The DUTCH approach
Implementation of nutritional routines
from a Dutch national perspective
Marian van Bokhorst – de van der Schueren
PhD, RD,
VU University Medical Center
Amsterdam, The Netherlands
Content
• Fighting malnutrition in the Netherlands
-
What is the Dutch approach?
-
What were the keys to success?
-
Is the Dutch approach exploitable in other
countries?
The Dutch approach in 10 steps
1. A multidisciplinary steering group with national key
persons (representatives professional associations)
2. Up-to-date prevalence data to create and sustain
awareness
3. Quick and easy screening tools with treatment plan
4. Screening and treatment as mandatory quality
indicators
5. Evidence based – validated tools and cost-effectiveness
research
The Dutch approach in 10 steps
6. Ministry of Health is key stakeholder and help from the
political arena
7. Implementation projects in all care settings
8. Toolkit in free accessible ‘format to be custom made’ &
best practices
9. Multidisciplinary project teams in all institutions
10.Training programs and workshops
2004
•
LPZ (annual measurement of care problems)
cross-sectional measurements of malnutrition across all
health-care setting in the Netherlands, n ~30.000 patients per
year
LPZ, annual measurements of care problems
started in 2004, ± 30.000 participants per year
Univ
Hosp
General
Hosp
Nursing
Home
Home
for
Elderly
Mentally
retarded
Home
Care
2004
N=25633
35,8%
37,5%
24,0%
16,0%
20,6%
27,4%
2005
N=28211
44,1%
38,6%
22,4%
16,5%
21,4%
24,8%
Meijers JMM, Schols JMGA, van Bokhorst-de van der Schueren MAE, Dassen T,
Janssen MAP, Halfens RJG. Malnutrition prevalence in the Netherlands. Results
of the annual Dutch National Prevalence Measurement of Care Problems. British
Journal of Nutrition 2008: 100: 5: 1-7
Meijers JMM, et al. Malnutrition prevalence in the Netherlands: results of the
annual Dutch prevalence measurement of care problems. British Journal of
Nutrition 2009; 101:417-324
1. Dutch Malnutrition Steering Group (DMSG)
• DMSG: A multidisciplinary steering group with
national key persons
– professors, doctors, dietitians, policy advisors and
researchers on key positions in relevant medical
and nutritional fields
Goal: fighting malnutrition together with
– the Dutch Annual Measurement of Care Problems
(LPZ)
– the Dutch Ministry of Health
– the Dutch Society for Clinical Nutrition and
Metabolism (NESPEN)
Points of departure to convince policy makers
• Increase awareness: best practices, examples of
malnutrition in hospitals
• Malnutrition is expensive
• Screening and treatment of malnutrition can save money
• There are European ‘white papers’
How did we convince the minister?
•
Show ‘scary’ photo’s
Best practices
How did we convince the minister?
• Show facts:
• Malnutrition is a huge problem, involving 30-40% of
hospital patients
• Costs of malnutrition are high: more complications,
increased length of hospital stay etc.
• Cost effectiveness study available: to shorten the mean
length of hospital stay by 1 day for all malnourished
patients, a mean investment of (max) € 76 in
nutritional screening and treatment is needed
Kruizenga et al.,
American Journal
of Clinical
Nutrition, Vol. 82,
No. 5, 1082-1089,
November 2005
A patient’s journey:
Symptoms

Screening
Recovery
Nutritional Status
Assessment
Intervention
Home
Hospital
Time 
Home
2. Up-to-date prevalence data to create and sustain
awareness (N= 30.000)
65+**
Steady decrease in malnutrition
prevalence rates, still 1:4 / 1:5
Dutch Annual Measurement of Care Problems 2010
3. Quick and easy screening tools with
treatment plan
SNAQ screening tools : QUICK AND EASY
SCREENING!!!!
• No training needed
• No equipment needed (scale nor stadiometer)
• No calculations
• Takes less than 5 minutes
• Screening results are connected to a treatment plan
Instruments recommended
by ESPEN
Specifically for
elderly
Quick and easy instruments, requiring
no calculations
4. Screening as a mandatory quality indicator
( (Health Care Inspectorate)
• Screening and treatment mandatory in all health care
settings
–
Malnutrition is defined as one of the main health care
issues
–
Screening and optimal treatment of malnutrition
becomes part of the main policy goals of the individual
hospitals, nursing homes and home care organizations.
