The Case

A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder caused by the lack of vitamin B1 – was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. The patient was alert and oriented to his name, but not the date or location, on admission.  He became agitated and uncooperative during the hospitalization, with presumed delirium. Soft restraints with mitts were required to maintain life-sustaining lines and chest tubes. Over the first 10 days of hospitalization, the patient refused most oral nutrition and medications. On day 11, he was taken to the operating room for video-assisted thoracoscopic (VATS) decortication of his pleural space due to his persistent empyema. After returning to the ward, his diet order was not restarted. The patient received maintenance intravenous fluids but had no other nutrition for four days postoperatively, until he finally expressed hunger and it was noted that he was not receiving meals. 

During this time, the nursing staff had also stopped offering oral medications because of the patient's numerous prior refusals. As a result, he did not receive any of his prescribed oral medications for hypertension or his metronidazole for the aspiration pneumonia. Once the patient expressed hunger, the diet order was restarted, and a feeding consult was ordered. The patient was identified as having difficulty swallowing and ultimately a percutaneous endoscopic gastrostomy (PEG) tube was placed to deliver both nutrition and medications. 

The Commentary

by Adrianne M Widaman, PhD, RD

Hospital-acquired (HA) malnutrition is prevalent, underdiagnosed and undertreated.^1-4 It is estimated that 25-50% of patients are malnourished when admitted to the hospital yet only 8% receive a diagnosis of malnutrition and nutritional status often worsens during hospitalizations.^4-8 Malnutrition is often treated as an ancillary concern that is not prioritized in acute care until overt symptoms, such a pressure ulcers, significant weight loss or failure to thrive occur. This case highlights how nutrition care can be neglected when a multidisciplinary team is not included in patient care.^2,3,9-12 In this case, the admitting diagnosis of aspiration pneumonia suggesting dysphagia did not trigger a referral to a Registered Dietitian (RD) for a nutrition assessment or a Speech Language Pathologist (SLP) for a swallow evaluation on day 1. Not until a ‘feeding consult’ was ordered on day 14+ of the hospital stay was swallow function assessed. Consequently, inadequate energy and nutrient intake continued for 10 days followed by forced starvation for four days due to a diet order error that inappropriately extended a nil per os (NPO) order. The NPO (aka “nothing by mouth”) order restricted not only food, but also the medication needed to treat the patient’s aspiration pneumonia and hypertension. This commentary highlights two errors that led to HA malnutrition in this case and discusses systemwide strategies to combat HA malnutrition.

Malnutrition can be easily missed when a patient is being admitted. There is no single laboratory or diagnostic test for malnutrition; instead a thorough nutrition assessment including multiple signs and symptoms is required. For example, sarcopenia in hospitalized older adults is common and often missed without a nutrition-focused physical exam.¹³ It can be assumed that the patient in this case had a history of malnutrition based on the history of Wernicke-Korsakoff encephalopathy, caused by a thiamine deficiency that is often associated with alcoholism.¹⁴ It is unclear whether the patient received the Clinical Institute Withdrawal Assessment (CIWA) protocol, including intravenous thiamine, upon admission. If not, the delirium may have been a sign of encephalopathy, which is commonly misdiagnosed. In this patient, inadequate energy and protein intake over 14 days led to hospital-acquired malnutrition. Poor intake also may have caused or contributed to agitation and delirium¹⁵ and may have worsened swallow function necessitating PEG tube placement.¹⁶

How does HA malnutrition happen? For 10 days this patient frequently refused oral intake. Patients refuse meals for a multitude of reasons.¹⁷ First, it is imperative to determine whether the refusal of food is a conscious choice or a symptom of a disease process.¹⁷ In this patient, his refusal to eat or take medications was assumed to be a conscious choice. Patients have the right to voluntarily refuse to eat.¹⁸ However, it is very possible that the refusal was a symptom of his dysphagia due to fear of choking or past experiences of difficulty swallowing. His mental status would have limited his ability to communicate this fear. “Anchoring bias is the cognitive trap of allowing first impressions to exert undue influence on the diagnostic process…[with] the tendency to hold on to the initial diagnosis even in the face of disconfirming evidence” (PSNet Glossary https://psnet.ahrq.gov/glossary). In this case, because it was assumed that the patient’s refusal to eat was a conscious choice, no investigation for a medical reason was undertaken. Nursing also may have assumed that there was no need to obtain an order to restart diet or oral medications, as the patient would likely refuse. This bias likely led to the patient being inappropriately held fasting for four days.

