Clinical Nutrition 29 (2010) 552e559
Contents lists available at ScienceDirect
Clinical Nutrition journal homepage: http://www.elsevier.com/locate/clnu
Original Article
How nutritional risk is assessed and managed in European hospitals: A survey of 21,007 patients findings from the 2007e2008 cross–sectional nutritionDay survey Karin Schindler a, *, Elisabeth Pernicka b, Alessandro Laviano c, Pat Howard d, Tatjana Schütz e, Peter Bauer b, Irina Grecu f, Cora Jonkers g, Jens Kondrup h, i, Olle Ljungqvist j, Mohamed Mouhieddine k, Claude Pichard l, Pierre Singer m, Stéphane Schneider n, Christian Schuh o, Michael Hiesmayr k, The NutritionDay Audit Team a
Department of Internal Medicine III, Division of Endocrinology and Metabolism, Medical University Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria Center for Medical Statistics, Informatics and Intelligent Systems, Section for Medical Statistics, Medical University Vienna, A-1090 Vienna, Austria c Department of Clinical Medicine, University La Sapienza, Viale dell’Università 37, I-00185 Rome, Italy d 1 School Cottages, Norton Hawkfield, Somerset BS39 4HD, UK e Medical Clinic, Division Gastroenterology/Hepatology/Endocrinology, Charité Universitätsmedizin Berlin, Charitéplatz 1, D-10117 Berlin, Germany f Clinic for Anesthesiology and ICU, Clinical Emergency Hospital of Bucharest, Bucharest 7000, Romania g Nutrition Support Team, Dietetic Department, Academic Medical Center, NL-1100 DD, Amsterdam, The Netherlands h Department of Human Nutrition, Royal Veterinary and Agricultural University, Frederiksberg, Denmark i Nutrition Unit 5711, Rigshospitalet, 2100 Copenhagen, Denmark j Karolinska Institutet, CLINTEC Karolinska University Hospital Huddinge, S-141 86 Stockholm, Sweden k Division Cardiac-, Thoracic-, Vascular Anaesthesia and Intensive Care, Medical University Vienna, A- 1090 Vienna, Austria l Clinical Nutrition, Geneva University Hospital, Avenue Micheli-du-Crest 24, CH-1211 Geneva, Switzerland m General Intensive Care Department, Rabin Medical Center University Hospital, Beilinson Campus, 49 100 Petah Tiqwa, Israel n Nutritional Support Unit, Pôle Digestif, Hôpital de l’Archet, F-06202 Nice Cedex 3 e INSERM U907, France o Center for Medical Statistics, Informatics and Intelligent Systems, Section on Medical Expert and Knowledge-Based Systems, Medical University Vienna, A-1090 Vienna, Austria b
a r t i c l e i n f o
s u m m a r y
Article history: Received 13 September 2009 Accepted 2 April 2010
Background & aims: Recognition and treatment of undernutrition in hospitalized patients are not often a priority in clinical practice. Objectives: We investigated how the nutritional risk of patients is determined and whether such assessment influences daily nutritional care across Europe and in Israeli hospitals. Methods: 1217 units from 325 hospitals in 25 countries with 21,007 patients participated in a longitudinal survey “nutritionDay” 2007/2008 undertaken in Europe and Israel. Screening practice, the type of tools used and whether energy requirements and intake are assessed and monitored were surveyed using standardized questionnaires. Results: Fifty-two percent (range 21e73%) of the units in the different regions reported a screening routine which was most often performed with locally developed methods and less often with national tools, the Nutrition Risk Screening-2002, or the Malnutrition Universal Screening Tool. Twenty-seven percent of the patients were subjectively classified as being “at nutritional risk”, with substantial differences existing between regions. Independent factors influencing the classification of nutritional risk included age, BMI ¼1500 kcal in 76% of the patients, but 43% of patients did not reach this goal. Conclusions: The process of nutrition risk assessment varied between units and countries. Additionally, energy goals were frequently not met. More effort is needed to implement current guidelines within daily clinical practice. Ó 2010 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Keywords: Screening Nutritional risk Practice nutritionDay Europe
1. Background and aims
* Corresponding author. Tel.: þ43 1 40400 2032; fax: þ43 1 40400 4364. E-mail address:
[email protected] (K. Schindler).
