Health System Quality Improvement: Impact of Prompt Nutrition Care on Patient Outcomes and Health Care Costs

Meehan, Anita MSN, RN-BC, ONC, FNGNA; Loose, Claire MA, RD, LD; Bell, Jvawnna MPH, MBA; Partridge, Jamie PhD, MBA; Nelson, Jeffrey PhD; Goates, Scott PhD

doi: 10.1097/NCQ.0000000000000177

Among hospitalized patients, malnutrition is prevalent yet often overlooked and undertreated. We implemented a quality improvement program that positioned early nutritional care into the nursing workflow. Nurses screened for malnutrition risk at patient admission and then immediately ordered oral nutritional supplements for those at risk. Supplements were given as regular medications, guided and monitored by medication administration records. Post–quality improvement program, pressure ulcer incidence, length of stay, 30-day readmissions, and costs of care were reduced.

NICHE Program (Ms Meehan) and Food & Nutrition Department (Ms Loose), Cleveland Clinic–Akron General, Akron, Ohio; and Health Economics and Outcomes Research (Ms Bell and Drs Partridge and Goates) and Nutrition Science (Dr Nelson), Abbott Nutrition Research and Development, Columbus, Ohio.

Correspondence: Scott Goates, PhD, Health Economics and Outcomes Research, Abbott Nutrition Research and Development, 3300 Stelzer Rd, Columbus, OH 43219 (

The authors thank Jason Shawbell, MS (HI), BSN, RN, and Andy Harvey, BS, BA, for their technical knowledge and support in data collection, and Nancy Beinlich, MSN, CWON, for her support of the resource nurse program. The authors would also like to thank Cecilia Hofmann, PhD. for her assistance in preparing the manuscript.

Jamie Partridge, Jeffrey Nelson, and Scott Goates are employed by Abbott Nutrition Research and Development. Jvawnna Bell was employed by Abbott Nutrition during the time of the study. Abbott Nutrition provided travel funding for Anita Meehan to speak at a conference. Abbott products were used in the intervention. Ms Loose declares no conflict of interest.

Accepted for publication: December 16, 2015

Published ahead of print: February 22, 2016

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

Article Outline

AMONG HOSPITALIZED PATIENTS, disease-associated malnutrition is a common and widespread problem. Alarmingly, malnutrition or its risk occurs in as many as 50% of patients admitted to hospitals in the United States and around the world.1–3 Yet, malnutrition is often overlooked and undertreated in hospital settings.4–6 In fact, some patients experience worsening of their nutritional status while hospitalized—resulting from common hospital routines (traditional preparation for surgery, missed mealtimes for medical procedures, and NPO (nil per os) orders,7 insufficient hospital staffing or education about nutrition care,8 and patients' disease-related barriers to food intake (disease-related anorexia, too tired to eat, or feeding difficulties).6,9 Older adults are particularly vulnerable to undernutrition or specific nutrient deficiencies because they often have diseases and disabilities that limit dietary intake.3,10–12

Malnutrition has negative impacts on patients and the health care system, leading to more complications, slowed recovery, and higher costs of care. Study results show that malnourished hospital patients, compared with their adequately nourished peers, are more likely to experience pressure ulcers,13 postsurgical infections,14,15 and falls16 and are at greater risk for death.17,18 These adverse outcomes contribute to the excessive financial burden on our health care system in the form of costly complications, longer hospital stays, and more frequent readmissions.2,19,20 Nutrition screening and interventions (eg, oral nutritional supplements [ONS]) have proven effective for improving patient outcomes and reducing overall costs of care for patients who are malnourished or at risk for malnutrition.21–28 For example, several studies of hospitalized patients showed that nutrition screening and assessment, when followed by intervention as needed, could shorten length of stay (LOS) by at least 2 days.24,28,29

Given their integral role during a patient's hospital stay, nurses are ideally positioned to identify patients at risk for malnutrition and facilitate their treatment.30–32 A nurse-led program was initiated at Akron General Medical Center ([AGMC], Akron, Ohio), a Magnet hospital and level 1 trauma center, and a recent addition to the Cleveland Clinic Health System, to update the hospital nutrition care process and streamline its delivery. The program followed a quality improvement program (QIP), starting with the establishment of an interdisciplinary core team. The team's objectives were to (1) identify specific process reforms to improve the efficiency and rate of providing nutritional support for patients admitted to AGMC, and (2) determine whether such reforms would lead to positive outcomes, both clinical and economic.

