Prathibha Varkey, MBBS, MPH, MHPE

History

A careful history elicits the majority of information needed to determine the cause and severity of malnutrition.16 Patients should be questioned about a typical day's oral intake prior to hospitalization, and about factors that affect their intake such as sensory deficits, fine motor dysfunction, or chewing and swallowing difficulties, which often decline in chronically ill and elderly patients. Nutrition may be affected by financial difficulties or limited social support, and access to food should be assessed.

Physical Findings

Weight loss is the best physical exam predictor of malnutrition risk, although nutritional depletion can occur in a very short time in acutely ill or injured patients before substantial weight loss has occurred. The likelihood of malnutrition is increased if a patient has: a body mass index (BMI) <18.5 kg/m²; unintentional loss of >2.3 kg (5 lb) or 5% of body weight over 1 month; and unintentional loss of >4.5 kg (10 lb) or 10% of body weight over 6 months.17 Weight loss may be masked by fluid retention from chronic conditions, such as heart failure, or from volume resuscitation in the acutely ill patient.9, 16

Body mass index can be misleading, as age‐related height loss may artificially increase BMI, and height may be difficult to accurately measure in a kyphotic, unsteady, or bedridden patient. The clinician may find evidence of loss of subcutaneous fat or muscle mass in patients with chronic illness, but these findings may not be evident in the acutely ill patient.9 Other physical exam assessments of malnutrition, such as arm span, skinfold thickness, and arm circumference are not reliable.16

Laboratory Tests

Biochemical markers, including transferrin, albumin, and prealbumin, have not been proven as accurate predictors of nutrition status because they may change as a result of other factors not related to nutrition.15, 18 Serum albumin, for example, may be more reflective of the degree of metabolic stress.19 Prealbumin has a serum half‐life much shorter than albumin or transferrin (approximately 2448 hours) and is perhaps the most useful protein marker to assess the adequacy of nutritional replacement after the inflammatory state is resolved.18

Calculating Caloric Requirements

Energy expenditure measurement is considered the gold standard to determine patients' caloric needs. Actual measurement by methods such as indirect calorimetry, which measures oxygen consumption and carbon dioxide production, and calculates energy expenditure, is challenging in everyday clinical settings. Predictive equations often are used as alternative methods to estimate patients' caloric requirements.20 There is no consensus among the 3 North American societies' guidelines (the Canadian Clinical Practice Guidelines; the American Dietetics Association's evidence‐based guideline for critical illness; and the Society of Critical Care Medicine and American Society of Parenteral and Enteral Nutrition's joint guideline) as to the best method.21

In the simplest equation, caloric needs are estimated by calories per kilogram.22 In obese patients, using actual body weight will overestimate needs, but using ideal body weight may cause underfeeding. A small study comparing predictive equations in obese hospitalized patients found the Harris‐Benedict equations (H‐BE) using adjusted body weight and a stress factor to be most accurate, but only in 50% of patients.23 Most clinicians are familiar with the H‐BE, but alternatives such as calories per kilogram or the Mifflin St.‐Jeor equation24 are often used (S. Brantley (May 5, 2012), S. Lundy (May 23, 2012), personal communication).

Indications for Nutritional Intervention

In adults without preexisting malnutrition, inadequate nutritional intake for approximately 714 days should prompt nutritional intervention.25, 26 This timeline should be shorter (37 days) in those with lower energy reserves (eg, underweight or recent weight loss) or significant catabolic stress (eg, acutely ill patients).27, 28 Other patient populations shown to benefit from nutritional intervention include: postoperative patients who are anticipated to be NPO for more than 7 days or to be taking less than 60% of estimated caloric needs by postoperative day 10; preoperative patients with severe malnutrition29; those with gastrointestinal cancer undergoing elective surgery30; and stroke patients with persistent dysphagia for more than 7 days.31

Dietary Modifications

The purpose of the diet is to provide the necessary nutrients to the body in a well‐tolerated form. Diets can be modified to provide for individual requirements, personal eating patterns and food preferences, and disease process and digestive capacity. Dietary adjustments include change in consistency of foods (eg, pureed, mechanical soft), increase or decrease in energy value, increase or decrease in the type of food or nutrient consumed (eg, sodium restriction, fiber enhancement), elimination of specific foods (eg, gluten‐free diet), adjustment in protein, fat, and carbohydrate content (eg, ketogenic diet, renal diet, cholesterol‐lowering diet), and adjustment of the number and frequency of meals.32

Dietary supplementation (eg, Boost, Ensure) is common practice in persons diagnosed with such conditions as cancer, diabetes, and cardiovascular disease. Supplements enhance the diet by increasing the total daily intake of a vitamin, a mineral, an amino acid, an herb or other botanical33, and should not be used as a meal substitute.34 These supplements are varied in content of calories, protein, vitamins, and minerals. Various flavors and consistencies are also available. Several oral supplements are reviewed in Table 1.

Enteral Nutrition

Enteral nutrition (EN) support should be provided to patients who have functioning gastrointestinal (GI) tracts but are unable to take adequate calories orally. Compared to parenteral nutrition (PN), EN is associated with favorable improvements in inflammatory cytokines, acute phase proteins, hyperglycemia, insulin resistance, nosocomial infections, mortality, and cost.35 Enteral feeds are more physiologic than parenteral feeds, maintain GI structure and integrity, and avoid intravenous (IV) access complications. Patients with normal nutritional status on admission who require EN should be receiving over 50% of their caloric needs within the first week of hospital stay.25 Malnourished patients should reach this minimum goal within 35 days of admission.27, 28 EN is not contraindicated in the absence of bowel sounds or in the presence of increased gastric residuals.35 Withholding enteral feedings for gastric residual volumes <250 mL36, 37 or reduced bowel sounds can result in inadequate caloric intake or inappropriate use of PN.27

Gastric feedings are more physiologic than small bowel feedings, can be given by bolus or continuous infusion, and can be given by tubes that are easy to place at the bedside. Post‐pyloric feedings (nasoduodenal or nasojejunal) may be associated with a lower risk of pneumonia, and should be considered in high‐risk patients such as those receiving continuous sedatives or neuromuscular blockers.36 Post‐pyloric tube placement usually requires endoscopy, fluoroscopy, or electromagnetic guidance. Percutaneous feeding tubes (gastrostomy or jejunostomy) should be considered in those who require tube feedings for longer than 30 days.38

Assessment of patient requirements and disease state, as well as extensive knowledge of available formulas, is important in the selection of the appropriate enteral formula.39 Standardized formulas are used for most patients. The provision of adequate water must be considered with these formulas, particularly in the long‐term care and home settings.40 Many specialized formulas are designed for a particular disease state or condition, some of which are further reviewed in Table 2.

