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Pediatric Malnutrition and its Effect on Readmission Rates and Length of Stay

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Pediatric Malnutrition and its Effect on Readmission Rates and Length of Stay
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De Freitas, Daniella Carolina
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The goal of this project is to evaluate if pediatric patients at UF Health Shands Children's Hospital who had nutrition consultations had longer lengths of stay and 30-day readmission rates than all patients, as well as to evaluate the evidence based literature behind practices in screening, assessing for, and continuing care for pediatric malnutrition. Data was collected from a monthly report generated through Decision Support Services at UF Health Shands Hospital. The data was used to compare differences in lengths of stay and readmission rates of pediatric patients who required nutrition consultations and all patients, January through December of 2018. On average, the length of stay for patients who needed a nutrition consultation was 7.73 days. The average length of stay for all pediatric patients was 5.16 days. 12.34% of all pediatric patients were readmitted within 30 days of discharge, whereas 24.67% of patients who needed a nutrition consult were readmitted. We can't say that pediatric malnutrition causes these rates to increase, however it is clear that this may be a factor. More research is needed to identify the specific factors contributing to the discrepancies in readmission rates and lengths of stays in these populations and ultimately improve patient outcomes. ( en )
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Awarded Bachelor of Science in Nursing, cum laude, on May 8, 2018. Major: Nursing
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College or School: College of Nursing
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Advisor: Sandra Citty. Advisor Department or School: Nursing

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Copyright Daniella Carolina De Freitas. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 1 Pediatric Malnutrition and its Effect on Readmission Rates and Length of Stay Daniella C. De Freitas Faculty Mentor: Sandra W. Citty, PhD, ARNP BC University of Florida College of Nursing

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 2 Abstract The goal of this project is to evaluate if ped iatric patients at UF Health Shands Children's Hospital who had nutrition consultations had longer lengths of stay and 3 0 day readmission rates than all patients as well as to evaluate the evidence based literature behind practices in s creening, assessing for, and continuing care for pediatric malnutrition. Data was collected from a monthly report generated through Decision Support Services at UF Health Shands Hospital. The data was used to compare differences in lengths of stay and read mission rates of p ediatric patients who required nutrition consultations and all patients January through December of 2017 On a verage, the length of stay for patient s who needed a nutrition consultation was 7.73 days. The average length of stay for all p ediatric patients was 5.16 days. 12.34% of all pediatric patients were readmitted within 30 days of discharge, whereas 24.67% of patients who needed a nutrition consult were readmitted. We can't say that pediatric malnutrition causes these rates to increas e, however it is clear that this may be a factor. More research is needed to identify the specific factors contributing to the discrepancies in readmission rates and lengths of stays in these populations and ultimately improve patient outcomes.

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 3 Int roduction This is a compelling time to be exploring and researching pediatric malnutrition. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), along with other organizations and individuals, have recently set out to reinvent the way t hat pediatric malnutrition is defined, diagnosed, and treated ( Mehta et al., 2013.) Due to the large variability that currently exists across these domains in the United States, the nutritional status of many patients is being overlooked and ineffectively managed. Malnutrition in children in the United States and other developed countries is largely due to secondary factors such as infection s malabsorption inflammation, and deterioration in chronic disease (Beer, Juarez, Vega, & Canada, 2015.) We know tha t pediatric patients who are malnourished have higher hospital costs, increased length of stays, and a greater incidence of care needed after discharge from a hospitalization (Abdelhad i e t al., 2016.) This paper will explore the way that pediatric malnutrition is identified at UF Health at Shands Children's Hospital, as well as the readmission rates and length of stays of patients under the age of 18 who needed a nutrition consultation compared to those who did not. Through evaluation of this data, we set out to understand whether pediatric malnutrition, and therefore the practices surrounding it, had any effect on readmission rates and length of stay. If so, what can be done? Purpose This paper is intended to evaluate the effect of pediatric malnu trition on length of stay and readmission rates at UF Health at Shands Children's Hospital, and whether these variables

