statement of need: understanding and implementing the new .../media/grandrounds... · understanding...

1

Understanding and Implementing the New Definition of Malnutrition

Terese Scollard MBA RDN LD FAND

Medical Grand Rounds

St Charles Medical Center

Bend Oregon

January 17 2014

Terese M Scollard MBA RDN LD

Malnutrition is a major contributor to increased morbidity and mortality decreased function and quality of life increased frequency and length of hospital stay and higher health care costs New guidelines have changed the nutritional assessment methods The St Charles Supervisor of Clinical Documentation Improvement requested education to update physicians on the new guidelines citing a lack of understanding of the new criteria This activity addresses competencies ldquomedical knowledgerdquo ldquopatient carerdquo and ldquosystems-based practicerdquo This education is also relevant to documentation improvement specialists medical coders dietitians and nurses

Statement of Need

The views expressed herein are those of the presenter and do not necessarily represent St Charles Medical Center views The material herein is accurate as of the date it was presented and is for educational purposes only and

not intended as a substitute for medical advice

2

Learning Objectives

1 Increase understanding to apply the (2012) international consensus characteristics for adult disease-related malnutrition and their application in patient care

2 Examine updates on the relationship of inflammation serum albumin and relationship to adult disease-related malnutrition

3 Demonstrate how consistent documentation enables clinicians to better establish prevalence of malnutrition and in turn target cost effective interventions

4 Examine in-office and hospital tools to reduce incidence and identify patients at risk for adult disease-related malnutrition

5 Discuss future care models to prevent the negative economic impact of adult disease-related malnutrition

Note we will be discussing adult malnutrition in light of energy balance and

protein anabolism and catabolism rather than micronutrients

3 4

ldquoI suspect that one of the largest pockets of unrecognized malnutrition in America and in Canada too exists not in rural slums or urban ghettos but in the private rooms and wards of our big city hospitalsrdquo ldquoMany undesirable practices concerning the nutritional care of hospitalized patients have their roots in long-standing neglect of nutrition in medical education and in health care delivery systemsrdquo Charles E Butterworth MD Nutrition Today 1974

The Skeleton in the Hospital Closet

httpwwwuabedunutritionabouthistorystart=1 accessed 362012

CL Krumdieck In memoriam Dr Charles Edwin Butterworth Jr Am J Clin Nutr November 1998 68 981-2 5

Dr Butterworthrsquos list 1974

bull Failure to record heightweight

bull Frequent staff rotation

bull Diffusion of patient care responsibility

bull Prolonged use of glucosesaline iv

bull Withholding meals due to tests

bull Inadequate tube feeding unsanitary and uncertain composition

bull Ignorance of composition of vitamin mixtures and other nutritional products

bull Failure to recognize increased nutrition needs for injuryillness

bull Surgical procedures without first optimizing nutrition failure to give nutrition after surgery

bull Failure to appreciate role of nutrition in infectionoveruse antibiotics

bull Lack of communication and interaction between MD and RD

bull Lack of RD concern about every patient in hospital

bull Delay of nutrition until advanced state of depletion

bull Limited availability of laboratory tests to assess nutrition status

bull Failure to use those that are available

6

2

What contributors to

malnutrition have you observed

7

Malnutrition ldquoThe Cinderella of Modern Medicinerdquo

bull Viewed as ldquoOld technologyrdquo

bull Failure to define in a way that engages physicians to cause it to be taken seriously

bull Vague definitions and degree of it which requires interventions

bull Imprecise and perceived to disagree on how to diagnose and describe prevalence

Stratton R Green CElia M Disease-Related Malnutrition an Evidence-Based Approach to Treatment CABI Publishing 2003

8

httpwwwfightmalnutritioneufileadminimagesmalnutritionConsequences_of_malnutritionJPG accessed 22813 9

httpwwwbapenorgukabout-malnutritionintroduction-to-malnutritionshowall=ampstart=1 10

Krausersquos Food and the Nutrition Care Process 13th ed L Mahan S Escott Stump J Raymond P 132 11

Disease-related Malnutrition

ldquohellipdecline in lean body mass with the potential for functional impairmentrdquo at multiple levelsmdashie molecular physiologic andor gross motorrdquo

