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Yenni et al. | Amerta Nutrition Vol. 8 Issue 1 (March 2024). 130-138
e
LITERATURE REVIEW OPEN ACCESS
English Version
The Relationship between Quality of Nutrition Care and Length of

Hospitalization: a Literature Review
Hubungan Mutu Asuhan Gizi dengan Lama Rawat Inap Pasien di Rumah
Sakit: Sebuah Studi Literatur
Fitri Yenni1*, Martalena BR. Purba2, Ahmad Syauqy3
1Department of Nutritional Sciences, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
2Association of Indonesian Nutritional Education Institutions, Nutrition Science Study Program, Department of Community
Nutrition, Faculty of Human Ecology, Bogor Agricultural Institute (FEMA IPB) IPB Darmaga Campus, Bogor, Indonesia
3Center of Nutrition Research, Universitas Diponegoro, Semarang, Indonesia
ABSTRACT
ARTICLE INFO Background: Inpatients’ needs for nutrition are fulfilled by providing food services based
on their specific requirements. Further, interventions focusing on improving their
Received: 09-02-2023 nutritional wellbeing can reduce their length of stay and at the same time improve the
Accepted: 31-12-2023 hospital’s service quality.
Published online: 08-03-2024 Objectives: The objective of this study is that to identify the relationship between
quality of nutritional care and the patient's length of stay.
*Correspondent: Methods: This research reviews past quantitative studies available in the databases of
Fitri Yenni NCBI-PUBMED, Springer Link, Cochrane and Google Scholar. They must be peer-
[email protected] reviewed articles published in English from 2017 to 1 October 2022, and the mean age
of the patients being discussed is 18 years or more. As this study only reviews full
DOI: articles, abstract-only texts were excluded. In addition, the data form the selected
10.20473/amnt.v8i1.2024.130- papers were extracted by three researchers.
138 Discussion: From many factors influencing patient’s length of stay, besides the fact that
comorbidities affect the duration of the disease suffered by the patient, malnutrition
Available online at: during illness is the most dominant one. Comorbidities affect the duration of the disease
https://e- suffered by the patient. Length of stay is influenced by patients’ nutritional intake, so
journal.unair.ac.id/AMNT screening on which at hospital admission is crucial for their health status and length of
stay.
Keywords: Conclusions: For hospitals, improving the quality of their nutrition services helps focus
Malnutrition, Quality of their attention to nutritional care, and rapid intervention can shorten length of stay. In
Nutritional Care, Length of addition, malnutrition is significantly worsened by mealtime barriers and poor food
Hospitalization intake and prolongs length of stay.
INTRODUCTION care plan’s implementation, and 5) suitability

Hospital is a health service institution which intervention according to the patient's condition1,2.
provides comprehensive individual health services and Issues concerning nutritional care service were
inpatient services. One of its focus is nutritional services, recognized by, one of which, Adhyka & Machmud (2020).
a system provided and adjusted to the patient's clinical Conducting their research at Reginal Public Hospital X in
condition, nutritional status, and metabolism. The Solok, they found that the problem was caused by poor
nutritional needs of inpatients are met by providing food food processing equipment, unavailability of Nutrition
suitable for each patient's specific requirements. For Service Guide as well as poor SOPs and documentation3.
optimal nutritional fulfillment, various healthcare Furthermore, Mardianingsih, et al. (2020), who had her
disciplines be involved and collaborated to support the research in a regional public hospital in Manokwari of
nutritional care team whenever needed. Nutritional care Papua, which is considered underperforming in terms of
is a series of organized and structured activities which nutritional care, described that inadequate nutritional
allow for the identification of nutritional needs and the care is characterized by untimely food distribution, high
provision of care to meet those needs. The quality of amount of food leftover, and inaccuracy in providing diets
hospitals’ nutritional care is determined by 1) the timely for patients4. Gliseer et al. (2020) stated that there are
provision of assessment or study plan, 2) documented differences in the quality of nutritional care in state
nutritional care plan in the medical record, 3) patient hospitals in Austria, Switzerland and Turkey. Austrian and
response-based care plan revision, 4) monitoring on the Swiss hospitals have better nutritional care than Turkish
hospitals, as proven by the fact that the prevalences of
Copyright ©2023 Faculty of Public Health Universitas Airlangga

