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The Academy of Nutrition and Dietetics/The American Society for Parenteral and Enteral Nutrition
Consensus Malnutrition Characteristics: Application in Practice
Ainsley Malone and Cynthia Hamilton
Nutr Clin Pract 2013 28: 639 originally published online 31 October 2013
DOI: 10.1177/0884533613508435

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508435
research-article2013
NCPXXX10.1177/0884533613508435Nutrition in Clinical PracticeMalone and Hamilton

Invited Review
Nutrition in Clinical Practice
Volume 28 Number 6
The Academy of Nutrition and Dietetics/The American December 2013 639­–650
© 2013 American Society
Society for Parenteral and Enteral Nutrition Consensus for Parenteral and Enteral Nutrition

Malnutrition Characteristics: Application in Practice DOI: 10.1177/0884533613508435

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hosted at
online.sagepub.com

Ainsley Malone, MS, RD, LD, CNSC1; and Cynthia Hamilton, MS, RD, LD2

Abstract
Malnutrition in adult hospitalized patients has been a significant issue for almost 40 years. Changes in 2007 to the diagnosis related
groups reimbursement methodology, as outlined by the Center for Medicare and Medicaid Services, provided an impetus to improve the
diagnosis and documentation of malnutrition in adult patients. Being able to accurately assess, diagnose, and document malnutrition has
been challenged by the lack of a standard malnutrition definition. In 2012 a workgroup of the Academy of Nutrition and Dietetics and
the American Society for Parenteral and Enteral Nutrition published a consensus paper outlining characteristics for the diagnosis of adult
hospital malnutrition. Using the etiology approach for defining malnutrition as outlined by Jensen and colleagues, 6 general characteristics
are outlined with specific thresholds to delineate severe and nonsevere malnutrition. The purpose of this article is to provide practical
strategies for criteria implementation and to describe one institution’s experience in implementing a broad-based “malnutrition program”
within its healthcare system. (Nutr Clin Pract. 2013;28:639-650)

Keywords
nutrition assessment; malnutrition; nutritional status

The recognition of malnutrition in adult hospitalized patients
has existed for almost 40 years. Beginning with the classic
1974 article “The Skeleton in the Hospital Closet” by Dr
Charles Butterworth and subsequent work by Drs George
Blackburn and Bruce Bistrian, nutrition clinicians have contin-
ued to recognize the importance of assessing hospitalized
patients for malnutrition risk and document the presence of
malnutrition.1,2 The 1977 publication by Blackburn and
Bistrian offered a well-defined methodology for malnutrition
assessment based on the prevailing understanding of disease
pathophysiology and nutrient metabolism.2
In 2007, the Centers for Medicare and Medicaid Services
(CMS) altered its reimbursement processes to incorporate a
disease severity component of which malnutrition was
included.3 Based on an individual patient’s diagnosis(s), the
addition of malnutrition as a comorbid condition provides an
opportunity for increased reimbursement reflecting a higher
cost for delivery of care. As a result of this process change,
multiple queries from members of both the Academy of
Nutrition and Dietetics (the Academy) and the American
Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) as
well as from CMS regarding specific malnutrition criteria
prompted the creation of an Academy/A.S.P.E.N. Malnutrition
Workgroup. This workgroup was charged with developing a
standardized approach to diagnosing malnutrition in the adult
hospitalized patient
In 2012, the Academy/A.S.P.E.N. Malnutrition Workgroup
culminated their work with the publication of the Consensus
Statement: Academy of Nutrition and Dietetics and the
American Society for Parenteral and Enteral Nutrition:
Characteristics Recommended for the Identification and Docu­
mentation of Adult Malnutrition (Undernutrition).4 This paper
provided a framework for diagnosing malnutrition using the
construct developed by the International Guidelines Group.5
The use of an etiology basis for malnutrition diagnosis is cou-
pled with the delineation of specific criteria or characteristics
to define malnutrition (Table 1 outlines these general charac-
teristics). The authors of this consensus statement outlined a
short term “call to action” for clinicians to consider how to
begin implementing the recommended characteristics within
their practice setting. The purpose of this article is to provide
practical strategies for criteria implementation and to describe
one institution’s experience in implementing a broad based
“malnutrition program” within their healthcare system.
From 1Mt. Carmel West, Columbus, Ohio; and 2Center for Human
Nutrition, Cleveland Clinic, Cleveland, Ohio.
Financial disclosure: None declared.
This article originally appeared online on October 31, 2013.
Corresponding Author:
Ainsley Malone, MS, RD, LD, CNSC, Pharmacy Department, Mt.
Carmel West, 793 West State St, Columbus, OH 43222, USA.
Email: ainsleym@earthlink.net.

