Underernæring og ernæringsbehandling i spesialisthelsetjenesten
The main objective of this dissertation research was to objectively evaluate the Bergen Nutritional Strategy. This was accomplished by conducting three studies, each addressing different aspects of the strategy. Methods: Nutritional registrations performed as point-prevalence surveys were conducted every three months during 2008 and 2009. NRS 2002 was used to classify patients as ‘at nutritional risk’ or ‘not at risk’. Data on hospitalisation were obtained from the patient administrative system. Patients: For the eight point-prevalence surveys in 2008 and 2009, 5849 adult hospitalised patients were subject for inclusion; 3604 patients were included in study I, and 3279 patients were included in studies II and III. Results: In study I, 1230 (34%) of 3604 patients were at nutritional risk. Among these, 53% received nutritional treatment, and dieticians were involved in the treatment of only 5%. The proportion of patients who were screened increased significantly from the first to the last survey (p=0.012). However, the proportion of patients who received nutrition treatment did not increase during the study period (p=0.66). In study II, 3279 patients were followed for one year. Of these, 29% were at nutritional risk, as assessed by NRS 2002. Being at nutritional risk was strongly associated with increased morbidity and mortality. Even the initial screening robustly identified adverse outcomes. Every single item of the screening tool was found to be a significant independent risk predictor. A positive response to one or more of the initial four questions in NRS 2002 was associated with increased risk of morbidity and mortality, and positive answers to all four questions were associated with a 13 times greater risk of dying during the following year (OR 13.0, 95% CI 4.52 to 37.6). In study III, compared to well-nourished patients, those at nutritional risk were more often female (53% vs.50%); underweight (mean Body Mass Index [BMI] 21.4 vs. 25.3 kg/m2); and older (mean age: 67.8 vs. 63.0 years). The prevalence of nutritional risk increased with age, being 40% for patients =80 years and 21% for those <40 years old. It is important to note, that even the younger patients (18-39 years), overweight and obese patients (BMI>25 kg/m2), and patients with fewer than four diagnoses were frequently found to be at nutritional risk. A high prevalence of nutritional risk was found in nearly all patient groups and hospital units. Conclusions: This comprehensive study of a university hospital patient population revealed that a high proportion of the patients in this university hospital were at nutritional risk during the study period. Far from being simply an academic finding, this risk was strongly associated with adverse outcomes, sometimes even death. Nutritional depletion is a significant risk factor for morbidity, increased use of hospital services, and premature death. Our findings support the elevated need for nutritional screening in hospitals. Patients at nutritional risk were identified in all disease categories and all ages. A screening tool is immensely valuable for categorising patients at nutritional risk, and NRS 2002 was found to be suitable for identifying high-risk patients. The initial four questions of NRS 2002 were strong predictors of hospitalisation, morbidity, and most importantly, mortality, among hospitalised patients. Thus the combined use of just these four questions would be appropriate and effective to use as an initial screening of hospitalised patients. Implementation of the Bergen Nutritional Strategy improved the screening performance among the hospital staff, but did not improve the patients’ nutritional treatment. Therefore, more intense efforts are necessary to improve nutritional practice and staff knowledge in hospitals.
Styrken ved dette prosjektet er at det for første gang er iverksatt en ernæringsstrategi på et stort sykehus der kvartalsvise punktprevalensundersøkelser gjennomføres i den hensikt å overvåke og forbedre ernæringspraksis. Prosjektet evaluerer en høyt prioritert satsning og et stort tverrfaglig samarbeid ved et universitetssykehus på en systematisk måte. Resultatene har nasjonal og internasjonal overføringsverdi fordi denne satsningen er i tråd med nasjonale og internasjonale retningslinjer for forebygging og behandling av sykdomsrelatert underernæring. Studien har kvalitetssikret og evaluert ett av de anbefalt screeningsverktøyene på et stort pasientmateriale. Dette screeningskjemaet inngår nå i pasientsikkerhetskampanjen sitt Trygg Pleie (screening for ernæring, fall og trykksår) . Studien har synliggjort den ekstra byrden det er for helsetjenesten når pasienter har utviklet ernæringsmessig risiko. Dette ble gjort ved å vise hvor mange pasienter som har utviklet tilstanden, hvilke pasientgrupper som er mest utsatt og konsekvenser. Studiens resultat er et godt grunnlag for å anbefale helsetjeneste å identifisere ernæringsmessig risiko for å forebygge underernæring. Den valgte metoden er hensiktsmessig. Metoden kan forenkles ved å bruk første del av screeningverktøyet og likevel finne alle risikopasientene. Resultatene er med i grunnlaget for nasjonalt ernæringsarbeidet i helsetjenesten, blant annet ved at Nasjonal kompetansetjeneste for sykdomsrelatert underernæring er opprettet og at ernæring er blitt del av den nasjonale pasientsikkerhetskampanjen.
Nutritional risk profile in a university hospital population
The prevalence of nutritional risk varies according to several factors. We aimed to determine the nutritional risk profile in a large Norwegian hospital population, specifically by age, disease category and hospital department.
