Objectives Hospital-wide documentation improvement After this presentation, the attendee will be able to: Define Pediatric Malnutrition Susan Goolsby, MS, RD, LD Assistant Director Clinical Nutrition Understand the benefit of diagnosing malnutrition to patient outcomes Develop and implement a process to identify and document malnutrition in their practice setting Idea for project Various Listservs Adult hospital QI project webinars ASPEN/AND Etiology-Related definitions for Pediatric Malnutrition 1
Is there a problem? Review of patient measurements/z-scores Who do we need on the bus? Team Formation Who were the stakeholders? Who did we need? Purpose Statement To improve the process of identifying and documenting malnutrition and related comorbidities to improve patient safety/outcomes and increase revenue through proper coding/billing. 2
Business Case Increased documentation of malnutrition: Improves patient outcomes in several key areas including: decreased hospital acquired infections; decreased fall risk; decreased hospital acquired wounds improved wound healing. Increases revenue through an increased case mix index. Problem Statement Underdiagnosing malnutrition < 1% diagnosed at ACH National data: 25-35% 35% 30% 25% 20% 15% 10% 5% 0% ACH Nation Work Group Goals Pediatric Malnutrition Defined PRIMARY: Improve patient outcomes decrease hospital acquired infections & wounds improve wound healing decrease fall risk decrease readmission rate SECONDARY: Increase revenue by increasing the case mix index. 3
Pediatric Malnutrition An imbalance between nutrient requirements and intake odeficits of energy, protein, or micronutrients o Negatively affecting growth and development o Non-illness related o Illness related Figure 1. Defining malnutrition in hospitalized children: Key concepts. Table 1. Practical Scheme for Pediatric Malnutrition Definition. Mehta N M et al. JPEN J Parenter Enteral Nutr 2013;37:460-481 Copyright by The American Society for Parenteral and Enteral Nutrition Mehta N M et al. JPEN J Parenter Enteral Nutr 2013;37:460-481 Copyright by The American Society for Parenteral and Enteral Nutrition 4
Anthropometrics Weight Length/Height Mid-upper Arm circumference (MUAC) Triceps skin fold (TSF) Mid-arm muscle circumference (MAMC) Growth Dynamic changes Weight Length/Height Declining z-score Why use z-scores? Extreme values Z-scores Mechanism Starvation or decreased nutrient intake Anorexia nervosa Anorexia due to illness Food deprivation due to poor socioeconomic status or neglect Malabsorption/nutrient loss Diarrhea Vomiting Hypermetabolism or increased energy requirement Chronic disease Altered utilization of nutrients secondary to inflammation Fever Outcomes Screening for malnutrition on admission or at the beginning of an illness allows assessment of current nutrition status and facilitates early detection of subsequent nutrition deterioration related to the illness. Mehta N M et al. J Parenter Enteral Nutr 2013;37:465 5
Rollout Adolescent Unit Infant Toddler Unit (ITU) Education needed Dietitian education & professional development Coder Physician Nurse Physical Assessment Training 6
Physical Assessment Micronutrient deficiencies Fat loss Muscle wasting Edema Malnu-what? Measurement issues Fluid variances Risk of overdiagnosing Finding z-scores Malnutrition Diagnosis for Peds (> 3 months to <20 years of age) BMI or Wt/Lt (if <2 yrs) Z-score (found on Health Point growth chart) Mild or at risk (-)1 to (-) 1.99 Moderate (-)2 to (-)2.99 Severe <(-)3 Chronic > =3 months With Stunting: Ht or Lt Z-score <(-)2 Measurement Issues: Actual Height Growth Chart 7
Answers to Arguments 2-20 Z-score Calculator 0-24 month z-score calculator 8
Lessons learned Complexity Data People Surprises Interest level What is next Roll out to outpatient areas Continue to monitor compliance Improved Documentation INCREASED 119% 9
On the horizon Malnutrition of Obesity Documentation of other nutrition-related diagnoses References Mehta NM, et al. Defining Pediatric Malnutrition: A paradigm Shift Toward Etiology- Related Definitions. JPEN 2013 37: 460-81. Bhatia J. ASPEN takes the Lead Toward Defining Pediatric Malnutrition. JPEN 2013; 37: 444-5 Johnson, J. Coding for Malnutrition-A Success Story. Webinar provided by WVU Healthcare. Lingtak-NeanderC, et al. American Society for Parenteral and Enteral Nutrition Research Agenda. Downloaded online: http://pen.sagepub.com/content/early/2013/11/04/0148607113508783 CorkinsMR, et al. Malnutrition Diagnoses in Hospitalized Patients: United States, 2010. Downloaded online: http://pen.sagepub.com/content/early/2013/11/15/0148607113512154 Hecht C, et al. Disease associated malnutrition correlates with length of hospital stay in children. Clinical Nutrition 2014; XX: 1-7. Jensen GL, Malone A. Improving Patient Outcomes: Interdisciplinary Approach to Recognizing & Treating Malnutrition. Webinar provided by Penn State University and Mt. Carmel West Hospital. Viewed 1/2013. Academy/ASPEN Clinical Characteristics that the RD can obtain and Document to Support a Diagnosis of Malnutrition. Available at http://nutritioncaremanual.org/category.cfm?ncm_category_id=11. References (cont.) Barker LA, Gout BS, Crowe TC. Hospital Malnutrition: Prevalence, Identification and Impact on Patients and the Healthcare System. IntJ Environ Res Public Health. 2011; 8(2): 514-27. Secker DJ, JeejeebhoyKN. How to Perform Subjective Global Nutritional Assessment in Children. J Acad Nutr Diet. 2012; 112: 424-31. JeVennA, DeChiccoR, HipskindP. Objective Structured Clinical Exams in a Dietetic Training Program. Support Line: Acad Nutr Diet. 2014 10