Education and documentation strategies to improve malnutrition diagnosis in hospitalized children: A quality improvement project.

Publisher: Wiley Country of Publication: United States NLM ID: 8606733 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1941-2452 (Electronic) Linking ISSN: 08845336 NLM ISO Abbreviation: Nutr Clin Pract Subsets: MEDLINE

Publication: 2018- : [Hoboken, NJ] : Wiley
Original Publication: [Baltimore, Md. : Williams & Wilkins, c1986-

Quality Improvement* ; Documentation*/standards ; Documentation*/methods ; Nutrition Assessment* ; Child, Hospitalized* ; Malnutrition*/diagnosis; Humans ; Child ; Child, Preschool ; Nutritionists ; Infant ; Child Nutrition Disorders/diagnosis ; Male ; Female ; Hospitalization ; Practice Guidelines as Topic

Background: The Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) published malnutrition guidelines in 2014. In 2015, our institution implemented a quality improvement project focused on malnutrition identification with the goal to improve the diagnosis of malnutrition in hospitalized children.
Methods: Our project included three approaches: education, nutrition assessment, and documentation initiatives. Education initiatives focused on physicians at all levels of training. Nutrition screening was completed on all patients admitted to our institution. Registered dietitians (RDs) conducted nutrition assessments and identified and documented malnutrition based on AND/ASPEN guidelines. Documentation initiatives included development of automatic text and template changes to allow import of RD-assigned malnutrition diagnosis into physician documentation. We met with members of our clinical documentation integrity team regularly to review the results of these initiatives starting in 2016.
Results: The total diagnosed cases of malnutrition increased from 208 cases in 2016 at the start of our monitoring to >800 cases per year in 2020-2022. Unspecified (no severity assigned) protein calorie malnutrition as a percentage of total malnutrition diagnoses decreased from 36.9% in 2016 to <10% since 2018. Children with severe malnutrition have remained the largest portion of children with a malnutrition diagnosis, with >40% of children with malnutrition diagnosed with severe malnutrition.
Conclusion: Our education and documentation initiatives have led to both improved diagnosis of malnutrition and accurate identification and documentation of malnutrition severity. These initiatives could be utilized to improve malnutrition diagnosis and documentation at other institutions caring for hospitalized children.
(© 2023 The Authors. Nutrition in Clinical Practice published by Wiley Periodicals LLC on behalf of American Society for Parenteral and Enteral Nutrition.)

Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology‐related definitions. JPEN J Parenter Enteral Nutr. 2013;37(4):460‐481.
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.
Hecht C, Weber M, Grote V, et al. Disease associated malnutrition correlates with length of hospital stay in children. Clin Nutr. 2015;34(1):53‐59.
Marchand S, Lapauw B, Eeckloo K, Deschepper M. Malnutrition risk and severity: Impact on patient outcomes and financial hospital reimbursement in a tertiary teaching hospital. Clin Nutr ESPEN. 2022;48:386‐392.
Topal A, Tolunay O. Effect of malnutrition on length of hospital stay in children. Turk Arch Pediatr. 2021;56(1):37‐43.
Niseteo T, Hojsak I, Kolaček S. Malnourished children acquire nosocomial infections more often and have significantly increased length of hospital stay. Clin Nutr. 2020;39(5):1560‐1563.
Guenter P, Abdelhadi R, Anthony P, et al. Malnutrition diagnoses and associated outcomes in hospitalized patients: United States, 2018. Nutr Clin Pract. 2021;36(5):957‐969.
Hulst JM, Huysentruyt K, Joosten KF. Pediatric screening tools for malnutrition: an update. Curr Opin Clin Nutr Metab Care. 2020;23(3):203‐209.
Becker P, Carney LN, 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). Nutr Clin Pract. 2015;30(1):147‐161.
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.
Hulst JM, Zwart H, Hop WC, Joosten KFM. Dutch national survey to test the STRONGkids nutritional risk screening tool in hospitalized children. Clin Nutr. 2010;29(1):106‐111.
Moeeni V, Walls T, Day AS. The STRONGkids nutritional risk screening tool can be used by paediatric nurses to identify hospitalised children at risk. Acta Paediatr. 2014;103(12):e528‐e531.
Bouma S. Diagnosing pediatric malnutrition: paradigm shifts of etiology‐related definitions and appraisal of the indicators. Nutr Clin Pract. 2017;32(1):52‐67.
Abdelhadi RA, Bouma S, Bairdain S, et al. Characteristics of hospitalized children with a diagnosis of malnutrition: United States, 2010. JPEN J Parenter Enteral Nutr. 2016;40(5):623‐635.
Sonoo T, Iwai S, Inokuchi R, Gunshin M, Kitsuta Y, Nakajima S. Embedded‐structure template for electronic records affects patient note quality and management for emergency head injury patients: an observational pre and post comparison quality improvement study. Medicine. 2016;95(40):e5105.
Lorenzetti DL, Quan H, Lucyk K, et al. Strategies for improving physician documentation in the emergency department: a systematic review. BMC Emerg Med. 2018;18(1):36.
Bensinger A, Wilson F, Green P, Bloomfeld R, Dharod A. Sustained improvement in inflammatory bowel disease quality measures using an electronic health record intervention. Appl Clin Inform. 2019;10(5):918‐926.

Keywords: hospitalized child; malnutrition; nutrition assessment; quality improvement

Date Created: 20231011 Date Completed: 20240503 Latest Revision: 20240503

20240503

10.1002/ncp.11080

37817534