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640 Nutrition in Clinical Practice 28(6)

Table 1.  General Characteristics for the Diagnosis of for ongoing risk assessment have not been studied or well
Malnutrition.4 described. Examples of specific components to monitor for
malnutrition risk may include diet order, length of time with
•• Weight loss suboptimal nutrient intake, oral diet intake, and participation in
•• Inadequate energy intake multidisciplinary rounds.
•• Loss of muscle mass
•• Loss of subcutaneous fat
•• Fluid accumulation Inflammation
•• Hand grip strength
Once nutrition risk has been identified, using an etiology
approach to describing malnutrition will involve assessing the
patient for the presence of inflammation. It is now well under-
stood that inflammation is a potent contributor to disease
Table 2.  Parameters Useful to Assess for Inflammation.4 related malnutrition and is a not a valid marker of nutrition
Laboratory Clinical status.11 Initially the inflammatory response is a desired
response to a host “insult” and is generally self limiting.12 It is
● Decreased serum albumin ● Fever when the response becomes exaggerated and prolonged that its
● Decreased serum transferrin ● Hypothermia effects on nutrition status can be profound.11 While there is no
● Decreased serum prealbumin ● Presence of infection one “parameter” to verify the presence of inflammation, a con-
● Elevated C-reactive protein ● Urinary tract infection stellation of measures including those from the laboratory as
● Elevated blood glucose ● Pneumonia well those demonstrated clinically by the patient may be useful
● Decreased or increased white ● Blood stream infection
in delineating the presence of inflammation. Table 2 outlines
blood cell count ●W ound or incisional
infection these potential parameters.
● Increased percentage of
neutrophils in the cell ● Abscess The influence of inflammation on visceral protein levels is
differential now well established and as such these “negative acute phase
● Decreased platelet count proteins” may be considered to reflect the presence of inflam-
● Marked negative nitrogen   mation.11 While the specific level of a particular visceral pro-
balance tein cannot in of itself specify the severity of the inflammatory
response, it can be evaluated in the context of the patient’s
overall clinical picture. Congruent to this understanding is the
potential for “positive acute phase proteins” such as C-reactive
protein (CRP),11 to assist in identifying inflammation. In
Malnutrition Assessment response to infection or tissue inflammation, CRP production
is stimulated by several cytokines, particularly, interleukin-6,
Nutrition Risk interleukin-1, and tumor necrosis factor-alpha. Like many
As outlined by the consensus document, the first step in assess- acute phase proteins, CRP increases rapidly and dramatically
ing patients for malnutrition is to identify those patients con- in response to a variety of infectious or inflammatory condi-
sidered at “risk.” For patients newly admitted to the hospital, tions.12,13 Significantly elevated CRP levels have been demon-
this is best accomplished through nutrition screening, a process strated in the presence of infection and sepsis,13 while lower
adopted by the Joint Commission in 1996 as a required prac- levels are more common in low-lying inflammatory states such
tice.6 How hospitals implement this requirement is quite vari- as obesity, malignancies, and chronic organ failure.14-17 Table 3
able with some developing their own “screening tool” and outlines various acute and chronic disease entities where
others using validated screening tools such as the Malnutrition inflammation is likely to be present. Once inflammation along
Screening Tool or the Nutrition Risk Screening 2002.7 Several with its severity has been identified, the patient will be further
organizations including A.S.P.E.N. recommend the use of a assessed. If malnutrition is identified based on the specific cri-
valid nutrition screening tool to identify those high risk patients teria, the etiology of that patients malnutrition will be deter-
who are likely to be malnourished.8 For a more thorough mined using the algorithm outlined in Figure 1.
review of applicable nutrition screening tools, please see
Skipper et al.9 Other “screening” processes to identify patients
Malnutrition Characteristics
“at malnutrition risk” during the course of their hospitalization
are of importance since it is well documented that malnutrition The Academy/A.S.P.E.N. Malnutrition workgroup identified 6
can develop while in the hospital despite being normally nour- characteristics to assess for the presence of malnutrition. If a
ished upon admission.10 Such processes are often institution patient demonstrates 2 or more characteristics, malnutrition
specific and are developed based on hospital demographics, can be diagnosed with its severity further defined via specific
service entities, and/or average length of stay. Processes used thresholds and/or descriptives. Tables 4 and 5 outline the 6

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Malone and Hamilton 641

Table 3.  Association of Acute and Chronic Conditions Associated With the Inflammatory Response.20

Acute Disease—Severe Inflammatory Response Chronic Disease—Mild to Moderate Inflammatory Response

Adult respiratory distress syndrome Cardiovascular disease
Closed head injury Celiac disease
Critical illness Chronic pancreatitis
Major abdominal surgery Chronic obstructive pulmonary disease
Major infection/sepsis Congestive heart failure
Multitrauma Cystic fibrosis
Systemic inflammatory response syndrome Dementia
Severe burns Diabetes mellitus
Severe acute pancreatitis Inflammatory bowel disease
  Hematologic malignancies
  Metabolic syndrome
  Neuromuscular disease
  Obesity
  Organ failure/transplant (kidney, liver, heart, lung, or gut)
  Pressure wounds
  Rheumatoid arthritis
  Solid tumors

Adapted from A.S.P.E.N. Adult Nutrition Support Core Curriculum, 2nd ed.

