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Diagnosis and treatment of (disease-related) in-hospital malnutrition: The performance of medical and nursing staff
Clinical Nutrition (2008) 27, 431e438
available at www.sciencedirect.com
http://intl.elsevierhealth.com/journals/clnu
ORIGINAL ARTICLE
Diagnosis and treatment of (disease-related) in-hospital malnutrition: The performance of medical and nursing staff J.W. Bavelaar a,f, C.D. Otter b,f, A.A. van Bodegraven c,g, A. Thijs d,g, M.A.E. van Bokhorst-de van der Schueren e,* a VU University, Faculty of Earth and Life Sciences, Institute of Health Sciences, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands b VU University, Faculty of Medicine, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands c VU University medical center, Department of Gastroenterology, De Boelelaan 1117, PO Box 7057, 1007 MB Amsterdam, The Netherlands d VU University medical center, Department of Internal Medicine, De Boelelaan 1117, PO Box 7057, 1007 MB Amsterdam, The Netherlands e VU University medical center, Department of Nutrition and Dietetics, De Boelelaan 1117, PO Box 7057, 1007 MB Amsterdam, The Netherlands
Received 1 February 2007; accepted 3 January 2008
KEYWORDS Malnutrition; Medical and nursing staff; Diagnosis; Screening; Assessment; Treatment
Summary Background & aims: Malnutrition continues to be an important problem in health care which is still under recognized and underrated in developed countries. This study aims to describe current practice in diagnosing and treating malnutrition by medical doctors, medical students and nurses prior, during and after hospitalisation. Methods: Prospective analysis of current practice in assessing nutritional status and prescribing treatment by medical and nursing staff in a cohort of hospitalised patients from the general medical wards of the VU University Medical Center, Amsterdam. Comparison of objective identification of malnutrition by an independent observer with subjective identification by the medical and nursing staff. Quantification of diagnosing, treating and communicating malnutrition before, during and following hospital stay by medical doctors, medical students and nurses by evaluating the written information in medical and nursing charts, and referral and discharge letters.
* Corresponding author. Tel.: þ31 20 4442159/4444. E-mail address: [email protected] (M.A.E. van Bokhorst-de van der Schueren). f Tel.: þ31 20 598 9898. g Tel.: þ31 20 444 4444. 0261-5614/$ - see front matter ª 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2008.01.016
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J.W. Bavelaar et al. Results: Three hundred and ninety-five women and men, aged 19e96 years, were included from June to September 2005. The prevalence of malnutrition was 31.9%. Nutritional information was not mentioned in written referrals. Medical doctors performed nutritional assessment in 15.3%, medical students in 52.8%, and nurses in 29.9% of their patients. Medical doctors were the most capable of differentiating between malnourished and well-nourished patients as a basis for undertaking nutritional assessment, although this was still inadequate. Little nutritional intervention was applied during hospital stay. Information on nutritional status was lacking in most discharge letters. Nutritional follow-up was appointed in 1.2%. Conclusions: Nutritional assessment and intervention were not sufficiently applied by any professional at any stage of the pre-, actual and post-hospitalisation period. ª 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Introduction Malnutrition is a common problem in hospitalised patients in developed countries. Prevalence varies greatly depending on population, patient setting and definition used. In a British study, using ‘MUST’ (Malnutrition Universal Screening Tool), the prevalence of malnutrition risk ranged from 19% to 60% in in-patients.1 The German hospital malnutrition study, including almost 1900 patients from 13 hospitals, showed a malnutrition rate of 27.4%, using Subjective Global Assessment.2 According to the results of the Dutch annual national prevalence study on health care problems in 2004, 2005 and 2006 (in 25,633, 28,211 and 29,368 patients, respectively), the prevalence of malnutrition in university hospitals in The Netherlands ranges from 24.3% to 29.9%.3e5 Disease-related malnutrition has been associated with an increased risk of clinical complications and an increased length of hospital stay inducing increased health-related costs.6e9 Nutritional intervention has shown to be effective in reducing complications, length of hospital stay, improving wound healing, improving well-being and lowering mortality rates in malnourished patients.10e14 Therefore, early detection and treatment of malnutrition are of benefit for patients and health care systems. Despite the growing evidence of the detrimental effects of malnutrition, it is still under diagnosed.15 In 2001, the Dutch Dietetic Association reported that only 50% of the malnourished patients from a national prevalence survey (n Z 6150, malnourished n Z 800) were identified by the medical staff.16 Similar findings were found in other countries. Scottish in-patients showed a prevalence of malnutrition of 13%; 75% of malnourished patients were not diagnosed as such.17 In a study in Canadian hospitalised patients malnutrition was observed in 69% of patients. Of these, only one patient was identified as being malnourished by the house staff.18 In a Danish study, 22% of the patients were nutritionally at risk, and only 25% of these patients received an adequate amount of energy and protein. The main causes for inadequate nutritional care were lack of instructions to deal with these problems, and lack of basic knowledge.19 Another Danish study concluded that nearly 40% of patients were at nutritional risk, and only a minor part of these patients were identified. Among the obvious triggers for a nutrition plan (weight, BMI, weight loss, dietary intake and severity of
disease), only severity of disease was clearly associated with the presence of a nutrition plan.20 Scottish studies from the 1990s of last century already revealed that the provision of artificial nutritional support was unsatisfactory (prescribed nutrient delivery was not achieved in a third and nutritional outcomes not achieved in 56% of patients) and that malnutrition remained largely unrecognized in approximately 50% of patients.21,22 From these publications, it may be concluded that malnutrition continues to be an important problem in health care which is still under recognized and underrated in developed countries. To our knowledge, current practice of doctors, nurses and students in diagnosing and treatment of malnutrition has not been studied in a hospital setting. This study prospectively describes the current practice of medical doctors, medical students and nurses, in the diagnosis and treatment of malnutrition prior to and during hospitalisation and on discharge. This includes referral from the general practitioner (GP), nutritional screening, assessment and nutritional intervention during hospitalisation, and follow-up of nutritional care after discharge.
Patients and methods Patients From the 25th June 2005 until the 25th September 2005, current practice of medical doctors, medical students and nurses in terms of diagnosing and treating malnutrition was prospectively studied in relation to all newly admitted patients of the general medical wards of the VU University Medical Center, Amsterdam by evaluating the written information in medical and nursing charts and referral and discharge letters. Nutritional status of patients was assessed by an independent observer within the first 72 h after admission and any records of diagnosis and treatment of malnutrition in the charts were recorded prospectively until discharge. Discharge letters were examined 6 months after patients’ discharge to study transfer of nutritional interventions and care from hospital to the GP. Patients who visited the hospital for day-care and patients who were admitted and dismissed during a single weekend were excluded from the study. The medical and
Diagnosis and treatment of in-hospital malnutrition nursing staff were not informed about the conduct and purpose of the study. The study was approved by the Medical Ethical Committee of the VU University Medical Center.
