Prognostic impact of disease-related malnutrition

This review focuses on the studies investigating the prognostic implications of disease-related malnutrition. Malnutrition is a common problem in patients with chronic or severe diseases. Prevalence of hospital malnutrition ranges between 20% and 50% depending on the criteria used in order to determine malnutrition and the patient's characteristics. Furthermore, nutritional status is known to worsen during hospital stay which is partly due to the poor recognition by the medical staff and adverse clinical routines. Studies have repeatedly shown that clinical malnutrition however has serious implications for recovery from disease, trauma and surgery and is generally associated with increased morbidity and mortality both in acute and chronic diseases. Length of hospital stay is significantly longer in malnourished patients and higher treatment costs are reported in malnutrition. Since it has been demonstrated that proper nutritional care can reduce the prevalence of hospital malnutrition and costs, nutritional assessment is mandatory in order to recognise malnutrition early and initiate timely nutritional therapy.     

Incidence of nutritional risk and causes of inadequate nutritional care in hospitals

BACKGROUND AND AIMS: Many patients in hospitals are undernourished and nutritional care is inadequate in most hospitals. The aim of this investigation was to gain insight into how this situation could be improved. METHODS: Seven hundred and fifty randomly selected patients were screened at admission in three hospitals and surveyed during their entire hospitalization. Each time a patient was not treated according to a clearly defined nutritional standard, the nurse responsible for the patient was interviewed about possible reasons according to preformed questionnaires. RESULTS: The investigators found that 22% of the patients were nutritionally at-risk, and that only 25% of these patients received an adequate amount of energy and protein. The departments had only screened for nutritional problems in 60% of the cases. Only 47% of the patients, who the departments judged to be at-risk patients, had a nutrition plan worked out, and only about 30% of the at-risk patients were monitored by the departments by recording of dietary intake and/or body weight. The main causes for inadequate nutritional care were lack of instructions to deal with these problems, and lack of basic knowledge with respect to dietary requirements and practical aspects of the hospital's food provision. Patient-related aspects and the system of food provision also contributed, but only to a small degree. CONCLUSIONS: These findings form the basis of the strategy to improve nutritional care in these hospitals.     

A team approach to the audit of nutritional care in community hospitals

This paper discusses a collaborative multidisciplinary exploratory audit project to examine the nutritional care received by patients within Norwich Community Health Partnership NHS Trust. A project team was formed to identify the key areas and develop an audit tool. An audit assistant was employed to assist the team with this particular project. Eleven community hospitals were involved; catering, nursing, dietetic staff and patients took part. The key areas that the audit project examined were nutritional adequacy, documentation and recording of nutritional assessments, nurses>> nutritional knowledge base, patients>> perceptions of the meal service, and good nutritional practice. Overall the results were better than initially anticipated. Where pertinent issues were identified, discussions are taking place within the Trust to write an action plan, implement recommendations and re-audit.     

State of malnutrition in Cuban hospitals

OBJECTIVE: We assessed the current state of undernutrition as observed in 1905 patients hospitalized in 12 Cuban health care institutions, as part of a Latin American, multinational survey similar in design and goals. METHODS: We surveyed 1905 randomly selected patients from 12 Cuban hospitals in a two-phase study. Patients' clinical charts were audited in phase 1, the Subjective Global Assessment was used to assess patients' nutritional status in phase 2. The study was locally conducted by a properly trained team. RESULTS: The frequency of undernutrition in Cuban hospitals was 41.2% (95% confidence interval = 38.9 to 43.4), and 11.1% of patients were considered severely undernourished. Statistically significant (P < 0.05) univariate relations were identified between undernutrition and patient's age and sex. Nutritional status was a dependent of the patient's instruction level (P < 0.05). Patients' nutritional status was statistically associated with the presence of cancer and infection. Undernutrition was highly prevalent among cancer patients, no matter the stage of medical or surgical treatment. Undernutrition became extremely frequent after surgical treatment in non-cancer patients. High nutritional risks hospital services/specialties were identified: geriatrics (56.3%), critical care (54.8%), nephrology (54.3%), internal medicine (48.6%), gastroenterology (46.5%), and cardiovascular surgery (44.8%). Malnutrition rates increased progressively with prolonged length of stay. CONCLUSION: A high malnutrition rate was observed among participating hospitals. The design and inception of policies that foster intervention programs focusing on early identification of hospital malnutrition and its timely management is suggested to decrease its deleterious effects on outcomes of health care in the participating hospitals.     