Open access under a CC BY – SA license | Joinly Published by IAGIKMI & Universitas Airlangga
How to cite: Yenni, P., Purba, M. B. R., & Syauqy, A. (2024) The Relationship between Quality of Nutrition Care and Length of Hospitalization: a Literature
Review: Hubungan Mutu Asuhan Gizi dengan Lama Rawat Inap Pasien di Rumah Sakit: Sebuah Studi Literatur. Amerta Nutrition, 8(1), 130–138.
p-ISSN: 2580-9776 (Print) 131
patient malnutrition in Austria and Switzerland are 16.5% obstacles, further study is of great importance. Therefore,
and 14.5%, lower than in Turkey of 33.7%. In addition, the this study explores more deeply in the relationship
rates of referral to nutritionists in Austria and Switzerland between the quality of nutritional care and the patient’s
are 35.8% and 37.7%, while those in Turkey reaches 61%4,5. length of stay. Apart from being a comparison and lesson,
Abrha et al. (2019) stated that the quality of the findings of this study are expected to contribute in
nutritional care is the main predictor for patients’ length providing suggestions and recommendations for
of stay. They recommended nutritional screenings on hospitals to pass the obstacles and solve the problems
patients upon their arrival and food provision according about nutritional care.
to their nutritional status, the results of which is quicker
responses to the unfavorable condition6. Siegil et al. METHODS
(2019) also emphasized that actions by hospitals focusing This research reviews quantitative studies
on the quality of nutritional care can shorten the time conducted in a number of countries. The included ones
required for malnutrition diagnosis and treatment, which are those which use patients of all ages as the population
can also significantly reduce length of stay. In addition, and discuss length of stay and nutritional care quality
supervision to nutritional screening officers can speed up measurement. Further, the studies were limited to
the nutritional care delivery. Therefore, interventions papers which had undergone peer-reviewed selection,
focusing on inpatients’ nutrition improvement, apart were published in English from 2017 to October 1st 2022
from reducing the length of stay, also serve as a strategy with preference on the more recent ones, could be
for improving the hospital’s services quality. Moreover, accessed in full, and had the average population age of 18
experts have even recommended a number of efforts to years and older. The article search was conducted from
ensure effective nutritional care in hospitals by involving November 6 to 19 in 2022 on PubMed, Springer Link,
all patients, clarifying and defining roles for all doctors, Google Scholar, Cochrane and SAGE databases. Abstract-
using routine screening to identify nutritional risks, using only texts, proceedings, and dissertations were excluded,
validated, easy-to-implement, and easy-to-use screening and articles with duplicates were removed. Table 1 details
tools, initiating nutritional interventions immediately for the search keywords, and table 2 describes the
patients at the risk of malnutrition, preparing and characteristics of the selected articles. The data form the
implementing individualized nutrition plans, monitoring selected papers were extracted by three researchers.
patients' nutritional status during their hospital stay, and Following the search, the articles were screened
creating a post-discharge nutritional plan6,7. independently and assessed based on predetermined
Past studies have left research gaps in terms of inclusion and exclusion criteria. The exclusion also applied
nutrition services from nutritional care or other nutrition should the research had inappropriate population
service programs in hospitals. Several obstacles were characteristics, conducted interventions, or came up with
found in in several hospitals in the effort of reducing findings irrelevant with the purpose of this study. The
length of stay; one of which is sub-optimal quality of screenings resulted in eight articles. They were then
nutritional care. Some have never assessed the quality of selected for data extraction and analyzed. The analysis
their nutritional care for inpatients. Insufficiency in time were performed on the reference details, research
and resources for assessing such quality. Therefore, the objectives, and research design (i.e., type of research,
acquired data was still below 100% even though this sample size, setting, data collection methods, and
program must continue. Due to the several identified instruments), and findings.
Table 1. Keywords for the titerature search

Search Keywords Journal Database Number of Articles
NCBI – PUBMED 12249
Quality of nutritional care; length of Springer Link 4348
hospitalization Cochrane 16
Google Scholar 15100
NCBI (The National Center for Biotechnology Information); PUBMED (Publisher Medline)

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Electronic-based article search results: NCBI- Duplicate articles, time span 5 years,
PubMed (n = 12,249); Springer Links (n=4,348); journal type not research article, not
Google Scholar (n = 15,100); Cochrane (n=16) full text (n= 31,713)
Selection results through inclusion criteria