Data collection Referral letters from the GP to the specialist were reviewed in order to evaluate any pre-hospital observations of nutritional screening, assessment or diagnosis of malnutrition. Medical and nursing charts were meticulously analysed during hospitalisation to obtain records of diagnosis and treatment of malnutrition by medical doctors (including house officers and medical staff), medical students and nurses. The following criteria were searched for: 1. Within 72 h after admission to hospital: - medical history parameters: reported changes in weight, appetite, eating pattern, use of any nutritional supplements, nausea, vomiting and defecation pattern; - physical parameters: measurement of weight and height; - subjective global nutritional assessment: any remarks about patients’ nutritional status after physical examination. 2. During hospitalisation: medical doctors’ performance with regard to further nutritional assessment and prescription of nutritional intervention: - nutritional intake analysis: order to register patient’s nutritional intake; - nutritional intervention: order to supplement vitamins and/or trace elements or additional feeding (proteineenergy enriched diet, oral nutritional support, tube feeding or parenteral nutrition); - nutritional assessment: height and weight measurement, and other nutritional assessment parameters such as anthropometry, indirect calorimetry or bioelectric impedance analysis. 3. On discharge: evaluation of all written recommendation about nutritional follow-up in discharge letters. Additional medical information (such as medical diagnosis) was retrieved from the electronic hospital information system whenever available. Within 72 h after admission to hospital, patients’ nutritional status was measured separately by an independent observer (CDO) using the body mass index (BMI) and/or the Short Nutritional Assessment Questionnaire (SNAQª) (Table 1). BMIemortality curves suggest that mortality is increased when the BMI is lower than 18.5 kg/m2. 14,23The SNAQª has been proven to be an easy, short, valid and reproducible questionnaire for the early detection of hospital malnutrition.24 Patients were qualified severely malnourished if they had a BMI < 18.5 and/or a SNAQ score 3 points, and patients were qualified moderately malnourished if they had a BMI between 18.5 and 20.0 kg/m2 and/or a SNAQ score of 2 points, according to prior definitions.24
433 Table 1 (SNAQª)
The Short Nutritional Assessment Questionnaire
Have you lost weight unintentionally? More than 6 kg in the last 6 months More that 3 kg in the last month Have you experienced a decreased appetite over the last month? Have you used supplemental drinks or tube feeding over the last month?
3 Points 2 Points 1 Point 1 Point
2 Points: risk of malnutrition. 3 Points: malnutrition.
Data analysis The complete sample of data consisted of 395 patients (Fig. 1). This sample was used for the actual description of diagnosis and treatment of malnutrition. To study medical and nursing staff awareness of nutritional status, only patients in whom objective nutritional status had been measured by the independent observer (CDO) within 72 h after admission were included (n Z 347). The performance of medical staff with respect to further nutritional assessment and/or interventions during hospitalisation was described for 324 patients. Results are described in percentages. Student’s t-tests were used for continuous variables. Pearson’s c2 test was applied for univariate analysis to compare between the well-nourished patients and the severely and moderately malnourished patients. To compare between groups with expected cell values under 5, Fisher’s exact test was used. A value of p < 0.05 was considered to indicate statistical significance. All data were analysed using SPSS version 11.5.
Results A total of 395 patients were included in the study. Patients were admitted under the following specialties: general medicine (48.7%), gastroenterology (22.6%), nephrology (14.0%), rheumatology (7.6%), dermatology (4.3%) or other (2.8%). In a subgroup of 347 patients, data on nutritional status were derived by the independent observer (87.8%). For 71 patients (18% of the complete sample), only
Total population N=395
No objective nutritional status available N=48
Objective nutritional status available N=347
No follow-up data during hospitalisation available N=23
Admission data + data of further nutritional assesssment / intervention available N=324
Figure 1
Flow diagram of patient inclusion.
434
J.W. Bavelaar et al.
admission data (within 72 h after admission) but no data of the period of hospitalisation were available. The mean age of the population was 59.5 19.4. Patient characteristics are described in Table 2.
nourished population (10.2 vs. 7.2 days, independentsamples t-test: p Z 0.014). No difference with respect to sex and age was found between the malnourished and well-nourished population.
Malnutrition
Stages of hospital admission
Based on BMI and/or SNAQ score, 126 patients (31.9%) were malnourished. Most patients were classified malnourished based on a SNAQ score 2; only 28 patients had a BMI < 18.5. Within this population 123 patients (31.1%) were severely malnourished and 3 patients (0.8%) were moderately malnourished. Mean BMI of malnourished patients was 22.1 5.1. Two hundred and twenty-one patients (55.9%) were well-nourished (mean BMI 26.0 5.6). Nutritional status in 48 patients (12.2%) could not be established due to inability of the independent researcher to obtain objective criteria of malnutrition at admission. The prevalence rates of malnutrition varied strongly between different specialties, with high percentages in gastroenterology (55.0%) and nephrology (43.9%) patients. The lowest prevalence of malnutrition was observed in dermatology patients (17.6%). The median length of hospital stay was significantly longer in the malnourished population than in the well-
Before hospitalisation A written referral from the GP was present for 56 patients (14.2%). Nine of these patients were malnourished; no mention of nutrition was stated in any of the referral letters.
Table 2
Patients characteristics n
%
Sex Men Women
173 222
43.8 56.2
Specialty Internal medicine Gastroenterology Nephrology Rheumatology Dermatology Other
192 89 55 30 17 11
48.7 22.6 14.0 7.6 4.3 2.8
a 19,9
Medical History parameters
65,2 35,0 9,9
Physical parameters
50,0 35,8
61 35 31 30 25 25 19 16 15 14 13 13 27
18.8 10.8 9.6 9.3 7.7 7.7 5.9 4.9 4.6 4.3 4.0 4.0 8.3
Medical doctor Medical student Nurse
12,4 17,0
Global nutritional assessment
a,b
Reason for admission Diseases of the digestive system Diseases of the respiratory system Cardiovascular diseases Endocrine and metabolic diseases Diseases of the genitourinary system Laboratory deviations Infectious diseases Neoplasms External causes Locomotor system Dermis and subcutis Blood and immune system Other
Assessment within 72 h after admission to hospital Medical doctors examined all patients (100%) within 72 h after admission. The examination included assessment of nutritional status in 15.3%. Medical students examined 22.3% of all patients and performed nutritional assessment in half of them. Eighty percent of all patients were examined by nurses; in 29.9% nutritional assessment was performed. Fig. 2a and b show the performance on medical history, physical and global physician’s nutritional assessment for the total population and the malnourished population. Medical doctors performed nutrition assessment more often in malnourished than in well-nourished patients (e.g. p Z 0.036 for weight measurement), although this was only done in a minority of all (malnourished) patients, for example: in 75.8% of all malnourished patients, no weight measurement was performed by a medical doctor. Medical
0,6
0
20
40
60
80
100
(%) patients
b 20,4
Medical history parameters
70,4 46,9 18,7
Physical parameters
55,6 38,3
Global nutritional assessment
Medical doctor Medical student Nurse
23,2 14,8 0,0
a
We categorized the reason for admission according to the 10th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD10), we only used the main diagnosis for classification regardless any subsidiary diagnoses. b Data on reason for admission are only presented for patients with complete data (n Z 324).