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Quality improvement nutrition team

An interdisciplinary quality improvement (QI) team was assembled to evaluate and revise the hospital process for nutrition screening and intervention. The number of team members varied over time, ranging from 7 to 20, depending on activities in different phases of the QI project. Members represented the following departments, all of which were relevant to the nutrition administration process: nursing, nutrition (dietitians), administration, pharmacy, data analysis and research, information technology, and medicine (physicians). The team's review of the literature revealed that use of ONS during hospitalization can benefit patients who are malnourished or at risk of malnutrition.25,27,33,34 Ultimately, the team developed a system in which nurses screened patients' nutritional status on admission and prescribed ONS for those at malnutrition risk. The ONS prescription was recorded in the electronic medical record (EMR) and was linked to the medication administration record (MAR), which, in turn, sent cues to the nurse for ONS dose, delivery, and record of compliance.

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Population, intervention, outcomes measured

We used retrospective medical record audits to assess treatments and outcomes for adult patients (aged ≥18 years) admitted to AGMC between 2011 and 2013. We compared records of patients admitted between July and December 2011 with those admitted between July and December 2013. The QI intervention with medication pass ONS implementation occurred in January 2012. We chose the second half of 2013 as the postintervention period to provide sufficient time for the intervention to become standard of care, and we compared similar time periods (second half of 2011 and 2013) to control for potential seasonal differences.

Nutritional risk was determined using the Malnutrition Screening Tool.35 Prior to the QI changes, patients were screened by nurses, and those with malnutrition risk were referred to a dietitian for nutrition assessment, who would then write recommendations for nutritional support pending physician approval. Post-QI, nurses continued to screen patients for malnutrition risk, but when risk was identified, nurses ordered intervention with ONS. The nurse's order was entered in the EMR. The EMR automatically transmitted the ONS prescription to the MAR and also notified the dietitian to evaluate the patient and validate the prescription. The EMR order then electronically cued the MAR for prompt start of medication pass ONS. ONS portions (∼90 mL/dose; Ensure Complete, Abbott Nutrition) were given to patients 3 times each day for the total target intake volume of 1 serving per day.

We assessed the following outcomes: (1) time from nutrition screening to initiation of nutrition intervention (for patients at risk of malnutrition); (2) use of ONS by at-risk patients; (3) hospital-acquired pressure ulcers (HAPUs); (4) hospital LOS; (5) rate of hospital readmission (within 30 days); and (6) cost per hospitalization episode (inflation-adjusted to 2013 dollars).

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Data collection and statistical analyses

Outcomes were tabulated retrospectively from records of patients admitted either before or after the QIP was implemented. As a Magnet hospital, our facility routinely compiles data on pressure ulcers as a nurse-sensitive quality indicator (National Database of Nursing Quality Indicators [NDNQI]).

The proportion of admitted patients using ONS pre-QIP was compared with the post-QIP proportion using a 2-sample t test. For LOS, readmissions, and hospitalization costs, mean values with standard errors were calculated. The sample was divided into 2 groups based on patients' primary diagnoses. We placed patients with the 10 diagnoses most commonly treated with ONS in a nutrition-sensitive group, and all other patients were placed in the control group. A difference-in-difference methodology was used to assess the impact of the intervention and control for potential confounders. We hypothesized that if the QIP was successful, we would see a greater change in the nutrition-sensitive group, those with diagnoses amenable to treatment by ONS, than in the control group. Statistical differences were determined by means comparison t tests.

