The state of the provision of nutritional care to hospitalized patients—Results from The Elan-Cuba Study

ARTICLE IN PRESS Clinical Nutrition (2006) 25, 1015–1029

http://intl.elsevierhealth.com/journals/clnu

ORIGINAL ARTICLE

The state of the provision of nutritional care to hospitalized patients—Results from The Elan-Cuba Study Sergio Santana Porbe ´n The Cuban Group for the Study of Hospital Malnutrition, Habana, Cuba Received 9 October 2005; accepted 10 April 2006

KEYWORDS Elan–Cuba study; Hospital malnutrition; Quality control; Quality assessment; Good practices; Nutritional intervention; Nutritional assessment; Nutritional support; Artificial nutrition

Summary Current nutritional care provision to 1905 patients hospitalized in 12 Cuban hospitals is presented in this article, diagnosed after conducting the Hospital Nutrition Survey (HNS), as part of the activities comprising the Cuban Study of Hospital Malnutrition (Elan–Cuba). The obtained HNS results were contrasted with standards regarding the nutritional assessment of hospitalized patient, the diagnosis of nutritional disorders occurring in the patient, and the identification of patients in need of nutritional intervention. The Elan–Cuba Study returned a 41.2% malnutrition rate [Barreto Penie´ J, Cuban Group for the Study of Hospital Malnutrition. State of malnutrition in Cuban hospitals. Nutrition 2005;21:487–97]. However, malnutrition was recorded as an independent diagnosis in only 0.4% of the surveyed clinical charts. It could not be shown that medical care teams were systematically applying any of the techniques and procedures recommended for the assessment of the nutritional status of hospitalized patients. In the best of the cases, only 40.6% of the surveyed patients had their height and weight recorded in their clinical charts at admission, 9.0% of those with more than 15 days of hospitalization had a prospective value of weight, and less than 20.0% of them had their serum albumin levels and/or their counts of Lymphocytes annotated on their clinical charts. Although 10.9% of the surveyed patients (median of the subcategories values; range: 3.5–41.2%) fulfilled an indication for nutritional intervention, support (enteral and/or parenteral) was only provided to less than 15.0% of them, with the exception made of patients on NPO, of whom 32.3% received either of the two modes of artificial nutrition listed above. It is to be noticed that none of the patients with chronic organic failure were on nutritional support at the time of the survey. The current nutritional care provision to the hospitalized patient might explain the increased rates of hospital malnutrition documented in the Elan–Cuba Study, and should lead to the design and urgent implementation of nutritional and metabolic intervention programs in the surveyed

Corresponding author at: Nutritional Support Group, Hospital Clı´nico-Quiru ´rgico ‘‘Hermanos Ameijeiras’’, San La ´zaro 701, Ciudad

Habana 10300, Cuba. Fax: +44(0) 1865 853 149. E-mail address: [email protected]. 0261-5614/$ - see front matter & 2006 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2006.04.001

ARTICLE IN PRESS 1016

S.S. Porbe´n hospitals, given the deleterious effects of nutritional disorders upon the ultimate results of the medical and surgical actions, and the quality and costs of medical care. & 2006 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Introduction The Cuban Hospital Malnutrition Surveya was conducted between 2000 and 2003, with the purpose of diagnosing the current state of undernutrition among the patients attended at selected hospitals from the National Health System. The results of the Elan–Cuba Study have been previously printed.1 Current nutritional care provision to 1905 patients attended at the 12 surveyed hospitals is presented in this article. The goal of this follow-up study was to assess the current institutional practices for diagnosing and documenting malnutrition, preventing fasting, and indicating/starting Artificial (Parenteral/Enteral) Nutrition schemes.