0
20
40
60
80
100
(%) patients
Figure 2 (a) Application of nutritional assessment at admission, within the total population, subdivided by profession. (b) Application of nutritional assessment at admission, within the malnourished population, subdivided by profession.
Diagnosis and treatment of in-hospital malnutrition
Nutritional intake analysis
7,4
Total population Malnourished population
13,1
Nutritional intervention
435
26,7 39,4
Nutritional assessment
28,6 31,6
0
20
40
60
80
100
(%) patients
Figure 3 Medical doctors’ performance on nutritional care during hospitalisation within the total and malnourished population.
students and nurses made no distinction between malnourished and well-nourished patients in performing nutrition assessment. During hospitalisation Medical doctors’ performance with regard to further nutritional assessment and prescription of nutritional intervention was analysed. More malnourished than well-nourished patients were weighed twice or more during hospitalisation (Pearson’s c2: p Z 0.007), although 41% of malnourished patients were weighed only once or never. BMI was recorded in only 8 patients, more so in malnourished (n Z 6) than in well-nourished patients (n Z 2). Vitamins and trace element status were assessed biochemically once in 99 patients and more than once in 10 patients, with no statistically significant difference between malnourished and well-nourished patients (Pearson’s c2: p Z 0.271). Advanced nutritional assessment (indirect calorimetry, bioelectrical impedance, anthropometry) was applied in only 3 patients who all were found to be malnourished. Dietary intake records were maintained in 24 patients. A statistically significant relationship was found between keeping a nutritional record and the occurrence of malnutrition (Pearson’s c2: p Z 0.003). Fig. 3 illustrates that medical doctors’ nutritional assessment performance during hospitalisation was higher within the malnourished population in comparison with the well-nourished population. Still, nutritional actions were performed in less than 40% of all malnourished patients. Table 3
Post-discharge Discharge letters from specialists to GPs were examined to determine whether attention was drawn to the patient’s nutritional status. A (temporary) discharge letter within 6 months after discharge was available for 334 patients (84.6%). Mention of some form of nutritional assessment was only made in 2 patients’ discharge letters. Nutritional intervention during hospitalisation was described in the discharge letters in 27 cases out of 127 patients who had received some form of nutritional advice or intervention. In 16 patients a plan with respect to nutritional care to be executed after hospital discharge was presented in the letter. In 4 patients (1.2%), nutritional follow-up after hospital discharge was specifically mentioned. A dietitian was responsible in 1 case; the responsibility for this follow-up plan was indeterminate in 3 cases.
Discussion The purpose of this study was to gain insight into the current practice of diagnosing, treating and communication on malnutrition related to hospital stay by medical doctors, medical students and nurses.
The application of vitamin preparations and additional feeding by dietitian and medical doctor Well-nourished
Dietitian Vitamin preparations Additional feeding Medical doctor Vitamin preparations Additional feeding a
Of the 324 patients who were followed during hospitalisation, a dietitian was consulted for 51 patients. Of the 126 malnourished patients, 31 were seen by a dietitian, and of the 221 well-nourished patients 16 patients were consulted by a dietitian. The dietitian consulted another 4 patients in the group of 48 patients of whom the independent researcher was unable to objectively assess the nutritional status. Supplementation of vitamin preparations and additional feeding is illustrated in Table 3. When a dietitian was consulted vitamins were supplemented in 25 out of 31 (80.6%) of the malnourished patients and to 50% of the well-nourished patients (Fishers’ exact, p Z 0.045). When no dietitian was involved, vitamins were supplied to 19 malnourished patients (27.9%) and to 42 wellnourished patients (24.3%) (NS). Another 32 patients with an unobjectified nutritional status at admission to hospital received vitamin supplementation. Dietitians advised to provide additional feeding in 80.6% of malnourished patients; medical doctors in 13.2%.
Malnourished
Significance (Pearson’s c2) 0.045a
Yes No Yes No
8 8 6 10
(50.0) (50.0) (37.5) (62.5)
25 6 25 6
(80.6) (19.4) (80.6) (19.4)
Yes No Yes No
42 131 12 161
(24.3) (75.7) (6.9) (93.0)
19 49 9 59
(27.9) (72.1) (13.2) (86.8)
Fisher’s exact test (2-sided) was used.
0.003
0.556 0.119
436 This study demonstrates a malnutrition prevalence of 31.9% in several general medical wards of the VU University medical center, which is in accordance with previously and more recently reported Dutch data.3e5,16 In a series of 3 cross-sectional study covering almost 30,000 patients per year in the Netherlands, the prevalence of malnutrition was found to range between 30% and 40% in non-surgical wards in both general and university hospitals.3e5 From these data we deduce that our population is representative for other hospital populations. Moreover, similar data were obtained in recent British and German studies.1,2 This study revealed a high percentage of patients at risk of severe malnutrition and very little patients at moderate risk. We know from earlier Dutch studies that moderate malnutrition is indeed infrequently diagnosed in clinical patients.3e5,16,24 However, this study aimed to investigate behaviour of the medical and nursing staff for all malnourished patients, regardless the severity of malnutrition. In addition, the SNAQ allows for discrimination between malnourished and well-nourished patients. In Dutch hospitals, only the most acutely ill patients are usually admitted to a hospital. These more complex patients are very often also found to be severely malnourished when applying the SNAQ malnutrition screening tool, as we have described in a previous paper.25 BMI is a well-accepted instrument to objectively determine malnutrition.6 In this study, malnourished patients showed a mean BMI within the normal range, which is consistent with the commonly prevalent overweight of patients in the pre-illness period. These normal BMI’s tend to be confusing for medical and nursing staff, because malnourished patients often do not present with obvious signs of malnutrition, such as clear-cut underweight. Applying a quick and easy screening instrument, such as SNAQ, may facilitate earlier recognition of malnourished patients. The SNAQ has recently been validated for the hospital population. It has been designed against objective parameters of malnutrition (BMI and undesired weight loss) and does not need any calculation by the nurses who perform the screening, which makes the instrument easy to use.24 A potential disadvantage of ‘quick and easy’ assessment tools to determine malnutrition, not specifically in this study but more in general, is that these instruments identify patients at risk of malnutrition. Additionally, patients qualified as malnourished by these instruments require further nutritional assessment to diagnose malnutrition definitely. A prospective analysis of the current practice of medical doctors, medical students and nurses in diagnosing and treating malnutrition in a hospital setting has, to our knowledge, not earlier been described in literature. Therefore, no data are available to determine differences in the diagnostic process between hospitals. However, there is no reason to assume differences between teaching or nonteaching, large or small, and specialized or general hospitals, because malnutrition and inadequate diagnosis and treatment have been reported to be common problems in almost all hospital settings in developed countries.26,27 Medical doctors examined 100.0%, medical students 22.3%, and nurses 81.5% of all patients within 72 h after admission. Even though the medical, nurses’ and students’ charts all contain pre-printed questions on (at least) patients’ weight and height, these questions were often not filled out.
