Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation, and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation. METHODS: A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified Delphi review. A multiround review and revision process served to develop seven guidance statements. RESULTS: The final round of review was highly favorable, with 99% overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection, or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (milligrams per deciliter or milligram per liter) for the clinical laboratory that is being used. CONCLUSION: Confirmation of inflammation should be guided by clinical judgment based on underlying diagnosis or condition, clinical signs, or CRP.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach.

BACKGROUND & AIMS: The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation in support of the etiologic criterion for inflammation. METHODS: A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified-Delphi review. A multi-round review and revision process served to develop seven guidance statements. RESULTS: The final round of review was highly favorable with 99 % overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (mg/dL or mg/L) for the clinical laboratory that is being used. CONCLUSION: Confirmation of inflammation should be guided by clinical judgement based upon underlying diagnosis or condition, clinical signs, or CRP.

Current nutrition assessment practice: A 2022 survey.

BACKGROUND: Malnutrition remains a significant problem in patients with acute or chronic illnesses. Nutrition assessment is an important component in detecting malnutrition; but not always performed using a standardized tool. This survey on nutrition assessment evaluates current clinical practices on the assessment, diagnosis, and treatment of malnutrition. METHODS: This 2022 survey of US-based nutrition clinicians collected data on assessment parameters used in hospitals, long-term care facilities, and the home care setting. RESULTS: A total of 686 surveys were available for analysis. Ninety-seven percent of adult and 91% of pediatric responding clinicians indicated that a dietitian completed the assessment. Parameters used most frequently among adult clinician respondents included nutrient intake, current weight, and weight history, those used by pediatric clinician respondents included nutrient intake, weight-for-age z score, and weight-for-length/height z score. Eighty-nine percent of adult clinicians in all care settings and 85% of pediatric clinicians use the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Indicators of Malnutrition (AAIM). Respondents reported malnutrition rates of 32%-40% for adults and 4%-30% for pediatric patients, depending on the setting. Appropriate interventions for those with malnutrition (as perceived by the survey respondents) were ordered 70% of the time. CONCLUSION: This survey demonstrated significant use of the AAIM by both adult and pediatric clinicians across care settings. Reported malnutrition rates are consistent with others published in the literature. The authors suggest that quality improvement efforts should focus on the 30% of patients with malnutrition but without a reported appropriate nutrition intervention.

Hospital Nutrition Assessment Practice 2016 Survey.

BACKGROUND: Malnutrition is a significant problem for hospitalized patients in the United States. Nutrition assessment is an important step in recognizing malnutrition; however, it is not always performed using consistent parameters. METHODS: A survey among U.S. American Society for Parenteral and Enteral Nutrition (ASPEN) members was conducted to collect data on nutrition assessment parameters used in hospitals and to establish how facilities use their electronic health record (EHR) to permit data retrieval and outcome reporting. RESULTS: The survey was developed by the ASPEN Malnutrition Committee and was sent to 5487 U.S. ASPEN members, with 489 responding for a 9% response rate. Ninety-eight percent of adult and 93% of pediatric respondents indicated a registered dietitian completed the nutrition assessment following a positive nutrition screen. Variables most frequently used among adult respondents included usual body weight, ideal body weight, and body mass index. Among pediatric respondents, weight-for-age and height-for-age percentiles and length/height-for-age percentile were most frequently used. Both adult and pediatric respondents indicated use of physical assessment parameters, including muscle and fat loss and skin assessment. Eighty-seven percent of adult and 77% of pediatric respondents indicated they are using the Academy of Nutrition and Dietetics (Academy) and ASPEN Consensus Malnutrition Characteristics for Adult and Pediatric Malnutrition, respectively. Overall, 97% of respondents indicated nutrition assessment documentation was completed via an EHR. Of all respondents, 61% indicated lack of clinical decision support within their EHR. CONCLUSION: This survey demonstrated significant use of the Academy/ASPEN malnutrition consensus characteristics.

Nutritional Status and Mortality in the Critically Ill.

