Nutritional screening and prevalence of hospital malnutrition risk. University Hospital of the UANL, Monterrey

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FFP: fresh frozen plasma." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Felipe Mercado-del Angel, Rogelio Cazares-Tamez, Carlos G. Díaz-Olachea, Fernando Pérez-Chavez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Felipe" "apellidos" => "Mercado-del Angel" ] 1 => array:2 [ "nombre" => "Rogelio" "apellidos" => "Cazares-Tamez" ] 2 => array:2 [ "nombre" => "Carlos G." "apellidos" => "Díaz-Olachea" ] 3 => array:2 [ "nombre" => "Fernando" "apellidos" => "Pérez-Chavez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X1665579614676005?idApp=UINPBA00004N" "url" => "/16655796/0000001600000065/v0_201607061452/X1665579614676005/v0_201607061452/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "titulo" => "Nutritional screening and prevalence of hospital malnutrition risk. University Hospital of the UANL, Monterrey" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "165" "paginaFinal" => "170" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Patricia R. Áncer-Rodríguez, Carmen Porrata-Mauri, Manuel Hernández-Triana, Karla Salinas-Zamora, Verónica Bernal-García, Samantha Trejo-Guzmán, Blanca González-García, Mayra Herrera-López, Anel de la Torre-Salinas, Clemente Rojas-Ramírez, Dionicio A. Galarza-Delgado" "autores" => array:11 [ 0 => array:3 [ "nombre" => "Patricia R." "apellidos" => "Áncer-Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Carmen" "apellidos" => "Porrata-Mauri" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 2 => array:3 [ "nombre" => "Manuel" "apellidos" => "Hernández-Triana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "Karla" "apellidos" => "Salinas-Zamora" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 4 => array:3 [ "nombre" => "Verónica" "apellidos" => "Bernal-García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 5 => array:3 [ "nombre" => "Samantha" "apellidos" => "Trejo-Guzmán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 6 => array:3 [ "nombre" => "Blanca" "apellidos" => "González-García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 7 => array:3 [ "nombre" => "Mayra" "apellidos" => "Herrera-López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 8 => array:3 [ "nombre" => "Anel" "apellidos" => "de la Torre-Salinas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 9 => array:3 [ "nombre" => "Clemente" "apellidos" => "Rojas-Ramírez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 10 => array:3 [ "nombre" => "Dionicio A." "apellidos" => "Galarza-Delgado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Outpatient Clinic No. 2, Nutrition Clinic, “Dr. José Eleuterio González” University Hospital, School of Medicine, UANL, Monterrey, Mexico" "etiqueta" => "a" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Departament of Internal Medicine, “Dr. José Eleuterio González” University Hospital, School of Medicine, UANL, Monterrey, Mexico " "etiqueta" => "b" "identificador" => "affb" ] ] ] ] "textoCompleto" => "Introduction Malnutrition is a major public health problem which affects the entire world, not only less favored economies, but developed countries as well.1 Patients admitted to a hospital are a group especially vulnerable to malnutrition, with a high prevalence, around 20-50%, depending on the diagnostic criteria.2-11 The Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE for its Spanish acronym) hosted the first Latin American Study of Hospital Malnutrition in the biennial 1999-2001, which found a malnutrition frequency of 51.2%.12 In Mexico there are few studies on the subject; however, the existing conducted studies suggest a severe situation to take into account by the health system.13-15 Hospital malnutrition is defined as malnutrition which affects hospitalized patients as a result of a complex interaction between illnesses, food and nutrition.1,16 It is a distinct entity whose term was coined in the 70s, as a result of the studies by Bistrian, where he made evident the high prevalence of this condition in hospitalized patients.17 In 1974 Butterworth used the term “iatrogenic malnutrition” to describe body composition disorders of hospital patients caused by the actions or omissions of the medical team, and documented some practices which contributed to the patients’ nutritional deterioration, like omission of responsibilities in nutritional care, prolonged use of intravenous nutrition, deficiency in the monitoring or register of dietary intake and inexistence of proper nutritional support.18,19 The etiology of hospital malnutrition is multifactorial and includes causes related to the disease itself: intake reduction, response to aggression, mechanical obstruction of the gastrointestinal tract, pharmaceutics, advanced age, an increase in requirements, an increase of its losses, and inflammatory conditions; causes related to hospitalization: a change in habits, reactive emotional situations, complementary examinations, surgical treatments, pharmaceutics, chemotherapy-radiotherapy, hospitality; causes related to the medical