Critical Role of Nutrition in Improving

Quality of Care: An Interdisciplinary

Call to Action to Address Adult
Hospital Malnutrition
Kelly A. Tappenden, Beth Quatrara, Melissa L. Parkhurst, Ainsley M. Malone,
Gary Fanjiang, and Thomas R. Ziegler
he United States is entering a

T new era of health care deliv-

ery in which changes in
health care policy are driving an
increased focus on costs, quality, and
transparency of care. This new focus
on improving the quality and effi-
ciency of hospital care highlights an
urgent need to revisit the long-stand-
ing challenge of hospital malnutri-
tion and elevate the role of nutrition
care as a critical component of
patient recovery. Malnutrition is
common in the hospital setting and
can affect clinical outcomes and
costs adversely, but it often is over-
looked. Although results of interven-
tion studies vary, addressing hospital
malnutrition has the potential to
improve quality of patient care and
clinical outcomes, and reduce costs
(Barker, Gout, & Crowe, 2011).
Today, it is estimated at least one-
third of patients arrive at the hospi-
tal malnourished (Barker et al., 2011;
Bistrian, Blackburn, Hallowell, &
Heddle, 1974; Christensen &
Gstundtner, 1985; Lim et al., 2012;
The current era of health care delivery, with its focus on providing high-
quality, affordable care, presents many challenges to hospital-based
health professionals. The prevention and treatment of hospital malnu-
trition offers a tremendous opportunity to optimize the overall quality of
patient care, improve clinical outcomes, and reduce costs. Unfortunately,
malnutrition continues to go unrecognized and untreated in many hos-
pitalized patients. This article represents a call to action from the inter-
disciplinary Alliance to Advance Patient Nutrition to highlight the critical
role of nutrition intervention in clinical care and suggest practical ways
for prompt diagosis and treatment of malnourished patients and those
at risk for malnutrition. We underscore the importance of an interdisci-
plinary approach to addressing malnutrition both in the hospital and in
the acute post-hospital phase. It is well recognized that malnutrition is
associated with adverse clinical outcomes. Although data vary across
studies, available evidence shows early nutrition intervention can reduce
complication rates, length of hospital stay, re-admission rates, mortality,
and cost of care. The key is to identify patients systematically who are
malnourished or at risk and to promptly intervene. We present a novel
care model to drive improvement, emphasizing the following six princi-
ples: (1) create an institutional culture where all stakeholders value
nutrition; (2) redefine clinicians’ roles to include nutrition care; (3) rec-
ognize and diagnose all malnourished patients and those at risk; (4)
rapidly implement comprehensive nutrition interventions and continued
monitoring; (5) communicate nutrition care plans; and (6) develop a
comprehensive discharge nutrition care and education plan.

Kelly A. Tappenden, PhD, RD, FASPEN, is Kraft Foods Human
Nutrition Endowed Professor, Department of Food Science and Human
Nutrition, University of Illinois at Urbana-Champaign, Urbana, IL. (The
Academy of Nutrition and Dietetics).
Beth Quatrara, DNP, RN, CMSRN, ACNS-BC, is Clinical Nurse
Specialist, University of Virginia Health System, Charlottesville, VA.
(Academy of Medical-Surgical Nurses).
Melissa L. Parkhurst, MD, is Associate Professor of Medicine,
University of Kansas Medical Center, Kansas City, KS. (Society of
Hospital Medicine).
Ainsley M. Malone, MS, RD, CNSC, is Nutrition Support Dietitian, Mt.
Carmel West Hospital, Columbus, OH. (American Society for Parenteral
and Enteral Nutrition).
Gary Fanjiang, MD, is Vice President, Medical Affairs, Abbott Nutrition,
Columbus, OH.
Thomas  R. Ziegler, MD, is Professor of Medicine, Department of
Medicine, Emory University School of Medicine, Atlanta, GA. (Society of
Hospital Medicine).
Notes: Kelly A. Tappenden, Beth Quatrara, Melissa L. Parkhurst, Ainsley
M. Malone, and Thomas R. Ziegler are members of the Steering
Committee of the Alliance to Advance Patient Nutrition who have been
chosen by the professional organizations they represent and reimbursed
for Alliance-related expenses. Abbott Nutrition has provided funding to
the member organizations of the Alliance and to Dr. Marithea Goberville
of Science Author, Inc., for writing assistance.
The Journal of the Academy of Nutrition and Dietetics, Journal of
Parenteral and Enteral Nutrition, and MEDSURG Nursing arranged to
publish this article simultaneously in their publications. Minor differences
in style may appear in each publication but the article is substantially the
same in each journal.

