An European survey of structure and organisation of nutrition support teams in Germany, Austria and Switzerland

[Comprehensive nutrition therapy in hospitals - Wishful thinking or reality? A survey-based cross-sectional study of the nutritional therapy in hospitals of Baden-Württemberg]

INTRODUCTION

Malnutrition is widespread in German hospitals, has a negative impact on therapeutic success and quality of life, and it leads to increasing costs. An individualized nutritional support by nutritional professionals in accordance with current guidelines was shown to reduce mortality of malnourished inpatients. Ideally, nutritional support is conducted by an interdisciplinary nutrition support team. Current data on the nutritional therapy in German hospitals is missing.

METHODS

In order to ascertain the current status of nutritional support in hospitals in the federal state of Baden-Württemberg, clinic managements of all hospitals in Baden-Württemberg received an online questionnaire. Affiliated hospitals, specialist hospitals, as well as hospitals with less than 50 beds were excluded from the analysis.

RESULTS

The response rate was 84% (n = 94). The presence of a nutrition support team was reported by 34% of the hospitals. Twelve percent of the hospitals meet the structural characteristic of the OPS Code 8-98j Ernährungsmedizinische Komplexbehandlung, which means that their nutrition support team includes a physician. A validated nutritional risk screening is performed in 72% of the hospitals. Only 40% of the hospitals report that this is performed throughout every department. Nutrition support teams are more often concerned with malnutrition, enteral and parenteral nutrition as compared to nutritionists who are not organized in a team. Moreover, nutrition support teams have a wider range of tasks and more often a physician as a team member. Also, nutritional risk screenings are more often applied in hospitals with nutrition support teams.

DISCUSSION

Compared with a nationwide survey from 2004, there are markedly more nutrition support teams available in hospitals in Baden-Württemberg. When compared internationally, however, the rate of nutrition support teams is still low. In addition, there is no comprehensive nutritional care available. High-quality nutritional support is more often found in hospitals with nutrition support teams.

CONCLUSION

There is still a great potential of improving clinical nutritional care in hospitals in Baden-Württemberg. Moreover, an increase in nutrition support teams, also comprising medical members, should be achieved. Therefore, legal regulations and a sufficient refinancing are indispensable.

Exploring the practice of nutritional support during hospitalization across physicians, dietitians, and pharmacists based in Saudi Arabia

Background

Nutritional support has a pivotal role in preventing and treating malnutrition. Recognizing the gaps in nutritional support practice can aid the development of tailored nutritional protocols. Therefore, this study aimed to assess the current practices, attitudes, and perceptions related to nutritional support for hospitalized patients in one of the largest Middle Eastern countries.

Methods

A cross-sectional study was conducted among different healthcare professionals currently working in hospitals in Saudi Arabia and involved in nutritional support practice. Data were collected using convenient sample via a self-administered web-based questionnaire.

Results

A total of 114 participants were included in this study. The majority were dietitians (54%), followed by physicians (33%) and pharmacists (12%), and were from the western region (71.9%). Various attitudes in many practices were observed among the participants. Only 44.7% of the participants had a formal nutritional support team. The mean confidence level of all respondents was significantly higher for enteral nutrition practice (7.7 ± 2.3) than for parenteral nutrition practice (6.1 ± 2.5) (p < 0.01). The confidence level for enteral nutrition practice was significantly influenced by nutritional qualification (β = 0.202, p < 0.05), type of healthcare facility (β = 0.210, p < 0.05), profession (β = -0.308, p < 0.01), and years of experience (β = 0.220, p < 0.05).

Conclusion

This study comprehensively assessed various aspects of nutritional support practice in Saudi Arabia. Healthcare practice of nutritional support should be guided by evidence-based guidelines. Professional qualification and training in nutritional support are essential for promoting practice in hospitals.

Multidisciplinary nutritional management improves nutritional and hospitalized outcomes of patients with esophageal cancer undergoing chemoradiotherapy: A randomized control trial

BACKGROUND

This study aimed to investigate the effects of multidisciplinary whole-course nutrition management on the nutritional status and complications during the course of treatment in patients with esophageal cancer (EC) undergoing chemoradiotherapy.