team: misuse of therapeutic fasts, lack of nutritional assessment, lack of intake control, dilution of responsibilities; causes related to health authorities: lack of nutritionists, absence of nutrition units, lack of dietician-nutritionist acknowledgement, and lack of a coordinated and multidisciplinary work.1,17,20 Hospital malnutrition usually enters a vicious cycle, despite the fact that the patient has increased requirements, they tend to not be met, causing depletion and exhaustion of energy and nutrimental reserves and thus increasing his/ her consumption needs. There are reports confirming that hospitalized patients, in general, do not consume the necessary amount of energy and nutriments to cover their requirements, which worsens their nutritional condition.21-23 Once established, malnutrition sensibly affects the organisms’ response capabilities to medical-surgical treatment, impedes proper healing and increases the risk of suture dehiscence and sore outbreaks, placing the patient in a situation of immunosuppression which makes him/her susceptible to opportunistic infections. If not treated in a timely manner, malnutrition may lead to the patient’s death.9,24-28 For over 25 years it has been known that malnutrition is one of the main and more frequent causes of mortality in hospitalized individuals. Early work dates back to 1936, when Studdley reported that weight losses over 20% of the total weight increase mortality rate in hospitalized patients by 10 times.29 According to Howard, “each and every patient who is admitted to a hospital has the right to expect his/her nutritional requirements to be provided.”30 but in reality how many patients receive proper nutrition in clinics and hospitals? Probably, the answer to that question is shown in different statistics in Europe, US, or in the IBRANUTI study, where numbers show that close to 50% of hospitalized patients have some type of malnutrition.4 Nutritional screening and a proper nutrition are part of the rights of every patient who is admitted to a hospital, thus making it essential for these requirements to be met. Without a doubt, analysis of the ethical aspects in clinical practice contributes to the improvement in healthcare quality.31-33 In order to reduce hospital malnutrition, the development of formal and coordinated intervention is imposed, with specific objectives which include the implementation of recognized methods of nutritional screening which allows us to program a timely and proper nutritional plan for at-risk patients.34-36 In 2003 the Resolution on Food and Nutritional Care in Hospitals was published by the Council of Europe’s Committee of Ministers, who took on the political commitment of the 18 signing countries. This resolution includes elements of obliged consideration on nutritional assessment, the identification and prevention of causes of malnutrition, nutritional counseling, conventional diets and artificial diets. Moreover, this resolution highlights the proper distribution of responsibilities among healthcare authorities, hospital and clinical management. Even though the resolution lacks an obligatory compliance rule, it functions as a starting point of reflection in many hospitals, thus motivating them to raise the need for implementing nutritional screening and acting protocol methods.37 Nevertheless, it is still far from its generalization, as shown in a survey conducted in 75 Spanish hospitals (half of them without a clinical nutrition unit in the organization chart), where only 15% had systemic nutritional screening on admission.38 In many countries, hospitals must provide a nutritional screening in order to go through a quality certification process, as with hospitals in the US (Joint Commission’s accreditation requirement JCAHO).39 In Mexico it is a requirement as well (General Health Council standards AOP.1.6 and AOP.1.7, Establishment Certification Commission for Medical Attention, National Certification System of Medical Attention Establishments, Certification Standards for Hospitals, Version 2011, active since January 2011). The “Dr. José E. González” University Hospital of the UANL is the only one with third-level care in the northwest of Mexico for a population without medical or social security coverage, with a mid-low or low socioeconomic level. Today there are 500 beds, 22 departments and 20 clinical services, of which 17 and 18 respectively have a close relationship with food and nutrition. One of their duties is to guarantee the patient’s safety and to keep the hospital certification processes up-to-date, thus making it necessary to establish a nutritional screening as an indispensable step in the medical care of every admitted patient. For this purpose, the development and implementation of nutritional screening began in several clinical areas of the hospital since early 2012, as a pilot program. After almost two years of implementation of screening and data collection, a diagnosis of the process needed to be conducted. Some of the objectives of this investigation were to evaluate the level of execution of the screening in clinical areas and establish the prevalence of