The Importance of Properly Documenting Malnutrition States

Malnutrition is a very common condition in the hospitalized patient. Up to 40% of the hospitalized patients can have some degree of malnutrition (1), and, severe malnutrition can rage between 8.4 and 21.4% (2,3). Surprisingly, in spite of being so common, this condition is one of the most under-documented conditions. 

This condition, if present, is associated with worse outcomes than if not present. A poorly nourished body will respond poorly to infection and other insults through a weakened immune system. The extracellular and intracellular compartments become depleted of electrolytes and other substances essential for the proper functioning of tissues. All this translates into a state associated with higher severity of illness and risk of mortality.

Making sure that malnutrition is properly documented and  stratified, i.e, specifying mild moderate or severe, is key for the following reasons:

- It helps seeking proper reimbursement for resources consumed in the care of this condition.

- It would accurately reflect severity of Illness (SOI) and risk of mortality (ROM).

- Quality measures such as observed/expected mortality rates and risk adjusted mortality rates are influenced by the presence or absence of malnutrition.

The ASPEN Criteria are an accepted way of identifying malnutrition and staging it. They rely on history to obtain information regarding weight and loss of food intake, they use the physical exam to describe the loss of muscle and adipose tissue, the presence of edema and the reduction of handgrip strength. Variables such as albumin and pre albumin and measurements such as weight are not considered diagnostic criteria. 

The fact that malnutrition is an under-documented condition may be a driver for increasing the queries for that diagnosis. in order to avoid fraud and abuse, it is critical to keep a high quality of the query, consistent with policies and regulations. The queries always need to be supported by the right clinical indicators and have to be non-leading. The dietitian’s evaluation is a valuable document that will help with queries and communication with providers.

In conclusion, malnutrition is very common, it is under-documented and it is related to poor medical outcomes. Documenting malnutrition impacts quality reporting and improves reimbursement. The ASPEN criteria are used to diagnose it and, in order to avoid fraud and abuse, queries have to be thoroughly supported.

Marco A. Ramos MD, CCDS

References

1. Barker LA, Gout BS, Crowe TC. Hospital Malnutrition: Prevalence, Identification and Impact on Patients and the Healthcare System. International Journal of Environmental Research and Public Health. 2011;8(2):514-527. 

2. Rocandio AM, Arroyo M, Ansotegui L. Assessment of nutritional status on hospital admission: nutritional score. European Journal of Clinical Nutrition 2003; 57: 824–831. 

3. Constans T, Bacq Y, Brechot JF, Guilmot JL, Choutet P, Lamisse F. Protein-energy malnutrition in elderly medical patients. Journal of the American Geriatric Society.1992;40:263–8.

5 Reasons to Join A Weight Loss Challenge

I have been in several weightless challenges in the past, and here are 5 things that I have “gained” from “losing”. 

ACCOUNTABILITY: 

Having to be accountable to a coach, and do weekly weigh ins, makes us focus on the numbers on the scale. That weekly number on the scale tells us if we are doing things right, or if we need to modify some things. Our coach can have a conversation with us of what we might need to do to switch things up, and get onto the right path. Plus, we are accountable to the group. The majority of people do not like to quit things.  This forces us keep dredging forward, even when our brain might be telling us to stop.  

STRONGER FRIENDSHIPS:  

Struggling together with other people, is known to help form bonds, and strengthen relationship.  Sometimes these bonds can be so strong that the result is finding life-long friends.  Workouts are funner as a group! Learn from other group members about their difficulties, and how they overcame them. Friends can help solve weightloss or health questions, and can help us become stronger and more healthy individuals.