J.W. Bavelaar et al. Medical doctors performed nutritional assessment in only 15.3% of their patients, but when they did, they seemed the most capable of the health care professional groups in differentiating between malnourished and wellnourished patients. Nurses performed nutritional assessment in 29.9% of their patients but did not discriminate between well-nourished and malnourished patients. Medical students performed nutritional assessment in 52.8% of their patients and also did not select between malnourished and well-nourished patients. Random assessment by nurses can be explained by the absence of in-depth knowledge and awareness of importance of nutritional issues.20,21 Medical students are still in training, which explains random assessment. Instruction of medical students in assessment of nutritional status did not result in improved knowledge or practice in a Canadian study.18 Therefore, we would propose that standardised protocols for nutritional screening, assessment and treatment could be helpful to structure the process and to define responsibilities between the different disciplines involved. Remarkably, none of the professions obtained a complete overview on the patients’ health status with regard to the nutritional status, despite it being a highly prevalent and clinically significant problem. Medical doctors rarely performed nutritional assessment or prescribed intervention during hospitalisation. Medical students performed better in terms of quantity of examinations. It seems that over time after qualification, attention to nutritional status looses priority in the medical examination. Nutritional assessment by means of medical history, physical examination or global parameters was performed in less than 40% of malnourished patients. Weight measurement was performed in 78.8% of malnourished patients. Nutritional follow-up after hospital discharge was prescribed in only 4 patients (1.2%). Finally, little communication from and towards the GP took place concerning nutritional status, assessment and intervention. This study carries several limitations: the used definition of malnutrition includes 18.5 kg/m2 as a cut-off point for a too low body mass.4,17 A Danish review pointed out that the optimal range of BMI for elderly people (65þ years) may be higher than currently assumed (24e29 kg/m2 rather than 20e25 kg/m2). Therefore, elderly patients with a BMI of 18.4e24 kg/m2 (in this study mean BMI for malnourished patients was 22.5 5.1) should not necessarily be considered to have sound nutritional status.28 With a mean age of 59.5 years in this study, malnutrition may therefore have been underestimated. Documentation of nutritional status by the GP in referral letters to the specialist was inadequate or absent for the majority of patients. A limitation of this analysis is that only written referrals were evaluated. It may have been that other forms of communication were used, such as telephone calls which are rather common (although these are strictly spoken insufficient for obvious reasons). The investigator (CDO) was present on the general medical wards for the 3 months of the study. Even though the medical and nursing staff were not informed about the purpose of the study, it is still possible that the presence of the investigator may have influenced their performance.
Diagnosis and treatment of in-hospital malnutrition Subjectively, we did not notice any change in attitude of the staff towards nutrition during this study, but we were not able to assess this objectively. The analysis of diagnosis and treatment of malnutrition was based on written information in medical and nursing charts. It is likely that to some extent, communication and performances may have been underreported in the charts. Also, it has not been documented whether doctors were aware of the reports of medical students and nurses and vice versa. Since it is unlikely that they were all absolutely independent, the awareness of malnutrition among the different disciplines may have been higher than described in this manuscript. In conclusion, we have demonstrated that recognition and treatment of malnutrition continue to be a problem in hospitalised patients. Nutritional screening, assessment and intervention were not sufficiently nor completely applied by any of the involved professionals at any stage of hospitalisation. If improved recognition of malnutrition is desirable, we suggest to include the questions from simple, valid and reliable screening instruments for malnutrition (such as SNAQ, MUST or NRS 200224,29,30) in standard protocols, to be applied by nurses and/or doctors, to ensure that all patients are screened on admission to hospital and at regular intervals during their stay. Also, documentation of this information should be standardised and preferably computerised. In addition, clear guidelines on how to intervene in case of malnutrition are essential. Well-described responsibilities for all participating disciplines and assignment of more sophisticated techniques to one responsible discipline with expert knowledge for the patients at highest nutritional risk seem obligatory to ensure improvement in patient care.
Conflict of interest statement None of the authors has a conflict of interest.
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Acknowledgments AAvB, AT and MAEvB were responsible for conception, design, and interpretation of data. CDO was responsible for data collection. JWB, and MAEvB were responsible for drafting the article. JWB, MAEvB, AAvB and AT were responsible for the critical revision of the article. All authors finally approved the version to be published. Guarantor: M.A.E. van Bokhorst-de van der Schueren.
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Maastricht: Universiteit Maastricht: sectie Verplegingswetenschap, 2005, ISBN 90-806663-6-X. Halfens RJG, Janssen MAP, Meijers JMM, Wansink SW. Landelijke Prevalentiemeting Decubitus en andere zorgproblemen: Herziene resultaten zevende jaarlijkse meting 2004. Maastricht: Universiteit Maastricht, sectie verpleegwetenschap, 2004, ISBN 90-806663-5-1. Halfens RJG, Janssen MAP, Meijers JMM. Rapportage resultaten Landelijke Prevalentiemeting Zorgproblemen 2006. Maastricht: Datawyse/Universitaire Pers Maastricht, 2006, ISBN 90-806663-7-8. Stratton RJ, Green CJ, Elia M. Disease related malnutrition: an evidence-based approach to treatment. 1st ed. Cambridge: CABI Publishing; 2003. p. 1e34. Robinson G, Goldstein M, Levine GM. Impact of nutritional status on DRG length of stay. J Parenter Enteral Nutr 1987; 11(1):49e51. Pirlich M, Schutz T, Kemps M, Luhman N, Burmester GR, Baumann G, et al. Prevalence of malnutrition in hospitalized medical patients: impact of underlying disease. Dig Dis 2003; 21(3):245e51. Bapen. Malnutrition costs the UK more than £7.3 billion of actual expenditure each year e double the projected £3.5 billion cost of obesity. Bapen; 2006. Ref Type: Internet Communication. Kruizenga HM, Van Tulder MW, Seidell JC, Thijs A, Van Bokhorstde van der Schueren MAE. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr 2005;82:1082e9. van Bokhorst-de van der Schueren MA, Klinkenberg M, Thijs A. Profile of the malnourished patient. Eur J Clin Nutr 2005; 59(10):1129e35. Schroeder D, Gillanders L, Mahr K, Hill GL. Effects of immediate postoperative enteral nutrition on body composition, muscle function, and wound healing. J Parenter Enteral Nutr 1991;15(4):376e83. O’Loughlin E, Forbes D, Parsons H, Scott B, Cooper D, Gall G. Nutritional rehabilitation of malnourished patients with cystic fibrosis. Am J Clin Nutr 1986;43(5):732e7. Flodin L, Svensson S, Cederholm T. Body mass index as a predictor of 1 year mortality in geriatric patients. Clin Nutr 2000; 19(2):121e5. Campbell SE, Avenell A, Walker AE. Assessment of nutritional status in hospital in-patients. QJM 2002;95(2):83e7. Kruizenga HM, Wierdsma NJ, van Bokhorst-de van der Schueren MAE, Hollander HJ, Jonkers-Schuitema CF, van der Heijden E, et al. Screening of nutritional status in The Netherlands. Clin Nutr 2003;22(2):147e52. Kelly IE, Tessier S, Cahill A, Morris SE, Crumley A, McLaughlin D, et al. Still hungry in hospital: identifying malnutrition in acute hospital admissions. QJM 2000;93(2):93e8. Singh H, Watt K, Veitch R, Cantor M, Duerksen DR. Malnutrition is prevalent in hospitalized medical patients: are housestaff identifying the malnourished patient? Nutrition 2006;22(4):350e4. Kondrup J, Johansen N, Plum LM, Bak L, Larsen IH, Martinsen A, et al. Incidence of nutritional risk and causes of inadequate nutritional care in hospitals. Clin Nutr 2002;21(6):461e8. Rasmussen HH, Kondrup J, Staun M, Ladefoged K, Kristensen H, Wengler A. Prevalence of patients at nutritional risk in Danish hospitals. Clin Nutr 2004;23(5):1009e15. McWhirter JP, Hill K, Richards J, Pennington CR. The use, efficacy and monitoring of artificial nutritional support in a teaching hospital. Scott Med J 1995;40(6):179e83. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. Br Med J 1994;308:945e8. FAO/WHO/UNU. Energy and protein requirements. Geneva: WHO; 1985. Technical Report Series 724. Kruizenga HM, Seidell JC, de Vet HC, Wierdsma NJ, van Bokhorstde van der Schueren MA. Development and validation of