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 4 are any different for this particular population compared to all patients. Another goal was to study the evidence based literature behin d practices in screening, assessing for, and continuing care for pediatric malnutrition. Many of these studies have improved outcomes for pediatric patients, and we hope that through expression of the data and identification of strategic interventions in t he literature, outcomes can be improved at UF Health at Shands Children's Hospital. Background and Statistics Defining Pediatric Malnutrition Historically, "malnutrition" has been comprised of a wide variety of definitions This ambiguity can lead to di screpancies between the reported prevalence of malnutrition in children and the accurate value, as well as the true impact it has on health and outcomes (Mehta et al., 2013.) In an attempt to lessen these discrepancies and to provide a basis for more effec tive future research that might, in turn, develop evidence based nutrition practice, the American Society for Parental and Enteral Nutrition (A.S.P.E.N.) developed a working, uniform definition for malnutrition (undernutrition). They defined pediatric mal nutrition as "an imbalance between nutrient requirement and intake, resulting in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes" (Mehta et al., 2013 p. 462 .) Their defi nition pays mind to the etiology behind the incidence of malnutrition, whether it is illness related or environment/behavior related, as well as its chronicity, either lasting less than 3 months (acute) or greater than 3 months (chronic). The goal is to im prove and standardize

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 5 variables surrounding pediatric malnutrition as new research presents itself and old practices prove to be outdated and inaccurate. Prevalence of Pediatric Malnutrition Globally, malnutrition accounts for 52.5% of pediatric deaths and is associated with a greater risk of morbidity and mortality (Tette, Sifah, & Nartey, 2015.) It is suspected that the true prevalence of pediatric malnutrition in the hospital setting in the United States is drastically unreported. This is attributed to a variety of reasons, one of them being the incomplete documentation of malnutrition a fter diagnosis. This was perceived to be the case in a study at a pediatric hospital in 2013, where it was noted that only 3% of patients who received a coded diagnosis of malnutrition by a registered dietitian had this medical diagnosis documented in their chart. In the years following, after further education, work with specialists, and protocols were initia ted, the percentage of patients who had their diagnosis of malnutrition properly documented in their charts increased to 71% (Abdelhad i et al., 2013.) This study, alongside others, adds suspicion to the accuracy of reported pediatric malnutrition in the ho spitalized setting in the US. Another study, utilizing multiple nationally representative databases, analyzed the prevalence of pediatric malnutrition in hospitals in the United States from 2002 to 2011. Over the span of those years, the percentage of di agnoses increased from 1.9% to 3.7% (Carvalho Salemi et al., 2018.) In 2010, approximately 80,710 hospitalized patients in the United States below the age of 17 had a coded malnutrition diagnosis (Abdelhadi et al., 2013.) A study at Texas Children's Hospit al surveyed the average percentage of patients being discharged with a coded diagnosis of malnutrition based off of codes according to International Classificati on of Disease (ICD) (version 9). A pproximately 2% of its patients were diagnosed with malnutrition, however w hen patients were reevaluated to account for ideal body weight (Waterlow criteria) and z

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 6 scores, the average number of patients discharged with malnutrition increased to include approximately 20% (Beer, Juarez, Vega, & Canada, 2015.) Assessment Before pediatric malnutrition can be addressed and interventions can begin, it must be identified. The American Society for Parental and Enteral Nutrition (A.S.P.E.N.), through t he establishment of an etiology based definition and a consens us statement on indicators that can be used to identify and document pediatric malnutrition, intends to standardize the way we diagnose and care for this vulnerable population. Essential to the accurate diagnosis of pediatric malnutrition, is indication of the most sensitive tool for identifying it (Becker et al., 2014.) A.S.P.E.N., along with the World Health Organization, have recommended the use of z scores for evaluating anthropometric measures like weight, height, BMI, and mid upper arm circumference ( MUAC). When more than a single parameter can be used, it is recommended to also quantify weight and length velocity over time. There are several statistical parameters used to assess and compare anthropometric values for pediatric patients, and a very co mmonly used method is through percentiles Percentiles indicate where a child's measurements lie on a curve that will describe what percentage of a reference population would lie either above or below said measurements. Its ability to at times be ambig uo us and nonspecific illustrates shortcomings to its use over other methods To be able to diagnose pediatric malnutrition and document the true severity, a statistical measure with more precision is necessary. Z scores, using units of standard deviation or SD, describe how far a child's weight varies from the mean of others at their same height using reference charts (Mehta et al., 2013.) Z scores can be useful in determining the threshold between moderate and severe

