By Cheryl Hsu, Writer, Nourish Health
Dr. Karen Cross has a bustling Plastic and Reconstructive Surgery practice at St. Michael’s Hospital in Toronto, where she specializes in complex tissue healing. Her patients come to her when their wounds won’t heal; some are diabetics with chronic foot wounds, while others have traumatic injuries or are having a hard time recovering from past surgeries.
For the most part, Dr. Cross has a “healthier” patient population than the hospital at-large since the surgeries she performs are elective and the patients are given the time to assess the potential risks and benefits, Despite that fact, some of the patients she was seeing had open wounds for months (or even years) when they come to her for the first time. She suspected that those non-healing wounds were a sign of a deeper problem: malnutrition.
Dr. Cross and her research team led by Dr. Julie Perry set out to screen all the patients in her clinic for risk of malnutrition using a questionnaire developed and tested by the Canadian Malnutrition Task Force (CMTF). The results were astounding: one in four of Dr. Cross’ patients were found to be at risk for malnutrition, and one in two diabetics with foot wounds were at nutritional risk. They concluded that it is vital to identify malnourished patients prior to surgery because malnutrition can cause significant complications after the surgery and with non-healing wounds.
Seeing and understanding malnutrition
“Nutrition needs to be seen as a vital part of health, and screening for it a non-issue. Like blood pressure measurement, assessing malnutrition should be automatic; you know what to do and there is a system of care in place to respond.”
We know that proper nutrition and eating healthy food promotes health, supports organ function, and is vital to healing. However, nutritional status is not consistently assessed among patients entering the Canadian hospital system. This is in spite of the fact that malnutrition is predictive of medical and surgical complications and other negative health outcomes, to the extent that the 30-day mortality rates of malnourished patients are more than 6 times than those of patients with good nutritional status. A national study conducted by the Canadian Malnutrition Task Force has revealed 20-45 per cent of patients admitted are malnourished. The same study found that there are significantly higher in-hospital costs for malnourished patients, due to greater lengths of stay and readmission rates. If this is the case, why are we not seeing malnutrition as a national health crisis that needs to be addressed?
Some of this comes from the public misconceptions about malnourishment and what it looks like. People who are malnourished may not self-identify as such; for example, being overweight or obese is also a form of malnourishment. Malnutrition is when the body does not get the right amount -- whether is a deficiency or excess -- of the vitamins and nutrients it needs to maintain healthy tissues and organ function. A lot of people see malnutrition as something that is more prevalent in developing countries, or more relevant to children and elder care rather than adult care.
Minimum screening for malnutrition in Canadian hospitals
““We showed the hospital that it’s really simple, it doesn’t add anything that delays the admission process; but what this does is allow you to save yourself on the cost of hospital stays and complications down the road.” ”
The exciting thing is that Canada is currently leading evidence-based research around addressing malnutrition in acute care settings. The Canadian Malnutrition Task Force is developing solutions that promote early identification of nutrition challenges for patients in hospitals and proposing actions to address the problem. Focussing on interventions in acute care is a powerful nutrition care pathway because it drives most of the costs of the Canadian health care system.
The CMTF has developed and tested a quick and simple tool to screen for malnutrition when a patient is admitted into the hospital. The Canadian Nutritional Screening Tool consists of two questions: (1) have you lost weight in the past 6 months without trying to? (2) Have you been eating less than usual for a week?; where 2 “yes” answers indicate nutritional risk. This screening tool is an intervention that can be implemented at no additional cost, but it does beg the question of how the healthcare system can -- and should -- respond.
One of the biggest barriers to addressing malnutrition is uncertainty around the capacity of hospitals to provide a pathway of care for the patients who are flagged at risk. However, simple interventions like making sure that patient meal times are protected and working with food services to offer comforting, appealing and culturally appropriate foods are ways to ensure that patients are not leaving their food uneaten. In the UK, there are protocols where at-risk patients are provided with red trays as a visual indicator to prompt dieticians and nurses to help those patients read menus, choose healthy foods, and receive physical support to eat. These opportunities see the hospital as a critical intervention site to educate a captive audience of patients about nourishing eating and lifestyle practices before they enter back into the community.
More recently, the Canadian Malnutrition Task Force began testing and implementing a ‘nutritional care pathway’ in ten hospitals to evaluate its impact. Where their first study was focussed around identifying the impact and prevalence of malnutrition, the second study looks at the practical, actionable solutions that hospitals can take on.
Malnutrition forces us to look at the role of the community
“We know that food is medicine, yet we do not prescribe healthy food nor is it covered under health insurance. We need to establish that food plays a key role in the systemic health of patients.”
Addressing the root causes of malnutrition cannot be limited within hospital walls. The next step is to link up with whole-of-community approaches to understanding how malnutrition is linked to other social determinants of health – including food insecurity, lack of education, poor housing and poverty.
However, the power and value of starting with screening for malnutrition in hospitals is that the health care sector can no longer ignore malnutrition as a hypothetical problem. There are now black and white numbers indicating that up to 45% of patients come in malnourished. There is mounting evidence about the negative health outcomes of malnutrition and financial costs of increased length of hospital stay and readmission rates in dollars and cents. A data-driven argument can be made to policy and decision-makers that investing in the role of food in health care, from increasing nutritional support in the hospital to enhancing food service, can lead to significant health care savings and better health outcomes in the long run.