By Catherine D’Andrea, RDN, LDN, and Marcia Nusgart, RPh

alnutrition is a leading cause of morbidity and mortality, especially among older hospitalized adults, yet it often goes undiagnosed and therefore untreated. It has been established that malnourished hospitalized patients experience slower wound healing, higher risks of infection, and longer length of stay.^1,2

Malnutrition is a burdensome condition associated with a 34% higher cost for a hospital stay compared with a non-malnourished patient.³ Sufficient macronutrients (carbohydrates, protein, fats, and water) and micronutrients (vitamins and minerals) are vital for the body to support tissue integrity and prevent breakdown. Research supports that weight loss and difficulties with eating can increase the incidence of pressure injuries.⁴ The Academy of Nutrition and Dietetics, Avalere Health, and other stakeholders are leading the charge in closing malnutrition gaps with the Malnutrition Quality Improvement Initiative (MQii), a national nutrition-focused quality improvement) initiative. The primary goal of the MQii is to advance evidence-based, high-quality, patient-driven care for hospitalized older adults who are malnourished or at risk for malnutrition. The MQii makes available a set of four malnutrition-focused electronic clinical quality measures (eCQMs) and a MQii Toolkit that includes resources guiding implementation of quality improvement activities. The four malnutrition eCQMs have been adopted throughout the nation as a part of the MQii Learning Collaborative consisting of 307 hospitals and health care systems across 38 states.

Global Malnutrition Composite Score

The MQii is now working to support adoption of the Global Malnutrition Composite Score (GMCS), the composite measure encompassing components of the four malnutrition eCQMs into the Centers for Medicare & Medicaid Services (CMS) Hospital Inpatient Quality Reporting (IQR) Program. The Academy of Nutrition and Dietetics is the GMCS measure steward, and Avalere Health is the measure developer. The overall composite score is derived from averaging the individual performance scores for the following component measures⁵:

1. Screening for malnutrition risk at admission
2. Completing a nutrition assessment for patients who screened positively for risk of malnutrition
3. Appropriately documenting malnutrition diagnosis in the patient’s medical record when indicated by the assessment findings
4. Developing a nutrition care plan for malnourished patients, including the recommended treatment plan

In early June 2021, the Measure Applications Partnership recommended this composite measure for inclusion in the Hospital IQR Program pending endorsement from the National Quality Forum (NQF) Prevention and Population Health Standing Committee. NQF will make its final endorsement decision in the summer of 2021. This presents an important step toward advancing high-quality malnutrition care in hospitals around the country. In turn, this can have an impact on wound care.

Advocacy and Call to Action

Stakeholders, including the Alliance of Wound Care Stakeholders, have played an important role in advocacy efforts bringing national attention to this issue of the need for improved malnutrition care in our health care system. Research has demonstrated some of the impacts of malnutrition on wound healing. Nutritional deficiencies impede the normal processes that allow progression through stages of wound healing. Malnutrition has also been related to decreased wound tensile strength and increased infection rates. Additionally, malnourished patients can develop pressure injuries, infections, and delayed wound healing that result in chronic non-healing wounds. The Alliance has represented a wound care perspective through several sets of comments to the NQF. There is still opportunity for other organizations, as well as individual providers, to submit comments in support of the Global Malnutrition Composite Score through June 28, 2021. Consider submitting your experiences and knowledge about high-quality nutrition care for malnourished patients. Specifically, it will be important to address the gap in malnutrition care and the importance of the inclusion of malnutrition quality measures in CMS regulations.

To submit your comments, visit the comment letter submission form on regulations.gov.

References

1. Barker L, Gout B, Crowe T, et al. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011;8:514-527.

2. Pratt KJ, Hernandez B, Blancato R, et al. Impact of an interdisciplinary malnutrition quality improvement project at a large metropolitan hospital. BMJ Open Qual. 2020;9(1):3000735. doi:10.1136/bmjoq-2019-000735.

3. Curtis LJ, Bernier P, Jeejeebhoy K, et al. Costs of hospital malnutrition. Clin Nutr. 2017;36(5):1391-1396.

4. Munoz N. Malnutrition and pressure injuries. WoundSource. January 4, 2018. https://www.woundsource.com/blog/malnutrition-and-pressure-injuries. Accessed June 21, 2021.

5. Valladares AF, McCauley SM, Khan M, D’Andrea C, Kilgore K, Mitchell K. Development and evaluation of a global malnutrition composite score [E-pub ahead of print]. J Acad Nutr Diet 2021 Mar 10. doi:10.1016/j.jand.2021.02.002.

6. Stechmiller J. Understanding the role of nutrition and wound healing. Nutr Clin Pract. 2010;25(1):61-68. doi: 10.1177/0884533609358997

The Alliance of Wound Care Stakeholders is a nonprofit multidisciplinary trade association of health care professional and patient organizations whose mission is to promote quality care and access to products and services for people with wounds through effective advocacy and educational outreach in the regulatory, legislative, and public arenas.