Malnutrition Underrecognized to the Detriment of Hospitalized Patients

Malnutrition is a highly prevalent and underdiagnosed condition among hospitalized patients in the United States. While up to 50% are malnourished or at risk for malnutrition, only 8% receive a medical diagnosis. In addition patients with undiagnosed malnutrition are at risk for several complications including poor wound healing, higher infection rates, and impaired ambulation. Left untreated, nutritional deficiencies can slow recovery and lead to longer hospital stays and increased hospital readmissions.

Cleveland Clinic in Florida took significant steps in 2021 to address this issue by restructuring the clinical nutrition services provided by inpatient and outpatient teams based in South Florida, making substantial progress in a short time.

“Nutrition is a critical underpinning to good health, and we know that even mild cases of malnutrition can prolong illness,” says board-certified gastroenterologist Tolga Erim, DO, Chair of the Department of Gastroenterology, Hepatology and Nutrition at Cleveland Clinic in Florida. “That’s why we’ve elevated the role of clinical nutrition in patient care and enhanced our services.”

An operational blueprint

Cleveland Clinic’s Center for Human Nutrition in Ohio has provided care for patients with nutritional disorders for more than four decades, focusing on nutrition therapy, gut rehabilitation, and nutritional support. The Center provided an operational blueprint for the Florida team that fosters interprofessional collaboration between registered dietitians, dietetic technicians, nurses, pharmacists and physicians to develop and implement individualized plans for patients with specialized nutrition needs.

“Since taking steps to create an internally staffed nutrition team to care for hospital-based patients, our program now aligns with the best practices of our Ohio counterparts,” shares Dr. Erim.

Building a nutrition team

Today, a team of more than a dozen registered dietitians and dietetic technicians serve the inpatient population at Cleveland Clinic Weston Hospital, a 230-bed tertiary care facility, as well as individuals receiving outpatient services. This includes RDs with specialized training embedded in several key departments – Bariatrics, Endocrinology, Transplant, Cancer, Gastroenterology and Executive Health.

“Our team provides regular nutritional support as well as advanced interventions for about 1,000 patients each month,” says Andrew Ukleja, MD, Director of Nutrition Center at Cleveland Clinic Weston. “We work with patients to ensure optimal nutrition as they cope with a broad array of diseases and conditions, including diabetes, kidney disease, digestive disorders, cancer and obesity.”

Dr. Ukleja credits team development and physician support for the program’s success, pointing to the Clinic’s investment in professional development and educational offerings, as well as career advancement opportunities. “Our RDs are treated as knowledgeable professionals and frequently sought out for consultation,” he says.

Signs of success

As a national and international referral center for GI care and specialty surgery, including solid organ transplantation, Cleveland Clinic in Florida draws patients with very complex conditions including unviable digestive systems, ostomies, inflammatory bowel disease, short bowel syndrome and malabsorption syndromes. For seven consecutive years, the gastroenterology and GI surgery program within the Ellen Leifer Shulman and Steven Shulman Digestive Disease Center at Cleveland Clinic Weston Hospital has been the only nationally ranked program in South Florida by U.S. News & World Report.

“We provide a very sophisticated level of care, often for patients who come to us clinically frail or nutritionally compromised,” explains Dr. Ukleja. “Our nutrition team is responsible for assessing patients for nutritional risk and identifying individuals for risk of malnutrition, so that our healthcare providers can establish a proper diagnosis required to implement nutritional interventions.”

These interventions may include:

• Nutrition counseling
• Personalized diet prescription
• Medications to improve digestion and absorption
• Oral rehydration solutions and oral nutrition supplements
• Enteral feeding
• Parenteral nutrition

In the Florida program’s first year malnutrition diagnoses increased by nearly 25% over 2020, an early indicator of success. Ultimately, the goal is to also see corresponding improvements in patient outcomes, such as shorter lengths of stay and lower hospital readmission rates.

An educational resource

Cleveland Clinic Florida’s clinical nutrition team has many functions beyond assessing and treating malnutrition. Dr. Ukleja says one of his most important responsibilities is educating colleagues on the role nutrition plays in treating diseases. “The gap in nutrition education in medical school is well documented, which is why I host physician lectures promoting the value of nutritional interventions in patient care,” he adds.

Meanwhile, RDs in the Department of Bariatrics provide complementary care, participating in medical weight loss therapy and working with patients before and after bariatric surgery. Others participate in shared medical appointments for patients with diabetes and primary care patients needing weight loss support. The team also conducts community education and outreach.