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 7 pediatric malnutrition, and can aid healt h care providers in the accurate documentation of a child's condition, as well as in deciphering the best plan of care for the patient. Z scores can yield precision for certain anthropometric measures, but there can st ill be drawbacks to their use. Bouma (2016 ) notes that monitoring for a decrease in weight for length z score (WHz) might lead to an unfortunate underdiagnosing of pediatric malnutrition in stunted children, as well as an inaccurate over diagnosing in taller children. A better and more sensi tive indicator in this case would be to evaluate weight for age z scores (WAz), which wouldn't be influenced by the child's stature. Bouma (2016) describes a nutritional screening tool which was developed following the guidance of the paradigm shift to eti ology based definitions laid out by A. S.P.E.N. In its implementation, the "MTool" detected that the use of z scores placed the burden of proof on health care providers. If a pediatric patient was classified greater than 2 standard deviations below the norm, the role of the healthcare provider was then to assess thoroughly enough to show that this child is not malnourished, other than the other w ay around. UF Health at Shands Hospital, which has also implemented the use of z scores based on guidelines from A.S.P.E.N., utilizes a variation of Malnutrition Screening Tool (MST) scores to identify pediatric patients who are in need of a nutrition co nsultation by a dietitian. This tool is comprised of 3 questions: has the patient experienced a decrease in appetite, has the patient had unintentional weight loss ove r the last 6 months, and are they on home TPN or tube feeds. This is not a tool used for diagnosing malnutrition, conversely a positive screening based on these questions indicates a referral for consultation from a registered dietitian. Prior research has extensively explored MST scores in their appropriateness and validity in older adult pat ient s, however prior studies have failed to evaluate its use in pediatrics. A UF Health registered dietitian relayed that there has been discussion about the use of a different screening tool for

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 8 pediatric patients, however there were barriers to this change that included the necessity for greater nursing participation in its execution and the possibility of the change leading to inaccurate results. Currently, nurses at UF Health perform this adapted MST evaluation upon a patient's admission. If a patient is referred for a nutrition consult, the registered dietitian h as 48 hours to complete the consult, although they are normally completed sooner. This particular hospital's policy is to follow up within 14 days of the consult, however depending on the severity of the patient, the registered dietitians will attend to this within 7 days or sooner. The dietiti ans are able to create a schedule that assists them with identifying which patients need to be seen and when. There are not currently any protocols in place rega rding follow up after discharge (K. Kisilewicz, personal communication, February 18, 2018.) There are several avenues by which a pediatric patient might be referred for a nutrition consultation. As stated above, the MST score which is performed is just one method for identifying pediatric patients who will receive a nutrition consult Another avenue would be throu gh a physician's referral. This is based on physician preference and might occur when a patient has a certain etiology such as cystic fibrosis, a congenital heart defect, short gut, etc. A nutrition consult may also be initiated as a result of a regist ered dietitian's screening, such as a review of newly admitted patients to see if they are small or have poor weight gain, as well as if they rece ive tube feeds or TPN at home. The current practice for screening for malnutrition (post admission) is not systema tic, and is as variable as it is dependent on individuals' approaches and provider behavior. Prior studies have substantiated the appropriateness of MST scores for use in adult populations, and it has been reported that nurses perceive the MST as "straightforw ard",