If concerned about formula tolerance, one solution is to initiate the formula at a low rate and increase to the goal rate over 2448 hours. Dilution of enteral formulas is not necessary to assure optimal tolerance. Continuous feedings are recommended for most patients initially and after tolerance has been established, bolus feedings can be attempted if the feeding tube terminates in the stomach. Bolus feedings, where 240480 mL of formula are delivered through a syringe over 1015 minutes, may be more physiological for patients. This regimen can be repeated 46 times daily to meet nutrition goals.41

Parenteral Nutrition

PN provides macronutrients such as carbohydrates, protein, and fat; micronutrients such as vitamins, minerals, electrolytes, and trace elements are added in appropriate concentrations. PN may also provide the patient's daily fluid needs. The timing of PN initiation depends upon the patient's initial nutritional status. ASPEN does not recommend PN during the first 7 days of hospitalization in critically ill patients with normal nutritional status. If the patient is not receiving 100% of caloric needs from EN after 7 days, supplemental PN should be considered. However, if on admission a patient is already malnourished and EN is not feasible, PN should be initiated and continued until the patient is receiving at least 60% of caloric needs by enteral route.42 This includes patients with intestinal obstruction, ileus, peritonitis, malabsorption, high output enterocutaneous fistulae, intestinal ischemia, intractable vomiting and diarrhea, severe shock, and fulminant sepsis.10, 43

Standardized commercial PN products are available and reduce the number of steps required between ordering and administration, as compared to customized PN, which is compounded for a particular patient. However, despite improved efficiency and lower cost, there is no evidence that standardized preparations are safer to patients than customized solutions. Institutions utilizing standardized PN must also have a mechanism to customize formulas for those with complex needs.44

Creating a customized parenteral solution involves several basic steps. Total caloric requirement may be estimated using a predictive formula, as previously discussed; calories/kg of ideal body weight is the simplest method. Most hospitalized patients require 2030 calories/kg/d. Daily fluid requirement may be based on kilocalories (kcal) delivered, or by ideal body weight (eg, 1 mL/kcal or 3040 mL/kg). More fluid may be needed in patients with significant sensible or insensible losses; those with renal failure or heart failure should receive less fluid.

Protein needs are calculated by multiplying ideal body weight (kg) by estimated protein needs in g/kg/d (1.22 g/kg/d for catabolic patients). Protein should provide approximately 20% of total calories. Protein restriction is not required in renal impairment; acutely ill patients on renal replacement therapy should receive 1.51.8 g/kg/d. In hepatic failure patients, protein should be restricted only if hepatic encephalopathy fails to improve with other measures.

Knowing the protein, kcal, and fluid needs of the patient, the practitioner divides the remaining non‐protein calories between carbohydrates and fat. Approximately 70%85% of non‐protein calories should be provided as carbohydrates (dextrose), up to 7 g/kg/d. The other 15%30% are as fat, in lipid solutions, providing a maximum of 2.5 g/kg/d. Lipid solutions are provided as either 10% (1.1 kcal/mL) or 20% (2.2 kcal/mL) concentrations.43, 44 Propofol's contribution to fat intake complicates estimating total fat intake in critically ill patients.45

Standardized parenteral multivitamin preparations are available; the clinician must determine if preparations containing vitamin K are appropriate. Of the trace elements, copper and manganese should be restricted in hepatobiliary disease.44

Acutely ill patients receive PN as a 24‐hour infusion, to minimize its impact on volume status and energy expenditure,46 providing 50% of needs on infusion day one and reaching goal within 4872 hours, rather than cyclic infusions over shorter intervals. Daily assessments of vital signs, intake and output, and weight are necessary to monitor volume status.

Once a patient is taking at least 60% of caloric needs either by mouth or by EN, PN can be discontinued. Tapering the infusion is not required, as abrupt discontinuation has not been demonstrated to cause symptomatic hypoglycemia.47, 48

Adverse Effects and Complications of Nutrition Support

Regarding EN, complications include those related to tube placement and maintenance, infections, and medical complications of the feeds themselves. Some of the adverse effects of the enteral formulas may be attenuated. Diarrhea, which occurs in up to 20% of patients, may be avoided with slow feed advancement, use of low‐osmotic formulas, or fiber additives.51 Gastric distention and abdominal pain may improve with slow feed advancement and continuous (rather than bolus) feeds. Small‐bore tubes and acid‐reducing medications may decrease gastroesophageal reflux, and aspiration pneumonia may be avoided by semi‐recumbent positioning and post‐pyloric feeding.52

Complications of PN may be grouped as mechanical, infectious, and metabolic. The mechanical complications of central line placement include pneumothorax, arterial puncture, hematoma, air embolism, and line malpositioning. Catheter‐related deep venous thrombosis may occur. Patients on PN through a central line are at risk for central line‐associated bloodstream infections.25 The metabolic complications such as hyperglycemia, electrolyte disorders, hepatic steatosis, and volume overload may have severe consequences, such as heart failure or neuromuscular dysfunction, thus they require close attention.53

A complication of nutrition support that may occur regardless of route is the refeeding syndrome. Refeeding syndrome describes fluid shifts and electrolyte abnormalities that occur after initiation of oral, enteral, or parenteral nutrition in a malnourished or starved patient.54, 55 There are no formal criteria for diagnosing refeeding syndrome.

In the starved state, the body switches from carbohydrate to protein and fat metabolism. Reintroduction of carbohydrates stimulates insulin release with glycogen, fat, and protein synthesis. Associated uptake of glucose, potassium, magnesium, phosphate, and water into cells causes electrolyte and fluid abnormalities. Although hypophosphatemia is the hallmark of refeeding syndrome, it is not pathognomonic. Additional disturbances include hypokalemia, hyperglycemia, hypomagnesemia, thiamine deficiency, and fluid imbalance.49 Patients at risk of refeeding should have serum electrolytes, magnesium, phosphorus, and glucose checked before nutrition support starts. The degree of laboratory abnormalities, if any, and the clinical course of refeeding guides the frequency of subsequent blood tests.56 These consequences of refeeding can adversely affect every major organ system and may result in death.57

Starvation physiology underlies all risk factors for refeeding syndrome. In hospitalized patients, those at risk for refeeding include, but are not limited to, the elderly, oncology patients, postoperative patients, alcohol‐dependent patients, those with malabsorptive states, those who are fasting or chronically malnourished, and those on diuretic therapy.54, 57 The National Institute for Health and Clinical Excellence (NICE) of England and Wales has published criteria to identify patients at high risk for refeeding (Table 3).56 Identification of at‐risk patients and attention to their nutritional needs prevents refeeding syndrome.

ASPEN and NICE have each issued guidelines for initiating nutrition support in patients at risk for refeeding. ASPEN guidelines recommend feeding start at approximately 25% of the estimated goal, with advancement to goal over 35 days. ASPEN recommends fluid and electrolyte status be monitored as needed.50 The NICE guidelines recommend starting nutrition support at a maximum of 10 kcal/kg/d with slow increase to meet or exceed full needs by 47 days. For extremely malnourished patients (eg, BMI <14 kg/m², or negligible intake for >15 days), they recommend starting at 5 kcal/kg/d. For patients at high risk of developing refeeding syndrome, the NICE guidelines recommend vitamin repletion immediately before and during the first 10 days of feeding (thiamine, vitamin B, and a balanced multivitamin/trace element supplement). Cardiac monitoring is recommended for this group as well as any patients who are at risk for cardiac arrhythmias. Careful monitoring of fluid balance and restoring circulatory volume is recommended, as is repletion of potassium, phosphate, and magnesium.56

History

A careful history elicits the majority of information needed to determine the cause and severity of malnutrition.16 Patients should be questioned about a typical day's oral intake prior to hospitalization, and about factors that affect their intake such as sensory deficits, fine motor dysfunction, or chewing and swallowing difficulties, which often decline in chronically ill and elderly patients. Nutrition may be affected by financial difficulties or limited social support, and access to food should be assessed.