OBJECTIVES: The association between nutritional status and mortality in critically ill patients is unclear based on the current literature. To clarify this relation, we analyzed the association between nutrition and mortality in a large population of critically ill patients and hypothesized that mortality would be impacted by nutritional status. DESIGN: Retrospective observational study. SETTING: Single academic medical center. PATIENTS: Six thousand five hundred eighteen adults treated in medical and surgical ICUs between 2004 and 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All cohort patients received a formal, in-person, standardized evaluation by a registered dietitian. The exposure of interest, malnutrition, was categorized as nonspecific malnutrition, protein-energy malnutrition, or well nourished and determined by data related to anthropometric measurements, biochemical indicators, clinical signs of malnutrition, malnutrition risk factors, and metabolic stress. The primary outcome was all-cause 30-day mortality determined by the Social Security Death Master File. Associations between nutrition groups and mortality were estimated by bivariable and multivariable logistic regression models. Adjusted odds ratios were estimated with inclusion of covariate terms thought to plausibly interact with both nutrition status and mortality. We used propensity score matching on baseline characteristics to reduce residual confounding of the nutrition status category assignment. In the cohort, nonspecific malnutrition was present in 56%, protein-energy malnutrition was present in 12%, and 32% were well nourished. The 30-day and 90-day mortality rates for the cohort were 19.1% and 26.6%, respectively. Nutritional status is a significant predictor of 30-day mortality following adjustment for age, gender, race, medical versus surgical patient type, Deyo-Charlson index, acute organ failure, vasopressor use, and sepsis: nonspecific malnutrition 30-day mortality odds ratio, 1.17 (95% CI, 1.01-1.37); protein-energy malnutrition 30-day mortality odds ratio, 2.10 (95% CI, 1.70-2.59), all relative to patients without malnutrition. In the matched cohort, the adjusted odds of 30-day mortality in the group of propensity score-matched patients with protein-energy malnutrition was two-fold greater than that of patients without malnutrition. CONCLUSION: In a large population of critically ill adults, an association exists between nutrition status and mortality.

Association between blood alcohol concentration and mortality in critical illness.

OBJECTIVE: In animal models of renal, intestinal, liver, cardiac, and cerebral ischemia, alcohol exposure is shown to reduce ischemia-reperfusion injury. Inpatient mortality of trauma patients is shown to be decreased in a dose-dependent fashion relative to blood alcohol concentration (BAC) at hospital admission. In this study, we examined the association between BAC at hospital admission and risk of 30-day mortality in critically ill patients. DESIGN: We performed a 2-center observational study of patients treated in medical and surgical intensive care units in Boston, Massachusetts. SETTING: Medical and surgical intensive care units in 2 teaching hospitals in Boston, Massachusetts. PATIENTS: We studied 11850 patients, 18 years or older, who received critical care between 1997 and 2007. The exposure of interest was the BAC determined in the first 24 hours of hospital admission and categorized a priori as BAC less than 10 mg/dL (below level of detection), 10 to 80 mg/dL, 80 to 160 mg/dL, and greater than 160 mg/dL. The primary outcome was all-cause mortality in the 30 days after critical care initiation. Secondary outcomes included 90- and 365-day mortality after critical care initiation. Mortality was determined using the US Social Security Administration Death Master File, and 365-day follow-up was present in all cohort patients. Adjusted odds ratios (ORs) were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both BAC and mortality. Adjustment included age, sex, race (white or nonwhite), type (surgical vs medical), Deyo-Charlson index, sepsis, acute organ failure, trauma, and chronic liver disease. RESULTS: Thirty-day mortality of the cohort was 13.7%. Compared to patients with BAC levels less than 10 mg/dL, patients with levels greater than or equal to 10 mg/dL had lower odds of 30-day mortality; for BAC levels 10 to 79.9 mg/dL, the OR was 0.53 (95% confidence interval [CI], 0.40-0.70); for BAC levels 80 to 159.9 mg/dL, it was 0.36 (95% CI, 0.26-0.49); and for BAC levels greater than or equal to 160 mg/dL, it was 0.35 (95% CI, 0.27-0.44). After multivariable adjustment, the OR of 30-day mortality was 0.97 (0.72-1.31), 0.79 (0.57-1.10), and 0.69 (0.54-0.90), respectively. When the cohort was analyzed with sepsis as the outcome of interest, the multivariable adjusted odds of sepsis in patients with BAC 80 to 160 mg/dL or greater than 160 mg/dL were 0.72 (0.50-1.04) or 0.68 (0.51-0.90), respectively, compared to those with BAC less than 10 mg/dL. In a subset of patients with blood cultures drawn (n=4065), the multivariable adjusted odds of bloodstream infection in patients with BAC 80 to 160 mg/dL or greater than 160 mg/dL were 0.53 (0.27-1.01) or 0.49 (0.29-0.83), respectively, compared to those with BAC less than 10 mg/dL. CONCLUSIONS: Analysis of 11850 adult patients showed that having a detectable BAC at hospitalization was associated with significantly decreased odds of 30-day mortality after critical care. Furthermore, BAC greater than 160 mg/dL is associated with significantly decreased odds of developing sepsis and bloodstream infection.

The relationship among obesity, nutritional status, and mortality in the critically ill.

