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Open access Quality improvement report BMJ Open Qual: first published as 10.1136/bmjoq-2019-000735 on 24 March 2020. Downloaded from
Impact of an interdisciplinary
malnutrition quality improvement
project at a large metropolitan hospital
1 2 3
Kelsey Jones Pratt , Beverly Hernandez, Robert Blancato,
4 1
Jeanne Blankenship, Kristi Mitchell
To cite: Pratt KJ, Hernandez B, AbstrAct Problem
Blancato R, et al. Impact of an As many as 50% of hospitalised patients are estimated Tampa General Hospital (TGH) is a private,
interdisciplinary malnutrition to be malnourished or at risk of malnutrition on hospital not- for- profit, 1010- bed teaching hospital in
quality improvement project admission, but this condition often goes unrecognised, Tampa, Florida. Located in a metropolitan
at a large metropolitan undiagnosed and untreated. Malnutrition is associated
hospital. BMJ Open Quality area in the southeastern USA, it serves a
2020;9:e000735. doi:10.1136/ with an elevated need for continued medical interventions, dozen counties with a combined population
bmjoq-2019-000735 higher costs of care and increased patient safety risks. of over four million people. The top three
Tampa General Hospital (TGH), a large teaching hospital ethnic groups represented among patients
► Additional material is in the southeastern USA, initiated a project to improve
published online only. To view the quality of patient care at its institution. They did this admitted at the time of the study are Cauca-
please visit the journal online first by focusing on improving the care quality for their sian (52%), African- American (21%) and
(http:// dx. doi. org/ 10. 1136/ Hispanic (8%). Approximately 44% of
bmjoq- 2019- 000735). malnourished patients (or patients who were at risk of
malnourishment) and by using elements of the national its patients are 65 and older and 40% are
Malnutrition Quality Improvement Initiative (MQii) Toolkit Medicare or Medicare Advantage benefi-
Received 16 May 2019 as a mechanism to measure and improve quality. The ciaries. TGH has over 7300 employees on
Revised 14 February 2020 aim of this study was to evaluate the impact of quality staff and has been designated with Magnet
Accepted 1 March 2020 improvement interventions on patient length of stay
status in nursing care for the past 4 years.
(LOS), infection rates and readmissions, particularly It is a designated Centre of Excellence for
for malnourished patients. The structure of the MQii cardiac services, cancer care and integrative
and the use of the MQii Toolkit helped staff members medicine.
identify problems and systematically engage in quality
improvement processes. Using the MQii Toolkit, TGH In 2015, TGH had hospital-wide goals http://bmjopenquality.bmj.com/
implemented a multipronged approach to improving the of reducing patient length of stay (LOS),
treatment of malnourished patients that involved creating infection rates and readmission rates. As
interdisciplinary teams of staff and identifying gaps in TGH began that project, they recognised
care that could be improved through a series of changes that malnutrition is an underdiagnosed
to hospital- wide clinical workflows. They enhanced condition associated with adverse patient
interdisciplinary coordination through increased dietitian outcomes. Optimal nutrition care, as
engagement, the use of electronic health record alerts outlined in the clinical workflow in figure 1,
and new surgical protocols. These interventions lasted aims to fully diagnose and manage malnu-
© Author(s) (or their 8 months in 2016 and data reported here were collected trition.1 In 2015, a dietitian- led clinical team
employer(s)) 2020. Re- use from 985 patients before the interventions (2015) and
permitted under CC BY- NC. No 1046 patients after the interventions (2017). The study at TGH evaluated its own clinical work- on January 4, 2023 by guest. Protected by copyright.
commercial re- use. See rights examines how these process changes affected LOS, flows to uncover gaps in care for malnour-
and permissions. Published by ished patients. Barriers that they identified
BMJ. infection rates and readmissions at TGH. Following included:
1Center for Healthcare implementation of these quality improvement processes, ► Nurses did not consistently use the vali-
Transformation, Avalere Health, patients who were malnourished or at risk of malnutrition dated Malnutrition Screening Tool
Washington, DC, USA had a 25% reduction in LOS (from 8 to 6 days, p<0.01) 2
2Clinical Nutrition Services, and a 35.7% reduction in infection rates (from 14% (MST) that was built into the electronic
Tampa General Hospital, Tampa, to 9%, p<0.01). No statistically significant changes in health record (EHR) to identify at- risk
Florida, USA readmission rates were observed. This study adds to patients at admission, thereby missing
3Defeat Malnutrition Today,
Washington, DC, USA a growing body of literature on quality improvement opportunities to trigger nutrition consults
4Policy Initiatives and Advocacy, processes hospitals can undertake to better identify and for patients.
