Malnutrition Education Intervention for Mercy Medical Center Redding
Malnutrition Education Intervention for Mercy Medical Center Redding
The Mercy Medical Center in Redding, California, a 267-bed non-profit level II trauma center within the Dignity Health healthcare system (Mercy Medical Center Redding, 2013), appears to be unaware of a growing concern about the impact of inpatient malnutrition on health care outcomes. A word search on Mercy's website using the word 'malnutrition' retrieved only one result and this document discusses malnutrition in a patient resource guide ("Search," 2014). The lack of apparent concern about inpatient malnutrition among hospital clinicians and administrators is not atypical of many U.S. hospitals, but a few have begun to take this issue seriously (Vesely, 2014). Close to one-third of all patients admitted to hospitals in the U.S. are estimated to suffer from malnutrition (Vesely, 2014, p. 32), whether due to unexplained weight loss, loss of appetite, or drug-induced dietary changes (Sheperd, 2009), but only 3% are ever diagnosed with this condition (Corkins et al., 2014). This prevalence estimate also applies to patients residing in hospitals, because malnutrition often goes undetected, even when it has an iatrogenic etiology (Bavelaar et al., 2008).
The Alliance to Advance Patient Nutrition (AAPN) represents the collaborative efforts of Abbott Nutrition, the Academy of Medical-Surgical Nurses, the Academy of Nutrition and Dietetics, and the Society of Hospital Medicine (AAPN, 2013). The goal of the AAPN is to improve patient nutrition practices and therefore health care outcomes. If malnutrition is left untreated the risk of complications, delayed wound healing, infections, longer hospital stays, readmissions, and mortality increase significantly (Bavelaar et al., 2008). In the current climate of healthcare cost awareness, malnutrition cannot be ignored. The main categories of malnutrition are kwashiorkor (ICD-9-CM 260), malnutrition of a moderate degree (ICD-9-CM 262), and marasmus (ICD-9-CM 261), with the first two representing protein intake insufficiency and the latter also involving insufficient carbohydrate ingestion (Sheperd, 2009). All are eligible for significant Medicare reimbursement (Bryant, 2012).
The City of Redding is located at the northern-most end of California's Central Valley and is home to approximately 90,000 citizens. An estimated 22.8 and 16.4% of Redding residents are under 18-years of age or 65 and older, respectively (U.S. Census Bureau, 2014). The median household income is about 30% below the California average, which is consistent with a greater proportion of the population living below the federal poverty line. In 2002, close to 18% of school children within California's Central Valley were eligible for welfare assistance and over 50% were receiving subsidized lunches, although children living in the North Valley fared slightly better (Danenberg, Jepsen, & Cerdan, 2002, p. v, vii). This is a solidly blue collar town, with more residents completing high school and not attending college compared to the rest of the state (U.S. Census Bureaur, 2014). Redding is a relatively homogenous community ethnically, with over 80% of the population sef-identifying as Caucasian. The next biggest ethnic group is Hispanics, which represents only 8.7% compared to 37.6% state-wide.
The academic environment in Redding is limited, with only two academic institutions offering nursing degrees and none providing graduate level coursework (Board of Registered Nursing, 2013). Accordingly, Shasta County where Redding is located has been designated a registered nurse (RN) shortage area by the State of California (OSHPD Healthcare Workforce Development Division, 2011). Approximately 70% of voters supported the Republican presidential candidate in the last five general elections, so it is a politically conservative city (City-Data.com, 2013). In 2011, the Shasta Regional Medical Center owned by Prime Healthcare Services captured the attention of a watchdog group because of a surge in kwashiorkor Medicare claims (Williams, Jewett, & Doig, 2011). The allegations of Medicare fraud could make it difficult for other local hospitals to implement a malnutrition screening program if it results in significantly higher prevalence rates; however, this should not be a significant barrier, only a consideration.
The mission statement of Mercy Redding emphasizes meeting the healthcare needs of the poor and disenfranchised (Mercy Medical Center Redding, 2014). Accordingly, Mercy Redding is committed to engaging with the community and making a positive contribution. For example, during fiscal year 2013 Mercy Redding contributed over $43 thousand dollars to the Good News Rescue Mission to support heart health programs for the homeless and very low income residents. Given Mercy Redding's focus on serving the poorest residents of the city it seems reasonable to assume that a higher percentage of its patients would be suffering from malnutrition. Of the five core values Mercy Redding identifies with, stewardship and excellence seem most relevant to identifying and treating inpatient malnutrition. Stewardship is defined as promoting healing and wholeness, while excellence means exceeding expectations through teamwork and innovation. Despite these important values, however, Mercy Redding does not include evidence-based practice in its vision. On the positive side, over 98% of nursing staff are RNs (California Department of Health Care Services, 2012).
