Quality improvement project to Reducing the Malnutrition Rate of ICU patients from 43% to 20%

Rajeswari^a, Katheeresan^b, Sivagami^c, Sowndarya^d, Dharmendran^e

^aSenior Dietitian, Kauvery Hospital, Salem

^bSenior Assistant Nursing Superintendent, Kauvery Hospital, Salem

^cAssistant Nursing Superintendent, Kauvery Hospital, Salem

^dJunior Executive Quality, Kauvery Hospital, Salem

^eAssistant Manager Quality, Kauvery Hospital, Salem

Background

During the month of September-November, 2022, we observed that prolonged ICU stays can lead to malnutrition, which can compromise the patient’s immune system and overall health. Patients in the ICU often require prolonged periods of bed rest, and they may be unable to eat or drink normally due to mechanical ventilation, gastrointestinal issues, or other medical complications. Additionally, they may experience inflammation and metabolic changes that increase the body’s demand for nutrients. These factors can lead to a negative energy balance, where the body is not getting enough calories to meet its needs, and malnutrition can develop.

Problem Definition

9 cases were reported in the month of September, 9 cases were reported in the month of October and 6 cases were reported in the month of November whose length of stay was more than 4 days

Impact of VAP

Compromise the patient’s immune system and overall health. Malnutrition increases ICU length of stay by up to 4 days and hospital length of stay by up to 8 days. (Average length of stay in ICU: 3 days; Hospital: 4 days).

Impact on the Institution

Patients and attenders will lose confidence over the treatment provided in the institute. Further, they may not visit again and also will not refer their colleagues/relatives to our institution.
The top management may not have a good impression about the ICU Team.
May affect our organisation’s brand image.
May affect the target of quality indicators.
May fail to achieve our business objectives.

Process Sequence

Tools Used to Identify Malnutrition

Malnutrition Universal Screening Tool (MUST) in ICU: This tool includes questions about recent weight loss, BMI, and acute disease effect. Patients are classified as low, medium, or high risk for malnutrition

Significance of CAT score

CAT (C- Reactive Protein, Albumin, Total Lymphocyte Count)
Albumin: Albmin is a protein that is commonly used to assess nutritional status. A low albumin level may indicate malnutrition, but it can also be affected by other factors such as inflammation.
Total lymphocyte count: Malnutrition can affect the immune system, and a low total lymphocyte count may indicate malnutrition.
C-reactive protein (CRP): CRP is an acute phase protein that can indicate inflammation. High levels of CRP may make it difficult to interpret other nutritional markers

MRC -Muscle Strength Scale by Physiotherapists

Here is the modified MRC scale:

0 – no contraction detected

1 – Normal strength

2 – Mild weakness

3 – Moderate weakness

4 – Severe weakness

5 – Complete paralysis

“A tool that combined the MUST score, MRC scale, and laboratory values of CRP, TLC, and albumin to assess and grade malnutrition in ICU patients”

Problem Analysis

Validation was done for all the probable causes and significant causes were identified through verification. 3 significant causes were found out

How analysis was done for all the 4 valid causes and root cause was identified.

Malabsorption in ICU patients – 1st root cause
Incorrect Placement of Feeding Tube – 2nd root cause
Inappropriate formulation of calories and proteins – 3rd root cause

Data analysis was done in the month of December for each of the valid causes and solutions were developed

Data Analysis – 1: Medications may interfere with the absorption of nutrients, such as antibiotics that disrupt the gut microbiome or chemotherapy drugs that cause gastrointestinal side effects
Solution – 1 : Administered medication with food, Enteric coated Formulations, Precautious prophylactic Counter Medicines for Diarhoea, vomiting and Nausea for enhanced Absorption
Data Analysis – 2: Lack of Visual Aids, Videos and Mock drills on Insertion of the Feeding Tube – 2nd root cause
Solution – 2: Setting Up Drawings, Posters,Visual Aids, Video Training, Mock drills and Hands on Training by the Educator, competency assessment, Product Orientation in Pharmacy
Data Analysis – 3: Computed our own Guidelines with the Adequate Lab findings, Physiotherapy chart and Dietician Chart – 3rd root cause
Solution – 3: A combined Malnutrition assessment Tool with MUST SCORES+CAT SCORE+MRC SCALE

Standardization

A need-based checklist was created and SOP was updated based on the implemented solutions after obtaining approval from Deputy Medical Administrator

Outcome

Benefits

Tangible Benefits

Improved clinical outcomes: Adequate nutrition can lead to faster recovery and reduced morbidity and mortality rates.
Reduced length of hospital stay: Proper nutrition can help reduce the length of hospital stay, which can save on healthcare costs (ICU length of stay reduced from 4 days to 2 days)
Decreased healthcare costs: Adequate nutrition can reduce the need for additional medical interventions, medications, and other treatments.

Intangible benefits

Improved quality of life: Proper nutrition can improve patients’ physical and mental well-being, leading to an improved quality of life.
Increased patient satisfaction: Adequate nutrition can improve patients’ overall satisfaction with their care.
Improved staff morale: When patients have better outcomes and are more satisfied with their care, staff morale can improve.

Discussion

Malnutrition is a preventable during the hospital stay of patient, providing the right feed at right time in right route and precaution taken are appropriate

Ms. Rajeswari

Senior Dietitian

Mr. Katheeresan

Senior ANS

Ms. Sivagami

ANS

Ms. Sowndarya

Junior Executive Quality

Mr. Dharmendran

Assistant Manager Quality

Quality improvement project to Reducing the Malnutrition Rate of ICU patients from 43% to 20%