Does not meet the inclusion criteria (n=10)
(n=16)
Results of articles which pass the screening

process and consideration of eligibility (n= 6)
Figure 1. Prism flow diagram of the article selection process

p-ISSN: 2580-9776 (Print) 133
Table 2. Literature related to the relationship between quality of nutritional care and patient’s length of stay
No Author Research Title Research Location Research Design Year Research Characteristics
1. Kiss Noemi, et al8. Predicting Hospital Length of Sixty countries (155,524 patients Cross Sectional 2021 ▪ Average age: 18-70 years
Stay at Admission Using in nutrition Day data) ▪ Method: Global Observational Data
Global and Country-Specific ▪ Inclusion: Inpatients who were treated on the
Competing Risk Analysis of day of the study, were willing to participate and
Structural, Patient, and were willing to be followed up 30 days later.
Nutrition-Related Data from ▪ Instruments: Questionnaires regarding hospital
nutritionDay 2007-2015 departments, questionnaires regarding patients
from the perspective of medical professionals,
data on hospital nutritional care and
questionnaires from the patient's perspective.
2. Vong Tyrus, et al9. Malnutrition Increases Five affiliated hospitals: Johns Retrospective Cohort 2022 ▪ Number of samples: 4,311 patients
Hospital Length of Stay and Hopkins Hospital, Baltimore, Study ▪ Average age: 58.78 years
Mortality among Adult Maryland; Bayview Hospital, ▪ Method: Database of inpatients from related
Inpatients with COVID-19 Baltimore, Maryland; Howard hospitals.
County General Hospital, ▪ Inclusion: Malnourished patients diagnosed
Columbia, Maryland; Suburban with mRNA Covid-19
Hospital, Bethesda, Maryland; ▪ Instrument: Patient medical record
and Sibley Hospital, Bethesda,
Maryland
3. Abrha Mulugeta, Nutritional Status Significantly Ethiopia Single cohort study 2019 ▪ Number of samples: 324 patients
et al6. Affects Hospital Length of Stay ▪ Average age: > 18 years
among Surgical Patients in ▪ Method: multi-stage random sampling
Public Hospitals of Northern ▪ Inclusion: Hospital patients who underwent
Ethiopia: Single Cohort Study surgery during the research study period and
were willing to be the research sample
▪ Instrument: Questionnaire containing
sociodemographic characteristics, clinical
information, dietary assessment and
biochemical tests
4. Ringel Joanna, et Impact of Gaps in Care for New York Presbyterian-Weill Retrospective study 2019 ▪ Number of samples: 229 malnourished patients
al12 Malnourished Patients on Cornell Medical Center. ▪ Average age: > 18 Years
Length of Stay and Hospital ▪ Method: Registration data from two dietitians
Readmission ▪ Inclusion: Patients with the minimum age of 18
years registered in the medicine unit during the
study period who were diagnosed with
malnutrition (ICD9 code 262 or 263.0)
▪ Instrument: Two data registers in the medicine
unit of New York Presbyterian-Weill Cornell
hospital.
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Table 2. Literature related to the relationship between quality of nutritional care and patient’s length of stay
No Author Research Title Research Location Research Design Year Research Characteristics
5. Liu Hongpeng, et Nutritional Status According China Prospective cohort 2021 ▪ Number of samples: 5,516 inpatients
al13 to the Short-Form Mini study ▪ Average age: > 65 years
Nutritional Assessment (MNA- ▪ Method: Database of inpatients from related
SF) and Clinical Characteristics hospitals
as Predictors of Length of ▪ Inclusion: Inpatients aged over 65 years whose
Stay, Mortality, and data is complete
Readmissions among Older ▪ Instruments: MNA-SF Screening Tool, structured
Inpatients in China: A National Case Report Form (CRF), communication
Study platform based on WeChat Application for
timely feedback.
6. Keller, et al14 Improving the Standard of Five hospitals in Canada Observational 2018 ▪ Number of samples: 1,250 Patients
Nutritional Care in Hospital: ▪ Average age: Adult patients
Mealtime Barriers Reduced ▪ Method: Observation
with Implementation of the ▪ Inclusion: Inpatients, not experiencing cognitive
Integrated Nutrition Pathway impairment, willing to be research respondents,
for Acute Care consuming oral diet
▪ Instruments: Nutrition screening form,
Mealtime Audit Tool (MAT), My Meal Intake
Tool (M-MIT).

