091110 Kondrup IHF Rio

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Lecture at 36th World Hospital Congress of International Hospital Federation in Rio de Janiero, November 2009

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  • Kondrup J et al. Nestle Nutr Workshop Ser Clin Perform Programme 2009;12:1-14.
  • 091110 Kondrup IHF Rio

    1. 1. NUTRITION AND PATIENT SAFETY <ul><li>Three good reasons for proper nutritonal care: </li></ul><ul><ul><li>It improves clinical outcome </li></ul></ul><ul><ul><li>It is a human right issue </li></ul></ul><ul><ul><li>Quality management demands it </li></ul></ul><ul><li>The process that can be audited in accreditation </li></ul><ul><li>Accreditation in Denmark </li></ul><ul><li>Awareness in Europe </li></ul>Rigshospitalet Department of Human Nutrition University of Copenhagen Nutritional risk - How to identify patients in nutritional risk and interfere earlier. Jens Kondrup, professor, dr med sci
    2. 2. RCT: Complications % mortality Stratton RJ, Green CJ, Elia M. Disease-related malnutrition. CABI Publishing 2003 24% vs. 44% 1) Infections 2) 17 % vs. 24% 1) Mortality 1) P <0.001; 2) 10 RCTs only 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 28% vs. 46% 1) Complications
    3. 3. Meta-analysis: Surgery Stratton RJ, Green CJ, Elia M. Disease-related malnutrition 2003
    4. 4. 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
    5. 5. Kondrup et al. Nestle Nutr Workshop Ser Clin Perform Programme 2009;12:1-14.
    6. 6. 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
    7. 7. Prevalence: Care Large care gap! 33 1) Plan (req, food type, monitor) 1) Related to recent weight loss and severity of disease, but not to BMI or recent intake 33 Recent dietary intake 19 Recent weight loss 64 Weight % of at-risk ptt Information in records 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.
    8. 8. It is doable: Results of 1 years’ improvement & training in 3 hospitals (local, regional and university) <ul><li>More patients were screened by NRS-2002 </li></ul><ul><li>20% versus 4% </li></ul><ul><li>More patients had recording of food intake </li></ul><ul><li>65% versus 31% </li></ul><ul><li>More patients were weighed </li></ul><ul><li>65% versus 39% </li></ul><ul><li>The nurses improved in knowledge </li></ul><ul><li>36% versus 14% correct answers </li></ul>
    9. 9. Intake UPS  This is the solution  Johansen et al. Clin Nutr 2004;23:539-550.
    10. 10. European Council’s Committee of Ministers Resolution November 12th 2003 on Food in Hospitals: https://wcm.coe.int/ViewDoc.jsp?id=85747&Lang=en <ul><li>Considering </li></ul><ul><li>access to a safe and healthy variety of food is a fundamental human right </li></ul><ul><li>the unacceptable number of undernourished hospital patients in Europe </li></ul><ul><li>etc </li></ul>
    11. 11. Council of Europe’s Committee of Ministers : Resolution November 12th 2003 <ul><li>The member states should: </li></ul><ul><li>Implement national recommendations based on the principles in the Appendix </li></ul><ul><li>Ensure the widest possible dissemination among all parties concerned: </li></ul><ul><ul><li>public health authorities </li></ul></ul><ul><ul><li>hospital staff </li></ul></ul><ul><ul><li>primary health care sector </li></ul></ul><ul><ul><li>Patients </li></ul></ul><ul><ul><li>researchers and non-governmental organizations </li></ul></ul>
    12. 12. International Joint Commission standards <ul><li>Assessment of Patients </li></ul><ul><ul><li>1.6: Patients are screened for nutritional status and ... referred for further assessment and treatment when necessary. </li></ul></ul><ul><li>Care of Patients </li></ul><ul><ul><li>4: A variety of food choices, appropriate for the patient’s nutritional status and consistent with his or her clinical care, are regularly available. </li></ul></ul><ul><ul><li>5: Patients at nutrition risk receive nutrition therapy. </li></ul></ul><ul><li>Patient and Family Education </li></ul><ul><ul><li>4: Patient and family education include ...nutritional guidance... </li></ul></ul>
    13. 13. NUTRITION AND PATIENT SAFETY <ul><li>Three good reasons for proper nutritonal care: </li></ul><ul><ul><li>It improves clinical outcome </li></ul></ul><ul><ul><li>It is a human right issue </li></ul></ul><ul><ul><li>Quality management demands it </li></ul></ul><ul><li>The process that can be audited in accreditation </li></ul><ul><li>Accreditation in Denmark </li></ul><ul><li>Awareness in Europe </li></ul>Rigshospitalet Department of Human Nutrition University of Copenhagen Nutritional risk - How to identify patients in nutritional risk and interfere earlier. Jens Kondrup, professor, dr med sci
    14. 14. Nutrition support: a structured process ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:415-421 Audit Communication
    15. 15. Screening: NRS 2002 – based on evidence from RCTs ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:415-421. The patient is categorized according to most affected variable Nutritional status Severe 3 Moderate 2 Mild 1 Grade Score 3 months 50-75 2 months 25-50  20.5 >18.5 1 month 5% recent weight loss 0-25 Recent dietary intake, % of requirement  18.5 BMI
