Malnutrition AlertA Model to Reduce Iatrogenic Malnutrition

Management of Neurological Disorders for the Primary Care Provider

Portland Oregon

November 12 2015

Terese M Scollard MBA RDN LD FAND

Malnutrition is a major contributor to increased morbidity and mortality decreased function and quality of life increased frequency and length of hospital stay and higher health care costs

The views expressed herein are those of the presenter and do not necessarily represent Providence Health and Services The material herein is accurate as of the date it was presented and is for educational purposes only and not intended as a substitute for medical or coding advice

Presenter has no conflict of interest

Statement

2

Learning Objectives

1 Describe the 2012 AcademyASPEN international consensus and characteristics for adult disease related malnutrition and their application in acute and ambulatory care settings

2 Examine updates on the relationship of inflammation serum albumin and relationship to adult disease-related malnutrition

3 Demonstrate how interdisciplinary care is critical to identification screening documentation treatment and avoidance of harmful consequences for adults with disease-related malnutrition

3

httpwwwfightmalnutritioneufileadminimagesmalnutritionConsequences_of_malnutritionJPG accessed 228134

Malnutrition is a major contributor to increased morbidity and mortality decreased function and quality of life increased frequency and length of hospital stay and higher health care costs

The views expressed herein are those of the presenter and do not necessarily represent Providence Health and Services The material herein is accurate as of the date it was presented and is for educational purposes only and not intended as a substitute for medical or coding advice

Presenter has no conflict of interest

Statement

2

Learning Objectives

1 Describe the 2012 AcademyASPEN international consensus and characteristics for adult disease related malnutrition and their application in acute and ambulatory care settings

2 Examine updates on the relationship of inflammation serum albumin and relationship to adult disease-related malnutrition

3 Demonstrate how interdisciplinary care is critical to identification screening documentation treatment and avoidance of harmful consequences for adults with disease-related malnutrition

3

httpwwwfightmalnutritioneufileadminimagesmalnutritionConsequences_of_malnutritionJPG accessed 228134

Learning Objectives

1 Describe the 2012 AcademyASPEN international consensus and characteristics for adult disease related malnutrition and their application in acute and ambulatory care settings

2 Examine updates on the relationship of inflammation serum albumin and relationship to adult disease-related malnutrition

3 Demonstrate how interdisciplinary care is critical to identification screening documentation treatment and avoidance of harmful consequences for adults with disease-related malnutrition

3

httpwwwfightmalnutritioneufileadminimagesmalnutritionConsequences_of_malnutritionJPG accessed 228134

httpwwwfightmalnutritioneufileadminimagesmalnutritionConsequences_of_malnutritionJPG accessed 228134

Nutr Clin Pract October 2010

vol 25 no 5 548-554 5

6

Admitted NG TF start x 4 days

DC wo TF ldquoeating wellrdquo

Met w OP RD average 300cald

PEG gravity feed started

ED MD ldquowell developed well nourishedrdquo

Initial wt end of ~June 214Oct (4 months later) 174 ~18 weight loss 39 lbsShaking weakness no appetite nausea

PEG recommended by OP RD

Chemo amp Rad Onccompleted 87

Onc MD changed assessment to malnourished

Krausersquos Food and the Nutrition Care Process 13th ed L Mahan S Escott Stump J Raymond P 132 7

Words that Describe MalnutritionNutritional Anasarca

AthrepsiaAtrepsy

Nutritional AtrophySevere Calorie Deficiency

Protein DeficiencyMultiple Deficiency Syndrome

Protein DeprivationArested Development due to Malnutrition

Wasting DiseaseNutritional Dwarfism

Famine EdemaInanition Edema

Starvation EdemaEmaciation

Nutritional HydropsHypoproteinosis

Inanition with edemaInanition due to malnutrition

Malnutrition degree 1st 2nd 3rd mild moderate severeProtein Calorie Malnutrition NEC

Protein Calorie Severe NECProtein Calorie due to specified underlying condition

PediatrophiaPluricarential syndrome of infancy

Plurideficiency syndrome of infancyPolycarential syndrome of infancy

PrekwashiorkorGrowth retardation due to malnutritionPhysical retardation due to malnutrition

KwashiorkorMarasmus

Adult KwashiorkorHypoalbuminemic MalnutritionHypoproteinemic malnutrition

Combined Malnutrition

8

+= International Consensus

Guideline Committee

httpswwwnutritioncareorgProfessional_ResourcesGuidelines_and_StandardsGuidelines2010__Adult_Starvation_and_Disease-Related_Malnutrition

Etiology ndash based approach that incorporates understanding of the inflammatory response

9

6

Admitted NG TF start x 4 days

DC wo TF ldquoeating wellrdquo

Met w OP RD average 300cald

PEG gravity feed started

ED MD ldquowell developed well nourishedrdquo

Initial wt end of ~June 214Oct (4 months later) 174 ~18 weight loss 39 lbsShaking weakness no appetite nausea

PEG recommended by OP RD

Chemo amp Rad Onccompleted 87

Onc MD changed assessment to malnourished

Krausersquos Food and the Nutrition Care Process 13th ed L Mahan S Escott Stump J Raymond P 132 7

Words that Describe MalnutritionNutritional Anasarca

AthrepsiaAtrepsy

Nutritional AtrophySevere Calorie Deficiency

Protein DeficiencyMultiple Deficiency Syndrome

Protein DeprivationArested Development due to Malnutrition

Wasting DiseaseNutritional Dwarfism

Famine EdemaInanition Edema

Starvation EdemaEmaciation

Nutritional HydropsHypoproteinosis

Inanition with edemaInanition due to malnutrition

Malnutrition degree 1st 2nd 3rd mild moderate severeProtein Calorie Malnutrition NEC

