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 onderwerp etc zie >Menu > Beeld > Koptekst en voettekst blad 56