Jensen GL Bistrian B Roubenoff R Heimburger DC Malnutrition syndromes A conundrum vs continuum JPEN J Parenter Enteral Nutr 200933(6)710-716

ldquoHistoric definitions for malnutrition syndromes have promoted widespread confusion and misdiagnosis They also do not encompass a modern understanding of the role of inflammatory responserdquo Gordon Jensen MD PhD Past-President ASPEN Professor and Head Department of Nutritional Sciences the Penn State University 2010 httpswwwnutritioncareorgIndexaspxid=4792 accessed 5162013

12

3

Modern Nutrition in Health and Disease 6th ed Chapter 22 ldquoMalnutrition in Hospital

Patients Assessment and Treatmentrdquo

CE Butterworth Jr and Roland Weinsier 1978 Lea amp Febiger Philidelphia

13 13

Nutr Clin Pract October 2010

vol 25 no 5 548-554

14

Words that Describe Malnutrition Nutritional Anasarca

Athrepsia Nutritional Atrophy

Severe Calorie Deficiency Protein Deficiency

Multiple Deficiency Syndrome Protein Deprivation

Arested Development due to Malnutrition Wasting Disease

Nutritional Dwarfism Famine Edema

Inanition Edema Starvation Edema

Emaciation Nutritional Hydrops

Hypoproteinosis Inanition with edema

Inanition due to malnutrition Malnutrition degree 1st 2nd 3rd mild moderate severe

Protein Calorie Malnutrition NEC Protein Calorie Severe NEC

Protein Calorie due to specified underlying condition Pediatrophia

Pluricarential syndrome of infancy Plurideficiency syndrome of infancy Polycarential syndrome of infancy

Prekwashiorkor Growth retardation due to malnutrition Physical retardation due to malnutrition

Kwashiorkor Marasmus

Adult Kwashiorkor Hypoalbuminemic Malnutrition Hypoproteinemic malnutrition

Combined Malnutrition

15

A Vision for the Identification of Adult Malnutrition in All Settings

Wouldnrsquot it be amazing to have standardized definitionscharacteristics and to know the prevalence of Adult Malnutrition inhellip

Our World

Our Health Delivery System

Our World

Our Country

copyTerese Scollard MBA RD LD 16

+ = International Consensus

Guideline Committee

httpswwwnutritioncareorgProfessional_ResourcesGuidelines_and_StandardsGuidelines2010__Adult_Starvation_and_Disease-Related_Malnutrition

Etiology ndash based approach that incorporates understanding of the inflammatory response

17

Etiology Based Malnutrition Definitions

18

Yes Mild to Moderate

Degree

Yes Marked

Inflammatory Response

No

Nutritional Risk Identified

Compromised intake or loss of body mass

Inflammation present No Yes

Starvation Related Malnutrition

(pure chronic starvation anorexia nervosa)

Chronic Disease ndash Related Malnutrition

(organ failure pancreatic cancer rheumatoid arthritis

sarcopenic obesity)

Acute Disease or Injury-Related Malnutrition

(major infection burns trauma closed head injury)

Jensen GL JPEN 200933710

18

4

Nutrition Risk Screening

bull Determines at-risk patients bullIn all settings of care or targeted patient populations bullMultiple validated tools are available bullCompliance with Joint Commission and CMS admission screening to hospital

19

20

21

Mini-Nutrition Assessment Malnutrition Universal Screening Tool

httpwwwmna-elderlycomformsMNA_englishpdf

httpwwwncbinlmnihgovpmcarticlesPMC2964075

httpwwwbapenorgukscreening-for-malnutritionmustmust-toolkitthe-must-itself

Short Nutritional Assessment

Questionnaire

httpfightmalnutritioneu

Screening Needs ActionIntervention to be of Value


22


Degree

Yes Marked


No








sarcopenic obesity)




22

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

23

Classic The Minnesota Semi-starvation Experiment

Colorado State University tape or DVD

httpwwwepiumneducvdepivideoaspid=4047

Starvation-Related Malnutrition in Adults

(Malnutrition of social or environmental circumstances)

24

5

bull distinguish the effects of semi-starvation on the bodys strength composition physiological status and mood from the confounding effects of such underlying diseases as cancer intestinal malabsorption renal insufficiency emphysema etc ndash illnesses that often give rise to conditioned PCM

bull The Minnesota group showed clearly that semi-starvation can be independently responsible for an array of psychological problems such as anxiety depression and hypochondria

bull From their studies it is possible to

demonstrate a clear relationship between a decline in fat-free mass and PCM-associated morbidity

Nutrition amp Metabolism 2005 24 VanItallie httpwwwnutritionandmetabolismcomcontent214 accessed 91913 25