Protein Calorie Severe NECProtein Calorie due to specified underlying condition

PediatrophiaPluricarential syndrome of infancy

Plurideficiency syndrome of infancyPolycarential syndrome of infancy

PrekwashiorkorGrowth retardation due to malnutritionPhysical retardation due to malnutrition

KwashiorkorMarasmus

Adult KwashiorkorHypoalbuminemic MalnutritionHypoproteinemic malnutrition

Combined Malnutrition

8

+= International Consensus

Guideline Committee

httpswwwnutritioncareorgProfessional_ResourcesGuidelines_and_StandardsGuidelines2010__Adult_Starvation_and_Disease-Related_Malnutrition

Etiology ndash based approach that incorporates understanding of the inflammatory response

9

Krausersquos Food and the Nutrition Care Process 13th ed L Mahan S Escott Stump J Raymond P 132 7

Words that Describe MalnutritionNutritional Anasarca

AthrepsiaAtrepsy

Nutritional AtrophySevere Calorie Deficiency

Protein DeficiencyMultiple Deficiency Syndrome

Protein DeprivationArested Development due to Malnutrition

Wasting DiseaseNutritional Dwarfism

Famine EdemaInanition Edema

Starvation EdemaEmaciation

Nutritional HydropsHypoproteinosis

Inanition with edemaInanition due to malnutrition

Malnutrition degree 1st 2nd 3rd mild moderate severeProtein Calorie Malnutrition NEC

Protein Calorie Severe NECProtein Calorie due to specified underlying condition

PediatrophiaPluricarential syndrome of infancy

Plurideficiency syndrome of infancyPolycarential syndrome of infancy

PrekwashiorkorGrowth retardation due to malnutritionPhysical retardation due to malnutrition

KwashiorkorMarasmus

Adult KwashiorkorHypoalbuminemic MalnutritionHypoproteinemic malnutrition

Combined Malnutrition

8

+= International Consensus

Guideline Committee

httpswwwnutritioncareorgProfessional_ResourcesGuidelines_and_StandardsGuidelines2010__Adult_Starvation_and_Disease-Related_Malnutrition

Etiology ndash based approach that incorporates understanding of the inflammatory response

9

Words that Describe MalnutritionNutritional Anasarca

AthrepsiaAtrepsy

Nutritional AtrophySevere Calorie Deficiency

Protein DeficiencyMultiple Deficiency Syndrome

Protein DeprivationArested Development due to Malnutrition

Wasting DiseaseNutritional Dwarfism

Famine EdemaInanition Edema

Starvation EdemaEmaciation

Nutritional HydropsHypoproteinosis

Inanition with edemaInanition due to malnutrition

Malnutrition degree 1st 2nd 3rd mild moderate severeProtein Calorie Malnutrition NEC

Protein Calorie Severe NECProtein Calorie due to specified underlying condition

PediatrophiaPluricarential syndrome of infancy

Plurideficiency syndrome of infancyPolycarential syndrome of infancy

PrekwashiorkorGrowth retardation due to malnutritionPhysical retardation due to malnutrition

KwashiorkorMarasmus

Adult KwashiorkorHypoalbuminemic MalnutritionHypoproteinemic malnutrition

Combined Malnutrition

8

+= International Consensus

Guideline Committee

httpswwwnutritioncareorgProfessional_ResourcesGuidelines_and_StandardsGuidelines2010__Adult_Starvation_and_Disease-Related_Malnutrition

Etiology ndash based approach that incorporates understanding of the inflammatory response

9

+= International Consensus

Guideline Committee

httpswwwnutritioncareorgProfessional_ResourcesGuidelines_and_StandardsGuidelines2010__Adult_Starvation_and_Disease-Related_Malnutrition

Etiology ndash based approach that incorporates understanding of the inflammatory response

9

Disease-related Malnutrition

ldquohellipdecline in lean body mass with the potential for functional impairment at multiple levelsmdashie molecular physiologic andor gross motorrdquo

Jensen GL Bistrian B Roubenoff R Heimburger DC Malnutrition syndromes A conundrum vs continuum JPEN J Parenter Enteral Nutr 200933(6)710-716

ldquoHistoric definitions for malnutrition syndromes have promoted widespread confusion and misdiagnosis They also do not encompass a modern understanding of the role of inflammatory responserdquo

Gordon Jensen MD PhD Past-President ASPEN Professor and Head Department of Nutritional Sciences the Penn State University 2010 httpswwwnutritioncareorgIndexaspxid=4792 accessed 5162013

10

Etiology Based Malnutrition Definitions

11

YesMild to Moderate

Degree

YesMarked

Inflammatory Response

No

Nutritional Risk Identified

Compromised intake or loss of body mass

Inflammation present No Yes

Starvation Related Malnutrition

(pure chronic starvation anorexia nervosa)

Chronic Disease ndash Related Malnutrition

(organ failure pancreatic cancer rheumatoid arthritis

sarcopenic obesity)

Acute Disease or Injury-Related Malnutrition

(major infection burns trauma closed head injury)

