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Development of Measures for Malnutrition at Landspitali – National University Hospital

Development of Measures for Malnutrition at Landspitali – National University Hospital. Inga Thorsdottir professor Unit for Nutrition Research Landspitali and University of Iceland Faculty of Food Science and Nutrition, School of Health Sciences University of Iceland. Subject of the day.

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Development of Measures for Malnutrition at Landspitali – National University Hospital

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  1. Development of Measures for Malnutrition at Landspitali – National University Hospital Inga Thorsdottir professor Unit for Nutrition Research Landspitali and University of Iceland Faculty of Food Science and Nutrition, School of Health Sciences University of Iceland

  2. Subject of the day Distribution of malnutrition - Definition and Cause Identification (full nutrition assessment) Effects/Complications Cost of malnutrition in hospital Quality indicators of nutritional care Actions by UNR Prevalence - FNA and valid screening Four patient groups The screening – always similar everywhere Stop malnutrition Hospital wide screening - Key role http://www.rin.hi.is/en

  3. Why research nutritional status? • Malnutrition • Inpatients • Outpatients • Elderly • Free living • Institutionalized • Evaluation on nutritional status needed! • Available for 17% patients submitted for dietetic treatment • Disregarded for hospitalized patients (Thorsdottir et al. 1999)

  4. Malnutrition – what and why Malnutrition = Imbalance between intake and requirement which results in altered metabolism & impaired function and well-being Malnutrition as Undernutrition = Nutritional status of deficiency of energy, protein and other nutrients Cause of malnutrition/undernutrition = Disease and associated intake of nutrients AND insufficient actions of avoidance / unawareness / Lack of QIs ?

  5. Full Nutrition Assessment (FNA)to identify malnutrition as undernutrition of protein and energy in hospitalized patients(Thorsdottir et al, Clin Nutr 1999; Thorsdottir et al, J Am Diet Assoc 2001; Thorsdottir et al, J Hum Hutr Dietet. 2005; Geirsdottir & Thorsdottir, Food Nutr Res 2008 ) 1. Weight and Height (BMI) 2. Triceps Skinfold Thickness (TST) 3. Mid-Arm Muscle Circumference (MAMC) 4. Serum Albumin 5. Serum Prealbumin 6. Total Lymphocyte Count (TLC) 7. Unintentional Weight Loss Malnutrition defined as having ≥3 of the seven parameters below (1-6) or above reference

  6. Severe complications to malnutrition in hospitalized patients • Perioperative: -Impaired wound healing and infections (Rai et al, Orthopedics ’02; Schneider et al, Brit J Nutr ’04) -Impaired ventilatory drive and decreased respiratory muscle function (Jagoe et al, Thorac Surg ’01) -Increased post-operative complication (Gupta et al, Br J Nutr ’04; Gupta et al, Am J Clin Nutr ’04; Barbosa-Silva & Barros, Clin Nutr ’05; Hassen et al, Eur J Vasc Endovasc Surg ’07) • Morbidity in acute disease/hip fracture (Bachrach-Lindström et al, Clin Nutr ’01) • Increased length of hospital stay (Edington et al, Clin Nutr ’00; Correira & Campos Nutrition ’03; Kyle et al, JPEN ’04; Pirlich et al, Clin Nutr ’06) • Increased mortality in a number of patient groups (Landi et al, Arch Int Med ’00; Madill et al, J Heart Lung Transplant ’01; Alberino et al, Nutrition ’01; Lawson et al, ’01; Soler-Cataluna et al, Chest ’05)

  7. Cost Malnutrition increases patient cost by 25-300% (Correia et al, Clin Nutr ’03; Ockenga et al, Clin Nut ’05; Kruizenga et al, Am J Clin Nutr ’05) Correct treatment save hospital costs by up to 50% (Galban et al Crit Care Med ’00; Braga et al, JPEN ’05; Gianotti et al, Shock ’00) Obligatory screening saves at least 2% of total hospital costs Action: • UNR has measured nutritional status and developed/validated a screening method in groups of hospitalized patients • Work on prevention: Nutrition and physical activity of elderly-proteins and structuring of muscles • Currently UNR leads clinical guidelines, harmonization of nutrition therapy between the hospital’s departments – started by hospital wide screening 2010