May-June 2013 • Vol. 22/No. 3 147

Alliance to Advance Patient Nutrition
The time is now to implement a novel,
comprehensive nutrition care model as part of
improved quality standards and leverage proven
examples for success.
Somanchi, Tao, & Mullin, 2011),
and, if left untreated, many of those
patients will continue to decline
nutritionally (Somanchi et al., 2011),
which may adversely impact their
recovery and increase their risk of
complications and re-admission.
Hospital malnutrition is not a
new problem but “The Skeleton in
the Hospital Closet” was brought to
light in Butterworth's call for prac-
tices aimed at proper diagnosis and
treatment of malnourished patients
(Butterworth, 1974). As we enter a
new era of health care delivery, the
time is now to implement a novel,
comprehensive nutrition care model
as part of improved quality stan-
dards and leverage proven examples
for success.
Effective management of malnu-
trition requires collaboration among
multiple clinical disciplines. In many
hospitals, malnutrition continues to
be managed in silos, with knowledge
and responsibility provided predomi-
nantly by the dietitian. However, the
new era of quality care will require a
deliberately more holistic and inter-
disciplinary process to address this
critical issue. All members of the clin-
ical team must be involved, includ-
ing nurses who perform initial nutri-
tion screening and develop innova-
tive strategies to facilitate patient
compliance, dietitians who complete
nutrition assessment/diagnosis and
develop evidence-based interven-
tions, pharmacists who evaluate
drug-nutrient interactions, and phy-
sicians (including hospitalists), who
oversee the overall care plan and doc-
umentation to support reimburse-
ment for services. Recognition of this
problem and the opportunity to
improve patient care were the impe-
tus behind creating the Alliance to
Advance Patient Nutrition (Alliance).
The Alliance brings together the
Academy of Medical-Surgical Nurses
(AMSN), the Academy of Nutrition
148
and Dietetics (AND), the American
Society for Parenteral and Enteral
Nutrition (A.S.P.E.N.), the Society of
Hospital Medicine (SHM), and
Abbott Nutrition. The Alliance is
made possible with support from
Abbott Nutrition. These health
organizations are dedicated to the
advancement of effective hospital
nutrition practices to help improve
patients’ medical outcomes and sup-
port all clinicians in collaborating on
hospital-wide nutrition procedures.
The established charter of the
Alliance is to champion improved
hospital nutrition practices through
identification of malnourished and
patients at risk for malnutrition, early
nutrition intervention and treat-
ment, and inclusion of nutrition as a
standard component of all care
processes.
Nutrition intervention for malnu-
trition patients is a low-risk, cost-
effective strategy to improve quality
of hospital care, but it requires inter-
disciplinary collaboration. As repre-
sentatives of the Alliance, we
announce a call to action. We aspire
to facilitate the institution of univer-
sal nutrition screening, rapid and
appropriate nutrition interventions
utilizing effective interdisciplinary
nutrition partnerships, and integra-
tion of comprehensive strategies to
prevent or treat hospital malnutri-
tion. This paper is not intended to
provide practice-based guidelines, but
rather highlights available data on
the critical role nutrition plays in
improving patient outcomes, outlines
an innovative nutrition care model,
underscores the importance of an
interdisciplinary approach to address
hospital malnutrition, and identifies
challenges believed to impair optimal
nutrition care. In addition, specific
solutions that can be employed by
dietitians, nurses, physicians, and
other health care professionals, such
as nurse practitioners, physician assis-
May-June 2013 • Vol. 22/No. 3
tants, pharmacists, and diet techni-
cians, registered, are provided.
Burden of Hospital
Malnutrition
Although estimates of the preva-
lence of malnutrition vary by setting,
subgroup, and method of assess-
ment, the prevalence of malnutri-
tion in hospitals is particularly star-
tling. At least one-third of patients in
developed countries are malnour-
ished upon admission to the hospi-
tal (Barker et al., 2011; Bistrian et al.,
1974; Christensen & Gstundtner,
1985; Somanchi et al., 2011), and, if
left untreated, approximately two-
thirds of those patients will experi-
ence a further decline in their nutri-
tion status during inpatient stay
(Somanchi et al., 2011). Unfor-
tunately, despite the availability of
validated screening tools, malnutri-
tion continues to be underrecog-
nized in many hospitals (Kirkland,
Kashiwagi, Brantley, Scheurer, &
Varkey, 2013). Moreover, among
patients who are not malnourished
upon admission, approximately one-
third may become malnourished
while in the hospital (Braunschweig,
Gomez, & Sheean, 2000).
Historically, a variety of tools and
definitions have been used through-
out the nutrition literature. For the
purposes of this paper, mild through
severe malnutrition will be the focus
and is the intent when the term
“malnutrition” is used.
Malnutrition is defined most
simply as any nutrition imbalance
(Dorland’s Illustrated Medical Dic-
tionary, 2011) that affects both
overweight and underweight pa-
tients alike and is described general-
ly as either “undernutrition” or
“overnutrition” (White, Guenter,
Jensen, Malone, & Schofield, 2012).
Hospitalized patients, regardless of
their body mass index (BMI), typi-
cally suffer from undernutrition
because of their propensity for
reduced food intake due to illness-
induced poor appetite, gastroin-
testinal symptoms, reduced ability
to chew or swallow, or nil per os
(NPO) status for diagnostic and
therapeutic procedures. In addition,
Alliance to Advance Patient Nutrition
The time is now to implement a novel,
comprehensive nutrition care model as part of
improved quality standards and leverage proven
examples for success.
Somanchi, Tao, & Mullin, 2011),
and, if left untreated, many of those
patients will continue to decline
nutritionally (Somanchi et al., 2011),
which may adversely impact their
recovery and increase their risk of
complications and re-admission.
Hospital malnutrition is not a
new problem but “The Skeleton in
the Hospital Closet” was brought to
light in Butterworth's call for prac-
tices aimed at proper diagnosis and
treatment of malnourished patients
(Butterworth, 1974). As we enter a
new era of health care delivery, the
time is now to implement a novel,
comprehensive nutrition care model
as part of improved quality stan-
dards and leverage proven examples
for success.
Effective management of malnu-
trition requires collaboration among
multiple clinical disciplines. In many
hospitals, malnutrition continues to
be managed in silos, with knowledge
and responsibility provided predomi-
nantly by the dietitian. However, the
new era of quality care will require a
deliberately more holistic and inter-
disciplinary process to address this
critical issue. All members of the clin-
ical team must be involved, includ-
ing nurses who perform initial nutri-
tion screening and develop innova-
tive strategies to facilitate patient
compliance, dietitians who complete
nutrition assessment/diagnosis and
develop evidence-based interven-
tions, pharmacists who evaluate
drug-nutrient interactions, and phy-
sicians (including hospitalists), who
oversee the overall care plan and doc-
umentation to support reimburse-
ment for services. Recognition of this
problem and the opportunity to
improve patient care were the impe-
tus behind creating the Alliance to
Advance Patient Nutrition (Alliance).
The Alliance brings together the
Academy of Medical-Surgical Nurses
(AMSN), the Academy of Nutrition
148
and Dietetics (AND), the American
Society for Parenteral and Enteral
Nutrition (A.S.P.E.N.), the Society of
Hospital Medicine (SHM), and
Abbott Nutrition. The Alliance is
made possible with support from
Abbott Nutrition. These health
organizations are dedicated to the
advancement of effective hospital
nutrition practices to help improve
patients’ medical outcomes and sup-
port all clinicians in collaborating on
hospital-wide nutrition procedures.
The established charter of the
Alliance is to champion improved
hospital nutrition practices through
identification of malnourished and
patients at risk for malnutrition, early
nutrition intervention and treat-
ment, and inclusion of nutrition as a
standard component of all care
processes.
Nutrition intervention for malnu-
trition patients is a low-risk, cost-
effective strategy to improve quality
of hospital care, but it requires inter-
disciplinary collaboration. As repre-
sentatives of the Alliance, we
announce a call to action. We aspire
to facilitate the institution of univer-
sal nutrition screening, rapid and
appropriate nutrition interventions
utilizing effective interdisciplinary
nutrition partnerships, and integra-
tion of comprehensive strategies to
prevent or treat hospital malnutri-
tion. This paper is not intended to
provide practice-based guidelines, but
rather highlights available data on
the critical role nutrition plays in
improving patient outcomes, outlines
an innovative nutrition care model,
underscores the importance of an
interdisciplinary approach to address
hospital malnutrition, and identifies
challenges believed to impair optimal
nutrition care. In addition, specific
solutions that can be employed by
dietitians, nurses, physicians, and
other health care professionals, such
as nurse practitioners, physician assis-
May-June 2013 • Vol. 22/No. 3
tants, pharmacists, and diet techni-
cians, registered, are provided.
Burden of Hospital
Malnutrition
Although estimates of the preva-
lence of malnutrition vary by setting,
subgroup, and method of assess-
ment, the prevalence of malnutri-
tion in hospitals is particularly star-
tling. At least one-third of patients in
developed countries are malnour-
ished upon admission to the hospi-
tal (Barker et al., 2011; Bistrian et al.,
1974; Christensen & Gstundtner,
1985; Somanchi et al., 2011), and, if
left untreated, approximately two-
thirds of those patients will experi-
ence a further decline in their nutri-
tion status during inpatient stay
(Somanchi et al., 2011). Unfor-
tunately, despite the availability of
validated screening tools, malnutri-
tion continues to be underrecog-
nized in many hospitals (Kirkland,
Kashiwagi, Brantley, Scheurer, &
Varkey, 2013). Moreover, among
patients who are not malnourished
upon admission, approximately one-
third may become malnourished
while in the hospital (Braunschweig,
Gomez, & Sheean, 2000).
Historically, a variety of tools and
definitions have been used through-
out the nutrition literature. For the
purposes of this paper, mild through
severe malnutrition will be the focus
and is the intent when the term
“malnutrition” is used.
Malnutrition is defined most
simply as any nutrition imbalance
(Dorland’s Illustrated Medical Dic-
tionary, 2011) that affects both
overweight and underweight pa-
tients alike and is described general-
ly as either “undernutrition” or
“overnutrition” (White, Guenter,
Jensen, Malone, & Schofield, 2012).
Hospitalized patients, regardless of
their body mass index (BMI), typi-
cally suffer from undernutrition
because of their propensity for
reduced food intake due to illness-
induced poor appetite, gastroin-
testinal symptoms, reduced ability
to chew or swallow, or nil per os
(NPO) status for diagnostic and
therapeutic procedures. In addition,
 Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition

they may have increased energy,
protein, and essential micronutri-
ent needs because of inflammation,
infection, or other catabolic condi-
tions. A consensus statement by
AND and A.S.P.E.N. published in
May 2012 defines malnutrition as
the presence of two or more of the
following characteristics: insufficient
energy intake, weight loss, loss of
muscle mass, loss of subcutaneous
fat, localized or generalized fluid
accumulation, or decreased func-
tional status (White et al., 2012).
The importance of identifying at-
risk patients is highlighted by data
showing that malnutrition is associ-
ated with many adverse outcomes,
including an increased risk of pres-
sure ulcers and impaired wound
healing, immune suppression and
increased infection rate, muscle
wasting and functional loss increas-
ing the risk of falls, longer length of
hospital stay, higher re-admission
rates, higher treatment costs, and
increased mortality (Barker et al.,
2011). Therefore, malnutrition places
a heavy burden on the patient, clini-
cian, and health care system.
Many of the adverse outcomes
influenced by malnutrition are
potentially preventable. Nosocomial
infections are a prime example.
Approximately 2 million nosocomi-
al infections occur annually in the
United States (Jarvis, 1996), and
those patients are more likely to
spend time in the intensive care
unit, be re-admitted, and die as a
result (Kirkland, Briggs, Trivette,
Wilkinson, & Sexton, 1999). A retro-
spective study by Fry, Pine, Jones,
and Meimban (2010) examined
nearly 1 million surgical patients
(N=887,189) treated at 1,368 hospi-
tals to determine the risk of nosoco-
mial infections and understand bet-
ter the underlying patient character-
istics influencing that risk. The
analysis showed patients with pre-
existing malnutrition and/or weight
loss had a 2- to 3-fold increased risk
of developing Clostridium difficile
enterocolitis, surgical-site infection,
or postoperative pneumonia, and a
greater than 5-fold higher risk of
mediastinitis after coronary artery
bypass graft surgery or catheter-asso-
ciated urinary tract infection.
Malnutrition and/or weight loss also
correlated with an approximate four
fold higher risk of developing a pres-
sure ulcer. These data are supported
further by a prospective multivariate
analysis demonstrating that malnu-
trition is an independent risk factor
for nosocomial infections (Schneider
et al., 2004).
Impaired wound healing can influ-
ence length of hospital stay signifi-
cantly, and the literature supports a
strong correlation between nutrition
and wound healing. Hospitalized
patients are at increased risk because
loss of significant lean body mass
(LBM) accelerates during bed rest
(Paddon-Jones et al., 2006; Paddon-
Jones et al., 2004). A 10% loss of LBM
results in immune suppression and
increases the risk of infection, and a
loss of more than 15% to 20% of total
LBM will impair wound healing
(Demling, 2009; Moran, Custer, &
Murphy, 1980). A loss of 30% or more
leads to the development of sponta-
neous wounds such as pressure ulcers,
an increased risk of pneumonia, and a
complete lack of wound healing
(Demling, 2009; Moran et al., 1980).
These complications also are associat-
ed with a substantial mortality risk,
particularly in older patients. A study
evaluating the care processes for hos-
pitalized Medicare patients (N=2,425;
age ≥65) at risk for pressure ulcer
development showed that 76% of
patients were malnourished, and esti-
mated compliance with nutrition
consultation was low (34%) (Lyder et
al., 2001).
Data from several recent studies
show that malnutrition also may
influence hospital re-admission rates
(Allaudeen, Vidyarthi, Maselli, &
Auerbach, 2011; Kassin et al., 2012;
Mudge et al., 2011). These studies
evaluated multiple factors to identify
individuals at increased risk of re-
admission. The largest of these stud-
ies, a retrospective observational
analysis of more than 10,000 consec-
utive admissions (N=6,805), reported
a 30-day re-admission rate of 17%
(Allaudeen et al., 2011). Co-morbidi-
ties that significantly increased the
risk of re-admission included conges-
tive heart failure, renal disease, can-
cer, weight loss (not defined), and
iron deficiency anemia. Weight loss
correlated with a 26% increase in risk
of re-admission (adjusted odds
ratio=1.26) (Allaudeen et al., 2011).
In a large single-center study of
1,442 general surgery patients, the
30-day re-admission rate was 11%
(Kassin et al., 2012). The most com-
mon reasons for re-admission were
gastrointestinal problems/complica-
tions (28% of re-admissions), surgi-
cal infections (22%), and failure to
thrive/malnutrition (10%). These
findings are consistent with the
hypothesis that poor nutrition con-
tributes to post-hospital syndrome,
which together with a variety of
other factors, such as sleep distur-
bance, pain, and discomfort, can
increase the risk of 30-day re-admis-
sion dramatically, often for reasons
other than the original diagnosis
(Krumholz, 2013).
Finally, poor clinical outcomes
associated with malnutrition con-
tribute to higher hospitalization
costs. As outlined above, patients
who are malnourished have higher
rates of infections, pressure ulcers,
impaired wound healing, and other
adverse outcomes requiring greater
nursing care and more medications.
In turn, these complications can
contribute to longer lengths of hos-
pital stay and higher rates of re-
admission, all of which indirectly
contribute to higher hospital costs
(Barker et al., 2011). Indeed, a study
conducted in the United Kingdom
estimated the annual expenditure for
managing patients at medium or
high risk of disease-related malnutri-
tion to be €10.5 billion (Euro) ($11.3
billion USD, based on 2003 exchange
rates), more than half of which was
related directly to hospital care
(Russell, 2007).
These studies strongly suggest the
consequences of unrecognized and
untreated malnutrition are substan-
tial, not only for patients’ quality of
care but also from a cost perspective.
Malnutrition negatively affects clini-
cal outcomes and results in higher
costs, and, with the changing health
care landscape, reimbursement for
costs associated with preventable
events will be reduced. All clinicians
must take action to address these con-
cerns, improve patient quality of life,
and increase health care system value.