Figure 1.  Etiology approach to the diagnosis of malnutrition.

Based on Jensen et al.11

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642 Nutrition in Clinical Practice 28(6)

Table 4.  Characteristics to Diagnose Severe Malnutrition.4

Acute Illness or Injury Related Chronic Disease Related Social or Environmental Related
Characteristic Malnutrition Malnutrition Malnutrition
Weight loss >2%/1 week >5%/1 month >5%/1 month
  >5%/1 month >7.5%/3 months >7.5%/3 months
  >7.5%/3 months >10%/6 months >10%/6 months
  > 20%/1 year > 20%/1 year
Energy intake ≤50% for ≥5 days ≤75% for ≥1 month ≤50% for ≥1 month
Body fat Moderate depletion Severe depletion Severe depletion
Muscle mass Moderate depletion Severe depletion Severe depletion
Fluid accumulation Moderate → severe Severe Severe
Grip strength Not recommended in intensive Reduced for age/gender Reduced for age/gender
care unit

Table 5.  Characteristics to Diagnose Nonsevere (Moderate) Malnutrition.4

Acute Illness or Injury Related Chronic Disease Related Social or Environmental Related
Characteristic Malnutrition Malnutrition Malnutrition
Weight loss 1%-2%/1 week 5%/1 month 5%/1 month
  5%/1 month 7.5%/3 months 7.5%/3 months
  7.5%/3 months 10%/6 months 10%/6 months
  20%/1 year 20%/1 year
Energy intake <75% for >7 days <75% for ≥1 month <75% for ≥3 months
Body fat Mild depletion Mild depletion Mild depletion
Muscle mass Mild depletion Mild depletion Mild depletion
Fluid accumulation Mild Mild Mild
Grip strength Not applicable Not applicable Not applicable

characteristics and their respective thresholds for both severe
and nonsevere (moderate) malnutrition. Gathering the respec-
tive data to determine if malnutrition is present requires a sys-
tematic approach beginning with review of the patient’s
medical record, verbal discussion with the patient and/or care-
giver coupled with physical assessment. The following infor-
mation will highlight each of the 6 malnutrition characteristics
and offer further detail specific to their use.
Weight Loss
Assessing weight loss in a specific patient requires the ability
to obtain the patient’s usual or previous body weight along
with his or her current weight. Admission weight is frequently
obtained by the admitting clinician as either an actual or
reported measurement. Caution must be exercised in evaluat-
ing admission weights in those patients who have been fluid
resuscitated or who are demonstrating signs of dehydration. In
these settings, it will require further assessment by the clinician
to ascertain the patient’s “dry” weight for evaluation. When
interviewing the patient and/or caregiver, the clinician must
identify the patient’s “usual” body weight and at what point in
time the patient demonstrated that weight. This can be difficult
for the patient and/or caregiver to remember. Often times it
may coincide with a recent surgical procedure or before the
patient was diagnosed with his or her current disease entity.
It may be that the clinician can obtain a patient’s previous
weight from a recent hospitalization or from information avail-
able at the physician’s office. If the nutrition assessment is
being conducted during the patient’s hospitalization, the
admission weight can be compared to the patient’s current
weight for evaluation.2,18,19
Certain factors may contribute to inaccuracies with obtain-
ing weight loss information. In addition to the underlying fluid
status, which can mask weight loss, other factors include the
inability of the patient to recall his or her weight correctly as
well as equipment error and measurement/documentation
error.20
Insufficient Energy Intake
Identifying how well a newly admitted patient has been able to
consume nutrients is best achieved through verbal questioning
of the patient and/or caregiver. In those who have been hospi-
talized, reviewing meal intake data, assessing “calorie counts,”
and/or reviewing enteral/parenteral intake via intake and out-
put records will provide data for assessment. It should be noted
that “calorie counts” can be problematic in providing adequate

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Malone and Hamilton 643

Table 6.  Specific Areas to Assess for Subcutaneous Fat Loss.

Mild-Moderate
Exam Areas Tips Severe Malnutrition Malnutrition Well Nourished
Orbital Region – View patient when Hollow look, Slightly dark circles, Slightly bulged fat pads.
Surrounding the standing directly in depressions, dark somewhat hollow Fluid retention may mask
Eye front of them, touch circles, loose skin look loss
above the cheekbone
Upper Arm Region: Arm bent, roll skin Very little space Some depth pinch, but Ample fat tissue obvious
Triceps/biceps between fingers, do between folds, not ample between folds of skin
not include muscle in fingers touch
pinch
Thoracic and Lumbar Have patient press Depression between Ribs apparent, Chest is full; ribs do not
Regions: Ribs, hands hard against a ribs very apparent. depressions between show. Slight to no
Lower back, solid object Iliac Crest very them less pronounced. protrusion of the Iliac
Midaxillary line prominent Iliac Crest somewhat Crest
prominent