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DISCUSSION the patient's stay and post-discharge nutritional plan are

Nutrition services are one of the hospital services important components of the nutritional care process20.
engaged in standardized nutritional care process. This In addition, it is essential to measure patients’ nutritional
process is the responsibility of professional nutritionists status upon their departure from the treatment room. A
or dietitians, whose work is oriented to disease 3-month long food intake data collection should be held
prevention and treatment especially in the field of food to find out exactly the incidence of malnutrition
and nutrition, in either hospitals or other health service experienced by patients and to speed up their healing
units. In addition, this process ensures that patients' food process21.
intake needs are met since food is a basic human need Sriram et al. (2017) stated that appropriate
and is believed to be a factor in preventing and curing nutritional care based on the previously done screening
disease15. process can reduce patient’s length of hospitalization and
Malnutrition and poor diet have been linked to hospital costs. Nutritional sufficiency measurement and
incidence of death in hospitals. Identifying patients at risk its documentation, assessment, treatment, and discharge
and providing nutritional care are fundamental aspects planning are important priorities for nutrition quality
for optimizing medical care in hospitals8. For nutritionists, improvement initiatives22. In addition, Keller et al. (2018)
measuring the impact of nutritional care on a patient's found that malnutrition is significantly worsened by
clinical course is a challenge while making evidence-based mealtime barriers and poor food intake and prolongs the
decisions. Furthermore, lack of information regarding duration of hospitalization14.
nutritional care can lead to inappropriate measurements The largest areas of required quality
of clinical parameters, which can potentially result in improvement in nutritional care process are the use of
inefficient care8. A study on the nutritional health of validated tools for nutrition screening, increased
inpatients was also conducted by Hariani et al. (2021). emphasis on malnutrition diagnosis, and discharge
They found that the availability of workers who are expert planning. Moreover, poor nutritional status and
in conducting food services for patients and planning malnutrition have been shown to be adversely associated
suitable menu can accelerate patient’s healing period16. In with several functional, clinical, and economic outcomes.
addition, providing nutritional intake to patients is more They also increase the risk of comorbid complications,
complex than providing for healthy people in general longer hospital stays, more frequent hospitalizations,
since patients’ appetite and mental condition change due mortality, and health care cost addition. These are not
to the disease they suffer from, the reduced physical found in treated patients who are given adequate
activity and their reactions to medications17. nutritional care23-25.
The high prevalence of malnutrition in hospitals This review research has a number of strengths
reflects the quality of their services. The recovery time of and weaknesses which can be opportunities for further
patients is influenced by the severity of the disease, the research. It involves studies that used large and
treatment process run by the hospital, and the nutritional representative samples for populations in all age groups
intake. Patients with low nutritional status have longer and involves research from various countries so that
time of stays, incur higher hospital costs, and have a trends in differences in results based on distinctiveness in
higher risk of dying in hospital15. Tesfay et al. (2020) ethnicity, race, inter-group and sexual orientation can be
explained that the median length of stay from identified. However, the completeness and optimality of
hospitalization to recovery is estimated at fifteen days; this study in measuring the quality of nutritional care in
this finding was obtained by including patients with nutrition services in hospitals could not be achieved.
malnutrition and comorbidities10. Furthermore, to date there has been no research which
The increasing trend of nutrition-related disease has assessed and measured the quality of nutritional care
cases requires special nutritional management. in nutrition services in hospitals in order to optimize
Therefore, quality nutritional services are needed to inpatient services for malnourished patients. Therefore,
achieve and maintain optimal nutritional status and further research is needed regarding the relationship
accelerate healing1. Improvements in nutritional quality between the quality of nutritional care and the length of
emphasizes the importance of validated nutritional hospitalization of patients in Indonesia as it can be used
screening, in addition to their association with better as the basis for strengthening, improving and optimizing
adherence to dietary intake, nutritional care, as well as nutritional care quality policies for nutrition services in
lower prevalence of malnutrition18,19. Furthermore, hospitals.
nutritional screening, assessment and intervention during