HELPS US THINK OUTSIDE THE BOX: 

A challenge is exactly that….a “CHALLENGE”!  We are challenged to think and act differently; think outside of the box, and perhaps do things that we would never had tried outside of The Challenge.  It challenges us to take a hard look at our lifestyle and eating habits, and challenges us to clean up our daily routines and stop dieting mistakes (i.e. eating too many processed foods, consuming foods that aren’t nutrient dense, drinking too much diet soda, eating too much salt, eating too large of portions, etc.).  We might even read a health magazine, book or documentary to help us learn new information about food and it’s relation to our body.  It challenges us to give our bodies a break from these cycles of ‘eating abuse’ that can lead to disease and pain.  When we feel healthier, we tend to make better decisions and have a better outlook on life.

FOCUSED/SHORT TERM GOAL:  

It gives us a calendar day to count down to….the goal is in sight!  We can push ourselves harder knowing that it is not an infinite diet, and the struggle will not always be like it is during the challenge.  For example, I wouldn’t normally say to myself “hey, I only worked out one time today…it’s a Friday night...lets hop on the treadmill!”. The challenge is a short time (56 days, but who’s counting!?!?!) to become stronger, and healthier.  Often, this leads people to make permanent changes in their every day life, because they feel so vibrant and healthy.

REGAIN OUR OWN PERSONAL POWER:

It feels amazing to see the number on the scale go backwards instead of forward!!!  We feel like we are in control of our lifestyle.  We choose to focus on the foods we put into our mouth.  We choose to join a gym; get outside and move around; try something new.  This is a wonderful feeling of empowerment.  Sometimes we dig so deep that we find our own power, and end up breaking cycles of addiction. Our clothes begin to fit better.  It’s a win-win situation!!!

By Alana Garcia-Ramos

The Opioid Epidemic. The Role of Healthcare Workers in Resolving it

It is no secret that there is an opioid epidemic and that is causing numerous deaths related to overdoses of heroin and other opioid “painkillers”. Also, there is the added problem of infections caused by the use of intravenous street drugs, which include HIV and hepatitis B and C. Many people get addicted to opioid “painkillers” in the healthcare setting. Opioid use usually starts as treatment for painful conditions, however, due to the potent addictive effects of these drugs, dependance can follow. Once a person is dependent on opioids it is only a matter of time for illegal consumption to begin. 

For many years, there has been a very liberal approach to the prescription and ordering of opiate analgesics. This has served as one of the starting points for this epidemic and all the social issues derived from it. It is also no secret that there is a black market for the opioid pills, where they have a high price. It is also no secret that a large percentage of filled opioid prescriptions end up on the black market

Physicians and other healthcare workers have become aware of this issue and there are many initiatives, starting from personal practice preferences, to healthcare institution based approaches. There are a variety of non-opioid analgesics than can be used in combination, together with surgical techniques such as nerve blocks that can be useful in certain cases. Opioids can be left as last resort medication and they can still be used liberally (in a controlled fashion) in end of life situations, such as hospice care 

Marco A. Ramos MD

Documenting Malnutrition. Part 5

The Physical Exam (PE) in Severe Malnutrition in the Setting of Chronic Illness

The criteria for the physical findings in malnutrition in the setting of chronic illness are stricter than the ones of malnutrition in the setting of chronic illness. This means that the findings have to be more obvious to be considered positive. However, the signs and regions that are evaluated are essentially the same.

When we assess the periorbital region we look for how sunken the eyes look in the orbital cavity. When we assess the tricipital fold, we see how much tissue can our fingers grab when we separate the triceps muscle from the skin and subcutaneous tissue and when we examine the ribcage, we assess how prominent the rib bones look. 

In order to diagnose severe malnutrition in the setting of chronic illness, the adipose tissue loss has to be “severe”, compared to severe malnutrition in the setting of acute illness in which the loss only has to be “moderate”.

When we evaluate the muscle tissue loss we have to look to the same regions of the body as described for severe malnutrition in the setting of acute illness.

Again, the ASPEN criteria are very subjective and in this case, what we are looking for is how depressed the hollow in the temporal region may be and how prominent the bony structures may look in all the other regions. The muscle size of the thighs and calves can also be assessed subjectively. In order to diagnose severe malnutrition in the setting of chronic illness, the muscle tissue loss has to be “severe”.