Reprinted with permission from White JA. Nutrition Care Manual. Academy of Nutrition and Dietetics; 2013.

data for evaluation. For those newly admitted patients who
have been able to consume oral foods, information should be
obtained from the patient and/or caregiver as to the patient’s
general meal intake over a specific period.20-21 In those who
have been previously or are currently hospitalized, identifying
periods of inadequate intake will assist in delineating the over-
all percentage of a patient’s energy intake he or she has been
able to achieve.
The objective data obtained from medical record review
and/or patient/caregiver interview will be compared to the
patient’s estimated energy requirements. This will then deter-
mine the specific percentage of requirements the patient has
achieved and therefore which severity level is demonstrated
for this characteristic. Requirements can be measured via indi-
rect calorimetry, for example in the critically ill patient, or can
be estimated with prediction equations such as Mifflin St-Jeor
or Penn State.22-23
Physical Assessment Components
Three of the 6 malnutrition criteria are those that must be deter-
mined through performance of a nutrition focused physical
exam. This aspect of physical assessment is an important con-
tribution by the registered dietitian (RD) as when coupled with
the patient interview it can provide sufficient data to diagnose
the presence of malnutrition. Nutrition-focused physical
assessment will assist in identifying the presence of muscle
and/or subcutaneous fat loss, the presence of fluid accumula-
tion, along with the severity of these characteristics. Tables 6
and 7 outline specific areas of the body to assess for fat and
muscle loss along with details for delineating severity of the
loss, if applicable.
Nutrition-focused physical exam is a component of the nutri-
tion care process and is an important competency for all RDs.
This component of dietetic practice is included in the Academy
of Nutrition and Dietetics: Revised 2012 Standards of Practice
in Nutrition Care and Standards of Professional Performance for
Registered Dietitians.24 In the Nutrition Assessment Standard
1.3, “each RD shall assess nutrition focused physical findings
including those, among others, muscle and subcutaneous fat
wasting and signs of edema.”24 In addition, the Accreditation
Council for Education in Nutrition and Dietetics has included
nutrition-focused physical assessment as a competency for
supervised practice program participants. Performing nutrition
focused physical assessment is increasing among RDs.
Compared to the 1995 and 2000 Dietetics Practice Audits,
Mackle and colleagues in 2003 demonstrated greater use of
physical assessment parameters by RDs.25
The presence of fluid accumulation is accessed via physical
exam evaluating both the presence of local and/or generalized
accumulation.4 It is important to first evaluate overall fluid sta-
tus to help determine other etiologies for any fluid accumula-
tion. Areas useful to assess include the lower and upper
extremities, face and eyes, the scrotal area and ascites. In those
patients with underlying disease states such as congestive heart
failure or chronic kidney disease, discerning fluid accumula-
tion due to malnutrition will be difficult. Table 8 outlines 1
method for assessment of edema.
Hand Grip Strength
Hand grip strength has been validated as a proxy for lean
body mass and as such was chosen by the workgroup as an
important functional parameter in assessing for malnutri-
tion.4,26 Assessment of grip strength is performed via a dyna-
mometer by those experienced/trained in its use. Abnormal
grip strength measurements will be based on the specified
dynamometer utilized. Diseases and/or conditions that limit
the patient’s ability to perform a valid hand grip strength mea-
surement must be considered including, among others, rheuma-
toid arthritis, cerebrovascular accident, neuromuscular disease,
and dementia. In addition, patients who are heavily sedated and/

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644 Nutrition in Clinical Practice 28(6)

Table 7.  Specific Areas to Assess for Muscle Loss.

Mild-Moderate
Exam Area Tips Severe Malnutrition Malnutrition Well Nourished
Temple Region: View patient when Hollowing, scooping, Slight depression Can see/feel well
Temporalis Muscle standing directly in front depression defined muscle
of them, ask patient to
turn head side to side
Clavicle Bone Region: Look for prominent bone. Protuding, prominent bone Visible in male, some Not visible in male,
Pectoralis Major, Make sure patient is not protrusion in female visible but not
Deltoid, Trapezius hunched forward prominent in female
Muscles
Clavicle and Acromion Patient arms at side: Shoulder to arm joint looks Acromion process may Rounded, curves at
Bone Region: Deltoid observe shape square, bones prominent; slightly protrude arm/shoulder/neck
Muscle acromion protrusion very
prominent
Scapular Bone Ask patient to extend Prominent, visible bones, Mild depression or Bones not prominent,
Region: Tapezius, hands straight out, push depressions between ribs/ bone may show no significant
Supraspinus, against solid object. scapula or shoulders/ slightly depressions
Infraspinus Muscles spine
Dorsal Hand: Look at thumb side of Depressed area between Slightly depressed Muscle bulges, could
Interosseous muscle hand; look at pads of thumb–forefinger be flat in some well
thumb when tip of nourished people
forefinger touching tip
of thumb
Lower body less sensitive to change
Patellar Region: Ask patient to sit with leg Bones prominent, little sign Knee cap less Muscles protrude,
Quadricep Muscle propped up bent at knee of muscle around knee prominent, more bones not prominent
rounded
Anterior Thigh Region: Ask patient to sit prop leg Depression/line on thigh, Mild depression on Well rounded, well
Quadricep Muscles up on low furniture; obviously thin inner thigh developed
grasp quads to
differentiate amount of
muscle tissue from fat
tissue.
Posterior Calf Region: Grasp the calf muscle to Thin, minimal to no muscle Not well developed Well-developed bulb
Gastrocnemius Muscle determine amount of definition of muscle
tissue

Reprinted with permission from White JA. Nutrition Care Manual. Academy of Nutrition and Dietetics; 2013.