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Hospital records of nearly 20 000 patients were evaluated retrospectively. The age range was from 18 to 111 years, with an overall mean age of 59 years, and there were slightly more women than men (Table 1).

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QIP reduced time to ONS initiation

For pre-QI measurement of time to ONS, we conducted a retrospective chart audit of 30 patients admitted to the neuroscience unit. The average time from identification of malnutrition risk to the patient receiving intervention was 2.3 days. Post-QI, the wait time for ONS initiation was reduced to less than 24 hours. Thus, having the nurse order ONS reduced delay time by more than 1 day.

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Administration of ONS to patients increased

Comparing post-QI with pre-QI practices, the proportion of patients receiving ONS increased significantly (P < .01) by 33%: from 6.1% of total (613/10 106 pre-QI) to 8.1% (794/9761 post-QI).

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Hospital LOS and probability of 30-day readmission decreased

The average LOS was 4.87 days in the pre-QI control group, whereas post-QI control patients experienced an average LOS of just 4.47 days, a reduction of 0.40 days (Table 2). As expected, the impact of medication pass ONS on LOS was more apparent among patients whose diagnoses were typically treated with nutritional supplementation; the average LOS in this group fell from 5.74 to 4.97 days—an improvement of 0.77 days (Table 2).

The probability of readmission to the hospital within 30 days of discharge was 14.4% for the pre-QI control group and nonsignificantly lower at 13.8% in the post-QI group. Examination of the patients with nutrition-sensitive diagnoses revealed a more profound improvement in the probability of readmission; probability of readmission declined from 19.7% pre-QI to 16.3% post-QI (P < .01). Consistent with our hypothesis, the change in the nutrition-sensitive group was greater than that in the control group (P < .05) (Table 2).

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HAPUs decreased

Nutrition support is thought to play a role in preventing the development of hospital-acquired conditions such as HAPUs. Based on NDNQI data, there were 40 incident HAPUs in the last 2 quarters of 2011, compared with just 20 in the last 2 quarters of 2013, indicating that our QI was associated with a 50% reduction in incident HAPUs (Table 2).

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Cost of hospitalization reduced

Finally, we examined whether nutrition support affects the patient's hospital charges. Patients whose diagnoses are commonly treated with nutrition support saw a compelling $969 (8.8%) average reduction in their total hospital bill (P < .01). In contrast, patients with diagnoses not commonly treated with nutrition support experienced a smaller, nonsignificant, decrease in costs of $217 (2.1%; Table 2). Such findings are consistent with our hypothesis that the impact of the QI is expected to be greater among those with diagnoses that are considered to be nutrition-sensitive.

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This nurse-led study examined the impact of a QI-designed nursing nutrition protocol for hospitalized patients. According to the protocol, (1) nurses screened patients for malnutrition risk at admission, (2) nurses prescribed ONS for patients at risk, and (3) EMR/MAR systems were used to support ONS distribution and audit patient compliance.

We found both expected and unexpected benefits from the nursing nutrition protocol. By adding medication pass ONS to the EMR/MAR, the nurse could initiate nutritional intervention in an efficient and timely way. The system automatically entered a consult to the dietitian for a comprehensive nutritional assessment, advice, and care, so patients did not have to wait for dietitian recommendations before receiving nutrition support. We also found that giving ONS with medications, as opposed to on a meal tray, conveyed to each patient that ONS was as important as medication. The net result was that a higher proportion of hospital patients received ONS; the rate increased from 6.1% of pre-QI to 8.1% post-QI patients, which suggests that the revised nutrition practice captured patients who were overlooked in pre-QI practices.