Materials and methods The Elan–Cuba Study: design and conduction The design and conduction of the Elan–Cuba Study have been previously presented.1 Briefly, major second- and tertiary-level Cuban health care institutions admitting adult (+19 years of age) patients in surgical as well as non-surgical and critical care wards were selected for inclusion in this survey. Twelve hospitals completed the procedures advanced by the organizers. Patients able to walk up to a scale and stand still while being measured and weighted were randomly selected from the participating hospital population. The nutritional status of 1905 finally recruited patients was established by means of the Subjective Global Assessment (SGA) after a face-to-face interview with him/her (or their relatives).2 The patient received an A (not malnourished), B (moderately undernourished/at risk of undernutrition), or C (severely undernourished) score, respectively, after administering the form. The design of the Elan–Cuba Study also included the Hospital Nutrition Survey (HNS) specifically aimed to establish the current nutritional care provision to the patients attended at the participating hospitals. As shown in Appendix A, the HNS form comprised sections for recording the patient’s a

Referred heretofore as the ELAN-CUBA Study.

sociodemographical and administrative data; as well as his/her current health problems, with special emphasis on the diagnosis of sepsis and cancer; the conduction of major surgical procedures; the occurrence of non-volitional fasting; the current provision of foods per mouth, as well as the use of dietetic suplements; the conduction of Enteral Nutrition schemes; and the conduction of Parenteral Nutrition schemes.b The HNS form was filled by the local surveyors after an audit of the patient’s clinical chart, following the instructions documented in the corresponding Standard Operating Procedure [PNO 3.001.00: Encuesta de Nutricio ´n Hospitalaria. Manual de Procedimientos. Grupo de Apoyo Nutricional. Hospital Clı´nico-Quiru ´rgico ‘‘Hermanos Ameijeiras’’. Segunda Edicio ´n. Ciudad Habana: 2001]. The forms with the results of the HNS were reviewed, ammended, entered into an application created ad hoc with Access 7.0 (Office’97 from Microsoft, USA), and filed by the Head of the local surveyor team. The National Coordinating Team reunited, assembled and consolidated the databases with the locally obtained HNS results, as supplied by the local surveyors teams, before proceeding to data reduction and statistical–mathematical treatment.

Identification of patients fulfilling an indication for nutritional support The Elan–Cuba Study database was searched for patients fulfilling any of the nine conditions for initiating nutritional support. They were as follows: being on Nil Per Oris (NPO) at the time of the survey3; being on fasting for 5 (or more) days3,4; to have suffered from weight loss X20%5; to spend 15 (or more) days of hospitalization1,6; to suffer from a septic state, either imported from the community/ acquired within the hospital1,7,8; to have a diagnosis of cancer1,9,10; to have X5 days elapsed since a surgical operation1,11; to suffer from chronic organic failure1,12–16; and to have scored B/C after administering the SGA form.17 b

The Hospital Nutrition Survey was designed by the Scientific Committee of the LatinAmerican Study of Hospital Malnutrition to be used by local surveyors in their corresponding countries.41

ARTICLE IN PRESS Provision of nutritional care—The Elan-Cuba Study

Construction of standards and indicators of quality The elaboration of judgements about the quality of current nutritional care provision to hospitalized patients implies the existence of standards representatives of what could be held as the ‘‘Good Practices in Feeding and Nutrition’’. Although it is possible that these good practices might have not be explicitly formulated, they nevertheless can be derived from the Bad Practices previously detailed.3 A standard is a general statement about what should be a desirable nutritional care practice in keeping with the ‘‘Good Practices’’. For its implementation, the standard must be translated into the corresponding indicator(s) of quality. Each indicator must be associated with a specification of quality: a number setting the expected behaviour of the pertaining indicator.18–21 The standards, indicators and specifications of quality that were used to assess the current nutritional care provision to hospitalized patients are shown in Appendix B. There were 21 indicators distributed among 4 standards. They covered issues related with the nutritional assessment of the hospitalized patient, the dietetic regimes prescribed to the patient, the ocurrence of fasting, the use of diet supplements, and the need for nutritional intervention. The standards, indicators and specifications of quality were derived from the guidelines and recommendations made by professional societies and other bodies of experts22–30 and/or as the complement of the Bad Practices previously detailed.3 For the purposes of this article, it is not intended that standards, indicators and specifications of quality shown in Annex 2 to be an exhaustive list. The indicators shown in Appendix B were estimated from the data locally collected in the recovered HNS forms, and thus, served to reduce the results of the HNS. The estimated value of the indicator of quality was contrasted with its corresponding specification, as advanced in Appendix B. The indicator was denoted as Satisfactory if its estimated value was equal or higher than the pertaining specification.

