NRS-2002 components, nutritional score and severity of disease score, and their association with hospital length of stay and mortality.

BACKGROUND: Malnutrition is a substantial issue in hospitals, leading to prolonged length of hospital stay, increased perioperative morbidity and increased mortality. There are several validated screening tools for malnutrition, one of which is the Nutritional Risk Screening 2002 (NRS). It screens patients based on recent weight loss, reduction of recent food intake, body mass index (BMI), severity of disease and age. Higher NRS scores have been shown to be negatively associated with patients’ outcomes such as increased morbidity and mortality. OBJECTIVES: The aim of the study was to evaluate how the two NRS components Nutritional Score (NS) and Severity of Disease Score (SDS) are associated with patients’ length of hospital stay and mortality. METHODS: All patients admitted to the medical department of a large community hospital in Switzerland were screened for malnutrition using the nutrition screening NRS during the years 2014 to 2017. Data on patients’ NRS, primary diagnosis, number of secondary diagnoses, mortality, length of stay (LOS), discharge, sex and age were collected. The association between the NRS components and LOS/mortality was estimated using a linear mixed-effects regression model and a logistic regression model, respectively, with adjustment for confounders (age, sex, comorbidity, diagnosis group, mode of discharge and year of hospitalisation). RESULTS: The evaluation of the outcomes of 21,855 hospitalisations demonstrated that the NS was associated with an increment in the LOS of 5.5–12.3% per score point, depending on the diagnosis group. An increase in the SDS by one point was associated with an increase in the LOS of 2.2–11.3%. The odds for all-cause in-hospital mortality were increased by 44.1% (95% confidence interval [CI] 33.7–55.2%) per point in the NS, and by 73% (95% CI 57.5–90.1%) per point in the SDS. CONCLUSIONS: Increases in both components of the NRS are associated with longer LOS. The NS has a slightly stronger impact on LOS compared to the SDS and its effect is dependent on the patient’s diagnosis group. Increases in the SDS are linked to a higher mortality than increases in the NS.

Are Four Simple Questions Able to Predict Weight Loss in Outpatients With Metastatic Cancer? A Prospective Cohort Study Assessing the Simplified Nutritional Appetite Questionnaire.

BACKGROUND: Severe weight loss is directly responsible for up to one-fifth of all cancer deaths and has a major impact on quality of life. The simplified nutritional appetite questionnaire (SNAQ) was validated to predict weight loss within 6 mo in community-dwelling adults and nursing home residents. METHODS: We prospectively assessed the SNAQ in 133 palliative cancer outpatients. The SNAQ predictions were validated after 3 and 6 mo with the observed weight change. In addition, the treating oncologists gave their predictions concerning future weight loss according to their clinical judgment. RESULTS: A significant weight loss of 5% of the original body weight within 6 mo occurred in 20 (24%) of the 133 patients. The SNAQ predicted weight loss with a sensitivity of 0.38 and a specificity of 0.66 (P-value 0.81). The treating oncologists predicted weight loss with a sensitivity of 0.67 and a specificity of 0.7 (P-value 0.002). CONCLUSION: The SNAQ does not represent a useful tool to predict impending weight loss in palliative cancer outpatients. The predictions of the treating oncologists were more reliable than those from the SNAQ, but remain poor. Better methods to predict weight loss in this patient group are therefore required.

Early combined parenteral and enteral nutrition for pancreaticoduodenectomy - Retrospective cohort analysis.

BACKGROUND: Suggested guidelines for nutritional support after pancreaticoduodenectomy are still controversial. Recent evidence suggests that combining enteral nutrition (EN) with parenteral nutrition (PN) improves outcome. For ten years, patients have been treated with Early Combined Parenteral and Enteral Nutrition (ECPEN) after PD. The aim of this study was to report on rationale, safety, effectiveness and outcome associated with this method. METHODS: Consecutive PD performed between 2003 and 2012 were analyzed retrospectively. Early EN and PN was standardized and started immediately after surgery. EN was increased to 40 ml/h (1 kcal/ml) over 24 h, while PN was supplemented based on a daily energy target of 25 kcal/kg. Standard enteral and parenteral products were used. RESULTS: Sixty-nine patients were nutritionally supplemented according to ECPEN. The median coverage of kcal per patients related to the total caloric requirements during the entire hospitalization (nutrition balance) was 93.4% (range: 100%-69.3%). The nutritional balance in patients with needle catheter jejunostomy (NCJ) was significantly higher than in the group with nasojejunal tube (97.1% vs. 91.6%; p < 0.0001). Mortality rate was 5.8%, while major complications (Clavien-Dindo 3-5) occurred in 21.7% of patients. Neither the presence of preoperative malnutrition nor the application of preoperative immunonutrition was associated with postoperative clinical outcome. CONCLUSION: This is the first European study of ECPEN after PD. ECPEN is safe and, especially in combination with NCJ, provides comprehensive coverage of caloric requirements during the postoperative phase. Clinical controlled trials are needed to investigate potential benefits of complete energy supplementation during the early postoperative phase after PD.