Physical Findings

Weight loss is the best physical exam predictor of malnutrition risk, although nutritional depletion can occur in a very short time in acutely ill or injured patients before substantial weight loss has occurred. The likelihood of malnutrition is increased if a patient has: a body mass index (BMI) <18.5 kg/m²; unintentional loss of >2.3 kg (5 lb) or 5% of body weight over 1 month; and unintentional loss of >4.5 kg (10 lb) or 10% of body weight over 6 months.17 Weight loss may be masked by fluid retention from chronic conditions, such as heart failure, or from volume resuscitation in the acutely ill patient.9, 16

Body mass index can be misleading, as age‐related height loss may artificially increase BMI, and height may be difficult to accurately measure in a kyphotic, unsteady, or bedridden patient. The clinician may find evidence of loss of subcutaneous fat or muscle mass in patients with chronic illness, but these findings may not be evident in the acutely ill patient.9 Other physical exam assessments of malnutrition, such as arm span, skinfold thickness, and arm circumference are not reliable.16

Laboratory Tests

Biochemical markers, including transferrin, albumin, and prealbumin, have not been proven as accurate predictors of nutrition status because they may change as a result of other factors not related to nutrition.15, 18 Serum albumin, for example, may be more reflective of the degree of metabolic stress.19 Prealbumin has a serum half‐life much shorter than albumin or transferrin (approximately 2448 hours) and is perhaps the most useful protein marker to assess the adequacy of nutritional replacement after the inflammatory state is resolved.18

Calculating Caloric Requirements

Energy expenditure measurement is considered the gold standard to determine patients' caloric needs. Actual measurement by methods such as indirect calorimetry, which measures oxygen consumption and carbon dioxide production, and calculates energy expenditure, is challenging in everyday clinical settings. Predictive equations often are used as alternative methods to estimate patients' caloric requirements.20 There is no consensus among the 3 North American societies' guidelines (the Canadian Clinical Practice Guidelines; the American Dietetics Association's evidence‐based guideline for critical illness; and the Society of Critical Care Medicine and American Society of Parenteral and Enteral Nutrition's joint guideline) as to the best method.21

In the simplest equation, caloric needs are estimated by calories per kilogram.22 In obese patients, using actual body weight will overestimate needs, but using ideal body weight may cause underfeeding. A small study comparing predictive equations in obese hospitalized patients found the Harris‐Benedict equations (H‐BE) using adjusted body weight and a stress factor to be most accurate, but only in 50% of patients.23 Most clinicians are familiar with the H‐BE, but alternatives such as calories per kilogram or the Mifflin St.‐Jeor equation24 are often used (S. Brantley (May 5, 2012), S. Lundy (May 23, 2012), personal communication).

Indications for Nutritional Intervention

In adults without preexisting malnutrition, inadequate nutritional intake for approximately 714 days should prompt nutritional intervention.25, 26 This timeline should be shorter (37 days) in those with lower energy reserves (eg, underweight or recent weight loss) or significant catabolic stress (eg, acutely ill patients).27, 28 Other patient populations shown to benefit from nutritional intervention include: postoperative patients who are anticipated to be NPO for more than 7 days or to be taking less than 60% of estimated caloric needs by postoperative day 10; preoperative patients with severe malnutrition29; those with gastrointestinal cancer undergoing elective surgery30; and stroke patients with persistent dysphagia for more than 7 days.31

Dietary Modifications

The purpose of the diet is to provide the necessary nutrients to the body in a well‐tolerated form. Diets can be modified to provide for individual requirements, personal eating patterns and food preferences, and disease process and digestive capacity. Dietary adjustments include change in consistency of foods (eg, pureed, mechanical soft), increase or decrease in energy value, increase or decrease in the type of food or nutrient consumed (eg, sodium restriction, fiber enhancement), elimination of specific foods (eg, gluten‐free diet), adjustment in protein, fat, and carbohydrate content (eg, ketogenic diet, renal diet, cholesterol‐lowering diet), and adjustment of the number and frequency of meals.32

Dietary supplementation (eg, Boost, Ensure) is common practice in persons diagnosed with such conditions as cancer, diabetes, and cardiovascular disease. Supplements enhance the diet by increasing the total daily intake of a vitamin, a mineral, an amino acid, an herb or other botanical33, and should not be used as a meal substitute.34 These supplements are varied in content of calories, protein, vitamins, and minerals. Various flavors and consistencies are also available. Several oral supplements are reviewed in Table 1.

Enteral Nutrition

Enteral nutrition (EN) support should be provided to patients who have functioning gastrointestinal (GI) tracts but are unable to take adequate calories orally. Compared to parenteral nutrition (PN), EN is associated with favorable improvements in inflammatory cytokines, acute phase proteins, hyperglycemia, insulin resistance, nosocomial infections, mortality, and cost.35 Enteral feeds are more physiologic than parenteral feeds, maintain GI structure and integrity, and avoid intravenous (IV) access complications. Patients with normal nutritional status on admission who require EN should be receiving over 50% of their caloric needs within the first week of hospital stay.25 Malnourished patients should reach this minimum goal within 35 days of admission.27, 28 EN is not contraindicated in the absence of bowel sounds or in the presence of increased gastric residuals.35 Withholding enteral feedings for gastric residual volumes <250 mL36, 37 or reduced bowel sounds can result in inadequate caloric intake or inappropriate use of PN.27

Gastric feedings are more physiologic than small bowel feedings, can be given by bolus or continuous infusion, and can be given by tubes that are easy to place at the bedside. Post‐pyloric feedings (nasoduodenal or nasojejunal) may be associated with a lower risk of pneumonia, and should be considered in high‐risk patients such as those receiving continuous sedatives or neuromuscular blockers.36 Post‐pyloric tube placement usually requires endoscopy, fluoroscopy, or electromagnetic guidance. Percutaneous feeding tubes (gastrostomy or jejunostomy) should be considered in those who require tube feedings for longer than 30 days.38

Assessment of patient requirements and disease state, as well as extensive knowledge of available formulas, is important in the selection of the appropriate enteral formula.39 Standardized formulas are used for most patients. The provision of adequate water must be considered with these formulas, particularly in the long‐term care and home settings.40 Many specialized formulas are designed for a particular disease state or condition, some of which are further reviewed in Table 2.

If concerned about formula tolerance, one solution is to initiate the formula at a low rate and increase to the goal rate over 2448 hours. Dilution of enteral formulas is not necessary to assure optimal tolerance. Continuous feedings are recommended for most patients initially and after tolerance has been established, bolus feedings can be attempted if the feeding tube terminates in the stomach. Bolus feedings, where 240480 mL of formula are delivered through a syringe over 1015 minutes, may be more physiological for patients. This regimen can be repeated 46 times daily to meet nutrition goals.41

Parenteral Nutrition

PN provides macronutrients such as carbohydrates, protein, and fat; micronutrients such as vitamins, minerals, electrolytes, and trace elements are added in appropriate concentrations. PN may also provide the patient's daily fluid needs. The timing of PN initiation depends upon the patient's initial nutritional status. ASPEN does not recommend PN during the first 7 days of hospitalization in critically ill patients with normal nutritional status. If the patient is not receiving 100% of caloric needs from EN after 7 days, supplemental PN should be considered. However, if on admission a patient is already malnourished and EN is not feasible, PN should be initiated and continued until the patient is receiving at least 60% of caloric needs by enteral route.42 This includes patients with intestinal obstruction, ileus, peritonitis, malabsorption, high output enterocutaneous fistulae, intestinal ischemia, intractable vomiting and diarrhea, severe shock, and fulminant sepsis.10, 43

Standardized commercial PN products are available and reduce the number of steps required between ordering and administration, as compared to customized PN, which is compounded for a particular patient. However, despite improved efficiency and lower cost, there is no evidence that standardized preparations are safer to patients than customized solutions. Institutions utilizing standardized PN must also have a mechanism to customize formulas for those with complex needs.44

Creating a customized parenteral solution involves several basic steps. Total caloric requirement may be estimated using a predictive formula, as previously discussed; calories/kg of ideal body weight is the simplest method. Most hospitalized patients require 2030 calories/kg/d. Daily fluid requirement may be based on kilocalories (kcal) delivered, or by ideal body weight (eg, 1 mL/kcal or 3040 mL/kg). More fluid may be needed in patients with significant sensible or insensible losses; those with renal failure or heart failure should receive less fluid.

