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Teaming up to protect patients from malnutrition

Toronto, December 7, 2016

By James Wysotski

Registered dietitian Jackie Song assesses a patient to determine if she’s malnourished
Registered dietitian Jackie Song assesses a patient to determine if she’s malnourished. (Photo by Katie Cooper)

What does malnutrition look like? Not always what one might think.

"People have a picture in their minds of how a malnourished person looks, but sometimes patients who look well are at the highest risk," said Jackie Song, a registered dietitian in the Cardiovascular Intensive Care Unit. For example, 24 per cent of overweight patients are at risk, according to the Canadian Malnutrition Task Force.

At St. Michael’s Hospital, one-third of all patients admitted are moderately to severely malnourished, said Song. The key is identifying them right away because malnutrition is associated with increased risk of death, impaired healing, more falls and longer stays in hospital.

The process of identification is challenging because malnutrition is often a byproduct of social determinants of health or prolonged sickness with whatever caused the hospital visit. The instinct is to focus treatment on what’s diagnosed on admission, so Kim Bradley, the manager of Collaborative Practice and Education, said she wants to see malnutrition as a co-diagnosis.

"It's not just about getting the medicine to you because food has such an important role in getting you well," she said. “Food is medicine."

The newly formed interprofessional Nutrition and Hydration Working Group – which includes Bradley and Song – seeks to implement best practices for the identification and treatment of malnourished patients. This means screening all patients, increasing documentation and creating mealtime strategies for at-risk patients

“Screening is the big priority,” said Song. “If we can't ID them, we won't know who to prioritize.”

   
More than 75 per cent of patients are satisfied with the food here, but one in three eats less than half. So what’s keeping them from eating?

Patients say...

  • 40 per cent could not open the packages
  • 23 per cent were poorly positioned to eat
  • 22 per cent missed meals for procedures
  • 18 per cent could not reach their meal
  • 62 per cent were interrupted by staff during meals
  • 34 per cent did not get replacement meals when missed
  • 13 per cent did not receive help when they needed it
  • 58 per cent did not get what they ordered
  • 42 per cent were disturbed by noises or smells

While screening already occurs in some settings, Bradley said she wants everyone to be screened when they are admitted as inpatients or visit a family health team – because the diagnosis isn’t made often enough. And then at-risk patients would see a dietitian for assessment and to document the diagnosis so that appropriate help is given.

Early identification, when coded properly, ensures people get treated. One idea the working group is considering would be adding a diagnosis to the meal entry system so that a visual trigger such as a different-coloured placemat or meal tray would let staff know this patient needs to eat.

Protecting patients at mealtime is a common thread to the group’s ideas because one in three patients eat less than half of their food. Reasons vary from being unable to open packages or reach food, to staff interruptions or being sent for procedures.

The goal is awareness so that all staff takes ownership of improving patient outcomes. For example, once finished caring for a patient, they can ensure side tables are within reach or have meals reheated. And if volunteers or non-clinicians see uneaten meals, they’d know someone needs to hear a report.

“It's a team approach,” said Song. “We all have to work together to make sure conditions are optimal for faster recoveries."

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael's Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.