Table 8.  Assessment of Edema. could be considered for functional assessment include general
performance status, ability to perform activities of daily living,
1+ 2 mm depression, barely detectable ability to tolerate physical therapy, and ability to wean from
Immediate rebound
mechanical ventilation. Validity and usability testing of addi-
2+ 4mm deep pit
A few seconds to rebound
tional functional parameters will shed light on alternate param-
3+ 6 mm deep pit eters that may be useful in addition to grip strength.
10-12 seconds to rebound
4+ 8 mm: very deep pit General Considerations in Applying the
>20 seconds to rebound
Malnutrition Characteristics
Based on Hogan M. Medical-Surgical Nursing. 2nd ed. Salt Lake City,
UT: Prentice Hall; 2007. When evaluating a patient’s specific malnutrition criteria the
possible etiologies for malnutrition may not always be clear. It
may be that the patient’s characteristics fit within >1 etiology,
or unresponsive such as those in the intensive care unit (ICU) for example, in both acute illness and chronic disease related
will be unable to complete hand grip measurements. malnutrition. The malnutrition etiology can change as clinical
Some practitioners have chosen not to utilize hand grip course evolves which is why characteristics should be rou-
strength7 in assessing for malnutrition. Other parameters that tinely assessed at frequent intervals. Some degree of 1 or more

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Malone and Hamilton 645

characteristics may be present in patients without malnutrition. Physical assessment.  Head/face: severe temporal wasting
Conversely, characteristics may not be present in patients at Shoulders/torso: Prominent scapula and clavicle; severe rib
high risk for malnutrition. These patients are likely those who prominence
are well nourished prior to admission and due to the nature of Arms: severe loss of subcutaneous fat in triceps area
their illness are considered “high risk,” that is, the burn or mul- Lower extremities: prominent knee bone with noted loss of
tiple trauma patient. Close and frequent monitoring of these quadriceps muscle
patients will be essential as nutrition status may certainly No evidence of fluid accumulation in upper or lower
change as clinical condition changes.4,19 extremities
In addition, it is important to point out that the use of
an etiology approach in the diagnosis and documentation of Clinical data.  White blood cells: normal
malnutrition in a specific patient should lead to collaborative Temperature: 98.4°F
efforts between the RD and the physician. Confirmation of the Serum albumin level: 4.3 g/dL
RD’s findings and malnutrition nutrition diagnosis can result in Prealbumin: 15.6 mg/dL
accurate documentation in the medical record and most impor-
tantly timely and appropriate nutrition intervention Functional status.  Patient was unable to perform her activities
The following 2 patient cases highlight the application of of daily living (ADLs) and was living with her parents who
the malnutrition characteristics in assessing for malnutrition. were assisting in her care.
These were patients presented to this author’s facility, a 450-
bed teaching institution.
What Is This Patient’s Nutrition Status?
Severe malnutrition related to social/environmental circum-
Patient Case 1
stances.
Admission History No evidence of inflammation
She meets several criteria for this diagnosis:
A 24-year-old female was admitted directly from her physi-
cian’s office for “malnutrition” secondary to gastroparesis. She Weight loss
had been referred to this surgeon for evaluation of gastric pacer •• 1 year– 38%
placement. Her chief complaints involved early satiety, nausea, •• 3 months: 24%
and vomiting over 6 months. The severity of her symptoms had •• 1 month: 15%
worsened over the past month.
Energy intake
Past Medical History •• Over last month: 360 kcal/day
•• Estimated over last 3 months: 600 kcal/day
This was unremarkable other than for admitting diagnosis. •• <50% of estimated energy requirements (1225 kcal/day)

Nutrition Risk Assessment Physical assessment

•• Severe loss of both muscle and subcutaneous fat in mul-
Admission nutrition screen: Malnutrition Screening Tool Score tiple areas
of 5—referral to RD. RD completed nutrition assessment in
next 24 hours. Functional assessment
•• Unable to perform ADLs—severe impairment
Clinical Presentation
This patient achieved 4 of the 6 defined criteria along with
Anthropometrics.  Height: 62 inches functional impairment. The RD collaborated with the patient’s
Current weight: 68 pounds physician and determined that enteral feeding initiation would
Weight 1 year ago: 110 pounds be the most appropriate nutrition intervention to begin nutri-
Weight 3 months ago: 90 pounds tion repletion.
Weight 1 month ago: 80 pounds