Protein needs are calculated by multiplying ideal body weight (kg) by estimated protein needs in g/kg/d (1.22 g/kg/d for catabolic patients). Protein should provide approximately 20% of total calories. Protein restriction is not required in renal impairment; acutely ill patients on renal replacement therapy should receive 1.51.8 g/kg/d. In hepatic failure patients, protein should be restricted only if hepatic encephalopathy fails to improve with other measures.

Knowing the protein, kcal, and fluid needs of the patient, the practitioner divides the remaining non‐protein calories between carbohydrates and fat. Approximately 70%85% of non‐protein calories should be provided as carbohydrates (dextrose), up to 7 g/kg/d. The other 15%30% are as fat, in lipid solutions, providing a maximum of 2.5 g/kg/d. Lipid solutions are provided as either 10% (1.1 kcal/mL) or 20% (2.2 kcal/mL) concentrations.43, 44 Propofol's contribution to fat intake complicates estimating total fat intake in critically ill patients.45

Standardized parenteral multivitamin preparations are available; the clinician must determine if preparations containing vitamin K are appropriate. Of the trace elements, copper and manganese should be restricted in hepatobiliary disease.44

Acutely ill patients receive PN as a 24‐hour infusion, to minimize its impact on volume status and energy expenditure,46 providing 50% of needs on infusion day one and reaching goal within 4872 hours, rather than cyclic infusions over shorter intervals. Daily assessments of vital signs, intake and output, and weight are necessary to monitor volume status.

Once a patient is taking at least 60% of caloric needs either by mouth or by EN, PN can be discontinued. Tapering the infusion is not required, as abrupt discontinuation has not been demonstrated to cause symptomatic hypoglycemia.47, 48

Adverse Effects and Complications of Nutrition Support

Regarding EN, complications include those related to tube placement and maintenance, infections, and medical complications of the feeds themselves. Some of the adverse effects of the enteral formulas may be attenuated. Diarrhea, which occurs in up to 20% of patients, may be avoided with slow feed advancement, use of low‐osmotic formulas, or fiber additives.51 Gastric distention and abdominal pain may improve with slow feed advancement and continuous (rather than bolus) feeds. Small‐bore tubes and acid‐reducing medications may decrease gastroesophageal reflux, and aspiration pneumonia may be avoided by semi‐recumbent positioning and post‐pyloric feeding.52

Complications of PN may be grouped as mechanical, infectious, and metabolic. The mechanical complications of central line placement include pneumothorax, arterial puncture, hematoma, air embolism, and line malpositioning. Catheter‐related deep venous thrombosis may occur. Patients on PN through a central line are at risk for central line‐associated bloodstream infections.25 The metabolic complications such as hyperglycemia, electrolyte disorders, hepatic steatosis, and volume overload may have severe consequences, such as heart failure or neuromuscular dysfunction, thus they require close attention.53

A complication of nutrition support that may occur regardless of route is the refeeding syndrome. Refeeding syndrome describes fluid shifts and electrolyte abnormalities that occur after initiation of oral, enteral, or parenteral nutrition in a malnourished or starved patient.54, 55 There are no formal criteria for diagnosing refeeding syndrome.

In the starved state, the body switches from carbohydrate to protein and fat metabolism. Reintroduction of carbohydrates stimulates insulin release with glycogen, fat, and protein synthesis. Associated uptake of glucose, potassium, magnesium, phosphate, and water into cells causes electrolyte and fluid abnormalities. Although hypophosphatemia is the hallmark of refeeding syndrome, it is not pathognomonic. Additional disturbances include hypokalemia, hyperglycemia, hypomagnesemia, thiamine deficiency, and fluid imbalance.49 Patients at risk of refeeding should have serum electrolytes, magnesium, phosphorus, and glucose checked before nutrition support starts. The degree of laboratory abnormalities, if any, and the clinical course of refeeding guides the frequency of subsequent blood tests.56 These consequences of refeeding can adversely affect every major organ system and may result in death.57

Starvation physiology underlies all risk factors for refeeding syndrome. In hospitalized patients, those at risk for refeeding include, but are not limited to, the elderly, oncology patients, postoperative patients, alcohol‐dependent patients, those with malabsorptive states, those who are fasting or chronically malnourished, and those on diuretic therapy.54, 57 The National Institute for Health and Clinical Excellence (NICE) of England and Wales has published criteria to identify patients at high risk for refeeding (Table 3).56 Identification of at‐risk patients and attention to their nutritional needs prevents refeeding syndrome.

ASPEN and NICE have each issued guidelines for initiating nutrition support in patients at risk for refeeding. ASPEN guidelines recommend feeding start at approximately 25% of the estimated goal, with advancement to goal over 35 days. ASPEN recommends fluid and electrolyte status be monitored as needed.50 The NICE guidelines recommend starting nutrition support at a maximum of 10 kcal/kg/d with slow increase to meet or exceed full needs by 47 days. For extremely malnourished patients (eg, BMI <14 kg/m², or negligible intake for >15 days), they recommend starting at 5 kcal/kg/d. For patients at high risk of developing refeeding syndrome, the NICE guidelines recommend vitamin repletion immediately before and during the first 10 days of feeding (thiamine, vitamin B, and a balanced multivitamin/trace element supplement). Cardiac monitoring is recommended for this group as well as any patients who are at risk for cardiac arrhythmias. Careful monitoring of fluid balance and restoring circulatory volume is recommended, as is repletion of potassium, phosphate, and magnesium.56

History

A careful history elicits the majority of information needed to determine the cause and severity of malnutrition.16 Patients should be questioned about a typical day's oral intake prior to hospitalization, and about factors that affect their intake such as sensory deficits, fine motor dysfunction, or chewing and swallowing difficulties, which often decline in chronically ill and elderly patients. Nutrition may be affected by financial difficulties or limited social support, and access to food should be assessed.