METHODS

A total of 36 EC patients undergoing chemoradiotherapy were divided into a control group (n = 18) and an intervention group (n = 18). Participants in the control group were given routine nutritional support, whereas those in the intervention group were provided whole-course nutrition management from the nutrition support team. Nutrition-related indicators, that is, serum albumin level (ALB), hemoglobin (Hb), and C reactive protein were assessed before, during, and after treatment in both groups. The incidence of complications (e.g., lymphocytopenia, radiation esophagitis, and myelosuppression), clinical outcomes, length of hospital stay, and hospital costs were also recorded. Differences between the 2 groups were tested using the Mann-Whitney U and chi-square tests.

RESULTS

The ALB and Hb levels of the patients in the control group decreased significantly [ALB: -2.6 (-5.6, 0), P = .01; Hb: -12.0 (-27.0, -2.0), P = .04] and C reactive protein increased [8.9 (2.9, 14.9), P = .02] compared to those before treatment, while the indicators of participants in the intervention group did not change (P > .05). The incidence of grade ≥ II lymphocytopenia was higher in the control group than that in the intervention group (33.3% vs 61.1%, P = .03). Moreover, compared with the control group, the average length of hospital stay decreased by 12 days [47 (40, 50) vs 35 (23, 40), P = .001], and in-patient expenses decreased by 20,504 CNY in the intervention group (P = .004).

CONCLUSION

Multidisciplinary whole-course nutrition management can maintain the nutritional status of patients with EC undergoing chemoradiotherapy. This may lower the incidence of complications, shorten hospital stays, and reduce in-patient expenses.

Aufgabenverteilung verschiedener Professionen innerhalb klinischer Ernährungsteams in Deutschland

Abstrakt Hintergrund Die Implementierung neuer ernährungstherapeutisch ausgerichteter Studiengänge auf dem Markt und somit in Ernährungsteams, macht eine neue Betrachtung der Aufgabenverteilung innerhalb der Teams notwendig, weshalb in dieser Befragung die Aufgabenverteilung für klinische Ernährungsteams erfasst wurde.

Methoden Mittels standardisiertem halboffenen Fragebogen wurden Ernährungsteams in deutschen Kliniken zur Aufgabenverteilung der Teammitglieder befragt. Die Erstellung des Fragebogens wurde mit dem Portal maQ-Online durchgeführt und die Auswertung der Daten fand in Excel statt.

Ergebnisse 30 Ernährungsfachkräfte aus neun verschiedenen Bundesländern nahmen an der Befragung teil. Dabei kam heraus, dass eine Differenzierung der Aufgaben innerhalb eines Ernährungsteam unter den verschiedenen Professionen unzureichend vorgenommen wird. Nahezu alle Teammitglieder werden beispielsweise für ernährungstherapeutische Aufgaben eingesetzt. Lediglich die Aufgabe der Teamleitung fällt meist dem ärztlichen Personal (50 %) und Diätassistenten mit zusätzlich akademisch erworbener Qualifikation (44 %) zu.

Schlussfolgerung Eine fehlende Differenzierung der Aufgabengebiete von Teammitgliedern klinischer Ernährungsteams, entsprechend des jeweiligen Kompetenzprofils, kann zum Qualitätsverlust ernährungstherapeutischer Maßnahmen führen. Der wachsende Markt an ernährungstherapeutisch ausgerichteten Studiengängen macht auch für Arbeitgeber die Kompetenzprofile unüberschaubar und einen Einsatz unabhängig der jeweiligen Qualifikation resultierend.

RECALSEEN. Subgroup: Patient care in the clinical nutrition units of the Spanish National Health System

INTRODUCTION

Artificial nutrition (AI) is one of the most representative examples of coordinated therapeutic programs, and therefore requires adequate development and organization. The first clinical nutrition units (CNUs) emerged in the public hospitals of the Spanish National Health System (NHS) in the 80s and have gradually been incorporated into the departments of endocrinology and nutrition (DENs). The purpose of our article is to report on the results found in the RECALSEEN study as regards the professional and organizational aspects relating to CNUs and their structure and operation.

