feedm.e. malnutrition awareness and education for hospital ......6671 ± 2351 4949 ± 2466 0.018*...

feedM.E. Malnutrition

Awareness and Education

for Hospital Administrators

5001 1113 0139 A 1

© 2013 Abbott Laboratories | 2

Company Confidential

Feed Patients Right.

Feed Patients Now.

Malnutrition Is a Problem That Can Be Solved

Worldwide 20 to 50% of

hospitalized patients are

malnourished—a situation with

serious negative impact on

patient outcomes and

healthcare costs.

THE PROBLEM

Nutrition intervention, such as

oral nutrition supplements

(ONS) immediately upon

admission, helps lessen

adverse effects of

malnutrition and enhance

patient response to treatment

and recovery.

The feedM.E.

Nutrition Care

Pathway helps make

nutrition intervention

stepwise and simple.

THE SOLUTION




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Nutrition Practices for Hospital Administrators

o Malnutrition takes high

health and financial tolls.

o Nutrition interventions

improve patient outcomes

and cut hospital costs.

o Common barriers impede

best-practice nutrition but

can be overcome with

guidelines, protocols,

training and reinforcement.

o To identify risk of

malnutrition and to guide

nutrition care, follow our

Nutrition Care Pathway.




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Malnutrition prevalence • Health tolls • Excess healthcare costs

Evidence shows that malnutrition worsens clinical outcomes

and adds to the overall costs of care.

Malnutrition Is Common and Costly




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50% of

European hospital

patients > 80 years

and nursing home

patients were at risk

of malnutrition3

27% in Beijing

hospitals at

malnutrition

risk9

42.5% in Jinling

hospital were

malnourished based

on low body mass

index or recent

weight loss10

32%

malnutrition

prevalence in

56 hospitals in

Australia and

New Zealand8

Malnutrition Is Common in Hospitals Worldwide

1. Norman K, et al. Clin Nutr. 2008;27:5-15. 2. Vanderwee K, et al. Clin Nutr. 2010;29:469-476. 3. Kaiser MJ, et al. J Am Geriatr Soc. 2010;58:1734-1738. 4. Meijers JM, et al. Br J Nutr. 2009;101:417-423. 5. Barreto

Penie J. Nutrition. 2005;21:487-497. 6. Waitzberg DL, et al. Nutrition. 2001;17:573-580. 7. Charlton KE, et al. Nutr Health Aging. 2010;14:622-628. 8. Agarwal E, et al. Clin Nutr. 2012;31:41-47. 9. Liang X, et al. Asia Pac

J Clin Nutr. 2009;18:54-62. 10. Zhang L, et al. Asia Pac J Clin Nutr. 2013;22:206-213.

43% in Cuban

hospitals were

moderately

malnourished and

11% were severely

malnourished5

48% in

Brazilian

hospitals were

malnourished6

Prevalence of hospital malnutrition ranged between 20 and 50%1

Malnutrition risk in

43% of hospitalized

elderly Belgian

patients; 33%

malnourished2

19% of Dutch

nursing home

patients were

malnourished4 51% of older

Australians in

rehabilitation

hospitals were

at risk of

malnutrition7




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Malnutrition Is Associated With Illness, Injury, and Hospitalization

1. Imoberdorf R, et al. Clin Nutr. 2010;29:38-41

2. Krumholz HM. N Engl J Med. 2013;368:100-102.

3. Li HJ, et al. J Adv Nurs. 2013;69:1691-1703.

4. Hiesmayr M, et al. Clin Nutr. 2009;28:484-491.

Risk of dying increases when food

intake is limited by illness or injury4

Loss of lean body mass delays

recovery and impedes rehabilitation3

Hospitalization itself often

worsens nutritional status2

Anyone who is sick or injured is at risk of

malnutrition, especially older people1




Feed Patients Now. 7

Imoberdorf R, et al. Clin Nutr. 2010;29:38-41.