Physical Findings

Weight loss is the best physical exam predictor of malnutrition risk, although nutritional depletion can occur in a very short time in acutely ill or injured patients before substantial weight loss has occurred. The likelihood of malnutrition is increased if a patient has: a body mass index (BMI) <18.5 kg/m²; unintentional loss of >2.3 kg (5 lb) or 5% of body weight over 1 month; and unintentional loss of >4.5 kg (10 lb) or 10% of body weight over 6 months.17 Weight loss may be masked by fluid retention from chronic conditions, such as heart failure, or from volume resuscitation in the acutely ill patient.9, 16

Body mass index can be misleading, as age‐related height loss may artificially increase BMI, and height may be difficult to accurately measure in a kyphotic, unsteady, or bedridden patient. The clinician may find evidence of loss of subcutaneous fat or muscle mass in patients with chronic illness, but these findings may not be evident in the acutely ill patient.9 Other physical exam assessments of malnutrition, such as arm span, skinfold thickness, and arm circumference are not reliable.16

Laboratory Tests

Biochemical markers, including transferrin, albumin, and prealbumin, have not been proven as accurate predictors of nutrition status because they may change as a result of other factors not related to nutrition.15, 18 Serum albumin, for example, may be more reflective of the degree of metabolic stress.19 Prealbumin has a serum half‐life much shorter than albumin or transferrin (approximately 2448 hours) and is perhaps the most useful protein marker to assess the adequacy of nutritional replacement after the inflammatory state is resolved.18

Calculating Caloric Requirements

Energy expenditure measurement is considered the gold standard to determine patients' caloric needs. Actual measurement by methods such as indirect calorimetry, which measures oxygen consumption and carbon dioxide production, and calculates energy expenditure, is challenging in everyday clinical settings. Predictive equations often are used as alternative methods to estimate patients' caloric requirements.20 There is no consensus among the 3 North American societies' guidelines (the Canadian Clinical Practice Guidelines; the American Dietetics Association's evidence‐based guideline for critical illness; and the Society of Critical Care Medicine and American Society of Parenteral and Enteral Nutrition's joint guideline) as to the best method.21

In the simplest equation, caloric needs are estimated by calories per kilogram.22 In obese patients, using actual body weight will overestimate needs, but using ideal body weight may cause underfeeding. A small study comparing predictive equations in obese hospitalized patients found the Harris‐Benedict equations (H‐BE) using adjusted body weight and a stress factor to be most accurate, but only in 50% of patients.23 Most clinicians are familiar with the H‐BE, but alternatives such as calories per kilogram or the Mifflin St.‐Jeor equation24 are often used (S. Brantley (May 5, 2012), S. Lundy (May 23, 2012), personal communication).

Indications for Nutritional Intervention

In adults without preexisting malnutrition, inadequate nutritional intake for approximately 714 days should prompt nutritional intervention.25, 26 This timeline should be shorter (37 days) in those with lower energy reserves (eg, underweight or recent weight loss) or significant catabolic stress (eg, acutely ill patients).27, 28 Other patient populations shown to benefit from nutritional intervention include: postoperative patients who are anticipated to be NPO for more than 7 days or to be taking less than 60% of estimated caloric needs by postoperative day 10; preoperative patients with severe malnutrition29; those with gastrointestinal cancer undergoing elective surgery30; and stroke patients with persistent dysphagia for more than 7 days.31

Dietary Modifications

The purpose of the diet is to provide the necessary nutrients to the body in a well‐tolerated form. Diets can be modified to provide for individual requirements, personal eating patterns and food preferences, and disease process and digestive capacity. Dietary adjustments include change in consistency of foods (eg, pureed, mechanical soft), increase or decrease in energy value, increase or decrease in the type of food or nutrient consumed (eg, sodium restriction, fiber enhancement), elimination of specific foods (eg, gluten‐free diet), adjustment in protein, fat, and carbohydrate content (eg, ketogenic diet, renal diet, cholesterol‐lowering diet), and adjustment of the number and frequency of meals.32

Dietary supplementation (eg, Boost, Ensure) is common practice in persons diagnosed with such conditions as cancer, diabetes, and cardiovascular disease. Supplements enhance the diet by increasing the total daily intake of a vitamin, a mineral, an amino acid, an herb or other botanical33, and should not be used as a meal substitute.34 These supplements are varied in content of calories, protein, vitamins, and minerals. Various flavors and consistencies are also available. Several oral supplements are reviewed in Table 1.

Enteral Nutrition

Enteral nutrition (EN) support should be provided to patients who have functioning gastrointestinal (GI) tracts but are unable to take adequate calories orally. Compared to parenteral nutrition (PN), EN is associated with favorable improvements in inflammatory cytokines, acute phase proteins, hyperglycemia, insulin resistance, nosocomial infections, mortality, and cost.35 Enteral feeds are more physiologic than parenteral feeds, maintain GI structure and integrity, and avoid intravenous (IV) access complications. Patients with normal nutritional status on admission who require EN should be receiving over 50% of their caloric needs within the first week of hospital stay.25 Malnourished patients should reach this minimum goal within 35 days of admission.27, 28 EN is not contraindicated in the absence of bowel sounds or in the presence of increased gastric residuals.35 Withholding enteral feedings for gastric residual volumes <250 mL36, 37 or reduced bowel sounds can result in inadequate caloric intake or inappropriate use of PN.27

Gastric feedings are more physiologic than small bowel feedings, can be given by bolus or continuous infusion, and can be given by tubes that are easy to place at the bedside. Post‐pyloric feedings (nasoduodenal or nasojejunal) may be associated with a lower risk of pneumonia, and should be considered in high‐risk patients such as those receiving continuous sedatives or neuromuscular blockers.36 Post‐pyloric tube placement usually requires endoscopy, fluoroscopy, or electromagnetic guidance. Percutaneous feeding tubes (gastrostomy or jejunostomy) should be considered in those who require tube feedings for longer than 30 days.38

Assessment of patient requirements and disease state, as well as extensive knowledge of available formulas, is important in the selection of the appropriate enteral formula.39 Standardized formulas are used for most patients. The provision of adequate water must be considered with these formulas, particularly in the long‐term care and home settings.40 Many specialized formulas are designed for a particular disease state or condition, some of which are further reviewed in Table 2.

If concerned about formula tolerance, one solution is to initiate the formula at a low rate and increase to the goal rate over 2448 hours. Dilution of enteral formulas is not necessary to assure optimal tolerance. Continuous feedings are recommended for most patients initially and after tolerance has been established, bolus feedings can be attempted if the feeding tube terminates in the stomach. Bolus feedings, where 240480 mL of formula are delivered through a syringe over 1015 minutes, may be more physiological for patients. This regimen can be repeated 46 times daily to meet nutrition goals.41

Parenteral Nutrition

PN provides macronutrients such as carbohydrates, protein, and fat; micronutrients such as vitamins, minerals, electrolytes, and trace elements are added in appropriate concentrations. PN may also provide the patient's daily fluid needs. The timing of PN initiation depends upon the patient's initial nutritional status. ASPEN does not recommend PN during the first 7 days of hospitalization in critically ill patients with normal nutritional status. If the patient is not receiving 100% of caloric needs from EN after 7 days, supplemental PN should be considered. However, if on admission a patient is already malnourished and EN is not feasible, PN should be initiated and continued until the patient is receiving at least 60% of caloric needs by enteral route.42 This includes patients with intestinal obstruction, ileus, peritonitis, malabsorption, high output enterocutaneous fistulae, intestinal ischemia, intractable vomiting and diarrhea, severe shock, and fulminant sepsis.10, 43

Standardized commercial PN products are available and reduce the number of steps required between ordering and administration, as compared to customized PN, which is compounded for a particular patient. However, despite improved efficiency and lower cost, there is no evidence that standardized preparations are safer to patients than customized solutions. Institutions utilizing standardized PN must also have a mechanism to customize formulas for those with complex needs.44

Creating a customized parenteral solution involves several basic steps. Total caloric requirement may be estimated using a predictive formula, as previously discussed; calories/kg of ideal body weight is the simplest method. Most hospitalized patients require 2030 calories/kg/d. Daily fluid requirement may be based on kilocalories (kcal) delivered, or by ideal body weight (eg, 1 mL/kcal or 3040 mL/kg). More fluid may be needed in patients with significant sensible or insensible losses; those with renal failure or heart failure should receive less fluid.