hospital malnutrition risk.Materials and methods A retrospective analysis was carried out with nutritional screening primary data from six clinical areas: adult and postsurgical intensive care unit (ICU), surgery, internal medicine, neurology, orthopedics and pensioners. Primary data, monitored by the nutrition clinic, was obtained in the period between July 2012 and December 2013. Nutritional Risk Screening (NRS 2002) was the method used to obtain the nutritional screening.40 This method includes a nutritional assessment aimed at detecting malnutrition risk (weight loss, body mass index and lowered intake), as well as an assessment of the severity of the disease and the increase of the nutritional requirements which it may condition. Age is considered an additional risk factor if the patient is more than 70 years old. The NRS indicates the need for a deeper nutritional assessment if the global score is ≥3. The NRS screening method is recommended by the European Society of Parenteral and Enteral Nutrition (ESPEN) to apply to hospitalized patients, it is applicable to most patients, fast and easy to complete. The most subjective data is the assessment of the severity of the disease, which can influence the final result. However, the variability among observers is small when applied by trained personnel (nurses, doctors, nutritionists). This method was developed by the ESPEN in 2002 and was designed from a retrospective analysis of 128 controlled clinical trials focused on nutritional assessment, nutrition support and patient evolution; it is validated to detect those patients who present malnutrition risk, but does not categorize it.1 In order to consider the prevalence of malnutrition risk as valid, the sample size was calculated from a supposed mean malnutrition risk of 50%, according to the data obtained in other studies conducted in different health institutions in Mexico.14,15 A required sample of 3200 patients was estimated to detect an absolute difference of the prevalence with a potency of 80% (β=.20) and a confidence level of 95% (Software SampleSize, EpiInfo 7.1.2.0). The data of the number of admitted patients were obtained directly from the respective departments. Screening adherence percentages are expressed as an average of the 6 months evaluated in the year 2012 and all 12 months of 2013, as a total and by clinical area where the screening was being implemented. For the prevalence of malnutrition risk calculation the following data were used: the number of patients who obtained a score >3 during the survey and the number of patients who were screened. The nutritional screening form was filled out directly by the nutrition clinic personnel during 2012. However, in 2013 it became part of the residents’ responsibilities, as a part of the patient’s medical history. Primary data collected, after cleaning and cross checking, was stored in a digital container created with Microsoft Office Excel. The variables of interest were reduced to location statisticians (average) and aggregation (percentages) using SPSS 11.0 (SPSS Inc.; Pennsylvania, United States). The protocol of this study was approved by the ethics committee of the hospital, MI14-003.Results A total of 5611 patients were screened, 38% of the patients admitted between July 2012 and December 2013 in all six clinical areas being evaluated. In 2012 screening accomplishment was 55%; the clinical area with the highest rate of screening was the ICU (75%) and the lowest orthopedics (35%). During 2012 screening decreased considerably, with an accomplishment rate of 31%; the clinical area with the highest rate of screening was the ICU (63%) and the lowest was orthopedics (11%). Very low screening execution percentages during 2013 compared with 2012 were found in two clinical areas: surgery and orthopedics (table 1).<img alt="Table 1 Percentage of satisfactory nutritional screening, July 2012-December 2013, University Hospital, UANL" src="304v16n65-90367601fig1.jpg"></img> Average prevalence of hospital malnutrition risk was 54%, with the highest prevalence in the ICU (96%) and the lowest in orthopedics (17%). An elevated prevalence was observed in surgical areas (58%), internal medicine (52%) and neurology (49%) (table 2).<img alt="Table 2 Hospital malnutrition risk prevalence, July 2012-December 2013, University Hospital, UANL" src="304v16n65-90367601fig2.jpg"></img>Discussion Nutritional screening accomplishment was low in 2012 as well as 2013, considering it should be practiced in 100% of admitted patients, and during the first 24 h of admission. In 2012 the screening accomplishment was higher, because it was performed directly by the personnel of the nutrition clinic, whilst in 2013 this activity was assumed by the residents of the different clinical areas, which was linked to a reduction of 17% in its execution. One of the possible associated factors with this low accomplishment was the fact that this action was not a part of the routine practices of the hospital and there wasn’t an awareness of its necessity. It is known that basic work teams fail at recognizing the presence of nutritional disorders or malnutrition risk in