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 9 "simple", and "good." These views, although affirmative, have not always guaranteed increased adherence to routine malnutrition screening This same study that features nursing perceptions of MST scores identified that on a particular un it, only 4% of patients had MST scores completed Although the tool was appraised as easy to use, this study broaches the issue that there are wide ranging barriers to adherence in completing and documenting a screening tool P oor prioritization of a nutrition assessment, high workload, skill, level of support, and education were some of the factors attributed to this low rate of completion (Raja et al., 2008.) In a setting which relies on this tool as a preliminary nutrition sc reening noncompliance could be detrimental to the health of pati ents who get overlooked. N utrition assessments are a routine part of a patient's admission at UF Health Shands Children's Hospital, so adherence to completing the screening might not be a pro blem. Nonetheless, this study advances the importance of recognizing barriers and weaknesses to implementing a different nutritional screening tool, and exposes how essential nursing perceptions and overall support are in the execution of these tasks. Equa lly important to identifying malnutrition in a hospitalized pediatric patient and intervening early is ensuring that patients admitted for extended periods are not becoming malnourished throughout their stay. Research by Joosten and Hulst (2008) suggests that longer lengths of hospital stay lead to increased likelihood of developing s erious nutritional deficiencies. A lack of a valid and universal pediatric malnutrition screening tool is partially accountable for the fact that routine screening for malnut rition is seldom performed (Joosten & Hulst, 2008.) A.S.P.E.N. has given particular emphasis to the necessity of performing serial z scores on children who have longer hospital length of stays (Mehta et al., 2013.) Their consensus statement establishes tha t as soon as the diagnosis of malnutrition in a pediatric patient is made, the frequency of subsequent nutrition assessments must also be determined (Becker et al., 2014.)

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 10 The association between longer length of stay and weight loss has been well document ed in adults, however studies on this topic in pediatric patients are much more limited. (Braunschweig, Gomez, & Sheean, 2000.). A study investigating pediatric nutrition screening tools reported that out of hospitalized pediatric patients who had a length of stay of at least 4 days, 35% lost weight. This study corroborates the notion that assessing pediatric patients for malnutrition solely on admission might overlook a considerable number of patients who may develop nutritional deficits throughout their hospital stay (Hulst, Zwart, Hop, & Joosten, 2010.) Methods A search through the literature was done using Health Science Databases, Pubmed, and internet searches to gather recent evidenc e on the prevalence, identification, and consequences of pediatric malnutrition in the hospital setting, and its effect on length of stays and readmission rates. Some key search terms were "pediatric malnutrition prevalence", "pediatric malnutrition in hos pitals", "assessment of pediatric malnutrition in hospitals", and "documentation of pediatric nutrition". Studies published within the last 10 years were included, and studies that noted prevalence of malnutrition were refined to ones conducted only in the United States. I met and communicated regularly with my research mentor, Dr. Sandra Citty, through the entirety of the project. We evaluated data from a report that is generated monthly from Decision Support Services at UF Health Shands Hospital. T he rep orts were generated each month from January 2017 to December 2017, and the data includes patients age 18 years and under. The reports are titled "Monthly Readmit Rate for Discharged Patients Who needed Nutrition Consult ", "Monthly Readmit Rate for Discharg ed Peds Patients ", "Monthly Readmit Rate for Discharged Patients

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 11 Who needed Nutrition Consult by Discharge Unit", and "Monthly Readmit Rate for Discharged Peds Patients by Discharge Unit". These reports also included averag e length of stay for each month, for the populations at whole and separated by uni t. These were used to compare differences in lengths of stay and readmission rates of p ediatric patients who required nutrition consultations and those who did not. Further, a n interview was conducted with a UF Health Pediatric Dietitian, in person and via email, to discuss current practices and protocol s for pediatric malnutrition at UF Health Shands Children's Hospital This initial evaluation of malnutrition impact on quality indicators, such as readmissio n, was submitted to the QIPR registry for UF Health. Results The results were based off of 10,336 pediatric discharges from January of 2017 through December of 2017. A total of 6,878 of these pediatric patients required nutrition consultations. Accordi ng to the data that we evaluated, the 30 day readmission rates for all pediatric patients in 2017 was 12.34%. The average length of stay for all pediatric patients was 5.16 days. The 30 day readmission rates for pediatric patients who needed a nutrition co nsult in 2017 was double that for all patients, at 24.67%. The average length of stay for patients who needed a nutrition consultation was 7.73 days. The mortality rate for patients who required a nutrition consult was higher than the rate for all patients, at 2.30% and 0.98 %, respectively. We also evaluated the data above for each pediatric unit separately. For all pediatric patients o n unit E the 30 day readmission rate was 14.76% and the average length of stay was 22.46 days. On the same unit, patients who required a nutrition consultation had a 30 day readmission rate of 25% and an average length of stay of 47.40 days.

