091110 Kondrup IHF Rio

NUTRITION AND PATIENT SAFETY

Three good reasons for proper nutritonal care: It improves clinical outcome It is a human right issue Quality management demands it

The process that can be audited in accreditation Accreditation in Denmark Awareness in Europe

RigshospitaletDepartment of Human Nutrition University of Copenhagen

Nutritional risk - How to identify patients in nutritional risk and interfere earlier.

Jens Kondrup, professor, dr med sci

RCT: Complications % mortality

Meta-analysis of 27 RCTs with 1710 patients (complications) and

30 RCTs with 3250 patients (mortality).Neurology, GI disease, liver disease, malignant disease, elderly, abdominal surgery,

orthopaedic surgery, critical illness/injury, burns.Hospital or community

Oral supplements or tube feeding

Complications 28% vs. 46%1)

Infections2) 24% vs. 44%1)

Mortality 17 % vs. 24%1)

1) P <0.001; 2)10 RCTs only

Stratton RJ, Green CJ, Elia M. Disease-related malnutrition. CABI Publishing 2003

Meta-analysis: Surgery

Patient group Surgery

Improvements in functional outcome or in clinical outcome following oral or enteral feeding in hospital patients

Orthopaedics Improved retention of bone mineral Shorter rehabilitation time Improved clinical course Shorter length of hospital stay

Surgery Earlier return of bowel function Improvement in gut permeability Greater wound-healing rate Lower rate of postoperative complications, including infective complications Lower rate of reoperation Retention of skeletal (hand-grip) muscle strength Improved physical and mental health/quality of life Shorter length of hospital stay Lower mortality

Critically ill Improvement in gut permeability Improved immune function. Lower number of infective complications.

Burns Fewer wound infections

Stratton RJ, Green CJ, Elia M. Disease-related malnutrition 2003

BAPEN cost

Based on 33% longer LOS and twice as frequent hospitalisations for at-risk patients and the average bed day cost (£ 258).

Russell. Clin Nutr Suppl 2007; 2: 25–32

Percent of patients malnourished in European Hospitals

21 % (14.341 of 67.094)Papers and abstracts 2002-2007.

Finla

nd

Norway

Denm

ark

Scandin

avia

Nether

lands

Belgiu

m UK

Germ

any

Czech

Rep

Poland

Austria

Switzer

land

Slove

nia

Croat

ia

Spain

Portugal

Turkey

12 c

ountries

0

20

40

60

80

100%

ma

lno

uri

sh

ed

Kondrup et al. Nestle Nutr Workshop Ser Clin Perform Programme 2009;12:1-14.

NICE (UK): Clinical Guideline 32.Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Costing report.London: National Institute for Health and Clinical Execellence (NICE); 2006.

..it is estimated that 30% of patients in all wards are screened

Prevalence: Care

Nutritional care in Denmark A random sample of 15 departments in internal medicine,

orthopaedics, abdominal surgery (N= 590) Rasmussen et al. Clin Nutr 2004;23:1009-15.

Information in records % of at-risk ptt

Weight 64

Recent weight loss 19

Recent dietary intake 33

Plan (req, food type, monitor) 331) 1) Related to recent weight loss and severity of disease, but not to BMI or recent intake

Large care gap!

It is doable:Results of 1 years’ improvement & training in 3 hospitals (local, regional and university)

More patients were screened by NRS-2002

20% versus 4% More patients had recording of food intake

65% versus 31% More patients were weighed

65% versus 39% The nurses improved in knowledge

36% versus 14% correct answers

Proportion of patients receiving 75% of requirements (N)

Control Team0

20

40

60

80

100

<75% 75%

(90)(96)

Team of nurse & dietitian:1) motivation of patient and staff2) rigid planning3) rigid supervision4) change in delivery method with insufficientintakeStaff

Per

cen

t o

f p

atie

nts

Intake UPS

This is the solution

Johansen et al. Clin Nutr 2004;23:539-550.

Considering• access to a safe and healthy variety of food is a

fundamental human right• the unacceptable number of undernourished

hospital patients in Europe• etc

European Council’s Committee of MinistersResolution November 12th 2003 on Food in Hospitals: https://wcm.coe.int/ViewDoc.jsp?id=85747&Lang=en

The member states should:• Implement national recommendations based on the

principles in the Appendix• Ensure the widest possible dissemination among all

parties concerned:• public health authorities• hospital staff• primary health care sector• Patients• researchers and non-governmental organizations

Council of Europe’s Committee of Ministers:Resolution November 12th 2003

International Joint Commission standards Assessment of Patients

1.6: Patients are screened for nutritional status and ... referred for further assessment and treatment when necessary.

Care of Patients 4: A variety of food choices, appropriate for the patient’s

nutritional status and consistent with his or her clinical care, are regularly available.

5: Patients at nutrition risk receive nutrition therapy. Patient and Family Education

4: Patient and family education include ...nutritional guidance...

Nutrition support:a structured process

When in doubt: Assessment

Screening MonitoringNutrition Plan

RequirementAbility/Mode of Feeding

Plan for Monitoring

+

-weekly

-

+

ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:415-421

AuditCommunication

Screening:NRS 2002 – based on evidence from RCTsESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:415-421.

Nutritional statusNutritional status

GradeGradeScoreScore

MildMild11

ModerateModerate22

SevereSevere33

BMIBMI 20.5 >18.520.5 >18.5 18.518.5

Recent dietary intake,Recent dietary intake, % of requirement % of requirement

50-7550-75 25-5025-50 0-250-25

5% recent weight loss5% recent weight loss 3 months3 months 2 months2 months 1 month1 month

The patient is categorized according to most affected variable

ScreeningNRS 2002 – based on evidence from RCTsESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:415-421.