MATERIALS AND METHODS

Data were collected from the RECALSEEN study, a cross-sectional, descriptive study of the DENs in the Spanish NHS in 2016. The survey was compiled from March to September 2017. Qualitative variables were reported as frequency distributions (number of cases and percentages), and quantitative variables as the mean, median, and standard deviation (SD).

RESULTS

A total of 88 (70%) DENs, out of a total of 125 general acute hospitals of the NHS with 200 or more installed beds, completed the survey. CNUs were available in 83% of DENs (98% in hospitals with 500 or more beds). As a median, DENs had one nurse dedicated to nutrition (35% did not have this resource). Fifty-three percent of DENs with nutrition units had dieticians integrated into the unit (median: 1). DENs located in hospitals with 500 or more beds are more complex and have a wide portfolio of monographic unit services (morbid obesity, 78.3%; artificial home nutrition, 87%; chronic diseases, 65.2%) and specific techniques (impedanciometry, 78%). However, only 14% of the centers perform universal screening tests for malnutrition, and a secondary diagnosis of malnutrition only appears in 12.3 reports per 1000 hospital discharges.

DISCUSSION

After the 1997 and 2003 studies, the results of 2017 show a marked growth and consolidation of CNUs within the DENs in most hospitals. Today, the growth of this specialty is largely due to the care demand created by hospital clinical nutrition. CNUs still have an insufficient nursing staff and dietitians/nutritionists, and in the latter case, atypical contracts or grants funded by research projects or the pharmaceutical industry are common. Units for specific nutritional diseases and participation in multidisciplinary groups, quite heterogeneous, are concentrated in hospitals with 500 or more beds and represent an excellent opportunity for CNU development.

CONCLUSIONS

Many DENs of Spanish hospitals include CNUs where care is provided by endocrinologists, who devote most of their time to clinical nutrition in more than half of the hospitals. This is most common in large centers with a high workload in relation to staffing. There is considerable heterogeneity between hospitals in terms of both the number and type of activity of the CNUs.

Parenteral nutrition in emergency surgery: A multicentre cross-sectional study

BACKGROUND

Emergency general surgical patients are inherently at high risk of malnutrition. Early decision-making with implementation is fundamental to patient recovery. For many patients, parenteral nutrition (PN) is the only feeding option available. The present study assessed the timing and outcomes of this decision-making process.

METHODS

A sample of at least 10 consecutive adult patients admitted as a general surgical emergency to eight UK hospitals over 1 year who had received PN was identified. Patient demographics, basic descriptors and nutritional data were captured. Process measures regarding dates decisions were made or activities completed were extracted from records, as were outcome measures including PN complications. Six time frames examining the process of PN delivery were analysed. Associations between categorical and binary variables were investigated with a chi-squared test with significance determined as p < 0.05.

RESULTS

In total, 125 patients were included. Intestinal obstruction was the most common diagnosis with 59% of all patients deemed high risk on nutritional assessment at admission. Median time to decision for PN was 5 days following admission (n = 122, interquartile range = 7). Patients received PN for a mean of 11 days. Eighty-five percent of patients developed a complication, with a phosphate abnormality being the most commonly reported (54%). Only altered blood glucose levels appeared to correlate with a delay in starting PN (p < 0.01).

CONCLUSIONS

The present study shows there are delays in the decision to use PN in the acutely ill surgical patient. Once initiated, the pathway is relatively short. There are high rates of electrolyte abnormalities in this population.