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 12 For all pediatric patients on un it D, the 30 day readmission rate was 17.74% and the average length of stay was 6.78 days. Patients on unit D who needed a nutrition consultation had a 30 day readmission rate of 32.43% and an average length of stay of 9.59 days. For all pediatric patien t s on unit C, the 30 day readmission rate was 53.20% and the average length of stay was 4.89 days. Patients on unit C who needed a nutrition consultation had a 30 day readmission rate of 60.26% and an average length of stay of 11.08 days. For all ped iatri c patients on unit B the 30 day readmission rate was 8.80% and the average length of stay was 2.87 days. Patients on unit B who needed a nutrition consultation had a 30 day readmission rate of 30.69% and an average length of stay of 5.96 days. For all pe diatric patients on unit A the 30 day readmission rate was 10.43% and the average length of stay was 3.44 days. Patients on unit A who needed a nutrition consultation had a 30 day readmission rate of 26.09% and an average length of stay of 6.52 days. Table 1 30 day Readmission Rates (%) and Length of Stay (Days) by Population All Patients and Patients Who Required Nutrition Consultations Unit 30 day Readmission Rate, All Patients 30 day Readmission Rate, Nutrition Consult Length of Stay All Patients Length of Stay, Nutrition Consult A 10.43% 26.09% 3.44 6.52 B 8.80% 30.69% 2.87 5.96 C 53.20% 60.26% 4.89 11.08 D 17.74% 32.43% 6.78 9.59 E 14.76% 25 .00 % 22.46 47.40 Discussion Across all units, readmission rates and average length of stay were consistently higher, and in cases double the amount, for pediatric patients at UF Health Shands Children's Hospital

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 13 who needed nutrition consultations compared to pediatric patients as a whole. The average length of stay was 2.57 days longer for those who needed a nutrition consultation, and they were readmitted to the hospital within 30 days of discharge at twice the rate. We cannot say that pediatric malnutrition causes these rates to increase, however it is clear that this may be a factor. The re are evidenced based interventions in the literature that could help to improve screening of, diagnosis, and management of pediatric patients with malnutrition. These changes could help to reduce 30 day readmis sion rates and length of stay and notably de crease hospital costs, but even more importantly, improve quality of life for these patients, and improve health outcomes. Results compared to the literature A study in by Berry et al. (2013) assessed data from 72 children's hospitals in the United States in 2010, analyzing about 568,845 admissions over the course of a year. They found that the average unadjusted 30 day readmission rate for all hospitalized pediatric patients was 6.5%. Comparatively, this is a much smaller percentage than the readmission r ates for pediatric patients at UF Health Shands Children's Hospital's rate, which in 2017 was 12.34%. It is important to note that this study excludes some populations whi ch our data collection does not ( e.g. patients on chemotherapy), and this may contrib ute to the difference in reported values. The data from this study is from 2010 and if available, the national rate of 30 day readmissions for pediatric hospitals in 2017 would be a much more desirable value for comparison T he unadjusted readmission rate of the study falls short of addressing the variance in patient acuity also considering that patients with a coded diagnosis of malnutrition are more likely to be discharged from a teaching hospital (Abdelhadi et al., 2013.) Even so, the 30 day readmissi on rates are notably higher, and even more so for the population of pediatric patients who needed a nutrition consultation 24.64%.

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 14 In recent years, f inancial and clinical implications have dramatically shaped queries on the topic of reduction of readmiss ion rates. Often, in the adult population, readmission rates are considered concurrent with hospital performance and quality of care The correlation between the two in the pediatric population is currently being investigated. Research by Bardach et al. (2 013) reports that pediatric readmissions which occur within a year are not uncommon, and each year these carry the cost of more than $1 billion. It might be important to identify whether pediatric readmissions to UF Health Shands Children's Hospital are pr eventable, and what interventions can be implemented to decrease their frequency. Several studies agree that interventions surrounding nutrition are successful in reducing the number of unplanned readmissions (Sriram et al., 2017; Bally et al., 2016). What can be done to reduce readmission rates? A study by Dr. Sriram and colleagues (2017) illustrates application of a nutrition focused quality improvement program that reduced readmissions by 20%. The project began with the choice of a validated screening t ool and the development of an electronic medical record which would cue completion of the screening tool on admission. If the patient was identified to have been at risk of malnutrition, there were nurse ordered oral nutrition supplements (ONS) given to th e patient within 24 hours of the screening. Shortly after, the patient would receive a consultation by a dietitian. At discharge, the patients who participated in this project received coupons for the ONS, directions for ONS use at home and reinforcement f o r adherence to the regimen, and literature on nutrition. A transition call center nurse would reach out to the patient 48 72 hours post discharge to confirm use of ONS, and then an automated phone system would make calls 2, 3, and 4 weeks post discharge.