May-June 2013 • Vol. 22/No. 3 149

Alliance to Advance Patient Nutrition

0.95) (Avenell & Handoll, 2010). A

The benefits of nutrition intervention in meta-analysis of four randomized tri-
terms of improving key clinical outcomes als (N=1,224) also showed that, in
patients with no pressure ulcers at
are well documented. baseline, high-protein ONS resulted
in a significant 25% lower incidence
of ulcers compared with routine care
(Stratton et al., 2005). In addition,
Impact of Nutrition tions but remains unclear in others. evidence indicates nutrition inter-
Intervention on Key In addition, numerous studies have vention can reduce the risk of falls in
Outcomes shown improved body weight, LBM, frail and malnourished older adult
and grip strength with dietary coun- patients. In 210 malnourished older
The benefits of nutrition inter-
seling, with or without ONS adults newly admitted to an acute-
vention in terms of improving key
(Baldwin & Weekes, 2011). A grow- care hospital, intervention with a
clinical outcomes are well docu-
ing number of studies have exam- protein- and energy-rich diet, ONS,
mented. Numerous studies, predom-
ined the impact of ONS in malnour- calcium/ vitamin D supplements,
inantly in patients age 65 and older
ished patients, providing the frame- and counseling reduced the inci-
with or at risk for malnutrition, have
work for our call to action. Evidence dence of falls by approximately 60%
shown the potential of specific nutri-
supporting intervention with EN compared with routine care (10% vs.
tion interventions to reduce compli-
and PN is beyond the scope of the 23%) (Neelemaat et al., 2012).
cation rates, length of hospital stay,
current paper and will be addressed Avoidance of these preventable
re-admission rates, cost of care signif-
in subsequent reviews. events can shorten length of hospi-
icantly, and, in some studies, mortal-
ity (Avenell & Handoll, 2006, 2010; tal stay, decrease morbidity and mor-
Clinical Complications tality, and reduce liability for the
Brugler, DiPrinzio, & Bernstein,
Studies evaluating the efficacy of hospital.
1999; Cawood, Elia, & Stratton,
ONS consumption generally have
2012; Gariballa et al., 2006; Milne et Length of Stay
shown a variety of metabolic im-
al., 2009; Milne, Potter, & Avenell,
provement and, in many studies, a Consistent with evidence nutri-
2005; Milne, Avenell, & Potter, 2006;
reduction in several clinical complica- tion intervention can reduce clinical
Neelemaat et al., 2012; Philipson et
tions. One meta-analysis including complications, providing strong
al., 2013; Somanchi Tao & Mullin,
seven studies (N=284) indicates that nutrition care can also reduce the
2011; Stratton Green & Elia, 2003).
patients receiving ONS had reduced length of hospital stay. In a prospec-
Nutrition intervention strategies rep-
complication rates (e.g., infections, tive study conducted at The Johns
resent a broad spectrum of options
gastrointestinal perforations, pressure Hopkins Hospital, nutrition screen-
that can be organized into four cate-
ulcers, anemia, and cardiac complica- ing involving a team approach to
gories: (1) food and/or nutrient
tions) compared with control patients address malnutrition and earlier
delivery, (2) nutrition education, (3)
(Stratton, Green, & Elia, 2003). More intervention reduced the length of
nutrition counseling, and (4) coordi-
recently, a large Cochrane systematic hospital stay by an average of
nation of nutrition care. Food and/or
review of 24 studies involving 6,225 3.2 days in severely malnourished
nutrient delivery requires an individ-
patients age 65 and older at risk for patients (Somanchi et al., 2011), and
ualized approach that includes ener-
malnutrition demonstrated fewer this translated into substantial cost
gy- and nutrient-dense food, com-
complications (e.g., pressure sores, savings of $1,514 per patient. Two
plete oral nutrition supplements
deep vein thrombosis, and respiratory meta-analyses have shown signifi-
(ONS) that provide macronutrients
and urinary infections) among cantly reduced length of hospital stay
(from carbohydrate, fat, and protein
patients receiving ONS compared with in patients receiving ONS compared
sources) combined with micronutri-
routine care (relative risk [RR] 0.86; with control patients. One analysis
ents (mixtures of complete vitamins,
95% confidence interval [CI] 0.75- demonstrated a reduced average
minerals, and trace elements); enter-
0.99) (Milne, Potter, Vivanti, & length of hospital stay ranging from
al nutrition (EN), which in the con-
Avenell, 2009). Available evidence 2 days for surgical patients to 33 days
text of this report refers to nutrients
indicates high-protein ONS to be par- for orthopedic patients (p<0.004)
provided into the gastrointestinal
ticularly effective at reducing the risk (Stratton et al., 2003). Additionally,
tract via a tube; and/or parenteral
of complications. A systematic review patients with a lower BMI (<20)
nutrition (PN). Although the nutri-
of older adult patients (age 65 and received the greatest benefit from
tion support literature generally has
older) with hip fractures demonstrat- optimized food and/or nutrient
featured smaller trials and observa-
ed a more effective reduction in the delivery. Likewise, in a recent meta-
tional studies rather than large mul-
number of long-term medical compli- analysis of nine randomized trials
ticenter randomized controlled tri-
cations with high-protein ONS (>20% (N=1,227), high-protein ONS signifi-
als, evidence strongly supports the
total energy from protein) than low- cantly reduced length of stay by an
importance of nutrition interven-
protein or non-protein containing average of 3.8 days (p=0.040) com-
tion. The value of EN and PN is well
supplements (RR 0.78; 95% CI 0.65- pared with routine care (Cawood,
established in select patient popula-