Prevalence of malnutrition in adults in Queensland public hospitals and residential aged care facilities

Aim: To determine the prevalence of malnutrition in Queensland public acute and residential aged care facilities, and explore effects of variables associated with malnutrition in these populations. Methods: A multicentre, cross‐sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single‐day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same‐day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression. Results: A mean of 34.7 ± 4.0% and 31.4 ± 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, male (in residential aged care facilities), metropolitan location of facility and medical specialty, in particular, oncology and critical care. Conclusion: Malnutrition is significant in public acute and residential aged care facilities in Queensland. Action must be taken to increase the recognition, prevention and treatment of malnutrition especially in high‐risk groups.     

Evaluation of nutritional counselling in HIV-associated malnutrition

In HIV-infected patients, the outcome of counselling as the first step of a nutritional intervention programme was evaluated, in order to identify clinical and nutritional predictors for its efficacy. 75 HIV-infected patients were investigated, most with advanced disease. Nutritional status was determined by body weight, bioelectrical impedance and 7-day food intake record. Prior mean weight loss was 10% (range = +4% to -31%). Counselling facilitated weight gain in 40 75 patients (1-4 months later, overall mean difference +1.4 +/- 6.2%) and in 14 34 patients (8-11 months later, overall mean difference -1.4 +/- 9.0%). Weight changes correlated with changes in body cell mass (r(2) = .69, p < .001) and in body fat (r(2) = .29, p < 0.05), but not extracellular mass. Underlying conditions such as AIDS definition, fever, and diarrhoea correlated to prior weight loss (p < .001) but not to the outcome of counselling. Low energy intake (before counselling, < 31.5 kcal/kg) did not correlate to prior weight loss but it predicted further weight loss (p < 0.05 towards normal intake). High energy intake (> 38.5 kcal/kg) correlated (p < 0.05) with more prior weight loss but not with further weight changes. Nutritional counselling may be an effective first-line intervention for malnourished HIV infected patients. More than half of patients gain weight without other nutritional treatment. Whereas the severity of malnutrition is influenced by the underlying disease, fever, and diarrhoea, the course of weight change after nutritional intervention is not. Counselling may reduce the nutritional impact of these risk factors. In patients with low spontaneous intake, efficacy of counselling alone is limited, but it may help to identify those who require more invasive nutritional treatment.     

住院病人的营养不良风险筛查

目的:采用主观全面评定法(SGA),营养风险评估2002(NRS 2002),营养不良通用筛查工具(MUST)和微型营养评定简表(MNA-SF),对住院病人进行评估,以确定营养风险筛查工具的临床适用性. 方法:对856例住院病人在入院后48 h内采用4种营养筛查工具进行营养筛查,以MNA简表为标准,绘制其他3种营养筛查工具的ROC曲线及曲线下面积(AUC),评估其特异性、灵敏度和Youden指数. 结果:使用MUST、SGA、NRS 20002以及MNA-SF进行评估,营养不良或存在营养不良风险的检出率分别为13.3％,13.6％,49.5％和56.0％.以MNA-SF为标准,绘制SGA、NRS 2002和MUST的ROC曲线,AUC分别为0.616、0.809和0.715,灵敏度分别为23.8％、74.5％和46.8％;特异性分别为99.5％、87.3％和96.3％;Youden指数分别为0.233、0.618和0.431.结论:4种营养筛查工具中,NRS 2002的灵敏度和正确性最高,建议病人入院时采用NRS 2002进行营养筛查.     