In terms of timeliness, the interval between nutritional screening and provision of ONS decreased from more than 2 days pre-QI to less than 24 hours post-QI. Malnutrition risk screening within 24 hours led to prompt identification of risk, which, in turn, led to prompt treatment with ONS. Malnutrition risk screening within 24 hours of admission is required by The Joint Commission.36

Comparing pre-QI and post-QI outcome measures demonstrated specific benefits to timely nutrition care—fewer complications (such as HAPUs), decreased LOS, and lower rates of 30-day readmission. In turn, costs per hospitalization episode were reduced. Specifically, our already low incidence of HAPUs was halved, LOS was shortened by 0.77 days in patients with diagnoses that commonly necessitated ONS use, and rates of 30-day hospital readmissions were lowered by 17% in these patients. Hospitalization costs were reduced an average of $969 per nutrition-sensitive patient.

Over the course of the QIP, the team addressed both perceived and actual barriers. As an actual barrier, the initiation of the program coincided with an upgrade in the EMR system, resulting in a need to reexamine the entire process of malnutrition risk screening and nutrition support. Upgrading the documentation system meant no changes could be made to the current documentation information. This unanticipated event hindered our initial plan to add the ONS to the top of the list of oral supplements for ease of documentation. Nurses had to scroll to the bottom of a long list of supplements to document ONS administration, product name, amount, and time. After a few weeks of observation, it was clear that the QI team needed to develop a more efficient way to record ONS prescription, monitor delivery as prescribed, and audit the process. It was anticipated that these goals could be met if the EMR was linked to the MAR; however, the team was concerned there would be an objection from pharmacy administration to listing a nurse-ordered ONS among other medications. The issue was discussed with representatives from pharmacy; they understood the problem in the larger perspective and readily agreed to include ONS in the MAR. This change was critical to the success of the program, as it provided a way to ensure consistent, targeted distribution of the supplement and allowed a means to monitor the program.

In summary, our study results underscore the value of QI as a way to increase attention to hospital nutrition care, make nutrition practice changes, and test effectiveness of these changes. We specifically showed how involvement of nurses in nutrition screening and ONS prescription could improve nutrition care and subsequent outcomes. We streamlined nutrition practice by using the EMR/MAR to cue ONS administration at medication pass, and we found that the MAR was a useful tool to monitor patient compliance with ONS use. With all of these improvements and efficiencies, we showed that timely and appropriate ONS use could yield better health outcomes with lower costs of care.