Jensen GL JPEN 20093371011

Nutrition Risk Screeningbull Determines at-risk patients

bullIn all settings of care or targeted patient populations

bullMultiple validated tools are available

bullMany facilities have not updated to validated tools (tools tested in EHR)

bullCompliance with Joint Commission and CMS admission screening to hospital

12

predict the probability of a better or worse outcome due to nutritional factors and whether nutritional treatment is likely to influence this Outcome from treatment may be assessed in a number of waysImprovement or at least prevention of deterioration in mental and physical functionReduced number or severity of complications of disease or its treatmentAccelerated recovery from disease and shortened convalescenceReduced consumption of resources eg LOS and other prescriptions

httpwwwncbinlmnihgovpmcarticlesPMC2964075 ClinEpidemiol 2010 2 209ndash216Published online 2010 Oct 21 doi 102147CLEPS11265PMCID PMC2964075Measuring nutritional risk in hospitalsHenrik H Rasmussen

Nutrition Risk Screeningbull Determines at-risk patients

bullIn all settings of care or targeted patient populations

bullMultiple validated tools are available

bullMany facilities have not updated to validated tools (tools tested in EHR)

bullCompliance with Joint Commission and CMS admission screening to hospital

12

predict the probability of a better or worse outcome due to nutritional factors and whether nutritional treatment is likely to influence this Outcome from treatment may be assessed in a number of waysImprovement or at least prevention of deterioration in mental and physical functionReduced number or severity of complications of disease or its treatmentAccelerated recovery from disease and shortened convalescenceReduced consumption of resources eg LOS and other prescriptions

httpwwwncbinlmnihgovpmcarticlesPMC2964075 ClinEpidemiol 2010 2 209ndash216Published online 2010 Oct 21 doi 102147CLEPS11265PMCID PMC2964075Measuring nutritional risk in hospitalsHenrik H Rasmussen

Etiology Based Malnutrition Definitions

13

YesMild to Moderate

Degree

YesMarked

Inflammatory Response

No

Nutritional Risk Identified

Compromised intake or loss of body mass

Inflammation present No Yes

Starvation Related Malnutrition

(pure chronic starvation anorexia nervosa)

Chronic Disease ndash Related Malnutrition

(organ failure pancreatic cancer rheumatoid arthritis

sarcopenic obesity)

Acute Disease or Injury-Related Malnutrition

(major infection burns trauma closed head injury)

Jensen GL JPEN 20093371013

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

14

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

14

httpwwwepiumneducvdepivideoaspid=4047

Starvation-Related Malnutrition in Adults

(Malnutrition of social or environmental circumstances)

Figure 1 Hypothetical relationship of Starvation-related Malnutrition (top graph) and Disease-related Malnutrition (bottom graph) assuming the inflammatory condition is relatively constant with changes in lean body mass Jensen G L et al JPEN J Parenter Enteral Nutr 201034156-159

Hypothetical relationship ndashStarvation Related Malnutrition w amp wo Nutritional Support

SRM = Starvation Related Malnutrition NS = Nutritional SupportPSRM = Partial Starvation Related Malnutrition

16

Etiology Based Malnutrition Definitions

17

YesMild to Moderate

Degree

YesMarked

Inflammatory Response

No

Nutritional Risk Identified

Compromised intake or loss of body mass

Inflammation present No Yes

Starvation Related Malnutrition

(pure chronic starvation anorexia nervosa)

Chronic Disease ndash Related Malnutrition

(organ failure pancreatic cancer rheumatoid arthritis

sarcopenic obesity)

Acute Disease or Injury-Related Malnutrition

(major infection burns trauma closed head injury)

Jensen GL JPEN 20093371017

Chronic Disease-Related Malnutrition

(organ failure pancreatic cancer rheumatoid arthritis sarcopenic obesity)

amp

Acute Disease or Injury-Related Malnutrition

(major infection burns trauma closed head injury)

bull Immune changes especially cellular immunity

bull Muscle and organ changes-reduction in mass and function

bull GI changesbull Gut damaged by

bull Decrease in mesenteric blood flow-operations proceduresbull Altered mucous bull Altered acid and bile secretion bull Altered gut motility bull Damaged villi bull Enzyme decrease

18

Figure 1 Hypothetical relationship of Starvation-related Malnutrition (top graph) and Disease-related Malnutrition (bottom graph) assuming the inflammatory condition is relatively constant with changes in lean body mass Jensen G L et al JPEN J ParenterEnteral Nutr 201034156-159

Hypothetical Relationship Acute or Chronic Disease or Injury-Related Malnutrition

19

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

20

Etiology Based Malnutrition Definitions

17

YesMild to Moderate

Degree

YesMarked

Inflammatory Response

No

Nutritional Risk Identified

Compromised intake or loss of body mass

Inflammation present No Yes

Starvation Related Malnutrition

(pure chronic starvation anorexia nervosa)

Chronic Disease ndash Related Malnutrition

(organ failure pancreatic cancer rheumatoid arthritis

sarcopenic obesity)

Acute Disease or Injury-Related Malnutrition

(major infection burns trauma closed head injury)

Jensen GL JPEN 20093371017

Chronic Disease-Related Malnutrition

(organ failure pancreatic cancer rheumatoid arthritis sarcopenic obesity)

amp

Acute Disease or Injury-Related Malnutrition

(major infection burns trauma closed head injury)

bull Immune changes especially cellular immunity

bull Muscle and organ changes-reduction in mass and function

bull GI changesbull Gut damaged by

bull Decrease in mesenteric blood flow-operations proceduresbull Altered mucous bull Altered acid and bile secretion bull Altered gut motility bull Damaged villi bull Enzyme decrease