438 a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ). Clin Nutr 2005;24(1):75e82. 25. Kruizenga HM, De Jonge P, Seidell JC, Neelemaat F, Van Bodegraven AA, Wierdsma NJ, et al. Are malnourished patients complex patients? Health status and care complexity of malnourished patients detected by the short nutritional assessment questionnaire. Eur J Intern Med 2006;17(3):189e94. 26. Garrow J. Starvation in hospital. BMJ 1994;308(6934):934. 27. Council of Europe, Committee of Ministers. Resolution on food and nutritional care in hospitals. Adopted by the committee of ministers on 12 November 2003. Ref Type: Report.
J.W. Bavelaar et al. 28. Beck AM, Ovesen L. At which body mass index and degree of weight loss should hospitalized elderly patients be considered at nutritional risk? Clin Nutr 1998;17(5):195e8. 29. Elia M. The ‘MUST’ report. Nutritional screening of adults: a multidisciplinary responsibility. In: Malnutrition Advisory Group (MAG), editor. Redditch: BAPEN; 2003. Ref Type: Report. 30. Kondrup J, Rasmussen H, Hamberg O, Stanga Z. Nutritional risk screening (NRS 2002): a new method based on analysis of controlled clinical trials. Clin Nutr 2003;22(3): 321e36.
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ORIGINAL ARTICLE
Diagnosis and treatment of (disease-related) in-hospital malnutrition: The performance of medical and nursing staff J.W. Bavelaar a,f, C.D. Otter b,f, A.A. van Bodegraven c,g, A. Thijs d,g, M.A.E. van Bokhorst-de van der Schueren e,* a VU University, Faculty of Earth and Life Sciences, Institute of Health Sciences, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands b VU University, Faculty of Medicine, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands c VU University medical center, Department of Gastroenterology, De Boelelaan 1117, PO Box 7057, 1007 MB Amsterdam, The Netherlands d VU University medical center, Department of Internal Medicine, De Boelelaan 1117, PO Box 7057, 1007 MB Amsterdam, The Netherlands e VU University medical center, Department of Nutrition and Dietetics, De Boelelaan 1117, PO Box 7057, 1007 MB Amsterdam, The Netherlands
Received 1 February 2007; accepted 3 January 2008
KEYWORDS Malnutrition; Medical and nursing staff; Diagnosis; Screening; Assessment; Treatment
Summary Background & aims: Malnutrition continues to be an important problem in health care which is still under recognized and underrated in developed countries. This study aims to describe current practice in diagnosing and treating malnutrition by medical doctors, medical students and nurses prior, during and after hospitalisation. Methods: Prospective analysis of current practice in assessing nutritional status and prescribing treatment by medical and nursing staff in a cohort of hospitalised patients from the general medical wards of the VU University Medical Center, Amsterdam. Comparison of objective identification of malnutrition by an independent observer with subjective identification by the medical and nursing staff. Quantification of diagnosing, treating and communicating malnutrition before, during and following hospital stay by medical doctors, medical students and nurses by evaluating the written information in medical and nursing charts, and referral and discharge letters.
* Corresponding author. Tel.: þ31 20 4442159/4444. E-mail address: [email protected] (M.A.E. van Bokhorst-de van der Schueren). f Tel.: þ31 20 598 9898. g Tel.: þ31 20 444 4444. 0261-5614/$ - see front matter ª 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2008.01.016
432
J.W. Bavelaar et al. Results: Three hundred and ninety-five women and men, aged 19e96 years, were included from June to September 2005. The prevalence of malnutrition was 31.9%. Nutritional information was not mentioned in written referrals. Medical doctors performed nutritional assessment in 15.3%, medical students in 52.8%, and nurses in 29.9% of their patients. Medical doctors were the most capable of differentiating between malnourished and well-nourished patients as a basis for undertaking nutritional assessment, although this was still inadequate. Little nutritional intervention was applied during hospital stay. Information on nutritional status was lacking in most discharge letters. Nutritional follow-up was appointed in 1.2%. Conclusions: Nutritional assessment and intervention were not sufficiently applied by any professional at any stage of the pre-, actual and post-hospitalisation period. ª 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Introduction Malnutrition is a common problem in hospitalised patients in developed countries. Prevalence varies greatly depending on population, patient setting and definition used. In a British study, using ‘MUST’ (Malnutrition Universal Screening Tool), the prevalence of malnutrition risk ranged from 19% to 60% in in-patients.1 The German hospital malnutrition study, including almost 1900 patients from 13 hospitals, showed a malnutrition rate of 27.4%, using Subjective Global Assessment.2 According to the results of the Dutch annual national prevalence study on health care problems in 2004, 2005 and 2006 (in 25,633, 28,211 and 29,368 patients, respectively), the prevalence of malnutrition in university hospitals in The Netherlands ranges from 24.3% to 29.9%.3e5 Disease-related malnutrition has been associated with an increased risk of clinical complications and an increased length of hospital stay inducing increased health-related costs.6e9 Nutritional intervention has shown to be effective in reducing complications, length of hospital stay, improving wound healing, improving well-being and lowering mortality rates in malnourished patients.10e14 Therefore, early detection and treatment of malnutrition are of benefit for patients and health care systems. Despite the growing evidence of the detrimental effects of malnutrition, it is still under diagnosed.15 In 2001, the Dutch Dietetic Association reported that only 50% of the malnourished patients from a national prevalence survey (n Z 6150, malnourished n Z 800) were identified by the medical staff.16 Similar findings were found in other countries. Scottish in-patients showed a prevalence of malnutrition of 13%; 75% of malnourished patients were not diagnosed as such.17 In a study in Canadian hospitalised patients malnutrition was observed in 69% of patients. Of these, only one patient was identified as being malnourished by the house staff.18 In a Danish study, 22% of the patients were nutritionally at risk, and only 25% of these patients received an adequate amount of energy and protein. The main causes for inadequate nutritional care were lack of instructions to deal with these problems, and lack of basic knowledge.19 Another Danish study concluded that nearly 40% of patients were at nutritional risk, and only a minor part of these patients were identified. Among the obvious triggers for a nutrition plan (weight, BMI, weight loss, dietary intake and severity of
disease), only severity of disease was clearly associated with the presence of a nutrition plan.20 Scottish studies from the 1990s of last century already revealed that the provision of artificial nutritional support was unsatisfactory (prescribed nutrient delivery was not achieved in a third and nutritional outcomes not achieved in 56% of patients) and that malnutrition remained largely unrecognized in approximately 50% of patients.21,22 From these publications, it may be concluded that malnutrition continues to be an important problem in health care which is still under recognized and underrated in developed countries. To our knowledge, current practice of doctors, nurses and students in diagnosing and treatment of malnutrition has not been studied in a hospital setting. This study prospectively describes the current practice of medical doctors, medical students and nurses, in the diagnosis and treatment of malnutrition prior to and during hospitalisation and on discharge. This includes referral from the general practitioner (GP), nutritional screening, assessment and nutritional intervention during hospitalisation, and follow-up of nutritional care after discharge.