September 29 1950 SCIENCE ldquoEven in times of comparative peace and prosperity man suffers from malnutrition including semi-starvation or actual starvation as a result of disease injury individual poverty nutritional ignorance inequitable food distribution and crop failure These factors are aggravated in many parts of the world by population pressures that tend to exceed the food productionrdquo Science 29 September 1950 371-376 [DOI101126science1122909371] News and Notes The Residues of Malnutrition and Starvation Laboratory of Physiological Hygiene University of Minnesota Minneapolis September 29 1950

26

Figure 1 Hypothetical relationship of Starvation-related Malnutrition (top graph) and Disease-related Malnutrition (bottom graph) assuming the inflammatory condition is relatively constant with changes in lean body mass Jensen G L et al JPEN J Parenter Enteral Nutr 201034156-159

Hypothetical relationship ndash Starvation Related Malnutrition w amp wo Nutritional Support

SRM = Starvation Related Malnutrition NS = Nutritional Support PSRM = Partial Starvation Related Malnutrition

27

Starvation-Related Malnutrition (pure chronic starvation anorexia nervosa)

bull Leaner person has a higher rate of weight loss than the obese person during fasting

bull Leaner person has a greater loss of lean tissue

bull The rate of weight loss influences function during food shortage

bull Loss of body weight means fat and muscle loss

bull Loss of body weight means organ mass loss

bull Shifts in body fluids Stratton Elia Disease-Related Malnutrition an Evidence-Based Approach to Treatment p 114

28

Chronic Disease-Related Malnutrition in Adults

amp


29


30


Degree

Yes Marked


No








sarcopenic obesity)




30

6

Inflammation

Promotes

bull Metabolic dysregulation

bull Hyperglycemia

bull Decreased visceral proteins

bull Muscle catabolism

bull Edema

bull Anorexia

bull Malaise deconditioning

Can Blunt

Favorable responses to nutrition intervention

bull Gordon Jensen MD PhD 2011 ADA Food amp Nutrition Conference and

Expo

31


Hypothetical Relationship Acute or Chronic Disease or Injury-Related Malnutrition

32


33


Complications relative to loss of lean body mass

34


Priority for Protein Intake vs Loss of Lean Tissue

35

Chronic Disease-Related Malnutrition

(organ failure pancreatic cancer rheumatoid arthritis sarcopenic obesity)

amp



bull Immune changes especially cellular immunity

bull Muscle changes-reduction in mass and function

bull GI changes

bull Gut damaged by bull Decrease in mesenteric blood flow-operations procedures bull Altered mucous bull Altered acid and bile secretion bull Altered gut motility bull Damaged villi bull Enzyme decrease

36

7

Why not serum albuminvisceral proteins

bullInflammatory disease illness injury elicit a cytokine-mediated acute phase response

ndash Alters hormone secretion and target organ function

ndash Favors a catabolic state that results in metabolic alterations

bull Over the short run the acute phase metabolic response with resulting catabolism is likely an appropriate adaptive response

bull If the underlying stressor is severe protracted or repeated then adverse outcomes will result

Inflammation can blunt favorable responses to nutrition intervention

Nutrition alone is ineffective in preventing muscle loss in inflammation

Academy of Nutrition and Dietetics Evidence Analysis Library AlbuminPrealbumin

Gordon Jensen MD PhD 37

AlbuminPre-albumin

ldquoPre-albumin levels decreasing likely due to poor nutritionrdquo

bullRemains in textbooks and publications

bullChallenging to use other phrasing after so long a pattern

bullA measure of morbidity and mortality

bullMuch used leverage for over 30 years to prompt treatment action

bullSee The Academy Evidence Analysis Library

so what do we do now to get action

The Time is NOW Elevating the Role of Nutrition for Better Patient Outcomes 2012 Pre-FNCE Conference Philadelphia PA October 2012

14

38

39

Rationale for Developing AcademyASPEN Malnutrition DiagnosesMarkers

bull No standardization

bull Multiple Definitions

bull Multiple Diagnostic (ICD-9) Codes

bull Multiple characteristics used to diagnose

bull Limited evidence base

bull Emerging role of inflammation

ndash Influence on Assessment Parameters

ndash Influence on Response to Nutrition intervention

ndash Anti-inflammatory Interventions Nutrition interventions outcomes divergence

40

+

= Malnutrition markers and

recommendations to National Center of Vital and Health

Statistics (NCVHS) (determine codes)

41

Task of Academy Malnutrition Work group (Adults)