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 15 This project was successful in decreasing not only readmission rates, but also length of stays for patients who participated. Their conclusions evidence that the use of a validated malnutrition screening tool alongside punctual administration of oral nutr ition supplements could help to decrease readmission rates and length of stay. Readmission rates were lowered by around 20% as a result of these quality improvement interventions, and length of stay was also reduced similarly. This study was performed in t he adult population; however, the design of the project could be reproduced to be applied to pediatrics. It is important to note that although MST (which is used and adapted throughout UF Health at Shands Hospital) is a validated malnutrition screening too l for adults, the same can't be said for its use in pediatrics. This study is incredibly valuable in its presentation of the ability of a nutrition focused project to catalyze large scale change in values like 30 day readmission rates and length of stay. E mphasis on and coordination of timely outpatient follow up can also considerably influence readmission rates When researched in pediatric patients with asthma those who had lower access to primary care after hospitalization had increased rates of readmi ssion, regardless of the quality of that care (Auger, Kahn, Davis, Beck, & Simmons, 2013.) Improving coordination and facilitation of care after hospital discharge might be a pivotal part of a hospital's reduction of preventable readmissions. This problem was identified by a UF Health Dietitian as a barrier to treating malnutrition. She acknowledged that many patients are discharged without plans for a follow up with a dietitian. Many will have a primary care follow up scheduled for after discharge, however a targeted follow up with a dietitian might be more focused and effective for the malnouri shed patient (K. Kisilewicz, personal communication, February 18, 2018.) A.S.P.E.N. recommends that processes intended to ensure continuity of care should be establi shed as soon as a child is diagnosed with malnutrition. Initiating this at the time

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 16 of diagnosis might help to increase the likelihood of successful coordination of care The type of follow up care received may affect outcomes and readmissions, as well as how soon a patient receives this follow up after discharge. Previous studies proffer great success in the effective use of health information exchange in reducing 30 day readmission rates. One method involves a way for patients to access their health record at home, to include the details of their medication regimen and much more. A study employed the use of a tele monitoring system which aided partnered healthcare clinics and case managers in following patient s at high risk for readmission. This system, with the aid of case management, was associated with a 44% decrease in readmissions within 30 days in the population which was high risk (Kash, Baek, Davis, Champagne Langabeer, & Langabeer, 2017.) Pediatric pat ients with anemia or neutropenia, ventricular shunt procedures, and sickle cell anemia crisis are among some of the populations at high risk for readmission (Berry et al., 2013 .) Strategies that target the use of effective health information exchange could be helpful in coordinating follow up. What can be done to reduce length of stay? Pediatric patients diagnosed with malnutrition on average have a greater length of stay than patients who do not, and their care is costlier Lakdawalla et al. (2014) studie d a national sample of patients in the United States over 11 years, primarily patients aged 2 8. The study looked at the relationship between oral nutrition supplementation (ONS) and hospital length of stay and episode cost (the amount incurred on the hosp ital to deliver care). The use of ONS significantly decreased the length of stays of patients receiving ONS. In addition, ONS decreased the cost per episode of hospitalization by approximately $1,768 adding up to around $57.8 million annually nationwide. These results help to confirm that the use of oral nutrition