the patient. The reasons can be multiple and overlap in their influence; it is also possible that the different nutritional needs that may be present are difficult to recognize in everyday clinical practice, especially in adult patient care. In general, the possible objective and subjective causes, which may have affected the nutritional screening accomplishment, were: absence of specific form in clinical history, form’s lack of completion or improper completion, lack of a normalized procedure of operation which rules all activities related to nutritional screening, lack of proper training, lack of a multidisciplinary concept in nutritional care, a possible responsibility dilution and the possible lack of conviction by the doctor of the importance of food-nutrition in normal and pathological states. Nutritional education has been forgotten in medical curricular formation in a large number of countries, or it is taught in a very superficial manner.41 However, the doctor must be trained to properly assess each patient’s nutritional risk and thus be able to request the required nutritional support in a timely manner. This principle can be initially satisfied with the proper execution of nutritional screening as an essential part of the clinical history and should be performed by the doctor. Even though the whole screening process, as well as its control, must be responsibility of the nutrition clinic. Prevalence of malnutrition risk in hospital areas where nutritional screening is performed can be considered high, if compared to the rates reported in medical literature.2-15 This fact demands urgent and strong actions from the hospital’s health policies. There are studies that show the nutritional state deteriorating during hospitalization if there isn’t proper food, nutritional and metabolic support.21 On the other hand, the moment of assessment of the nutritional state is also an important factor linked to malnutrition risk and presence. Several studies prove the need to perform nutritional evaluations as soon as possible in hospitalized patients, because they evidence a higher malnutrition risk when they are evaluated during hospitalization in comparison to the patients who are evaluated at the moment of hospital admission.27,42 Hospital malnutrition not only alters treatment efficacy, it also increases risk of complications and morbi-mortality, prolongs hospital stay and increases premature re-admission rates, which all affects healthcare costs negatively.43-52 Healthcare costs linked to hospital malnutrition have been recently calculated by the European Society of Parenteral and Enteral Nutrition at 170 billion euros a year.38 Mal-nourished patients have a higher possibility of needing successive hospital admissions, which may be 30-70% higher than that of well-nourished patients. Moreover, it is well-known that nutritional intervention improves the patient’s prognosis in numerous diseases. The associated expense to nutritional support was estimated to be less than 3% of the total expense generated by malnutrition; hence savings as a result of timely nutritional intervention are considerable, especially from the reduction of hospital stay and the lower need of extended-care facilities.38 Given the findings of the present study, the development of standard operating procedures to organize nutritional screening processes in the hospital, with the corresponding formats validated for different groups of patients (children and teenagers, adults, elderly and babies); to provide nutritional screening coverage of all clinical areas of the hospital and to all the patients who are admitted, within the first 24 h, in addition to the completion of the clinical history; development of training courses aimed at the healthcare personnel responsible for its execution (doctors, residents, nurses); the development of a monitoring plan for nutritional screening and follow-up actions, including a deep evaluation of the nutritional state of every patient detected to be at-risk of malnutrition, all this in a multidisciplinary work context, should be an important priority.Acknowledgements We give special thanks to the management staff of the “Dr. José Eleuterio González” University Hospital of the School of Medicine of the UANL for their contribution to the development and implementation on nutritional screening.Financing The authors declare that they did not receive any sponsorship to conduct this study.Conflict of interests The authors declare not to have any conflict of interests.