Global Malnutrition Composite Score

The Global Malnutrition Composite Score for a facility demonstrates how many of the clinically eligible components of evidence-based malnutrition care were documented for the qualifying population. The goal for the final score is for its value to be closer to 100%. Because it is a composite score, facilities can evaluate which component is not at 100% completion, and thus, directly address the gap(s) in service to address malnutrition care. In addition, the GMCS follows the evidence- and consensus-based Nutrition Care Process (NCP)​​, a quality improvement process designed to standardize terminology and improve consistency in nutrition care to improve outcomes. The four steps of the NCP, Nutrition Assessment and Reassessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation, are captured in the measure observations of the GMCS. Though not a formal part of the NCP, nutrition screening is a process by which individuals enter the NCP after identification as at risk for malnutrition. Consistency in these steps allows for improved and individualized care to treat patients based on their level of malnutrition and/or malnutrition risk based on both clinical risk factors and patient preferences. 

The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates an interprofessional care team that begins with the identification of an initial risk population for a more thorough nutrition-focused physical examination (NFPE) by the RDN. The RDN in turn provides the necessary treatment recommendations to address nutritional status and the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or other eligible provider. The four components, when measured only individually, provide merely a fraction of the necessary information on quality of care for patients at-risk of malnutrition. For example, knowing which patients have been assessed out of those who were initially identified as at-risk, but not knowing if the appropriate proportion of patients were screened upon admission, would be an insufficient assessment of quality of care. The GMCS’ inclusion of both individual components and a composite score allows organizations to evaluate data and drive change based on their individual performance.  

The GMCS supports timely malnutrition risk screening and hand off to the RDN for appropriate nutrition assessment for patients at-risk for malnutrition. For patients identified with a moderate or severe malnutrition from the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other qualified healthcare professional and the execution of the nutrition care plan by an RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis, and care planning results in better identification of malnourished patients and subsequent improvements in rates of nutrition intervention for the malnourished.​​

Nutrition Screening 

Nutrition screening is defined as the process of identifying individuals who may have a nutrition diagnosis and therefore may benefit from nutrition assessment and interventions by an RDN.​​ All hospitalized patients should be screened for risk of malnutrition and/or nutrition-related problems.   Nutrition screening tools are intended to be simple and require little to no training to execute, thereby allowing for completion by a variety of health professionals, particularly in the acute care setting. 

As a workflow element of the NCP, nutrition screening plays an integral role in clinical workflows as the entry point to the NCP to ensure patients are properly channeled to RDNs for nutrition assessments and associated interventions. Likewise, referrals to and/or care pathways including the RDN or nutrition, serve as a parallel route, allowing clinicians to use their judgement in identifying patients that may benefit from RDN assessment and interventions.  Because this is a requirement by The Joint Commission, this workflow should already be present in acute care facilities. Though optimization work may be needed, little effort should be required from implementors. 

If there is a need to improve the score in this observation, measure entities may benefit from identifying barriers to completing the screening. A process improvement project can be done to identify and address the facility specific barrier(s). As a reminder, in the absence of nutrition screening, a hospital dietitian referral and/or care pathway decision point can prompt the RDN to complete a nutrition assessment, identify the nutrition status, and develop a patient-specific nutrition care plan of malnutrition treatments and interventions. ​​ Creating a standardized set of criteria for initiating a dietitian referral may improve appropriate referral rates while minimizing referrals that do not truly require RDN assessment and/or intervention.​​

Nutrition Assessment   

​​​The second step in optimal nutrition care for patients identified as at risk for malnutrition is performing a nutrition assessment. Nutrition assessment is a systematic approach for collecting, classifying, and synthesizing essential data to describe nutritional status​. Using structured nutrition care terminology supports clear and consistent communication of nutrition care indicators representing the unique contribution of the RDN, relevant to supporting a nutrition status problem(s), and understandable to the interdisciplinary team. In the case of validated malnutrition assessment tools, structured nutrition concepts are useful because the indicators are defined and determined to be accurate to support malnutrition identification. RDNs provide a critical analysis of the nutrition findings and compare them against suitable reference standards with a distillation of the most relevant data to support the existence of a nutrition problem and its etiology, also known as the cause and/or contributing factors, of a nutrition problem.

If the scores for this observation were to be low, measure entities are encouraged to involve the facility RDN, and any other affected staff, in reviewing the current process of alerting the RDN when there is a referral or an At Risk nutrition screening result. Once the current process is defined, and gaps are identified, staff can develop a process that addresses the needs with the available resources.    

Nutrition Diagnosis 

Documentation of a malnutrition diagnosis in the electronic health record (EHR) may vary widely based on hospital policies, RDN and physician/eligible clinician practices, and use of the NCP. Diagnosis and documentation of malnutrition to address a patient’s condition with an appropriate plan of care and communication of patient needs to other care providers is essential to the provision of high-quality care. The nutrition diagnosis problem, found in the Nutrition Assessment, using structured NCP terminology in a PES (problem, etiology, and sign/symptom) statement is a concise communication to the physician and/or eligible clinician of the finding, its cause, and the supporting evidence, thus offering a focused summary of the nutrition status and eliminating the need for providers to review and digest the RDN nutrition assessment analysis. 

If this observation has a low score, measure entities will need to address identify the common reasons for the gap between RDN nutrition diagnosis during the Nutrition Assessment, and the physician or eligible clinician’s malnutrition diagnosis. Most of the time, educating the physician or eligible clinician in the process of the RDN nutrition diagnosis, and how the PES statement supports the malnutrition diagnosis, is a step towards improving this score. Resources including the EHR system can be leveraged to support improved communication between RDN and physician or eligible clinician and close the gap in care. 

Nutrition Care Plan 

Optimal nutrition care best practice is comprised of appropriate recognition, diagnosis, and documentation of the nutrition status of a patient to address their condition with an appropriate plan of care addressing the cause of the problem and communicating patient needs to other care providers. ​​Nutrition interventions that address the malnutrition diagnosis in hospitalized patients are key to support patient outcomes.

Appropriate and timely identification of patients eligible for a nutrition assessment, along with subsequent physician or eligible clinician notification of nutrition problem statements and recommended interventions including markers for monitoring the effectiveness of the intervention, are critical in diagnosing malnutrition and providing the necessary follow-up care. ​ 

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It is important to note that as an established process, the RDN usually includes the Nutrition Care Plan as part of the Nutrition Assessment done in that observation step. Addressing low scores in this step is expected to be mostly through the analysis of steps in place to ensure the Nutrition Care Plan is developed by the RDN, once the malnutrition diagnosis is identified, and that this is actually coded/mapped to the correct data set in the reporting process.