From the European Health Management Association
Understanding patient nutrition: A case study of the organizational and managerial dimension to good clinical care
Health Services Management Research 2013, Vol. 26(4) 137–138 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0951484814527211 hsm.sagepub.com
Jeni Bremner
Introduction Feeding people when they are in hospital may seem to be one of the most basic things human beings can do for one another, and such a fundamental part of the process of care is that it might not merit much attention. However, in the context of healthcare, across most countries in Europe, hospitals time and again show themselves unequal to this seemingly simple task. Recent hospital scandals from a number of different European countries report that patients were left without water for extended periods, or given food that they were unable to reach or eat or which was not suitable for their needs. As a consequence, under-nutrition among hospital inpatients is serious and widespread problem which has significant effects for patients (in increased morbidity and mortality)1 and for organizations (in reduced quality of care, increased costs and resource use, and poor outcomes).2 This is a significant institutional failing and the prevalence of under-nutrition is estimated to be high. As methods of detection are not standardized, it is difficult to make an accurate assessment, but some studies show that up to 25% of hospital patients and up to 90% of nursing home residents are under-nourished or at risk of under-nourishment.3 Under-nourished patients have surgery complication rates two to three times higher than in patients who are well nourished. Under-nutrition has a negative effect on recovery and wound healing, and leaves patients increasingly exposed to hospital-borne infections. In addition to the effects on patient outcomes, this translates into significant costs for healthcare systems. A UK study estimated that disease-related malnutrition costs the UK up to 7.4 billion.4
Why patient nutrition is a management problem Despite the impact on patient outcomes and the high prevalence of malnourishment, there is little evidence of
management or policy interest in the topic. The European Health Management Association (EHMA) and the European Hospital and Healthcare Federation (HOPE) organized a workshop in November 2012 on good patient nutrition. With the support of a group of leading clinical, policy and management experts, the workshop sought to understand why it is so difficult for hospitals to organize clinical systems of care to ensure that this most basic human need is consistently and properly met. The identified key barriers which are relevant to both hospital and homecare settings, can be summarized as follows: . Lack of time, staff shortages and poor cross-disciplinary collaboration, leading to poor malnutrition detection and follow-up. . Low food quality, inappropriate mealtime structures and schedules (with little or no food available between scheduled meals) coupled with unnecessarily restrictive diets. . Very low levels of funding for patient food meaning the quality, presentation and edibility is compromised. . Lack of training in nutrition and health promotion for nurses and other caregivers. . Lack of knowledge about the dietary needs and preferences of individual patients. . Little patient autonomy and voice so opportunities for patients to have a say in their own nutrition management limited. In all health systems, staffing levels are under pressure and few care assistants or nurses have either the
European Health Management Association, UK Corresponding author: Jeni Bremner, European Health Management Association Ltd, 6th floor, Rue Belliard 15-17, 1040 Brussels, Belgium. Email: [email protected]
Downloaded from hsm.sagepub.com at Glasgow University Library on June 29, 2015
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Health Services Management Research 26(4)
skills to detect malnourishment or the specialist nutritional knowledge to address it. These problems are further complicated by the outsourcing of hospital catering services, which is common across Europe. This often means that the people delivering the food to patients have little or no connection to the ward team, so the food can be delivered and removed without a health professional being aware of how much any patient has eaten. This is a system which, at its worst, can allow vulnerable patients to become seriously malnourished while in hospital. Operational complications are compounded by a lack of any systematic reimbursement for both enteral and parenteral home nutritional support. In some countries there is no funding mechanism at all to support specialist nutritional support at home. Such a situation is the product of a lack of management and clinical leadership, leading to at best poorly defined responsibility or, more commonly, no defined responsibility for ensuring that patients are getting both the right kind of food and the time and support to eat it.
Actions to manage patient nutrition better It was clear from the workshop that solutions needed to be found at the clinical frontline, supported by clear management and financial frameworks. One idea was to develop a formal nutrition pathway, or alternatively a strong nutritional dimension to existing patient pathway systems and documentation. Ideally, care plans should be put in place that ensure that not only do patients get nutritional support whilst in hospital but that that support, including enteral and parenteral nutrition, continues after hospital discharge where needed. Such a pathway could start with systematic screening to identify patients’ needs followed by, if needed, specialist nutritional support. A growing number of countries are focusing on nutritional screening of patients but, as we learnt from the workshop, screening by itself is not sufficient. An example from the Netherlands showed that they were managing to screen more than 70% of patients admitted to hospital, but of those found to be malnourished only 40% received adequate nutritional support during their hospital stay. To make such pathways happen, a clear clinical, management and reimbursement framework is needed that enables collaboration and coordination of nutritional care support between hospitals, home care and nursing homes. In line with recommendations from the Council of Europe, reimbursement of nutritional
treatments and dietary counselling should be guaranteed and allocation of integrative financing processes such as diagnosis-related group (DRG) would enable better cost management. For health professionals, and physicians, nurses and caregivers in particular, there is an urgent need to develop quality standards for nutrition in patient care that can be shared across disciplines and incorporated into the curriculum for every health-related profession.
