Use of outcome metrics to measure quality in education and training
Weight as an outcome measure in hospital patients and role of catering services
2
OUTCOMES RESEARCH Nurrition Vol. 13, No. 6, 1997 GUEST EDITORS : ANNE COBLE VOSS, PHD, RD Manager, Outcomes Research Ross Products Division Columbus, Ohio, USA SIMON ALLISON, MD, FRCP Consultant Physician Department of Medicine Queens Medical Centre Nottingham, United Kingdom Weight as an Outcome Measure in Hospital Patients and Role of Catering Services SIMON ALLISON, MD, FRCP From the Department of Medicine, Queens Medical Centre, Nottingham, United Kingdom Although the importance of func- tional and clinical criteria of outcome has rightly been emphasized in the recent lit- erature, simple surrogate measurements such as change in weight remain im- portant too, whether or not they are ac- companied by measures of functional change or clinical outcome. Weight change can also be a useful surrogate outcome measure when studying trends in large groups of patients. We are used to the notion that weight for height is one of the main screening criteria for identi- fying malnourished patients on admis- sion, but the subsequent change in weight during hospital stay may also yield much important information. For example, the average change in weight of the patient population during hospital stay may reflect the efficacy of the nutri- tional care strategy of the hospital as a whole. Such a strategy requires an ade- quate screening protocol to identify pa- tients at risk; good catering practices; the availability of palatable high-energy, high-protein diets from the kitchen; and, for a minority of patients, efficient ser- vices to provide oral supplements or arti- ficial nutrition. In McWhirter and Pen- nington’s ’study of 500 patients admitted to a teaching hospital, 40% had some degree of malnutrition on admission and >80% of these lost more weight while in hospital, thus confirming other work Nutrition 13:583-584, 1997 OElsevier Science Inc. 1997 Printed in the USA. All rights reserved. that has shown deterioration of nutri- tional status during prolonged hospital stay. One of the major reasons for this outcome was demonstrated in a study from our own group, presented at the British Association of Parenteral and En- teral Nutrition (BAPEN) Congress in December 1996.2 We found that, in our hospital, over 40% of food sent from the kitchen to the wards was not consumed and was therefore wasted. Percentage waste was measured by weighing all food leaving the ward during a month, and its value was assessed by a dietitian. The average patient intake was calcu- lated from the food supplied to the whole ward, minus the amount wasted, divided by the number of patients on that ward. This showed that the patients were con- suming only 75% of recommended re- quirements. The reasons for this are mul- tiple: the quality and presentation of the food, its serving and accessibility, lack of help for disabled patients, and interfer- ence at mealtimes by ward rounds, pro- cedures, etc. This study will form a basis for improving catering practices, and for later auditing the effects of such im- provements, thereby closing the audit loop. That weight loss during hospital stay is not inevitable was demonstrated by Kondrup et al.,3 also in a presentation at the recent BAPEN Congress. In a study ELSEVIER carried out at the Rigshospitalet in Co- penhagen over a 4-y period, he showed that weight loss of >5% could be limited to <lo% of the patients judged to be nutritionally at risk. This outcome was achieved through a good screening and referral system, as well as good catering practices. Over 5 y, 5500 patients were referred to the nutrition department, over 1000 of whom were managed mainly (60% of dietary intake) by the delivery of palatable high-energy, high-protein food from the hospital kitchen. In each case, energy requirements were calcu- lated by the factorial method,“,5 includ- ing a surplus for weight gain’ in under- weight patients. A stress factor was ap- plied only in febrile or multiple-trauma patients. Dietary intake and body weight were recorded 3-4 times weekly. Kondrup and his colleagues also used the change in weight during hospital stay to calculate retrospectively the energy con- sumption by difference, and were there- fore able to gauge the accuracy of their original estimates of energy require- ments, as well as the adequacy of food provision. Even allowing an empirical stress factor of 1.1 X calculated resting metabolic rate, and allowing for the cost of weight gain in underweight patients, the provision of a total energy intake of 1.3 - 1.4 x estimated resting expenditure was sufficient for weight gain or mainte- 0899-9007/97/$17.00 PIT s0899-9007(97)00147-0
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Transcript of Weight as an outcome measure in hospital patients and role of catering services
OUTCOMES RESEARCH Nurrition Vol. 13, No. 6, 1997
GUEST EDITORS :
ANNE COBLE VOSS, PHD, RD Manager, Outcomes Research
Ross Products Division Columbus, Ohio, USA
SIMON ALLISON, MD, FRCP Consultant Physician
Department of Medicine Queens Medical Centre
Nottingham, United Kingdom
Weight as an Outcome Measure in Hospital Patients and Role of Catering Services
SIMON ALLISON, MD, FRCP
From the Department of Medicine, Queens Medical Centre, Nottingham, United Kingdom
Although the importance of func- tional and clinical criteria of outcome has rightly been emphasized in the recent lit- erature, simple surrogate measurements such as change in weight remain im- portant too, whether or not they are ac- companied by measures of functional change or clinical outcome. Weight change can also be a useful surrogate outcome measure when studying trends in large groups of patients. We are used to the notion that weight for height is one of the main screening criteria for identi- fying malnourished patients on admis- sion, but the subsequent change in weight during hospital stay may also yield much important information. For example, the average change in weight of the patient population during hospital stay may reflect the efficacy of the nutri- tional care strategy of the hospital as a whole. Such a strategy requires an ade- quate screening protocol to identify pa- tients at risk; good catering practices; the availability of palatable high-energy, high-protein diets from the kitchen; and, for a minority of patients, efficient ser- vices to provide oral supplements or arti- ficial nutrition. In McWhirter and Pen- nington’s ’ study of 500 patients admitted to a teaching hospital, 40% had some degree of malnutrition on admission and >80% of these lost more weight while in hospital, thus confirming other work
Nutrition 13:583-584, 1997 OElsevier Science Inc. 1997 Printed in the USA. All rights reserved.
