knowledge deficit and other psychological causes such as depression or disease. Malnutrition Intervention Protocols The evidence for protocols MQii malnutrition assessment and decision tool The pediatric dietitian and order writing privileges Malnutrition intervention questions Do patients diagnosed with malnutrition consistently receive intervention? Are recommended or prescribed nutrition interventions clearly outlined? Do interventions get started within 24 hours of diagnosis? Is there a effective system for communication of the nutrition plan? Is the implementation of the nutrition plan documented in the EMR? Are nutrition interventions effectively administered and recorded? Are oral nutritional supplements (ONS) delivered and recorded? Do staff track, monitor and record food, ONS intake? 23

24 Malnutrition Intervention Protocols The benefits of nutrition care protocols are to standardize care and automate the process of nutrition care rather than leaving this to individuals to plan and initiate the intervention, advance the care and make necessary and timely modifications Feeding protocols include common elements, such as determination of protein and energy goals and advancement guidelines to those goals Children receiving ONS were found to have higher energy intakes than children who did not receive ONS and children undergoing cancer treatment who consumed ONS were less likely to experience weight loss then children who did not Malnutrition Intervention Protocols In a study of nutritional practices and their relationship to clinical outcomes in critically ill children, those for whom feeding protocols were employed had lower rates of infection, independent of severity of illness. Children with the lowest energy intakes, less than 33% of estimated need, an indicator of severe malnutrition, had the highest mortality rates. Children with an energy intake from 33%-66% of estimated need, had a significantly decreased the risk of death. References Mehta N, Bechard L, Cahill N, et al. Nutritional practices and their relationship to clinical outcomes in critically ill children An international multicenter cohort study. Crit Care Med. 2012; 40(7): Heyland DK, Cahill N, Dahaliwal R, et al. Impact of enteral feeding protocols on enteral nutrition delivery: Results of a multicenter observational study. JPEN. 2010; 34(6): Francis DK, Smith J, Saljuqi T, Watling RM. Oral protein calorie supplementation for children with chronic disease. Cochrane Database Syst Rev May 27;(5):CD Doi / Gurlek-Gokcebay D, Emir S, Bayhan T, Demir HA, Gunduz M, Tunc B. Assessment of nutrition status in children with cancer and effectiveness of oral nutritional supplements. Ped Hematol Onc. 2015;32(6):

25 Mild malnutrition intervention protocol Offer % of energy needs - High calorie-high protein diet ( x estimated energy-protein needs) 3 meals/1-2 scheduled snacks per day Oral nutritional supplements (to provide 50% of estimated energy-protein needs) Obtain a 3 day analysis of nutrient intake (calorie count) Provide education on increasing intake of high calorie, high protein foods and ingredients added to foods to increase the energy and protein content of foods. Moderate malnutrition intervention protocol Implement Mild malnutrition intervention protocol Re-assess for improvement in recommended indicators Weight gain velocity Adequacy of intake as percentage of estimated need BAZ / WHZ If all indictors unchanged, consider providing nutrition support at 50% of measured (or estimated) energy and protein need until the child improves and meets nutrition care goals, growth goals or mild malnutrition criteria Severe malnutrition intervention protocol Provide / administer 100% of the child s measured (or estimated) energy and protein needs either by mouth or nutrition support. Re-assess nutritional status by recommended indicators frequently until the child improves and meets nutrition care goals, growth goals or moderate malnutrition criteria, at which time Moderate malnutrition therapy protocol may be implemented. 25

26 References Lakdawalla D, Mascarenhas M, Jena AB, et al. Impact of oral nutritional supplements on hospital outcomes in pediatric patients JPEN. 2014; 38 supp(2):42s-49s Huynh DT, Estorninos E, Capeding R, et al Longitudinal growth and health outcomes in nutritionally-at-risk children who received long-term nutritional intervention. J Hum Nutr Diet. Doi: /jhn Gentles E, Mara J, Diamantidi K, et al. Delivery of enteral nutrition after the introduction of practice guidelines and participation of dietitians in pediatric critical care clinical teams. J Acad Nutr Diet ;114(12): Derver N, Dowsett D, Gleeson E, Carr S, Cornish C. Evaluation of over and underfeeding following the introduction of a protocol for weaning from parenteral to enteral nutrition in the intensive care unit. NCP. 2012; 27(6): Mikhailov T, Kuhn E, Mani J, et al. Early enteral nutrition is associated with lower mortality in critically ill children. JPEN. 2014; 38(4): Daskalou E, Tsinopoulou A, Lampoudi T. et al. Malnutrition in hospitalized pediatric patients assessment, prevalence and association to adverse outcomes. J Am Coll Nutr. 2016;35(4): Koen FM, Joosten MD, Hulst JM. Malnutrition in pediatric hospitalized patients: Current Issues. Nutrition. 2011;27: Dietitians with order writing privileges Document malnutrition assessment, diagnosis and intervention protocol in EMR Enter order for mild moderate or severe malnutrition intervention protocol into EMR Initiate / implement intervention protocol Document implementation of malnutrition intervention protocol in EMR Dietitians without order writing privileges Document malnutrition assessment, diagnosis and intervention protocol in EMR Contact the child s primary provide Notify them of the assessment and diagnosis and recommended intervention Monitor the EMR for activation of order Once the order is activated / Initiate / implement intervention protocol Document implementation of malnutrition intervention protocol in EMR 26

27 Monitoring and evaluation Document implementation of malnutrition intervention protocol Monitor and evaluate all recommended indicators for the identification and documentation of pediatric malnutrition for which information / data is available Establish and document frequency of monitoring. Evaluate outcomes Policy and Procedure Title: Malnutrition Intervention Protocol Purpose: to ensure timely identification, documentation, and treatment of pediatric malnutrition Policy: Within 24 hours of admission all children will be screened for malnutrition risk and referred to a pediatric dietitian for assessment if malnutrition risk is present. Within 24 hours of completion of the malnutrition risk screen the pediatric dietitian will assess the nutritional status of the child and identify, document and treat malnutrition if present. Procedure: Screening: the nursing staff will complete the nutrition screen in the EHR within 24 hours of the admission of the patient. Assessment: the clinical nutrition staff / pediatric dietitian will complete the initial nutrition assessment of the patient within 24 hour of the nutrition screen. When present, the RD will diagnosis malnutrition and determine its cause and assign a level of acuity/severity and document this in the EMR. Intervention: the RD will develop and implement a nutrition therapy plan for the treatment of pediatric malnutrition to include the appropriate malnutrition protocol. Mild malnutrition protocol: 1. High calorie-high protein diet ( x estimated energy-protein needs) 3 meals/1-2 scheduled snacks per day 2. Oral nutritional supplements (to provide 50% of estimated energy-protein needs) 3. Obtain a 3 day analysis of nutrient intake (calorie count) Moderate malnutrition protocol: Severe malnutrition protocol: Dietitians with order writing privileges Dietitians without order writing privileges will Monitoring and Evaluation: What s Next Outcomes research data, data, data Publish your findings: Papers, posters, presentations Policies and procedures: Establish standards for prevalence, interventions, monitoring and evaluation 27

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