Bridging Policy and Service Performance of Hospital-Based Nutrition Support by Healthcare Information Technology

Although the healthcare policy was implemented to incentivize the multidisciplinary services of hospital-based nutrition support team (NST) in South Korea, timely completion of the services has been challenging in the hospitals. We enhanced NST healthcare information technology (NST-HIT) to bridge the gap between policy implementation and seamless execution of the policy in the hospital system. A 48 month pre-test-post-test study was performed, including a 12 month pre-intervention period, a six month intervention period, and a 30 month post-intervention period. The enhanced NST-HIT provided sufficient patient data and streamlined communication processes among end-users. A Student's t-test showed that the timely completion rate of NST consultations, the reimbursement rate of NST consultations, average response times of NST physicians and nurses, and length of hospital stay significantly improved during the post-intervention period. A segmented regression analysis of interrupted time series showed that the average response times of NST physicians had sustained after the interventions. We believe that well-structured, multi-pronged initiatives with leadership support from the hospital improved service performance of hospital NST in response to national-level healthcare policy changes.

[Pillars for excellence in nutrition support units. Regulation]

Introduction

Nutritional assessment and treatment, necessary for the prevention and treatment of disease-related malnutrition, should be carried out by a multidisciplinary team where each member has well-defined skills and functions, and mechanisms are established to allow adequate coordination, both in the inpatient and outpatient settings. In Spain, the development and implementation of these teams or units dedicated to clinical nutrition has been very important: today they are present in most hospitals. This paper reviews the characteristics of clinical nutrition units, the functions of their team members, and the regulatory framework in our country.

RECALSEEN. Subgroup: Patient care in the clinical nutrition units of the Spanish National Health System

INTRODUCTION

Artificial nutrition (AI) is one of the most representative examples of coordinated therapeutic programs, and therefore requires adequate development and organization. The first clinical nutrition units (CNUs) emerged in the public hospitals of the Spanish National Health System (NHS) in the 80s and have gradually been incorporated into the departments of endocrinology and nutrition (DENs). The purpose of our article is to report on the results found in the RECALSEEN study as regards the professional and organizational aspects relating to CNUs and their structure and operation.

MATERIALS AND METHODS

Data were collected from the RECALSEEN study, a cross-sectional, descriptive study of the DENs in the Spanish NHS in 2016. The survey was compiled from March to September 2017. Qualitative variables were reported as frequency distributions (number of cases and percentages), and quantitative variables as the mean, median, and standard deviation (SD).

RESULTS

A total of 88 (70%) DENs, out of a total of 125 general acute hospitals of the NHS with 200 or more installed beds, completed the survey. CNUs were available in 83% of DENs (98% in hospitals with 500 or more beds). As a median, DENs had one nurse dedicated to nutrition (35% did not have this resource). Fifty-three percent of DENs with nutrition units had dieticians integrated into the unit (median: 1). DENs located in hospitals with 500 or more beds are more complex and have a wide portfolio of monographic unit services (morbid obesity, 78.3%; artificial home nutrition, 87%; chronic diseases, 65.2%) and specific techniques (impedanciometry, 78%). However, only 14% of the centers perform universal screening tests for malnutrition, and a secondary diagnosis of malnutrition only appears in 12.3 reports per 1000 hospital discharges.

DISCUSSION

After the 1997 and 2003 studies, the results of 2017 show a marked growth and consolidation of CNUs within the DENs in most hospitals. Today, the growth of this specialty is largely due to the care demand created by hospital clinical nutrition. CNUs still have an insufficient nursing staff and dietitians/nutritionists, and in the latter case, atypical contracts or grants funded by research projects or the pharmaceutical industry are common. Units for specific nutritional diseases and participation in multidisciplinary groups, quite heterogeneous, are concentrated in hospitals with 500 or more beds and represent an excellent opportunity for CNU development.

CONCLUSIONS

Many DENs of Spanish hospitals include CNUs where care is provided by endocrinologists, who devote most of their time to clinical nutrition in more than half of the hospitals. This is most common in large centers with a high workload in relation to staffing. There is considerable heterogeneity between hospitals in terms of both the number and type of activity of the CNUs.