150 May-June 2013 • Vol. 22/No. 3

 Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
Elia, & Stratton, 2012). A recent ret-
rospective analysis utilized informa-
tion from more than one million
adult inpatient cases found in the
2000-2010 Premier Perspectives
Database™, maintained by the Pre-
mier Healthcare Alliance – repre-
senting a total of 44 million hospi-
tal episodes from across the United
States or approximately 20% of all
inpatient admissions in the United
States. Within this sample, ONS
reduced length of hospital stay by
an average of 2.3 days or 21%, and
the average cost savings was $4,734
or 21.6% compared with routine
care (Philipson, Thornton Snider,
Lakdawalla, Stryckman, & Goldman,
2013).
Re-Admissions
Hospital re-admission rate is
another important outcome that can
be improved through nutrition inter-
vention. Thirty-day re-admission
rates decreased from 16.5% to 7.1%
in a community hospital that imple-
mented a comprehensive malnutri-
tion clinical pathway program
focused on identification of at-risk
patients, nutrition care decisions,
inpatient care, and discharge plan-
ning (Brugler, DiPrinzio, & Bernstein,
1999). A prospective randomized
trial in acutely ill patients 65 to
92 years of age (N=445) demonstrat-
ed a significantly lower 6-month re-
admission rate among those who
received a normal hospital diet plus
high-protein ONS compared with
those patients who received only the
normal hospital diet (29% vs. 40%,
respectively; hazard ratio [HR] 0.68,
95% CI 0.49-0.94) (Gariballa, Forster,
Walters, & Powers, 2006). Finally,
analysis of the Premier Perspectives
Database showed that use of ONS
reduced 30-day re-admission rates by
6.7% (Philipson et al., 2013), indicat-
ing the significant real-world benefit
of nutrition intervention on a key
patient outcome.
Mortality
Several meta-analyses have also
demonstrated reduced mortality in
patients receiving optimized oral
nutrition care. An analysis of 11
studies (N=1,965) found significantly
lower mortality rates among hospi-
May-June 2013 • Vol. 22/No. 3
talized patients receiving ONS (19%)
compared with control patients
(25%; p<0.001) (Stratton et al.,
2003). This represented a 24% over-
all reduction in mortality, and
patients with lower average BMI
(<20) receiving ONS significantly
had a greater reduction in mortality.
Among elderly patients hospitalized
for hip fracture, fewer patients had
an unfavorable combined outcome
(mortality or medical complication)
if they received ONS versus routine
care (RR 0.52; 95% CI 0.32-0.84)
(Avenell & Handoll, 2006). Another
systematic review of 32 studies
(N=3,021) found that, in elderly
patients, ONS significantly reduced
mortality compared with routine
care (RR 0.74; 95% CI 0.59-0.92)
(Milne, Potter, & Avenell, 2005).
Subgroup analyses from the original
Cochrane review and two updates
have consistently shown reduced
mortality in undernourished pa-
tients receiving ONS compared with
routine care (Milne, Avenell, &
Potter, 2006; Milne et al., 2009;
Milne et al., 2005).
Collectively, these data provide
solid evidence that nutrition inter-
vention significantly contributes to
improved clinical outcomes and
reduced cost of care, primarily in
patients 65 years of age and older
and those with or at risk for malnu-
trition. However, it is important to
note that isolated studies and meta-
analyses have not demonstrated
such significantly improved clinical
outcomes with nutrition interven-
tion (Baldwin & Weekes, 2011; Beck,
Holst, & Rasmussen, 2013; Burden,
Todd, Hill, & Lal, 2012; Hendry et al.,
2010; Langer et al., 2012). Thus,
additional research studies, particu-
larly well-powered, randomized con-
trolled clinical trials, are always ben-
eficial to further explore the effects
of nutrition intervention on clinical
outcomes and to assess how those
benefits may translate into cost sav-
ings. Nevertheless, given the impor-
tance of adequate nutrition to cell
and organ function, coupled with
promising clinical data reported to
date, the time is now to act on the
evidence at hand and implement
nutrition intervention strategies
shown to be safe and efficacious.
Alliance Nutrition Care
Recommendations
If we are to make progress toward
improving nutrition care practices
that guarantee every malnourished
or at-risk patient is identified and
treated effectively, we must proac-
tively identify barriers impacting the
provision of nutrition care. Toward
this end, at least six key challenges
must be overcome. First, despite at
least one-third of hospitalized
patients being admitted malnour-
ished, a majority of these patients
continue to go unrecognized or
are inadequately screened (Elia,
Zellipour, & Stratton, 2005). Second,
while the responsibility of patients’
nutrition care is often placed on the
dietitian, many institutions lack ade-
quate dietitian staffing to properly
address all patients. Third, nutrition
care is often delayed due to the
patient’s medical status, lack of diet
order, and time to nutrition consult.
In fact, a study at Johns Hopkins
found that time to consultation
from admission is nearly 5 days
(Somanchi et al., 2011), which is
similar to the average length of hos-
pital stay (Centers for Disease
Control and Prevention, 2009).
Fourth, nurses provide and oversee
patient care 24/7, observe nutrition
intake and tolerance, and interact
continually with the patient and
family/caregivers, yet they are not
consistently included in nutrition
care (Willand & Luker, 2007). Fifth,
in many care environments, physi-
cian sign-off is required to imple-
ment a nutrition care plan. Dietitian
recommendations are implemented
in only 42% of cases (Skipper, Young,
Rotman, & Nagl, 1994). Finally,
many patients experience difficulty
in consuming meals without assis-
tance, contributing to more than
half of hospitalized patients not fin-
ishing their meals (Hiesmayr et al.,
2009).
To address these barriers and shift
the paradigm of nutrition care, the
Alliance Steering Committee, whose
members possess broad-ranging
expertise and clinical experience,
developed several key principles
for advancing patient nutrition.
Through a series of meetings con-
151
Alliance to Advance Patient Nutrition
The Alliance’s Key Principles for Advancing Patient Nutrition
Principle 1:
Create Institution Culture
Principle 2:
Redefine Clinicians’ Roles to
Include Nutrition
Principle 3:
Recognize and Diagnose ALL
Patients at Risk
Principle 4:
Rapidly Implement Interventions
and Continued Monitoring
Principle 5:
Communicate Nutrition
Care Plans
Principle 6:
Develop Discharge Nutrition
Care and Education Plan
Abbreviation: EHR = electronic health record
ducted over the past year, the com-
mittee explored the following topics:
empowerment of all clinicians,
recognition and diagnosis of all
patients, same-day automatic inter-
vention for all at-risk patients, edu-
cation and involvement of patients
in their nutrition care, and apprecia-
tion of the value of nutrition by all
hospital stakeholders. Six principles
deemed essential elements of opti-
mal patient nutrition care were
derived from these topics (see Figure
1). Attainment of these six ideals,
however, will require processes and
collaboration among all hospital
stakeholders, including dietitians,
152
FIGURE 1.
• Know the facts – nutrition improves patient outcomes
• Support adequate and appropriate nutrition intervention
• Identify motivated champions among hospital stakeholders
• Empower dietitians
• Secure nurse and physician leadership
• Engineer teamwork (e.g., daily team huddles) to include nutrition
• Assure accountability for malnutrition identification
• Use valid screening tool and criteria to assess/diagnose malnutrition
• Include fields for malnutrition characteristics in EHR
• Establish policy to feed patients within 24 hours of “at-risk” screen
• Create EHR prompt for diet order when “at-risk” screening data entered
• Monitor patient’s food and oral nutrition supplement consumption
• Leverage EHR to standardize nutrition documentation
• When present, ensure coding of mild, moderate, or severe malnutrition as
complicating condition to primary diagnosis
• Ensure care discussions include nutrition
• Ensure nutrition care plan incorporated into discharge plan
• Educate patients and their family/caregivers
• Communication with the patient’s health care providers
nurses, physicians, and administra- overall clinical outcomes. Clinicians
tors, each of whom must fulfill a role and administrators often fail to prior-
in this effort (see Table 1). Translation itize understanding the extent of
of these processes into a practical malnutrition in their institutions and
interdisciplinary nutrition care algo- its potential impact on cost and/or
rithm is illustrated in Figure 2. quality of care. Nurses and physicians
receive limited formal nutrition edu-
Principle 1: Create an cation during training and often do
Institutional Culture Where
not prioritize nutrition among the
All Stakeholders Value
Nutrition competing priorities nutrition within
patient care. Failing to prioritize
True progress requires that all hos- nutrition within an institution may
pital stakeholders, including clini- limit available nutrition intervention
cians and administrators, fully un- options and human resources (e.g.,
derstand the pervasiveness of hospi- dietitians and nutrition-focused nurs-
tal malnutrition and the effect pa- es and physicians) required for opti-
tient nutrition care may have on mal nutrition care. To be successful,
May-June 2013 • Vol. 22/No. 3
 TABLE 1.
Summary of Alliance’s Nutrition Care Recommendations for Key Hospital Stakeholders

Key Hospital Stakeholders

Principle Dietitian Nurse Physician Hospital Administrator
1. Create an • Serve as primary authority on • Recognize the essential role • Provide leadership • Become a nutrition champion
Institutional “all things nutrition” nurses play in achieving underscoring nutrition care as and provide support for the
Culture Where All • Educate key hospital enhanced patient outcomes an essential part of patient- development of effective
Stakeholders stakeholders on improved through individualized nutrition centered care nutrition care processes
Value Nutrition patient outcomes and reduced care • Know evidence regarding • Share quality and economic
costs achieved with optimal • Incorporate nutrition into impact of malnutrition and gains to be made by investing
nutrition care routine care checklists and effectiveness of nutrition in nutrition care with hospital
• Host hospital-wide learning processes intervention leadership team
opportunities at regular • Include patient’s nutrition intake • Include dietitian in daily team
intervals into team huddles huddles/rounds
• Incorporate nutrition into
routine care checklists and
processes

2. Redefine • Actively contribute nutrition • Ensure practices are in place to • Empower dietitian to • Support nutrition education of
Clinicians’ Role to expertise and engage other support implementation of cooperatively lead nutrition clinicians needing initial training
Include Nutrition team members with nutrition intervention care as clinical team member and continuing education

May-June 2013 • Vol. 22/No. 3

Care assessment data on progress
made with nutrition care efforts
• Regularly participate in
interdisciplinary rounds.
• Develop processes to ensure • Support nurse work processes • Provide ordering privileges to
nutrition screening and dietitian- to include nutrition screening dietitian for issues relating to
prescribed intervention occurs and intervention the nutrition care process
within the targeted timeframes
• Facilitate nursing interventions
to treat patients who are
malnourished or at risk

3. Recognize and • Utilize standard malnutrition • Screen every hospitalized • Consider nutrition status as an • Ensure EHR captures
Diagnose All characteristics set forth by AND patient for malnutrition as part essential attribute of medical screening data and malnutrition
Malnourished and A.S.P.E.N. guidelines of regular workflow procedures assessment, monitoring, and criteria with the appropriate
Patients and • Establish competence in • Communicate screening care plans triggers in place for initiating
Those at Risk nutrition-focused physical results through use of EHR the next steps when positive
assessment • Rescreen patients at least screens or diagnostic
weekly during hospital stay assessment are obtained
• Communicate changes in
clinical condition indicative of
nutrition risk