Nutritional surveys are performed routinely at Haukeland University Hospital, Norway. During eight surveys in 2008–2009, 3279 patients were categorized according to the Nutritional Risk Screening tool (NRS 2002). The overall prevalence of nutritional risk was 29%, highest in patients with infections (51%), cancer (44%) and pulmonary diseases (42%), and in the departments of intensive care (74%), oncology (49%) and pulmonology (43%). Further, nutritional risk was identified in 40% of patients aged =80 years compared to 21% of age <40 years and 35% of patients with emergency admissions compared to 19% with elective admissions. Related to the tool components, nutritional risk was most common in patients with low BMI (<20.5 kg/m2) (95%) and/or high comorbidity (>7 diagnoses) (45%). However it was also high in patients with BMI =25 kg/m2 (12%) and in those with fewer than 7 diagnoses (26%). Nutritional risk was most common among patients with high age, low BMI, more comorbidity, and with infections, cancer or pulmonary diseases, and patients who were discharged to nursing homes. However, the highest number of patients at nutritional risk had BMI in the normal or overweight range, were 60–80 years old, and were found in departments of general medicine or surgery. Importantly, younger patients and overweight patients were also affected. Thus, nutritional risk screening should be performed in the total patient population in order to identify, within this heterogeneous group of patients, those at nutritional risk.
Four questions predict morbidity, mortality and health care costs
Nutritional care for hospital in-patients is potentially important but challenging. We investigated the association between nutritional status and clinical outcomes.
Eight prevalence surveys were performed at Haukeland University Hospital, Norway, during 2008-2009. In total 3279 patients were classified as being at nutritional risk or not according to the Nutritional Risk Screening (NRS 2002) tool. The initial four questions of NRS 2002 assess dietary intake, weight loss, body mass index (BMI) and illness severity.
The overall prevalence of nutritional risk was 29%. Adjusted mean days for hospitalisation was 8.3 days for patients at nutritional risk and 5.0 days for patients not at risk (p<0.001). In adjusted models, patients at nutritional risk had increased one-year mortality (OR 4.07, 95% CI 2.90 to 5.70), morbidity (OR 1.59, 95% CI 1.18 to 2.13), and were 1.24 (95% CI 1.16 to 1.32) times more likely to have had an new admission during the three previous years and the one subsequent year, compared to patients not at risk. A ‘positive’ response to the initial four questions was associated with increased risk of morbidity and mortality. Patients with a reduced dietary intake during the last weeks had OR 1.72 (95% CI 1.03 to 2.85) for one-year mortality. Patients with a positive answer on all the initial four questions had ten times increased risk for mortality the following year, OR 13.0 (95t% CI 4.52 to 37.6).
In conclusion, he four initial questions of the NRS 2002 robustly identify nutritional risk and were strong predictors of hospitalisation, morbidity and most importantly mortality among hospitalised patients. Thus, these simpler and short questions are robust indicators for subsequent poor outcomes.
Underernæring og ernæringsbehandling ved Haukeland Universitetssykehus
Hver tredje voksne somatiske pasient ved Haukeland Universitetssykehus har utviklet en sykdomsrelatert underernæringstilstand som medfører flere døgn på sykehus, økt sykelighet og dødelighet det påfølgende året.
Som foregangssykehus gjennomfører Haukeland Universitetssykehus kvartalsvise ernæringsregistreringer for å overvåke ernæringspraksis og forekomst av ernæringsmessig risiko. Det første arbeidet viser at sykehuset blir stadig flinkere til å identifisere ernæringsmessig risiko, noe som er et viktig skritt mot bedre ernæringspraksis. Hver tredje pasient er i ernæringsmessig risiko, bare halvparten av disse får ernæringstiltak og 5 % får konsultasjon med klinisk ernæringsfysiolog. Det er krevende å innføre nye rutiner i sykehus. Mer ernæringskompetanse er nødvendig for å forbedre ernæringsarbeidet i sykehusene. Gjentatte prevalensundersøkelser foreslås innført nasjonalt som et verktøy for økt fokus og forbedring av ernæringsrutinene i helsetjenesten. (Implementation of nutritional guidelines in a university hospital monitored by repeated point prevalence surveys. Eur J Clin Nutr. 2012 Mar;66(3):388-93.)
Det andre arbeidet følger pasientene i ett år etter utskrivning og viser at de som ble identifisert til å være i ernæringsmessig risiko under ernæringsregistreringene har signifikant flere diagnoser, lengre sykehusopphold, flere nye innleggelser og høyere dødelighet sammenlignet med de som ble registrert uten slik risiko. Resultatet endret seg bare marginalt etter at det ble justert for alder og kjønn. Vi identifiserte fire enkle spørsmål som indikerer høy risiko på mortalitet og morbiditet blant voksne, somatiske pasienter i spesialisthelsetjenesten (The Bergen nutritional Strategy: Four questions predict morbidity, mortality and expences.)
Nutritional risk profile in a university hospital population.
Clin Nutr 2015 Aug;34(4):705-11. Epub 2014 aug 12
PMID: 25159298 - Inngår i doktorgradsavhandlingen
The nutritional strategy: four questions predict morbidity, mortality and health care costs.
Clin Nutr 2014 Aug;33(4):634-41. Epub 2013 sep 18
PMID: 24094814 - Inngår i doktorgradsavhandlingen
Nutritional risk profile in a university hospital population
Clinical Nutrition 2014