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Table 3. Summary of included studies related to quality of nutritional care and length of stay
No Author Data Type Research Result
1. Kiss Noemi, et al8. Secondary data from the nutritionDay Population Length of hospitalization has a strong relationship with age, affected organs and disease
of 2006-2015 incidence in the study sample.
2. Vong Tyrus, et al9. Covid-19 data obtained from hospital platforms; In the overall, adult patients diagnosed with Covid-19 and malnutrition are associated with
malnutrition data obtained from patient screening an 87.9% increase in length of stay.
3. Abrha Mulugeta, et al6. Primary data acquired via standardization, Length of illness, history of surgery, nutritional status (BMI and MUAC) are the predictors
structuring, direct interviews and direct of length of hospitalization for patients undergoing surgery. There is a great need for
biochemical and clinical test measurements malnutrition screening when admitting patients so that the supplements given to patients
suit their nutritional status and specific malnutrition deficiencies.
4. Ringel Joanna, et al12. Secondary data harvested from two entities which The procedure/test gap in the hospital has a twice higher impact on patients’ longer
handle patient’s register hospitalization time. Mitigation of care gaps can reduce hospitalization, which is expected
to reduce the risk of infection and the treatment costs.
5. Liu Hongpeng, et al13. Secondary data from eligible study subjects The result of this study demonstrates that the low MNA-SF score was related to a significant
recruited from selected hospitals, enrolled increase in length of hospitalization. The average hospitalization for patients with a low
consecutively; from surveys administered by MNA-SF score (i.e., 0-7 or malnourished) is 9-13 days. Meanwhile, patients with an MNA-SF
trained nurses using a structured Case Report score of 12-14 have the average length of stay of 7-9 days. In addition to increasing the
Form (CRF); data quality assured by nurses training length of hospitalization in hospital, malnutrition in the elderly also has an impact on the
and testing before assessing patients; a quality risk of death and readmission within ninety days. The use of nutritional assessment tools in
control team being developed by the researchers; all hospitalized patients in China is urgently needed. Moreover, MNA-SF combined with
a WeChat-based communication being developed hemoglobin levels can be used to identify older hospitalized patients with a high risk of
to guarantee timely feedback; a proxy adverse clinical outcomes. The results of this study have important implications for hospital
interviewees (usually a spouse or other legal service planning.
guardian) being interviewed in the case of the
participant being unable to answer the questions
by themselves
6. Keller, et al14. Primary data obtained from observations on meal In this study changes within and across locations were observed over time in food intake
times and patient’s food intake; Secondary data and length of hospitalization. The study shows that malnutrition is significantly worsened
acquired from the patient’s medical records and by mealtime barriers and poor food intake and prolongs hospitalization
nutritional screening result
Note: NCBI (The National Center for Biotechnology Information); BMI (Body Mass Index); MUAC (Mid-Upper Arm Circumference measure); MNA-SF (Mini Nutritional Assessment-Short Form).

p-ISSN: 2580-9776 (Print) 137
CONCLUSIONS treatment outcome of severely malnourished

For hospitals, improving the quality of nutrition children admitted to Ayder referral hospital: a
services helps them focus on nutritional care, while rapid cross-sectional study. BMC Nutr. 3, 1–9 (2017).
intervention can shorten the length of hospitalization. 12. Ringel, J. B. et al. Impact of gaps in care for
Health and economic outcomes among malnourished malnourished patients on length of stay and
inpatients can be significantly improved through hospital readmission. BMC Health Serv. Res. 19,
nutrition-focused quality improvement interventions. 1–6 (2019).
13. Liu, H. et al. Nutritional status according to the
ACKNOWLEDGMENTS short-form mini nutritional assessment (MNA-SF)
The researchers would like to express their and clinical characteristics as predictors of length
gratitude to the authors of the research journals used in of stay, mortality, and readmissions among older
this study and to all people who have supported and inpatients in China: a national study. Front. Nutr.
assisted in them in providing data and information for the 10 (2022).
completion of this study. 14. Keller, H. H. et al. Improving the standard of
nutritional care in hospital: mealtime barriers
Conflict of Interest and Funding Disclosure reduced with implementation of the Integrated
Nutrition Pathway for Acute Care. Clin. Nutr.
ESPEN 28, 74–79 (2018).
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e-ISSN: 2580-1163 (Online)

p-ISSN: 2580-9776 (Print) 130

The Relationship between Quality of Nutrition Care and Length of

INTRODUCTION care plan’s implementation, and 5) suitability

Copyright ©2023 Faculty of Public Health Universitas Airlangga

Table 1. Keywords for the titerature search

Copyright ©2023 Faculty of Public Health Universitas Airlangga

Selection results through inclusion criteria

Results of articles which pass the screening

Figure 1. Prism flow diagram of the article selection process

Copyright ©2023 Faculty of Public Health Universitas Airlangga

Copyright ©2023 Faculty of Public Health Universitas Airlangga

DISCUSSION the patient's stay and post-discharge nutritional plan are

Copyright ©2023 Faculty of Public Health Universitas Airlangga

Copyright ©2023 Faculty of Public Health Universitas Airlangga

CONCLUSIONS treatment outcome of severely malnourished

Copyright ©2023 Faculty of Public Health Universitas Airlangga

Copyright ©2023 Faculty of Public Health Universitas Airlangga

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