Patients and methods Patients From the 25th June 2005 until the 25th September 2005, current practice of medical doctors, medical students and nurses in terms of diagnosing and treating malnutrition was prospectively studied in relation to all newly admitted patients of the general medical wards of the VU University Medical Center, Amsterdam by evaluating the written information in medical and nursing charts and referral and discharge letters. Nutritional status of patients was assessed by an independent observer within the first 72 h after admission and any records of diagnosis and treatment of malnutrition in the charts were recorded prospectively until discharge. Discharge letters were examined 6 months after patients’ discharge to study transfer of nutritional interventions and care from hospital to the GP. Patients who visited the hospital for day-care and patients who were admitted and dismissed during a single weekend were excluded from the study. The medical and
Diagnosis and treatment of in-hospital malnutrition nursing staff were not informed about the conduct and purpose of the study. The study was approved by the Medical Ethical Committee of the VU University Medical Center.
Data collection Referral letters from the GP to the specialist were reviewed in order to evaluate any pre-hospital observations of nutritional screening, assessment or diagnosis of malnutrition. Medical and nursing charts were meticulously analysed during hospitalisation to obtain records of diagnosis and treatment of malnutrition by medical doctors (including house officers and medical staff), medical students and nurses. The following criteria were searched for: 1. Within 72 h after admission to hospital: - medical history parameters: reported changes in weight, appetite, eating pattern, use of any nutritional supplements, nausea, vomiting and defecation pattern; - physical parameters: measurement of weight and height; - subjective global nutritional assessment: any remarks about patients’ nutritional status after physical examination. 2. During hospitalisation: medical doctors’ performance with regard to further nutritional assessment and prescription of nutritional intervention: - nutritional intake analysis: order to register patient’s nutritional intake; - nutritional intervention: order to supplement vitamins and/or trace elements or additional feeding (proteineenergy enriched diet, oral nutritional support, tube feeding or parenteral nutrition); - nutritional assessment: height and weight measurement, and other nutritional assessment parameters such as anthropometry, indirect calorimetry or bioelectric impedance analysis. 3. On discharge: evaluation of all written recommendation about nutritional follow-up in discharge letters. Additional medical information (such as medical diagnosis) was retrieved from the electronic hospital information system whenever available. Within 72 h after admission to hospital, patients’ nutritional status was measured separately by an independent observer (CDO) using the body mass index (BMI) and/or the Short Nutritional Assessment Questionnaire (SNAQª) (Table 1). BMIemortality curves suggest that mortality is increased when the BMI is lower than 18.5 kg/m2. 14,23The SNAQª has been proven to be an easy, short, valid and reproducible questionnaire for the early detection of hospital malnutrition.24 Patients were qualified severely malnourished if they had a BMI < 18.5 and/or a SNAQ score 3 points, and patients were qualified moderately malnourished if they had a BMI between 18.5 and 20.0 kg/m2 and/or a SNAQ score of 2 points, according to prior definitions.24
433 Table 1 (SNAQª)
The Short Nutritional Assessment Questionnaire
Have you lost weight unintentionally? More than 6 kg in the last 6 months More that 3 kg in the last month Have you experienced a decreased appetite over the last month? Have you used supplemental drinks or tube feeding over the last month?
3 Points 2 Points 1 Point 1 Point
2 Points: risk of malnutrition. 3 Points: malnutrition.
Data analysis The complete sample of data consisted of 395 patients (Fig. 1). This sample was used for the actual description of diagnosis and treatment of malnutrition. To study medical and nursing staff awareness of nutritional status, only patients in whom objective nutritional status had been measured by the independent observer (CDO) within 72 h after admission were included (n Z 347). The performance of medical staff with respect to further nutritional assessment and/or interventions during hospitalisation was described for 324 patients. Results are described in percentages. Student’s t-tests were used for continuous variables. Pearson’s c2 test was applied for univariate analysis to compare between the well-nourished patients and the severely and moderately malnourished patients. To compare between groups with expected cell values under 5, Fisher’s exact test was used. A value of p < 0.05 was considered to indicate statistical significance. All data were analysed using SPSS version 11.5.
Results A total of 395 patients were included in the study. Patients were admitted under the following specialties: general medicine (48.7%), gastroenterology (22.6%), nephrology (14.0%), rheumatology (7.6%), dermatology (4.3%) or other (2.8%). In a subgroup of 347 patients, data on nutritional status were derived by the independent observer (87.8%). For 71 patients (18% of the complete sample), only
Total population N=395
No objective nutritional status available N=48
Objective nutritional status available N=347
No follow-up data during hospitalisation available N=23
Admission data + data of further nutritional assesssment / intervention available N=324
Figure 1
Flow diagram of patient inclusion.
434
J.W. Bavelaar et al.
admission data (within 72 h after admission) but no data of the period of hospitalisation were available. The mean age of the population was 59.5 19.4. Patient characteristics are described in Table 2.
nourished population (10.2 vs. 7.2 days, independentsamples t-test: p Z 0.014). No difference with respect to sex and age was found between the malnourished and well-nourished population.