More than 1 in 5 patients over age 65 was severely undernourished or at

risk for under-nutrition upon hospital admission

Risk for Malnutrition Increases With Age

Switzerland

Diminished functional status (handgrip strength)




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Malnutrition Has Adverse Impacts on Outcomes

1. Loser C. Dtsch Arztebl Int. 2010;107:911-917. 2. Shepherd A. Nurs Times. 2009;105:18-20.

DECREASES1,2

GI, pulmonary,

and renal function

Recovery from

illness

Mental state

Immunocompetence

Recovery from injury

Quality of life

INCREASES1,2

GI, pulmonary,

and renal function

Overall

complication rate

Rate, duration,

severity of infections

Hard-to-heal wounds,

pressure ulcers

Immobility,

risk of falling

Need of help

and care

Mortality risk




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Malnutrition Increases Risk of Post-surgical Complications

Fry DE, et al. Arch Surg. 2010;145:148-151.

9

Pre-existing malnutrition increases risk for post-surgical

complications by 2- to 5-times.

USA




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1. Schneider SM, et al. Br J Nutr. 2004;92:105-111. 2. Lee S, et al. Yonsei Med J. 2003;44:203-209.

Malnutrition Increases Risk of Hospital-acquired Infections

10

France1

Malnutrition increases risk of

hospital-acquired infection

nearly 5-fold (OR, 4.98).

Korea2

Severely malnourished

ICU patients were 2.1

times more likely to get

an infection.




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Malnutrition Is Associated With Falling in Hospitals

1. Bauer JD, et al. J Hum Nutr Diet. 2007;20:558-564.

Well-nourished

by SGA* n=27; mean ± S.D.

Malnourished

by SGA* n=22; mean ± S.D.

P-value

Age (years) 69.8 ± 14.1 72.8 ± 14.1 0.453

MST,* admission

No risk (0,1)

Risk (≥ 2)

21

6

6

16

< 0.001*

Weight (kg) 75.4 ± 13.9 63.0 ± 12.8 0.002*

Body mass index 25.9 ± 3.9 22.1 ± 3.4 0.003*

Energy intake

(Kj)

6671 ± 2351 4949 ± 2466 0.018*

Protein intake (g) 77.2 ± 29.5 56.4 ± 30.4 0.022*

*Malnutrition screening Tool, MST. Subjective Global Assessment, SGA. Nutritional status was determined as well-nourished (SGA A)

or Malnourished (SGA B + C); statistical significance is reported at P< 0.05.

Australia: patients who fell during hospitalization

‘Fallers’ had a high prevalence of malnutrition; nutrition intervention is

recommended for people who fall during hospitalization.




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Malnutrition Negatively Impacts Health-related QOL

12

EuroQol-5D QOL Dimensions

Kvamme JM, et al. Qual Life Res. 2011;20:575-582.

Quality of Life

Pain/ discomfort

Mobility

Self-care Usual

activities

Anxiety/ depression

Norway

n= 3286 people

aged 65-87 yrs

Health-related Quality of Life

(HRQoL) was significantly

reduced in older people with

increased risk of

malnutrition.




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Malnutrition Is Associated With Serious Morbidity and Mortality

13

1. Sullivan DH, et al. J Gen Intern Med. 2002;17:923-932. 2. Stratton RJ, et al. Br J Nutr. 2006;95:325-330.

3. Correia MI, Waitzberg DL. Clin Nutr. 2003;22:235-239. 4. Prasad N, et al. J Ren Nutr. 2010;20:384-391.

Brazil3: In-hospital

mortality was higher in

malnourished than in

nourished patients

(12.4% vs 4.7%).

India4: Malnourished

dialysis patients were at

3-fold higher risk of

mortality compared to

nourished peers.

UK2: Hospital patients at

high risk for malnutrition had

greater post-release

mortality compared to low-

risk patients (24% vs. 5% at

3 months).