Academy of Nutrition and treat malnourished patients. Hospitals and health systems ► Hospital clinicians were not actively using
Dietetics, Chicago, Illinois, USA can benefit from adopting similar institution- wide, quality a high- quality nutrition assessment tech-
improvement projects, while policy- makers’ support for nique (such as the Nutrition- Focused
Correspondence to such programmes can spur more rapid uptake of nutrition- Physical Examination) to confirm malnu-
Kelsey Jones Pratt; focused initiatives across care delivery settings.
kjones@ avalere. com trition in those identified as at risk.
Pratt KJ, et al. BMJ Open Quality 2020;9:e000735. doi:10.1136/bmjoq-2019-000735 1
Open access BMJ Open Qual: first published as 10.1136/bmjoq-2019-000735 on 24 March 2020. Downloaded from
Figure 1 Nutrition care clinical workflow. EHR, electronic health record.
► Hospital dietitians had order writing privileges, but background
their orders were not thoroughly incorporated into As many as 50% of hospitalised patients are estimated
patient treatment plans. 4–6
to be malnourished or at risk of malnutrition. Malnu-
► Malnutrition treatment recommendations were not trition is defined as the inadequate intake of nutrients,
fully integrated into the discharge planning process. particularly protein, over time, and can occur in indi- http://bmjopenquality.bmj.com/
The project team identified that at baseline in 2015, 985 viduals of any weight, including those who are over-
patients were malnourished or at risk of malnutrition, 7
weight or obese. Malnutrition is prevalent in highly
according to the Academy of Nutrition and Dietetics vulnerable populations, such as individuals with chronic
(“the Academy”)/American Society for Parenteral and disease, illness, injury and poor social determinants of
Enteral Nutrition Malnutrition Clinical Characteristics. 5 8
health. While malnutrition is rarely the primary reason
Out of a total of 48 636 patients admitted in 2015, 43% for patient hospitalisations, it can compound the severity
of patients over 65 years were malnourished or at risk of illness and slow recovery. Studies estimate that only 8%
of malnutrition. Using Agency for Healthcare Research 3
of hospitalised patients are diagnosed with malnutrition,
and Quality Healthcare Cost and Utilization Project even though evidence- based nutrition interventions exist on January 4, 2023 by guest. Protected by copyright.
(HCUP) data on the average cost of an inpatient stay that can improve accuracy of screening and assessment
per malnourished patient (up to US$25 200), compared and minimise the development of malnutrition-related
with a well- nourished counterpart (US$12 500), TGH 7 9
complications.
extrapolated this number and estimated its annual Many studies demonstrate correlations between malnu-
3
cost of malnutrition to be over US$12 million. While trition and elevated needs for continued medical inter-
that number may be overstated since TGH’s patient ventions, higher costs of care and increased patient safety
population includes those at risk, at-risk patients often risks. For example, malnourished hospitalised patients
become malnourished and incur comparable costs. As experience slower wound healing, higher risks of infec-
a result of these analyses, TGH pursued an interdisci- 4
tion and longer LOS. Malnourished patients are also
plinary quality improvement (QI) project focused on an 56% more likely to be readmitted to the hospital within 30
institution- wide series of QI changes to rapidly improve days and have a higher likelihood of being discharged to
care for patients who were malnourished or at risk. The 10
other healthcare facilities for ongoing health services. It is
aim of the QI project was to reduce LOS, infection rates therefore unsurprising that hospital costs for malnourished
and 30- day readmissions and associated costs within 12 6
patients are 31%–34% higher, with cost per readmission
months of the intervention. 3 11
26%–34% higher, than for well- nourished patients.
2 Pratt KJ, et al. BMJ Open Quality 2020;9:e000735. doi:10.1136/bmjoq-2019-000735
Open access BMJ Open Qual: first published as 10.1136/bmjoq-2019-000735 on 24 March 2020. Downloaded from
Emerging evidence suggests malnutrition- focused as malnourished or at risk during the postintervention
QI can have a beneficial impact on these patient period. Only deidentified data from the EHR that reflected
7 8 12–15
outcomes. A number of recent studies demon- characteristics of the entire patient population were
strating successful results of QI programmes focused collected, thereby negating the need for randomisation
on malnutrition were published in a supplement to the or selection or individual patient consent.