1 Convert these clinical conditions into practical bedside clinical characteristics

bull Starvation-Related Malnutrition and bull DiseaseInjury Related Malnutrition

2 Propose additional detail to ICD-9 so they would be meaningful codes

42

8

43

A Bridge to a Unified System

Adult Malnutrition - Clinical presentation - Will change - Altered Metabolic Status - Treatment specific to pre-disposing factors

-Starvation -Chronic disease -Acute disease or injury

Tool to Bridge - Academy amp ASPEN Consensus - Reasonable amp reliable literature and research-based criteria at this time - Will change with further clinical understanding - NOT the ldquobe-all end-allrsquo criteria for adult malnutrition

ICD Classification - A system to categorize and communicate adult malnutrition - Allows for benchmarking prevalence

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical Association From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 2012 American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics 52012

Consensus Statement Characteristics

Recommended for the Identification and

Documentation of Adult Malnutrition

44

ICD-9 Codes ndash Two Levels of Severity

262 - Other Severe Protein Calorie Malnutrition 2630 ndash Malnutrition of a Moderate Degree

Three Typical Etiologies

Acute IllnessInjury ndash severe acute inflammation

Chronic Illness ndash mild to moderate chronic inflammation

SocialEnvironmental Circumstances ndash without inflammation

Six Characteristics

Weight Loss

Insufficient Energy Intake

Loss of Subcutaneous Fat

Loss of Muscle Mass

Localize or Generalized Fluid Accumulation

Diminished Functional Status - measured by hand grip strength

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical Association 45

Characteristics to Diagnose Adult Malnutrition

bull Inadequate intake

bull Unintended weight loss

bull Physical Exam

bull Functional Status

lt50-75 estimated needs ndash By History

ndash Observed

Occurs at Any BMI ndash Blackburn Criteria

Muscle Loss

Subcutaneous Fat Loss

Fluid Accumulation ndash Localized

ndash Generalized

Hand Grip Strength

Any 2 (or more) Characteristics Recommended for Diagnosis J Acad Nutr Diet 2012112(5)730-738

46

Severe Malnutrition in Adults J Acad Nutr Diet 2012112(5) 730-738

For Example ICD-9 Code 262

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss gt21 week

gt51 month gt753 months

gt51 month gt753 months gt106 months

gt 201 year


gt 201 year

Energy Intake lt 50 for gt 5 days lt 75 for gt 1 month lt 50 for gt 1 month

Body Fat Moderate Depletion Severe Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion Severe Depletion

Fluid Accumulation Moderate Severe Severe Severe

Hand Grip Strength Not Recommended in ICU Reduced for AgeGender Reduced for AgeGender

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical Association From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012

47



Weight Loss 1-21 week 51 month

753 months

51 month 753 months 106 months

201 year


201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical Association

Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 48

9

httpwellblogsnytimescom20130429overweight-patients-face-biasnl=healthampemc=edit_hh_20130430ampgoback=gde_1806863_member_236999858 Accessed 572013 Physicians build less rapport with obese patients K Gudzune1daggeret al Obesity A Research Journal 101002oby20384 Copyright copy 2013 The Obesity Society

ldquoI think a lot of them are compassionate and donrsquot realize this is going onrdquo Dr Katz said ldquoThe antipathy for obesity is really rooted in our culture We should expect better from doctors and train them betterrdquo

Obese and Malnourished Yes

49

Muscle Mass and Function in Malnutrition

bull Reduction in Muscle Mass bull Reduction in Muscle Function

bull Muscle function is sensitive to reduction in nutritional intake even before any change in muscle mass occurs

bull Heart bull Respiratory muscle bull Hand grip strength

Stratton Elia Disease-Related Malnutrition an Evidence-Based Approach to Treatment p 116

The Health Risk of ObesitymdashBetter Metrics Imperative Rexford S Ahima and Mitchell A Lazar Science 23 August 2013 856-858 The impact of a high BMI on mortality is in question calling for a rethinking of how metabolic health is assessed Accessed Sept 23 2013

50

Documentation and Work Flow

Acute Care Disease-Related Malnutrition Work Flow

Upon admission patients are screened by Nursing and MD Consults to Nutrition

Registered Dietitian (RD) assesses patients with nutrition risk factors

RD reviews malnutrition findings with MDNPPA team collaborates on plan of care with documentation