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 17 supplementation should not be overlooked during pediatric hospitalizations, and can substantially decrease patients' length and costs of stay. Another study conducted in Michigan which effectiv ely reduced length of stay of pediatric patients is not as recent, although noteworthy. Researchers at University of Michigan Mott Children's Hospital (UMMCH) set out to investigate whether comparing their data to other children's hospitals from a database could help to detect areas for improvement, and if the hospital could implement clinical changes to advance those areas. They identified the opportunity to enhance care for children with asthma in their hospital, noting that their length of stay was sligh tly longer and the cost per case was higher than the average from the database. The researchers met with clinicians to work to target different processes for improvement accurate documentation, standardized orders, and standardized education for patients parents initiated on admission. Within 3 years, the cost per case, length of stay, and 30 day readmission rates have been lower than the national cohort, and this has been sustained (Sedman et al., 2004.) This study promotes that projects guided by compa rison of data can manifest in less costly and higher quality care to more children. Lessons learned Pediatric patients at UF Health Shands who needed a nutrition consultation had longer length of stay and almost double the rate of 30 day readmissions. W e can't say definitively that there is a correlation, however clearly malnutrition may be a factor in these variables, and quality improvement studies in the past that target nutrition have been successful in reducing both length of stay and readmission ra tes in patients. This could be an effective approach, as an improvement in nutrition status in patients who are malnourished lower s the chances of recurrence of illness

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 18 after hospital discharge. A.S.P.E.N. underlines the importance of using a validated mal nutrition screening tool, as well as determining how often a patient will be reevaluated as soon as the diagnosis of malnutrition is made (Becker et al., 2014.) Screening for malnutrition is traditionally completed upon admission, and seldom after admission in patients who were not diagnosed with malnutrition, although it is evidence d that roughly 35% of patients who have a length of stay of at least 4 days experi ence weight los s (Hulst, Zwart, Hop, & Joosten, 2010.) P atients with a coded diagnosis of malnutrition have been shown to have a length of stay that is 2.5 times longer than patients who did not The national average rate of 30 day readmissions for hospitalized pediatric patients in 2010 was around 6.5% (Berry et al., 2013.) At Shands Hospital in 2017, the average was 12.34% and double that, 24.64%, for patients who required a nutrition consultation. The data evaluated in this study can be used as a basis for comparison as evidence based projects for improvement are initiated in an attempt to improve outcomes and better manage malnutrition in the pediatric population. Next steps in quality improvement are needed to evaluate the causations of this inc reased readmission rate for this population and ultimately improve patient outcomes.

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 19 References Abdelhadi, R.A., Bouma, S., Bairdain, S., Wolff, J., Legro, A., Plogsted, S., the ASPEN Malnutrition Committee. (2016). Characteristics of H ospitalized Children With a Diagnosis of Malnutrition: United States, 2010. Journal of Parenteral and Enteral Nutrition, 40 (5), 623 635. DOI: 10.1177/0148607116633800. Auger, K.A., Kahn, R.S., Davis, M.M., Beck, A.F., Simmons, J.M. (2013). Medical Home Qua lity and Readmission Risk for Children Hospitalized with Asthma Exacerbations. American Academy of Pediatrics 131 (1), 64 70. DOI: 10.1542/peds.2012 1055 Berry, J.G., Toomey, S.L., Zaslavsky, A.M., Jha, A.K., Nakamura, M.M., Klein, D.J., Feng, Shuster, M .A. (2013) Pediatric Readmission Prevalence and Variability Across Hospitals JAMA 309(4), 372 380 DOI: 10.1001/jama.2012.188351 Bally, M.R., Blaser Yildirim, P.Z., Bounoure, L., Gloy, V.L., Mueller, B., Briel, M., Schuetz, P. (2016). Nutritional Support and Outcomes in Malnourished Medical Inpatients. JAMA Internal Med 176 (1), 43 53. DOI: 10.1001/jamainternmed.2015.6587 Bardach, N .S., Vittinghoff, E., Asteria Penaloza, R., Edwards, J.D., Yazdany, J., Lee, H.C., Boscardin, W.J., Dudley, R.A. (2013). Measuring Hospital Quality Using Pediatric Readmission and Revisit Rates. American Academy of Pediatrics 132 (3), 429 436. DOI: 10.154 2/peds.2012 3527 Becker, P.J., Carney, L.N., Corkins, M.R., Monczka, J., Smith, E., Smith, E.S., Spear, B.A., White, J.V. (2014) Journal of the Academy of Nutrition and Dietetics, 11 4 (12), 1988 2000. https://doi.org/10.1016/j.jand.2014.08.026

