Clinical Malnutrition

Registered dietitian nutritionists have the opportunity and responsibility to be at the forefront of the prevention and treatment of malnutrition. Poor nutritional status is often referred to as clinical malnutrition or undernutrition and applies to individuals who are overweight and underweight.

The evidence-based tools and resources below allow actions to improve and implement protocols for screening and assessing, diagnosing and providing a care plan for treating individuals with or at risk for food insecurity and malnutrition across the healthcare continuum.

Malnutrition Quality Improvement Initiative

The Malnutrition Quality Improvement Initiative is a project of the Academy of Nutrition and Dietetics, Avalere Health, and other stakeholders who collaborate to provide guidance and expertise for clinical malnutrition. The Academy of Nutrition and Dietetics and Abbott support the MQii. The Academy works together with MQii partners and engages stakeholders to discuss malnutrition quality improvement and care transitions documented in our Dialogue Proceedings. The primary goal is to advance evidence-based, high-quality, patient-driven care for hospitalized older adults who are malnourished or at-risk for malnutrition.

To accomplish its objectives, the MQii designed key tools for real-world application, a MQii Toolkit and a set of four electronic clinical quality measures, or eCQMs. These tools mutually support one another guiding hospitals and organizations with malnutrition quality improvement to achieve better health outcomes. The MQii Toolkit provides practical, interdisciplinary tools and resources to support hospitals establish best practices and adopt the eCQMs to evaluate their success in meeting the standards of care. Find out the what, who, when, why and how on eCQMs by reviewing the FAQs.

The MQii Learning Collaborative is a community of clinicians committed to improving delivery of malnutrition care in hospitals and health systems across the US. The MQii Learning Collaborative was established in 2016 and continues today with over 300 hospitals in 38 states participating. . These hospitals undertake a data-driven, patient-centered, malnutrition quality improvement project at their respective organizations using a best practices Toolkit and use malnutrition eCQMs to track and monitor improvement. Their results are highlighted in the 2020 JPEN article, How a Malnutrition Quality Improvement Initiative Furthers Malnutrition Measurement and Care: Results From a Hospital Learning Collaborative. Featured MQii successes can be reviewed in numerous articles and abstracts published in the October 2019 Supplement to the Journal of the Academy of Nutrition and Dietetics, Malnutrition Quality Improvement Initiative Yields Value for Interdisciplinary Patient Care and Clinical Nutrition Practice.

Global Malnutrition Composite Score
Components of the nutrition quality measures for malnutrition screening, assessment, malnutrition diagnosis and development of a care plan for treatment have been combined into a composite measure to score hospitals on their efforts to identify malnutrition and improve care. The Global Malnutrition Composite Score, or GMCS incentivizes screening all older adults for malnutrition risk at hospital admission, assessing those found to be malnourished and at risk for malnutrition, documenting diagnosed malnutrition, and developing a nutrition care plan with implementing intervention and treatment before discharge which then follows patients as they transition to the next point of care setting. The GMCS, MUC20-0032 is included on the December 2020 final published Centers for Medicare & Medicaid Services (CMS) 2020 Measures Under Consideration (MUC) List. In June 2021, the National Quality Forum's Consensus Standards Approval Committee unanimously endorsed the GMCS, NQF #3592. Endorsement indicates a measure is "best in class" and brings the measure one step closer to CMS program adoption.

Malnutrition Quality Measures included in QCDRs
The Centers for Medicare & Medicaid Services (CMS) has approved inclusion of new Malnutrition Quality Measures into two Qualified Clinical Data Registries (QCDRs) for RDNs to participate in the 2020 and 2021 Merit-based Incentive Payment System (MIPS). The new Malnutrition Quality Measures included in the Premier Clinician Performance Registry and the U.S. Wound Registry promote health care team collaboration with measures for physician and RDN reporting. These measures are for MIPS reporting via QCDRs and do not replace the previous four (4) malnutrition eCQMs and the Global Malnutrition Composite Score measure (composite measure). For more information, listen to the QCDR Microlearning Series (1.0 CPEU) and review the FAQs.

