Dr Alain Pradignac,
Therapeutic Nutrition Unit, CHU – Hautepierre, France
Email : [email protected]
Pr Jean Louis Schlienger,
President of the Feeding-Nutrition Liaison Committee,
CHU – Hautepierre, FranceEmail : [email protected]
Feeding, just like drinking, breathing or sleeping, is a fundamental need for all human beings. In the event of a pathology requiring hospitalisation, the patient’s diet is often regulated secondary to the priorities of care, the bulk of the healthcare professionals’ concerns being focused on taking care of the disease at the origin of the hospitalisation. The lack of investment by nurses in nutritional problems is due to their lack of availability, and sometimes to their lack of knowledge. As a result, 30 to 50% of hospitalised patients are undernourished in varying degrees.
An Administrative/ Management Factor?
A recent study highlighted that up to 60 % of patients are undernourished upon their departure from hospital, demonstrating the appearance or the worsening of undernourishment at the time of their hospital stay. Obviously, hospitals are structures supposed to improve the state of health of patients who remain there. This defect in nutritional care worsens the state of health of patients by the co-morbidities favoured by undernourishment (infections, healing defects, loss of autonomy…). Consequently, it threatens the often precarious budgetary balance of hospitals, insofar as these induced pathologies are at the origin of an excessive medicinal consumption and an increase in the length of stay. It is today well documented that the majority of complications and cost overruns induced by undernourishment could be prevented by adequate nutritional intervention, often not very expensive, which will be all the more effective as it will have been adapted to the needs of the undernourished patient.
Experience of CLAN
One of the major difficulties of being responsible for optimal nutrition stems from the non-detection of undernourishment. This is a real problem within our hospitals, identified as of 2002 at the University Hospitals of Strasbourg. The results of a survey had then led the Liaison Committee for Food Nutrition (Comité de Liaison Alimentation Nutrition - CLAN), operational since 2000, to set up a multi-professional think-tank with the aim of improving this situation. This working group recommended the deployment of a “nutrition consultant” within each functional unit of adults. These voluntary carers (care assistants, nurses), are responsible for practising daily nutritional vigilance at the patient’s bedside. They underwent a day’s training in nutritional diagnosis and in the methods of assuming nutritional responsibility according to the recommendations of the National Programme for Health Nutrition (PNNS) published in 2003. On that occasion, a guide for good practice in nutritional care was developed, as well as an information tool available via the intranet and accessible to all, in order to facilitate the calculation of anthropometric parameters and nutritional indexes recommended by the experts of the PNNS. Two evaluations (in June 2005 and in June 2006) of this innovative action highlighted a noticeable improvement in the evaluation of the nutritional state of hospitalised patients. However, progress remains to be achieved in the knowledge of the usual weight of patients and in the calculation of Body Mass Index, for example.
The consultants in nutrition were required to locate the identified nutritional symptoms of patients during their annual training. This training even made it possible to improve the standard of the nutritional headings of health records, often neglected in daily practice. These efforts, carried out in the nutritional evaluation and the assumption of responsibility, should facilitate and strengthen communication between the various actors of care with regard to the nutritional problems of their patients. The work of the dieticians is somewhat improved with a refocus on advice and dietary prescriptions and the care teams are more receptive to recommended nutritional orders. These actions should contribute to reducing the indifference shown by a number of hospital doctors with regard to nutritional problems. The common use of validated tools and of a precise and concise vocabulary make it possible to convey nutritional information in a minimum amount of time, thus encouraging doctors to react or to call upon a nutritional doctor who will advise or ensure nutritional care of the undernourished patient.
The coherence of this device should be completed by the installation of a transverse and mobile nutrition unit, the real keystone of this innovative action which is still in a phase of experimentation, with the aim of providing, upon request, all of the hospital’s functional units with a specialist and relevant opinion at the patient’s bedside, validating the prescriptions of the previous actors and ensuring therapeutic nutritional advice, in particular when an assisted nutritional prescription becomes necessary. The overall success of the experimentation with consultants in nutrition in hospitals results moreover from a strong involvement of the CLAN and of the installation under its control of a multi-professional steering committee in charge of setting up evaluation surveys and developing the results, as well as the preparation of future actions of internal communication arising from the data obtained.
An accurate nutritional diagnosis constitutes an essential prerequisite for any responsibility for nutritional care. The behavioural modifications necessary for a better nutritional evaluation undergo a regular evaluation of accomplished progress. Through the setting up of corrective actions, the aim is to reduce the variations noted compared to the recommendations made by the evaluation of professional practices. This procedure is already in place in our hospital, where improvement in the nutritional care of patients also constitutes one of the strengths of the new medical project. The aim is to improve the state of health of hospitalised patients while progressing the efficiency of care, of which nutrition is a part, which can only favourably influence good management of the hospital.