[Oral nutritional supplements are effective, purposeful and economic]. / Der Einsatz von Trinknahrung ist wirksam, zweckmäßig und wirtschaftlich.

Numerous studies have shown that medically indicated sip feeding is an effective and cost-saving mean to combat malnutrition. Particularly, acutely ill, elderly, polymorbid internal and surgical patients benefit from sip feeding. In Switzerland, the reimbursement of medically indicated sip feeding at home by the compulsory health insurance is critically important for the good of the patient and cost optimization. This is particularly true in the longer-term considering the demographic trends in Switzerland with an important increase of the elderly population. Therefore, the reimbursement of sip feeding was requested from the Federal Department of Home Affairs - with success. Since July 2012, medically indicated sip feeding at home is covered by the compulsory health insurance provided that a medical diagnosis according to the strict and well-defined guidelines from the Society for Clinical Nutrition Switzerland (SSCN) is given.

[Malnutrition in the era of DRG]. / Mangelernährung im Zeitalter von DRG.

Malnutrition in hospital patients is of important medical and economic significance. The adverse consequences of malnutrition on quality of life and many more factors such as morbidity, mortality, tolerance of treatments and length of hospital stay are well documented in the medical literature. Nevertheless, the effects of malnutrition are still often underestimated and hence malnutrition is not recognised as a distinct diagnosis. Moreover, malnutrition is rarely documented in medical reports and often not adequately treated with adverse effects. The reason for this neglectfulness are diverse, e. g. inadequate training of doctors and nurses in clinical nutrition and lack of sensibilisation of the hospital staff for the problem of malnutrition. Therefore, a systematic screening for malnutrition is rarely undertaken in Swiss hospitals. The introduction of the Swiss-DRG system (DRG, diagnosis related groups) in January 2012 gave the chance to boost recording and to document malnutrition in a standardised way in the patient history, and to code precisely malnutrition as a distinct diagnosis. Moreover, this approach allowed to document the specific nutritional therapy. Here, we describe the way of documenting and coding malnutrition in the Swiss-DRG system and the medical and economic consequences of this procedure.

Home artificial nutrition in Switzerland: an epidemiological survey from 2005 to 2009.

BACKGROUND AND AIMS: Home artificial nutrition (HAN), including oral nutritional supplements (ONS) and enteral (HEN) and parenteral (HPN) nutrition, is an established, important treatment for malnourished patients. The aim of this study was to analyze the epidemiological data of patients on HAN in Switzerland. METHODS: This retrospective study recorded all new cases of HAN in Switzerland from January 2005 to December 2009. RESULTS: A total of 12,917 cases were recorded: 6,731 (52%) males and 6,186 (48%) females, with a mean age of 65.0 ± 17.6 years. The number of patients on ONS was 7,827 (57.4%), on HEN 3,966 (39.4%) and on HPN 433 (3.2%). The most common underlying disease category was neoplasms (6,519, 50.7%). The number of patients on ONS increased from 57.0% (n = 1,252) to 60.8% (n = 2,039), and on HPN from 2.1% (n = 45) to 4.0% (n = 134) between 2005 and 2009. CONCLUSIONS: This first analysis of the large-scale Swiss registry of HAN shows that approximately half of the patients received ONS, whereas HPN was rarely delivered. The frequency of ONS and HPN increased from the year 2005 to 2009. In accordance with previous European studies, malignant tumors were by far the most frequent indication for HAN.

Prevalence of undernutrition on admission to Swiss hospitals.