Malnutrition Resources from the Academy of Nutrition and Dietetics

Academy of Nutrition and Dietetics Health Informatics Infrastructure
ANDHII provides the tools to track malnutrition in practice. Through the electronic nutrition care process and terminology, ANDHII can be used to track and report the incidence and prevalence of malnutrition alongside the impact of nutrition care on the clinical characteristics of malnutrition and patient outcomes.

Evidence Analysis Library
The Academy's Evidence Analysis Library published two systematic reviews in 2018. The Nutrition Screening Adults review examines the validity and reliability of adult nutrition screening tools. The cost of the malnutrition screening procedure was also reviews. The scope of the Nutrition Screening Pediatric review was to determine the validity and reliability of 14 pediatric nutrition screening tools to identify risk of malnutrition related to under- or over-nutrition and to determine if results varied according to users of the tools.

House of Delegates Dialogue Outcomes on Malnutrition
In 2015, the Academy's House of Delegates conducted a dialogue session to explore how RDNs can be leaders in the identification and management of malnutrition. Read the fact sheet with outcomes as a result of the meeting.

Journal of the Academy of Nutrition and Dietetics

The Journal publishes a multitude of malnutrition-related content, organized within the following collections:

Malnutrition Coding
This eatrightPRO page contains resources on hospital reimbursement for malnutrition and practice tools.

Nutrition Care Manual
The Adult, Pediatric, and Sports Nutrition Care Manuals are professional practice resources consisting of the largest client education library and current evidence-based nutrition recommendations for adults, children, and athletes. The Nutrition Care Manuals are updated annually and in 2019 the Adult Nutrition Care Manual included a brand new section with all-inclusive guidance for providing malnutrition care.

Nutrition Care Process and Terminology
The electronic Nutrition Care Process and Terminology provides up-to-date standardized language for documentation of malnutrition diagnoses, supporting evidence and nutrition interventions. The 2015 edition adds etiology-based malnutrition diagnosis terms to mirror the Academy and ASPEN consensus paper and all eNCPT malnutrition terms are mapped to SNOMED-CT for full compatibility with clinical information systems.

Nutrition Focused Physical Exam Hands-on Training Workshop
The Academy offers in-person training for registered dietitian nutritionists to accurately identify and nutrition diagnose adult or pediatric patients with, or at risk for, malnutrition. While a nutrition-focused physical exam is only one component of the nutrition assessment, it can provide necessary supportive data. Pocket guides for both pediatric and adult nutrition-focused physical exams are available in eatrightSTORE.

Malnutrition Resources from Other Organizations

Abbott Nutrition
The Abbott Nutrition Health Institute provides free RDN CPEU, including a certificate of training in adult malnutrition.

Alliance for Aging Research
The Alliance for Aging Research's website contains information on malnutrition in older adults including a short film, quiz and a health care professional tip sheet.

ASPEN Malnutrition Toolkit
Health care professionals can access malnutrition definitions, a nutrition care algorithm, screening and assessment tools, publications and more via ASPEN's Malnutrition Toolkit. Malnutrition-related online educational opportunities also are available.

Canadian Malnutrition Task Force
The Canadian Malnutrition Task Force provides malnutrition screening, diagnostic, treatment and monitoring resources on its website. Also available are guidelines, protocols, research posters and information on advocating for a culture of change in hospital foodservice

Defeat Malnutrition Today
A coalition including the Academy and many other organizations, Defeat Malnutrition Today emphasizes malnutrition screening and intervention. The website features infographics, articles, studies and the National Blueprint: Achieving Quality Malnutrition Care for Older Adults.

ENact Nutrition
Nestlé Health Science developed this web-based, integrated enteral nutrition program aimed at improving patient outcomes through the adoption of nutrition-focused quality improvement initiatives in the hospital setting.

Toolkit for Using the AHRQ Quality Indicators
The QI Toolkit is designed to support hospitals in assessing and improving the quality and safety of care they provide.