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Practical aspects of implementing screening and
treatment of malnutrition in Dutch
hospitals Marian van Bokhorst de van der
Schueren PhD, RD, VU University Medical
Center Amsterdam, The Netherlands
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Dutch prevalence data
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• Steady decrease in malnutrition prevalence rates,
  still 14 / 15

Dutch Annual Measurement of Care Problems 2010
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1. Dutch Malnutrition Steering Group (DMSG)

• DMSG A multidisciplinary steering group with
  national key persons
• professors, doctors, dietitians, policy advisors
  and researchers on key positionsin relevant
  medical and nutritional fields
• Goal fighting malnutrition together with
• the Dutch Annual Measurement of Care Problems
  (LPZ)
• the Dutch Ministry of Health
• the Dutch Society for Clinical Nutrition and
  Metabolism (NESPEN)

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Points of departure to convince policy makers

• Increase awareness best practices, examples of
  malnutrition in hospitals
• Malnutrition is expensive
• Screening and treatment of malnutrition can save
  money
• There are European white papers

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How did we convince the minister?

• Show scary photos

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Best practices
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Assortment

• protein and energy dens liquids (chocolate
  milk,milkshake)
• cake
• deserts
• little buns (ham, cheese)
• pancake
• (fish) salad
• cheese

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Show effectiveness and cost-effectiveness

• Effectiveness
• Changes in nutritional status
• Use of sip feeds and tube feeding
• Number of dietetic consultations
• Length of stay
• Costs
• SNAQ-cart
• Time involved in screening
• Extra work for diet assistent
• Extra work for dietitian
• Ratio costs / effects cost effectiveness

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Results

• Recognition of malnutrition rises from 50 to
  80
• Earlier start of nutritional intervention (from
  day 6 to day 2)
• Decrease in Length of Stay of malnourished
  patients
• Cost effectiveness 76 euro to save one day of
  hospital admission
• (Costs for 1 day in a university hospital 476
  EUR and for a general hospital 337 EUR)

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Shorten a patients journey
Symptoms Screening Assessment
?
Recovery
Nutritional Status
Intervention
Home Hospital Home
Time ?
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Screening as a mandatory quality indicator (
(Health Care Inspectorate)

• Screening and treatment mandatory in all health
  care settings
• Malnutrition is defined as one of the main health
  care issues
• Screening and optimal treatment of malnutrition
  becomes part of the main policy goals of the
  individual hospitals, nursing homes and home care
  organizations.
• Ongoing collection and feedback of malnutrition
  data by the Dutch Health Care Inspectorate

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Multidisciplinary project teams with authority

• Top-down
• Agreement with the board of Directors.
• Multidisciplinary project team with the key
  persons
• Bottum-up
• Ward-level team of a nurse, dietitian and
  physician

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Multidisciplinary teams

• Members and tasks
• Frequency of meetings
• Points to be discussed
• Responsibilities
• Communication and education plan

http//www.fightmalnutrition.eu/fileadmin/content/
fight_malnutrition/methodology/Multidisciplinary_p
roject_team_and_agenda.doc
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Training programs and workshops

• Training of the project leaders (nurses,
  dietitians, managers)
• 1. How to start with implementation of
  malnutrition screening? (4 hours)
• 2. Education in malnutrition screening and
  treatment (1 day, 1,5-2 months after the start
  meeting)
• 3. Follow up and group session on patient and
  implementation cases (4 hours, 3 months after
  educational meeting, and 1 year after meeting)
• Workshops with these aspects in one day
• Multidisciplinary screening and treatment
  guideline

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Feedback and follow-up

• Refreshment
• Posters
• Exchange of best practices
• Award for the best performing hospital
• Learning from other disciplines
• Sharing ideas on the website

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Quality indicator on screening

• Hospital Indicators
• Screening of malnutrition
• 1a. Do you systematically screen nutritional
  status of all adult patients on admission to
  hospital? Yes/no
• 1b.  Do you use SNAQ (Short Nutritional
  Assessment Questionnaire), MUST (Malnutrition
  Universal Screening Tool), or another instrument
  to screen patients nutritional status? Yes / No?
  
• 2. How many patients (percentage of total)
  were screened on malnutrition at admission?
• 3. What percentage of patients scored moderate
  malnutrition?    
•  
• 4. What percentage of patients scored severe
  malnutrition?

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Daily practice in our own hospital

• Introduction of the SNAQ screening instrument to
  the electronic nurses admission questionnaire
• Pop-up screens with outcomes of SNAQ screening
• ICT application to management-database to be
  able to present hospital data by the end of the
  year

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SNAQ score (obligatory !)
other nutritional questions (voluntary)
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Goal Realisation
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Evaluation of the process learning by time.