Results Nine categories of patients with an indication for nutritional support were identified in the Elan–Cuba Study database. The numbers of patients (with the corresponding percentages from the total sample

1017 study size) fulfilling any of these conditions are shown in Table 1. The median of the subcategories values was 10.9%. Values ranged from 3.5% (patients on NPO at the time of the survey) to 41.2% (patients scoring B/C after administering the SGA form). Table 2 shows the estimates for the indicators of the appropiateness of nutritional care as currently provided to 1905 patients hospitalized in 12 participating institutions.

Regarding the nutritional assessment of the patient There was not a scale within less than 50 m from the patient’s bed in 337 [17.7%] of the instances. However, although it was available in the remaining 82.3%, only 40.5% of the surveyed patients were weighted and measured on admission. Four hundred and thirty-seven [22.9%] of the surveyed patients had been hospitalized for 15 days (or more), but a prospective value of the patient’s weight was registered in only 38 [8.7%] of their charts. Due to the cross-sectional nature of this study, the proportion of patients weighted on discharge was not estimated, and so, data on compliance with this standard are not presented in the present report. The diagnosis of malnutrition was annotated in just 8 [0.4%] of the clinical charts reviewed. If

Table 1 Patients in the Elan–Cuba Study fulfilling indications for nutritional support. Category

Number of patients [%]

Patients on Nil Per Oris Patients on fasting for 5 days (or more). Weight loss X 20% Patients with 15 days (or more) of hospitalization Patients with a septic state either imported from the community/ acquired within the hospital Diagnosis of cancer Patients with X 5 days elapsed since their operation Patients with chronic organic failure Patients who scored B/C after administering the SGA form

65 [3.4] 119 [6.2] 208 [10.9] 437 [22.8] 479 [25.1]

242 [12.7] 114 [5.9] 147 [7.7] 784 [41.2]

Results for each category are presented as number of patients along with percentages from total sample study size.

ARTICLE IN PRESS 1018 Table 2

S.S. Porbe´n Current state of nutritional care provision to hospitalized patients.

Standard

Estimated value of the indicator [%]

Standard 1. Regarding the nutritional assessment of the patient:  There should be scales placed less than 50 m from the bed of the patient.  The patient should be measured and weighted on admission.  In every patient with 15 days (or more) of hospital stay: The patient’s weight should be regularly measured and registered. A weekly frequency is recommended.  If it is present: The diagnosis of malnutrition should be documented in the patient’s clinical chart any time within the first 72 h of admission.  The basal (on admission) values of serum albumin of the patient should be annotated in his/her clinical chart any time within the first 72 h of admission.  The basal (on admission) counts of lymphocytes of the patient should be annotated in his/her clinical chart any time within the first 72 h of admission.  In every patient with 15 days (or more) of hospital stay: The values of serum albumin of the patient should be regularly measured and registered in his/her clinical chart. A semi-monthly frequency is recommended.  In every patient with 15 days (or more) of hospital stay: The counts of Lymphocytes of the patient should be regularly measured and registered in his/ her Clinical chart. A semi-monthly frequency is recommended.

82.3 40.5 8.7

0.4 10.1 13.2 9.4

17.8

Standard 2. Regarding the dietetic regimes prescribed to the patient: The diet prescribed to the patient should be in correspondence with his/her current health condition, and be capable of satisfying the nutrient requirements that are increased by concurrent metabolic stress situations.