USA1: Older hospital patients

with low BMI (< 22 kg/m2)

were more likely to

experience life-threatening

complications than were

those with higher BMI

(15.4% vs. 4%).




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Financial Costs Associated With Malnutrition Are High

1. Freijer K, et al. Clin Nutr. 2013;32:136-141. 2. Lim SL, H, et al. Clin Nutr. 2012;31:345-350.

Netherlands1

Added costs of care for

managing disease-related

malnutrition was estimated as

2.1% of the country’s total

national health expenditures.

Across Europe, such costs

would total €120 billion

annually.

Malnourished patients

had longer stays in hospital

(6.9 days vs 4.6 days,

P < 0.001) and 2-fold higher

rates of readmission within

15 days compared to

adequately-nourished

peers—both with expensive

consequences.

Singapore2




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Malnutrition and Increased Daily Hospital Costs

Correia MI, Waitzberg DL. Clin Nutr. 2003;22:235-239.

Brazil

N=709 patients in 25 hospitals

15

Malnourished patients had higher daily costs of care, and they stayed longer in the

hospital (16.7 days vs 10.1 days for nourished patients) causing still greater costs.




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Malnutrition and Increased Total Hospitalization Costs

Amaral TF, et al. Clin Nutr. 2007;26:778-784.

Portugal n=469 patients

16

The hospitalization cost for a malnourished patient was more than double

that of a patient who was not classified as nutritionally-at-risk.




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Oral nutrition supplements • Outcome benefits • Cost savings

Clinical evidence underscores advantages of nutrition intervention.

Feeding Hospitalized Patients: the Impact




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Outcome Benefits With ONS

Outcome benefit Study design and findings

Lower incidence of pressure ulcers

Meta-analysis of results from 4 RCTs showed significantly lowered

incidence among elderly hospitalized patients (OR 0.75) who used

ONS (2-26 weeks) compared to non-users.1 Studies were done in

Switzerland, Sweden, France, and the Netherlands.

Greater handgrip strength

Meta-analysis of results from 4 RCTs showed that ONS users

(mean age > 65 years) had significantly improved handgrip strength

compared to controls.2

Studies were done in the UK, Sweden, and Germany.

Improved QOL

During a 3-month post-hospitalization interval, malnourished

patients who received individualized nutrition care with ONS and

dietary counseling scored higher on all 8 QOL scales, compared to

only 3 scales with dietary counseling.3 This study was conducted in

Germany.

Reduced mortality risk

Meta-analysis of nutrition trials in older people.4 In subgroup

analysis of those who were undernourished, ONS use significantly

reduced risk of mortality by more than 20%. Studies were done at

sites around the world.

Randomized, controlled trial, RCT; odds ratio, OR; oral nutrition supplements, ONS; quality of life, QOL 1. Stratton RJ, et al. Ageing Res Rev. 2005;4:422-450. 2. Cawood AL, Elia M, Stratton RJ. Ageing Res Rev. 2012;11:278-296.

3. Norman K, et alEur J Clin Nutr. 2011;65:735-742. 4. Milne AC, et al Cochrane Database Syst Rev. 2009:CD003288.




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Oral Nutrition Supplement Use Lowers Costs of Hospital Care

19

Philipson TJ, et al. Am J Manag Care. 2013;19:121-128.

USA Database of 44 million inpatient episodes, with >700,000 episodes that included the use of ONS; each

ONS-user was paired with a non-user who had a similar health condition (propensity matching)

ONS use was associated

with 21.6% reduction in

hospitalization cost

Each dollar spent on ONS

generated $52.63 in savings

from reduced episode

cost

EPISODE COST

ONS use was associated with

21.0% reduction in LOS

LENGTH OF STAY ONS was associated with a 6.7%

reduction in probability of 30-day

readmission

Each dollar spent on ONS

generated at least $2.56

from avoided 30-day

readmissions

30-DAY

READMISSION




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Health Benefit: Fewer Complications in Hospitals

20

Baltimore and Beijing

n=1831

Jie B, et al. Nutrition. 2010;26:1088-1093.




