July/August 2000

Malnutrition Treatment Program Reduces Length of Stay, Readmission Rates at St. Francis in Wilmington

A malnutrition treatment program developed at St. Francis Hospital in Wilmington, Del., has significantly improved key outcomes for patients at high risk for malnutrition. A 1998 study of this patient population revealed that their:
  • Average length of stay dropped from 10.8 to 8.1 days.
  • Incidence of major complications dropped from 75.3 percent to 17.5 percent.
  • 30-day readmission rates dropped from 16.5 percent to 7.1 percent.
Linda Brugler, RD, CDN, manager of medical nutrition therapy at St. Francis, will share the process behind the performance improvement in a lecture at the Joint Commission for the Accreditation of Healthcare Organizations’ National Conference on Quality and Safety in Health Care this October in Chicago, Ill. "We have developed and refined the program during the last six years," said Brugler. "We looked not only at the benefits a malnutrition treatment program would deliver to patients, but the cost benefits of restorative therapy." Margaret Gavigan, vice president of clinical operations for Catholic Health Initiatives, calls the program a great example of a clinical effectiveness project. "The project is driven by a multidisciplinary team and is achieving excellent results in terms of clinical outcomes and patient satisfaction," she said. "This is the type of work that hospitals must undertake to meet patient demands for quality and to differentiate themselves in their markets." Nationwide, studies suggest that 30 to 50 percent of hospitalized patients are at risk for malnutrition. In 1993, St. Francis participated in a nationwide benchmark study that compared 12 hospitals on the timeliness of nutrition intervention and length of stay for high-risk patients. The data showed that St. Francis had opportunities for improvement in initiating nutrition care plans for acutely ill patients. Those results led to the development of a screening and intervention process by a physician-chaired interdisciplinary team. The team included physicians and representatives from nutrition, nursing, pharmacy, medical technology, quality management, social services and home care. The team’s objective was to design a program that would:
  • Accurately identify high-risk patients.
  • Outline a standard course of nutrition care for high-risk patients during hospitalization.
  • Identify desired patient outcomes.
  • Provide guidelines for specific interventions.
  • Keep the process physician-driven.
  • Communicate discharge nutrition plans to subsequent care providers.
The team originally designed a four-stage pathway that outlined the progression and timing of care. An outcome study conducted in 1996 showed that the pathway improved the identification of high-risk patients from 25.9 to 86 percent and improved the timeliness of nutrition intervention from 6.9 days to 2.4 days. The team then redesigned the pathway for the average eight-day length of stay for high-risk patients (see sidebar), which allowed nutrition care guidelines to be keyed to specific days. According to Brugler, one challenge has been building awareness and acceptance of the program among physicians and within the hospital community. "You have to convince people that it’s advantageous to do things in a new way," she said. "That can only be done with proof statements, so we had to continuously monitor the effectiveness of the process and communicate the results. We have some physician champions who are extremely effective in gaining physician acceptance and support." The team also conducted physician focus groups to determine how physicians want to receive information about patients’ nutrition needs. "We found that they want direct communication from our dietitians," Brugler said. "We use a form that goes into the order section of patient files to make specific intervention recommendations. The form reduces the number of phone calls we make to physicians, and the nurses also use it as a tool to direct physician attention to patients’ nutrition needs." Today, St. Francis continues to refine the pathway. "We’re working to fine-tune the identification of patients at risk for malnutrition," said Brugler. "Pinpointing the patients who will benefit most from restorative therapy helps us better utilize our resources." Brugler’s lecture at the Joint Commission’s conference will take place on October 5, 2000. St. Francis Hospital Malnutrition Treatment Pathway The malnutrition treatment program at St. Francis Hospital is integrated into the care plan of all acute care patients, including the discharge process.
Care Timeline Expected Outcomes
Day 1-2 High-risk patients identified and nutrition care decided
Day 3-4 Treatment in progress
Day 5 Therapeutic level of care achieved
Day 6-7 Therapeutic level of care maintained
Day 8 Discharge care plan communicated to next care provider