Inpatient Malnutrition Education Intervention
Implementing effective malnutrition screening requires modification of nursing workflow processes. Accordingly, an education intervention for malnutrition screening would probably be most effective if it was based on experiential learning theory as outlined by David Kolb in 1984 (Lisko & O'Dell, 2010). According to Kolb, learning occurs when the experience is transformed. Implementation of a nursing education intervention to identify patients suffering from malnutrition would be most effective, therefore, if it took place during patient admissions, nursing rounds, patient handoffs, and patient discharges. The person best situated to implement and enforce malnutrition screening, treatment, and follow-ups is the charge nurse. Based on best practice recommendations the only costs associated with implementing this education intervention would by the extra hours required of the charge nurse, since any costs associated with treatment would be reimbursed. Two weeks of full-time equivalent (FTE) hours for the development of an education intervention, along with six hours per week for the next six months, should be sufficient to implement malnutrition screening education into the relevant nursing workflow tasks. At Mercy Redding the cost of an average hour of work by an RN is about $45 (California Department of Health Care Services, 2012), so the budget for the intervention would be [80 hrs + (26 x 6 hrs)] x $45 = $10,620. See Appendix for the intervention outcome evaluation tool.
AAPN. (2013). Who we are. Retrieved from http://malnutrition.com/alliance.
AAPN. (2014). Nutrition care recommendations: Nurse. Retrieved from http://static.abbottnutrition.com/cms-prod/malnutrition.com/img/Alliance_Roles_Nurse_2014_v1.pdf.
Bavelaar, J.W., Otter, C.D., van Bodegraven, A.A., Thijs, A., & van Bokhorst-de van der Schueren, M.A.E. (2008). Diagnosis and treatment of (disease-related) in-hospital malnutrition: The performance of medical and nursing staff. Clinical Nutrition, 27, 431-8.
Board of Registered Nursing. (2013). Pre-Licensure RN Programs. Retrieved from http://www.rn.ca.gov/schools/rnprograms.shtml.
Bryant, G. (2012). Gloryanne's Corner: Compliance with physician queries needed. Retrieved from https://hfma-nca.org/HFMAMembers/SharedFiles/TheEdge_May2012.pdf.
California Department of Health Care Services. (2012). Report on the Audit of Rate Development Branch Schedules, Mercy Medical Center Redding. Retrieved from http://www.dhcs.ca.gov/dataandstats/reports/Documents/AI_Acute_2008_K-O/0140_0608_106450949.pdf.
City-Data.com. (2013). Redding, California. Retrieved from http://www.city-data.com/city/Redding-California.html.
Corkins, M.R., Guenter, P., DiMaria-Ghalili, R.A., Jensen, G.L., Malone, A., Miller, S. et al. (2014). Malnutrition diagnosis in hospitalized patients: United States, 2010. Journal of Parenteral and Enteral Nutrition, 38(2), 186-95.
Danenberg, A., Jepsen, C., & Cerdan, P. (2002). Student and School Indicators for Youth in California's Central Valley. Retrieved from http://www.ppic.org/content/pubs/report/R_902CJR.pdf.
Lisko, S.A. & O'Dell, V. (2010). Integration of theory and practice: Experiential learning theory and nursing education. Nursing Education Perspectives, 31(2), 106-8.
Mercy Medical Center Redding. (2014). Community benefit report FY2013. Community Benefit Implementation Plan FY2014. Retrieved from http://www.dignityhealth.org/stellent/groups/public/@xinternet_con_sys/documents/webcontent/196191.pdf.
OSHPD Healthcare Workforce Development Division. (2011). Registered Nurse Shortage Areas (RNSAs) by county: Using the mean as the analytical unit. Retrieved from http://gis.oshpd.ca.gov/atlas/content/report/shortage/rnsa.pdf.
Search. (2014). Retrieved from http://redding.mercy.org/search/index.htm.
Sheperd, A. (2009). Nutrition support 1: Risk factors, causes and physiology of malnutrition. Nursing Times, 105(4), 18-20.
U.S. Census Bureau. (2012). Table 214. Households and persons having problems with…