Upon discharge Coders review medical records and assign ICD-9 codes which generate data to monitor population and provide

potential reimbursement to hospital for acuity and MD for patient severity

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012

52

bull Describe (succinctly and descriptively) objective evidence and details supporting malnutrition criteria and characteristics

bull Documentation of additional data builds supporting evidence

bull Subjective information is important too Describe pertinent evidence and associations to under nutrition

bull Quantify data bull Time frames of deficits actual weight change and percentages over time bull Intake percentages and estimates of intake compared to short term and long

term targets (especially calories and protein) bull Include nutrition physical assessment descriptions

bull Avoid vernacular Talk about nutrients food metabolism bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve

nutritional status in the future

Quality Documentation

53

No single piece of information means a patient is malnourished bull Use critical thinking bull Consider the whole patient situation bull Nutrition history bull Ongoing ability to access and consume food bull Weight history bull Food and liquids intake history bull Metabolism

Assessment of malnutrition occurs at this point in time regardless of the prognosis Documentation does not replace care advocacy communication concerns questions and observations with other team members

When Documenting Malnutrition Remember

54

10


bull Failure to weighmeasure and record heightweight

bull Frequent staff rotation bull Diffusion of patient care

responsibility bull Prolonged use of glucosesaline iv bull Withholding meals due to tests bull Inadequate tube feeding

unsanitary and uncertain composition










55

Challenges amp Opportunities

httpwwwmedicaregovhospitalcompareAspxAutoDetectCookieSupport=1

57 httpiomeduReports2012Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-Americaaspx 58

Nutrition Alert Portland Terese Scollard MBA RD LD Manager Clinical Nutrition Services Nutrition Services

Project summary 20 to 25 of Providence acute care hospital admissions include patients with adult disease related malnutrition (DRM) This proposal is to investigate and implement simple electronic triggers work flow and basic resources for lower level interventions so that physicians and nursing staff in PMG will be alerted to weight loss and other malnutrition risk factors early in order to intervene and prevent nutritional compromise and hospital re-admission

Affordable Services

Improve Population Health

Best Care Experience

Simple and inexpensive first line interventions cost much less than tube feedings hospital infections non-healing wounds muscle function loss and weakness Ultimately preventing infections readmissions and morbidity

Recently released international standards define characteristics of adult disease related malnutrition We will incorporate many of these useful tools including connection with electronic health records and early ongoing patient tracking

Reduce and minimize trauma of nutritional rescue attempts and reduce or minimize hospitalization or re-hospitalization

High High High

Transform the delivery of clinical care

OR Region Votes 121

2012 Investment $4850

Estimated ROI $124150

1Q 2013 Managing Execution amp Results Project Team James Carlisle MD Scott Gudger Eric Bergstrom Regis Peregrin Kathy Phillips Carolyn Bingham Mike Phillips MD Teresa Ballard

Jim Bradley

Building Engagement contacted above persons and then referred to persons who have access to data that might be helpful and who can obtain

data Discussed nature of project and timing of availability of data especially in light of complications with Epic data transfers into our data bases for analysis Included topic as part of regional medical nutrition committee work 1212

Triple Aim Goal Setting no changes two phases are emerging 1st is to obtain data and a listing of data needs has been made 2nd phase will be to determine steps for action based on the data results Data examples malnourished discharged to PMG volume visits utilization of health care services post dc and utilization by Medicare and other populations by zip code weight tracking in PMG those at low BMIrsquos for age

Lessons Learned Epic implementation slowed but did not delay setting up and organizing needs and determining questions for project

Upcoming Key Milestones Locating a resource to obtain the data within the Analytics group

8

59

G8418 CALCULATED BMI BELOW THE LOWER PARAMETER AND A FOLLOW-UP PLAN WAS DOCUMENTED IN THE MEDICAL RECORD

httpwwwhipaaspacecomMedical_BillingCodingHealthcareCommonProcedureCodingSystemG8418

60

11

Consumer- Education for Self Management bull A culture of partnership with patients bull Self management tools bull Resources bull Health Literacy attention bull How to interact with health care providers httpwwwahrqgovpatients-consumersindexhtml httpwwwnestle-nutritioncomClinical_Resourcestoolsaspx 61

httpwwwphsoregonorgvideoview=d203426faaed7x480x293 local TV spot 55

Community Education and Video

62

Oregon AND Public Policy Committee DRAFT Proposal to Health Share Oregon CCO

Malnutrition Alert Oregon Purpose To create accountability and value and minimize the negative health and economic impact of disease-related malnutrition for the adult population in Oregon