<hr></hr> Received: July 2014; Accepted: September 2014 *Corresponding author: Consulta No. 2, Clínica de Nutrición, Hospital Universitario “Dr. José Eleuterio González”, Facultad de Medicina, Universidad Autónoma Nuevo León (UANL), Ave. Madero y Gonzalitos s/n, Colonia Mitras Centro, CP 64460, Monterrey, Nuevo León, México. E-mail address:<a href="mailto:patyaner@hotmail.com" class="elsevierStyleCrossRefs">patyaner@hotmail.com</a> (P.R. Áncer Rodríguez)." "pdfFichero" => "304v16n65a90367601pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec686839" "palabras" => array:3 [ 0 => "Nutritional screening" 1 => "Hospital malnutrition risk" 2 => "Adults" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:1 [ "resumen" => " Introduction: Hospital malnutrition risk has prevalence values of 20%-50%, and it is a major health problem in the health institutions worldwide. Objective: To assess the accomplishment of nutritional screening and the prevalence of hospital malnutrition risk in a University Hospital. Materials and methods: A retrospective analysis was carried out with nutritional screening, using primary data from six clinical areas obtained in the period between July 2012 and December 2013. According to previous results in Mexican health institutions and considering a mean malnutrition risk prevalence of 50%, it was calculated that a sample size of 3200 subjects was required for the assessment of valid risk values. Patients with values ≥3 on the Nutritional Risk Screening (NRS, 2002) were classified as carriers of nutritional risk. Results: A total of 5611 patients (38% of all patients admitted) were studied. The rate of screening declined from 55% in 2012 to 31% in 2013. During the whole period, 3034 patients were classified with risk of malnutrition (54% prevalence). Conclusions: The prevalence of hospital malnutrition risk was high. The accomplishment of the nutritional screening was deficient, and declined between 2012 and 2013. The lack of nutritional screening does not meet the vital care requirements of hospitalized patients and prevents the timely treatment of those at malnutrition risk." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "304v16n65-90367601fig1.jpg" "imagenAlto" => 837 "imagenAncho" => 2104 "imagenTamanyo" => 192646 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Percentage of satisfactory nutritional screening, July 2012-December 2013, University Hospital, UANL" ] ] 1 => array:8 [ "identificador" => "tbl2" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "304v16n65-90367601fig2.jpg" "imagenAlto" => 587 "imagenAncho" => 2091 "imagenTamanyo" => 106075 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Hospital malnutrition risk prevalence, July 2012-December 2013, University Hospital, UANL" ] ] 2 => array:7 [ "identificador" => "tbl3" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Percentage of satisfactory nutritional screening, July 2012-December 2013, University Hospital, UANL" ] ] 3 => array:7 [ "identificador" => "tbl4" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Hospital malnutrition risk prevalence, July 2012-December 2013, University Hospital, UANL" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:52 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Desnutrición y Enfermedad. 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Patricia R. Áncer-Rodrígueza, Carmen Porrata-Mauria, Manuel Hernández-Trianaa, Karla Salinas-Zamoraa, Verónica Bernal-Garcíaa, Samantha Trejo-Guzmána, Blanca González-Garcíaa, Mayra Herrera-Lópeza, Anel de la Torre-Salinasa, Clemente Rojas-Ramíreza, Dionicio A. Galarza-Delgadob

a Outpatient Clinic No. 2, Nutrition Clinic, Dr. José Eleuterio González University Hospital, School of Medicine, UANL, Monterrey, Mexico

b Departament of Internal Medicine, Dr. José Eleuterio González University Hospital, School of Medicine, UANL, Monterrey, Mexico

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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction </span></p><p class="elsevierStylePara"> Malnutrition is a major public health problem which affects the entire world&#44; not only less favored economies&#44; but developed countries as well&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara"> Patients admitted to a hospital are a group especially vulnerable to malnutrition&#44; with a high prevalence&#44; around 20-50&#37;&#44; depending on the diagnostic criteria&#46;<span class="elsevierStyleSup">2-11</span> The Latin American Federation of Nutritional Therapy&#44; Clinical Nutrition and Metabolism &#40;FELANPE for its Spanish acronym&#41; hosted the first Latin American Study of Hospital Malnutrition in the biennial 1999-2001&#44; which found a malnutrition frequency of 51&#46;2&#37;&#46;<span class="elsevierStyleSup">12</span> In Mexico there are few studies on the subject&#59; however&#44; the existing conducted studies suggest a severe situation to take into account by the health system&#46;<span class="elsevierStyleSup">13-15</span></p><p class="elsevierStylePara"> Hospital malnutrition is defined as malnutrition which affects hospitalized patients as a result of a complex interaction between illnesses&#44; food and nutrition&#46;<span class="elsevierStyleSup">1&#44;16</span> It is a distinct entity whose term was coined in the 70s&#44; as a result of the studies by Bistrian&#44; where he made evident the high prevalence of this condition in hospitalized patients&#46;<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara"> In 1974 Butterworth used the term &#8220;iatrogenic malnutrition&#8221; to describe body composition disorders of hospital patients caused by the actions or omissions of the medical team&#44; and documented some practices which contributed to the patients&#8217; nutritional