Results to be presented in a separate communication

Standard 3. Regarding the use of diet supplements: Those not-malnourished patients needing diet supplementation to cover their nutrient requirements should be identified and treated.

0.4

Standard 4. Regarding the neccesity of nutritional intervention:  Patients on Nil Per Oris at the moment of the survey that had either scheme of nutritional support installed (enteral/parenteral).  Patients with X 5 days of fasting that had either scheme of nutritional support installed (enteral/parenteral).  Patients with weight loss X20% that had either scheme of nutritional support installed (enteral/parenteral).  Patients with a diagnosis of sepsis that had either scheme of nutritional support installed (enteral/parenteral).  Patients with a diagnosis of cancer that had either scheme of nutritional support installed (Enteral/Parenteral).  Patients with X5 days after being operated upon that had either scheme of nutritional support installed (enteral/parenteral).  Patients with X15 days of hospital stay that had either scheme of nutritional support installed (enteral/parenteral).  Patients with a diagnosis of a chronic organic disease (heart/kidney/lungs/ liver) that had either scheme of nutritional support installed (enteral/ parenteral).  Patients who scored B/C after conducting the SGA that had either scheme of nutritional support installed (enteral/parenteral).

32.3 13.4 4.8 5.0 4.5 7.0 4.3 0.0

4.2

Results for each category are presented as percentages of audited charts meeting the corresponding standard from total sample study size.

obesity is also considered a disorder of the patient’s nutritional status, the percentage of clinical charts containing a diagnosis of the nutritional status upon admission increased only up to 0.8% [16 charts as a

whole]. As a matter of fact, a reference (of any kind) to the nutritional status of the patient was annotated in just 16.0% of the reviewed Clinical charts.

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Six hundred and thirteen [32.2%] of the patients accumulated up to 3 days of hospitalization at the time of the survey. However, the basal (on admission) values of serum albumin had been measured in just 62 [10.1%] of them. Likewise, the basal lymphocyte counts had been obtained in only 81 [13.2%] of them. If the study serie is considered as a whole, the values of albumin and the lymphocyte counts were recorded in any moment within the first 72 h of admission in just 3.3% and 4.3% of the patients, respectively. In addition, although 437 [20.8%] of the surveyed patients had 15 (or more) days of hospitalization, only 41 [9.4%] of them had a prospective value of serum albumin in their charts. Similarly, a prospective lymphocyte count had been annotated in just 78 [17.8%] of them.

or parenteral nutrition at the moment the survey took place. Table 3 shows the current use of artificial (enteral/parenteral) nutrition techniques, as documented after conducting the Elan–Cuba Study. Medians for percentages of patients in each category receiving either of the two modes were as follows: enteral nutrition: 4.1% [range: 0.0–24.6%]; parenteral nutrition: 2.3% [range: 0.0–10.0%]. There were no statistically significant differences on the use of either mode of artificial nutrition (P40.05; Mann–Whitney–Wilcoxon test for differences between medians from independent populations). By all accounts, the usage of any mode of artificial nutrition in the surveyed patients was significantly low.

Regarding the dietetic regimes prescribed to the patient

Discussion

The dietetic regime currently prescribed to the surveyed patient was recovered from 1273 [66.8%] of the charts. The analysis of the dietetic practices recorded during the conduction of the Elan–Cuba Study, and their compliance with existing guidelines, will be the subject of a separate communication.

Regarding the diet supplementation Two hundred and sixty-seven [14.0%] patients who scored A (not malnourished) with the SGA form referred diminished food intakes, but nevertheless they were still able to eat solid foods. However, only one [0.4%] of these patients was taking an oral diet supplement in order to satisfy his/her daily nutrient requirements.