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 20 Beer, S.S. Juarez, M.D., Vega, M.W., Canada, N.L. (2015). Pediatric Malnutrition: Putting the New Definition and Standards Into Practice Nutrition in Clinical Practice, 30 (5), 609 624. DOI: 10.1177/0884533615600423 Bouma, S. (2016). Diagnosing Pediatric Malnutriti on Nutrition in Clinical Practice, 32 (1). https://doi.org/10.1177/0884533616671861 Braunschweig, C., Gomez, S., Sheean, P.M. (2000). Impact of Declines in Nutritional Status on Outcomes in Adult Patients Hospitalized for More than 7 Days. Journal of the A cademy of Nutrition and Dietetics. 100 (11), 1316 22. DOI: 10.1016/S0002 8223(00)00373 4 Carvalho Salemi, J., Salemi, J. L., Wong Vega, M.R., Spooner, K.K., Juarez, M.D., Beer, S.S., Canada N.L. (2018). Malnutrition among Hospitalized Children in the United States: Changing Prevalence, Clinical Correlates, and Practice Patterns between 2002 and 2011. Journal of the Academy of Nutrition and Dietetics, 118 (1), 40 51. https://doi.org/10.1016/j.jand.2017.02.015 Hulst, J.M., Zwart, H., Hop, W.C., Joosten, K.F. (2 009). Dutch National Survey to Test the STRONGkids Nutritional Risk Screening Tool in Hospitalized Children. Clinical Nutrition, 29 (1), 106 111. https://doi.org/10.1016/j.clnu.2009.07.006 Joosten, K.F., Hulst, J.M. (2008). Prevalence of Malnutrition in Ped iatric Hospital Patients. Current Opinion in Pediatrics, 20 (5), 590 596. DOI: 10.1097/MOP.0b013e32830c6ede Kash, B.A., Baek, J., Davis, E., Champagne Langabeer, T., Langabeer, J.R. (2017). Review of Successful Hospital Readmission Reduction Strategies and the Role of Health Information Exchange International Journal of Medical Informatics 104, 97 104. https://doi.org/10.1016/j.ijmedinf.2017.05.012

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PEDIATRIC MALNUTRITION AND ITS EFFECT ON READMISSION RATES AND LENGTH OF STAY 21 Lakdawalla, D.N., Mascarenhas, M., Jena, A.B., Vanderpuye Orgle, J., LaVallee, C., Linthicum, M.T., Snider, J .T. (2014). Impact of Orlan Nutrition Supplements on Hospital Outcomes in Pediatric Patients. Journal of Parenteral and Enteral Nutrition 38(2), 42 49. https://doi.org/10.1177/0148607114549769 Mehta, N. M., Corkins, M. R., Lyman, B., Malone, A., Goday, P.S., Carney, L.N., the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. (2013). Defining Pediatric Malnutrition: A Paradigm Shift Toward Etiology Related De finitions. Journal of Parenteral and Enteral Nutrition, Volume 37 (4), 460 481. DOI: 10.1177/0148607113479972 Raja, R., Gibson, S., Turner, A., Winderlich, J., Porter, J., Cant, R., Aronl, R. (2008). Nurses' Views and Practices Regarding Use of Validated Nu trition Screening Tools. Australian Journal of Advanced Nursing, 26 (1), 26 33. Sedman, A.B., Bahl, V., Bunting, E., Bandy, K., Jones, S., Nasr, S.Z., Schulz, K., Campbell, D.A. (2004). Clinical Redesign Using All Patient Refined Diagnosis Related Groups. Pediatr ics 114 (4), 965 969. DOI: 10.1542/peds.2004 0650 Sriram, K., Sulo, S., VanDerBosch, G., Partridge, J., Feldstein, J., Hegazi, R.A., Summerfelt, W.T. (2017). A Comprehensive Nutrition Focused Quality Improvement Program Reduces 30 Day Readmissions a nd Length of Stay in Hospitalized Patients Journal of Parenteral and Enteral Nutrition, 41 (3), 384 391. DOI: 10.1177/0148607116681468 Tette, E.M., Sifah, E.K., Nartey, E.T. (2015). Factors Affecting Malnutrition in Children and the Uptake of Interventions to Prevent the Condition. BMC Pediatrics 15, 189. https://doi.org/10.1186/s12887 015 0496 3