–
Ongoing collection and feedback of malnutrition data
by the Dutch Health Care Inspectorate
Daily practice in our own hospital
• Introduction of the SNAQ screening instrument to the
electronic nurses’ admission questionnaire
• Pop-up screens with outcomes of SNAQ screening
• ICT application to management-database to be able to
present hospital data by the end of the year
SNAQ score
(obligatory !)
other
nutritional
questions
(voluntary)
Evaluation of the process =
learning by time….
At:
2 weeks
6 weeks
3 months
6 months
1 year
yearly
% screening binnen 24 uur
100%
90%
80%
70%
2 weken
60%
6 weken
50%
3 maanden
40%
6 maanden
30%
20%
10%
0%
Heelkunde oncologie
VHON
Neurologie VNEU
VUmc
Ortopedie VNCO
Percentage screening ondervoeding per afdeling (2010)
100%
New admission n=13392, screened 75%
90%
80%
70%
60%
50%
40%
30%
20%
10%
VVAT
VTRA
VONI
VNEU
VNCO
VMPU
VLON
VKNO
VIG2
VIG1
VHON
VHEM
VGYN
VEKV
VCCH
ICAR
0%
Quality indicator, screening
Benchmark between hospitals
Publication bij
inspection of health
care,
Newspapers
Internet ‘kiesbeter.nl’
Number of hospitals and patients
in measurement
Hospitals
Patients
• 2007:
• 2008:
• 2009
N = 77
N = 94
N = 96
N≈
N≈
N≈
• 2010
N = 97
N ≈ 1.050.000
310.000
790.000
880.000
Quality indicator 1: All patients should be
screened for malnutrition at admission
2010: 72% of patients screened at admission
Percentage of patients screened for malnutrition at hospital
admission (2007-2010)
100%
90%
80%
65 %
70%
60%
52 %
72 %
56 %
50%
40%
30%
20%
10%
0%
2007
2008
2009
% patients screened at hospital admission
2010
Quality indicator, part 2
• Introduced in 2008
• Measurement of optimal treatment
• What is optimal treatment?
• No outcome parameters available at short notice
• Measure adequate intake instead? How much
protein, energy, by what day? How to measure
intake in all patients?
Indicator of performance, part 2
• Which percentage of malnourished patients reaches
optimal protein intake at the fourth day of admission to
hospital?
• Protein: 1,2 – 1,5 gram/per kg/day
Daily practice in our hospitals; daily overview of
patients admitted with SNAQ scores 3 and up
Quality indicator 2: malnourished patients should
meet their protein requirements on the 4th
day of admission
2010: 44% of malnourished patients with
adequate protein intake on day 4
Percentage of malnourished patients with an adequate protein
intake on day 4 of admission
(2008-2010)
100%
90%
80%
70%
60%
39 %
44 %
41 %
50%
40%
30%
20%
10%
0%
2008
2009
2010
% of patients with adequate protein intake on day 4
Quality indicator 2: malnourished patients should meet their protein
requirements on the 4th day of admission
Mean of all 100 Dutch hospitals:
44% of patients reaches 1,2-1,5 g P/kg on the 4th day
>60% optimal intake
11 hospitals
40-60% optimal intake
15 hospitals
<40% optimal intake
46 hospitals
No data
27 hospitals
- van Bokhorst – de van der Schueren, Nutr Clin Practice 2012; 274-280
- Leistra, Clin Nutr 2011; 484-489
Were do we go from here?