1 The Consensus Statement of the Academy of Nutrition and Dietetics and the American Society of Parenteral amp Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)1 is used as the characteristics data set for the diagnosis of disease related malnutrition in adults

2 Report prevalence of Adult Disease-Related Malnutrition for systems economic and outcomes analyses

3 Create consumer value through education about self-management and by partnerships with health care providers

63

httpwwwnestlenutrition-instituteorgresourceslibraryFreenutrition-highlightsNutrition-and-Enhanced-Recovery-in-SurgeryPagesNutrition-and-Enhanced-Recovery-in-Surgeryaspx

64

The first Strong for Surgery initiative addresses pre-operative nutrition intervention a priority topic identified by SCOAP clinicians and quality leaders Nutritional status is a major determinant of outcome for the high-risk surgical patient and is one of the most important pre-operative predictors of outcome in any type of surgery

Decreasing Malnutrition Prevalence the Dutch

Experience

65

httpwwwfightmalnutritioneufileadminimagesfight_malnutritionDUTCH_approach_MNI_Grant_Winner_2010__hand-out_pdf

66

12

57

1 Document malnutrition using Academy of Nutrition amp Dietetics and American

Society of Enteral and Parenteral Nutrition Consensus Characteristics

2 Consider use of validated screening tools and referrals in all settings of care early and for high risk populations Hospitals are only one location

3 From all care settings and home refer at-risk and malnourished persons for nutrition assessment intervention counseling and education by a registered dietitian

4 Coordinate processes to capture and report adult malnutrition in populations

5 Educate the public and colleagues for awareness and preventive action

6 Engage with Health Care Reform efforts to help your patients

Opportunities to reduce morbidity and save health care dollars

67

Thank you

Questions

teresescollardprovidenceorg 5032162496

68

Additional Notes and Resources

69

ICD-9 ICD-10 1012014

ICD-10 NAMING

262 E43 Unspecified severe protein-calorie malnutrition Applicable ToStarvation edema

2630 E440 Moderate protein-calorie malnutrition

2631 E441 Mild protein-calorie malnutrition

2638 No Code converts approximately to 2013 ICD-10-CM E46 Unspecified protein-calorie malnutrition

2639 E46 Unspecified protein-calorie malnutrition

Applicable To Malnutrition NOS Protein-calorie imbalance NOS

27801 E6601 Morbid (severe) obesity due to excess calories

78322 R636 Underweight Use Additional code to identify body mass index (BMI) if known (Z68-) Type 1 Excludes abnormal weight loss (R634) anorexia nervosa (F500-) malnutrition (E40-E46)

78321 R634 Abnormal weight loss

7994 R64 Cachexia Applicable To Wasting syndrome Code First underlying condition if known Type 1 Excludes abnormal weight loss (R634) nutritional marasmus (E41)

V854 Z684 Body mass index (BMI) 40 or greater adult Z6841 goes to Z6845 BY BMI 400 TO 70

260 E40 Kwashiorkor Peds

261 E41 Marasmus Peds

E42 Marasmic Kwashiorkor Peds

httpwwwicd10datacom accessed 51613 70

The Minnesota Semi-Starvation Experiment

Video or DVD

Mark Cole

970-491-5920 mcolecolostateedu

Colorado State University Academic Computing Network Services

Mail Stop 1018 Fort Collins CO 80523

71

Resources and Links to Efforts in Europe amp North America

Malnutrition Resource sites UK EU US CA Euopean Society of Enteral amp Parenteral Nutrition Video httpwwwespenorganother-weight-problem-video httpwwweuficorgarticleenartidTime-to-recognise-malnutrition-Europe European Food Information Council httpwwwyoutubecomwatchfeature=youtubeamphl=en-GBampv=Cqcc9bwi5tg httpmalnutritionandjrnlorg Malnutrition Resource site USA httpwwwfightmalnutritioneu The Netherlands and EU-excellent and well thought out httpwwwniceorguknicemediapdfcg032fullguidelinepdf httpwwwniceorguknicemedialive109782998129981pdf UK Guidelines httpwwwniceorgukCG032 UK Nutrition Support in Adults Oral nutrition support enteral tube feeding and parenteral nutrition ndash Costing Report and Excel Template httpwwwbapenorguk British professional resource site httpwwwwalesnhsuksites3Documents814GwentGuidelinesTreatmentUndernutrition5BSept105Dpdf Wales httpnutritioncareincanadaca Canada

