The DUTCH approach Implementation of nutritional routines from a Dutch national perspective

1. The DUTCH approach Implementation of nutritional routines from a Dutch national perspective Marian van Bokhorst – de van der Schueren PhD, RD, VU University Medical Center Amsterdam, The Netherlands

2. Content Fighting malnutrition in the Netherlands - What is the Dutch approach? What were the keys to success? Is the Dutch approach exploitable in other countries?

3. The Dutch approach in 10 steps A multidisciplinary steering group with national key persons (representatives professional associations) Up-to-date prevalence data to create and sustain awareness  Quick and easy screening tools with treatment plan Screening and treatment as mandatory quality indicators Evidence based – validated tools and cost-effectiveness research

4. The Dutch approach in 10 steps 6. Ministry of Health is key stakeholder and help from the political arena 7. Implementation projects in all care settings Toolkit in free accessible ‘format to be custom made’ & best practices Multidisciplinary project teams in all institutions Training programs and workshops

5. 2004 • LPZ (annual measurement of care problems) cross-sectional measurements of malnutrition across all health-care setting in the Netherlands, n ~30.000 patients per year

6. LPZ, annual measurements of care problemsstarted in 2004, ± 30.000 participants per year Meijers JMM, Schols JMGA, van Bokhorst-de van der Schueren MAE, Dassen T, Janssen MAP, Halfens RJG. Malnutrition prevalence in the Netherlands. Results of the annual Dutch National Prevalence Measurement of Care Problems. British Journal of Nutrition 2008: 100: 5: 1-7 Meijers JMM, et al. Malnutrition prevalence in the Netherlands: results of the annual Dutch prevalence measurement of care problems. British Journal of Nutrition 2009; 101:417-324

7. 1. Dutch Malnutrition Steering Group (DMSG) • DMSG: A multidisciplinary steering group with national key persons • professors, doctors, dietitians, policy advisors and researchers on key positions in relevant medical and nutritional fields Goal: fighting malnutrition together with • the Dutch Annual Measurement of Care Problems (LPZ) • the Dutch Ministry of Health • the Dutch Society for Clinical Nutrition and Metabolism (NESPEN)

9. Points of departure to convince policy makers • Increase awareness: best practices, examples of malnutrition in hospitals • Malnutrition is expensive • Screening and treatment of malnutrition can save money • There are European ‘white papers’

10. How did we convince the minister? • Show ‘scary’ photo’s

11. Best practices

12. How did we convince the minister? • Show facts: • Malnutrition is a huge problem, involving 30-40% of hospital patients • Costs of malnutrition are high: more complications, increased length of hospital stay etc. • Cost effectiveness study available: to shorten the mean length of hospital stay by 1 day for all malnourished patients, a mean investment of (max) € 76 in nutritional screening and treatment is needed • Kruizenga et al., American Journal of Clinical Nutrition, Vol. 82, No. 5, 1082-1089, November 2005

13. A patient’s journey: Symptoms Screening Assessment  Recovery Nutritional Status Intervention Home Hospital Home Time 

14. 2. Up-to-date prevalence data to create and sustain awareness (N= 30.000) 65+** Steady decrease in malnutrition prevalence rates, still 1:4 / 1:5 Dutch Annual Measurement of Care Problems 2010

15. 3. Quick and easy screening tools with treatment plan SNAQ screening tools : QUICK AND EASY SCREENING!!!! • No training needed • No equipment needed (scale nor stadiometer) • No calculations • Takes less than 5 minutes • Screening results are connected to a treatment plan

16. Instruments recommended by ESPEN Specifically for elderly Quick and easy instruments, requiring no calculations

17. 4. Screening as a mandatory quality indicator ( (Health Care Inspectorate) • Screening and treatment mandatory in all health care settings • Malnutrition is defined as one of the main health care issues • Screening and optimal treatment of malnutrition becomes part of the main policy goals of the individual hospitals, nursing homes and home care organizations. • Ongoing collection and feedback of malnutrition data by the Dutch Health Care Inspectorate

18. Daily practice in our own hospital • Introduction of the SNAQ screening instrument to the electronic nurses’ admission questionnaire • Pop-up screens with outcomes of SNAQ screening • ICT application to management-database to be able to present hospital data by the end of the year

19. SNAQ score (obligatory !) other nutritional questions (voluntary)

20. Evaluation of the process = learning by time…. At: 2 weeks 6 weeks 3 months 6 months 1 year yearly

21. New admission n=13392, screened 75%

22. Quality indicator, screeningBenchmark between hospitals Publication bij inspection of health care, Newspapers Internet ‘kiesbeter.nl’