• Outpatient screening for patients at
risk
Pre-operative (2007)
Geriatrics (2010)
Oncology (2012)
5. Evidence based – validated tools and
cost-effectiveness
research
1.0
0.8
0.6
0.4
0.0
Control patients
n=105
0.2
Probability intervention is cost-effective
Included patients, malnourished elderly
n=210
0
5000
10000
15000
20000
Ceiling ratio
to malnourished elderly
2000 4000 6000 8000
0
-2
from admission to hospital until 3 months after discharge
-1
-2000
nutritional intervention
North East: 60 %
South East: 39.9 %
South West: 0 %
North West: 0 %
0
1
-6000
Cost effectiveness of
Incremental costs pooled dataset
Intervention patients
n=105
ONS, Ca, Vit D
for 3 months after discharge
Incremental effects pooled datasets
2
Results
JAMDA 2011
•
•
•
•
Effects
Increase in body weight
Decrease in funcional
limitation
50% Reduction in falls
JAGS 2012
•
Costs during 3 months
•
No significant cost
differences between groups:
•
€ 445 (-2779 ; 3938)
•
Functional limitations
•
•
Calculated incremental costs
(ICER) to increase functional
limitations with one point
(on a six point scale):
•
€ 618
6. Ministry of Health is key stakeholder
(with help from the political arena)
• Early screening and optimal treatment of malnutrition is
defined as a goal in the government program
• Malnutrition is one of the four topics in the National Safety
Management System for Dutch hospitals
• Malnutrition screening score is accepted as indication for
reimbursement of medical nutrition by government and
health insurers
• Has funded the implementation projects and a cost
effectiveness analysis
7. Implementation projects in all care settings
• 2006-2009
• 2008-2011
• 2008-2012
Hospitals
Nursing homes
Home care and General Practice
• The hospital project received the “pearl of ZonMw” in
2009 (Netherlands Institute for health research and
development) for the most succesful implementation
project
Home Care
•2008-2012: implementation project
•Training of 125 home care organisations
•LESA
•Toolkit
Risk profile of malnourished, community dwelling elderly
1.Have you losst weight
68%
unintentionally?
2. Do you think your bodyweight is
51%
too low?
3. Have you eaten less than normal
last month?
4. Do you experience GI problems?
5. Do you think you eat unhealthy?
6.Do you need help with shopping
and cooking?
7. Do you suffer fatigue?
8. Do you suffer pain?
9. Do you feel sad or depressed?
51%
30%
13%
43%
57%
33%
19%
8. Toolkit with free accessible materials in
format to be custom made and best practices
• Guidelines and fact sheets
• Free format to be custom made
– Presentation for nurses, managers, doctors, ….
– Project plan
– Newsletter
– Patient
information
– …..
• Treatment plans
• Best practices
• Literature
Website: www.stuurgroepondervoeding.nl
with toolkits for different healthcare settings
2010 – MNI award for DUTCH approach!
No need to learn Dutch!
www.fightmalnutrition.eu in progress
bla 45
No need to learn Dutch!
www.fightmalnutrition.eu
bla 46
9. Multidisciplinary project teams with authority
• Hospitals and nursing homes:
Agreement with the board of Directors.
Multidisciplinary project team with the key persons
Ward-level team of a nurse, dietitian and physician
• Home care: Dietitian is project leader
10. Training programs and workshops
• Training of the project leaders (nurses, dietitians,
managers)
–
1. How to start with implementation of malnutrition
screening? (4 hours)
–
2. Education in malnutrition screening and treatment (1
day, 1,5-2 months after the start meeting)
–
3. Follow up and group session on patient and
implementation cases (4 hours, 3 months after
educational meeting, and 1 year after meeting)
• Workshops with these aspects in one day
• Multidisciplinary screening and treatment guideline
Future plans
• Further implementation of screening and treatment in
all health care settings
• Improvement of results
• Sharing knowledge and experience in Europe and
website in English
• Strengthening the chain
• A Ministry-funded “Malnutrition Knowledge Center”
• Improvement in the basic education of (clinical)
nutrition for doctors and nurses
Exploitable? What are our keys to success?
1. Quick and easy screening
2. Multidisciplinary steering group
3. Annual prevalence data
4. Help from the political arena and Ministry of Health
5. Message cost effectiveness treatment
6. The website! Documents in format to be custom made
7. Mandatory quality indicators
8. The evidence base
9. Multidisciplinary approach with the dietitian in “the
lead”
And…
Important conditions for success
1. Grants from Ministry of Health for projects in
Health Care setting
2. (Financial) help of the Dutch MNI (VNFKD):
1.
Annual donation
2.
Knowhow
3.
Support Public Affairs
Project leader(s): 2 days per week
Important conditions for success
3. Annual donation VNFKD for
1.
Coördinator : 1 or 2 days a week
2.
Extra hours project leaders 1 of 2 days a month
3.
Costs meetings, website, etc
4. ‘Golden’ team project leaders
1.
PL for research and development tools
2.
PL implementation & strategy
3.
Coördinator: large network and PR skills
Visit our site - in progress
•
www.fightmalnutrition.eu
•
info@fightmalnutrition.eu
Welcome to share your documents & toolkits!
Spread the news!
www.fightmalnutrition.eu
Welcome in Amsterdam !
M.vanbokhorst@vumc.nl
april ’15
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