Abbreviations: AND = Academy of Nutrition and Dietetics; A.S.P.E.N. = American Society for Parenteral and Enteral Nutrition; EHR = electronic health record; EN = enteral
nutrition; ONS = oral nutrition supplement; PN = parenteral nutrition; PO = oral

continued on next page

153
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition

154
Summary of Alliance’s Nutrition Care Recommendations for Key Hospital Stakeholders
Principle Dietitian
4. Rapidly Implement • Establish procedures to
Comprehensive support policy that patients
Nutrition identified as “at-risk” during
Intervention and nutrition screen receive
Continued automated nutrition intervention
Monitoring within 24 hours while awaiting
assessment, diagnosis, and
care plan
• Lead an interdisciplinary team
to establish nutrition algorithms
for use in various scenarios
when positive screens or
diagnostic assessments are
obtained
• Provide EN formulary and
micronutrient therapy options in
written form as a pocket-size
document; make readily
available to all staff to ensure
fast intervention
• Work with interdisciplinary
team to establish policies and
interdisciplinary practices to
maximize nutrient consumption
and monitoring needs
Abbreviations: AND = Academy of Nutrition and Dietetics; A.S.P.E.N. = American Society for Parenteral and Enteral Nutrition; EHR = electronic health record; EN = enteral
nutrition; ONS = oral nutrition supplement; PN = parenteral nutrition; PO = oral
May-June 2013 • Vol. 22/No. 3
TABLE 1. (continued)
Key Hospital Stakeholders
Nurse
• Ensure procedures allowing
patients identified as “at-risk”
during nutrition screen receive
automated nutrition
intervention within 24 hours
while awaiting assessment,
diagnosis, and care plan
• Develop procedures to provide
patients with meals at “off
times” if patient was not
available or under a restricted
diet at the time of meal
delivery
• Avoid disconnecting EN or PN
for patient repositioning,
ambulation, travel, or
procedures
• Work with interdisciplinary
practices to establish policies
and interdisciplinary practices
to maximize food/ONS
consumption
• Monitor food/ONS
consumption and
communicate to
dietitian/physician via EHR
Physician
• Support policy that provides
automated nutrition intervention
within 24 hours in patients
identified as “at-risk” during
nutrition screen, while awaiting
nutrition assessment,
diagnosis, and care plan
• Minimize nil per os periods for
your patient with scheduling of
procedures/tests and remain
mindful of “holds” on PO diets
Hospital Administrator
• Provide ordering privileges to
dietitian for issues relating to
the nutrition care process
(e.g., diet plans, ONS,
micronutrients, and calorie
counts)
• Ensure EHR includes
automatic triggers that initiate
nutrition protocol measures to
be reviewed when positive
screens are obtained
• Ensure EHR includes a
module for recording food/ONS
intake data and triggers
dietitian consult if consumption
is suboptimal
Alliance to Advance Patient Nutrition
continued on next page
 TABLE 1. (continued)
Summary of Alliance’s Nutrition Care Recommendations for Key Hospital Stakeholders

Key Hospital Stakeholders

Principle Dietitian
5. Communicate • If present, ensure mild, moder-
Nutrition Care ate, or severe malnutrition is
Plans included as complicating
condition in coding processes
• Assume responsibility for
ensuring a patient’s nutrition care
plan is documented carefully in
the EHR, updated regularly, and
communicated effectively to all
health care providers, including
post-acute facilities and primary
care physicians
• Lead an interdisciplinary team to
create and maintain
standardized policies,
procedures, and EHR-
automated triggers relevant to
Nurse
• Consult dietitian regarding
nutrient intake concerns
• If present, ensure mild,
moderate, or severe malnutrition
is included as complicating
condition in coding processes
• Incorporate nutrition discussion
into handoff of care and nursing
care plans
Physician
• Establish and reinforce
expectation that a patient’s
nutrition care plan is
documented carefully in the
EHR, updated regularly, and
communicated effectively to all
health care providers
• If present, ensure mild,
moderate, or severe
malnutrition is included as
complicating condition in
coding processes
Hospital Administrator
• If present, ensure mild,
moderate, or severe
malnutrition is included as
complicating condition in
coding processes
• Ensure EHR is adapted to
ensure nutrition diagnosis and
complete care plan is included
as a standard category of
medical assessment in the
central area of EHR

May-June 2013 • Vol. 22/No. 3

nutrition, including order sets and
protocols in the hospital’s EHR

6. Develop a • Provide patients, family
Comprehensive members, and caregivers
Discharge with nutrition education and
Nutrition Care and a comprehensive post-
Education Plan hospitalization nutrition care
plan
• Ensure patient and caregiver
understand the importance of
follow-up nutrition assessment
and education
• Provide specific information for
nutrition follow-up appointments
to patient and caregiver
• Include nutrition as a component
of all clinician conversations with
patients and their family
members/caregivers
• Reinforce the importance of
nutrition care and follow-up post-
discharge to patient and
caregiver
• Include nutrition as a
component of all clinician
conversations with patients
and their family members/
caregivers
• Provide expectation regarding
continuity of nutrition care,
including discharge planning
and patient education

Abbreviations: AND = Academy of Nutrition and Dietetics; A.S.P.E.N. = American Society for Parenteral and Enteral Nutrition; EHR = electronic health record; EN = enteral
nutrition; ONS = oral nutrition supplement; PN = parenteral nutrition; PO = oral

155
Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
Alliance to Advance Patient Nutrition

FIGURE 2.
The Alliance’s Approach to Interdisciplinary Nutrition Care

Hospital admission

Nurse
• Every patient screened within 24
Nutrition screen hours using validated tool Patient discharged on Nutrition care plan trans-
• Results document in EHR appropriate nutrition care ferred to next care setting
plan and PCP

Interdisciplinary
If not at risk, monitor, • Nutrition care included
Malnourished or at risk then rescreen within transition calls
and evaluations

Nutrition assessment Automatic intervention Patient fed and

ordered triggered in EHR consumption monitored*

Nurse
• Initiate food/ONS intake within
24 hours*
• Manage environments to
maximize consumption

Dietitian Physician
Nutrition assessment • Assessment includes AND and
If malnourished,
• Severity-coded diagnosis
conducted A.S.P.E.N. malnutrition charac- diagnosis documented documented in EHR
teristics

Interdisciplinary Interdisciplinary
Custom nutrition care • Dietitian: Create nutrition care Monitor and • Dietitian: Adjust
re-evaluate Discharge plan updated
plan created/ordered plan, order intervention nutrition care plan and
and document in EHR orders, as needed;
• Nurse: Facilitate adherence document in EHR Interdisciplinary
• Physician: Nutrition included in • Nurse: Monitor and • Nutrition care included
daily problems list/team huddles document changes in within discharge plan
intake, weight, and • Nutrition care follow-up
function scheduled
Interdisciplinary • Physician: Continue
Patient and family • Dietitian: Conduct comprehensive nutrition care discussion
education education/counseling
• Nurse: Reinforce teachings and
respond to questions *Patient fed orally unless specific contraindications exist
• Physician: Discuss nutrition
status/plan

Abbreviations: AND = Academy of Nutrition and Dietetics; A.S.P.E.N. = American Society for Parenteral and Enteral Nutrition;
EHR = electronic health record; ONS = oral nutrition supplement; PCP = primary care physician

institutions need motivated nutrition
champions at all levels of clinical care
and administration.
To ensure clinicians and hospital
leaders understand the clinical and
financial implications of malnutri-
tion and take proper steps to address
it, the Alliance offers the following
recommendations:
• Clinicians must be educated on
the recognition of malnourished
patients and evidence-based
nutrition interventions. Discus-
sion of nutrition care plans
should be a mandated compo-
nent of daily team meetings
(rounds or huddles).
• Malnutrition must be included
appropriately as part of the
patient’s diagnosis and nutrition
interventions must be viewed as
a core component of a patient’s
medical therapy. Nutrition treat-
ment plans should be addressed
with the same consistency and
rigor as other therapies.
• Hospital administrators must rec-
ognize the financial benefit of
optimal nutrition care. Insti-
tutional financial data must be
reviewed to identify challenges to
improving nutrition interven-
tion, project cost savings with

156 May-June 2013 • Vol. 22/No. 3

 Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
various nutrition interventions,
and revise budgets to facilitate
action. Budgets must support
adequate and appropriate nutri-
tion intervention as necessitated
by dietitian, nursing, and physi-
cian staff.
• Professional associations for dieti-
tians, nurses, physicians, and hos-
pital administrators must address
the widespread problem of hospi-
tal malnutrition. Discipline-
specific resources, such as toolkits
and practice bundles, evidence-
based publications, and continu-
ing education opportunities,
must be established and widely
available. Funding mechanisms
for nutrition-related research
should be established to identify
best practices for optimizing
nutrition care.
Principle 2: Redefine
Clinicians’ Roles to Include
Nutrition Care
Providing effective nutrition
intervention requires a champion
within and collaboration among all
disciplines involved in patient care.
All health care professionals in-
volved in patient care must be
empowered to influence nutrition
decisions. In many hospitals, howev-
er, the responsibility for nutrition
recommendations almost always
rests solely with the dietitian. Many
institutions lack nurse and physician
leaders who champion nutrition
care. Interdisciplinary leadership is
essential to ensure nutrition care is
valued and carries a high priority. To
ensure effective management of hos-
pital malnutrition, nurses and physi-
cians also must play a role.
In this regard, the Alliance recom-
mends redefining clinicians’ roles to
include responsibility for optimal
nutrition care, which can be accom-
plished as follows:
• Interdisciplinary teams must
discuss potential barriers and
solutions to recognize and treat
malnourished or at-risk patients
in their hospitals.
• Engage nurses to understand
nutrition risk factors, such as
under-consumed meals and
actions required on positive
malnutrition screenings. De-
May-June 2013 • Vol. 22/No. 3
velop and implement policies
that allow nurses to provide
complete nutrition care, such as
returning low-risk patients to
previous established feeding
orders following temporary
delays, initiating calorie counts,
and measuring body weight as
indicated. Policies that inhibit
nursing action inhibit optimal
patient nutrition. Prompt nurs-
ing action can reduce malnutri-
tion by creating focused meal-
times, managing mealtime envi-
ronments and staff mealtimes,
intervening with nutrition ther-
apies as appropriate, and desig-
nating a nutrition care nurse in
each clinical area to monitor
and evaluate implementation of
the policy (Jefferies, Johnson, &
Ravens, 2011).
• Given the extensive nutrition
expertise of dietitians, hospital
administrators such as a chief
medical officer must grant them
privileges for ordering diets,
ONS, vitamins, and calorie
counts to eliminate inefficien-
cies and prevent delays in food
and/or nutrient delivery. For
example, at the University of
Kansas Hospital (KUH), when
faced with delays in care because
the dietitian’s recommendations
were not being noted and
ordered by physician teams, the
nutrition support team obtained
ordering privileges for all dieti-
tians. These privileges include
ordering ONS, calorie counts,
patient weights, zinc, vitamin C
and multivitamins, and select
nutrition-related labs. This was
an important step in advancing
nutrition care at KUH by pro-
moting timely gathering of
assessment data and nimble
implementation and revision of
optimal nutrition interventions.
• Hospitalists must add nutrition
to their interdisciplinary ap-
proach to patient care and serve
as nutrition champions among
physicians. In support of this
effort, hospitalists should in-
clude a dietitian and nutrition-
focused nurse in team huddles,
and nutrition should be includ-
ed in the daily problem list.
Principle 3: Recognize and
Diagnose All Malnourished
Patients and Those at Risk
Given the high prevalence of hos-
pital malnutrition, each hospitalized
patient must receive proper nutri-
tion screening, with findings effec-
tively communicated to ensure
immediate assessment and prompt
nutrition intervention. Using vali-
dated screening tools to identify at-
risk patients is crucial because, for
many health care professionals with-
out nutrition training, screening is
currently superficial observation
wherein boxes are checked or
unchecked without reliable screen-
ing using a validated tool. Early iden-
tification of clinical criteria support-
ing a malnutrition diagnosis and
effective processes for communicat-
ing information related to the nutri-
tion care process are often absent.
Given these barriers, the Alliance is
announcing this call to action to
ensure prompt diagnosis and inter-
vention of hospitalized patients who
are malnourished or at risk for mal-
nutrition. Every hospital must insti-
tute an interdisciplinary approach to
nutrition care that is based on formal
policies and procedures ensuring the
early identification of patients who
are malnourished or at risk for mal-
nutrition, and implementation of a
comprehensive nutrition care plan.
Screening. Comprehensive nutri-
tion screening of all hospitalized
patients is critical for both the time-
ly identification of those at risk and
to prioritize patients requiring nutri-
tion assessment and intervention.
The Alliance supports the Joint
Commission’s recommendation for
nutrition screening within 24 hours
of admission to an acute care hospi-
tal and at frequent intervals
throughout hospitalization (Joint
Commission on Accreditation of
Healthcare Organizations, 2007) (see
Figure 2). Due to limited clinician
time and nutrition knowledge,
a simplified, practical, validated
screening tool must be used.
Numerous tools exist to screen for
malnutrition risk in hospitalized
patients (Anthony, 2008; Young,
Kidston, Banks, Mudge, & Isenring,
2013). Although no universally
accepted screening tool exists, it is
157
Alliance to Advance Patient Nutrition

TABLE 2.
Validated Malnutrition Screening Tools for Hospitalized Patients

Screening Tool Parameters/Scoring Development Validation

Malnutrition Screening Weight loss, appetite; 
 408 inpatients (mean age, 58 SGA: sensitivity 92%, specificity 61%;
Tool (MST) (Ferguson at-risk score ≥2 years); standard for MNA: sensitivity 92%, specificity 72%
et al., 1999) comparison: SGA; sensitivity (Correia et al., 2003)
93%; specificity 93%
Mini Nutritional Weight change, recent 155 community-dwelling MNA: sensitivity 90%, specificity 88%
Assessment-Short intake, BMI, acute dis- elders (mean age, 79 years); (MNA-SF cutpoint £11) (Lei et al., 2009)
Form (MNA-SF) ease, mobility, standard for comparison: MNA: sensitivity 89%, specificity 82%
(Rubenstein et al., dementia/depression; physician assessment of (MNA-SF cutpoint £11) (Kaiser et al.,
2001) at-risk score £11 nutritional status;
sensitivity 2009)
98%; specificity 100% (MNA- “Nutritional assessment”: sensitivity
SF cutpoint £10) 100%, specificity 38% (MNA-SF cutpoint
£10) (Ranhoff et al., 2005)

Malnutrition Universal Weight change, 8,944 inpatients, review of 128 SGA: sensitivity 61%, specificity 79%
Screening Tool (MUST) recent/predicted intake, trials (mean age not reported); (Kyle et al., 2006)
(Elia, 2003) BMI, acute disease;
 standard for comparison: SGA: sensitivity 72%, specificity 90%;
high-risk score ≥2 nutrition support trials MNA: κ = 0.39 (Velasco et al., 2011)
demonstrating improved MNA: κ = 0.55 (Stratton et al., 2004)
clinical outcomes; sensitivity
75%; specificity 55%
Nutritional Risk Weight change, recent Adapted from Malnutrition SGA: sensitivity 74%, specificity
Screening 2002 (NRS- intake, BMI, acute Advisory Group screening tool 87%;
MNA: κ = 0.39 (Velasco et al.,
2002) (Kondrup et al., disease, age; 2011)
2003) at-risk score ≥3 SGA: sensitivity 62%, specificity 63%
(Kyle et al., 2006)
MNA: κ = 1.00 (Martins et al., 2005)
Short Nutritional Weight change, appetite, 291 inpatients (mean age, 58 BMI <18.5 or recent weight loss >5%:
Assessment supplements/tube feeding; years); s
 tandard for sensitivity 79%, specificity 83%
Questionnaire (SNAQ©) at-risk score ≥2 comparison: BMI <18.5 or (Kruizenga et al., 2005)
(Kruizenga, Van Tulder weight loss >5%; sensitivity
et al., 2005) 86%; specificity 89%

Abbreviations: BMI = body mass index; MNA = Mini Nutritional Assessment; SGA = Subjective Global Assessment
Note: Adapted from Young et al. (2013).

important to select a tool that is FIGURE 3.

practical and easy to use, and has Malnutrition Screening Tool (MST)
been validated in the patient popula-
tion of interest. Currently validated 1. Have you lost weight recently without trying?
screening tools include the Mal- No 0
nutrition Screening Tool (MST), Mini Unsure 2
Nutritional Assessment-Short Form If Yes, how much weight (kg) have you lost?
(MNA-SF), Malnutrition Universal 1-5 1
Screening Tool (MUST), Nutritional 6-10 2
Risk Screening 2002 (NRS-2002), and 11-15 3
>15 4
Short Nutritional Assessment Ques- Unsure 2 Weight Loss Score:
tionnaire (SNAQ©) (see Table 2) (Elia,
2003; Ferguson, Capra, Bauer, & 2. Have you been eating poorly because of a decreased appetite?
Banks, 1999; Kondrup, Rasmussen, No 0
Hamberg, & Stanga, 2003; Krui- Yes 1 Appetite Score:
zenga, Van Tulder et al., 2005;
Rubenstein, Harker, Salva, Guigoz, & Total MST Score (weight loss + appetite scores)
Vellas, 2001). Important aspects of
nutrition screening tools include sci- Note: Adapted from Ferguson et al. (1999).