Efficacy and Efficiency of Nutritional Support Teams

Malnutrition is frequent in patients during a hospital admission and may further worsen during the hospital stay without appropriate nutritional support. Malnutrition causes greater complication rates, morbidity, and mortality rates, which increases the length of hospital stay and prolongs rehabilitation. Early recognition of individual nutritional risk and timely initiation of a tailored nutritional therapy are crucial. Recent evidence from large-scale trials suggests that efficient nutritional management not only improves the nutritional status, but also prevents negative clinical outcomes and increases patients’ quality of life. Multifaceted clinical knowledge is required to ensure optimal nutritional support, according to a patient’s individual situation and to avoid potential complications. Furthermore, clear definition of responsibilities and structuring of patient, and work processes are indispensable. Interdisciplinary and multiprofessional nutritional support teams have been built up to ensure and improve the quality and safety of nutritional treatments. These teams continuously check and optimize the quality of procedures in the core areas of nutritional management by implementing nutritional screening processes using a validated tool, nutritional status assessment, an adequate nutritional care plan development, prompt and targeted nutritional treatment delivery, and provision of accurate monitoring to oversee all aspects of care, from catering to artificial nutrition. The foundation of any nutritional care plan is the identification of patients at risk. The aim of this narrative review is to provide an overview about composition, tasks, and challenges of nutritional support teams, and to discuss the current evidence regarding their efficiency and efficacy in terms of clinical outcome and cost effectiveness.

Association between indication for therapy by nutrition support team and nutritional status

The nutrition support team is a multidisciplinary team composed of medical doctors, registered nurses, pharmacists, and nutritionists, who evaluate the nutritional status of patients. The objective of this study was to determine the relationship between indications for nutrition support team therapy and the nutritional status of patients hospitalized in local major hospitals.Patients who were referred to a nutrition support team from January to December 2016 were enrolled. Patients were classified into 4 age groups, and the weight categories were determined using body mass index (BMI). Four of 6 indications were used for referral to a nutrition support team. The required calories were estimated, and the nutritional status was classified into malnutrition or eutrophia, based on the estimation.The proportion of elderly patients (37.0%) was higher than that of younger ones (28.3%). Patients with higher BMI had a relatively lower proportion of malnutrition. Patients receiving enteral nutrition had greater risk of malnutrition (adjusted odds ratio [aOR] = 3.77, 95% confidence interval [CI] = 2.71-5.24). Patients receiving parenteral nutrition (aOR = 0.38, 95% CI = 0.30-0.47) and treated in the intensive care unit (aOR = 0.70, 95% CI = 0.54-0.91) had lower risk of malnutrition. Patients with >3 indications for nutrition support team therapy had a lower risk of malnutrition than those with only 1 indication (aOR = 0.54, 95% CI = 0.37-0.77).Parenteral nutrition was the most common indication for referral to nutrition support team therapy; however, enteral nutrition had the poorest nutritional status. Patients receiving enteral nutrition who are referred to a nutrition support team need an intensive nutrition support strategy.

Development and validation of a questionnaire to evaluate the state of Iranian hospital nutrition support

Background

Recently, nutrition support was implemented as a part of clinical services in hospitals. The implementation of nutrition support needs to be assessed for its improvement.

Objective

This study aimed to develop and validate a questionnaire to assess the state of nutrition support in Iranian hospitals.

Methods

A mixed method approach was used in this study. This study was performed in training hospitals of Iran in 2016. In the development stage, pre-determined keywords were searched on international electronic databases. Additionally, semi-structural interviews were performed with 13 key informants based on purposive sampling. Themes were extracted from articles and interviews by thematic analysis. A primary questionnaire was generated based on extracted themes. In the validating stage, the content validity ratio (CVR) and content validity index (CVI) were used. The reliability of the questionnaire was also computed through a pilot study using Cronbach’s alpha test. SPSS version 16.0 was used for data analysis.

Results

Based on 16 items elicited from the content analysis, 110 questions were generated, out of which, 65 questions were selected. Then, 55 questions showing acceptable CVI and CVR were chosen for the pilot study. The Cronbach’s alpha coefficient of the questionnaire was found to be 0.80. This value remained stable for each item, even after an item was deleted.

Conclusion

For the first time, a validated questionnaire for the assessment of the state of nutrition support in hospitals was developed in a methodological approach process with high validity and reliability indexes which intended to be comprehensive based on the mixed method approach.