So, a PE may read like this:

“Mr X is a 62 year old gentleman who presented to the primary care provider’s (PCP) office with a history of diarrhea for 3 months.”

HENT: Eyes look severely sunken in orbital cavity

Musculoskeletal: Severely hollow temporal areas, severe reduction of muscle mass of interosseous muscles of the hands. Severely reduced skin fold at the level of the triceps. Ribcage shows severely marked ribs. 

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

Stroke: People at Risk and its Consequences

"Stroke" is a the common term for an "acute cerebral infarction", which means injury with loss of neurons of the brain tissue. There are 2 main causes for stroke: the obstruction of one of the arteries that feeds blood to the brain and bleeding from blood vessels in the brain. Both situations are very serious and can lead to loss of brain cells, loss of physical or intellectual function and death.

The people who are at risk for stroke are diabetics, people with high blood pressure, smokers, obese and patients with high cholesterol. If someone already has had a stroke he or she has a higher risk to have another one. In addition, for an individual who has coronary artery disease or peripheral artery disease, there is an increased risk of stroke. Atrial fibrillation (AF; an irregular heart beat) increases the chances of stroke, that is the reason why many persons with AF have to take an anticoagulant (blood thinner). Finally, there are genetic conditions that can increase the risk of stroke. Examples of this are sickle cell disease and increased coagulation disorders such as Factor V Leyden.

Stroke can be a devastating condition for the individual and it is definitely a major public health problem¹ due to the immense cost it represents. It accounts for approximately 320 billion dollars every year in healthcare direct and indirect expenditures². The patient has to deal with loss of function, which could be physical  (paralysis of arms, legs and/or face), and intellectual deficits like the loss memory and inability to speak. The recovery from stroke is usually slow and involves the use different levels of rehabilitation services.

References

1. Hankey GJ. StrokeHow Large a Public Health Problem, and How Can the Neurologist Help?. Arch Neurol. 1999;56(6):748-754. 

2. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation. 2016;133:e38-e360.

Marco A. Ramos MD

Documenting Malnutrition. Part 4

The Physical Exam (PE) in Severe Malnutrition in the Setting of  Acute Illness

The presence of physical findings of malnutrition in the setting of acute illness is more difficult to find than in the typically malnourished chronically ill patient. Because of this, the criteria are less strict. In addition, there is the complication that most likely we do not know the premorbid condition of a patient so it would be difficult to assess the loss of muscle mass or the loss of adipose tissue. 

In order to assess the adipose tissue loss, we have to look for the following regions of the body:

- The periorbital region

- The triceps region for the triceps skin fold

- The ribcage region

When we assess the periorbital region we look for how sunken the eyes look in the orbital cavity. When we assess the tricipital fold, we see how much tissue can our fingers grab when we separate the triceps muscle from the skin and subcutaneous  tissue and when we examine the ribcage, we assess how prominent the rib bones look. 

The ASPEN criteria to determine severity of the malnutrition are very subjective. For example, in order to diagnose non-severe malnutrition in the setting of acute illness the adipose tissue loss in the mentioned regions has to be “mild”. In order to diagnose severe malnutrition in the setting of acute illness, the adipose tissue loss has to be at least “moderate”.

When we evaluate the muscle tissue loss we have to look to the following regions of the body:

- The temporal region (temples)

- The supraclavicular region (clavicles)

- The interosseous region in the hands

- The shoulder region

- The scapula region

- The thigh region.

- The calf region

Again, the ASPEN criteria are very subjective and in this case, what we are looking for is how depressed the hollow in the temporal region may be and how prominent the bony structures may look in all the other regions. The muscle size of the thighs and calves can also be assessed subjectively. In order to diagnose non-severe malnutrition in the setting of acute illness the muscle tissue loss in the mentioned regions has to be “mild”. In order to diagnose severe malnutrition in the setting of acute illness, the muscle tissue loss has to be at least “moderate”.