INTRODUCTION: The association between obesity and mortality in critically ill patients is unclear based on the current literature. To clarify this relationship, we analyzed the association between obesity and mortality in a large population of critically ill patients and hypothesized that mortality would be impacted by nutritional status. METHODS: We performed a single-center observational study of 6,518 adult patients treated in medical and surgical ICUs between 2004 and 2011. All patients received a formal, in-person, and standardized evaluation by a registered dietitian. Body mass index was determined at the time of dietitian consultation from the estimated dry weight or hospital admission weight and categorized a priori as less than 18.5 kg/m (underweight), 18.5-24.9 kg/m (normal/referent), 25-29.9 kg/m (overweight), 30-39.9 kg/m (obesity class I and II), and more than or equal to 40.0 kg/m (obesity class III). Malnutrition diagnoses were categorized as nonspecific malnutrition, protein-energy malnutrition, or well nourished. The primary outcome was all-cause 30-day mortality determined by the Social Security Death Master File. Associations between body mass index groups and mortality were estimated by bivariable and multivariable logistic regression models. Adjusted odds ratios were estimated with inclusion of covariate terms thought to plausibly interact with both body mass index and mortality. We utilized propensity score matching on baseline characteristics and nutrition status to reduce residual confounding of the body mass index category assignment. RESULTS: In the cohort, 5% were underweight, 36% were normal weight, 31% were overweight, 23% had class I/II obesity, and 5% had class III obesity. Nonspecific malnutrition was present in 56%, protein-energy malnutrition was present in 12%, and 32% were well nourished. The 30-day and 90-day mortality rate for the cohort was 19.1 and 26.6%, respectively. Obesity is a significant predictor of improved 30-day mortality following adjustment for age, gender, race, medical versus surgical patient type, Deyo-Charlson index, acute organ failure, vasopressor use, and sepsis: underweight odds ratio 30-day mortality is 1.09 (95% CI, 0.80-1.48), overweight 30-day mortality odds ratio is 0.93 (95% CI, 0.80-1.09), class I/II obesity 30-day mortality odds ratio is 0.80 (95% CI, 0.67-0.96), and class III obesity 30-day mortality odds ratio is 0.69 (95% CI, 0.49-0.97), all relative to patients with body mass index 18.5-24.9 kg/m. Importantly, there is confounding of the obesity-mortality association on the basis of malnutrition. Adjustment for only nutrition status attenuates the obesity-30-day mortality association: underweight odds ratio is 0.74 (95% CI, 0.54-1.00), overweight odds ratio is 1.05 (95% CI, 0.90-1.23), class I/II obesity odds ratio is 0.96 (95% CI, 0.81-1.15), and class III obesity odds ratio is 0.81 (95% CI, 0.59-1.12), all relative to patients with body mass index 18.5-24.9 kg/m. In a subset of patients with body mass index more than or equal to 30.0 kg/m (n = 1,799), those with either nonspecific or protein-energy malnutrition have increased mortality relative to well-nourished patients with body mass index more than or equal to 30.0 kg/m: odds ratio of 90-day mortality is 1.67 (95% CI, 1.29-2.15; p < 0.0001), fully adjusted. In a cohort of propensity score matched patients (n = 3,554), the body mass index-mortality association was not statistically significant, likely from matching on nutrition status. CONCLUSIONS: In a large population of critically ill adults, the association between improved mortality and obesity is confounded by malnutrition status. Critically ill obese patients with malnutrition have worse outcomes than obese patients without malnutrition.

Improved care and reduced costs for patients requiring peripherally inserted central catheters: the role of bedside ultrasound and a dedicated team.

BACKGROUND: We conducted a prospective quality assurance (QA) study to determine if a team dedicated to placing peripherally inserted central catheters (PICCs) would improve patient care and reduce costs. METHODS: In April 2000, a dedicated team of physicians, physician assistants, nurses, and interventional radiologists (IR) was established to coordinate and approve all PICC placements at our hospital. Ultrasound (US) became available in November 2000 to assist with bedside PICC placement. A QA database was created allowing data from 3 time periods reflecting initiation of the PICC service (April-June 2000), initial implementation of bedside US-guided PICC placement (October-December 2000), and the current service (October-December 2002) to be analyzed and compared. RESULTS: For all time periods analyzed, the PICC team found that one-third of PICC requests was inappropriate and, therefore, disapproved placement. With addition of US, the bedside PICC placement rate increased to 94% compared with 73% at service initiation. This was associated with an overall 80% decrease in average patient waiting time for a PICC, facilitating more timely discharges from the hospital. Finally, placement costs were reduced by 9% six months after initiation of our service and by 24% after US became available. CONCLUSIONS: A dedicated PICC team improves patient care by preventing inappropriate PICC placements and decreasing patient waiting times. A PICC team with US capability also reduces costs by minimizing expensive use of IR facilities and reducing hospital lengths of stay. A dedicated PICC service should become the standard of care for all hospitals with high-volume PICC use.