Nutritional statusNutritional status Increased requirementsIncreased requirements

MildMild 11 MildMild 11 Chronic disease, ambulatory

ModerateModerate 22 ModerateModerate 22 Confined to bed due to illness

SevereSevere 33 SevereSevere 33 ICUICU

++ = Score= Score

Objective data Numeric scoreIf 3 nutrition treatment according to ESPEN guideline

Identifies malnutrition and risk for developing malnutrition

EuroOOPS*: Nutrition Practice as determinant of intake ≥75% of requirements in patients at-riskQuestions on practice based onBeck et al. Guidelines from Council of Europe. Clin Nutr 2001, 20: 455-460.

% patients ≥75%% patients ≥75%

Practice in departmentPractice in department Had: Yes/No Yes No P

Nutrition Committee 18/4 61 50 0.03

Screening Common 11/11 63 56 0.02

Monitoring Common 13/9 65 50 <0.0005

Snacks available 15/7 65 54 <0.0005

Ptt’s satisfaction feedback 14/8 65 50 <0.0005

NS: definition of responsibility, choice of menus; ICUs excluded

Unpublished data fromSorensen et al. Clin Nutr 2008;27:340-9.*5051 patients in 22 departments in 12 countries

Factors determining intakeOf the 1581 at-risk patients with LOS >3 days, 1017 (64%) were judged to have an intake 75% of requirements Logistic regression analysis: OR for intake ≥75% of requirements

OR P

Recent Intake at NRS screening (per score unit) 0.60 <0.0005

Geriatry vs. Surgery 0.29 <0.0005

Gastroenterology vs. Surgery 0.44 0.002

Oncology vs. Surgery 0.21 <0.0005

Internal Medicine vs. Surgery 0.30 <0.0005

TPN or TEN vs. Food or Supplements 3.10 <0.0005

Nutrition Practice Score (per # of practices) 1.33 0.001

Unpublished data fromSorensen et al. Clin Nutr 2008;27:340-9.

Introductory visit by International Joint Commission in Copenhagen in 1999

Medicine safetyMedicine safety HygieneHygiene Nutrition: blank eyes all overNutrition: blank eyes all over

Three areas you have to improve substantially before Three areas you have to improve substantially before considering accreditation:considering accreditation:

Copenhagen audit March 2006

Audit of approx. 1500 records among 4.500 beds in Copenhagen

0

10

20

30

40

50

60

70

80

90

100Screening?

Weekly re-screening?

If at-risk:nutrition plan?

If at-risk:>75% req > 75% time?

% o

f ca

ses

Accreditation 2002 & 2005

Kondrup et al. Nestle Nutr Workshop Ser Clin Perform Programme 2009;12:1-14.

Reliability of audit results480 patients in 24 departments in 5 hospitals in Copenhagen

Activity n/N Done, % Correct, %

Initial screening 374/480 78% 85%

Final screening 220/224 98% 89%

Food intake recording 106/143 74% 91%

Holm et al. ESPEN Congress 2006: Abstract # P 0281

Standards in Danish Accreditation of all hospitals from 2010:

1. Nutritional screening must be performed <24 h after admission.

2. A nutrition plan is defined for patients at-risk.Results including food intake are monitored.

Audit in Region Copenhagen: 8.500 beds in 10 hospitalsSample= 2698 records (November 2008)

Sample= 2619 records (May 2009)

Novem

ber 2

008

May

200

9

Novem

ber 2

008

May

200

9

Novem

ber 2

008

May

200

90

10

20

30

40

50

60

70

80

90

100 Screening < 24 h?

Nutrition plan when at risk ?

Food prescribed?

% Y

es (

of

rele

van

t)

Governmentally approved national guidelines in…

Denmark 2003France 2006Netherlands 2007Belgium 2007United Kingdom 2007Norway 2008

European Parliament resolution 25 September 2008 Malnutrition costs European healthcare systems similar

amounts as obesity and overweight

Malnutrition is a heavy burden …for the health care system, …results in increased mortality, longer hospital stays, greater complications and reduced quality of life for patients;

…treatment of complications due to malnutrition cost billions of euros in public funding every year;

Urges the Commission to …make malnutrition, alongside obesity, a key priority…

EU presidency declaration June 2009:STOP disease-related malnutrition and diseases due to malnutrition!

1) Public awareness and education2) Guideline development and implementation3) Mandatory screening

…actions need to be taken to prevent malnutrition from continuing

4) Research on malnutrition5) Training in nutritional care6) National nutritional care plans

Action plan:

to compromise the quality of life of patients, to cause unnecessary morbidity and mortality and to undermine the effectiveness of our health care systems

across Europe

NutritionDay 2007 & 2008:Survey of 21.007 patients in 1.217 units in 325 hospitals in 25 countries.Divided by region, 21% to 93% of the units screened for malnutrition on admission.

Schindler et al 2009, submitted

Screening tools used

NRS 200

2

MUST

Natio

nal

Local

0

10

20

30

40

% o

f u

nit

s

CONCLUSIONS

There are good clinical, economic and ethical reasons to improve nutritonal care.

The process and standards that can be audited are defined

It is doable



Context

Doctors

Nurses

Dietitians

Polititia

ns

Managers

Patien

ts

091110 Kondrup IHF Rio

Health & Medicine

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