So, a PE may read like this:

“Mr A is a 58 year old gentleman who presented to the emergency department (ED) with a history of nausea, vomiting and abdominal pain for 5 days.

HENT: Eyes look moderately sunken in orbital cavity

Musculoskeletal: Moderately hollow temporal areas, moderately reduced muscle mass of interosseous muscles of the hands. Moderately reduced skin fold at the level of the triceps. Ribcage shows moderately marked ribs. 

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

What is COPD? Who has it?

COPD stands for Chronic Obstructive Pulmonary Disease. There are 2 main conditions that are associated with COPD. The first condition is emphysema (the most common) and the second condition is chronic bronchitis. Smoking tobacco is the most common cause for COPD, although there are relatively rare genetic conditions that lead to similar changes without the influence of smoking cigarettes.

The term “chronic” represents that the anatomical changes in the lungs become fixed and may not reverse, although stopping smoking will certainly slow down the progression towards oxygen dependency. The term “obstructive” refers to the loss in elastic recoil of the lung tissue that will prevent the airways to be sufficiently opened at the time of exhaling air. This causes functional obstruction and air to be trapped in the lungs.

COPD can be a seriously debilitating condition. In its more severe form, it leads to the need of oxygen supplementation for the patient. In addition, a person with COPD is more prone to lung infections and even minor viral illnesses can cause acute respiratory failure. This can cause the need for intensive care and mechanical ventilation.

As it was mentioned before, smoking tobacco is the main culprit for this condition. It is never too late to stop smoking. COPD progression may not be stopped but it may be slowed down significantly. There are several medications that can be used in order to treat symptoms and reduce the functional obstruction in the airways. A physician will help any patient regarding smoking cessation and the treatment of COPD.

Marco A. Ramos MD

Documenting Malnutrition Part 3

The History of Present Illness (HPI) in Severe Malnutrition in the Setting of  Chronic Illness

Chronic disease is frequently associated with malnutrition Examples of this are cancer, liver disease, malabsorption syndromes, heart failure, etc. In these cases, the process that ends in a patient being hospitalized is an acute problem such as an infection or an acute dysfunction of an organ system. The malnutrition is in the background, predisposing the patient to a worse outcome.  When these situations occur, the weight loss, the decline in appetite and the physical changes in the patient’s body are not taken into account by the patient or the family when they refer the history. Questioning properly becomes very important. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines¹  states that in order to consider a patient having severe malnutrition in the setting of chronic illness, he or she has to consume less than 75% of the estimated energy requirement for at least 1 month. Since 2 criteria are needed, the requirement may be fulfilled by documenting weight loss or an aspect of the physical exam. Regarding the loss of weight criteria, ASPEN guidelines say that in order to consider a patient for having severe malnutrition in the setting of chronic illness, the loss of weight in 1 month has to be 5% or more. If the loss of weight happens in 3 month, it has to be 7.5% or more, if it happens in the preceding 6 months it has to be 10% or more and if it occurs in 1 year it has to be at least 20%

So, an HPI may read like this:

“Mrs Y is a 53 year old  lady who presented to the emergency department (ED) with a history of nausea, vomiting and diarrhea for 1 day. She was diagnosed with Crohn’s disease 5 years ago and in the past year she has had several flares. As an average, for the past month she has eaten only 50-70 % of her normal meals due to bloating and lack of appetite. In the past 6 months she has lost 15 pounds. She used to weigh 125 pounds. She presented to the ED because she was unable to keep any oral intake and she started to note a darker urine and a decrease in its volume”

Please note that the last piece of information can also be placed in the Review of Systems (ROS). The information in the HPI anticipates what is going to show in the Assessment and Plan (A/P)

References

1 http://www.baxternutritionacademy.com/ie/disease_related/identifying_malnutrition.html Retrieved December 13, 2016

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

Crohn’s Disease and its Complications

Crohn’s disease is an inflammatory disease of the bowel that can affect any part of the intestinal tract, from the mouth to the anus. It symptoms, may include abdominal pain, diarrhea, bloody stools, abdominal distention, and intestinal malabsorption.  It can also cause extra intestinal symptoms, such as fever, joint pain, skin rashes, eye problems and generalized fatigue.  Currently, it affects 0.32 percent of people in Europe and North America and its prevalence has been increasing over the past decades.

