Immunology Supervisor Cynthia Moore and Elia Mears, director of laboratory services at Leonard J. Chabert Medical Center, prepare to load samples for prealbumin testing.
Until a few years ago, protein-calorie malnutrition (PCM) was considered a relatively rare condition that affected only a small segment of the poor and elderly. Today, however, as a result of numerous studies, we know that this condition affects between 30 and 50 percent of hospitalized patients.
Even in its mildest form, malnutrition affects the body’s maintenance and repair systems. In its most severe form, it impairs the immune system, delays the healing process and weakens the body’s defense mechanisms for fighting infections.
Patients at risk are most commonly the sickest, and their malnutrition may be due to prolonged stress responses, hypermetabolism, disease, trauma, catabolism, prior improper nutritional intake, or any combination of these factors. Chronic malnutrition is typically found in nursing home patients, geriatric and home-health patients, as well as cancer patients.
Failure to identify the risk of malnutrition early in the hospital stay can lead to further deterioration of the patient’s health; higher morbidity and mortality; increased medical and pharmaceutical costs; and increased length of stay — all factors that contribute to increased costs.
The benefits of nutritional screening
Early assessment of PCM risk can improve outcomes for hospitalized patients by enabling the initiation of nutritional therapy, if required. In addition, monitoring nutritional status during the hospital stay can identify a decline or improvement, so alterations to treatment regimens can be made, if necessary.
Nutritional assessment, which has traditionally been the domain of dietitians and nurses, also offers a big opportunity for the clinical laboratory. Although vastly underutilized, the laboratory’s role in nutritional assessment may be one of the most effective tools hospitals have for improving outcomes and reducing costs. The laboratory can improve nutritional care and help reduce the costs of providing nutrition support associated with formulary, administration sets, labor and monitoring.
Adding timely objective data from biochemical markers would offer a sensitive and quantitative means for monitoring the degree of nutritional depletion or the adequacy of specific therapy.
Albumin vs. prealbumin
In the past, albumin was the long-favored marker when measuring protein levels. However, with a half-life of 21 days, albumin is slow to respond to nutrients a patient has ingested recently. In addition, albumin is affected by many non-nutritional factors and may not give an accurate picture of a patient’s true nutritional status.
Prealbumin, on the other hand, has a two-day half-life and therefore responds very quickly to a decrease in nutritional intake and nutritional restoration. Prealbumin has a high concentration of tryptophan, which has been shown to play a key role in the initiation of protein synthesis. It has one of the highest proportions of essential to non-essential amino acids of any protein in the body.
These factors, as well as a short half-life, small body pool, and quick response to lowered energy intake, make it a better indicator of visceral protein status and positive nitrogen balance than albumin.
At Leonard J. Chabert Medical Center in Houma, La., a 95-patient pilot study was conducted to determine which nutritional marker would have greater sensitivity in the detection of PCM — albumin or prealbumin.
Using an Array 360 CE protein system from Beckman Coulter of Fullerton, Calif., the hospital found that when prealbumin testing was used in conjunction with diagnosis and medical and nutritional history, it offered a more thorough admission screen for PCM than albumin. In addition, prealbumin was determined to be a more sensitive marker that allowed for earlier assessment and intervention, thus reducing length of stay. During the study, the hospital also found that its incidence of newly-admitted hospital patients suffering from malnutrition was as high as 65 percent.
Therefore, the medical center laboratory created a new clinical pathway, which included running the prealbumin test upon admission of each surgical, ICU and medical patient. The new protocol calls for patients to be retested twice a week until discharge if their prealbumin level is less than 18 mg/dL. Testing is repeated only once weekly if the prealbumin concentration rises above 18 mg/dL until the time of discharge. The dietitian is sent a daily list of all patients with prealbumin
levels less than 18 mg/dL so that a more detailed assessment can be made and therapy initiated.
The benefits of prealbumin testing
The incorporation of prealbumin testing into Leonard J. Chabert Medical Center’s nutritional assessment and monitoring program has provided several benefits.
Patient care has been improved thanks to early and accurate nutritional assessment that allows supplementation to begin immediately, before the patient’s condition declines. When supplementation is started earlier, less invasive procedures are quite effective. These factors can contribute significantly to decreased length of stay and a reduced re-admission rate.
This program has paved the way for laboratorians to participate more actively and directly in patient care. By taking an active role in advising and assisting the physician with the test selection and interpretation of results, laboratory utilization has been improved.
The improvement in patient care also has led to a direct financial benefit to the hospital of more than $600,000 a year. The majority of this savings is due to the decrease in length of stay (LOS).
Depending on the complexity of the patient condition, LOS was decreased anywhere from two to 10 days. Because a large percentage of its patients are either indigent or financed by Medicare, the hospital found it fiscally prudent to reduce LOS as much as possible without compromising patient care.
Early identification of PCM has allowed the hospital to use less expensive supplements and to decrease therapeutic albumin dispensing. It experienced an increase in its DRG reimbursement because it is coding its nutritional assessment testing.
The hospital also has decreased many pharmaceutical costs for nutritional products and supplements. With an early assessment of protein levels, we can begin to turn problems around with nutritional intervention. All these help the medical center achieve a significant cost savings.
The expanded role of the laboratory
In today’s managed care environment, laboratory directors are constantly challenged to prove the importance and value of laboratory information in diagnosis, prognosis, health status, monitoring and preventive measures. Nutritional testing offers an outstanding opportunity for laboratorians to have a significant impact on the quality care of hospitalized patients as well as wellness maintenance and health promotion.
Furthermore, the subject of nutrition and age is acquiring new importance as the elderly population increases in size and there is growing recognition of age-related changes in nutritional requirements.
Elia Mears is director of laboratory services at Leonard J. Chabert Medical Center in Houma, La.