Stuck in tradition-A qualitative study on barriers for implementation of evidence-based nutritional care perceived by nursing staff

AIMS AND OBJECTIVES

To explore the barriers for nutritional care as perceived by nursing staff at an acute orthopaedic ward, aiming to implement evidence-based nutritional care.

BACKGROUND

Previous studies indicate that nurses recognise nutritional care as important, but interventions are often lacking. These studies show that a range of barriers influence the attempt to optimise nutritional care. Before the implementation of evidence-based nutritional care, we examined barriers for nutritional care among the nursing staff.

DESIGN

Qualitative study.

METHODS

Four focus groups with thirteen members of the nursing staff were interviewed between October 2013-June 2014. The interview guide was designed according to the Theoretical Domains Framework. The interviews were analysed using qualitative content analysis.

RESULTS

Three main categories emerged: lacking common practice, failing to initiate treatment and struggling with existing resources. The nursing staff was lacking both knowledge and common practice regarding nutritional care. They felt they protected patient autonomy by accepting patient's reluctance to eat or getting a feeding tube. The lack of nutritional focus from doctors decreased the nursing staffs focus leading to nonoptimal nutritional treatment. Competing priorities, physical setting and limited nutritional supplements were believed to hinder nutritional care.

CONCLUSION

The results suggest that nutritional care is in a transitional state from experience- to evidence-based practice. Barriers for nutritional care are grounded in lack of knowledge among nursing staff and insufficient collaboration between nursing staff and the doctors. There is a need for nutritional education for the nursing staff and better support from the organisation to help nursing staff provide evidence-based nutritional care.

RELEVANCE TO CLINICAL PRACTICE

This study contributes with valuable knowledge before the implementation of evidence-based nutritional care. The study provides an understanding of barriers for nutritional care and presents explanations to why nutritional care has failed to become an integrated part of the daily treatment and care.

An Interdisciplinary Nutrition Support Team Improves Clinical and Hospitalized Outcomes of Esophageal Cancer Patients with Concurrent Chemoradiotherapy

Background:

The prevalence of malnutrition is very high in patients with cancer. The purpose of this study was to investigate whether or not a nutrition support team (NST) could benefit esophageal cancer patients undergoing chemoradiotherapy (CRT).

Methods:

Between June 2012 and April 2014, 50 esophageal cancer patients undergoing concurrent CRT were randomly assigned into two groups: The NST group and the control group. The nutritional statuses of 25 patients in the NST group were managed by the NST. The other 25 patients in the control group underwent the supervision of radiotherapy practitioners. At the end of the CRT, nutritional status, the incidence of complications, and completion rate of radiotherapy were evaluated. Besides, the length of hospital stay (LOS) and the in-patient cost were also compared between these two groups.

Results:

At the completion of CRF, the nutritional status in the NST group were much better than those in the control group, as evidenced by prealbumin (ALB), transferrin, and ALB parameters (P = 0.001, 0.000, and 0.000, respectively). The complication incidences, including bone marrow suppression (20% vs. 48%, P = 0.037) and complications related infections (12% vs. 44%, P = 0.012), in the NST group were lower and significantly different from the control group. In addition, only one patient in the NST group did not complete the planned radiotherapy while 6 patients in the control group had interrupted or delayed radiotherapy (96% vs. 76%, P = 0.103). Furthermore, the average LOS was decreased by 4.5 days (P = 0.001) and in-patient cost was reduced to 1.26 ± 0.75 thousand US dollars person-times (P > 0.05) in the NST group.

Conclusions:

A NST could provide positive effects in esophageal cancer patients during concurrent CRT on maintaining their nutrition status and improving the compliance of CRF. Moreover, the NST could be helpful on reducing LOS and in-patient costs.

[Organization and the Role of Nutirition Support Team]

With the development of specialized nutrition therapy and the need for interdisciplinary approach, nutrition support teams (NSTs) were created to optimize effectiveness and safety of nutritional therapy. NSTs are interdisciplinary support teams with specialty training in nutrition that are typically comprised of physicians, dietitians, nurses, pharmacists, and others. Their role includes nutrition screening, assessment, determination of nutrition needs, recommendations for appropriate nutrition therapy, management of nutrition support therapy, and monitoring. Studies have demonstrated significant improvements in patient nutrition status and improved clinical outcomes as well as reductions in costs when patients were appropriately managed by NSTs. Organization and the role of NSTs are discussed in this review.