Evaluation of the efficacy of nutritional screening tools to predict malnutrition in the elderly at a geriatric care hospital

BACKGROUND/OBJECTIVESMalnutrition in the elderly is a serious problem, prevalent in both hospitals and care homes. Due to the absence of a gold standard for malnutrition, herein we evaluate the efficacy of five nutritional screening tools developed or used for the elderly.SUBJECTS/METHODSElected medical records of 141 elderly patients (86 men and 55 women, aged 73.5 ± 5.2 years) hospitalized at a geriatric care hospital were analyzed. Nutritional screening was performed using the following tools: Mini Nutrition Assessment (MNA), Mini Nutrition Assessment-Short Form (MNA-SF), Geriatric Nutritional Risk Index (GNRI), Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Screening 2002 (NRS 2002). A combined index for malnutrition was also calculated as a reference tool. Each patient evaluated as malnourished to any degree or at risk of malnutrition according to at least four out of five of the aforementioned tools was categorized as malnourished in the combined index classification.RESULTSAccording to the combined index, 44.0% of the patients were at risk of malnutrition to some degree. While the nutritional risk and/or malnutrition varied greatly depending on the tool applied, ranging from 36.2% (MUST) to 72.3% (MNA-SF). MUST showed good validity (sensitivity 80.6%, specificity 98.7%) and almost perfect agreement (k = 0.81) with the combined index. In contrast, MNA-SF showed poor validity (sensitivity 100%, specificity 49.4%) and only moderate agreement (k = 0.46) with the combined index.CONCLUSIONSMNA-SF was found to overestimate the nutritional risk in the elderly. MUST appeared to be the most valid and useful screening tool to predict malnutrition in the elderly at a geriatric care hospital.     

Suicide prevention in hospitals

Summary The rationale for suicide prevention is based upon the concepts of crisis, ambivalence, communication, and action response. This paper describes how these concepts can be applied to suicide prevention in hospitals. For general medical-surgical hospitals, an essential problem is to prevent patients who are temporarily depressed or confused from falling from a height. A special suicide prevention committee which sponsors educational programs for the staff, reviews cases of suicide, considers improvements in the hospital design, and facilitates communication between nursing staff and physicians is recommended. Special clues to suicide in chronic patients and in psychiatric patients are described, together with measures for the psychological support and rehabilitation of such patients. Emphasis is placed on the need for follow-up and after care programs for discharged suicidal patients. Suicide prevention centers and community hospitals can cooperate effectively.

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Zusammenfassung Das Grundprinzip der Selbstmordprophylaxe beruht auf den Begriffen der Krise, der Ambivalenz, der sozialen Beziehungen und der Beachtung des sozialen Verhaltens. Die Arbeit beschreibt, wie these Begriffe für die Selbstmordprophylaxe in Spit?lern Verwendung finden k?nnen. In den allgemeinen medizinisch-chirurgischen Spit?lern besteht ein wichtiges Problem darin, vorübergehend deprimierte oder verwirrte Patienten daran zu hindern, da? she irgendwo hinunterfallen. Es wird empfohlen, ein spezielles Selbstmordprophylaxe-Komitee einzusetzen, welches Kurse für das Personal organisiert, Selbstmordf?lle untersucht, Verbesserungen in der Anlage von Spit?lern vorsieht sowie die Kommunikation zwischen dem Pflegepersonal und den ?rzten f?rdert. Besondere Hinweise auf Selbstmord bei chronischen und Psychiatrie-Patienten werden aufgezeigt, sowie die Ma?nahmen zur psychologischen Unterstützung und Rehabilitation derartiger Patienten. Besondere Bedeutung wird der notwendigen Nachpflege von Selbstmordpatienten zugemessen. Selbstmordprophylaxe-Zentren und Spit?ler k?nnen hier auf wirksame Wise zusammenarbeiten.

     

Evaluation of a semi-elemental enteral feed in patients with malabsorption and/or disease-related malnutrition

A semi-elemental energy-dense enteral feed was evaluated to determine its effect on nutritional repletion and tolerance in a diverse group of patients with malabsorption and/or disease-related malnutrition. Forty-nine patients (26 male, 23 female) entered and completed this multicentre study. Mean daily energy requirements were 2107 kcals of which 1704 kcals were prescribed from the enteral feed. Mean daily energy intake from the feed was 1472 kcals and patients consumed the feed for a mean of 13.2 days either as sole source of nutrition or as a supplement. Body weight changes were related to duration of feeding: patients who were fed for more than 14 days experienced a mean increase in body weight of 0.56 kg. Biochemical parameters of nutritional status, i.e. mean total protein and serum albumin, improved during the feeding period. Tolerance of the feed and clinical response to feeding were satisfactory. In patients with malabsorption and/or malnutrition a semi-elemental enteral feed represents a viable and palatable alternative to elemental diets when everyday food and whole protein feeds are not tolerated.