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PRE-OPERATIVE NUTRITION DIAGNOSIS Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center

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Page 1: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

PRE-OPERATIVE NUTRITION DIAGNOSIS

Ulises Torres, MD, FACSSurgical Critical Care

Co-Chair Nutrition Advisory Committee

University of Massachusetts Medical Center

Page 2: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Disclosures

None

Page 3: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

OBJECTIVES

At the end of this presentation you will be aware of the importance of:

1. Recognizing the syndromes of malnutrition

2. Clinical factors needed for the diagnosis of malnutrition in your own practice.

3. Importance of malnutrition in cardiac surgery outcomes

4. Options to improve your process of diagnosis, screening and

documentation

Page 4: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

First : Definitions

: PARENTERAL NUTRITION

: ENTERAL NUTRITION

CPN: compounded parenteral nutrition

SPN: standardized parenteral nutrition

: specialized or artificial nutrition (EN or PN)

: patient’s own volitional intake

Page 5: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 6: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

What is the best single indicator of malnutrition?

No single clinical or laboratory parameter can be recommended as an indicator for comprehensive evaluation.

Fischer et al. Nutr Clin Pract. 2015;30:239-248

Page 7: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

3 proposed syndromes

1. Starvation associated malnutrition:

Chronic malnutrition without inflammation

Page 8: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

2. Chronic disease-associated malnutrition:

Inflammation is chronic and of mild to moderate degree

Page 9: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

3. Acute disease of injury associated malnutrition

Inflammation is acute and of severe degree

Major infections, burns, trauma or closed head injury

Page 10: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

The guidelines…

Page 11: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

ASPEN/AND Consensus (2012)

Clinical characteristics to support a diagnosis of malnutrition:

Recent weight loss

Decreased appetite and intake

Loss of subcutaneous fat

Loss of muscle mass

Fluid accumulation

Decreased functional status

Page 12: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

ASPEN/AND Consensus (2012)

Clinical characteristics to support a diagnosis of malnutrition

Recent weight loss

Decreased appetite and intake

Loss of subcutaneous fat

Loss of muscle mass

Fluid accumulation

Decreased functional status

White JV, Guenter P, Jensen GL, et al. Consensus statement: Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). JPEN J Parent Ent Nutr. 2012;36:275-283.

Page 13: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

But that’s complicated!

To simplify, assess for:BMI < 20.5Weight loss in past 3 mos. (documented or reported)Reduced intake in past weekObserve for overt signs of muscle wasting/fat loss

If YES to any of the above; consider severity of illness (APACHE >10, hematologic malignancy, head injury, trauma, major abdominal surgery)

→ Nutrition consult to determine if criteria is met(Source - NRS 2002)

Education

Efficiency

&

Accuracy

Page 14: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Useful aid …..

Page 15: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 16: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 17: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 18: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 19: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

6 causes of muscle atrophy

C

H

O

P

I

N

Page 20: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Clinical signs and physical examination

Attention to parts of the body with high cellular turnover Weight loss + loss of muscle mass + edema should not be missed!

Page 21: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Body composition techniques

Impedance

CT scans

MRI

Ultrasound

Multicompartment models

Page 22: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Laboratory indicators

Albumin and Prealbumin are NOT to be used in cardiac care nutrition diagnosis post-operatively.

Page 23: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Dietary assessment

24 recall

Calorie and protein counts

Page 24: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

What is the most practical measure for clinical assessment?

Hand grip strength

Page 25: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Other practical measures for clinical assessment?

Page 26: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Concept of Nutritional risk

Page 27: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 28: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 29: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 30: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Malnutrition affect cardiac outcomes

Page 31: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 32: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 33: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 34: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 35: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 36: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

How is your hospital doing ?

Page 37: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 38: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 39: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

UMass – Acute Care (rate of dx)

E43, 44.0 – May 16: 1.4%

E43, E44.0 – June 16: 1.1 %

E43, E44.0 – July 16: 1.1 %

E43, E44.0 – Aug 16: 1.1 %

E43, 44.0 – May 17: 4.1%

E43, E44.0 – June 17: 3.4 %

E43, E44.0 – July 17: 3.4 %

E43, E44.0 – Aug 17: 4.2 %

UT – above data shows impact from program; also that we need wider engagement for additional ID of dx.

Page 40: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

E46 – Unspecified PCM

Used when the physician is unable to classify the degree of malnutrition.

Problematic because in the near future CMS will begin denying claims that omit the degree of malnutrition (mild, moderate, or severe)

Avg % Patients discharged with dx E46 (2017):

Acute: 4 %

ICU: 23 %

Page 41: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Malnutrition dx made by RD are low risk from audit perspective b/c we know there is sufficient documentation in chart to support diagnosis.

Malnut dx made by MD - ? Criteria are they using, can this be false/inaccurate dx

Page 42: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 43: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Process

Page 44: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

Process

Early identification of nutrition risk via nursing MST, RD screen

Nutrition assessment & identification of malnut dx

Communication of dx to provider via BPA

Provider acts upon BPA to add to hosp problem list Implement patient specific nutrition intervention; ongoing

eval of nutr prescription

Page 45: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 46: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 47: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 48: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 49: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None
Page 50: PRE-OPERATIVE NUTRITION DIAGNOSIS · Ulises Torres, MD, FACS Surgical Critical Care Co-Chair Nutrition Advisory Committee University of Massachusetts Medical Center. Disclosures None

THANK YOU

1. Recognize the 3 syndromes in malnutrition2. Diagnose it using the correct parameters 3. Know the outcomes in cardiac surgery4. Put it in practice, improve outcomes,

documentation and revenue


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