158 May-June 2013 • Vol. 22/No. 3

 Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
Etiology-Based Malnutrition Definitions
Starvation-Related
Malnutrition
(pure chronic starvation,
anorexia nervosa)
Note: Adapted with permission from White et al. (2012).
entific validation and easy adminis-
tration requiring no specialized
nutrition knowledge. For example,
the advantage of the MST is that it is
quick (takes <5 minutes) and
straightforward, consists of two sim-
ple questions evaluating weight
change and appetite (see Figure 3),
and was designed for use by busy
health care professionals not neces-
sarily trained in nutrition. These
tools allow nutrition screening to
become an integral part of routine
clinical practice without being
viewed as a burden or imposing a
significant extra workload on hospi-
tal staff.
Screening results must be docu-
mented within the electronic health
record (EHR) to allow for prompt
communication between the nurs-
ing staff and other health care team
members. When a positive nutrition
screen is obtained, the EHR should
be configured to trigger a query for
entry of a diet order or other appro-
priate intervention while the patient
awaits further assessment and devel-
opment of a nutrition care plan.
May-June 2013 • Vol. 22/No. 3
FIGURE 4.
Nutrition Risk Identified
Compromised intake or
loss of body mass
Inflammation Present?
No Yes
Mild to moderate
Chronic Disease-Related
Malnutrition
(organ failure, pancreatic
cancer, rheumatoid arthritis,
sarcopenic obesity)
Nurses must rescreen patients regu-
larly with adequate nutrition status
upon admission because many will
become at risk for malnutrition dur-
ing hospitalization. The MST can be
completed easily while nurses inter-
act with patients and their family/
caregivers and while conducting reg-
ular assessments for patients at risk
of pressure ulcers and falls.
Assessment and Diagnosis. Nutri-
tion assessment is a method of
obtaining, verifying, and interpret-
ing data needed to identify nutri-
tion-related problems, their causes,
and significance. The dietitian must
perform nutrition assessments in all
patients considered at risk based on
nutrition screening to characterize
and determine the cause of nutrition
deficits. Traditionally, changes in
acute-phase proteins, such as serum
albumin and prealbumin, were con-
sidered standard biomarkers for diag-
nosing malnutrition (White et al.,
2012). However, it is now well docu-
mented that serum levels of these
proteins are affected not only by
nutrition status but also by inflam-
Marked inflammatory response
Acute Disease- or Injury-
Related Malnutrition
(major infection, burns,
trauma, closed head injury)
mation, fluid status, and other fac-
tors. Consequently, these are no
longer considered reliable or specific
biomarkers for malnutrition. Consis-
tent with this evidence, as of 2012,
the AND and A.S.P.E.N. no longer
recommend using inflammatory
biomarkers for diagnosis of malnu-
trition.
To address the need for guidance
in this area, an International
Guidelines group convened in 2009
and developed an overarching etiolo-
gy-based definition of malnutrition
that takes into account the impor-
tant relationship between disease
and malnutrition (Jensen et al.,
2010). This broad definition de-
scribes three separate etiologies for
malnutrition (see Figure 4), two of
which include the presence of disease
(either acute or chronic). The AND
and A.S.P.E.N. subsequently devel-
oped a standardized set of diagnostic
criteria for adult malnutrition in rou-
tine clinical practice using this new
etiology-based definition (White et
al., 2012). No single parameter is
definitive for malnutrition; therefore,
159
 TABLE 3.

160
AND/A.S.P.E.N. Clinical Characteristics the Clinician Can Obtain and Document to Support a Diagnosis of Malnutrition

Malnutrition in the Context Malnutrition in the Context Malnutrition in the Context of Social
of Acute Illness or Injury of Chronic Illness or Environmental Circumstances
Clinical Characteristic Moderatea Severeb Moderatea Severeb Moderatea Severeb
Energy intake: Malnutrition is the result of inadequate food and < 75% of ≤ 50% of < 75% of ≤ 75% of < 75% of ≤ 50% of
nutrient intake or assimilation; thus, recent intake compared with estimated estimated estimated estimated estimated estimated
estimated requirements is a primary criterion defining malnutrition. energy energy energy energy energy energy
The clinician may obtain or review the food and nutrition history, requirement requirement requirement requirement requirement requirement
estimate optimum energy needs, compare them with estimates of for > 7 days for ≥ 5 days for ≥ 1 month for ≥ 1 month for ≥ 3 months for ≥ 1 month
energy consumed, and report inadequate intake as a percentage of
estimated energy requirements over time.
Interpretation of weight loss: The clinician may evaluate weight in %
 Time % Time % Time % Time % Time % Time
light of other clinical findings, including the presence of under- or 1-2 1 week >2 1 week 5 1 month >5 1 month 5 1 month >5 1 month
over-hydration. The clinician may assess weight change over time 5 1 month >5 1 month 7.5 3 month > 7.5 3 month 7.5 3 month > 7.5 3 month
reported as a percentage of weight lost from baseline. 7.5 3 month > 7.5 3 month 10 6 month > 10 6 month 10 6 month > 10 6 month
20 1 year > 20 1 year 20 1 year > 20 1 year
Physical findings: Malnutrition typically results in changes to the
physical exam. The clinician may perform a physical exam and
document any one of the physical exam findings below as an
indicator of malnutrition.
Alliance to Advance Patient Nutrition

Body fat: Loss of subcutaneous fat (e.g., orbital, Mild Moderate Mild Severe Mild Severe
triceps, fat overlying the ribs).
Muscle mass: Muscle loss (e.g., wasting of the temples, clavicles, Mild Moderate Mild Severe Mild Severe
shoulders, interosseous muscles, scapula, thigh, and calf).
Fluid accumulation: The clinician may evaluate generalized or Mild Moderate Mild Severe Mild Severe
localized fluid accumulation evident on exam (extremities, vulvar/ to severe
scrotal edema, or ascites). Weight loss is often masked by general-
ized fluid retention (edema), and weight gain may be observed.
Reduced grip strength: Consult normative standards supplied by NA Measurably NA Measurably NA Measurably
the manufacturer of the measurement device. reduced reduced reduced

May-June 2013 • Vol. 22/No. 3

Abbreviations: AND = Academy of Nutrition and Dietetics; A.S.P.E.N. = American Society for Parenteral and Enteral Nutrition; NA = not applicable
Notes:
a
The ICD-9 code for moderate malnutrition is 263.0.
b
The ICD-9 code for severe malnutrition is 262.0.
A minimum of two of the six characteristics above is recommended for diagnosis of either severe or nonsevere malnutrition.
Height and weight should be measured rather than estimated to determine body mass index (BMI).
Usual weight should be obtained to determine the percentage and the significance of weight loss.
Basic indicators of nutrition status, such as body weight, weight change, and appetite, may substantively improve with refeeding in the absence of inflammation.
Refeeding and/or nutrition support may stabilize but not significantly improve nutrition parameters in the presence of inflammation.
The National Center for Health Statistics defines chronic as a disease/condition lasting ≥ 3 months.
Serum proteins, such as serum albumin or prealbumin, are not included as defining characteristics of malnutrition because recent evidence analysis shows serum levels of
these proteins do not change in response to changes in nutrient intake.
Adapted with permission from White et al. (2012).
 Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
AND and A.S.P.E.N. proposed that
malnutrition be diagnosed when at
least two of the following six charac-
teristics are identified: (1) insufficient
energy intake, (2) weight loss, (3) loss
of subcutaneous fat, (4) loss of mus-
cle mass, (5) localized or generalized
fluid accumulation that may some-
times mask weight loss, and (6)
diminished functional status. The
magnitude and temporal aspects of
change among these dynamic char-
acteristics can be used to distinguish
between nonsevere and severe mal-
nutrition (see Table 3).
The Alliance recommends all cli-
nicians become familiar with and
use the AND and A.S.P.E.N. charac-
teristics for identification and docu-
mentation of malnutrition (White et
al., 2012) (see Figure 2). In patients
with or at risk of malnutrition, devel-
opment and initiation of a nutrition
care plan must occur within 48
hours of admission. Several patient
characteristics indicative of malnu-
trition (e.g., weight loss, loss of mus-
cle or fat, fluid retention, and cuta-
neous signs of micronutrient defi-
ciencies such as glossitis or cheliosis)
can be identified during routine
comprehensive assessments. As
noted earlier, changes in acute-phase
proteins should be interpreted with
caution and should not be used
exclusively to diagnose malnutri-
tion. These proteins are, however,
good indicators of inflammation. In
addition, other laboratory indicators
of inflammation (e.g., C-reactive
protein, white blood cell count, and
glucose levels) may be informative. A
clear understanding of the patient’s
chief complaint and medical history
is also important to appreciate the
potential for underlying inflamma-
tion, which can increase the risk of
malnutrition by increasing metabo-
lism. Conditions, such as fever,
infection, organ dysfunction, and
hyperglycemia, may be indicative of
underlying inflammation and con-
tribute to an etiology-based diagno-
sis, including identification of cur-
rently well-nourished patients at risk
for malnutrition.
Obtaining adequate information
from the patient or caregiver regard-
ing food and nutrient intake, body
May-June 2013 • Vol. 22/No. 3
weight changes, and functional
changes (e.g., ability to purchase and
cook food, and dental status) is
essential to identify periods of insuf-
ficient intake. Changes in physical
function (e.g., ambulation, chewing
ability, and mental status issues)
must be assessed and monitored as
appropriate based on individual
patient circumstances. Ensuring that
these various assessments are per-
formed routinely and carefully is
vital to an accurate diagnosis of mal-
nutrition. In addition, specific EHR
fields for the AND and A.S.P.E.N.
malnutrition characteristics must be
completed so that system alerts are
triggered when two of the six criteria
are documented, thereby clearly
communicating the malnutrition
diagnosis to the health care team.
Accurate coding of the malnutrition
diagnosis as a complicating condi-
tion of the primary diagnosis is also
critical to ensure adequate documen-
tation to support appropriate reim-
bursement and tracking of costs to
allow for a more accurate quantifica-
tion of the burden of malnutrition in
the future.
Principle 4: Rapidly
Implement Comprehensive
Nutrition Interventions and
Continued Monitoring
When a patient is identified as
malnourished, appropriate nutrition
intervention must be promptly
ordered and implemented (see
Figure 2). Barriers to this ideal are
varied, but often include (1) NPO
orders while patients await further
assessment, (2) lack of nursing proto-
col orders focused on nutrition, (3)
delay in assessment of nutrition sta-
tus due to insufficient dietitian
staffing, (4) dietitian recommenda-
tions unheeded due to the physi-
cian’s focus on other medical con-
cerns, (5) physician uncertainty with
product formulary and/or specific
micronutrient therapy options in
their hospitals, and (6) inadequate
food consumption due to poor
appetite, disease processes, and inter-
ruptions to meal times.
To overcome barriers to early and
optimal nutrition intervention, the
Alliance provides the following rec-
ommendations:
• Unless specific contraindica-
tions exist, prompt nutrition
intervention for all malnour-
ished patients must be a high
priority. Patients whose nutri-
tion status is identified as at-risk
through screening must be fed
within 24 hours by nurses while
awaiting a nutrition consult,
unless contraindicated. Exam-
ples of immediate nutrition
interventions may include mod-
ifications to diet, assistance with
ordering and eating meals, initi-
ation of calorie counts, and/or
addition of ONS. In many cases,
establishing automated process-
es that trigger upon a positive
screening will accomplish rapid
intervention best (e.g., prompt-
ing by the EHR to place a diet
order).
• Standard practices to maximize
nutrient consumption must be
adopted. Table 4 lists some prac-
tical approaches to support opti-
mal nutrition. In some cases it is
as simple as staying alert to
missed or poorly consumed
meals and communicating such
events to the dietitian so that
appropriate adjustments are
made.
• Actual consumption must be
monitored and intervention
adjusted as appropriate. Clini-
cians must adhere closely to the
documented nutrition care plan
and document success or failure
in the daily medical record.
Results of watchful monitoring
inform necessary changes to the
nutrition care plan so that short-
and long-term goals can be
achieved. For example, incom-
plete consumption of items on
the meal tray must prompt the
nurse to have a discussion with
the patient and, depending on
the severity of the intake deficit,
underlying nutritional status,
and other clinical issues, to call a
nutrition huddle.
161
Alliance to Advance Patient Nutrition