• At
• 2 weeks
• 6 weeks
• 3 months
• 6 months
• 1 year
• yearly

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New admission n13392, screened 75
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Quality indicator, screeningBenchmark between
hospitals
Publication bij inspection of health
care, Newspapers Internet kiesbeter.nl
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Number of hospitals and patients in measurement

• Hospitals Patients
• 2007 N 77 N 310.000
• 2008 N 94 N 790.000
• 2009 N 96 N 880.000
• 2010 N 97 N 1.050.000

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Quality indicator 1 All patients should be
screened for malnutrition at admission 2010
72 of patients screened at admission
72
65
56
52
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Quality indicator, part 2

• Introduced in 2008
• Measurement of optimal treatment
• What is optimal treatment?
• No outcome parameters available at short notice
• Measure adequate intake instead? How much
  protein, energy, by what day? How to measure
  intake in all patients?

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Quality indicator on treatment

• Which percentage of malnourished patients reaches
  optimal protein intake at the fourth day of
  admission to hospital?
• Protein 1,2 1,5 gram/per kg/day

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Ward responsibility
Referral (ICT application) for further assessment
and treatment
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Daily practice in our hospital daily overview of
patients admitted with SNAQ scores 3 and up
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Registration of intake on day four of admission
in the electronic patient chart
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Quality indicator 2 malnourished patients should
meet their protein requirements on the 4th day
of admission2010 44 of malnourished patients
with adequate protein intake on day 4
44
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39
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Quality indicator 2 malnourished patients should
meet their protein requirements on the 4th day
of admission
Mean of all 100 Dutch hospitals 44 of patients
reaches 1,2-1,5 g P/kg on the 4th day
gt60 optimal intake 11 hospitals
40-60 optimal intake 15 hospitals
lt40 optimal intake 46 hospitals
No data 27 hospitals
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• van Bokhorst de van der Schueren, Nutr Clin
  Practice 2012 274-280
• Leistra, Clin Nutr 2011 484-489

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Were do we go from here?

• Outpatient screening for patients at risk

Pre-operative (2007)
Geriatrics (2010)
Oncology (2012)
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Evidence based validated tools and
cost-effectiveness research
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We have expanded our knowledge to outpatients,
nursing homes and the community
Nursing homes
Outpatients
Inpatients
Community
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Home Care

• 2008-2012 implementation project
• Training of 125 home care organisations
• LESA
• Toolkit

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Risk profile of malnourished, community dwelling
elderly
1.Have you losst weight unintentionally? 68
2. Do you think your bodyweight is too low? 51
3. Have you eaten less than normal last month? 51
4. Do you experience GI problems? 30
5. Do you think you eat unhealthy? 13
6.Do you need help with shopping and cooking? 43
7. Do you suffer fatigue? 57
8. Do you suffer pain? 33
9. Do you feel sad or depressed? 19
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Toolkit with free accessible materials in
format to be custom made and best practices

• Guidelines and fact sheets
• Free format to be custom made
• Presentation for nurses, managers, doctors, .
• Project plan
• Newsletter
• Patient
• information
• ..
• Treatment plans
• Best practices
• Literature

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(No Transcript)
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Training programs and workshops

• Training of the project leaders (nurses,
  dietitians, managers)
• 1. How to start with implementation of
  malnutrition screening? (4 hours)
• 2. Education in malnutrition screening and
  treatment (1 day, 1,5-2 months after the start
  meeting)
• 3. Follow up and group session on patient and
  implementation cases (4 hours, 3 months after
  educational meeting, and 1 year after meeting)
• Workshops with these aspects in one day
• Multidisciplinary screening and treatment
  guideline

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Home Care

• 2008-2012 implementation project
• Training of 125 home care organisations
• LESA
• Toolkit

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Website www.stuurgroepondervoeding.nlwith
toolkits healthcare settings
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No need to learn Dutch!www.fightmalnutrition.eu
in progress
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Training programs and workshops

• Training of the project leaders (nurses,
  dietitians, managers)
• 1. How to start with implementation of
  malnutrition screening? (4 hours)
• 2. Education in malnutrition screening and
  treatment (1 day, 1.5-2 months after the start
  meeting)
• 3. Follow up and group session on patient and
  implementation cases (4 hours, 3 months after
  educational meeting, and 1 year after meeting)
• Workshops with these aspects in one day
• Multidisciplinary screening and treatment
  guideline

49
Welcome to share your documents toolkits!
Visit our site - in progress

• www.fightmalnutrition.eu
• info_at_fightmalnutrition.eu

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Spread the news!www.fightmalnutrition.eu
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Welcome in Amsterdam !M.vanbokhorst_at_vumc.nl