18

Figure 1 Hypothetical relationship of Starvation-related Malnutrition (top graph) and Disease-related Malnutrition (bottom graph) assuming the inflammatory condition is relatively constant with changes in lean body mass Jensen G L et al JPEN J ParenterEnteral Nutr 201034156-159

Hypothetical Relationship Acute or Chronic Disease or Injury-Related Malnutrition

19

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

20

Chronic Disease-Related Malnutrition

(organ failure pancreatic cancer rheumatoid arthritis sarcopenic obesity)

amp

Acute Disease or Injury-Related Malnutrition

(major infection burns trauma closed head injury)

bull Immune changes especially cellular immunity

bull Muscle and organ changes-reduction in mass and function

bull GI changesbull Gut damaged by

bull Decrease in mesenteric blood flow-operations proceduresbull Altered mucous bull Altered acid and bile secretion bull Altered gut motility bull Damaged villi bull Enzyme decrease

18

Figure 1 Hypothetical relationship of Starvation-related Malnutrition (top graph) and Disease-related Malnutrition (bottom graph) assuming the inflammatory condition is relatively constant with changes in lean body mass Jensen G L et al JPEN J ParenterEnteral Nutr 201034156-159

Hypothetical Relationship Acute or Chronic Disease or Injury-Related Malnutrition

19

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

20

Figure 1 Hypothetical relationship of Starvation-related Malnutrition (top graph) and Disease-related Malnutrition (bottom graph) assuming the inflammatory condition is relatively constant with changes in lean body mass Jensen G L et al JPEN J ParenterEnteral Nutr 201034156-159

Hypothetical Relationship Acute or Chronic Disease or Injury-Related Malnutrition

19

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

20

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

20

Inflammation

Promotes

bull Metabolic dysregulation

bull Hyperglycemia

bull Decreased visceral proteins

bull Muscle catabolism

bull Edema

bull Anorexia

bull Malaise deconditioning

Can Blunt

Favorable responses to nutrition intervention

21Gordon Jensen MD PhD 2011 ADA Food amp Nutrition Conference and Expo

Why not serum albuminvisceral proteins

bullInflammatory disease illness injury elicit a cytokine-mediated acute phase response

ndash Alters hormone secretion and target organ function

ndash Favors a catabolic state that results in metabolic alterations

bull Over the short run the acute phase metabolic response with resulting catabolism is likely an appropriate adaptive response

bull If the underlying stressor is severe protracted or repeated then adverse outcomes will result

Academy of Nutrition and Dietetics Evidence Analysis Library AlbuminPrealbumin

Gordon Jensen MD PhD22

Inflammation can blunt favorable responses to nutrition intervention

Nutrition alone is ineffective in preventing muscle loss in inflammation

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

Complications relative to loss of lean body mass

23

Why not serum albuminvisceral proteins

bullInflammatory disease illness injury elicit a cytokine-mediated acute phase response

ndash Alters hormone secretion and target organ function

ndash Favors a catabolic state that results in metabolic alterations

bull Over the short run the acute phase metabolic response with resulting catabolism is likely an appropriate adaptive response

bull If the underlying stressor is severe protracted or repeated then adverse outcomes will result

Academy of Nutrition and Dietetics Evidence Analysis Library AlbuminPrealbumin

Gordon Jensen MD PhD22

Inflammation can blunt favorable responses to nutrition intervention

Nutrition alone is ineffective in preventing muscle loss in inflammation

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

Complications relative to loss of lean body mass

23

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

Complications relative to loss of lean body mass

23

24Stuart M Phillips PhD FACN FACSM Professor McMaster University Ontario Canada presentation 9232014

74 year old sedentary man 70 year old tri-athlete

Muscle loss in Aging Protein and Exercise Needed

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

Priority for Protein Intake vs Loss of Lean Tissue

25

Nutrition Anabolism and the Wound Healing Process An Overview Robert H Demling MD ePlasty 2009965-94 httpwwwmedscapecomviewarticle711879_print accessed 4262013

Priority for Protein Intake vs Loss of Lean Tissue

25

Muscle Mass and Function in Malnutrition

bull Reduction in Muscle Mass

bull Reduction in Muscle Functionbull Muscle function is sensitive to reduction in nutritional

intake even before any change in muscle mass occursbull Heartbull Respiratory musclebull Hand grip strength

Stratton Elia Disease-Related Malnutrition an Evidence-Based Approach to Treatment p 11626

27

Lean Body Mass Loss with Age and Hospitalization D Paddon-Jones PhD 32014 NY Academy of Sciences

Paddon-Jones D Sheffield-Moore M Cree MG et al Atrophy and impaired muscle protein synthesis during prolonged inactivity and

stress J Clin Endocrinol Metab 2006914836-4841

28

29

Rationale for Developing AcademyASPEN Malnutrition DiagnosesMarkers

bull No standardization

bull Multiple Definitions

bull Multiple Diagnostic (ICD-9) Codes

bull Multiple characteristics used to diagnose

bull Limited evidence base

bull Emerging role of inflammation

ndash Influence on Assessment Parameters

ndash Influence on Response to Nutrition intervention

ndash Anti-inflammatory Interventions Nutrition interventions outcomes divergence

30

31

A Bridge to a Unified System

Adult Malnutrition- Clinical presentation- Will change- Altered Metabolic Status- Treatment specific to pre-disposing factors

-Starvation -Chronic disease -Acute disease or injury

Tool to Bridge - Academy amp ASPEN Consensus- Reasonable amp reliable literature and research-based criteria at this time- Will change with further clinical understanding - NOT the ldquobe-all end-allrsquo criteria for adult malnutrition