TABLE 4. in most hospitals:

Practices to Support Implementation of Nutrition Intervention • Nutrition care must be formally
documented via the central area
Practices on the medical record or in the
1. Screen every admitted patient for malnutrition, regardless of physical appearance. EHR with the following compo-
nents: (1) nutrition screening
2. Make every effort to ensure patients receive all EN or PN as prescribed to maxi-
mize benefit. results; (2) comprehensive nutri-
tion assessment data, including
3. Develop procedures to provide ONS in between meals or with medication admin-
those obtained from a nutrition-
istration to increase overall energy and nutrient intake.
focused physical assessment; (3)
4. Create a focused mealtime and supportive mealtime environment. nutrition diagnosis; (4) nutrient-
5. Take notice of patient meal consumption. medication interactions and
• Be vigilant to the amount of food eaten. diagnosis-related alterations in
• Sharing findings among the team (e.g., during team huddles) facilitates devel- requirements; (5) nutrition inter-
opment of a targeted nutritional plan.
vention(s) ordered and planned
6. Stay alert to missed meals. goals; (6) dietary intake pattern,
• Develop procedures to provide patients with meals at “off times” if patient was including percentage of food
not available or under a restricted diet at the time of meal delivery.
consumed with each meal and
7. Avoid disconnecting EN or PN for patient repositioning, ambulation, travel, or pro- consumption of any ordered
cedures. ONS; and (7) monitoring and
8. Consider managing symptoms of gastrointestinal distress while continuing to evaluation plan with specific
administer PO diet or EN. indices and timeframe for re-
• Nutrients may be administered while the source of distress is being identified assessment.
and treated.
• Hospitals must create and main-
9. Remain mindful of “holds” on PO diets or EN relative to procedures. tain standardized policies, pro-
• Take action to reduce the amount of time that a patient’s intake is restricted. cedures, and EHR-automated
10. Identify medications and disease conditions that interfere with nutrient absorption. triggers relevant to nutrition,
• Develop plans to minimize the impact. including nutrition-related and
specific diet order sets and pro-
Abbreviations: EN = enteral nutrition; ONS = oral nutrition supplements; PN = par-
tocols in the hospital’s EHR (e.g.,
enteral nutrition; PO = per oral
algorithms for initiating ONS,
EN, and PN orders).
• Nutrition care plan documenta-
tion must be included in the dis-
Principle 5: Communicate do not always occur. Most often,
charge summary to ensure that
Nutrition Care Plans nutrition status and progress are not
post-acute facilities/clinicians
All aspects of a patient’s nutrition adequately documented in the med-
fully understand all aspects of
care plan, including serial assess- ical record, making it difficult to
the nutrition care plan, includ-
ment and treatment goals, must be determine when and if patients are
ing goals, interventions, neces-
carefully documented in the EHR, consuming food and supplements.
sary resources, monitoring, and
regularly updated, and effectively In addition, nutrition standard oper-
evaluation.
communicated to all health care ating procedures and EHR-triggered
providers (see Figure 2). This will care are often lacking in the hospital, Principle 6: Develop a
allow informed engagement by all and nutrition care plans and medical Comprehensive Discharge
providers and continuity of treat- conditions are poorly communicat- Nutrition Care and
ment if the patient is transferred to ed to post-acute facilities and pri- Education Plan
another care setting. In addition, mary care physicians. A comprehensive, systematic ap-
accurate and thorough documenta- The Alliance recommends the fol- proach to managing nutrition from
tion is essential for proper disease lowing strategies to improve docu- admission through discharge and
coding (Funk & Ayton, 1995). For mentation and communication of beyond is needed to improve quality
example, prior to 2012, only severe the patient’s nutrition care plan, of care consistently (see Figure 2).
malnutrition could be coded as a including leveraging the various The risk always exists that nutrition
complicating condition with a pri- forms of EHR systems now routine goals achieved in the inpatient set-
mary diagnosis. However, as of
October 2012, mild or moderate
malnutrition can now be coded as a Successful management of hospital malnutrition
complicating condition (Depart- requires an interdisciplinary team approach and
ment of Health and Human Services,
2012). In practice, however, proper leadership that fosters open communication
documentation and communication among disciplines.

162 May-June 2013 • Vol. 22/No. 3

 Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition
ting may be lost if the continuity of
care is not adequately addressed at
the time of discharge (Kirkland et al.,
2013; Ukleja et al., 2010). In practice,
patients and family members/care-
givers rarely are educated adequately
on nutrition care by the hospital
team (Murphy & Girot, 2013).
Moreover, patient adherence to
nutrition orders during and follow-
ing a hospital stay is often poor, and
not all physicians are familiar with
the proper elements of a discharge
nutrition care plan. Failing to ad-
dress these challenges could result in
nutrition care shortcomings at one
of the most vulnerable stages in a
patient’s recovery.
To ensure continuity of care, sys-
tems must be put in place to provide
patients, family members, and care-
givers with nutrition education and
a comprehensive post-hospitaliza-
tion nutrition care plan. Toward this
end, the Alliance makes the follow-
ing recommendations:
• Nutrition must be a component
of all clinicians’ conversations
with patients and their families/
caregivers.
• The patient’s nutrition status,
nutrition recommendations, and
other interventions (e.g., ONS,
vitamin and mineral supple-
ments, and access to food), and
the post-discharge nutrition care
plan must be explained by the
clinical care team throughout the
inpatient stay and documented
in the EHR.
• Follow-up nutrition assessment
and education, combined with
specific follow-up appointment
information, must be provided
to the patient and his or her care-
giver at time of discharge.
• Hospitals must develop clear,
standardized written instruc-
tions for nutrition care at home,
including the rationale for and
details on diet instruction and
any recommended ONS, vita-
min and/or mineral supple-
ments that can be given to the
patient and his or her caregiver
upon hospital discharge.
• Nurses who manage patient tran-
sitions at discharge must priori-
tize nutrition within the care
plan. Post-hospitalization phone
May-June 2013 • Vol. 22/No. 3
Without question, nutrition care must be
made a high priority and systematized in
United States hospitals.
calls must be adapted to include
questions about dietary intake,
weight change, and access to
food, with concerns brought to
the dietitian’s attention. Dieti-
tians should be used to manage
post-hospital transitions for
patients who have malnutrition
as a primary or secondary diag-
nosis. Ensuring nutrition care is
part of the transition to home is a
key step in reducing hospital re-
admissions.
Conclusions
With the changing health care
environment, quality patient care
and cost containment are of utmost
importance. Early and automated
nutrition intervention coupled with
clinician collaboration are critical in
remediating the issue of malnutrition
in hospitals and has a strong poten-
tial to improve patient care and
reduce hospital costs. Successful
management of hospital malnutri-
tion requires an interdisciplinary
team approach and leadership that
fosters open communication among
disciplines. To be successful, all mem-
bers of the health care team must
understand the importance of nutri-
tion care in improving patient out-
comes and the financial impact of
failing to address this problem.
Processes must be put into place to
ensure that appropriate nutrition
intervention is provided and
patients’ nutrition status is moni-
tored routinely. Finally, additional
evidence quantifying the value of
nutrition care must be assessed
through broad research efforts, rang-
ing from outcomes research to
prospective randomized controlled
clinical trials. Funding for these ini-
tiatives is needed from institutional,
federal, foundation, and industry
sources. Without question, nutrition
care must be made a high priority
and systematized in United States
hospitals.
This article is a call to action from
the Alliance, challenging hospital-
based clinicians to incorporate the
proposed principles to evoke mean-
ingful improvement in nutrition care
within their institutions. This call
marks a step change in efforts to date
to improve nutrition among hospi-
talized patients. For the first time, it
unites professional organizations in a
common pursuit, to raise awareness
about the problem of hospital mal-
nutrition and make meaningful
progress toward early nutrition inter-
vention and improved hospital treat-
ment practices, with the ultimate
goal of improving quality of care and
reducing costs. To accomplish this
will require interdisciplinary collabo-
ration by dietitians, nurses, and
physicians throughout the continu-
um of care so that patients receive
excellent nutrition care in the hospi-
tal and after discharge.
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ADDITIONAL READING
Singh, H., Watt, K., Veitch, R., Cantor, M., &
Duerksen, D.R. (2006). Malnutrition is
prevalent in hospitalized medical
patients: Are housestaff identifying the
malnourished patient? Nutrition, 22(4),
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165