Conclusions Poor patient nutrition can be seen as a signal of wider failings in healthcare organizations – a symptom of underlying causes like resource constraints, poor clinical leadership, diminished professionalism, inadequate care planning and coordination, and overall failings in management. The causes of poor nutrition, and the remedies, are not clinically complex or reliant on leading-edge technological developments. They are simply about the basic effective clinical management, linked to effective organizational management and leadership. While some of the proposed solutions – like more and better nutritional screening – are certainly to be welcomed, the workshop concluded that unless there is a clear focus on accountability for the quality of care in healthcare organizations and healthcare systems, these apparently simple but endemic problems are likely to persist. Declaration of conflicting interests The authors declare that there is no conflict of interest.
Funding The workshop mentioned in this briefing was supported by an unrestricted educational grant from Baxter. Results of the workshop have also been published in a public report which is available online: http://www.ehma.org/files/PRINTABLE %20VERSION_EHMA_undernutrition_Final.pdf
References 1. Sorensen J, Kondrup J, Prokopowicz J, et al. EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr 2008; 27: 340–349. 2. Ljungqvist O and de Man F. Under-nutrition – a major health problem in Europe. Nutr Hosp 2009; 24: 368–370. 3. Elia M and Russell C. Combating malnutrition: recommendations for action. Report from the Group on Malnutrition, Led by BAPEN. Redditch: BAPEN, 2009. 4. Jones BM, Stratton RJ, Holden C, et al. Trends in artificial nutritional support in the UK 2000–2003. Annual report of the British Artificial Nutrition Survey (BANS). Redditch, Worcs: BAPEN, 2005.
Downloaded from hsm.sagepub.com at Glasgow University Library on June 29, 2015
Understanding patient nutrition: A case study of the organizational and managerial dimension to good clinical care
Health Services Management Research 2013, Vol. 26(4) 137–138 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0951484814527211 hsm.sagepub.com
Jeni Bremner
Introduction Feeding people when they are in hospital may seem to be one of the most basic things human beings can do for one another, and such a fundamental part of the process of care is that it might not merit much attention. However, in the context of healthcare, across most countries in Europe, hospitals time and again show themselves unequal to this seemingly simple task. Recent hospital scandals from a number of different European countries report that patients were left without water for extended periods, or given food that they were unable to reach or eat or which was not suitable for their needs. As a consequence, under-nutrition among hospital inpatients is serious and widespread problem which has significant effects for patients (in increased morbidity and mortality)1 and for organizations (in reduced quality of care, increased costs and resource use, and poor outcomes).2 This is a significant institutional failing and the prevalence of under-nutrition is estimated to be high. As methods of detection are not standardized, it is difficult to make an accurate assessment, but some studies show that up to 25% of hospital patients and up to 90% of nursing home residents are under-nourished or at risk of under-nourishment.3 Under-nourished patients have surgery complication rates two to three times higher than in patients who are well nourished. Under-nutrition has a negative effect on recovery and wound healing, and leaves patients increasingly exposed to hospital-borne infections. In addition to the effects on patient outcomes, this translates into significant costs for healthcare systems. A UK study estimated that disease-related malnutrition costs the UK up to 7.4 billion.4
Why patient nutrition is a management problem Despite the impact on patient outcomes and the high prevalence of malnourishment, there is little evidence of
management or policy interest in the topic. The European Health Management Association (EHMA) and the European Hospital and Healthcare Federation (HOPE) organized a workshop in November 2012 on good patient nutrition. With the support of a group of leading clinical, policy and management experts, the workshop sought to understand why it is so difficult for hospitals to organize clinical systems of care to ensure that this most basic human need is consistently and properly met. The identified key barriers which are relevant to both hospital and homecare settings, can be summarized as follows: . Lack of time, staff shortages and poor cross-disciplinary collaboration, leading to poor malnutrition detection and follow-up. . Low food quality, inappropriate mealtime structures and schedules (with little or no food available between scheduled meals) coupled with unnecessarily restrictive diets. . Very low levels of funding for patient food meaning the quality, presentation and edibility is compromised. . Lack of training in nutrition and health promotion for nurses and other caregivers. . Lack of knowledge about the dietary needs and preferences of individual patients. . Little patient autonomy and voice so opportunities for patients to have a say in their own nutrition management limited. In all health systems, staffing levels are under pressure and few care assistants or nurses have either the