Diet history.  Complained of early satiety after taking minimal
amounts of liquids and foods. Was drinking 4 ounces of a high-
calorie oral nutrition supplement and taking small amounts of
soft foods twice per day over past 3 months. Intake over recent
month averaged only 8 ounces of a high-calorie oral nutrition
supplement per day.
Patient Case 2
Admission History
A 59-year-old male was admitted from the Emergency
Department with acute rectal bleeding. Colonoscopy on hospi-
tal day (HD) 3 revealed a partially obstructing midrectal mass

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646 Nutrition in Clinical Practice 28(6)

suspicious for malignancy. On HD 6, the patient underwent a Functional assessment

lower anterior resection (colon) with anastomosis. •• Generalized weakness—not part of current criteria

This patient achieved 3 of the 6 defined criteria along with

Past Medical History mild functional impairment. Upon discussion with the patient’s
Cholecysectomy due to cholelithiasis; status post endo­scopic ret- physician, the need to initiate nutrition intervention was recog-
rograde cholangiopancreatography 9 months prior to admission. nized. Due to the patient’s ongoing prolonged ileus, it was
Diabetes mellitus–type 2 determined parenteral nutrition (PN) support would be the
most appropriate nutrition intervention.
It is important to note that the nutrition assessment process
Nutrition Risk Assessment for both patients required approximately 45-60 minutes by
Admission nutrition screen: Malnutrition Screening Tool the RD to complete. This included time for the electronic
Score: 0 medical record (EMR) review, patient visit, performance of
RD monitored patient during admission and completed fur- physical assessment, EMR documentation and for physician
ther assessment on HD 7 due to NPO status. collaboration.

Clinical Presentation Implementation of a Malnutrition

Anthropometrics. Height: 66 inches
Program
Current weight: 263 pounds Implementation of the consensus criteria4 is a process that is
Admission weight: 268 pounds best accomplished through a collaborative approach within the
Weight 3 months ago: 290 pounds (per patient interview by healthcare institution. To be successful in achieving the full
RD) spectrum of evaluating, diagnosing, documenting, and receiv-
ing reimbursement for malnourished patients requires collabo-
Diet history. NPO since admission ration between several healthcare professionals. While the
Anorexia and reduced oral intake over last 3 months— dietitian, physician, and nurse function at the patient bedside,
patient reported eating about half of his normal meal intake other “behind-the-scenes” healthcare personnel also contribute
during same time period. to the full implementation of these activities. This generally
includes those from the health information management
Physical assessment. No evidence of subcutaneous fat or mus- department (HIM) (clinical documentation, coding, reimburse-
cle loss ment, medical records), finance department, information
Bilateral lower extremities: pitting edema: 2+ technology, and hospital administration. We describe the
implementation of a malnutrition program incorporating the
Clinical data. White blood cells: 16 K consensus criteria in collaboration with all healthcare person-
Temperature: 99.9°F nel as described above at the Cleveland Clinic, a large health-
Serum albumin level: 1.8 g/dL care system comprising a main campus hospital and 8 regional
Prealbumin: 7.8 mg/dL hospitals.

Functional status. Physical therapy evaluation: generalized Establishing Support

weakness on admission
The consensus statement is an evidence-based document that
provides a purpose and rationale for hospital clinicians to
What Is This Patient’s Nutrition Status? develop a consistent approach to the identification and docu-
Severe malnutrition related to acute illness/injury mentation of malnutrition in healthcare institutions. The consen-
He meets several criteria and demonstrates significant sus statement was developed collaboratively by 2 of the country’s
inflammation: most credible professional nutrition societies, the Academy and
A.S.P.E.N., and therefore was used to establish our malnutrition
Weight loss program.4 Support for the program was first gained from our
•• 3 months: 9% physician nutrition director. Patient care treatment plans and
decisions are directed by physicians (or authorized providers) so
Energy intake establishing a physician-champion was important. Additional
•• No nutrient intake since hospital admission (7 days) support was also gained from an executive healthcare adminis-
trator. Apprising him of the anticipated effect of increased hospi-
Physical assessment tal reimbursement by identifying malnourished patients was
•• Moderate edema positively received. To promote institutional success of our