23. Number of hospitals and patients in measurement Hospitals Patients 2007: N = 77 N ≈ 310.000 2008: N = 94 N ≈ 790.000 2009 N = 96 N ≈ 880.000 2010 N = 97 N ≈ 1.050.000

24. Quality indicator 1: All patients should be screened for malnutrition at admission 2010: 72% of patients screened at admission 72 % 65 % 56 % 52 %

25. Quality indicator, part 2 • Introduced in 2008 • Measurement of optimal treatment • What is optimal treatment? • No outcome parameters available at short notice • Measure adequate intake instead? How much protein, energy, by what day? How to measure intake in all patients?

26. Indicator of performance, part 2 Which percentage of malnourished patients reaches optimal protein intake at the fourth day of admission to hospital? Protein: 1,2 – 1,5 gram/per kg/day

27. Daily practice in our hospitals; daily overview of patients admitted with SNAQ scores 3 and up

28. Quality indicator 2: malnourished patients should meet their protein requirements on the 4th day of admission2010: 44% of malnourished patients with adequate protein intake on day 4 44 % 41 % 39 %

29. Quality indicator 2: malnourished patients should meet their protein requirements on the 4th day of admission Mean of all 100 Dutch hospitals: 44% of patients reaches 1,2-1,5 g P/kg on the 4th day >60% optimal intake 11 hospitals 40-60% optimal intake 15 hospitals <40% optimal intake 46 hospitals No data 27 hospitals

30. van Bokhorst – de van der Schueren, Nutr Clin Practice 2012; 274-280 • Leistra, Clin Nutr 2011; 484-489

31. Outpatient screening for patients at risk Were do we go from here? Pre-operative (2007) Geriatrics (2010) Oncology (2012)

32. 5. Evidence based – validated tools and cost-effectiveness research

33. Included patients, malnourished elderly n=210 Cost effectiveness of nutritional intervention to malnourished elderlyfrom admission to hospital until 3 months after discharge Control patients n=105 Intervention patients n=105 ONS, Ca, Vit D for 3 months after discharge

34. Effects Increase in body weight Decrease in funcional limitation 50% Reduction in falls Costs during 3 months No significant cost differences between groups: € 445 (-2779 ; 3938) Functional limitations Calculated incremental costs (ICER) to increase functional limitations with one point (on a six point scale): € 618 Results JAMDA 2011 JAGS 2012

35. 6. Ministry of Health is key stakeholder(with help from the political arena) • Early screening and optimal treatment of malnutrition is defined as a goal in the government program • Malnutrition is one of the four topics in the National Safety Management System for Dutch hospitals • Malnutrition screening score is accepted as indication for reimbursement of medical nutrition by government and health insurers • Has funded the implementation projects and a cost effectiveness analysis

37. 7. Implementation projects in all care settings • 2006-2009 Hospitals • 2008-2011 Nursing homes • 2008-2012 Home care and General Practice • The hospital project received the “pearl of ZonMw” in 2009 (Netherlands Institute for health research and development) for the most succesful implementation project

38. Home Care • 2008-2012: implementation project • Training of 125 home care organisations • LESA • Toolkit

40. Risk profile of malnourished, community dwelling elderly

41. 8. Toolkit with free accessible materials in format to be custom made and best practices • Guidelines and fact sheets • Free format to be custom made • Presentation for nurses, managers, doctors, …. • Project plan • Newsletter • Patient information • ….. • Treatment plans • Best practices • Literature

44. Website: www.stuurgroepondervoeding.nlwith toolkits for different healthcare settings

45. 2010 – MNI award for DUTCH approach!

46. No need to learn Dutch!www.fightmalnutrition.eu in progress

47. No need to learn Dutch! www.fightmalnutrition.eu bla 46

48. Hospitals and nursing homes: • Agreement with the board of Directors. • Multidisciplinary project team with the key persons • Ward-level team of a nurse, dietitian and physician • Home care: Dietitian is project leader 9. Multidisciplinary project teams with authority

50. 10. Training programs and workshops • Training of the project leaders (nurses, dietitians, managers) • 1. How to start with implementation of malnutrition screening? (4 hours) • 2. Education in malnutrition screening and treatment (1 day, 1,5-2 months after the start meeting) • 3. Follow up and group session on patient and implementation cases (4 hours, 3 months after educational meeting, and 1 year after meeting) • Workshops with these aspects in one day • Multidisciplinary screening and treatment guideline