Protein needs are calculated by multiplying ideal body weight (kg) by estimated protein needs in g/kg/d (1.22 g/kg/d for catabolic patients). Protein should provide approximately 20% of total calories. Protein restriction is not required in renal impairment; acutely ill patients on renal replacement therapy should receive 1.51.8 g/kg/d. In hepatic failure patients, protein should be restricted only if hepatic encephalopathy fails to improve with other measures.

Knowing the protein, kcal, and fluid needs of the patient, the practitioner divides the remaining non‐protein calories between carbohydrates and fat. Approximately 70%85% of non‐protein calories should be provided as carbohydrates (dextrose), up to 7 g/kg/d. The other 15%30% are as fat, in lipid solutions, providing a maximum of 2.5 g/kg/d. Lipid solutions are provided as either 10% (1.1 kcal/mL) or 20% (2.2 kcal/mL) concentrations.43, 44 Propofol's contribution to fat intake complicates estimating total fat intake in critically ill patients.45

Standardized parenteral multivitamin preparations are available; the clinician must determine if preparations containing vitamin K are appropriate. Of the trace elements, copper and manganese should be restricted in hepatobiliary disease.44

Acutely ill patients receive PN as a 24‐hour infusion, to minimize its impact on volume status and energy expenditure,46 providing 50% of needs on infusion day one and reaching goal within 4872 hours, rather than cyclic infusions over shorter intervals. Daily assessments of vital signs, intake and output, and weight are necessary to monitor volume status.

Once a patient is taking at least 60% of caloric needs either by mouth or by EN, PN can be discontinued. Tapering the infusion is not required, as abrupt discontinuation has not been demonstrated to cause symptomatic hypoglycemia.47, 48

Adverse Effects and Complications of Nutrition Support

Regarding EN, complications include those related to tube placement and maintenance, infections, and medical complications of the feeds themselves. Some of the adverse effects of the enteral formulas may be attenuated. Diarrhea, which occurs in up to 20% of patients, may be avoided with slow feed advancement, use of low‐osmotic formulas, or fiber additives.51 Gastric distention and abdominal pain may improve with slow feed advancement and continuous (rather than bolus) feeds. Small‐bore tubes and acid‐reducing medications may decrease gastroesophageal reflux, and aspiration pneumonia may be avoided by semi‐recumbent positioning and post‐pyloric feeding.52

Complications of PN may be grouped as mechanical, infectious, and metabolic. The mechanical complications of central line placement include pneumothorax, arterial puncture, hematoma, air embolism, and line malpositioning. Catheter‐related deep venous thrombosis may occur. Patients on PN through a central line are at risk for central line‐associated bloodstream infections.25 The metabolic complications such as hyperglycemia, electrolyte disorders, hepatic steatosis, and volume overload may have severe consequences, such as heart failure or neuromuscular dysfunction, thus they require close attention.53

A complication of nutrition support that may occur regardless of route is the refeeding syndrome. Refeeding syndrome describes fluid shifts and electrolyte abnormalities that occur after initiation of oral, enteral, or parenteral nutrition in a malnourished or starved patient.54, 55 There are no formal criteria for diagnosing refeeding syndrome.

In the starved state, the body switches from carbohydrate to protein and fat metabolism. Reintroduction of carbohydrates stimulates insulin release with glycogen, fat, and protein synthesis. Associated uptake of glucose, potassium, magnesium, phosphate, and water into cells causes electrolyte and fluid abnormalities. Although hypophosphatemia is the hallmark of refeeding syndrome, it is not pathognomonic. Additional disturbances include hypokalemia, hyperglycemia, hypomagnesemia, thiamine deficiency, and fluid imbalance.49 Patients at risk of refeeding should have serum electrolytes, magnesium, phosphorus, and glucose checked before nutrition support starts. The degree of laboratory abnormalities, if any, and the clinical course of refeeding guides the frequency of subsequent blood tests.56 These consequences of refeeding can adversely affect every major organ system and may result in death.57

Starvation physiology underlies all risk factors for refeeding syndrome. In hospitalized patients, those at risk for refeeding include, but are not limited to, the elderly, oncology patients, postoperative patients, alcohol‐dependent patients, those with malabsorptive states, those who are fasting or chronically malnourished, and those on diuretic therapy.54, 57 The National Institute for Health and Clinical Excellence (NICE) of England and Wales has published criteria to identify patients at high risk for refeeding (Table 3).56 Identification of at‐risk patients and attention to their nutritional needs prevents refeeding syndrome.

ASPEN and NICE have each issued guidelines for initiating nutrition support in patients at risk for refeeding. ASPEN guidelines recommend feeding start at approximately 25% of the estimated goal, with advancement to goal over 35 days. ASPEN recommends fluid and electrolyte status be monitored as needed.50 The NICE guidelines recommend starting nutrition support at a maximum of 10 kcal/kg/d with slow increase to meet or exceed full needs by 47 days. For extremely malnourished patients (eg, BMI <14 kg/m², or negligible intake for >15 days), they recommend starting at 5 kcal/kg/d. For patients at high risk of developing refeeding syndrome, the NICE guidelines recommend vitamin repletion immediately before and during the first 10 days of feeding (thiamine, vitamin B, and a balanced multivitamin/trace element supplement). Cardiac monitoring is recommended for this group as well as any patients who are at risk for cardiac arrhythmias. Careful monitoring of fluid balance and restoring circulatory volume is recommended, as is repletion of potassium, phosphate, and magnesium.56

Setting

At the time of this study, the Division of Hospital Internal Medicine (HIM) at our institution consisted of 22 hospitalists, 11 NPs and 9 PAs (hereinafter NP/PAs), and 2 clinical assistants (CAs). The CAs assist with clerical duties not covered by Unit Secretaries:

• 1

  Obtaining outside records

• 2

  Clarifying referring physician contact information

• 3

  Scheduling follow‐up outpatient appointments for tests, procedures, and visits

• 4

  Attendance at morning handoff

Each CA can assist 3 or 4 daytime service teams.

Daytime Service Organization

Six HIM services, each managing up to 12 patients, are staffed by a partnership of 1 hospitalist and 1 NP/PA: Four services are primary general medicine services, and 2 consulting (orthopedic comanagement) services.

Night Coverage

Three of 4 primary daytime services and one consult service team transfer care to the (in‐house) night NP/PA. The night NP/PA addresses any acute‐care issues and reports at morning handoff to the 3 primary services and 1 consult service. In a designated conference room the morning handoff occurs, with at least 1 (day team) service representative present. This is usually the NP/PA, as the day team hospitalist concurrently receives a report on new admissions from the (in‐house) night hospitalist (who also covers one service and backs up the night NP/PA).