Regarding the neccessity of nutritional intervention Nutritional support (either enteral/parenteral) was administered to only 4.8% of the surveyed patients. This value represents the median of the percentages of patients who received either mode of artificial nutrition in each of the 9 categories detailed in Table 2. It is to be noticed the small percentage of patients subjected to nutritional support at the time of the survey. It must be called the attention upon the fact that none of those with organic chronic failure received any form of artificial nutrition. On the other hand, 32.3% of those on NPO received/was receiving either enteral

The Elan–Cuba Study represented the first of its kind to be conducted in this country aimed to understand the magnitude of the health problem posed by Energy-Nutrient Malnutrition (ENM) in the institutions of the National Health System. The nutritional status of 1905 patients attended at 12 Cuban hospitals, distributed among 6 provinces of the country, was discussed in a preceding article.1 It was disturbing to find that the current malnutrition rate was 41.2%, with values ranging between 35.9 and 68.0%. Similarly, the HNS has been the first documented attempt ever to assess the capability of Cuban medical care teams to recognize and properly record malnutrition occurring in the surveyed patients, the usage of techniques for anthropometric and biochemical assessment of nutritional status of hospitalized patient, and the installment of artificial nutrition schemes in selected patients. The results of the survey could not have been more frustrating. In spite that a scale was within the reach of the patient in 82.3% of the instances, only 40.5% of the participating subjects was measured and weighted on admission. What it is even more shocking: only 9.0% of those patients with 15 (or more) days of hospitalization had a prospective value of their weight recorded in the charts. Judging from the results of the survey, malnutrition is a non-existing health problem in the hospitals of the National Health System: less than 1.0% of the audited clinical charts had undernutrition entered as an independent diagnosis in the list of health problems of the hospitalized patient. There was not any reference to the

ARTICLE IN PRESS 1020 Table 3

S.S. Porbe´n Current use of artificial nutrition techniques.

Standard

Received enteral nutrition

Received parenteral nutrition

 Patients on Nil Per Oris at the moment of the survey that had either scheme of nutritional support installed.  Patients with X 5 days of fasting that had either scheme of nutritional support installed.  Patients with weight loss X 20% that had either scheme of nutritional support installed.  Patients with a diagnosis of sepsis that had either scheme of nutritional support installed.  Patients with a diagnosis of cancer that had either scheme of nutritional support installed.  Patients with X 5 days after being operated upon that had either scheme of nutritional support installed.  Patients with X 15 days of hospital stay that had either scheme of nutritional support installed.  Patients with a diagnosis of a chronic organic disease (heart/kidney/lungs/liver) that had either scheme of nutritional support installed.  Patients who scored B/C after conducting the SGA that had either scheme of nutritional support installed.

16 [24.6] 5 [4.2] 9 [4.3] 10 [2.1] 10 [4.1] 5 [4.4] 12 [2.7] 0 [0.0]

6 [9.2] 12 [10.0] 3 [1.4] 17 [3.5] 3 [1.2] 4 [3.5] 10 [2.3] 0 [0.0]

19 [2.4]

17 [2.2]

The number of patients [within brackets, percentages from those with an indication for its use in the corresponding category] that received any scheme of artificial nutrition are presented.

nutritional status of the patient in 84.0% of the reviewed clinical charts. These findings are in sharp contrast with the 41.2% hospital malnutrition rate returned by the Elan–Cuba study, as previously mentioned. Serum albumin and total lymphocyte counts have been considered classical biochemical measures of nutritional status of the patient, notwithstanding the fact they can be subjected to the influence of non-nutritional causes.31 Hypoalbuminemia and/or lymphopenia in a patient awaiting a surgical operation significantly increase the risk of postsurgical complications.32,33 In spite of these findings, less than 5.0% of the reviewed clinical charts had the values of serum albumin and the counts of lymphocytes recorded anytime within the first 72 hours after admission. A similar proportion of the audited charts contained prospective values of these markers.c Failure to recognize hospital malnutrition as a health problem with medical, ethical and economic overtones might then explain the low rates of usage c