Malnutrition
Stages of hospital admission
Based on BMI and/or SNAQ score, 126 patients (31.9%) were malnourished. Most patients were classified malnourished based on a SNAQ score 2; only 28 patients had a BMI < 18.5. Within this population 123 patients (31.1%) were severely malnourished and 3 patients (0.8%) were moderately malnourished. Mean BMI of malnourished patients was 22.1 5.1. Two hundred and twenty-one patients (55.9%) were well-nourished (mean BMI 26.0 5.6). Nutritional status in 48 patients (12.2%) could not be established due to inability of the independent researcher to obtain objective criteria of malnutrition at admission. The prevalence rates of malnutrition varied strongly between different specialties, with high percentages in gastroenterology (55.0%) and nephrology (43.9%) patients. The lowest prevalence of malnutrition was observed in dermatology patients (17.6%). The median length of hospital stay was significantly longer in the malnourished population than in the well-
Before hospitalisation A written referral from the GP was present for 56 patients (14.2%). Nine of these patients were malnourished; no mention of nutrition was stated in any of the referral letters.
Table 2
Patients characteristics n
%
Sex Men Women
173 222
43.8 56.2
Specialty Internal medicine Gastroenterology Nephrology Rheumatology Dermatology Other
192 89 55 30 17 11
48.7 22.6 14.0 7.6 4.3 2.8
a 19,9
Medical History parameters
65,2 35,0 9,9
Physical parameters
50,0 35,8
61 35 31 30 25 25 19 16 15 14 13 13 27
18.8 10.8 9.6 9.3 7.7 7.7 5.9 4.9 4.6 4.3 4.0 4.0 8.3
Medical doctor Medical student Nurse
12,4 17,0
Global nutritional assessment
a,b
Reason for admission Diseases of the digestive system Diseases of the respiratory system Cardiovascular diseases Endocrine and metabolic diseases Diseases of the genitourinary system Laboratory deviations Infectious diseases Neoplasms External causes Locomotor system Dermis and subcutis Blood and immune system Other
Assessment within 72 h after admission to hospital Medical doctors examined all patients (100%) within 72 h after admission. The examination included assessment of nutritional status in 15.3%. Medical students examined 22.3% of all patients and performed nutritional assessment in half of them. Eighty percent of all patients were examined by nurses; in 29.9% nutritional assessment was performed. Fig. 2a and b show the performance on medical history, physical and global physician’s nutritional assessment for the total population and the malnourished population. Medical doctors performed nutrition assessment more often in malnourished than in well-nourished patients (e.g. p Z 0.036 for weight measurement), although this was only done in a minority of all (malnourished) patients, for example: in 75.8% of all malnourished patients, no weight measurement was performed by a medical doctor. Medical
0,6
0
20
40
60
80
100
(%) patients
b 20,4
Medical history parameters
70,4 46,9 18,7
Physical parameters
55,6 38,3
Global nutritional assessment
Medical doctor Medical student Nurse
23,2 14,8 0,0
a
We categorized the reason for admission according to the 10th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD10), we only used the main diagnosis for classification regardless any subsidiary diagnoses. b Data on reason for admission are only presented for patients with complete data (n Z 324).
0
20
40
60
80
100
(%) patients
Figure 2 (a) Application of nutritional assessment at admission, within the total population, subdivided by profession. (b) Application of nutritional assessment at admission, within the malnourished population, subdivided by profession.
Diagnosis and treatment of in-hospital malnutrition
Nutritional intake analysis
7,4
Total population Malnourished population
13,1
Nutritional intervention
435
26,7 39,4
Nutritional assessment
28,6 31,6
0
20
40
60
80
100
(%) patients
Figure 3 Medical doctors’ performance on nutritional care during hospitalisation within the total and malnourished population.
students and nurses made no distinction between malnourished and well-nourished patients in performing nutrition assessment. During hospitalisation Medical doctors’ performance with regard to further nutritional assessment and prescription of nutritional intervention was analysed. More malnourished than well-nourished patients were weighed twice or more during hospitalisation (Pearson’s c2: p Z 0.007), although 41% of malnourished patients were weighed only once or never. BMI was recorded in only 8 patients, more so in malnourished (n Z 6) than in well-nourished patients (n Z 2). Vitamins and trace element status were assessed biochemically once in 99 patients and more than once in 10 patients, with no statistically significant difference between malnourished and well-nourished patients (Pearson’s c2: p Z 0.271). Advanced nutritional assessment (indirect calorimetry, bioelectrical impedance, anthropometry) was applied in only 3 patients who all were found to be malnourished. Dietary intake records were maintained in 24 patients. A statistically significant relationship was found between keeping a nutritional record and the occurrence of malnutrition (Pearson’s c2: p Z 0.003). Fig. 3 illustrates that medical doctors’ nutritional assessment performance during hospitalisation was higher within the malnourished population in comparison with the well-nourished population. Still, nutritional actions were performed in less than 40% of all malnourished patients. Table 3
Post-discharge Discharge letters from specialists to GPs were examined to determine whether attention was drawn to the patient’s nutritional status. A (temporary) discharge letter within 6 months after discharge was available for 334 patients (84.6%). Mention of some form of nutritional assessment was only made in 2 patients’ discharge letters. Nutritional intervention during hospitalisation was described in the discharge letters in 27 cases out of 127 patients who had received some form of nutritional advice or intervention. In 16 patients a plan with respect to nutritional care to be executed after hospital discharge was presented in the letter. In 4 patients (1.2%), nutritional follow-up after hospital discharge was specifically mentioned. A dietitian was responsible in 1 case; the responsibility for this follow-up plan was indeterminate in 3 cases.
Discussion The purpose of this study was to gain insight into the current practice of diagnosing, treating and communication on malnutrition related to hospital stay by medical doctors, medical students and nurses.
The application of vitamin preparations and additional feeding by dietitian and medical doctor Well-nourished
Dietitian Vitamin preparations Additional feeding Medical doctor Vitamin preparations Additional feeding a
Of the 324 patients who were followed during hospitalisation, a dietitian was consulted for 51 patients. Of the 126 malnourished patients, 31 were seen by a dietitian, and of the 221 well-nourished patients 16 patients were consulted by a dietitian. The dietitian consulted another 4 patients in the group of 48 patients of whom the independent researcher was unable to objectively assess the nutritional status. Supplementation of vitamin preparations and additional feeding is illustrated in Table 3. When a dietitian was consulted vitamins were supplemented in 25 out of 31 (80.6%) of the malnourished patients and to 50% of the well-nourished patients (Fishers’ exact, p Z 0.045). When no dietitian was involved, vitamins were supplied to 19 malnourished patients (27.9%) and to 42 wellnourished patients (24.3%) (NS). Another 32 patients with an unobjectified nutritional status at admission to hospital received vitamin supplementation. Dietitians advised to provide additional feeding in 80.6% of malnourished patients; medical doctors in 13.2%.
Malnourished
Significance (Pearson’s c2) 0.045a
Yes No Yes No
8 8 6 10
(50.0) (50.0) (37.5) (62.5)
25 6 25 6
(80.6) (19.4) (80.6) (19.4)
Yes No Yes No
42 131 12 161
(24.3) (75.7) (6.9) (93.0)
19 49 9 59
(27.9) (72.1) (13.2) (86.8)
Fisher’s exact test (2-sided) was used.
