1. 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

2. 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 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).

3. 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

4. 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

5. 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

6. 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

7. 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 ), Obese (BMI ), 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

8. Solve: BPAs

9. 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

10. 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

11. 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