    16. 16. Screening NRS 2002 – based on evidence from RCTs ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:415-421. Objective data  Numeric score If  3  nutrition treatment according to ESPEN guideline Identifies malnutrition and risk for developing malnutrition ICU 3 Severe 3 Severe = Score + Confined to bed due to illness 2 Moderate 2 Moderate Chronic disease, ambulatory 1 Mild 1 Mild Increased requirements Nutritional status
    17. 17. EuroOOPS*: Nutrition Practice as determinant of intake ≥75% of requirements in patients at-risk Questions on practice based on Beck et al. Guidelines from Council of Europe. Clin Nutr 2001, 20: 455-460. Unpublished data from Sorensen et al. Clin Nutr 2008;27:340-9. *5051 patients in 22 departments in 12 countries <0.0005 50 65 14/8 Ptt’s satisfaction feedback % patients ≥75% 15/7 13/9 11/11 18/4 Had: Yes/No <0.0005 50 65 Monitoring Common 0.02 56 63 Screening Common <0.0005 54 65 Snacks available NS: definition of responsibility, choice of menus; ICUs excluded 50 No 0.03 P 61 Yes Nutrition Committee Practice in department
    18. 18. Factors determining intake Of 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 Unpublished data from Sorensen et al. Clin Nutr 2008;27:340-9. <0.0005 3.10 TPN or TEN vs. Food or Supplements 1.33 0.30 0.21 0.44 0.29 0.60 OR 0.001 Nutrition Practice Score (per # of practices) <0.0005 <0.0005 0.002 <0.0005 <0.0005 P Oncology vs. Surgery Gastroenterology vs. Surgery Geriatry vs. Surgery Internal Medicine vs. Surgery Recent Intake at NRS screening (per score unit)
    19. 19. NUTRITION AND PATIENT SAFETY <ul><li>Three good reasons for proper nutritonal care: </li></ul><ul><ul><li>It improves clinical outcome </li></ul></ul><ul><ul><li>It is a human right issue </li></ul></ul><ul><ul><li>Quality management demands it </li></ul></ul><ul><li>The process that can be audited in accreditation </li></ul><ul><li>Accreditation in Denmark </li></ul><ul><li>Awareness in Europe </li></ul>Rigshospitalet Department of Human Nutrition University of Copenhagen Nutritional risk - How to identify patients in nutritional risk and interfere earlier. Jens Kondrup, professor, dr med sci
    20. 20. Introductory visit by International Joint Commission in Copenhagen in 1999 <ul><li>Medicine safety </li></ul><ul><li>Hygiene </li></ul><ul><li>Nutrition: blank eyes all over </li></ul>Three areas you have to improve substantially before considering accreditation:
    21. 21. Copenhagen audit March 2006 Accreditation 2002 & 2005 Kondrup et al. Nestle Nutr Workshop Ser Clin Perform Programme 2009;12:1-14.
    22. 22. Reliability of audit results 480 patients in 24 departments in 5 hospitals in Copenhagen Holm et al. ESPEN Congress 2006: Abstract # P 0281 Correct, % Done, % n/N Activity 91% 74% 106/143 Food intake recording 89% 98% 220/224 Final screening 85% 78% 374/480 Initial screening
    23. 23. Standards in Danish Accreditation of all hospitals from 2010: <ul><li>Nutritional screening must be performed <24 h after admission. </li></ul><ul><li>A nutrition plan is defined for patients at-risk. Results including food intake are monitored. </li></ul>
    24. 25. NUTRITION AND PATIENT SAFETY <ul><li>Three good reasons for proper nutritonal care: </li></ul><ul><ul><li>It improves clinical outcome </li></ul></ul><ul><ul><li>It is a human right issue </li></ul></ul><ul><ul><li>Quality management demands it </li></ul></ul><ul><li>The process that can be audited in accreditation </li></ul><ul><li>Accreditation in Denmark </li></ul><ul><li>Awareness in Europe </li></ul>Rigshospitalet Department of Human Nutrition University of Copenhagen Nutritional risk - How to identify patients in nutritional risk and interfere earlier. Jens Kondrup, professor, dr med sci
    25. 26. Governmentally approved national guidelines in… <ul><li>Denmark 2003 </li></ul><ul><li>France 2006 </li></ul><ul><li>Netherlands 2007 </li></ul><ul><li>Belgium 2007 </li></ul><ul><li>United Kingdom 2007 </li></ul><ul><li>Norway 2008 </li></ul>
    26. 27. European Parliament resolution 25 September 2008 <ul><li>Malnutrition costs European healthcare systems similar amounts as obesity and overweight </li></ul><ul><li>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; </li></ul><ul><li>Urges the Commission to …make malnutrition, alongside obesity, a key priority… </li></ul>
    27. 28. EU presidency declaration June 2009: STOP disease-related malnutrition and diseases due to malnutrition! <ul><li>to compromise the quality of life of patients, </li></ul><ul><li>to cause unnecessary morbidity and mortality and </li></ul><ul><li>to undermine the effectiveness of our health care systems across Europe </li></ul>1) Public awareness and education 2) Guideline development and implementation 3) Mandatory screening … actions need to be taken to prevent malnutrition from continuing 4) Research on malnutrition 5) Training in nutritional care 6) National nutritional care plans Action plan:
    28. 29. 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
    29. 30. CONCLUSIONS <ul><li>There are good clinical, economic and ethical reasons to improve nutritonal care. </li></ul><ul><li>The process and standards that can be audited are defined </li></ul><ul><li>It is doable </li></ul>Rigshospitalet Department of Human Nutrition University of Copenhagen Jens Kondrup, professor, dr med sci
    30. 31. Context

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