Improving Communication of Patient Malnutrition between Providers and Registered Dietitians Contributors: Jessica Moehling, BS; Anne Coltman, MS, RD, CNSC; Diane Sowa, MBA, RD; Sarah Peterson, PhD, RD, CNSC; Leslie Klemp MS, RN, NE-BC; Omar Lateef, DO; Brian Stein, MD

Ready: Problem An estimated 30-55% of all hospitalized patients are malnourished Patients who are malnourished have: Longer LOS Higher readmission rates Higher rates of mortality Higher rates of complications Higher hospital costs Minimal coding for malnutrition is a “hot topic” in nutrition today 3.2% of patients were discharged with a malnutrition diagnosis code in 2010 in the U.S. Coding for malnutrition can result in higher hospital reimbursement Somanchi, M. J Parenter Enter Nutr. 2011;35(2); Correia, MITD. Clin Nutr. 2003;22(3); Agarwal, E. Clin Nutr. 2013;32(5).

Ready: Goals & Scope This project focused on improving the communication of malnutrition and malnutrition severity between providers and RDs in order to increase coding for malnutrition Determine the baseline data for ICD-9 coding of malnutrition at RUMC Standardize and clarify RD identification and documentation of malnutrition Establish a direct line of communication between providers and RDs regarding patient malnutrition Improve provider documentation of malnutrition within patient electronic medical record

Understand: Current Process In a convenience sample of 120 patients at RUMC, 74 patients (62%) had some degree of malnutrition Determined using Subjective Global Assessment performed by a registered dietitian (SGA B or C) A retrospective chart audit determined assignment of ICD-9 malnutrition codes for the 74 patients deemed to have some degree of malnutrition Only 4 patients (5%) were coded with an ICD-9 malnutrition code

Understand: Current Process RD completes Initial Assessment of patient and determines nutrition status; documents SGA score and nutrition diagnosis Patient malnutrition severity is communicated to provider during... LOS Provider considers patient malnutrition status Disagrees or overlooks RD indicated malnutrition Malnutrition not added to problem list or provider note Agrees with RD indicated malnutrition Malnutrition added to problem list and provider note Patient coded for malnutrition After discharge RUMC coder looks through patient medical record Notices RD indicated malnutrition Contacts provider to add into problem list Overlooks RD indicated malnutrition Patient not coded for malnutrition Understand: Current Process

Solve: Solution Improve communication of patient malnutrition between providers and RDs Clarify and standardize RD identification of malnutrition Determined specific definitions for the 3 categories of malnutrition Update FNS Med Surg/Critical Care Flowsheet Includes Nutrition Status, Nutrition Status Indicators, and Nutrition Intervention Update Nutrition Assessment notes Pulls in updated FNS Med Surg/Critical Care Flowsheet rows to note Implement Best Practice Alerts (BPAs) Directly notify all providers of dietitian-indicated malnutrition and malnutrition severity upon opening the patient’s electronic medical record

Solve: FNS Med Surg/Critical Care Flowsheet Update SGA Row - Drop Down: A - Normal, B- Mild malnutrition, C- Severe malnutrition Nutrition Status - Drop Down: Mild protein-calorie malnutrition, Severe protein-calorie malnutrition, Underweight (represents a low BMI without malnutrition), Overweight (BMI of 25-29.9), Obese (BMI 30-39.9), Morbidly Obese (BMI>40), Normal Nutrition Status Indicator: Calorie/Protein Intake - No change in intake, Consuming 25% or less of needs, Consuming 25-50% of needs, Consuming 50-75% of needs Nutrition Status Indicator: Weight status - No weight change, significant weight loss Nutrition Status Indicator: Fat Wasting - No wasting, Mild wasting, Severe wasting Nutrition Status Indicator: Muscle Wasting - No wasting, Mild wasting, Severe wasting

Solve: BPAs

Solve: New Process RD completes Initial Assessment of patient and determines nutrition status; fills out new flowsheet rows for nutrition status and indicators and documents in Nutrition Assessment Note Providers receive BPA Malnutrition added to patient problem list and provider note Patient coded for malnutrition upon discharge

Hold: Maintenance Plan Once updates goes live, data can be collected to determine if process improvements result in greater coding for malnutrition Will run an independent t-test to determine if there is a significantly greater number of patients coded for malnutrition after process improvements compared to before process improvements Generated reports of actions related to BPAs Indicates percent of providers who add malnutrition into problem list Provides information on who uses the “Patient is not malnourished” and “Dismiss” functions

Hold: Maintenance Plan Resident Education Education will be provided to residents giving rationale for malnutrition coding and importance of correct utilization of BPAs Education will also indicate where in RD notes residents can go for further explanation of dietitian-selected nutrition status