[Perioperative nutritional therapy]

BACKGROUND

There is no difference in medical and nutritional therapy between elderly and young surgical patients. However, based on the high prevalence of malnutrition or a risk for malnutrition and the associated risk for complications, elderly surgical patients should receive special attention.

AIM

This article addresses the options in perioperative nutritional therapy and gives an overview on current guidelines and study results.

MATERIALS AND METHODS

The article includes a literature review of current national and international guidelines in the field of surgery and geriatrics. Cochrane reviews, systematic reviews, meta-analyses, and significant single studies are also included.

RESULTS

Contrary to former approaches, national and international organizations recommend to keep the duration of pre- and postoperative fasting as short as possible. The benefits of nutritional therapy in stabilization and improvement of the nutritional status of surgical patients has already been shown in several patient groups like patients undergoing major abdominal surgeries. For other patients groups, like patients with sepsis, further studies are needed to evaluate the benefit of a perioperative nutritional intervention.

Malnutrition in hospital: the clinical and economic implications

BACKGROUND

Undernutrition and malnutrition are common in hospitalized patients. Their combined prevalence on admission is estimated at 25% and is rising.

METHODS

Selective literature review with special consideration of current guidelines and meta-analyses.

RESULTS

The nutritional state of every patient should be assessed on admission with simple, established parameters, and patients suffering from under- or malnutrition should be treated with a targeted nutritional intervention based on the established stepwise treatment algorithm. Under- and malnutrition are an independent risk and cost factor with a significant influence on mortality, morbidity, length of hospital stay, and quality of life. Their direct costs alone amount to some 9 billion Euros in Germany each year. Therapeutic trials and meta-analyses have clearly documented the therapeutic benefit and cost-effectiveness of oral nutritional supplements and tube feeds. Targeted nutritional intervention is an integral part of medical treatment and prevention.

CONCLUSION

Undernutrition and malnutrition are common in hospitalized patients and are both medically and economically harmful. If they are detected early by targeted assessment and then treated appropriately according to the established stepwise treatment algorithm, better clinical outcomes and lower costs will result.

Parenteral and enteral nutrition in the management of neurosurgical patients in the intensive care unit

The iatrogenic malnutrition of neurosurgical patients in intensive care units (ICU) is an underestimated problem. It may cause a decrease in plasma albumin and oncotic pressure, leading to an increase in the amount of water entering the brain and increased intracranial pressure (ICP). This study was conducted to test the hypothesis that combined high-protein parenteral and enteral nutrition is beneficial for neurosurgical patients in ICU. A total of 202 neurosurgical patients in ICU (mean age+/-standard deviation, 56 years+/-16 years; male:female=1.2:1) were studied. Two consecutive 1-year time periods were compared, during which two different nutritional regimens were followed. In the first time period (Y1) patients were given a low-protein/high-fat formulation parenterally, followed by a standard enteral regimen. In the second time period (Y2) a protein-rich, combined parenteral and enteral diet was prospectively administered. The Glasgow Outcome Score was measured at 3-6 months after discharge. The following clinical parameters were recorded during the first 2 weeks after admission: ICP; albumin; cholinesterase (CHE); daily hours of ICP > 20 mmHg and cerebral perfusion pressure<70 mmHg; and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. It was found that overall albumin (32.4 g/L+/-4.1g/L vs. 27.5 g/L+/-3.6g/L) and CHE was higher during Y2, although the total energy supply, glucose and fat intake was lower. Higher GOS scores were seen when patients had lower APACHE II scores and received the Y2 nutritional regimen. During Y2, the total hours of ICP > 20 mmHg were fewer. With the Y2 nutrition, maintenance of adequate cerebral perfusion required less catecholamine medication and colloidal fluid replacement. Therefore, adequate nutrition is an important parameter in the management of neurosurgical patients in ICU.