72

13

Additional Reading

73

httpmalnutritionandjrnlorg

httpmalnutritioncom

httpwwwnestlenutrition-instituteorgsearchpagesadvancedsearchaspxq=malnutrition

httpwwwbapenorgukabout-malnutritionintroduction-to-malnutrition

wwwfightmalnutritioneu

74

MNA- Mini Nutrition Assessment for the Elderly httpwwwmna-elderlycomformsMNA_englishpdf an RN or trained aid would perform this gt65 years old

httpmna-elderlycomformsSelf_MNApdf

a patient could fill out most of this one gt65 years old

httpmna-elderlycomi-phonehtml

NRS 2002 httpwwwncbinlmnihgovpmcarticlesPMC2964075 for ldquoadultsrdquo

Malnutrition Universal Screening Tool (MUST) httpwwwbapenorgukscreening-for-malnutritionmustmust-toolkitthe-must-itself

httpwwwbapenorgukscreening-for-malnutritionmustmust-app

httpwwwbapenorgukscreening-for-malnutritionmust-calculator

Academy Evidence Analysis Library Validated Nutrition Risk Screening Tools

75 76

77 78

14

Patient Care Flow Chart

79

2

What contributors to

malnutrition have you observed

7

Malnutrition ldquoThe Cinderella of Modern Medicinerdquo

bull Viewed as ldquoOld technologyrdquo

bull Failure to define in a way that engages physicians to cause it to be taken seriously

bull Vague definitions and degree of it which requires interventions

bull Imprecise and perceived to disagree on how to diagnose and describe prevalence

Stratton R Green CElia M Disease-Related Malnutrition an Evidence-Based Approach to Treatment CABI Publishing 2003

8

httpwwwfightmalnutritioneufileadminimagesmalnutritionConsequences_of_malnutritionJPG accessed 22813 9

httpwwwbapenorgukabout-malnutritionintroduction-to-malnutritionshowall=ampstart=1 10

Krausersquos Food and the Nutrition Care Process 13th ed L Mahan S Escott Stump J Raymond P 132 11

Disease-related Malnutrition

ldquohellipdecline in lean body mass with the potential for functional impairmentrdquo at multiple levelsmdashie molecular physiologic andor gross motorrdquo

Jensen GL Bistrian B Roubenoff R Heimburger DC Malnutrition syndromes A conundrum vs continuum JPEN J Parenter Enteral Nutr 200933(6)710-716

ldquoHistoric definitions for malnutrition syndromes have promoted widespread confusion and misdiagnosis They also do not encompass a modern understanding of the role of inflammatory responserdquo Gordon Jensen MD PhD Past-President ASPEN Professor and Head Department of Nutritional Sciences the Penn State University 2010 httpswwwnutritioncareorgIndexaspxid=4792 accessed 5162013

12

3




13 13


vol 25 no 5 548-554

14


















15



Our World


Our World

Our Country



Guideline Committee



17


18


Degree

Yes Marked


No








sarcopenic obesity)




18

4



19

20

21






Questionnaire




22


Degree

Yes Marked


No








sarcopenic obesity)




22


23






24

5







26




27








28


amp


29


30


Degree

Yes Marked


No








sarcopenic obesity)




30

6

Inflammation

Promotes


bull Hyperglycemia



bull Edema

bull Anorexia


Can Blunt



Expo

31



32


33



34



35



amp





bull GI changes


36

7











AlbuminPre-albumin









14

38

39











40

+




41





42

8

43










44







Six Characteristics

Weight Loss



Loss of Muscle Mass







bull Physical Exam



ndash Observed


Muscle Loss



ndash Generalized

Hand Grip Strength


46







gt 201 year


gt 201 year







47




753 months


201 year


201 year









9




49







50









52









53




54

10















55






Affordable Services






High High High


OR Region Votes 121




Jim Bradley






8

59



60

11




62






63


64



Experience

65


66

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

3




13 13


vol 25 no 5 548-554

14


















15



Our World


Our World

Our Country



Guideline Committee



17


18


Degree

Yes Marked


No








sarcopenic obesity)




18

4



19

20

21






Questionnaire




22


Degree

Yes Marked


No








sarcopenic obesity)




22


23






24

5







26




27








28


amp


29


30


Degree

Yes Marked


No








sarcopenic obesity)