ICD Classification - A system to categorize and communicate adult malnutrition- Allows for benchmarking prevalence

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 2012 American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics 52012

Consensus Statement Characteristics

Recommended for the Identification and

Documentation of Adult Malnutrition

32

ICD-9 Codes ndash Two Levels of Severity

262 - Other Severe Protein Calorie Malnutrition2630 ndash Malnutrition of a Moderate Degree

Three Typical Etiologies

Acute IllnessInjury ndash severe acute inflammation

Chronic Illness ndash mild to moderate chronic inflammation

SocialEnvironmental Circumstances ndash without inflammation

Six Characteristics

Weight Loss

Insufficient Energy Intake

Loss of Subcutaneous Fat

Loss of Muscle Mass

Localize or Generalized Fluid Accumulation

Diminished Functional Status - measured by hand grip strength

2015 ICD-9-CM American Medical Association 33

262 Severe Malnutrition in Adults J Acad Nutr Diet 2012112(5) 730-738

For ExampleICD-9 Code 262

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Lossgt21 week

gt51 month gt753 months

gt51 month gt753 months gt106 months gt 201 year

gt51 month gt753 months gt106 months

gt 201 year

Energy Intake lt 50 for gt 5 days lt 75 for gt 1 month lt 50 for gt 1 month

Body Fat Moderate Depletion Severe Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion Severe Depletion

Fluid Accumulation Moderate Severe Severe Severe

Hand Grip Strength Not Recommended in ICU Reduced for AgeGender Reduced for AgeGender

2015 ICD-9-CM American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 34

For ExampleICD-9 Code 2630

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss1-21 week 51 month

753 months

51 month753 months106 months

201 year

51 month 753 months 106 months

201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2015 ICD-9-CM American Medical Association

2630 Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 523201235

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

27

Lean Body Mass Loss with Age and Hospitalization D Paddon-Jones PhD 32014 NY Academy of Sciences

Paddon-Jones D Sheffield-Moore M Cree MG et al Atrophy and impaired muscle protein synthesis during prolonged inactivity and

stress J Clin Endocrinol Metab 2006914836-4841

28

29

Rationale for Developing AcademyASPEN Malnutrition DiagnosesMarkers

bull No standardization

bull Multiple Definitions

bull Multiple Diagnostic (ICD-9) Codes

bull Multiple characteristics used to diagnose

bull Limited evidence base

bull Emerging role of inflammation

ndash Influence on Assessment Parameters

ndash Influence on Response to Nutrition intervention

ndash Anti-inflammatory Interventions Nutrition interventions outcomes divergence

30

31

A Bridge to a Unified System

Adult Malnutrition- Clinical presentation- Will change- Altered Metabolic Status- Treatment specific to pre-disposing factors

-Starvation -Chronic disease -Acute disease or injury

Tool to Bridge - Academy amp ASPEN Consensus- Reasonable amp reliable literature and research-based criteria at this time- Will change with further clinical understanding - NOT the ldquobe-all end-allrsquo criteria for adult malnutrition

ICD Classification - A system to categorize and communicate adult malnutrition- Allows for benchmarking prevalence

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 2012 American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics 52012

Consensus Statement Characteristics

Recommended for the Identification and

Documentation of Adult Malnutrition

32

ICD-9 Codes ndash Two Levels of Severity

262 - Other Severe Protein Calorie Malnutrition2630 ndash Malnutrition of a Moderate Degree

Three Typical Etiologies

Acute IllnessInjury ndash severe acute inflammation

Chronic Illness ndash mild to moderate chronic inflammation

SocialEnvironmental Circumstances ndash without inflammation

Six Characteristics

Weight Loss

Insufficient Energy Intake

Loss of Subcutaneous Fat

Loss of Muscle Mass

Localize or Generalized Fluid Accumulation

Diminished Functional Status - measured by hand grip strength

2015 ICD-9-CM American Medical Association 33

262 Severe Malnutrition in Adults J Acad Nutr Diet 2012112(5) 730-738

For ExampleICD-9 Code 262

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Lossgt21 week

gt51 month gt753 months

gt51 month gt753 months gt106 months gt 201 year

gt51 month gt753 months gt106 months

gt 201 year

Energy Intake lt 50 for gt 5 days lt 75 for gt 1 month lt 50 for gt 1 month

Body Fat Moderate Depletion Severe Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion Severe Depletion

Fluid Accumulation Moderate Severe Severe Severe

Hand Grip Strength Not Recommended in ICU Reduced for AgeGender Reduced for AgeGender

2015 ICD-9-CM American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 34

For ExampleICD-9 Code 2630

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss1-21 week 51 month

753 months

51 month753 months106 months

201 year

51 month 753 months 106 months

201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2015 ICD-9-CM American Medical Association

2630 Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 523201235

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

28

29

Rationale for Developing AcademyASPEN Malnutrition DiagnosesMarkers

bull No standardization

bull Multiple Definitions

bull Multiple Diagnostic (ICD-9) Codes

bull Multiple characteristics used to diagnose

bull Limited evidence base

bull Emerging role of inflammation

ndash Influence on Assessment Parameters

ndash Influence on Response to Nutrition intervention

ndash Anti-inflammatory Interventions Nutrition interventions outcomes divergence

30

31

A Bridge to a Unified System

Adult Malnutrition- Clinical presentation- Will change- Altered Metabolic Status- Treatment specific to pre-disposing factors