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Norman K, et al. Clin Nutr. 2008;27:5-15.

MALNUTRITION

MORBIDITY MORTALITY

READMISSIONS TREATMENT LENGTH OF STAY

INCREASED COST

Health Tolls and Financial Costs: Summary




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Barriers • Nutrition culture • Nutrition guidelines • Training and education

Achieving optimal nutrition starts at the top.

Common Barriers and Strategies to Achieve Best-practice Nutrition




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Too Often Patients’ Nutritional Needs Are Overlooked and Under-treated

o Only 50% of units conducted routine

nutrition screening on admission

o Even when energy goal was specified,

43% of patients did not meet goal

Schindler K, et al. Clin Nutr. 2010;29:552-559.

Europe-wide survey

of nutrition practices

in hospitals




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o 55% of malnourished patients ate less

than half of the food offered

Agarwal E, et al. Clin Nutr. 2012;31:41-47.

24h audit of nutrition

care in Australian

hospitals




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o In Chinese teaching hospitals, the proportion

of malnourished patients went from 8.2% on

admission to 11.5% at discharge.1

o Stroke patients hospitalized in South Korea

deteriorated from 12.2% undernourished at

baseline to 19.8% one week later.2

1. Liang X, et al. Asia Pac J Clin Nutr. 2009;18:54-62. 2. Yoo SH, et al. Arch Neurol. 2008;65:39-43.

Nutritional status worsens

during hospital stay




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Barriers to Best-practice: Time, Training, Money

Perceived barriers to updating

nutrition practice1,2 Why overcome this barrier?

Practice change takes time

Adoption of standardized, practical protocols

makes feeding decisions stepwise and logical,

which saves time.

Practice change requires staff

education and training

Achieving better nutritional status for patients

improves clinical outcomes and lowers costs of

care.

Practice change will cost a lot

Due to the high costs of care for malnourished

patients, hospitals can’t afford not to improve

nutrition care.

1. Cahill NE, et al. J Crit Care. 2012;27:727-734. 2. Jones NE, et al. Nutr Clin Pract. 2007;22:449-457.




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5 Steps to Overcome Barriers and Achieve Best-practice Nutrition

Know

nutrition

guidelines

OVERCOME

BARRIERS

Monitor

Progress

Create a

nutrition

culture

Educate and

train staff

Empower

champions




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Create a Culture That Values Nutrition

Mission and goals: NUTRITION

Guidelines

Education

Policies & Protocols

Training

Reinforce messages, refresh training

Guidelines

Training

Brantley SL. Nutr Clin Pract. 2009;24:335-343.




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Education and Training

• Grand rounds

presentations

• In-service training

sessions

• Workshops




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• Computer-based

learning modules

• Bedside instruction

for small groups or

one-on-one training




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• Visual reminders

such as posters

and checklists

• feedM.E. and other

Abbott Nutrition

training materials

as resources




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0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Know ICU nutrition

Nutrition support comfort

Importance of nutrition

1. Behara AS, et al. JPEN J Parenter Enteral Nutr. 2008;32:113-119. N

Evidence that healthcare professionals

need and want nutrition education and training USA: Attending physicians, fellows, and residents waited an average of 2.4,

1.8, and 2.6 days before addressing nutritional status in critically ill patients.




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Nutrition Support Teams and “Champions” Help Overcome Barriers

33

1. Delegge M, et al. Nutr Clin Pract. 2010;25:76-

84. 2. Mo YH, et al. Yakugaku Zasshi.

2011;131:1827-1833. 3. McClave SA, et al.

JPEN J Parenter Enteral Nutr. 2010;34:123S-

132S. 4. Thoresen L, et al. J Hum Nutr Diet.

