Lecture at 36th World Hospital Congress of International Hospital Federation in Rio de Janiero, November 2009

2. RCT: Complications % mortality Stratton RJ, Green CJ, Elia M. Disease-related malnutrition. CABI Publishing 2003 24% vs. 44% 1) Infections 2) 17 % vs. 24% 1) Mortality 1) P <0.001; 2) 10 RCTs only Meta-analysis of 27 RCTs with 1710 patients (complications) and 30 RCTs with 3250 patients (mortality). Neurology, GI disease, liver disease, malignant disease, elderly, abdominal surgery, orthopaedic surgery, critical illness/injury, burns. Hospital or community Oral supplements or tube feeding 28% vs. 46% 1) Complications

3. Meta-analysis: Surgery Stratton RJ, Green CJ, Elia M. Disease-related malnutrition 2003

4. BAPEN cost Based on 33% longer LOS and twice as frequent hospitalisations for at-risk patients and the average bed day cost (£ 258). Russell. Clin Nutr Suppl 2007; 2: 25–32

5. Kondrup et al. Nestle Nutr Workshop Ser Clin Perform Programme 2009;12:1-14.

6. NICE (UK): Clinical Guideline 32 . Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Costing report. London: National Institute for Health and Clinical Execellence (NICE); 2006. .. it is estimated that 30% of patients in all wards are screened

7. Prevalence: Care Large care gap! 33 1) Plan (req, food type, monitor) 1) Related to recent weight loss and severity of disease, but not to BMI or recent intake 33 Recent dietary intake 19 Recent weight loss 64 Weight % of at-risk ptt Information in records Nutritional care in Denmark A random sample of 15 departments in internal medicine, orthopaedics, abdominal surgery (N= 590) Rasmussen et al. Clin Nutr 2004;23:1009-15.

9. Intake UPS  This is the solution  Johansen et al. Clin Nutr 2004;23:539-550.

14. Nutrition support: a structured process ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:415-421 Audit Communication

15. Screening: NRS 2002 – based on evidence from RCTs ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:415-421. The patient is categorized according to most affected variable Nutritional status Severe 3 Moderate 2 Mild 1 Grade Score 3 months 50-75 2 months 25-50  20.5 >18.5 1 month 5% recent weight loss 0-25 Recent dietary intake, % of requirement  18.5 BMI

16. Screening NRS 2002 – based on evidence from RCTs ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:415-421. Objective data  Numeric score If  3  nutrition treatment according to ESPEN guideline Identifies malnutrition and risk for developing malnutrition ICU 3 Severe 3 Severe = Score + Confined to bed due to illness 2 Moderate 2 Moderate Chronic disease, ambulatory 1 Mild 1 Mild Increased requirements Nutritional status

17. EuroOOPS*: Nutrition Practice as determinant of intake ≥75% of requirements in patients at-risk Questions on practice based on Beck et al. Guidelines from Council of Europe. Clin Nutr 2001, 20: 455-460. Unpublished data from Sorensen et al. Clin Nutr 2008;27:340-9. *5051 patients in 22 departments in 12 countries <0.0005 50 65 14/8 Ptt’s satisfaction feedback % patients ≥75% 15/7 13/9 11/11 18/4 Had: Yes/No <0.0005 50 65 Monitoring Common 0.02 56 63 Screening Common <0.0005 54 65 Snacks available NS: definition of responsibility, choice of menus; ICUs excluded 50 No 0.03 P 61 Yes Nutrition Committee Practice in department

18. Factors determining intake Of the 1581 at-risk patients with LOS >3 days, 1017 (64%) were judged to have an intake  75% of requirements Logistic regression analysis: OR for intake ≥75% of requirements Unpublished data from Sorensen et al. Clin Nutr 2008;27:340-9. <0.0005 3.10 TPN or TEN vs. Food or Supplements 1.33 0.30 0.21 0.44 0.29 0.60 OR 0.001 Nutrition Practice Score (per # of practices) <0.0005 <0.0005 0.002 <0.0005 <0.0005 P Oncology vs. Surgery Gastroenterology vs. Surgery Geriatry vs. Surgery Internal Medicine vs. Surgery Recent Intake at NRS screening (per score unit)

21. Copenhagen audit March 2006 Accreditation 2002 & 2005 Kondrup et al. Nestle Nutr Workshop Ser Clin Perform Programme 2009;12:1-14.

22. Reliability of audit results 480 patients in 24 departments in 5 hospitals in Copenhagen Holm et al. ESPEN Congress 2006: Abstract # P 0281 Correct, % Done, % n/N Activity 91% 74% 106/143 Food intake recording 89% 98% 220/224 Final screening 85% 78% 374/480 Initial screening

29. NutritionDay 2007 & 2008: Survey of 21.007 patients in 1.217 units in 325 hospitals in 25 countries. Divided by region, 21% to 93% of the units screened for malnutrition on admission. Schindler et al 2009, submitted

31. Context