-Starvation -Chronic disease -Acute disease or injury

Tool to Bridge - Academy amp ASPEN Consensus- Reasonable amp reliable literature and research-based criteria at this time- Will change with further clinical understanding - NOT the ldquobe-all end-allrsquo criteria for adult malnutrition

ICD Classification - A system to categorize and communicate adult malnutrition- Allows for benchmarking prevalence

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 2012 American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics 52012

Consensus Statement Characteristics

Recommended for the Identification and

Documentation of Adult Malnutrition

32

ICD-9 Codes ndash Two Levels of Severity

262 - Other Severe Protein Calorie Malnutrition2630 ndash Malnutrition of a Moderate Degree

Three Typical Etiologies

Acute IllnessInjury ndash severe acute inflammation

Chronic Illness ndash mild to moderate chronic inflammation

SocialEnvironmental Circumstances ndash without inflammation

Six Characteristics

Weight Loss

Insufficient Energy Intake

Loss of Subcutaneous Fat

Loss of Muscle Mass

Localize or Generalized Fluid Accumulation

Diminished Functional Status - measured by hand grip strength

2015 ICD-9-CM American Medical Association 33

262 Severe Malnutrition in Adults J Acad Nutr Diet 2012112(5) 730-738

For ExampleICD-9 Code 262

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Lossgt21 week

gt51 month gt753 months

gt51 month gt753 months gt106 months gt 201 year

gt51 month gt753 months gt106 months

gt 201 year

Energy Intake lt 50 for gt 5 days lt 75 for gt 1 month lt 50 for gt 1 month

Body Fat Moderate Depletion Severe Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion Severe Depletion

Fluid Accumulation Moderate Severe Severe Severe

Hand Grip Strength Not Recommended in ICU Reduced for AgeGender Reduced for AgeGender

2015 ICD-9-CM American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 34

For ExampleICD-9 Code 2630

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss1-21 week 51 month

753 months

51 month753 months106 months

201 year

51 month 753 months 106 months

201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2015 ICD-9-CM American Medical Association

2630 Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 523201235

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

29

Rationale for Developing AcademyASPEN Malnutrition DiagnosesMarkers

bull No standardization

bull Multiple Definitions

bull Multiple Diagnostic (ICD-9) Codes

bull Multiple characteristics used to diagnose

bull Limited evidence base

bull Emerging role of inflammation

ndash Influence on Assessment Parameters

ndash Influence on Response to Nutrition intervention

ndash Anti-inflammatory Interventions Nutrition interventions outcomes divergence

30

31

A Bridge to a Unified System

Adult Malnutrition- Clinical presentation- Will change- Altered Metabolic Status- Treatment specific to pre-disposing factors

-Starvation -Chronic disease -Acute disease or injury

Tool to Bridge - Academy amp ASPEN Consensus- Reasonable amp reliable literature and research-based criteria at this time- Will change with further clinical understanding - NOT the ldquobe-all end-allrsquo criteria for adult malnutrition

ICD Classification - A system to categorize and communicate adult malnutrition- Allows for benchmarking prevalence

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 2012 American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics 52012

Consensus Statement Characteristics

Recommended for the Identification and

Documentation of Adult Malnutrition

32

ICD-9 Codes ndash Two Levels of Severity

262 - Other Severe Protein Calorie Malnutrition2630 ndash Malnutrition of a Moderate Degree

Three Typical Etiologies

Acute IllnessInjury ndash severe acute inflammation

Chronic Illness ndash mild to moderate chronic inflammation

SocialEnvironmental Circumstances ndash without inflammation

Six Characteristics

Weight Loss

Insufficient Energy Intake

Loss of Subcutaneous Fat

Loss of Muscle Mass

Localize or Generalized Fluid Accumulation

Diminished Functional Status - measured by hand grip strength

2015 ICD-9-CM American Medical Association 33

262 Severe Malnutrition in Adults J Acad Nutr Diet 2012112(5) 730-738

For ExampleICD-9 Code 262

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Lossgt21 week

gt51 month gt753 months

gt51 month gt753 months gt106 months gt 201 year

gt51 month gt753 months gt106 months

gt 201 year

Energy Intake lt 50 for gt 5 days lt 75 for gt 1 month lt 50 for gt 1 month

Body Fat Moderate Depletion Severe Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion Severe Depletion

Fluid Accumulation Moderate Severe Severe Severe

Hand Grip Strength Not Recommended in ICU Reduced for AgeGender Reduced for AgeGender

2015 ICD-9-CM American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 34

For ExampleICD-9 Code 2630

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss1-21 week 51 month

753 months

51 month753 months106 months

201 year

51 month 753 months 106 months

201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2015 ICD-9-CM American Medical Association

2630 Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 523201235

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

Rationale for Developing AcademyASPEN Malnutrition DiagnosesMarkers

bull No standardization

bull Multiple Definitions

bull Multiple Diagnostic (ICD-9) Codes

bull Multiple characteristics used to diagnose

bull Limited evidence base

bull Emerging role of inflammation

ndash Influence on Assessment Parameters

ndash Influence on Response to Nutrition intervention

ndash Anti-inflammatory Interventions Nutrition interventions outcomes divergence

30

31

A Bridge to a Unified System

Adult Malnutrition- Clinical presentation- Will change- Altered Metabolic Status- Treatment specific to pre-disposing factors

-Starvation -Chronic disease -Acute disease or injury

Tool to Bridge - Academy amp ASPEN Consensus- Reasonable amp reliable literature and research-based criteria at this time- Will change with further clinical understanding - NOT the ldquobe-all end-allrsquo criteria for adult malnutrition