Undernutrition is a common cause and consequence of disease with a significant negative impact on patients’ outcomes and quality of life as well as on health economics.1 It has been
0261-5614/$ e see front matter Ó 2010 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2010.04.001
K. Schindler et al. / Clinical Nutrition 29 (2010) 552e559
repeatedly demonstrated over many years that disease-related undernutrition occurs in 20e60% of hospitalized patients,2e4 and that the patients are not only frequently admitted in an undernourished state but their nutritional status deteriorates during their hospital stay.2,5 The consequences of undernutrition are multifaceted and potentially lethal. Despite such compelling evidence, undernutrition often remains undetected and untreated because it is not considered to be a clinical priority. Lack of awareness is the only one facet of the problem and insufficient knowledge and training are also the major obstacles to good nutritional care.4,6 So, when devising strategies to tackle undernutrition and subsequently integrating them into daily clinical routines, many factors have to be considered. These include the influence of the disease per se on both energy/nutrient requirements and food intake, as well as which tools are available for detecting undernourished patients and those at risk of nutritional deficiency. Additionally organizational issues must be considered, for instance how caregivers calculate energy goals and evaluate actual intake. The influence of disease on energy expenditure is well acknowledged.7,8 A variety of screening and assessment instruments has been developed to identify undernourished patients and those at risk,9e11 and these have been widely used to assess the prevalence of disease-related undernutrition in many different countries and patient groups.2,11e14 There are also generally accepted standards and guidelines for screening for disease-related malnutrition and for providing nutrition support in hospital.15e18 Despite this, uncertainties still exist about whether nutritional risk assessment is integrated within daily clinical practice in all European hospitals, since currently available data only reflect the practice in the Scandinavian region and the Netherlands, where screening is not routinely undertaken.6,13,19,20 Moreover, no information exists about whether the daily nutritional care in a single unit reflects existing recommendations or expert opinions. In an attempt to provide more information about these sensitive issues, which may enhance the implementation of effective programmes addressing hospital-related undernutrition at all levels of decision making, we aimed to determine how frequently patients are considered to be at nutritional risk across Europe and within Israel, and whether this assessment is translated into specific actions which influence daily nutritional care. In particular, we investigated whether nutrition screening is routinely performed, the type of screening tools which are used and the impact of these on the identification of patients at nutritional risk and their subsequent nutritional care. 2. Methods 2.1. Design The nutritionDay study is a European-wide standardized oneday multinational cross-sectional audit with a one-month followup undertaken in close collaboration with the European Society for Clinical Nutrition and Metabolism (ESPEN), the Austrian Society of Clinical Nutrition (AKE) and the Medical University, Vienna. The study has been designed so that data collection can be undertaken by local caregivers with no other external support and using just four carefully designed questionnaires. More detailed information about the overall aim and the recruitment to this study has been previously reported.21 Recruitment was performed in the same manner in 2007 and 2008. The coordinating center in Vienna gained ethical approval for multicenter data collection. Local approval was additionally necessary in some hospitals depending on different national standards and local interpretations for observational research and
553
audits. Patients were informed about nutritionDay, as well as about their right to refuse participation. 2.2. Questionnaires The questionnaires included domains about unit structure, and patients’ medical status. Caregivers were additionally asked to report whether patients were screened for malnutrition on admission to their unit (Yes/No), and which screening tool was used [Nutritional Risk Screening (NRS) 2002, Malnutrition Universal Screening Tool (MUST), national tool, local tool], whether the individual patients were classified at nutritional risk (Yes/No) on nutritionDay, their actual diet/nutrition therapy (hospital food, special diet, protein-energy supplements, enteral nutrition, enteral þ parenteral nutrition, parenteral nutrition, other. For this question more than one answer was possible), as well as their energy goal (