It is not the intent of this article to explore the pros and cons of serum albumin and total lymphocyte Counts as nutritional markers. These issues were thoroughly discussed by the author in a previous work. A commented review, along with important references, is presented in. 31

of artificial nutrition techniques among the surveyed patients. The average rate of usage of any type of nutritional therapy (enteral or parenteral) technique was 9.5%. Attention must be called upon the finding that none of the patients with a diagnosis of a chronic organic disease received any kind of nutritional support, notwithstanding the fact that these patients might eventually become cells/organs receptors.d In the best of the cases, only 32.3% of the patients on NPO (a classical prescription of nutritional intervention) received nutritional support of any kind. It must be stressed that nutritional therapy is not for universal application, because it can put the patient at risk of additional complications. Clinical and surgical scenarios when nutritional therapy is indicated have been described.23,24,101 Thus, nutritional therapy should be aimed to preserve the integrity of lean tissues, and minimize the occurrence of adverse events in the evolution of the illness and the response of the patient to the medical treatment.23,24 d If this subpopulation is expanded to accomodate one patient with intestinal failure due to a massive bowel resection (remaining segment: 50–60 cm of jejunum anastomosed to the right colon, with concomitant loss of the ileocecal valve) who received a course of parenteral nutrition, the total figure amounts to 0.7% of those with chronic organic failure.

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According to the results of the study presented in this article, 10.9% of the surveyed patients should have benefited with some technique of nutritional therapy, because of the current occurrence of a condition deteriorating his/her nutritional status. Although it is striking that patients in need of nutritional support might indeed represent minorities within the health institution, the size of these subpopulations should not be an excuse for differing the installment of the corresponding nutritional support schemes. It is particularly dissapointing that other teams of researchers, working in different geographical lattitudes, have reached to conclusions similar to those of the present study.34–43 In a 1994 Brittish survey, only 40.0% of the patients admitted to a hospital had values registered of some malnutrition indicator. 48.0% of these people had in their charts any reference to their nutritional status.35 The situation had not improved in a follow-up study conducted 3 years later.37 Extending the previously mentioned study, an audit of the documentation practices of nurses and junior doctors working in 70 Brittish hospitals revealed that at best 80.0% of the charts filled on admission had some reference to the nutritional status of the patient.36 60.0% of the interviewed practitioners declared they had not registered their patient’s weight because they felt it was unimportant. Yet, in a third report issued as recently as this year 2006, one out of 69 patients was documented as undernourished, in spite of a

69.0% hospital malnutrition rate, only two charts contained references to the nutritional status of surveyed patients, while weight loss history, appetite status, and current oral intake were recorded for fewer than 33.0% of patients.43 A fourth report found that nutritional support of any kind was administered to less than one-third of patients diagnosed as malnourished, notwithstanding the implications of their deteriorated nutritional status upon their evolution.40 There could be several reasons behind the current nutritional care provision as presented in this and other articles. They might even overlap in their influences. Some of them are summarized in Fig. 1. It is important to recognize that hospital malnutrition rates documented in this and other studies, as well as the unsatisfactory indicators of nutritional care provision to hospitalized patients, might be the logical consequences of outdated medical practices who have prevailed until the present time, and that should be reviewed, improved and henceforth overcome, by taking stepby-step, problem-oriented actions. The apparent incapability of the medical care teams to recognize signs of undernutrition in hospitalized patients is a common feature of all cited studies,35,36,40,43 pointing to insufficient (or the lack of it, for the same matter) training in Nutrition issues of medical practitioners,44–46 in spite of an enormous body of literature aimed to the teaching of these abilities.47–56 This incapability can

Figure 1 A model for understanding the current nutritional care provision.