  8. Quality Indicators of nutritional care • Nutritional QIs are • Caused by nutritional imbal. • Affect clinical outcome • Validated and reliable • Measured to improve nutritional care and treatment to those who need ! • Evidence based – Used for scientific evaluation and presented • Aimed to improve patient care and treatment

  9. Studies on nutritional status and screening for malnutrition at Landspitali Patients at admission to surgical and medical wards incl also information on nutritional status when submitted to dietitians with COPD additional study on intake, need and nutr balance with cancer in chemotherapy incl also study on intake, need and nutr balance AND test for routine screening and the request for dietary counseling at geriatric wards incl several screening methods, and additional studies to develop a screening for nursing homes, and measure other health/nutrition outcomes

  10. Two studies in a quality management project • Aims: To diminish malnutrition among hospitalized patients • Study 1. Information available on patients nutritional status, patients submitted to dietetic of other cause than obesity (n=167) • Study 2. Evaluate nine-questions screening sheet for malnutrition in patients (n=115) within 48 hours of admission to the hospital. Reference: FNA

  11. Results: • Study 1. Sufficient data to evaluate nutritional status was found for 17% of the patients submitted for dietetic advice • Study 2. Screening sheet identified 21% of the patients as malnourished and a full nutritional assessment 20%. The screening could be simplified Sensitivity of 0.69, Specificity of 0.91

  12. Conclusions: • Study 1. Evaluation of nutritional status in hospitalized patients has been disregarded • Study 2. Simple screening sheet can be used to identify patients in need of further nutritional assessment and treatment Many studies followed

  13. Aim: To evaluate and develop a screening method for malnutrition among patients with chronic obstructive pulmonary disease (COPD) • The screening sheet included 7 questions regarding nutritional status

  14. Screeningsheet • 7 questions • Measurements • height • weight • Calculate BMI and unintentional weight loss • Takes <5 minutes

  15. Results: • Full Nutrition Assessment (FNA) identified 38% malnourished • The screening sheet to be used for COPD patients resulted in sensitivity: 0.69 and Specificity: 0.90 • Conclusion: The simple screening sheet can be used to identify malnutrition among patients with COPD and which need further nutrition assessment and treatment.

  16. COPD patients cont. Thorsdottir I, Gunnarsdottir I. Energy intake must be increased among recently hospitalized patients with chronic obstructive pulmonary disease to improve nutritional status. J Am Diet Ass.2002;102:247-249 • The aim was to investigate energy and nutrient intake as well as nitrogen balances in COPD patients • More knowledge needed about intake and nutritional status development during the first days of hospitalisation • Conclusion: It seemed important to assure at least energy intake equivalent to140-145% of BEE and 1.2 g protein/kg body weight

  17. Aims: • To evaluate a screening sheet for malnutrition (SSM) • To investigate the nutritional status of cancer patients in chemotherapy • To study their diet intake and nitrogen balance • To test SSM for cancer patients in clinical routine and investigate patients view on dietary advise

  18. Screeningsheet • 7 questions • Measurements • height • weight • Calculate BMI and unintentional weight loss • Takes <5 minutes

  19. Results: • FNA defined 20% as malnourished and the screening sheet 23% • Sensitivity 0.83, specificity 0.96 and misclassification rate was 7% • Intake of energy and nutrients were within normal range but nitrogen balance significantly negative • Screening in clinical routine showed 41% malnourished • 80% regarded themselves in need of nutritional counseling -17% had received such advise

  20. Conclusions: • Malnutrition could be defined by the screening sheet • The patients seemed to be in catabolic condition even though they had normal intake – which underlines the importance of quality measures for nutritional status in this group • Screening in clinical routine showed higher prevalence of malnutrition (or high risk for malnutrition) ie 41%. These patients ask for nutritional advise