This condition is caused by a combination of genetic and environmental factors. There are several genes known to be strongly associated with the presence of Crohn’s disease¹. In addition, an environmental risk factors such as tobacco exposure, seems to be equally important. It is known that tobacco smokers are twice as likely to be affected by this entity than non smokers².

There are various degrees of severity for Crohn’s disease and it can be complicated by intestinal obstruction, fistula formation, gastrointestinal bleeding, intestinal perforation and abscesses. There is a higher risk of cancer in the areas of inflammation caused by Crohn’s disease. Due to the inflammatory nature of the condition, food malabsorption can develop leading to weight loss and malnutrition.

The treatment of Crohn’s disease has to include lifestyle changes such as stopping smoking and following dietary recommendations such as low dietary fiber, low casein and gluten free diet. In addition to this, there are certain medications that may be used for the exacerbations of the disease, such as steroids and some long term medications like methotrexate and biological therapies. At this point, the advise of a gastroenterologist is the most valuable tool.

Marco A. Ramos MD

References

1. Genome-wide association defines more than thirty distinct susceptibility loci for Crohn's disease. Barrett JC, Hansoul S, Dan L. Nicolae DL, et al. Nat Genet. 2008; 40(8): 955–962

2. Tobacco and IBD: Relevance in the understanding of disease mechanisms and clinical practice. Cosnes J. Best Pract Res Clin Gastroenterol. 2004; 8(3):481-96

Documenting Malnutrition. Part 2

The History of Present Illness (HPI) in Severe Malnutrition in the Setting of Acute Illness

Documenting malnutrition, specially in the acute setting is one of the most disregarded aspects in clinical documentation. Many acute disease processes that lead to hospitalization, are preceded by a reduction in the intake of food and/or loss of weight. For example, a patient who is diagnosed with pneumonia with septic shock, could have started the process one week prior to the admission with an upper respiratory tract infection and with loss of appetite. Due to the decline in oral intake, the patient could have lost some weight and some patients may track their own weight or there might be outpatient records showing previous weights when the patient was not having the acute illness. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines¹  state that to consider a patient having severe malnutrition in the setting of acute illness, a reduction of more than 50% of the estimated energy requirement has to be present for 5 days or more. Since 2 criteria are needed, the requirement may be fulfilled by documenting weight loss or an aspect of the physical exam. Regarding the loss of weight criteria, ASPEN guidelines say that in order to consider a patient for having severe malnutrition in the setting of acute illness, the loss of weight in 1 week has to be 2% or more. If the loss of weight happens in a month, it has to be 5% or more and if it happens in the preceding 3 months it has to be 7.5% or more.

So, an HPI may read like this:

“Mr X is a 74 year old gentleman who presented to the emergency department (ED) with a history of 7 days of progressive productive cough, dyspnea, anorexia and fever. The patient referred that 7 days prior to presentation he developed “cold”. He said that his oral intake was reduced to about 25% of a normal meal. 3 days prior to admission, he developed productive cough with a green sputum and 2 days prior, high fever quantified at 102 F. Due to the symptoms getting progressively worse and the addition of dyspnea on mild efforts, he decided to show up in the ED. He stated that his usual weight is 150 pounds and now he is weight 145 pounds.”

Please note that the last piece of information can also be placed in the Review of Systems (ROS). The information in the HPI anticipates what is going to show in the Assessment and Plan (A/P)

References

1 http://www.baxternutritionacademy.com/ie/disease_related/identifying_malnutrition.html Retrieved January 12, 2017

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement