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Dr Mary Hickson - Hospital nutritional care and protected mealtimes
 

Dr Mary Hickson - Hospital nutritional care and protected mealtimes

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    Dr Mary Hickson - Hospital nutritional care and protected mealtimes Dr Mary Hickson - Hospital nutritional care and protected mealtimes Presentation Transcript

    • Hospital Nutritional Care and Protected Mealtimes Dr Mary Hickson Therapy Research Lead, Imperial College Healthcare NHS Trust & Honorary Senior Lecturer, Imperial College London
    • Hospital population • 63% of 65-74 year olds and 72% of people aged over 75 years report a long-standing illness • Almost two thirds of general and acute hospital beds are used by people aged over 65 years • People over 75 years have on average significantly longer hospital stays 2002 data
    • Who are Elderly?
    • UK National Statistics, 2009
    • Prevalence of malnutrition • 3 million at risk of malnutrition in the UK • 93% live in the community Malaysia: • Children • Elderly – rural and care home populations • Increasing problems with obesity in adults
    • Prevalence of malnutrition
    • Increased risk in hospital Malnourished people have: Costs: £13 billion / year (UK)
    • Also: Mortality OR: 1.6-1.9 Functional Decline OR:2.2-2.8 Pressure Ulcers OR: 1.9-2.6 Infections OR: 1.5
    • Change in malnutrition risk 0 5 10 15 20 25 30 35 40 45 50 Not at risk Moderate Risk High Risk % week 1 week 2-3 Nematy et al. JHND 2006; 19(3): p209-18.
    • BMI on admission • Mean age 85.3yrs (sd=1.5) • Significantly lower mean BMI than UK elderly population • 22kg/m2 v 27kg/m2 • 36% had BMI <20kg/m2 • 72% had a BMI <24kg/m2
    • Energy deficit
    • 9 month follow up • Mortality • 9 deaths • 7 from high risk of malnutrition group • 1 moderate risk • 1 not at risk
    • Poor food intake 3083 3230 5040 6115 0 1000 2000 3000 4000 5000 6000 7000 B D E Normal Diet Category Energyintake(KJ) Wright et al, (2005) J Hum Nutr Diet 18(3) 213–219
    • General Hospital Patients • Daily meals provided 2007+/-479 kcal and 78+/-21 g of protein and exceeded patients' minimum needs by 41% and 15%, respectively. • 975/1416 (69%) patients did not eat enough. • The food intake of 572/975 (59%) underfed patients was not predominantly affected by disease but other factors. Dupertuis et al 2003
    • Factors associated with inadequate energy intake (multivariate analysis) • poor appetite • higher BMI • diagnosis of infection or cancer, • delirium • need for assistance with feeding. Mudge AM et al. Helping understand nutritional gaps in the elderly (HUNGER): A prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients. Clin Nutr. 2011 Jan 22; 30(3):320-5.
    • Hospital Malnutrition cycle
    • http://na.adapocketguide.com/vault/editor/Image/NCP-1.3.2.1grey1.gif
    • What is the best way to screen? 71 tools in the literature (Green & Watson 2005) • Only some are validated • Only any good if used routinely • Only any good if the results are followed through
    • Recommended tools • ESPEN –NRS 2002 (hospital use) –MUST (community) –MNA (elderly – NH / RC etc) • BAPEN –MUST (all areas)
    • Nutritional Risk Screening (NRS 2002) Table 1: Initial screening Ye s No 1 Is BMI <20? 2 Has the patient lost weight within the last 3 months? 3 Has the patient had a reduced dietary intake in the last week? 4 Is the patient severely ill ? (e.g. in intensive therapy) Yes: If the answer is 'Yes' to any question, the screening in Table 2 is performed. No: If the answer is 'No' to all questions, the patient is re-screening at weekly intervals. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status.
    • Table 2: Final screening Impaired nutritional status Severity of disease ( increase in requirements) Absent Score 0 Normal nutritional status Absent Score 0 Normal nutritional requirements Mild Score 1 Wt loss >5% in 3 mths or Food intake below 50-75% of normal requirement in preceding week. Mild Score 1 Hip fracture* Chronic patients, in particular with acute complications: cirrhosis*, COPD*. Chronic hemodialysis, diabetes, oncology. Moderate Score 2 Wt loss >5% in 2 mths or BMI 18.5 - 20.5 + impaired general condition or Food intake 25-50% of normal requirement in preceding week Moderate Score 2 Major abdominal surgery* Stroke* Severe pneumonia, hematologic malignancy. Severe Score 3 Wt loss >5% in 1 mth (>15% in 3 mths) or BMI <18.5 + impaired general condition or Food intake 0-25% of normal requirement in preceding week in preceding week. Severe Score 3 Head injury* Bone marrow transplantation* Intensive care patients (APACHE>10). Score: + Score: = Total score: Age: if  70 years: add 1 to total score above = age-adjusted total score: Score 3: the patient is nutritionally at-risk and a nutritional care plan is initiated Score < 3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status.
    • http://na.adapocketguide.com/vault/editor/Image/NCP-1.3.2.1grey1.gif
    • Taste and Smell Teeth and oral health Medical conditions Social Factors Psychological factors Appetite and thirst What prevents good intake?