Improvement Process

An improvement team was formed within the Division of HIM consisting of 3 hospitalists, 3 NP/PAs, and 2 CAs to assess the existing handoff process at 7:45am between the Night NP/PA and daytime services. The improvement team met, reviewed evidence‐based literature on handoffs and discussed our local process. Four problems were identified by consensus:

• 1

  Unpredictable start and finish times

• 2

  Inefficiency (time wasted)

• 3

  Poor environment (room noisy and distracting conversations)

• 4

  Poor communication (overwrought and meandering narratives).

Intervention

The improvement team structured a new handoff process to address these deficiencies.

• 1

  Environment: Moved to a smaller room (lower ceiling, less ambient noise).

• 2

  Identification: table cards designating seats for participants (reduced queries regarding what service are you, today?).

• 3

  Start Times: Each service team assigned a consistent start time (labeled on the table card) within a 15‐minute period, and although earlier reportage could occur, any service team present at their designated time has priority for the attention of the night NP/PA, and the opportunity to ask questions.

• 4

  Quiet and Focus: HIM members were reminded to remain quiet in the handoff room, so the service receiving report has the floor and personal conversations must not impede the principals.

• 5

  Visual Cue: Green Good to go sign placed on team table cards when no verbal was required.

• 6

  Written e‐Material: The improvement team required elements of a brief written report in a specified column of our existing electronic service list (ESL). The ESL is a custom designed template importing laboratory, medication, and demographic data automatically but also capable of free text additions (Figure 1). All providers were instructed to update the ESL every 12 hours.

• 7

  Admission and Progress Notes: After manual electronic medical record search, the CAs printed any notes generated in the preceding 12 hours and placed them by the team table card.

Figure 1

The improvement team provided education for the new process at a division meeting and through e‐mail. The recommended report sequence was night NP/PA reporting and day service teams asking questions and seeking clarifications. We discouraged editorial comments and chit‐chat.

A member of the improvement team monitored the new handoff process for 15 days, and 3 months later for 10 days.

Survey

An anonymous survey (Figure 2) concerning staff satisfaction with handoff was conducted immediately before and 15 days after the intervention. In the e‐mail containing the postintervention survey, providers were asked to respond only if they had been on service the preceding 15 days (and thus eligible to participate in handoff). To help insure this, the first question read, Have you been on service during the past 15 days?

Figure 2

Statistics

To compare the relationship of preintervention and postintervention survey responses, Fisher's exact test was used to compare categorical variables and 2 sample t‐test and Wilcoxon rank sum test were used for continuous variables. Comparisons that adjusted for the possibility of someone responding to both the preintervention and postintervention surveys were not performed since the surveys were anonymous. A P value <0.05 was considered statistically significant. For the item concerning the percentage of days morning report was attended while on service, based on a common standard deviation estimate of 35.3, we had 80% power to detect a difference of 29.1 (pre vs. post). This computation assumes a 2‐sample t‐test of = 0.05 with sample sizes of 36 and 18. We have 59% power to detect a difference of 27% (67% pre vs. 94% post) for those who at least agree that helpful information was conveyed during handoff. This computation is based on a 2‐sided Pearson 2 test with = 0.05.

Qualitative data analysis of respondents' answers to the open‐ended survey questions What would increase the likelihood of your attending handoff? and What feedback do you have regarding the changes to handoff? was performed using the constant comparative method14 associated with grounded theory approaches to identify themes and categories.15 To establish interrater reliability, three investigators (MCB, DTK, LLK) independently identified coding categories for the data set, compared results, redefined coding categories as needed, and reanalyzed the data until 80% agreement was reached.

Qualitative Data Analysis

Three themes were identified in both preintervention and postintervention surveys: timeliness, quality of report and environment (Table 2). In the preintervention survey, timeliness complaints involved inconsistent start time, prolonged duration of handoff, and inefficiency due to time wasted while teams waited for their handoff report. Comments about report quality mentioned the nonstandardized report process that included nonpertinent information and editorializing. Environmental concerns addressed noise from multiple service team members assembled in 1 large room and chatting while awaiting report. In the postintervention survey, respondents' comments noted improved efficiency, environment, and report quality.

Setting

At the time of this study, the Division of Hospital Internal Medicine (HIM) at our institution consisted of 22 hospitalists, 11 NPs and 9 PAs (hereinafter NP/PAs), and 2 clinical assistants (CAs). The CAs assist with clerical duties not covered by Unit Secretaries:

• 1

  Obtaining outside records

• 2

  Clarifying referring physician contact information

• 3

  Scheduling follow‐up outpatient appointments for tests, procedures, and visits

• 4

  Attendance at morning handoff

Each CA can assist 3 or 4 daytime service teams.

Daytime Service Organization

Six HIM services, each managing up to 12 patients, are staffed by a partnership of 1 hospitalist and 1 NP/PA: Four services are primary general medicine services, and 2 consulting (orthopedic comanagement) services.

Night Coverage

Three of 4 primary daytime services and one consult service team transfer care to the (in‐house) night NP/PA. The night NP/PA addresses any acute‐care issues and reports at morning handoff to the 3 primary services and 1 consult service. In a designated conference room the morning handoff occurs, with at least 1 (day team) service representative present. This is usually the NP/PA, as the day team hospitalist concurrently receives a report on new admissions from the (in‐house) night hospitalist (who also covers one service and backs up the night NP/PA).

Improvement Process

An improvement team was formed within the Division of HIM consisting of 3 hospitalists, 3 NP/PAs, and 2 CAs to assess the existing handoff process at 7:45am between the Night NP/PA and daytime services. The improvement team met, reviewed evidence‐based literature on handoffs and discussed our local process. Four problems were identified by consensus:

• 1

  Unpredictable start and finish times

• 2

  Inefficiency (time wasted)

• 3

  Poor environment (room noisy and distracting conversations)

• 4

  Poor communication (overwrought and meandering narratives).

Intervention

The improvement team structured a new handoff process to address these deficiencies.

• 1

  Environment: Moved to a smaller room (lower ceiling, less ambient noise).

• 2

  Identification: table cards designating seats for participants (reduced queries regarding what service are you, today?).

• 3

  Start Times: Each service team assigned a consistent start time (labeled on the table card) within a 15‐minute period, and although earlier reportage could occur, any service team present at their designated time has priority for the attention of the night NP/PA, and the opportunity to ask questions.

• 4

  Quiet and Focus: HIM members were reminded to remain quiet in the handoff room, so the service receiving report has the floor and personal conversations must not impede the principals.

• 5

  Visual Cue: Green Good to go sign placed on team table cards when no verbal was required.

• 6

  Written e‐Material: The improvement team required elements of a brief written report in a specified column of our existing electronic service list (ESL). The ESL is a custom designed template importing laboratory, medication, and demographic data automatically but also capable of free text additions (Figure 1). All providers were instructed to update the ESL every 12 hours.

• 7

  Admission and Progress Notes: After manual electronic medical record search, the CAs printed any notes generated in the preceding 12 hours and placed them by the team table card.

Figure 1

The improvement team provided education for the new process at a division meeting and through e‐mail. The recommended report sequence was night NP/PA reporting and day service teams asking questions and seeking clarifications. We discouraged editorial comments and chit‐chat.

A member of the improvement team monitored the new handoff process for 15 days, and 3 months later for 10 days.

