title: A method for implementation of nutritional therapy in hospitals.
abstract: OBJECTIVE
  Many barriers make implementation of nutritional therapy difficult in hospitals. In this study we investigated whether, a targeted plan made by the staff in different departments could improve nutritional treatment within selected quality goals based on the ESPEN screening guidelines.
  
  
  METHODS
  The project was carried out as a continuous quality improvement project. Four different specialities participated in the study with a nutrition team of both doctors, nurses, and a dietician, and included the following methods: (1) Pre-measurement: assessment of quality goals prior to study including the use of screening of nutritional risk (NRS-2002), whether a nutrition plan was made, and monitoring was documented in the records. (2) INTERVENTION: multidisciplinary meeting for the ward staff using a PC-based meeting system for detecting barriers in the department concerning nutrition, elaboration of an action plan and implementation of the plan. (3) Re-measurement: as in (1) based on information from records and patient interviews, and an evaluation based on focus group interview with the staff. Patients who gave informed consent to participate in the study (>14 years) were included consecutively. Mann-Whitney and Kruskal-Wallis test was used for ordinal data, and Pearson chi(2) test for nominative data. P values <0.05 were considered significant. The study was performed in accordance with the Research Ethics Committee.
  
  
  RESULTS
  In this study 141/122 patients were included before/after the implementation period with a mean weight loss within the last 3 months of 6.2 and 5.2 kg, respectively. Before the study we found that BMI was not measured. More than half of the patients had a weight loss within the last 3 months, and 40% had a weight loss during hospitalization, and this was not documented in the records. About 75% had a food intake less than normal within the last week, and nearly one-third were at a severe nutritional risk, and only 33% of these had a nutrition plan, and 18% a plan for monitoring. Barriers concerning nutrition included low priority, no focus, no routine or established procedures, and insufficient knowledge, lack of quality and choice of menus, and lack of support from general manager of the hospital. The staff introduced individually targeted procedures including assigning of responsibility, a nutrition record, electronic calculator of energy intake, upgrading of the dieticians and special diets, communication, and educational programs. A great consistency existed between barriers for targeted nutrition effort and ideas for improvement of the quality goals between the different departments. Quality assessment after study showed an overall significant improvement of the selected quality goals.
  
  
  CONCLUSIONS
  The introduction of a new method for implementation of nutritional therapy according to ESPEN screening guidelines seems to improve nutritional therapy in hospitals. The method included assessment of quality goals, identification of barriers and individual targeted plans for each department followed by an evaluation process. The model has to be refined further with relevant clinical endpoints.
authors.affiliation: Department of Gastroenterology, Aalborg Hospital, Aarhus University Hospital, 9000 Aalborg, Denmark. h.h.r@stofanet.dk
authors.forename: Henrik Højgaard
authors.initials: HH
authors.lastname: Rasmussen
authors.forename: Jens
authors.initials: J
authors.lastname: Kondrup
authors.forename: Michael
authors.initials: M
authors.lastname: Staun
authors.forename: Karin
authors.initials: K
authors.lastname: Ladefoged
authors.forename: Karen
authors.initials: K
authors.lastname: Lindorff
authors.forename: Lillian Mørch
authors.initials: LM
authors.lastname: Jørgensen
authors.forename: John
authors.initials: J
authors.lastname: Jakobsen
authors.forename: Hanne
authors.initials: H
authors.lastname: Kristensen
authors.forename: Anne
authors.initials: A
authors.lastname: Wengler
mesh_terms: D000368:Aged; D015992:Body Mass Index; D004046:Dietetics; D005260:Female; D017144:Focus Groups; D006284:Health Plan Implementation / Q000379:methods*; D006761:Hospitals; D006801:Humans; D008297:Male; D044342:Malnutrition / Q000175:diagnosis / Q000628:therapy; D009726:Nurses; D018529:Nutritional Support / Q000379:methods / Q000592:standards*; D010820:Physicians; D011786:Quality Control; D012307:Risk Factors; D012720:Severity of Illness Index; D015431:Weight Loss