0.003
0.556 0.119
436 This study demonstrates a malnutrition prevalence of 31.9% in several general medical wards of the VU University medical center, which is in accordance with previously and more recently reported Dutch data.3e5,16 In a series of 3 cross-sectional study covering almost 30,000 patients per year in the Netherlands, the prevalence of malnutrition was found to range between 30% and 40% in non-surgical wards in both general and university hospitals.3e5 From these data we deduce that our population is representative for other hospital populations. Moreover, similar data were obtained in recent British and German studies.1,2 This study revealed a high percentage of patients at risk of severe malnutrition and very little patients at moderate risk. We know from earlier Dutch studies that moderate malnutrition is indeed infrequently diagnosed in clinical patients.3e5,16,24 However, this study aimed to investigate behaviour of the medical and nursing staff for all malnourished patients, regardless the severity of malnutrition. In addition, the SNAQ allows for discrimination between malnourished and well-nourished patients. In Dutch hospitals, only the most acutely ill patients are usually admitted to a hospital. These more complex patients are very often also found to be severely malnourished when applying the SNAQ malnutrition screening tool, as we have described in a previous paper.25 BMI is a well-accepted instrument to objectively determine malnutrition.6 In this study, malnourished patients showed a mean BMI within the normal range, which is consistent with the commonly prevalent overweight of patients in the pre-illness period. These normal BMI’s tend to be confusing for medical and nursing staff, because malnourished patients often do not present with obvious signs of malnutrition, such as clear-cut underweight. Applying a quick and easy screening instrument, such as SNAQ, may facilitate earlier recognition of malnourished patients. The SNAQ has recently been validated for the hospital population. It has been designed against objective parameters of malnutrition (BMI and undesired weight loss) and does not need any calculation by the nurses who perform the screening, which makes the instrument easy to use.24 A potential disadvantage of ‘quick and easy’ assessment tools to determine malnutrition, not specifically in this study but more in general, is that these instruments identify patients at risk of malnutrition. Additionally, patients qualified as malnourished by these instruments require further nutritional assessment to diagnose malnutrition definitely. A prospective analysis of the current practice of medical doctors, medical students and nurses in diagnosing and treating malnutrition in a hospital setting has, to our knowledge, not earlier been described in literature. Therefore, no data are available to determine differences in the diagnostic process between hospitals. However, there is no reason to assume differences between teaching or nonteaching, large or small, and specialized or general hospitals, because malnutrition and inadequate diagnosis and treatment have been reported to be common problems in almost all hospital settings in developed countries.26,27 Medical doctors examined 100.0%, medical students 22.3%, and nurses 81.5% of all patients within 72 h after admission. Even though the medical, nurses’ and students’ charts all contain pre-printed questions on (at least) patients’ weight and height, these questions were often not filled out.
J.W. Bavelaar et al. Medical doctors performed nutritional assessment in only 15.3% of their patients, but when they did, they seemed the most capable of the health care professional groups in differentiating between malnourished and wellnourished patients. Nurses performed nutritional assessment in 29.9% of their patients but did not discriminate between well-nourished and malnourished patients. Medical students performed nutritional assessment in 52.8% of their patients and also did not select between malnourished and well-nourished patients. Random assessment by nurses can be explained by the absence of in-depth knowledge and awareness of importance of nutritional issues.20,21 Medical students are still in training, which explains random assessment. Instruction of medical students in assessment of nutritional status did not result in improved knowledge or practice in a Canadian study.18 Therefore, we would propose that standardised protocols for nutritional screening, assessment and treatment could be helpful to structure the process and to define responsibilities between the different disciplines involved. Remarkably, none of the professions obtained a complete overview on the patients’ health status with regard to the nutritional status, despite it being a highly prevalent and clinically significant problem. Medical doctors rarely performed nutritional assessment or prescribed intervention during hospitalisation. Medical students performed better in terms of quantity of examinations. It seems that over time after qualification, attention to nutritional status looses priority in the medical examination. Nutritional assessment by means of medical history, physical examination or global parameters was performed in less than 40% of malnourished patients. Weight measurement was performed in 78.8% of malnourished patients. Nutritional follow-up after hospital discharge was prescribed in only 4 patients (1.2%). Finally, little communication from and towards the GP took place concerning nutritional status, assessment and intervention. This study carries several limitations: the used definition of malnutrition includes 18.5 kg/m2 as a cut-off point for a too low body mass.4,17 A Danish review pointed out that the optimal range of BMI for elderly people (65þ years) may be higher than currently assumed (24e29 kg/m2 rather than 20e25 kg/m2). Therefore, elderly patients with a BMI of 18.4e24 kg/m2 (in this study mean BMI for malnourished patients was 22.5 5.1) should not necessarily be considered to have sound nutritional status.28 With a mean age of 59.5 years in this study, malnutrition may therefore have been underestimated. Documentation of nutritional status by the GP in referral letters to the specialist was inadequate or absent for the majority of patients. A limitation of this analysis is that only written referrals were evaluated. It may have been that other forms of communication were used, such as telephone calls which are rather common (although these are strictly spoken insufficient for obvious reasons). The investigator (CDO) was present on the general medical wards for the 3 months of the study. Even though the medical and nursing staff were not informed about the purpose of the study, it is still possible that the presence of the investigator may have influenced their performance.
Diagnosis and treatment of in-hospital malnutrition Subjectively, we did not notice any change in attitude of the staff towards nutrition during this study, but we were not able to assess this objectively. The analysis of diagnosis and treatment of malnutrition was based on written information in medical and nursing charts. It is likely that to some extent, communication and performances may have been underreported in the charts. Also, it has not been documented whether doctors were aware of the reports of medical students and nurses and vice versa. Since it is unlikely that they were all absolutely independent, the awareness of malnutrition among the different disciplines may have been higher than described in this manuscript. In conclusion, we have demonstrated that recognition and treatment of malnutrition continue to be a problem in hospitalised patients. Nutritional screening, assessment and intervention were not sufficiently nor completely applied by any of the involved professionals at any stage of hospitalisation. If improved recognition of malnutrition is desirable, we suggest to include the questions from simple, valid and reliable screening instruments for malnutrition (such as SNAQ, MUST or NRS 200224,29,30) in standard protocols, to be applied by nurses and/or doctors, to ensure that all patients are screened on admission to hospital and at regular intervals during their stay. Also, documentation of this information should be standardised and preferably computerised. In addition, clear guidelines on how to intervene in case of malnutrition are essential. Well-described responsibilities for all participating disciplines and assignment of more sophisticated techniques to one responsible discipline with expert knowledge for the patients at highest nutritional risk seem obligatory to ensure improvement in patient care.
Conflict of interest statement None of the authors has a conflict of interest.
437
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7.
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15. 16.
Acknowledgments AAvB, AT and MAEvB were responsible for conception, design, and interpretation of data. CDO was responsible for data collection. JWB, and MAEvB were responsible for drafting the article. JWB, MAEvB, AAvB and AT were responsible for the critical revision of the article. All authors finally approved the version to be published. Guarantor: M.A.E. van Bokhorst-de van der Schueren.
17.
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