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Feature Article

Delivering Care That Counts: Nutritional Screening of Patients with Chronic Wounds

Optimizing nutrition can do wonders for chronic wounds. This author takes a look at nutritional screening for patients, and how wound care practitioners, nurses and registered dieticians can meet patients’ nutritional needs as well as their own requirements for practice improvement and quality reporting. 

Registered dieticians are the newest practitioners subject to the Merit Based Incentive Payment System (MIPS). All practitioners subject to MIPS are required by the Centers for Medicare and Medicaid Services (CMS) to report quality measures (QMs) and participate in Practice Improvement Activities (IAs). Even if a physician is exempt from MIPS, to maintain specialty board certification, he or she must engage in a process called maintenance of certification (MOC), which usually requires the completion of at least one improvement activity. 

Nurses working on an advanced degree often must complete clinical projects, and hospitals may require that departments demonstrate a focus on patient quality of care. Dieticians, physicians, nurses and hospital departments may all be looking for an activity relevant to patients with chronic wounds. Few things are more basic to medical and nursing quality of care than ensuring patients have adequate nutrition. Additionally, few problems impact the outcome of patients with chronic wounds as ubiquitously or as significantly as poor nutrition. Thanks to the advocacy of organizations like the Academy of Nutrition and Dietetics, the Alliance of Wound Care Stakeholders, and the U.S. Wound Registry (USWR), wound care practitioners, nurses and registered dieticians can meet the nutritional needs of their patients and their own practice improvement and quality reporting requirements.

A Closer Look at Nutritional Assessment Improvement Activities 

Qualified Clinical Data Registries (QCDR), such as the USWR, can develop and report QMs that are relevant to a specific specialty, practitioner or patient group. 

The July issue of Today’s Wound Clinic carried an article called, “The Uphill Path to Value-Based Wound Care with Nutritional Assessment.”1 The article detailed the work of the Alliance of Wound Care Stakeholders and its member organizations, which partnered with the USWR to develop a suite of wound care relevant quality measures including a measure specifically targeting the nutritional assessment of patients with chronic non-healing wounds and ulcers, thanks to a generous educational grant from Nestlé. The USWR nutritional assessment quality measure allows practitioners to use any validated screening tool to ascertain the nutritional status of patients with chronic wounds and ulcers, and then create a plan of care based on the nutritional risk assessment.

While screening patients for their risk of poor nutrition is not difficult, reporting the nutritional assessment quality measure may be very difficult because of technological barriers created by the hospital’s electronic health record (EHR). However, the USWR has also developed Improvement Activities that are relevant to wound management.2 In fact, in 2017, CMS recognized a new category of IA targeting nutritional assessment.3 The goal of this IA is to identify those patients with wounds who are at moderate to high risk for nutritional deficits and make specific recommendations to improve their nutritional status. 

National and international organizations recommend that routine screening for vulnerable groups should be built into nutrition policies and quality programs. Although ample data exist to validate the role of nutrition in preventing or healing wounds, the importance of nutrition in the care of patients with chronic wounds is poorly recognized by healthcare providers in the USA, leading to a “gap in practice” for the recognition of nutritional deficits as well as appropriate clinical interventions to correct them. This IA uses the Nestlé Mini Nutritional Assessment (MNA), which has been validated in older people. The Nestlé Self-MNA which can be performed by the patient or caregiver.4–7 

Using the Self-MNA® by Nestlé, if a patient at risk of malnutrition has an MNA score of 8–11 and documented weight loss, the clinician should subsequently create a follow-up plan (e.g., diet enhancement and oral nutritional supplementation [ONS] of 400 kcal/day), close weight monitoring, and a more in-depth nutrition assessment. Malnourished patients with scores of 0–7 are offered treatment with nutritional intervention (ONS 400–600 kcal/day and diet enhancement), close weight monitoring and a more in-depth nutrition assessment.

Registered Dieticians and Nutritional Screening

Registered dieticians are the newest group of practitioners to become subject to MIPS. With funding from Abbott Laboratories, the Academy of Nutrition and Dietetics partnered with Avalere and the USWR to develop QCDR quality measures specific to RDs that can also be reported as improvement activities. An excellent article by McCauley and colleagues in the September 2019 issue of the Journal of the Academy of Nutrition and Dietetics provides details.8 The origin of these new outpatient focused QCDR quality measures is an ongoing quality improvement initiative to screen hospitalized patients for malnutrition.9 

One of the outpatient nutritional screening quality measures developed by the Academy of Nutrition and Dietetics focuses on patients with dehisced surgical wounds. Nutritional deficits are a very common, and commonly overlooked, contributing factor to the expensive problem of surgical dehiscence. 

How to Provide Nutritional Care That Counts

If you need to submit quality measure data or report IAs to CMS, the USWR can help. However, practitioners do not need to pay a fee to the USWR or report any data to CMS in order to initiate an improvement activity targeting nutritional assessment. You can read the articles available from the Academy, download screening tools and use the IA developed by the USWR, all free of charge. These materials can enable practitioners to implement their own nutritional screening program for patients with chronic wounds and ulcers. 

Our collective goal is to improve the quality of care among patients with wounds and ulcers by targeting improved nutrition. Good nutrition is fundamental to health and healing, important to all our patients, and relevant to the quality of care provided by practitioners at every level. Assessment of the nutritional status of patients with non-healing wounds is truly “care that counts.” n

Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.

Feature Article
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Caroline E. Fife, MD, FAAFP, CWS, FUHM
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References

1. Fife CE. The uphill path to value-based wound care with nutritional assessment. Today’s Wound Clinic. 2019; 13(7):16–20. 

2. U.S. Wound Registry. Available at https://uswoundregistry.com/improvement-activities/ . 

3. U.S. Wound Registry. Available at https://uswoundregistry.com/wp-content/uploads/2019/01/IA-9-Nutritional.pdf .

4. Vellas B, Villars H, Abellan G, et al. Overview of the MNA® - its history and challenges. J Nutr Health Aging. 2006; 10(6):456-465. 

5. Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for undernutrition in geriatric practice: developing the Short-Form Mini Nutritional Assessment (MNA-SF). J Geront. 2001; 56(6): M366-377. 

6. Guigoz Y. The Mini-Nutritional Assessment (MNA®) review of the literature - what does it tell us? J Nutr Health Aging. 2006; 10(6):466-487. 

7. Kaiser MJ, Bauer JM, Ramsch C, et al. Validation of the Mini Nutritional Assessment Short-Form (MNA®-SF): A practical tool for identification of nutritional status. J Nutr Health Aging. 2009; 13(9):782-788. 

8. McCauley MS, Khan M, D’Andrea C. Academy of Nutrition and Dietetics: Quality measures for malnutrition. J Acad Nutrit Diet. 2019; 119(9):1541–4. 

9. Avalere Health. Available at http://avalere-health-production.s3.amazonaws.com/uploads/pdfs/1418926720_Avalere_Health_MalnutritionLaunching_WhitePaper.pdf . 

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