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Malone and Hamilton 647
Table 9.  ICD-9 Codes for Nutrition Deficiencies (Applicable to
Adult Malnutrition).27
Term
Kwashiorkor
Marasmus
Other, severe protein-calorie malnutrition
Other and unspecified protein-calorie malnutrition
Moderate malnutrition
Mild malnutrition
Other protein-calorie malnutrition
Unspecified protein-calorie malnutrition
a
Recommended for diagnosis of severe malnutrition.
b
Recommended for diagnosis of nonsevere (moderate) malnutrition.
malnutrition program the physician-champion actively engaged
in communicating and collaborating with other physicians and
administrators.
Upon establishing institution support, a Malnutrition Task
Force was formed comprising dietitians and dietetic technicians
from the main campus and regional hospitals. The committee
met on a regular basis to design and implement the various com-
ponents of our program as described below. The completion of
the initial program aspects took approximately 18 months.
Benchmarking Malnutrition Data
Baseline data were gathered on our health system’s current
usage of the International Classification of Diseases (ICD)
codes for malnutrition (Table 9) prior to implementing the pro-
gram. The current version of ICD codes is the 9th version.27 The
finance department provided this data for in-patient hospital
stays for each hospital. The consensus statement recommends
ICD-9 code 262 for the diagnosis of severe protein-calorie mal-
nutrition and ICD-9 code 263.0 for moderate (nonsevere) mal-
nutrition. These ICD-9 codes have definitions that best match
the malnutrition criteria for severe and moderate (nonsevere)
malnutrition as established in the consensus statement.4 The
ICD-9 codes 262 and 263.0 are included in the CMS Medical
Severity-Diagnosis-Related Group classification with 262 as a
major comorbid condition/complication and 263.0 as a less
severe comorbid condition/complication. The application of
one of these malnutrition codes to the DRG may increase reim-
bursement. In addition, the overall rate of patients diagnosed
with malnutrition at each hospital was determined based on the
number of hospital discharges. Research studies indicate the
rate of malnutrition of hospitalized patients ranges from 15% to
60%,8 depending on the patient population and clinical criteria
used. However, U.S. statistical reports indicate that only 3% of
patients admitted to acute care settings are diagnosed with mal-
nutrition.4 Our intention is to gather data annually on code
usage for malnutrition with the expectation that severe and non-
severe malnutrition will be identified with the ICD-9 codes
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262 and 263.0, respectively. We also will investigate actual
received reimbursement for malnutrition. A recent report indi-
Code
cated significant reimbursement was received by a small hospi-
tal (100+/daily census) when malnutrition was identified by the
260 dietitian and subsequently documented by the physician in the
261 EMR.28
262a
263
263.0b Health Information Management and
263.1 Reimbursement Specialists
263.8
The HIM department and reimbursement specialists were con-
263.9
tacted early during our program development. These profes-
sionals are responsible for reviewing the patient medical record
and assuring the correct ICD-9 code assignment. Patient health
information must be fully documented, be accurate, and meet
the definition of the ICD-9 code, otherwise reimbursement for
services may not be obtained. We presented the consensus cri-
teria4 and goals of our malnutrition program to the department.
This was exceptionally well received, and they appreciated the
evidence-based criteria and documentation that would appear
in the EMR to substantiate the malnutrition diagnosis. They
noted it as being particularly helpful when collaborating with
physicians/providers during review of the patient medical
record since most health information, including malnutrition
documentation, can be gathered only from the authorized pro-
vider’s documentation for reimbursement
Dietitian Training for Diagnosing
Malnutrition
One of the most important aspects of the malnutrition program
was to educate and train the dietitians from our health system
hospitals (approximately 95 dietitians). The Cleveland Clinic
promotes standardization of clinical policies across our health
system; standardizing our malnutrition diagnosis and docu-
mentation process provided an opportunity to continue our
standardization efforts.
We designed a 2-part education program for dietitian train-
ing. Dietitians and dietetic interns were first required to attend
a half-day didactic program (2 dates were available) which
included the following lectures:
• etiology based definition of malnutrition
• clinical characteristics (consensus paper)
• nutrition assessment
• inflammation
• physical exam
• coding and documentation
• case studies (interactive)
All references and lecture materials were made available to
the dietitians and dietetic interns via a share-point website.
The lectures were videotaped and also made available on the
share-point website and subsequently are viewed by new
hires.
648 Nutrition in Clinical Practice 28(6)
The second part of our education program was to train the
dietitians and dietetic interns on performing a nutrition-focused
physical examination (NFPE). Several half-day training ses-
sions were scheduled at the Cleveland Clinic main campus
Simulation Center. The Simulation Center provided equip-
ment, including mannequins, examination rooms, classrooms,
and videotaping capabilities. It took approximately 8 months
to train all dietitians and interns due to the limited training
space. Dietitians and dietetic interns rotated each through 3
hands-on workshops for muscle and fat examination, edema
examination and micronutrient examination. While micronu-
trient deficiencies are not currently one of the consensus char-
acteristics, our Malnutrition Task Force felt they provided
supportive evidence for signs of malnutrition. The micronutri-
ent workshop included examination of hair, skin, eyes, oral
cavity, and nails for deficiencies.
Following the workshops we utilized the objective struc-
tured clinical exam (OSCE) method to assess the skills of RDs
utilizing the consensus criteria and performing a NFPE. The
OSCE method has been successful in training a variety of skills