BACKGROUND & AIMS: According to the literature, undernutrition is prevalent in 20-60% of patients on hospital admission. The differences in the rate of undernutrition arise from different diagnostic tools used in the studies. We aimed to investigate the prevalence of undernutrition in Swiss hospitals using a standardized screening tool. METHODS: All patients admitted to the departments of internal medicine of 7 Swiss hospitals were screened at entry for nutritional status using the Nutrition Risk Screening 2002 score. Patients with a score of 3 or more, which denotes severe undernutrition or patient "at risk" for undernutrition were analyzed. RESULTS: Between May 2003 and April 2006 32,837 patients were included in the study. 5978 (18.2%) had a score of 3 or more and were classified as severely undernourished or at high risk for undernutrition (age<45 y: 8%; 45-64 y: 11%; 65-84 y: 22%; >85 y: 28%). A nutritional intervention was made in 4175 patients (12.7%). CONCLUSIONS: Nearly one in five patients was severely undernourished or "at risk" for undernutrition. Undernutrition was directly related to age. Patients with a clear indication for nutrition therapy, as suggested by the formal screening procedure, obtained nutritional intervention in 70%.

Nutritional counseling improves quality of life and nutrient intake in hospitalized undernourished patients.

OBJECTIVE: Up to 60% of hospitalized patients are undernourished. We studied the impact of nutritional therapy on quality of life and food intake. METHODS: Undernourished patients were randomized into two groups. The nutritional therapy group (NT group) received individual nutritional counseling and interventions, including oral nutritional supplements if appropriate, by a dietitian. The oral nutritional supplement group (ONS group) received oral nutritional supplements in addition to hospital meals without further instruction or counseling. Study duration was 10 to 15 d. At baseline and before discharge (time point 1) we measured energy and protein intakes and quality of life. Quality of life was measured again 2 mo after discharge (time point 2). RESULTS: Energy and protein intakes increased between baseline and time point 1 in both groups (P=0.001). The NT group (n=18) met the energy requirements at time point 1 by 107% and of protein by 94%, the ONS group (n=18) by 90% and 88%, respectively. Hospital meals alone did not cover the requirements. From baseline to time point 1, quality of life increased in both groups. Quality of life increased further in the NT group from time point 1 to time point 2 (P=0.016), but not in the ONS group. CONCLUSION: Both interventions caused a significant increase in energy and protein intakes and quality of life. In the NT group every patient received an efficacious individualized intervention. In contrast, the 7 of 18 patients in the ONS group who did not consume ONS had no intervention at all. Therefore, undernourished patients should be counseled individually by a dietitian.

[Homeparenteral nutrition or nutrition for life]. / Heimparenterale Ernährung oder Ernährung um zu leben.

We describe the management of HPN on the basis of a case report. Since TPN is associated with severe complications such as catheter-related sepsis, thrombosis of venous access, metabolic disorders and liver disease, education and peer support of HPN-patients is an important issue and is associated with reduced depression, reduced septic complications and improved QoL. Although SBTx has advanced in the last years, SBTx is only an option when TPN failed, as survival rates after SBTx are still low compared to treatment with TPN.

Serumalbumin--a qualified parameter to determine the nutritional status?

OBJECTIVES: The primary objective of the study was to evaluate the relationship between serum albumin concentration and nutritional status. As a secondary objective, correlations between nutritional status, the length of hospital stay, the number of drugs taken and patients' age were assessed. METHODS: In a mono-centre non-interventional trial hospitalised patients were screened for undernutrition. Length of hospital stay, number of drug prescriptions, number of diagnoses, age and serum albumin concentration were recorded. Undernutrition was defined using the criteria of Edington et al. RESULTS: Of 232 screened patients, 102 entered the study, 52 men and 50 women with a mean age of 62.5 (SD+/-19.5) years. Twenty-nine (28.4%) patients were classified as undernourished and 73 as well-nourished. Nineteen of 25 (76%) undernourished patients showed a hypoalbuminaemia (30.5+/-6.5 g/l) compared with 74.5% (44/59) well-nourished patients (32.0+/-5.8 g/l, p 0.093). On average the length of hospital stay in undernourished patients was three days longer, which was statistically significant (p=0.009). CONCLUSIONS: Prevalence of undernutrition in the present pilot study was high and compared well with results from former studies. Serum albumin concentration could not discriminate between well and undernourished patients. Undernourished patients indicated longer length of hospital stay.