ARTICLE IN PRESS 1022 be explained, in part, by lack of the proper curricula in most medical teaching schools, as elegantly put in the Book Review section from an influential medical journal.57 The existing situation in the Americas was dealt in depth in an International Conference held at Mexico City in 2001, along with possible ways for improvement.58 In hospital settings, traditional ways of medical education such as ward-based teaching, grand rounds, clinical case presentations and peer-review sessions can be used to expose medical care teams to knowledge in Basic as well as Applied Nutrition. More formal ways such as specialized, post-graduate courses on Clinical Nutrition can be designed.59,60 Efforts are also being made under the joint auspices of the Latin American Federation of Parenteral and Enteral Nutrition (FELANPE) and the Spanish Society of Parenteral and Enteral Nutrition (SENPE) to improve the dissemination and promotion of knowledge in nutrition in the Americas.61 The current state of nutritional care provision might also have an economical origin. Under the present-day economical constraints, nutritional support is still not covered by reimbursement policies, a situation that could force the medical care teams to withheld these lives-saving therapies,62–64 notwithstanding the fact that malnutrition consequences might be (economically speaking) more devastating.42,65–69 ‘‘Economical reasons’’ have also dictated the termination of practices of medical and paramedical personnel acting as nutritional support specialists/therapists,70,71 an attitude in sharp contrast with reports demonstrating important money and resources savings as a result of their activity.72–76 However, putting aside money as an issue, hospital administrators tend to favour costly investments in state-of-the-art, late-, low-yielding-revenues technologies and equipments, disregarding more modest, quick-returning investment in nutritional care and support.77,78 A clear institutional policy for allocating resources and budgets covering the expenses incurred by nutritional support schemes should be designed and put into the practice in the concerned health centers. Finally, nutrition support organizations should be created and implemented with the mission of

S.S. Porbe´n designing and putting into practice the required intervention programs aimed to the early diagnosis, timely treatment and ultimate prevention of hospital malnutrition, as it has previously advanced.79,80 These intervention programs, which are based upon a methodological platform integrating recording and documentation policies, continuous education activities, cost analysis techniques, and quality control and assessment actions, should be aimed to expose health personnel to the ‘‘Good Practices of Feeding and Nutrition’’ of hospitalized patients. Drastic, short-term results can be achieved with minimal resources when these policies are implemented.81–84

Conclusions The Cuban Hospital Malnutrition Survey revealed the current state of nutritional care provision to patients assisted in hospitals of the National Health System. Highly prevalent rates of hospital malnutrition were accompanied with insufficient documentation of the nutritional status of the surveyed patients and low rates of usage of techniques for anthropometric and biochemical assessment of patient’s nutriture. Low rates of usage of artificial nutrition techniques that should have supported the patient’s nutriture during periods of increased nutrient demands, contributed to the replenishment of the lean body mass as a mean to ameliorate the deleteral effects of disease-related malnutrition, and provided wellbeing and quality of life, were also found. These findings should lead to the design and development of the required intervention programs that will ultimately lead to a better recognition, timely treatment and prevention of hospital malnutrition.

Acknowledgements The patients and their relatives, the local surveyor teams, and the local and national health authorities, for their understanding and support. The reviewers, for suggesting ways to improve the original manuscript.

ARTICLE IN PRESS Provision of nutritional care—The Elan-Cuba Study

Appendix A. Sample of the Hospital Nutrition Survey form. Page 1.

1023

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Sample of the Hospital Nutrition Survey form. Page 2.

S.S. Porbe´n

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Appendix B. Standards, indicators and specifications of quality See (Table B1).