to healthcare professionals. It was first developed for use with
medical students to objectively assess clinical competencies
such as history-taking, physical examination, communication
skills, and data interpretation.29 Students participate by moving
through a series of timed stations, with each station devoted to
a particular area of a predetermined competency. Each station
uses a standardized patient (trained to portray a medical condi-
tion) and an observer. The observer provides feedback to the
student at the end of each station. The OSCE has been used to
assess multiple dietetic student clinical skills including com-
munication skills and interviewing patients, interpretation and
food knowledge skills, performing a nutrition assessment,
planning a nutrition intervention, and calculating and planning
an enteral feeding regimen.30-32 We developed malnutrition
scenarios for use with the OSCE exercises and used our own
nutrition department members (dietitians, dietetic technicians,
managers, clerical support staff) as standardized patients and
observers (dietitian only). Training of the standardized patients
was provided by the Simulation Center manager. Dietitians
rotated through the scenarios in 15-minute intervals including
interviewing the patient, performing a NFPE and identifying
the presence and degree of malnutrition. The observer pro-
vided feedback to the dietitian on his/her performance.
Dietitians were provided with laminated pocket cards of the
Academy’s clinical characteristics table (Tables 4 and 5) for
use during the OSCE and subsequently for clinical practice.33
Evaluations of the workshops and OSCE sessions were col-
lected from the participating dietitians. In all, 98% rated the
overall experience as good to excellent and 97% rated the
OSCE as a good to excellent experience.
Documentation
The Malnutrition Task Force created a standard template
for documentation of malnutrition in the EMR and is used by
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the dietitians at all the hospitals. The template includes all 6
clinical characteristics of the consensus paper, including spe-
cific physical parameters and a final malnutrition diagnosis
section to indicate severe protein-calorie malnutrition, moder-
ate (nonsevere) malnutrition or no malnutrition identified. A
drop-down selection format is used for all characteristics and
for ease of moving through the documentation template
quickly. The development and implementation of the EMR
template required collaboration with a clinical informatic tech-
nology specialist.
Provider Education and Communication
We designed a malnutrition presentation (PowerPoint) to be
used by the dietitians to educate providers (physicians, nurse
practitioners, physicians assistants). Key components of the
presentation included dietitian documentation of malnutrition
in the EMR and the specific documentation steps required for
the provider. In addition, the importance of collaboration
between the dietitian and the provider when determining the
presence and degree of malnutrition and the subsequent care
plan was emphasized. Dietitians use the presentation for pro-
vider staff meetings and in-services. This was a first-step com-
munication process with providers, but we expect to explore
potential future communication methods, especially for new
hires.
Next Steps
As we move into our malnutrition program’s second year, we
will review malnutrition coding practices and reimbursement
data. We are continuing our training process including hands-
on workshops for NFPE and the OSCE method at our
Simulation Center for new dietitians and dietetic interns. To
ensure quality of dietitian practices, we are developing a con-
tinuous process improvement monitor for malnutrition docu-
mentation and a competency for the NFPE.
Summary
The consensus-based malnutrition criteria offers a standard-
ized approach to the assessment, diagnosis, and documentation
of malnutrition in the adult hospitalized patient. Assessing
nutrition risk followed by identifying the presence of inflam-
mation will delineate the patient’s malnutrition etiology.
Identifying a patient’s specific malnutrition characteristics
requires in-depth data gathering and patient assessment. As
usability and validity data is generated and reported, including
identification of specific patient population criteria such as for
the critically ill or obese, the malnutrition criteria will be
reevaluated, updated, and revised accordingly.
Developing an institution based malnutrition program will
most likely be directed by the Clinical Nutrition Department.
Identifying, treating, and documenting malnutrition is a col-
laborative effort between the bedside clinicians including the
Malone and Hamilton 649
Table 10.  Areas to Include When Developing a Malnutrition-
Identification Program.
•• Establish a physician-champion
-Collaborates with other physicians
-Addresses hospital medical executive council
•• Solicit hospital administration support
-Allocation of resources
•• Benchmark institutional data
-Collaborate with finance department
-Assess current use of ICD-9 codes for malnutrition
-Determine rate of overall malnutrition
•• Collaborate with health information management department
(reimbursement, medical records, coding)
-Review consensus criteria
-Determine documentation methods of malnutrition as it
applies to ICD-9 codes
•• Train dietitian staff
-6 consensus criteria and etiology
-Physical assessment skills for muscle, fat, fluid accumulation,
and functional status
•• Develop documentation template
-Include etiology and consensus criteria
-Collaborate with informatic technology (clinical support)
department for implementation into electronic medical record
•• Ensure nursing screening process
-Utilize nutrition screening tool for assessment of risk and to
consult the dietitian
•• Develop sustainable provider education
-Utilize methods such as presentations at department staff
meetings, electronic communication, online education
modules, bedside rounds
dietitian, physician (or provider) and nurse, and nonclinicians
such as health information management, reimbursement spe-
cialist, and finance and informatics technologists (Table 10).
For allocation of appropriate reimbursement, all healthcare
personnel must share the same vision to accurately identify
patient malnutrition utilizing the same clinical criteria.
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