30

6

Inflammation

Promotes


bull Hyperglycemia



bull Edema

bull Anorexia


Can Blunt



Expo

31



32


33



34



35



amp





bull GI changes


36

7











AlbuminPre-albumin









14

38

39











40

+




41





42

8

43










44







Six Characteristics

Weight Loss



Loss of Muscle Mass







bull Physical Exam



ndash Observed


Muscle Loss



ndash Generalized

Hand Grip Strength


46







gt 201 year


gt 201 year







47




753 months


201 year


201 year









9




49







50









52









53




54

10















55






Affordable Services






High High High


OR Region Votes 121




Jim Bradley






8

59



60

11




62






63


64



Experience

65


66

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

4



19

20

21






Questionnaire




22


Degree

Yes Marked


No








sarcopenic obesity)




22


23






24

5







26




27








28


amp


29


30


Degree

Yes Marked


No








sarcopenic obesity)




30

6

Inflammation

Promotes


bull Hyperglycemia



bull Edema

bull Anorexia


Can Blunt



Expo

31



32


33



34



35



amp





bull GI changes


36

7











AlbuminPre-albumin









14

38

39











40

+




41





42

8

43










44







Six Characteristics

Weight Loss



Loss of Muscle Mass







bull Physical Exam



ndash Observed


Muscle Loss



ndash Generalized

Hand Grip Strength


46







gt 201 year


gt 201 year







47




753 months


201 year


201 year









9




49







50









52









53




54

10















55






Affordable Services






High High High


OR Region Votes 121




Jim Bradley






8

59



60

11




62






63


64



Experience

65


66

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

5







26




27








28


amp


29


30


Degree

Yes Marked


No








sarcopenic obesity)




30

6

Inflammation

Promotes


bull Hyperglycemia



bull Edema

bull Anorexia


Can Blunt



Expo

31



32


33



34



35



amp





bull GI changes


36

7











AlbuminPre-albumin









14

38

39











40

+




41





42

8

43










44







Six Characteristics

Weight Loss



Loss of Muscle Mass







bull Physical Exam



ndash Observed


Muscle Loss



ndash Generalized

Hand Grip Strength


46







gt 201 year


gt 201 year







47




753 months


201 year


201 year









9




49







50









52









53




54

10















55






Affordable Services






High High High


OR Region Votes 121




Jim Bradley






8

59



60

11




62






63


64



Experience

65


66

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

6

Inflammation

Promotes


bull Hyperglycemia



bull Edema

bull Anorexia


Can Blunt



Expo

31



32


33



34



35



amp





bull GI changes


36

7











AlbuminPre-albumin









14

38

39











40

+




41





42

8

43










44







Six Characteristics

Weight Loss



Loss of Muscle Mass







bull Physical Exam



ndash Observed


Muscle Loss



ndash Generalized

Hand Grip Strength


46







gt 201 year


gt 201 year







47




753 months


201 year


201 year









9




49







50









52









53




54

10















55






Affordable Services






High High High


OR Region Votes 121




Jim Bradley






8

59



60

11




62






63


64



Experience

65


66

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

7











AlbuminPre-albumin









14

38

39











40

+




41





42

8

43










44







Six Characteristics

Weight Loss



Loss of Muscle Mass







bull Physical Exam



ndash Observed


Muscle Loss



ndash Generalized

Hand Grip Strength


46







gt 201 year


gt 201 year







47




753 months


201 year


201 year









9




49







50









52









53




54

10















55






Affordable Services






High High High


OR Region Votes 121




Jim Bradley






8

59



60

11




62






63


64



Experience

65


66

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

8

43










44







Six Characteristics

Weight Loss



Loss of Muscle Mass







bull Physical Exam



ndash Observed


Muscle Loss



ndash Generalized

Hand Grip Strength


46







gt 201 year


gt 201 year







47




753 months


201 year


201 year









9




49







50









52









53




54

10















55






Affordable Services






High High High


OR Region Votes 121




Jim Bradley






8

59



60

11




62






63


64



Experience

65


66

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

9




49







50









52









53




54

10















55






Affordable Services






High High High


OR Region Votes 121




Jim Bradley






8

59



60

11




62






63


64



Experience

65


66

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

10















55






Affordable Services






High High High


OR Region Votes 121




Jim Bradley






8

59



60

11




62






63


64



Experience

65


66

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

11




62






63


64



Experience

65


66

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

12

57









67

Thank you

Questions


68


69

ICD-9 ICD-10 1012014

ICD-10 NAMING

















Video or DVD

Mark Cole




71



72

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

13

Additional Reading

73


httpmalnutritioncom




74










75 76

77 78

14


79

14


79