Survey

An anonymous survey (Figure 2) concerning staff satisfaction with handoff was conducted immediately before and 15 days after the intervention. In the e‐mail containing the postintervention survey, providers were asked to respond only if they had been on service the preceding 15 days (and thus eligible to participate in handoff). To help insure this, the first question read, Have you been on service during the past 15 days?

Figure 2

Statistics

To compare the relationship of preintervention and postintervention survey responses, Fisher's exact test was used to compare categorical variables and 2 sample t‐test and Wilcoxon rank sum test were used for continuous variables. Comparisons that adjusted for the possibility of someone responding to both the preintervention and postintervention surveys were not performed since the surveys were anonymous. A P value <0.05 was considered statistically significant. For the item concerning the percentage of days morning report was attended while on service, based on a common standard deviation estimate of 35.3, we had 80% power to detect a difference of 29.1 (pre vs. post). This computation assumes a 2‐sample t‐test of = 0.05 with sample sizes of 36 and 18. We have 59% power to detect a difference of 27% (67% pre vs. 94% post) for those who at least agree that helpful information was conveyed during handoff. This computation is based on a 2‐sided Pearson 2 test with = 0.05.

Qualitative data analysis of respondents' answers to the open‐ended survey questions What would increase the likelihood of your attending handoff? and What feedback do you have regarding the changes to handoff? was performed using the constant comparative method14 associated with grounded theory approaches to identify themes and categories.15 To establish interrater reliability, three investigators (MCB, DTK, LLK) independently identified coding categories for the data set, compared results, redefined coding categories as needed, and reanalyzed the data until 80% agreement was reached.

Qualitative Data Analysis

Three themes were identified in both preintervention and postintervention surveys: timeliness, quality of report and environment (Table 2). In the preintervention survey, timeliness complaints involved inconsistent start time, prolonged duration of handoff, and inefficiency due to time wasted while teams waited for their handoff report. Comments about report quality mentioned the nonstandardized report process that included nonpertinent information and editorializing. Environmental concerns addressed noise from multiple service team members assembled in 1 large room and chatting while awaiting report. In the postintervention survey, respondents' comments noted improved efficiency, environment, and report quality.

Setting

At the time of this study, the Division of Hospital Internal Medicine (HIM) at our institution consisted of 22 hospitalists, 11 NPs and 9 PAs (hereinafter NP/PAs), and 2 clinical assistants (CAs). The CAs assist with clerical duties not covered by Unit Secretaries:

• 1

  Obtaining outside records

• 2

  Clarifying referring physician contact information

• 3

  Scheduling follow‐up outpatient appointments for tests, procedures, and visits

• 4

  Attendance at morning handoff

Each CA can assist 3 or 4 daytime service teams.

Daytime Service Organization

Six HIM services, each managing up to 12 patients, are staffed by a partnership of 1 hospitalist and 1 NP/PA: Four services are primary general medicine services, and 2 consulting (orthopedic comanagement) services.

Night Coverage

Three of 4 primary daytime services and one consult service team transfer care to the (in‐house) night NP/PA. The night NP/PA addresses any acute‐care issues and reports at morning handoff to the 3 primary services and 1 consult service. In a designated conference room the morning handoff occurs, with at least 1 (day team) service representative present. This is usually the NP/PA, as the day team hospitalist concurrently receives a report on new admissions from the (in‐house) night hospitalist (who also covers one service and backs up the night NP/PA).

Improvement Process

An improvement team was formed within the Division of HIM consisting of 3 hospitalists, 3 NP/PAs, and 2 CAs to assess the existing handoff process at 7:45am between the Night NP/PA and daytime services. The improvement team met, reviewed evidence‐based literature on handoffs and discussed our local process. Four problems were identified by consensus:

• 1

  Unpredictable start and finish times

• 2

  Inefficiency (time wasted)

• 3

  Poor environment (room noisy and distracting conversations)

• 4

  Poor communication (overwrought and meandering narratives).

Intervention

The improvement team structured a new handoff process to address these deficiencies.

• 1

  Environment: Moved to a smaller room (lower ceiling, less ambient noise).

• 2

  Identification: table cards designating seats for participants (reduced queries regarding what service are you, today?).

• 3

  Start Times: Each service team assigned a consistent start time (labeled on the table card) within a 15‐minute period, and although earlier reportage could occur, any service team present at their designated time has priority for the attention of the night NP/PA, and the opportunity to ask questions.

• 4

  Quiet and Focus: HIM members were reminded to remain quiet in the handoff room, so the service receiving report has the floor and personal conversations must not impede the principals.

• 5

  Visual Cue: Green Good to go sign placed on team table cards when no verbal was required.

• 6

  Written e‐Material: The improvement team required elements of a brief written report in a specified column of our existing electronic service list (ESL). The ESL is a custom designed template importing laboratory, medication, and demographic data automatically but also capable of free text additions (Figure 1). All providers were instructed to update the ESL every 12 hours.

• 7

  Admission and Progress Notes: After manual electronic medical record search, the CAs printed any notes generated in the preceding 12 hours and placed them by the team table card.

Figure 1

The improvement team provided education for the new process at a division meeting and through e‐mail. The recommended report sequence was night NP/PA reporting and day service teams asking questions and seeking clarifications. We discouraged editorial comments and chit‐chat.

A member of the improvement team monitored the new handoff process for 15 days, and 3 months later for 10 days.

Survey

An anonymous survey (Figure 2) concerning staff satisfaction with handoff was conducted immediately before and 15 days after the intervention. In the e‐mail containing the postintervention survey, providers were asked to respond only if they had been on service the preceding 15 days (and thus eligible to participate in handoff). To help insure this, the first question read, Have you been on service during the past 15 days?

Figure 2

Statistics

To compare the relationship of preintervention and postintervention survey responses, Fisher's exact test was used to compare categorical variables and 2 sample t‐test and Wilcoxon rank sum test were used for continuous variables. Comparisons that adjusted for the possibility of someone responding to both the preintervention and postintervention surveys were not performed since the surveys were anonymous. A P value <0.05 was considered statistically significant. For the item concerning the percentage of days morning report was attended while on service, based on a common standard deviation estimate of 35.3, we had 80% power to detect a difference of 29.1 (pre vs. post). This computation assumes a 2‐sample t‐test of = 0.05 with sample sizes of 36 and 18. We have 59% power to detect a difference of 27% (67% pre vs. 94% post) for those who at least agree that helpful information was conveyed during handoff. This computation is based on a 2‐sided Pearson 2 test with = 0.05.

Qualitative data analysis of respondents' answers to the open‐ended survey questions What would increase the likelihood of your attending handoff? and What feedback do you have regarding the changes to handoff? was performed using the constant comparative method14 associated with grounded theory approaches to identify themes and categories.15 To establish interrater reliability, three investigators (MCB, DTK, LLK) independently identified coding categories for the data set, compared results, redefined coding categories as needed, and reanalyzed the data until 80% agreement was reached.

Qualitative Data Analysis

Three themes were identified in both preintervention and postintervention surveys: timeliness, quality of report and environment (Table 2). In the preintervention survey, timeliness complaints involved inconsistent start time, prolonged duration of handoff, and inefficiency due to time wasted while teams waited for their handoff report. Comments about report quality mentioned the nonstandardized report process that included nonpertinent information and editorializing. Environmental concerns addressed noise from multiple service team members assembled in 1 large room and chatting while awaiting report. In the postintervention survey, respondents' comments noted improved efficiency, environment, and report quality.