2008;21:239-247. 5. Bourgault AM, et al. Crit

Care Nurse. 2007;27:17-22, 25-19.

OVERCOME

BARRIERS

Nutrition

Support

Teams1,2

Nutrition

Specialist

Physicians3

Dietitians4 Nutrition

“Champions”5




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Screen • Intervene • Supervene

Basic nutrition care is logical and stepwise.

Take Action: Follow the Nutrition Care Pathway




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Make Nutrition Screening a Routine Part of Care

Consider immediate

dietary fortification

or oral nutrition supplement

for all at-risk patients

Use alternate

protocol for end-of-

life patients

Screen for malnutrition risk on admission

• Does the patient have illness/injury that

has malnutrition risk?

• Appetite loss?

• Weight loss?

Screen and intervene on admission




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Intervene and Supervene

Assess needs and intervene with nutrition during hospitalization.1

Use Subjective Global Assessment (SGA)2

and other tools for malnutrition diagnosis

Route, access,

and timing

Select a

formula

Set energy and

protein goals

How and when? What? How much?

Track and modify nutrition in hospital

Plan for post-discharge nutrition

Plan for hospital nutrition

1. Correia M et al. J Am Med Dir Assoc. 2014;15:544-550

2. Detsky AS, et al. JPEN J Parenter Enteral Nutr. 1987;11:8-13.




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Choose Nutrition Intervention

Modify oral diet and/or use oral nutrition supplements

Use tube-fed enteral nutrition therapy

Use parenteral nutrition therapy

Hamilton C, Boyce VJ. JPEN J Parenter Enteral Nutr. 2013;37:808-815.

Ro

uti

ne r

esc

reen

ing

an

d

reas

sessm

en

t




Feed Patients Now.

Correia ITD, et al. 2013. Curr Opin Clin Nutr: Submitted.

Consider immediate

dietary fortification

or oral nutrition supplement

for all at-risk patients

Use alternate protocol

for end-of-life patients

Screen for malnutrition risk on admission

• Does the patient have illness/injury that

has malnutrition risk?

• Appetite loss?

• Weight loss?

Use Subjective Global Assessment (SGA)2

and other tools for malnutrition diagnosis

Route, access,

and timing

Select a

formula

Set energy and

protein goals

How and when? What? How much? Track and

modify

nutrition in

hospital

Plan for post-

discharge

nutrition

Plan for hospital nutrition

Ro

uti

ne r

esc

reen

ing

an

d r

eas

sessm

en

t

Intervene With Nutrition in Hospital; Supervene With Post-discharge Nutrition Care




Feed Patients Now.

Call to Action

NUTRITION CARE AT YOUR HOSPITAL

Know what to

do, and train

staff to do it

• Know evidence-based

nutrition guidelines.

• Use nutrition protocols.

• Train staff on best-nutrition

practices.

• Use teams/champions to

sustain quality care.

• Update practices and

training regularly.




Feed Patients Now.

Call to Action

NUTRITION CARE AT YOUR HOSPITAL

Evaluate

practice; adjust

and reassess

care processes.

• Benchmark practices and outcomes.

• Discuss findings with colleagues.

• Set change goals, e.g., reduce

practice variation, contain costs,

increase compliance.

• Implement changes, as needed, with

refreshed policies and training.

• Monitor compliance and outcomes;

share results with colleagues.




Feed Patients Now.

Take-home Messages on Hospital Nutrition Care

Malnutrition has negative effects on outcomes and cost of care.

Time, money, and training are common barriers to adoption of best-practice nutrition—but such barriers can be overcome.

A Nutrition Care Pathway guides nutrition care for hospitalized patients who are malnourished or at risk.

Nutrition interventions decrease morbidity, shorten LOS, lower mortality, reduce readmissions, and lower overall costs of care.

for Hospital

Administrators

5001 1113 0139 A 1

feedm.e. malnutrition awareness and education for hospital ......6671 ± 2351 4949 ± 2466 0.018*...

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