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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

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doi: 10.1097/NCQ.0000000000000177
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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.


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.

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).

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.



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).

Table 1. - Demographics of Patients Whose Records Were Retrospectively Evaluateda
Patient Group
Pre-QI (n = 10 106) Post-QI (n = 9761)
ONS (n = 613) No ONS (n = 9493) Nutrition-Sensitive (n = 1567) Control (n = 8539) ONS (n = 794) No ONS (n = 8967) Nutrition-Sensitive (n = 1574) Control (n = 8187)
Age, mean (range), y 72.0 (18-101) 59.1 (18-111) 69.5 (18-102) 58.1 (18-111) 69.9 (18-99) 59 (18-104) 69.2 (19-104) 58.2 (18-101)
Women, n (%) 374 (61) 5393 (57) 932 (59) 4836 (57) 444 (56) 5018 (56) 923 (58) 4539 (55)
Abbreviations: ONS, oral nutritional supplements; NOS, not otherwise specified; QI, quality improvement.
aSummary statistics displayed for patients by ONS order status (results columns 1, 2, 5 and 6) and by diagnosis-based nutritional sensitivity (results columns 3, 4, 7 and 8).

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.

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).

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).

Table 2. - Summary of QI Outcomesa
Pre-QIP Post-QIP Conclusion
LOS, mean, d
Control 4.87 (SE = 0.05) 4.47 (SE = 0.05)b Decreased by 0.40 d (8.3%)b
Nutrition-sensitive 5.74 (SE = 0.12) 4.97 (SE = 0.10)b Decreased by 0.77 d (13.4%)b
Decrease was 0.36 d greater for nutrition-sensitive patientsc
Readmission probabilityd
Control 14.4% (SE = 0.004) 13.8% (SE = 0.04)b Percent reduction of 4%
Nutrition-sensitive 19.7% (SE = 0.01) 16.3% (SE = 0.09)b Percent reduction of 17%
Reduced 13% more for the nutrition-sensitive group than for the control groupc
Hospital-acquired condition: Pressure ulcers 40 20 50% decrease after implementation of ONS medication pass
Cost of care, mean
Control $10 222 (SE = $135) $10 005 (SE = $127; NS) Decreased $217 (2.1%)e
Nutrition-sensitive $10 996 (SE = $312) $10 026 (SE = $268)b Decreased $969 (8.8%)b
Reduced $752 more for the nutrition-sensitive groupe
Abbreviations: LOS, length of stay; NS, nonsignificant; ONS, oral nutritional supplements; QI, quality improvement; QIP, quality improvement program.
aControl group: patients with diagnoses not usually treated with ONS (n = 8539 pre-QIP; n = 8187 post-QIP). Nutrition-sensitive group: patients with diagnoses that would commonly be treated with ONS (n = 1567 pre-QIP; n = 1574 post-QIP).
bP < .01.
cP < .05
dWithin 30 days of discharge.
eP value is not significant.

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).

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).

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.


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

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