that has shown deterioration of nutri- tional status during prolonged hospital stay. One of the major reasons for this outcome was demonstrated in a study from our own group, presented at the British Association of Parenteral and En- teral Nutrition (BAPEN) Congress in December 1996.2 We found that, in our hospital, over 40% of food sent from the kitchen to the wards was not consumed and was therefore wasted. Percentage waste was measured by weighing all food leaving the ward during a month, and its value was assessed by a dietitian. The average patient intake was calcu- lated from the food supplied to the whole ward, minus the amount wasted, divided by the number of patients on that ward. This showed that the patients were con- suming only 75% of recommended re- quirements. The reasons for this are mul- tiple: the quality and presentation of the food, its serving and accessibility, lack of help for disabled patients, and interfer- ence at mealtimes by ward rounds, pro- cedures, etc. This study will form a basis for improving catering practices, and for later auditing the effects of such im- provements, thereby closing the audit loop.
That weight loss during hospital stay is not inevitable was demonstrated by Kondrup et al.,3 also in a presentation at the recent BAPEN Congress. In a study
ELSEVIER
carried out at the Rigshospitalet in Co- penhagen over a 4-y period, he showed that weight loss of >5% could be limited to <lo% of the patients judged to be nutritionally at risk. This outcome was achieved through a good screening and referral system, as well as good catering practices. Over 5 y, 5500 patients were referred to the nutrition department, over 1000 of whom were managed mainly (60% of dietary intake) by the delivery of palatable high-energy, high-protein food from the hospital kitchen. In each case, energy requirements were calcu- lated by the factorial method,“,5 includ- ing a surplus for weight gain’ in under- weight patients. A stress factor was ap- plied only in febrile or multiple-trauma patients. Dietary intake and body weight were recorded 3-4 times weekly. Kondrup and his colleagues also used the change in weight during hospital stay to calculate retrospectively the energy con- sumption by difference, and were there- fore able to gauge the accuracy of their original estimates of energy require- ments, as well as the adequacy of food provision. Even allowing an empirical stress factor of 1.1 X calculated resting metabolic rate, and allowing for the cost of weight gain in underweight patients, the provision of a total energy intake of 1.3 - 1.4 x estimated resting expenditure was sufficient for weight gain or mainte-
0899-9007/97/$17.00 PIT s0899-9007(97)00147-0
584 WEIGHT AS AN OUTCOME MEASURE IN HOSPITAL PATIENTS
nance in 90% of the patients referred. This study provides a blueprint for an effective hospital-wide strategy for the nutritional care of inpatients and illus- trates the use of weight change as a mea- sure of outcome. The results are probably as good as possible, since there will al- ways be a proportion of patients who lose weight, either through diuretic treatment of edematous states, through treatment failure or noncompliance, or through the inevitable and progressive cachexia asso- ciated with terminal malignant or cardio- respiratory disease. The strong associa- tion of undernutrition with longer hospi- tal stay, and the shortening of hospital stay by earlier and more effective nutri- tional intervention reported by Tucker,’
emphasize that the studies previously de- scribed are of interest not just to clini- cians, but should be to hospital managers as well. Catering has too long been con- sidered part of the hotel budget and sepa- rated from therapeutic services. The idea that it may influence outcome is not new, but should be of continuing concern to all those involved in hospital service.
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REFERENCES
McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ 1994;308:945 Stephen AD, Beigg CL, Elliot ET, Mac- donald IA, Allison SP. Food provision, wastage and intake in elderly hospital pa- tients. Proc Nutr Sot 1997:in press
3. Kondrup J, Hansen BS, Ipsen B, Ronneby H. Requirements of the general hospital population: experience with 542 consecu- tive patients. Proc Nutr Sot 1997:in press
4. World Health Organization. Energy and protein requirements. Report of a Joint FAO/WHO/UNV Expert Consultation. Geneva: World Health Organization, 1985:90
5. Nielsen K, Kondrup J, Martinsen L, et al. Nutritional assessment and adequacy of di- etary intake in hospitalized patients with alcoholic liver cirrhosis. Br J Nutr 1993;69:665
6. Forbes GB. Do obese individuals gain weight more easily than non obese individ- uals? Am J Clin Nutr 1990;52:224
7. Tucker H. Cost containment through nutri- tion intervention. Clintec 1996. Nutr Rev 1996;54:111