ICD Classification - A system to categorize and communicate adult malnutrition- Allows for benchmarking prevalence

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 2012 American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics 52012

Consensus Statement Characteristics

Recommended for the Identification and

Documentation of Adult Malnutrition

32

ICD-9 Codes ndash Two Levels of Severity

262 - Other Severe Protein Calorie Malnutrition2630 ndash Malnutrition of a Moderate Degree

Three Typical Etiologies

Acute IllnessInjury ndash severe acute inflammation

Chronic Illness ndash mild to moderate chronic inflammation

SocialEnvironmental Circumstances ndash without inflammation

Six Characteristics

Weight Loss

Insufficient Energy Intake

Loss of Subcutaneous Fat

Loss of Muscle Mass

Localize or Generalized Fluid Accumulation

Diminished Functional Status - measured by hand grip strength

2015 ICD-9-CM American Medical Association 33

262 Severe Malnutrition in Adults J Acad Nutr Diet 2012112(5) 730-738

For ExampleICD-9 Code 262

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Lossgt21 week

gt51 month gt753 months

gt51 month gt753 months gt106 months gt 201 year

gt51 month gt753 months gt106 months

gt 201 year

Energy Intake lt 50 for gt 5 days lt 75 for gt 1 month lt 50 for gt 1 month

Body Fat Moderate Depletion Severe Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion Severe Depletion

Fluid Accumulation Moderate Severe Severe Severe

Hand Grip Strength Not Recommended in ICU Reduced for AgeGender Reduced for AgeGender

2015 ICD-9-CM American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 34

For ExampleICD-9 Code 2630

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss1-21 week 51 month

753 months

51 month753 months106 months

201 year

51 month 753 months 106 months

201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2015 ICD-9-CM American Medical Association

2630 Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 523201235

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

31

A Bridge to a Unified System

Adult Malnutrition- Clinical presentation- Will change- Altered Metabolic Status- Treatment specific to pre-disposing factors

-Starvation -Chronic disease -Acute disease or injury

Tool to Bridge - Academy amp ASPEN Consensus- Reasonable amp reliable literature and research-based criteria at this time- Will change with further clinical understanding - NOT the ldquobe-all end-allrsquo criteria for adult malnutrition

ICD Classification - A system to categorize and communicate adult malnutrition- Allows for benchmarking prevalence

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 2012 American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics 52012

Consensus Statement Characteristics

Recommended for the Identification and

Documentation of Adult Malnutrition

32

ICD-9 Codes ndash Two Levels of Severity

262 - Other Severe Protein Calorie Malnutrition2630 ndash Malnutrition of a Moderate Degree

Three Typical Etiologies

Acute IllnessInjury ndash severe acute inflammation

Chronic Illness ndash mild to moderate chronic inflammation

SocialEnvironmental Circumstances ndash without inflammation

Six Characteristics

Weight Loss

Insufficient Energy Intake

Loss of Subcutaneous Fat

Loss of Muscle Mass

Localize or Generalized Fluid Accumulation

Diminished Functional Status - measured by hand grip strength

2015 ICD-9-CM American Medical Association 33

262 Severe Malnutrition in Adults J Acad Nutr Diet 2012112(5) 730-738

For ExampleICD-9 Code 262

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Lossgt21 week

gt51 month gt753 months

gt51 month gt753 months gt106 months gt 201 year

gt51 month gt753 months gt106 months

gt 201 year

Energy Intake lt 50 for gt 5 days lt 75 for gt 1 month lt 50 for gt 1 month

Body Fat Moderate Depletion Severe Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion Severe Depletion

Fluid Accumulation Moderate Severe Severe Severe

Hand Grip Strength Not Recommended in ICU Reduced for AgeGender Reduced for AgeGender

2015 ICD-9-CM American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 34

For ExampleICD-9 Code 2630

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss1-21 week 51 month

753 months

51 month753 months106 months

201 year

51 month 753 months 106 months

201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2015 ICD-9-CM American Medical Association

2630 Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 523201235

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

A Bridge to a Unified System

Adult Malnutrition- Clinical presentation- Will change- Altered Metabolic Status- Treatment specific to pre-disposing factors

-Starvation -Chronic disease -Acute disease or injury

Tool to Bridge - Academy amp ASPEN Consensus- Reasonable amp reliable literature and research-based criteria at this time- Will change with further clinical understanding - NOT the ldquobe-all end-allrsquo criteria for adult malnutrition

ICD Classification - A system to categorize and communicate adult malnutrition- Allows for benchmarking prevalence

2012 ICD-9-CM Physician Volumes 1 and 2 American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 2012 American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics 52012

Consensus Statement Characteristics

Recommended for the Identification and

Documentation of Adult Malnutrition

32

ICD-9 Codes ndash Two Levels of Severity

262 - Other Severe Protein Calorie Malnutrition2630 ndash Malnutrition of a Moderate Degree

Three Typical Etiologies

Acute IllnessInjury ndash severe acute inflammation

Chronic Illness ndash mild to moderate chronic inflammation

SocialEnvironmental Circumstances ndash without inflammation

Six Characteristics

Weight Loss

Insufficient Energy Intake

Loss of Subcutaneous Fat

Loss of Muscle Mass

Localize or Generalized Fluid Accumulation

Diminished Functional Status - measured by hand grip strength

2015 ICD-9-CM American Medical Association 33

262 Severe Malnutrition in Adults J Acad Nutr Diet 2012112(5) 730-738

For ExampleICD-9 Code 262

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Lossgt21 week

gt51 month gt753 months

gt51 month gt753 months gt106 months gt 201 year

gt51 month gt753 months gt106 months

gt 201 year

Energy Intake lt 50 for gt 5 days lt 75 for gt 1 month lt 50 for gt 1 month

Body Fat Moderate Depletion Severe Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion Severe Depletion