Table B1 Standard

Indicator

Standard 1. Regarding the nutritional assessment of the patient:  There should be scales placed less than 50 m Number of instances where a scale was from the bed of the patient.41 placed p50 m from the bed of the patient.  The patient should be measured on Number of patients with the value of admission.85 height annotated on admission.  The patient should be weighted on Number of patients with the value of admission.85–90 weight annotated on admission.  The patient should be weighted on Number of patients with the value of discharge.91 weight annotated on discharge.  In every patient with more than 15 days of Number of patients with more than 15 hospital stay: The patient’s weight should be days of hospital stay who had annotated regularly measured and recorded. A weekly one (or more) prospective values of frequency is recommended.1,22,92,93 weight in their charts.  If it is present: The diagnosis of malnutrition Number of patients who had the diagnosis should be documented in the patient’s clinical of malnutrition annotated in their clinical chart any time within the first 72 h of charts. admission.22,94–97 Number of patients with p3 days of  The basal (on admission) values of serum hospital stay who have the basal values of albumin of the patient should be annotated in serum albumin annotated in their clinical his/her clinical chart any time within the first charts. 72 h of admission.87–90,94–97.  The basal (on admission) counts of Number of patients with p3 days of lymphocytes of the patient should be annotated hospital stay who have the basal counts of in his/her clinical chart any time within the first lymphocytes annotated in their clinical 72 h of admission 87–90,94–97 charts.  In every patient with more than 15 days of Number of patients with more than 15 hospital stay: The values of serum albumin of days of hospital stay who had annotated the patient should be regularly measured and one (or more) prospective values of serum recorded in his/her clinical chart. A semialbumin. monthly frequency is recommended.1,92,93  In every patient with more than 15 days of Number of patients with more than 15 hospital stay: The counts of lymphocytes of the days of hospital stay who had annotated patient should be regularly measured and one (or more) prospective counts of registered in his/her clinical chart. A semilymphocytes. monthly frequency is recommended.1,92,93 Standard 2. Regarding the dietetic regimes prescribed to the patient: Number of patients with a dietetic correspondence with his/her current health prescription correctly installed, regarding condition, and be capable of satisfying the the size of the sample. nutrient requirements that are increased by concurrent metabolic stress situations.96,97

 The diet prescribed to the patient should be in

Standard 3. Regarding the use of diet supplements: Number of patients who scored A with SGA supplementation to cover their nutrient that had any diet supplement indicated to requirements should be identified and compensate diminished food intakes. treated.98,99

 Those not-malnourished patients needing diet

Specification [%] 100.0

X90.0 X90.0 X90.0 X90.0

X90.0

X90.0

X90.0

X90.0

X90.0

X90.0

X 90.0

ARTICLE IN PRESS 1026

S.S. Porbe´n

Table B1 (continued ) Standard

Indicator

Specification [%]

Standard 4. Regarding the neccesity of nutritional intervention: Those patients in which a nutritional intervention is necessary given their current medical–surgical condition should be identified and treated:  Patients on Nil Per Oris.22,23,96,100–101 Number of patients on NPO at the time of X 90.0 the survey that had installed either scheme of nutritional support (enteral/ parenteral).  Patients with 5 days (or more) of Number of patients with 5 days (or more) X 90.0 fasting.22,23,101 of fasting that had installed either scheme of nutritional support (enteral/ parenteral). X 90.0  Patients with weight loss X 20%.5,22,23,101,105 Number of patients with weight loss X20% that had installed either scheme of nutritional support (enteral/parenteral). X 90.0  Patients with increased nutrient demands due Number of patients with a diagnosis of to the current disease: Sepsis.22,23,101,106 sepsis that had installed either scheme of nutritional support (enteral/parenteral). X 90.0  Patients with increased nutrient demands due Number of patients with a diagnosis of to the current disease: Cancer.22–23,101–103 cancer that had installed either scheme of nutritional support (enteral/parenteral). X 90.0  Patients who had 5 days (or more) after Number of patients with X5 days after undergoing a surgical operation.22,23,101,104 being operated upon that had installed either scheme of nutritional support (enteral/parenteral).  Patients with 15 days (or more) of hospital Number of patients with X 15 days of X 90.0 stay.1,22,23,92,93 hospital stay that had installed either scheme of nutritional support (Enteral/ Parenteral). X 90.0  Patients with special nutrient requirements: Number of patients with a diagnosis of Organic chronic failure.22,23,101,105–109 organic chronic disease (heart/kidney/ lungs/liver) that had installed either scheme of nutritional support (Enteral/ Parenteral).  Patients who scored B/C after conducting the Number of patients who scored B/C after X 90.0 SGA.22,23,110–111 conducting the SGA that installed either scheme of nutritional support (Enteral/ Parenteral).

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