  21. Aims: To evaluate the Mini Nutrient Assessment (MNA) and Screening Sheet for Malnutrition (SSM) by Full Nutritional Assessment (FNA) in elderly people. Having screening tool as fast and simple as possible. • Method: • MNA, SSM, FNA carried out on 60 hospitalised patients (>65 y) • Questions from the two screening tools used in multivariate stepwise linear regression • The regression model was simplified to be suitable in clinical routines

  22. Results: Malnourishment diagnosed by FNA in 58.3% elderly patients, no gender difference. • Conclusion: According to FNA • Malnutrition is frequent in elderly hospitalized patients • Four questions are sufficient to conduct precise nutritional screening for malnutrition in this group Unintended weight loss – BMI - Recent surgery - Loss of appetite • The sensitivity was 0.89 and specificity 0.88

  23. Elderly cont. Hjaltadóttir I, Ásgeirsdóttir AE, Árnadóttir B, Ottósdóttir H, Hermannsdóttir GJ, Ramel A, Thorsdóttir I. Assessment tool for malnutrition in elderly people. The Icelandic Journal of Nursing 2007;83(5):48-56 The aim was to investigate and evaluate SSM together with the RAI assessment to detect malnutrition in elderly patients Three questions could be used to screen for malnutrition in elderly. Unintended weight loss – BMI - Recent surgery -And can be used with the RAI assessment

  24. Elderly cont. Several other nutritional indicators have been investigated in the hospitalized elderly showing a multifactorial problem: • Hyperhomocysteinemia assoc negatively with folate and B-12 vitamins,positively with impaired renal function • Anemia in elderly assoc positively with protein-energy malnutrition detected by FNA and SSM • D-vitamin deficiency assoc positively with BMI • Ramel et al, Nutrition. 2008; 24:1116-1122 • Ramel et al, Ann Nutr Metab. 2007;51(6):527-32. • Ramel et al, Public Health Nutr. 2009;12(7):1001-5. 20 y 60 y 80 y

  25. Summary • Malnutrition identified in: • Departments of Medicine and Surgery (n=115) 20% of patients • Chronic obstructive pulmonary disease (n=34) 38% of COPD patients • Institutionalized elderly (n=60) 58% of elderly patients • Department of Oncology (n=30, n=100) 20% of participants in evaluation study and 41% of all cancers Screening finds 69% to >90% of malnutrition

  26. 7 Questions • Q5. Hospitalized for 5 days or more during previous 2 months? Yes No • Q6. Major surgery in the past month? Yes No If yes, list type ________________________ • Q7. Diseases – 5 points Yes No Burn >15 % Malnutrition Multiple trauma • Q1. Height:_____ m Weight:_____kg BMI: Kg/m² • Q2. Recent unintentional weight loss? Yes No If yes, how much?____kg In what time period? _____months • Q3. Age over 65 years? Yes No • Q4. Problems last weeks or months? A. Vomiting lasting more than 3 days ? B. Daily diarrhea (more than 3 liquid stools per day)? C. Continuous loss of appetite or nausea? D. Difficulty in chewing or swallowing?

  27. Nutrition day at Landspitali • Hospital wide screening day – early 2010 • Nutrition status screening at 40 depts involving 650 patients • Medium risk for malnutrition: 37.6% • Malnutrition detected (orHigh risk for malnutrition): 26.4% Highest risk observed at the Dept. of Geriatrics and Dept. of Oncology

  28. We have a key role in teamwork to improve nutritional care

  29. Patients in hospital 2010 *Burn > 15%, or hospitalized because of malnutrition, or multiple trauma

  30. Nutrition related problems

  31. Body Mass Index

  32. Body Mass Index

  33. Weight loss-categories Total hospitalized

  34. Risk of malnutrition

  35. Other problems

  36. Unit for Nutrition Research (UNR) UNR founded 1997. Established as a collaborative institution at the University of Iceland and Landspitali-University Hospital 2005 Nutritional sciences - nutrition throughout life span – focus on early life & family, elderly, hospitalized patients Dietary assessment studies - QIs Food constituents & association with human health Recommendations on food and nutrient intake Clinical and Health Care nutrition - QIs - Nutritional status & interventions - Evaluation of screening for malnutrition - Screening & clinical guide to fight malnutrition http://www.rin.hi.is/en

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