Fluid Accumulation Moderate Severe Severe Severe

Hand Grip Strength Not Recommended in ICU Reduced for AgeGender Reduced for AgeGender

2015 ICD-9-CM American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 34

For ExampleICD-9 Code 2630

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss1-21 week 51 month

753 months

51 month753 months106 months

201 year

51 month 753 months 106 months

201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2015 ICD-9-CM American Medical Association

2630 Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 523201235

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

ICD-9 Codes ndash Two Levels of Severity

262 - Other Severe Protein Calorie Malnutrition2630 ndash Malnutrition of a Moderate Degree

Three Typical Etiologies

Acute IllnessInjury ndash severe acute inflammation

Chronic Illness ndash mild to moderate chronic inflammation

SocialEnvironmental Circumstances ndash without inflammation

Six Characteristics

Weight Loss

Insufficient Energy Intake

Loss of Subcutaneous Fat

Loss of Muscle Mass

Localize or Generalized Fluid Accumulation

Diminished Functional Status - measured by hand grip strength

2015 ICD-9-CM American Medical Association 33

262 Severe Malnutrition in Adults J Acad Nutr Diet 2012112(5) 730-738

For ExampleICD-9 Code 262

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Lossgt21 week

gt51 month gt753 months

gt51 month gt753 months gt106 months gt 201 year

gt51 month gt753 months gt106 months

gt 201 year

Energy Intake lt 50 for gt 5 days lt 75 for gt 1 month lt 50 for gt 1 month

Body Fat Moderate Depletion Severe Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion Severe Depletion

Fluid Accumulation Moderate Severe Severe Severe

Hand Grip Strength Not Recommended in ICU Reduced for AgeGender Reduced for AgeGender

2015 ICD-9-CM American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 34

For ExampleICD-9 Code 2630

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss1-21 week 51 month

753 months

51 month753 months106 months

201 year

51 month 753 months 106 months

201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2015 ICD-9-CM American Medical Association

2630 Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 523201235

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

262 Severe Malnutrition in Adults J Acad Nutr Diet 2012112(5) 730-738

For ExampleICD-9 Code 262

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Lossgt21 week

gt51 month gt753 months

gt51 month gt753 months gt106 months gt 201 year

gt51 month gt753 months gt106 months

gt 201 year

Energy Intake lt 50 for gt 5 days lt 75 for gt 1 month lt 50 for gt 1 month

Body Fat Moderate Depletion Severe Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion Severe Depletion

Fluid Accumulation Moderate Severe Severe Severe

Hand Grip Strength Not Recommended in ICU Reduced for AgeGender Reduced for AgeGender

2015 ICD-9-CM American Medical AssociationFrom Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 5232012 34

For ExampleICD-9 Code 2630

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss1-21 week 51 month

753 months

51 month753 months106 months

201 year

51 month 753 months 106 months

201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2015 ICD-9-CM American Medical Association

2630 Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 523201235

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

For ExampleICD-9 Code 2630

Acute IllnessInjury Chronic Illness SocialEnvironmental

Weight Loss1-21 week 51 month

753 months

51 month753 months106 months

201 year

51 month 753 months 106 months

201 year

Energy Intake lt 75 for gt 7 days lt 75 for gt 1 month lt 75 for gt 3 months

Body Fat Mild Depletion Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild Mild

Hand Grip Strength Not Applicable Not Applicable Not Applicable

2015 ICD-9-CM American Medical Association

2630 Malnutrition of Moderate Degree J Acad Nutr Diet 2012112(5) 730-738

From Theory to Practice Optimizing Recognition and Documentation of Adult Malnutrition Academy of Nutrition and Dietetics 523201235

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

36Other Dynamometers are available Check Contracts with rehab services

Handgrip Dynamometer

Functional Assessment

2 sd below the mean for age and sex

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

No single piece of information means a patient is malnourishedmdashuse critical thinking and look at the whole situation patient nutrition history weight history intake history metabolism etc

Assessment of malnutrition occurs at this point in time regardless of the prognosis

Your documentation does not replace communications questions and observations with other team members

Clarify nutrition diagnosis and time lsquoPrior To Hospitalizationrsquo and lsquoDuring Hospitalizationrsquo

Patient may have more than one type of malnutrition in a sequence of events and over time Document history of past types and connect to present condition

Documentation Advice

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

bull Describe objective evidence time frame and details supporting malnutrition criteria and characteristics

bull ldquoWell nourished well developedrdquo use in malnourished patients confounds auditors

bull Subjective information is important Describe with associations to under nutrition

bull Include terms ldquoprotein-calorie malnutritionrdquo in notes and discharge plan

bull Quantify data bull Time frames of deficits actual weight change and percentages over timebull Actual Intake percentages and estimates of intake compared to short term and

long term targets (especially calories and protein)

bull Include nutrition physical assessment descriptions such as muscle mass and fat stores

bull Describe ongoing nutritional needs and nutrient targets to stabilize or improve nutritional status in the future Handoffrsquos and care transitions critical

Quality Documentation

38

Thank you

Questions

39

40

Thank you

Questions

39

40

40