Journal of the Academy of Nutrition and Dietetics that can be Changes in the proportion of patients identified with
accessed at https:// jandonline. org/ issue/ S2212- 2672( malnutrition or malnutrition risk were assessed using a
19) X0003- 9. While many studies evaluate the ability of difference in proportions test to evaluate statistical signif-
specific screening tools to correctly identify malnutrition icance at the 95% confidence level. To assess changes in
risk, few assess treatment and follow-up care activities.16–21 Whitney test was used to compare medians
LOS, a Mann-
Studies looking at the impact of specific nutrition inter- since these data are prone to outliers.
ventions have shown positive effects of an interdisciplinary
care team developing and implementing a comprehen- design
sive nutrition care and discharge plan.8 14
In 2016, TGH staff began their quality improvement
initiative by using the Malnutrition Quality Improvement
measuremenT Initiative (MQii) Toolkit, a set of resources that can be
The main processes tracked as part of this initiative 22
tailored to individual hospital needs. They did so because
included nutrition screening using the EHR-embedded they recognised that their existing strategies to care for
MST (TGH uses EPIC Hyperspace, 2019 as their EHR), malnourished patients were insufficient. The structure of
adjusting the nutrition assessment policy from comple- the MQii enabled them to uncover and address the nutri-
tion within 24–48 hours to completion within 24 hours, tion needs of these patients. The toolkit helps interdis-
and making simultaneous consults for both pharmacy ciplinary clinical teams determine gaps in identification
and dietitians for all new patients requiring total paren- and management of malnourished patients, undertake
teral nutrition. changes to address these gaps and coordinate care across
To assess the impact of this QI process, data were disciplines. It also offers guidance on engaging patients
collected on several hospital-prioritised outcomes: LOS, and caregivers in nutrition care, including opportuni-
infection rates (postoperative surgical site infections per ties for patient education and shared decision- making.
100 procedures) and readmissions among malnourished Finally, the toolkit includes a set of quality indicators that
patients and those at risk of being malnourished. Data may be employed to measure project impact and success.
were collected from the EHR for a 1- year period preim- TGH did not receive any funding to use these materials or
plementation (January 2015–December 2015) and again implement a malnutrition QI project.
for a year postimplementation (September 2016–August Using evidence- based best practice recommendations http://bmjopenquality.bmj.com/
2017). The earlier period provides a control group for esti- from the MQii Toolkit, an interdisciplinary team was
mating the effect of the QI interventions. This approach established that included dietitians, nurses, physicians,
uses temporal variation within the hospital, controlling pharmacists, coders, information technology (IT) staff,
for constant features specific to the hospital’s setting that social workers and other health professionals. TGH’s
could affect patient outcomes. This strategy was adopted dietitian- led team of clinicians identified a series of QI
because many of the most important confounders, such changes to implement based on the barriers to optimal
as hospital characteristics and local patient populations, malnutrition care outlined above. This project team
are relatively stable within a hospital over time. worked to identify a range of important care gaps, raise
In total, the analysis compared 985 patients who were awareness of these gaps, educate staff on best practices
malnourished or at risk of malnutrition during the and adopt the changes outlined in figure 2. Patient
preintervention period with 1046 patients identified informed consent was collected when dietitians provided on January 4, 2023 by guest. Protected by copyright.
Figure 2 Malnutrition quality improvement activities adopted by the hospital across the preadmission, inpatient and
postdischarge care continuum. AA, aortic aneurysm; BPA, Best Practice Alert; CLABSIs, central line-associated bloodstr eam
infections; EHR, electronic health record; NPO, ‘Nil per os’ (nothing by mouth); PAT, preadmission testing; RD, registered
dietitian; TPN, total parenteral nutrition.
Pratt KJ, et al. BMJ Open Quality 2020;9:e000735. doi:10.1136/bmjoq-2019-000735 3
Open access BMJ Open Qual: first published as 10.1136/bmjoq-2019-000735 on 24 March 2020. Downloaded from
education, but otherwise was not necessary to obtain from support prior to surgery—rather than the standard order
participants. The project received Institutional Review of NPO past midnight—resulted in more timely recovery,
Board approval in January 2016 and was implemented improved postsurgical outcomes and prevention of in-hos -
from January 2016 to August 2016. Overall, TGH put in 23
pital nutritional decline. This protocol, which allows
place a comprehensive series of interventions during the patients to receive a fibre- free, protein-free, clear liquid
implementation period with the goals of closing multiple carbohydrate beverage up to 2 hours before surgery, was
care gaps, improving clinician engagement and care established in partnership with the Chief of Anesthesi-
processes for patients with malnutrition and malnutrition ology and in support of Enhanced Recovery After Surgery
risk, and decreasing associated costs. protocols. To implement this change, a policy document,
To raise awareness about the screening, diagnosis and order set and tip sheets were disseminated to nurses and
treatment of malnutrition, a critical care gap identified physicians through trainings.
