Mangelernhrung in Schweizer Spitlern Dnutrition dans les hpitaux suisses

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Mangelernährung in Schweizer SpitälernDénutrition
dans les hôpitaux suisses

• Why care about nutrition support?
• Descriptive studies one side of the coin
• Intervention studies the other side of the coin
• A strategy to make others care
• Screening method
• OOPS in Denmark
• Copenhagen hospitals
• Board of Health in Denmark
• National survey in internal medicine
• Euro-1 OOPS study

Institute of Human Nutrition
Rigshospitalet
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One side of the coin
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SGA
Subjective Global Assessment HistoryWeight
change, dietary intake change, G-I symptoms,
functional capacity, disease requirements Physic
alSubcutaneous fat, musle wasting, edema SGA
rating (a subjective conclusion)A well
nourishedB moderately malnourishedC severely
malnourished Detsky et al. 1987 JPEN 11 8-13
SGA is screening for malnutrition - not for
malnutrition and risk of malnutrition, i.e. the
well-nourished ICU patient is not included
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Complications and mortality Isabel et al. Clin
Nutr 2003 22235-239
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Key question 1
Will nutrition support improve complications,
mortality, LOS and costs in patients selected by
SGA? Never tested in a controlled
trial!Predictive validity for SGA OK for
outcome but not for change in outcome after
intervention it is the same with other
screening tools
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The other side of the coin
A large number of trials show that nutritional
support improves clinical outcome not all
trials, however.
Meta-analysisStratton RJ, Green CJ, Elia M.
Disease-related malnutrition an evidence-based
approach. CABI Publishing 2003
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RCT Complications mortality
Stratton RJ, Green CJ, Elia M. Disease-related
malnutrition. CABI Publishing 2003
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Two sides of the same coin?
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Key question 2
Do the patients selected for these studies have a
common denominator, e.g. being at-risk by SGA
? Or Does the effect of nutritional support
apply only to the specific patient groups
included in the RCTs, in their specific clinical
and nutritional condition, or can it be
extrapolated to other patients? To ensure it is
the same coin develop a screening tool based on
evidence that outcome will change, i.e. the
available RCTs
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Overview

• Why care about nutrition support?
• Descriptive studies one side of the coin
• Intervention studies the other side of the coin
• A strategy to make others care
• Screening method
• OOPS in Denmark
• Copenhagen hospitals
• Board of Health in Denmark
• National survey in internal medicine
• Euro-1 OOPS study

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Basis of new screening tool
gt100 RCTs, some of which showed a positive effect
on clinical outcome while others did not. This
may be related to the degree of undernutrition
and the degree of stress-metabolism (i.e.
requirements). Can a rational screening tool be
derived from these RCTs?
www.espen.org ? educationKondrup et al. Clin
Nutr 2003 22415-421
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Components
Impaired nutritional status BMI (? present
condition) Recent weight loss (? past
tendency) Recent dietary intake (? future
tendency) Severity of disease/nutritional
requirements E.g. protein requirements in
various disease states (stress metabolism)
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NRS 2002
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proto
Suggested patient prototypes for severity of
disease Score 1 Chronic disease, admitted to
hospital due to complications. Patient is weak
but out of bed regularly. Protein requirement is
increased, but can be covered by oral diet or
supplements in most cases.Score 2Confined
to bed due to illness, e.g. following abdominal
surgery. Protein requirement is substantially
increased, but can be covered, although
artificial feeding is required in many
cases.Score 3 Intensive care with assisted
ventilation etc. Protein requirement is
increased and cannot be covered even by
artificial feeding. Protein breakdown and N loss
can be attenuated significantly.
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Litt analysis

• Predictive validity literature analysis
• Randomized controlled trials (RCTs) of the effect
  of nutritional support versus no support on
  clinical outcome.
• Published as full papers in English.
• Four authors independently classified the patient
  groups in the studies with respect to
  undernutrition and severity of disease, as
  absent, mild, moderate or severe.
• The 10 studies included in the screening system
  were "bench-marks".
• 128 RCTs with a total of 8944 patients were
  analyzed.
• Kondrup et al. Clin Nutr 2003 22 321-336

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All_score
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Score/outcome
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Diag grps
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UPS_RCT_method
Predictive validity with change of outcomeRCT
with 212 at-risk patients randomized to
departments routine or daily follow-up by team
of nurse and dietitian. Main outcome variable
LOSNDIthe length of stay responsive to nutrition
support Nutrition discharge index 3i.e.no aid
in toilet visits ? muscle functionno fever ?
reduction in infectionsno i.v. access ?
reduction in complications - scored blindly N
Johansen et al. in press Clin Nutr
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UPS_RCT_LOS
Johansen N et al. Clin Nutr in press
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NRS 2002 predictive validity

• is able to distinguish between RCTs with a
  positive effect on outcome and RCTs with no
  effect on outcome
• is able to select patients who will benefit from
  nutritional support (and perhaps also some who
  will not specificity?)

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Primary screening
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Overview

• Why care about nutrition support?
• Descriptive studies one side of the coin
• Intervention studies the other side of the coin
• A strategy to make others care
• Screening method
• OOPS in Denmark
• Copenhagen hospitals
• Board of Health in Denmark
• National survey in internal medicine
• Euro-1 OOPS study

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Implementation project OOPS! Screening
Kondrup et al. Clin Nutr 200221461-468
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Implementation project OOPS!

• Strategy
• The management should give detailed guidelines.
• Staff should be educated in elementary aspects of
  nutrition (screening, planning monitoring).
• - and of the hospitals food supply.
• Part of the hospital food should be prepared
  specifically for patients without appetite.

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Results of 1 years training of doctors and nurses

• More patients were screened
• 20 versus 4
• More patients had dietary recording
• 65 versus 31
• More patients were weighed
• 65 versus 39
• More patients had their requirements covered
  (with the aid of a nurse/dietitian team)
• 75 versus 40

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Overview

• Why care about nutrition support?
• Descriptive studies one side of the coin
• Intervention studies the other side of the coin
• A strategy to make others care
• Screening method
• OOPS in Denmark
• Copenhagen hospitals
• Board of Health in Denmark
• National survey in internal medicine
• Euro-1 OOPS study

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Re-accreditation of Copenhagen hospitals
byI-JCAHO in 2005Audit in Copenhagen Hospitals
April 2004Average and range for 6
hospitals1.100 records among 4.500 beds
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Danish National Board of Health 2003Detailed
guideline for doctors, nurses and dietitians

• Rationale
• Undernutrition is common in hospitals
• Reasonable evidence that treatment improves
  clinical outcome and is cost-effective
• Number of cases about nutrition in Patients
  Board of Complaints

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Danish National Board of HealthGuideline for
doctors and nurses in 2003

• Contents
• Screening
• Nutrition planRequirementsRoute of feedingPlan
  for monitoring
• ResponsibilityDoctors all except daily
  monitoringManagement implementation

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Voluntary quality improvement in departments of
internal medicine, averages from January 2004
N 71 departments and 3550 records (67 of all
eligible departments)
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Europe-1 OOPSOngoing studyImplementation of
nutritiopnal care in 30 departments (ICU,
surgery, internal medicine, gastroenterology,
oncology, neurology) in Europe and the Middle
East1238 discharged patients May 25th 2004
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Europe-1 OOPS
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Europe-1 OOPS Risk factors for complications
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Europe-1 OOPS analysis of Length of Stay
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Conclusions

• A meaningful screening tool is the key to make
  others care
• The combination of nutrition science with
  nutrition policy in hospitals is the key to make
  others act