HOSPITAL MALNUTRITION

Malnutrisi & dampaknya

Julistio Djais, dr., SpA(K), MKes

Pediatric Department – Hasan Sadikin Hospital
Bandung
 Malnutrition (WHO)
the cellular imbalance between the supply of nutrients
and energy and the body’s demand for them to ensure
growth, maintenance, and specific functions

imbalance of nutrients affects children differently than

adults
HOSPITAL MALNUTRITION

Malnutrition upon admission to the hospital

Hospital-acquired malnutrition
nutrient imbalance acquired during hospitalization
and
may occur with or without preexisting malnutrition
NUTRITION TODAY March/April
1974
In 1974 a seminal paper by Dr. Butterworth, "The skeleton in the hospital
closet," shook the medical establishment with dramatically documented
observations of what became known as hospital malnutrition.

Care of patients often developed severe nutritional disorders while in the

hospital.

£ the improvement of the nutritional support of patients and

to the elimination of long-established, ill-conceived hospital practices
conducive to poor nutrition.

The introduction of nutrition support teams, considered to be

indispensable
for good patient care
Malnutrition is associated with many adverse outcomes, including:
an increased risk of pressure ulcers and impaired wound healing,
immune suppression and increased infection rate,
muscle wasting and functional loss increasing the risk of falls,
longer length of hospital stay,
higher readmission rates,
higher treatment costs,
and increased mortality.

Malnutrition places a heavy burden on the patient, clinician, and health care
system
NUTRITION SUPPORT TEAM
ORGANIZATION AND PERSONAL

The organization for delivery of nutrition support varies widely among

hospital throughout USA

Nutrition Support Team structure falls broadly into 2 categories:

Centralized-managerial and Decentralized-consultative

Team members:
Dietitian – Physician – Nurse – Pharmacist

ASPEN Guidelines:
Standards of Practice, Nutrition Support Dietitian
Standards of Practice, Nutrition Support Physician
Standards of Practice, Nutrition Support Nurse
Standards of Practice, Nutrition Support Pharmacist
It is estimated that at least one third of patients in developed
countries have some degree of malnutrition upon admission to the
hospital

and, if left untreated, approximately two thirds of those patients will

experience a further decline in their nutrition status during inpatient
stay.

Unfortunately, despite the availability of validated screening tools,

malnutrition continues to be underrecognized in many hospitals.

Moreover, among patients who are not malnourished upon

admission, approximately one third may become malnourished
while in the hospital.
 ADA Strategic Plan
To Increase demand and utilization of services provided by members and
Empower members to compete successfully in a rapidly changing
environment
Nutrition Care Process (NCP) and Model

when a standardized process is implemented, less

variation and more predictability in terms of outcomes
occur

When providers of care, no matter their location, use a process consistently,

comparable outcomes data can be generated to demonstrate value

A standardized Nutrition Care Process effectively promotes the dietetics

professional
as the unique provider of nutrition care when it is consistently used as a systematic
method to think critically and make decisions to provide safe and effective nutrition
care
The NCP is a roadmap and consists of four separate interconnected steps:
Nutrition Assessment and Reassessment
Nutrition Diagnosis
Nutrition Intervention
Nutrition Monitoring and Evaluation

The four steps are divided into two components:

problem identification and problem solving.

Problem identification includes

Nutrition Assessment and Reassessment (Step 1)
Nutrition Diagnosis (Step 2)

Problem solving includes

Nutrition Intervention (Step 3)
Nutrition Monitoring and Evaluation (Step 4)
IMPACT OF NUTRITION INTERVENTION ON OUTCOMES

Nutrition intervention can be organized into four categories:

(1) food and/or nutrient delivery;
(2) nutrition education;
(3) nutrition counseling, and
(4) coordination of nutrition care.

Food and/or nutrient delivery requires an individualized approach that includes energy-
and nutrient-dense food, complete oral nutrition supplements (ONS); enteral nutrition
(EN); and/or parenteral nutrition (PN).
 SKRINING
HOSPITAL
MALNUTRITIO
PAGT N

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 proactively identify barriers impacting the provision of nutrition care.
malnourished patient unrecognized or are inadequately screened
lack adequate dietitian staffing to properly address all patients
nutrition care is delayed due to the patient’s medical status and time to nutrition consult
nurses provide and oversee patient care, yet they are rarely included in nutrition care
patients experience difficulty consuming meals without assistance, and not finishing
their meals
The identification of 2 or more of the following 6 characteristics is
recommended
for diagnosis:
• Insufficient energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Localized or generalized fluid accumulation that may sometimes mask
weight loss
• Diminished functional status as measured by hand-grip strength
Starvation Related Malnutrition (undernutrition) (NC-4.1.1)
Inadequate intake of protein and/or energy over a period of time sufficient to result in loss of
fat and/or muscle mass without apparent inflammation and in the context of environmental
and/or social circumstances.

Chronic Disease or Condition Related Malnutrition (undernutrition) (NC-4.1.2)

Inadequate intake of protein and/or energy over a period of time sufficient to result in loss of
fat and/or muscle mass with apparent mild to moderate inflammation and in the context of
chronic illness or condition.

Acute Disease or Injury Related Malnutrition (undernutrition) (NC-4.1.3)

Inadequate intake of protein and/or energy resulting in loss of fat and/or muscle mass with
apparent marked inflammatory response and in the context of acute illness or injury.
Non Illness Related Pediatric Malnutrition (NC-4.1.4)
Inadequate nutrient intake due to environmental or behavioral factors which may
negatively affect growth, development, and/or other outcomes.

Illness Related Pediatric Malnutrition (NC-4.1.5)

Nutrient deficit or imbalance due to disease or injury which may negatively affect
growth, development, and/or other outcomes.
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 is critical in remediating
the issue of malnutrition in hospitals and has a strong potential to improve patient care and reduce
hospital costs.

Successful management of hospital malnutrition requires an interdisciplinary team approach and

leadership that fosters open communication among disciplines.

This will require interdisciplinary collaboration by dietitians, nurses, and physicians throughout the
continuum of care so that patients receive excellent nutrition care in the hospital and after discharge.

To be successful, all members of the health care team must understand the importance of nutrition
care in improving patient outcomes 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 routinely monitored.