Preoperative fasting is a risk management strategy based on the assumption that if the stomach is empty, then the potential for aspiration of stomach contents during sedation is reduced.¹⁹ However, the required length for NPO is often overestimated leading to errors in diet orders.^20,21 Errors associated with diet orders are common.^9,20,22 Recent single-site, observational studies evaluated errors in NPO diet orders and found that one in four were avoidable and that most were extended >50% longer than necessary.^9,20 One study found that nearly 43% of the missed meals were avoidable.²⁰ Common characteristics associated with inappropriate and extended NPO orders include lack of physician knowledge of fasting guidelines, aversion to risk related to aspiration, adhering to a common practice that is no longer supported by evidence, ordering procedures before specialist consultations are completed, and scheduling barriers.²³ Like the patient in this case, 15% of patients in one study were kept NPO for at least three days with no documented reason.⁹

How long is it safe to keep patients fasting? First, there must be an evidence-based reason not to feed. In this case, four days of NPO was not warranted and detrimental to the health of the patient. Secondly, the length of time that it is safe to keep a patient NPO is based on the nutritional status of the patient. The question should not be: how long can we keep a patient NPO? Instead, it should be: is fasting necessary and does the risk of feeding outweigh the benefit of continued oral intake? To truly understand the risk of fasting, nutritional status must be assessed and the stage of malnutrition identified. NPO is ordered for 47% of medical-surgical patients, illustrating the potential magnitude and far-reaching effects of errors in diet ordering.²³

Approach to Improving Safety & Patient Safety Target

For cases like this one, improving patient safety starts with diagnosing malnutrition. Based on the past medical history (PMH) and admitting diagnosis, a referral to a registered dietitian should have been placed upon admission.²⁴ An extensive evaluation of past oral intake history was needed, including history of chewing and swallowing problems, duration of meal refusal prior to admit, and alcohol intake. This information can be gathered from the patient or caregiver. Anthropometric measurements such as body mass index, usual weight (from caregiver or past admissions), and unintentional weight loss should be assessed. A nutrition-focused physical examination should be performed to uncover any signs of malnutrition, such as adipose loss, muscle loss, or signs of nutrient deficiencies. The American Society for Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics have developed diagnostic criteria for malnutrition.²⁵ The stage of malnutrition and the nutrition intervention recommended by the dietitian should then be communicated to the physician.²⁶

For the patient in this case, a referral to an SLP for a swallow evaluation on admission would have likely indicated dysphagia. At that point, the SLP would have determined the appropriate modified solid and liquid texture for the diet or recommended enteral feeding if PO intake was unsafe. If the patient and/or medical power-of-attorney agreed, a PEG tube would have been placed and an optimal enteral feeding prescription calculated by the RD. Enteral feeding would have met 100% of estimated energy and nutrient needs, thereby preventing the HA malnutrition. Medications to treat the pre-existing hypertension and pneumonia should also have been given intravenously until PEG tube placement.

An extended NPO order contributed to this patient’s HA malnutrition.²⁶ The appropriateness and duration of NPO orders has been addressed in evidence-based guidelines from professional societies.²⁰ Contrary to some practice, some imaging studies and procedures do not require fasting.²³ In general, procedures requiring anesthesia/sedation require fasting from clear liquids for two hours, fasting from a light meal/milk for six hours, or fasting from fried/fatty meal for eight hours, to avoid aspiration risk per the guidelines of the American Society of Anesthesiologists (ASA).¹⁹ Finally, prioritizing the scheduling of the intervention for malnourished patients should be considered; a morning procedure will likely result in one missed meal compared to three meals missed for an evening procedure.²⁰ Guidelines from ASA and the guidelines summarized by Sorita et al. can be used to inform institutional NPO ordering policy.^19,20,27