European Health Management Association, UK Corresponding author: Jeni Bremner, European Health Management Association Ltd, 6th floor, Rue Belliard 15-17, 1040 Brussels, Belgium. Email: [email protected]
Downloaded from hsm.sagepub.com at Glasgow University Library on June 29, 2015
138
Health Services Management Research 26(4)
skills to detect malnourishment or the specialist nutritional knowledge to address it. These problems are further complicated by the outsourcing of hospital catering services, which is common across Europe. This often means that the people delivering the food to patients have little or no connection to the ward team, so the food can be delivered and removed without a health professional being aware of how much any patient has eaten. This is a system which, at its worst, can allow vulnerable patients to become seriously malnourished while in hospital. Operational complications are compounded by a lack of any systematic reimbursement for both enteral and parenteral home nutritional support. In some countries there is no funding mechanism at all to support specialist nutritional support at home. Such a situation is the product of a lack of management and clinical leadership, leading to at best poorly defined responsibility or, more commonly, no defined responsibility for ensuring that patients are getting both the right kind of food and the time and support to eat it.
Actions to manage patient nutrition better It was clear from the workshop that solutions needed to be found at the clinical frontline, supported by clear management and financial frameworks. One idea was to develop a formal nutrition pathway, or alternatively a strong nutritional dimension to existing patient pathway systems and documentation. Ideally, care plans should be put in place that ensure that not only do patients get nutritional support whilst in hospital but that that support, including enteral and parenteral nutrition, continues after hospital discharge where needed. Such a pathway could start with systematic screening to identify patients’ needs followed by, if needed, specialist nutritional support. A growing number of countries are focusing on nutritional screening of patients but, as we learnt from the workshop, screening by itself is not sufficient. An example from the Netherlands showed that they were managing to screen more than 70% of patients admitted to hospital, but of those found to be malnourished only 40% received adequate nutritional support during their hospital stay. To make such pathways happen, a clear clinical, management and reimbursement framework is needed that enables collaboration and coordination of nutritional care support between hospitals, home care and nursing homes. In line with recommendations from the Council of Europe, reimbursement of nutritional
treatments and dietary counselling should be guaranteed and allocation of integrative financing processes such as diagnosis-related group (DRG) would enable better cost management. For health professionals, and physicians, nurses and caregivers in particular, there is an urgent need to develop quality standards for nutrition in patient care that can be shared across disciplines and incorporated into the curriculum for every health-related profession.
Conclusions Poor patient nutrition can be seen as a signal of wider failings in healthcare organizations – a symptom of underlying causes like resource constraints, poor clinical leadership, diminished professionalism, inadequate care planning and coordination, and overall failings in management. The causes of poor nutrition, and the remedies, are not clinically complex or reliant on leading-edge technological developments. They are simply about the basic effective clinical management, linked to effective organizational management and leadership. While some of the proposed solutions – like more and better nutritional screening – are certainly to be welcomed, the workshop concluded that unless there is a clear focus on accountability for the quality of care in healthcare organizations and healthcare systems, these apparently simple but endemic problems are likely to persist. Declaration of conflicting interests The authors declare that there is no conflict of interest.
Funding The workshop mentioned in this briefing was supported by an unrestricted educational grant from Baxter. Results of the workshop have also been published in a public report which is available online: http://www.ehma.org/files/PRINTABLE %20VERSION_EHMA_undernutrition_Final.pdf
References 1. Sorensen J, Kondrup J, Prokopowicz J, et al. EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr 2008; 27: 340–349. 2. Ljungqvist O and de Man F. Under-nutrition – a major health problem in Europe. Nutr Hosp 2009; 24: 368–370. 3. Elia M and Russell C. Combating malnutrition: recommendations for action. Report from the Group on Malnutrition, Led by BAPEN. Redditch: BAPEN, 2009. 4. Jones BM, Stratton RJ, Holden C, et al. Trends in artificial nutritional support in the UK 2000–2003. Annual report of the British Artificial Nutrition Survey (BANS). Redditch, Worcs: BAPEN, 2005.
Downloaded from hsm.sagepub.com at Glasgow University Library on June 29, 2015