    • Taste and smell First taste of puree: Young 80% Old 33% Young 63% Old 7% Schiffman SS (1997) JAMA 278, (16) 1357-1362.
    • Roberts et al (1994) jama 272(20) 1601-1606 Underfeeding Ad libitum
    • 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 underfeeding hunger score underfeeding satiety score ad lib HS Ad lib SS young old Moriguti et al. (2000) J Gastroent Biol Sci, 55A, 12, B580-587
    • Re-nutrition Research suggests it is more difficult to treat malnutrition in the elderly than in the young. Hebuterne X, et al (1997) Clinical Nutrition 16, 283-289.
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    • Nutritional supplements • Reduced mortality: RR = 0.79 (95% CI: 0.64- 0.97) (undernourished only) • Weight gain: 2.2% (95% CI: 1.8%-2.5%) • Risk of complications reduced: RR=0.86 (95% CI 0.75-0.99) • But no difference in LoS: -0.8days (95% CI: -2.8d - 1.3d) • No functional benefits Milne AC, 2009, Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003288.
    • • Groups most likely to benefit from supplements are: – Over 75yrs – Unwell – Hospitalised – Given an addition 400kcal+ / day • Compliance seems to be good in many studies but this may be ‘trial effect’ • Worse in older adults in hospital Milne AC, 2009, Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003288.
    • Supplement use • UK NICE Guidance • Healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition. [A]
    • Timing of supplements • Give between meals • >1 hour before the next meal. • Supplements with meals adversely affects intake Wilson M-M.G. et al. (2002) Effect of liquid dietary supplements on energy intake in the elderly. Am J Clin Nutr. 75 p944-7.
    • High energy and protein meals • Improve energy and protein intake • Some evidence for weight gain • No evidence for functional gains • BUT • Weak study designs • Many fewer studies
    • Hospital related factors • Systems fail • Inflexible food service • Lack of food choices • Quality and presentation of food • Eating environment • Lack of clear responsibility for food • Low priority placed on food and eating in hospital
    • http://na.adapocketguide.com/vault/editor/Image/NCP-1.3.2.1grey1.gif
    • 0 10 20 30 40 50 60 70 80 South Eastern Southern Western Nordic CCEE total proportion of units screening Schindler et al. How nutritional risk is assessed and managed in European hospitals: A survey of 21,007 patients findings from the 2007– 2008 cross- sectional nutritionDay survey Volume 29, Issue 5, October 2010, Pages 552–559
    • What are screening rates in your hospital or wards?
    • http://na.adapocketguide.com/vault/editor/Image/NCP-1.3.2.1grey1.gif
    • How are patients at risk of malnutrition cared for in your hospital or wards?
    • Nutritional care • Nutritional care processes not well implemented • Limited studies with objective data • Inappropriate nutritional intervention • Inadequate mealtime assistance • Hospital mealtime environment • Inadequate monitoring
    • Nutrition care processes O’Flynn 2005 Clin Nutr
    • Nutrition Assistants • Duncan et al, (2006) Age Ageing, 35, 148-153 • Dietetic assistants in orthopaedic ward increased energy intake and decreased mortality. • Hickson et al (2004) Clin Nutr, 23, 69-77. • Healthcare assistants showed no benefit – but this was not targeted care. • Lassen et al (2008) BMC Hlth Serv Res. 8, 168 • Trained healthcare assistants – showed reduced food wastage
    • Volunteers • Wright et al (2008) J Hum Nutr Diet, 12, 555-562 • Volunteers to help dysphagic patients increased energy intake. • Robinson et al (2002) Geriatr Nurs. 23, 332-5. • Trained volunteers, Higher meal intake as % of food served • Walton et al (2008) Appetite 51, 244-8 • Increased energy and protein at lunch but only daily protein increased • Wong et al (2008) J Nutr, Hlth Aging 12, 309-12 • Volunteers to help semi-dependent patients, intake improved at lunch and weight increased
    • Assistance • Mixed results • Positive effects • Well accepted • But could reduce care provided by routine staff • Needs to be in context of improved nutrition care environment and assignment of responsibility
    • Mealtime environment • Improve the environment • Reduce interruptions • Focus on eating • Protected mealtimes • Family style dining • Ward dining room
    • Does protected mealtimes work? • Limited data • Lack of evidence of implementation • 1 study showed increased energy intake and reduced interruptions • Latest study: Modest increases in the proportion of elderly patients meeting their daily energy and protein requirements. Similar in both PM and assistants groups. Young AM et al. Clin Nutr. 2012. [Epub ahead of print]
    • Dining room to increase intake L. Wright, M. Hickson & G. Frost (2006) Eating together is important: using a dining room in an acute elderly medical ward increases energy intake. J Hum Nutr Dietet, 19, pp. 23–26
    • Take home messages • Hospital is a challenging environment to support nutritional intake • Screening is important but useless without implementation of care plans • Supplements work • Assistance, improved environment, & dinning rooms have a small effect