by the TGH staff, the project team performed trainings In addition to surgical patients, and as a means of
and educational sessions over the course of 8 months with further addressing the care gap related to malnutrition
clinical staff, social workers, nurse educators and regis- care, the project team sought to provide better pread-
tered dietitians at their scheduled department meetings. mission nutrition support to a subset of at- risk patients
Information was also posted to physician electronic infor- to optimise their nutritional status and prevent infection
mation boards. Trainings with clinicians aimed to share preadmission and postadmission. TGH began providing
data on malnutrition prevalence and best practices for free, early immunonutrition supplements and nutrition
nutrition care. education to high- risk patients with colorectal cancer or
Additionally, the project team worked with nursing abdominal aortic aneurysms in its preadmission testing
staff to ensure accurate and consistent use of the MST process.
during the intake process to improve identification of To improve nutrition care related to discharge plan-
malnutrition risk (one of the significant care gaps). The ning, the project team created an automated Best Prac-
project team provided specific education sessions to the tice Alert (BPA) system to flag malnourished patients for
Chief Nursing Officer and various hospital councils and the discharge planning team. This enabled physicians to
committees on the association between malnutrition and incorporate a review of the patients’ nutritional status
pressure ulcers and increased LOS. A Nurse Nutrition and postdischarge nutrition recommendations into
Council was established to review patient cases and intake discharge discussions. The BPA also triggered a consult
documentation, confirm appropriate identification of for the hospital’s social workers to perform a psychosocial
patients at risk of malnutrition and discuss opportunities assessment, determine what factors may inhibit patients
for continuous QI and collaboration. The council also from eating normally (eg, access to food, inability to feed
supported documentation changes to foster dietitian themselves) and connect them to appropriate commu-
consults for newly identified pressure ulcers. The results nity resources. Finally, capturing patients’ malnutrition http://bmjopenquality.bmj.com/
of the MST were also added to the patient’s summary to diagnoses as part of the discharge process allowed malnu-
improve visibility within the EHR. trition to be placed on patients’ problem lists for easy
The project team worked with IT on additional opportu- identification and intervention in case of readmission.
nities to solve care gaps by integrating patient nutritional Notably, TGH used existing clinical and administrative
status and care information into the EHR. A tool was staff to implement this series of interventions and did not
added to the EHR that automatically requested dietitian need to hire new personnel. Additionally, because the
consults for patients identified as at risk based on the nurse tools were available from the MQii at no cost to the institu-
intake screening. This allowed dietitians to see patients tion, the only implementation cost was staff time required
more rapidly for a comprehensive nutrition assessment to educate clinicians on malnutrition best practices and
to determine their nutritional status, form nutrition care work with hospital leadership and IT staff to support the on January 4, 2023 by guest. Protected by copyright.
recommendations and communicate nutritional needs collection of data. The permanence of many of these
to other providers. To ensure awareness among all care changes—including the automated BPA, revised NPO
team members, the hospital incorporated malnutrition procedures and tool integration into the EHR—helped
diagnostic criteria and intervention recommendations to eliminate the slate of gaps in malnutrition care and
into the EHR- based plan of care. Support from hospital ensure the sustainability of the process improvements.
leadership was gained through partnerships and presen-
tations to various hospital committees and TGH’s Inter-
disciplinary Documentation Team, which reviewed and
approved all updates to EHR documentation. sTraTegy
The project team also established hospital-wide partner - The aim of this project was to make a series of institution-
ships to address specific concerns about the malnutrition wide care improvements for patients who are malnour-
care gap. Physicians on the Medical Nutrition Committee ished or at risk of malnutrition to reduce LOS, infection
worked with the project team to create a new ‘nothing by rates, and 30- day hospital readmissions. The project
mouth’ (NPO) policy for surgeries. This occurred after team implemented one QI cycle, focused on raising
a review of the literature demonstrated that nutrition staff awareness, educating patients and improving
4 Pratt KJ, et al. BMJ Open Quality 2020;9:e000735. doi:10.1136/bmjoq-2019-000735
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