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1. Correia MI, Hegazi RA, Higashiguchi T, et al. Evidence-based recommendations for addressing malnutrition in health care: an updated strategy from the feedM.E. Global Study Group. J Am Med Dir Assoc. 2014;15(8):544–550.
2. Norman K, Pichard C, Lochs H, et al. Prognostic impact of disease-related malnutrition. Clin Nutr. 2008;27(1):5–15.
3. Wu ML, Courtney MD, Shortridge-Baggett LM, et al. Validity of the Malnutrition Screening Tool for older adults at high risk of hospital readmission. J Gerontol Nurs. 2012;38(6):38–45.
4. 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.
5. Schindler K, Pernicka E, Laviano A, et al. How nutritional risk is assessed and managed in European hospitals: a survey of 21,007 patients' findings from the 2007-2008 cross-sectional nutritionDay survey. Clin Nutr. 2010;29(5):552–559.
6. Tappenden KA, Quatrara B, Parkhurst ML, et al. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN J Parenter Enteral Nutr. 2013;37(4):482–497.
7. Krumholz HM. Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100–102.
8. Kuslapuu M, Jogela K, Starkopf J, et al. The reasons for insufficient enteral feeding in an intensive care unit: a prospective observational study. Intensive Crit Care Nurs. 2015;31(5):309–314.
9. Keller H, Allard J, Vesnaver E, et al. Barriers to food intake in acute care hospitals: a report of the Canadian Malnutrition Task Force. J Hum Nutr Diet. 2015;28(6):546–557.
10. Allard JP, Keller H, Jeejeebhoy KN, et al. Malnutrition at hospital admission—contributors and effect on length of stay: a prospective cohort study from the Canadian Malnutrition Task Force [published online ahead of print January 26, 2015]. JPEN J Parenter Enteral Nutr. doi:10.1177/0148607114567902.
11. Imoberdorf R, Meier R, Krebs, et al. Prevalence of undernutrition on admission to Swiss hospitals. Clin Nutr. 2010;29(1):38–41.
12. Kaiser MJ, Bauer JM, Ramsch C, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58(9):1734–1738.
13. Shahin ES, Meijers JM, Schols JM, et al. The relationship between malnutrition parameters and pressure ulcers in hospitals and nursing homes. Nutrition. 2010;26(9):886–889.
14. Thibault R, Makhlouf AM, Kossovsky MP, et al. Healthcare-associated infections are associated with insufficient dietary intake: an observational cross-sectional study. PLoS One. 2015;10(4):e0123695.
15. Fry DE, Pine M, Jones BL, et al. Patient characteristics and the occurrence of never events. Arch Surg. 2010;145(2):148–151.
16. Bauer JD, Isenring E, Torma J, et al. Nutritional status of patients who have fallen in an acute care setting. J Hum Nutr Diet. 2007;20(6):558–564.
17. Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003;22(3):235–239.
18. Lim SL, Ong KC, Chan YH, et al. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr. 2012;31(3):345–350.
19. Loser C. Malnutrition in hospital: the clinical and economic implications. Dtsch Arztebl Int. 2010;107(51/52):911–917.
20. Shepherd A. Nutrition support 1: risk factors, causes and physiology of malnutrition. Nurs Times. 2009;105(4):18–20.
21. de van der Schueren M, Elia M, Gramlich L, et al. Clinical and economic outcomes of nutrition interventions across the continuum of care. Ann N Y Acad Sci. 2014;1321:20–40.
22. Freijer K, Bours MJ, Nuijten MJ, et al. The economic value of enteral medical nutrition in the management of disease-related malnutrition: a systematic review. J Am Med Dir Assoc. 2014;15(1):17–29.
23. Philipson TJ, Snider JT, Lakdawalla DN, et al. Impact of oral nutritional supplementation on hospital outcomes. Am J Manag Care. 2013;19(2):121–128.
24. Thornton Snider J, Jena AB, Linthicum MT, et al. Effect of hospital use of oral nutritional supplementation on length of stay, hospital cost, and 30-day readmissions among Medicare patients with COPD. Chest. 2015;(6):1477–1484.
25. Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev. 2006;(4):CD001880.
26. Milne AC, Potter J, Vivanti A, et al. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev. 2009;(2):CD003288.
27. Stratton RJ, Ek AC, Engfer M, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005;4(3):422–450.
28. Holyday M, Daniells S, Bare M, et al. Malnutrition screening and early nutrition intervention in hospitalised patients in acute aged care: a randomised controlled trial. J Nutr Health Aging. 2012;16(6):562–568.
29. Somanchi M, Tao X, Mullin GE. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition. JPEN J Parenter Enteral Nutr. 2011;35(2):209–216.
30. Jefferies D, Johnson M, Ravens J. Nurturing and nourishing: the nurses' role in nutritional care. J Clin Nurs. 2011;20(3/4):317–330.
31. Neelemaat F, Meijers J, Kruizenga H, et al. Comparison of five malnutrition screening tools in one hospital inpatient sample. J Clin Nurs. 2011;20(15/16):2144–2152.
32. Ross LJ, Mudge AM, Young AM, et al. Everyone's problem but nobody's job: staff perceptions and explanations for poor nutritional intake in older medical patients. Nutr Diet. 2011;68(1):41–46.
33. Lochs H, Allison SP, Meier R, et al. Introductory to the ESPEN Guidelines on Enteral Nutrition: terminology, definitions and general topics. Clin Nutr. 2006;25(2):180–186.
34. Shortell SM, Bennett CL, Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Q. 1998;76(4):593–624, 510.
35. Ferguson M, Capra S, Bauer J, et al. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458–464.
36. The Joint Commission. Nutritional, functional, and pain assessments and screens. Published November 24, 2008. Accessed August 2015.

malnutrition; medication administration record; nutrition; nutrition risk screening; oral nutritional supplements; quality improvement

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