What would you do if you knew of a treatment that would improve your acutely ill inpatient’s immune function, lean muscle mass, wound healing, functional ability, and long-term survival, while reducing hospital costs, as well as risk of death, nosocomial infection, pressure ulcer, and hospital readmission? You would jump at it, right? Well, many of us do not. Most of us are not even recognizing that our patients need this treatment. Up to 70% of adult inpatients are suffering from inadequate treatment while we are measuring vital signs, perfecting electrolyte levels, and ordering expensive diagnostic tests. The treatment? Adequate nutrition.
In developed countries, 20-68% of adults are malnourished at the time of admission. This is due to acute, chronic, or acute on-chronic illness causing anorexia and inflammation that deplete fat and lean protein storage. Half have either lost weight or eaten poorly in the weeks prior to admission. During their hospital stay, they often are not allowed to eat in preparation for tests, sometimes on consecutive days. It is not surprising that sick inpatients do not eat enough calories to meet their metabolic needs, even with access to food. Even those with normal nutritional status on admission can develop malnutrition after 7 days in the hospital.
What is surprising is how under-recognized and undertreated this condition is. Studies from developed countries around the world have found less than 1/3 of adult inpatients had any documentation of weight or oral intake, and scant numbers had dieticians consulted or even the mention of nutrition status in their charts. In the United States, the Joint Commission on Accreditation of Healthcare Organizations requires inpatients be screened for malnutrition on admission and throughout their hospital stay; usually this is a nursing process. Yet, there is a disconnect somewhere between screening and treatment.
Recognition of the inpatient’s development of malnutrition requires a high degree of suspicion, and close, daily attention to oral and intravenous intake, patient weight, metabolic status such as fever, frequency of denial of oral intake, and wound healing are essential. Clearly, this is a multidisciplinary process best addressed as a team with nutritional status as part of the treatment plan. Today’s medicine does not do this process well at all, so it is left up to individual disciplines, particularly dieticians, to make the diagnosis. But dieticians have little control or influence over physician decisions. The physician is captain of the ship, who is too busy dealing with regulatory and healthcare institutional demands to consider a silent, almost invisible process that weakens a patient and only becomes visible in indirect ways, such as a pressure ulcer or a wound infection. Even then, attention to skin care or intravenous antibiotics does not address the underlying problem of inadequate protein stores.
Just providing calories is not the answer to this complex problem. Unfortunately, the research into appropriate and effective therapies to prevent and treat malnutrition is of poor quality. Just paying attention to a patient’s nutrition intake may provide benefits. Eighty-three percent of patients who received individualized attention to their intake consumed at least 75% of needed calories and had better outcomes, versus 30% of those receiving “usual care.”
Starve a cold, feed a fever? Vice versa? There may be an evolutionary reason for illness-associated anorexia. The pathogens causing disease may not receive necessary nutrients to maintain their high metabolic rate, whereas the patient may have enough nutritional stores to draw upon for the short term. Destruction of fever-damaged host proteins may be enhanced as well. However, a malnourished patient may be lacking leptin, a hormone secreted by fat cells that enhances immune function, and will have no reserves on which to draw. Currently, there is considerable debate and research underway trying to determine the optimal timing and amount of calories to provide critically ill patients.
However, researchers and clinicians who use this uncertainty to advocate for not feeding patients and allowing them to develop nosocomial malnutrition are ignoring common sense. While there may be a time to starve and a time to feed, there is no excuse for not addressing a sick patient’s nutritional needs.
This issue was first described in 1974! Billions of dollars of lost revenue and increased healthcare costs have been wasted by ignoring this potentially preventable condition. Screening, diagnosis, and appropriate supplementation can address this condition, improving patient outcomes and reducing costs. Let’s do this!
These findings are described in the article entitled Recognition and Prevention of Nosocomial Malnutrition: A Review and A Call to Action! recently published in the American Journal of Medicine. This work was conducted by Lisa L. Kirkland from the Mayo Clinic and Abbott Northwestern Hospital, Allina Health, as well as Erin Shaughnessy from the Phoenix Children’s Hospital.