Systems Change Needed/Quality Improvement Approach

A low risk, high value system change to target is malnutrition documentation.^28,29 Retrospective studies suggest at least 50% of patients with malnutrition are not coded for malnutrition in the electronic health record, which is a potentially costly mistake.^28,30 One retrospective study found that missing malnutrition documentation for seven patients represented a loss of $30,000 in reimbursement.³⁰ To begin the process of improving malnutrition documentation,³¹ a work group of dietitians, physicians, informaticists, quality improvement and medical billing personnel should be assembled. The EHR should be redesigned so that when the dietitian selects the level of malnutrition (none, mild, moderate, severe) and a nutrition intervention from a dropdown menu, this information auto-populates on the physician’s progress note as a problem. The level of malnutrition and the intervention must be included in the physician’s note to qualify as an ICD-10-CM comorbidity/complication, which may increase payment for the hospitalization from Medicare.²⁹ Best practices and other detailed information have been reported elsewhere.^32,33

In this particular case, multidisciplinary (including RD and SLP) care from day 1 would likely have improved the outcome.^2,3,24 In a multi-site, randomized implementation study designed to decrease days of NPO, an intervention that included education via printed and web-based materials, leadership, and quality improvement methods did not reduce fasting times.³⁴ Interestingly, the authors reported inter-professional issues (i.e., lack of communication and clarity of responsibility) as barriers to practice change; therefore, a focus on effective team work was recommended.³⁴ Similarly, in patients with NPO orders ≥ 3 days, nutrition intervention recommendations from the dietitian were only followed by the physician 50% of the time.⁹ Multidisciplinary rounds and nutrition support teams, traditionally consisting of MDs, RDs, RNs and PharmDs, have been successful at improving nutrition outcomes,^35,36 yet only 25% of hospitals have nutrition support teams.³⁷ Hospital leadership should consider supporting these multidisciplinary teams and provide adequate resources to refer medical surgical patients who are malnourished, eating poorly or NPO to these team rounds. A historical cohort study found that a multidisciplinary, multimodal approach significantly decreased pre- and post-operative fasting times in adults above 60 years of age.¹⁰ In the United States, it is estimated that close to fifty percent of hospitals do not grant Registered Dietitians diet order writing privileges³⁸; granting those privileges to Registered Dietitians has been shown to decrease diet order entry error by 15%.²² Finally, automatically generated referrals triggered by a nutrition-related PMH/admitting diagnosis would initiate dietitian involvement earlier in the hospital stay. The Joint Commission requires completion of a nutrition screen (NS) within 24 hours of admission. However, in this particular case, even a validated NS would likely not have identified the patient’s PMH of Wernicke-Korsakoff or admitting diagnosis as signs of nutrition risk; thus, an automatic referral system would be beneficial. The staffing needs of clinical dietitians would need to be re-evaluated to meet the increased workload of the resulting additional referrals.³⁸

Take-Home Points

• Malnutrition is prevalent yet difficult to diagnosis and track; therefore, referrals to a Registered Dietitian and Speech Language Pathologist should be made for patients with a history of malnutrition and when the admitting diagnosis has the potential to impact oral intake.
• Inappropriate and extended NPO orders lead to hospital acquired malnutrition. Evidence-based NPO ordering policies should be developed and followed.^19,20
• The first step to combatting malnutrition is to document it. Dietitians often identify the presence of malnutrition; however, it is not prioritized in the medical plan of care.
• Systems to automate communication between dietitians and physicians are helpful to prevent worsening malnutrition and to code appropriately for payment. Information about improving malnutrition-related quality of care is available at http://malnutritionquality.org/.³²
• Severe undernutrition can be avoided with a multidisciplinary team approach to patient care
   

Adrianne M Widaman, PhD, RD
Assistant Professor
Nutrition, Food Science and Packaging Department
San Jose State University, San Jose, CA
Clinical Dietitian
NorthBay Medical Center, Fairfield CA

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