加强儿科营养不良记录提高医院的觉悟和效益

　　美国住院儿童营养不良发生率高达25%，导致住院时间延长，医疗费用增加。为增加医生和营养师对营养不良的警觉，美国加利福尼亚州橙郡（奥兰治县）儿童医院对医生和营养师进行培训，推广2013年儿童营养不良的定义并将其应用于电子病历中，增强医疗团队的认识，确保最合理的医疗支出和适当的报销补偿，旨在改善患者的临床结局。

JPEN J Parenter Enteral Nutr. 2016;40(4):131-132.

Enhanced Documentation of Pediatric Malnutrition Increases Awareness and Revenue in the Hospital Setting.

Katherine H. Bennett; Caroline Steele.

Children's Hospital of Orange County, Orange, CA, USA.

Purpose: The impact of malnutrition on comorbidities and outcomes in the hospitalized patients, including length of stay and healthcare costs, has been well established. Older studies have indicated that up to 25% of hospitalized pediatric patients could be diagnosed with acute malnutrition. Therefore, proper identification and documentation in the hospital setting are critical to promote consistency in approach from the entire healthcare team and ensure that proper revenue is received to cover the additional resources malnourished patients need. In 2013, an interdisciplinary workgroup published comprehensive definitions for pediatric malnutrition. Their goal was to standardize definitions allowing for meaningful comparisons when evaluating outcomes and for use in future research. During fiscal year (FY) 2014, malnutrition was coded for 0.8% of all inpatient discharges, excluding the neonatal intensive care unit, at CHOC Children's. Because this is a 279-bed regional tertiary medical center, it was suspected that this number did not reflect the actual number of malnourished patients or the care being provided. There was also concern that without proper documentation and subsequent coding of malnutrition, appropriate hospital reimbursement was not being received. Therefore a project was initiated with the following objectives: (1) integrate the 2013 pediatric malnutrition definitions into the registered dietitian (RD) charting within the electronic medical record (EMR); (2) increase awareness among the medical team of the definitions and importance of properly identifying malnutrition to ensure optimal outcomes and appropriate reimbursement; and (3) ensure proper coding so that the diagnosis-related group generated resulted in the appropriate hospital reimbursement.

Methods: The RDs received comprehensive training on the new definitions as well as hands-on training for nutrition-focused physical assessment to assist in proper identification. The clinical nutrition note in the EMR was updated to include the standardized language and the system updated so that the malnutrition portion of the note could be forwarded to the attending physician. Once the RD identified and documented malnutrition, the appropriate malnutrition diagnosis would be added to the problem and diagnosis list within the EMR and forwarded to the attending physician for review. The attending physician could then sign the malnutrition note and work with the RD and the team to implement and document appropriate interventions.

Results: Identification of malnutrition for discharged inpatients >30 days old (excluding the neonatal intensive care unit) increased from 0.8% at baseline (FY 14) to 3.8% for FY 15 to 4.5% for the first 2 months of FY 16. This proper documentation has resulted in an estimated increase of $400,000 in revenue during the first 6 months of the project. In addition, there is increased awareness of malnutrition within the organization resulting in greater collaboration for earlier intervention. Malnutrition education has been provided to CHOC Children's physicians and staff in many forums, including grand rounds, Resident Noon Conference, physician division meetings, and hospital department head meetings. Outreach to community physicians to ensure continuity of care upon discharge is also underway.

Conclusions: Adoption of the 2013 standardized definitions for pediatric malnutrition and creation of enhanced documentation within the EMR has resulted in increased awareness within the organization. We hope that this increased awareness will result in improved outcomes. In addition, the correct coding of malnutrition has assisted in improving revenue, which in turn has offset the cost of additional staffing allocated to the clinical nutrition department.