deterioration&#44; like omission of responsibilities in nutritional care&#44; prolonged use of intravenous nutrition&#44; deficiency in the monitoring or register of dietary intake and inexistence of proper nutritional support&#46;<span class="elsevierStyleSup">18&#44;19</span></p><p class="elsevierStylePara"> The etiology of hospital malnutrition is multifactorial and includes causes related to the disease itself&#58; intake reduction&#44; response to aggression&#44; mechanical obstruction of the gastrointestinal tract&#44; pharmaceutics&#44; advanced age&#44; an increase in requirements&#44; an increase of its losses&#44; and inflammatory conditions&#59; causes related to hospitalization&#58; a change in habits&#44; reactive emotional situations&#44; complementary examinations&#44; surgical treatments&#44; pharmaceutics&#44; chemotherapy-radiotherapy&#44; hospitality&#59; causes related to the medical team&#58; misuse of therapeutic fasts&#44; lack of nutritional assessment&#44; lack of intake control&#44; dilution of responsibilities&#59; causes related to health authorities&#58; lack of nutritionists&#44; absence of nutrition units&#44; lack of dietician-nutritionist acknowledgement&#44; and lack of a coordinated and multidisciplinary work&#46;<span class="elsevierStyleSup">1&#44;17&#44;20</span></p><p class="elsevierStylePara"> Hospital malnutrition usually enters a vicious cycle&#44; despite the fact that the patient has increased requirements&#44; they tend to not be met&#44; causing depletion and exhaustion of energy and nutrimental reserves and thus increasing his&#47; her consumption needs&#46; There are reports confirming that hospitalized patients&#44; in general&#44; do not consume the necessary amount of energy and nutriments to cover their requirements&#44; which worsens their nutritional condition&#46;<span class="elsevierStyleSup">21-23</span></p><p class="elsevierStylePara"> Once established&#44; malnutrition sensibly affects the organisms&#8217; response capabilities to medical-surgical treatment&#44; impedes proper healing and increases the risk of suture dehiscence and sore outbreaks&#44; placing the patient in a situation of immunosuppression which makes him&#47;her susceptible to opportunistic infections&#46; If not treated in a timely manner&#44; malnutrition may lead to the patient&#8217;s death&#46;<span class="elsevierStyleSup">9&#44;24-28</span></p><p class="elsevierStylePara"> For over 25 years it has been known that malnutrition is one of the main and more frequent causes of mortality in hospitalized individuals&#46; Early work dates back to 1936&#44; when Studdley reported that weight losses over 20&#37; of the total weight increase mortality rate in hospitalized patients by 10 times&#46;<span class="elsevierStyleSup">29</span> According to Howard&#44; &#8220;each and every patient who is admitted to a hospital has the right to expect his&#47;her nutritional requirements to be provided&#46;&#8221;<span class="elsevierStyleSup">30</span> but in reality how many patients receive proper nutrition in clinics and hospitals&#63; Probably&#44; the answer to that question is shown in different statistics in Europe&#44; US&#44; or in the IBRANUTI study&#44; where numbers show that close to 50&#37; of hospitalized patients have some type of malnutrition&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara"> Nutritional screening and a proper nutrition are part of the rights of every patient who is admitted to a hospital&#44; thus making it essential for these requirements to be met&#46; Without a doubt&#44; analysis of the ethical aspects in clinical practice contributes to the improvement in healthcare quality&#46;<span class="elsevierStyleSup">31-33</span></p><p class="elsevierStylePara"> In order to reduce hospital malnutrition&#44; the development of formal and coordinated intervention is imposed&#44; with specific objectives which include the implementation of recognized methods of nutritional screening which allows us to program a timely and proper nutritional plan for at-risk patients&#46;<span class="elsevierStyleSup">34-36</span></p><p class="elsevierStylePara"> In 2003 the Resolution on Food and Nutritional Care in Hospitals was published by the Council of Europe&#8217;s Committee of Ministers&#44; who took on the political commitment of the 18 signing countries&#46; This resolution includes elements of obliged consideration on nutritional assessment&#44; the identification and prevention of causes of malnutrition&#44; nutritional counseling&#44; conventional diets and artificial diets&#46; Moreover&#44; this resolution highlights the proper distribution of responsibilities among healthcare authorities&#44; hospital and clinical management&#46; Even though the resolution lacks an obligatory compliance rule&#44; it functions as a starting point of reflection in many hospitals&#44; thus motivating them to raise the need for implementing nutritional screening and acting protocol methods&#46;<span class="elsevierStyleSup">37</span> Nevertheless&#44; it is still far from its generalization&#44; as shown in a survey conducted in 75 Spanish hospitals &#40;half of them without a clinical nutrition unit in the organization chart&#41;&#44; where only 15&#37; had systemic nutritional screening on admission&#46;<span class="elsevierStyleSup">38</span></p><p class="elsevierStylePara"> In many countries&#44; hospitals must provide a nutritional screening in order to go through a quality certification process&#44; as with hospitals in the US &#40;Joint Commission&#8217;s accreditation requirement JCAHO&#41;&#46;<span class="elsevierStyleSup">39</span> In Mexico it is a requirement as well &#40;General Health Council standards AOP&#46;1&#46;6 and AOP&#46;1&#46;7&#44; Establishment Certification Commission for Medical Attention&#44; National Certification System of Medical Attention Establishments&#44; Certification Standards for Hospitals&#44; Version 2011&#44; active since January 2011&#41;&#46;</p><p class="elsevierStylePara"> The &#8220;Dr&#46; Jos&#233; E&#46; Gonz&#225;lez&#8221; University Hospital of the UANL is the only one with third-level care in the northwest of Mexico for a population without medical or social security coverage&#44; with a mid-low or low socioeconomic level&#46; Today there are 500 beds&#44; 22 departments and 20 clinical services&#44; of which 17 and 18 respectively have a close relationship with food and nutrition&#46;</p><p class="elsevierStylePara"> One of their duties is to guarantee the patient&#8217;s safety and to keep the hospital certification processes up-to-date&#44; thus making it necessary to establish a nutritional screening as an indispensable step in the medical care of every admitted patient&#46;</p><p class="elsevierStylePara"> For this purpose&#44; the development and implementation of nutritional screening began in several clinical areas of the hospital since early 2012&#44; as a pilot program&#46; After almost two years of implementation of screening and data collection&#44; a diagnosis of the process needed to be conducted&#46;</p><p class="elsevierStylePara"> Some of the objectives of this investigation were to evaluate the level of execution of the screening in clinical areas and establish the prevalence of hospital malnutrition risk&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Materials and methods </span></p><p class="elsevierStylePara"> A retrospective analysis was carried out with nutritional screening primary data from six clinical areas&#58; adult and postsurgical intensive care unit &#40;ICU&#41;&#44; surgery&#44; internal medicine&#44; neurology&#44; orthopedics and pensioners&#46; Primary data&#44; monitored by the nutrition clinic&#44; was obtained in the period between July 2012 and December 2013&#46;</p><p class="elsevierStylePara"> Nutritional Risk Screening &#40;NRS 2002&#41; was the method used to obtain the nutritional screening&#46;<span class="elsevierStyleSup">40</span> This method includes a nutritional assessment aimed at detecting malnutrition risk &#40;weight loss&#44; body mass index and lowered intake&#41;&#44; as well as an assessment of the severity of the disease and the increase of the nutritional requirements which it may condition&#46; Age is considered an additional risk factor if the patient is more than 70 years old&#46; The NRS indicates the need for a deeper nutritional assessment if the global score is &#8805;3&#46;</p><p class="elsevierStylePara"> The NRS screening method is recommended by the European Society of Parenteral and Enteral Nutrition &#40;ESPEN&#41; to apply to hospitalized patients&#44; it is applicable to most patients&#44; fast and easy to complete&#46; The most subjective data is the assessment of the severity of the disease&#44; which can influence the final result&#46; However&#44; the variability among observers is small when applied by trained personnel &#40;nurses&#44; doctors&#44; nutritionists&#41;&#46; This method was developed by the ESPEN in 2002 and was designed from a retrospective analysis of 128 controlled clinical trials focused on nutritional assessment&#44; nutrition support and patient evolution&#59; it is validated to detect those patients who present malnutrition risk&#44; but does not categorize it&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara"> In order to consider the prevalence of malnutrition risk as valid&#44; the sample size was calculated from a supposed mean malnutrition risk of 50&#37;&#44; according to the data obtained in other studies conducted in different health institutions in Mexico&#46;<span class="elsevierStyleSup">14&#44;15</span> A required sample of 3200 patients was estimated to detect an absolute difference of the prevalence with a potency of 80&#37; &#40;&#946;&#61;&#46;20&#41; and a confidence level of 95&#37; &#40;Software SampleSize&#44; EpiInfo 7&#46;1&#46;2&#46;0&#41;&#46;</p><p class="elsevierStylePara"> The data of the number of admitted patients were obtained directly from the respective departments&#46; Screening adherence percentages are expressed as an average of the 6 months evaluated in the year 2012 and all 12 months of 2013&#44; as a total and by clinical area where the screening was being implemented&#46;</p><p class="elsevierStylePara"> For the prevalence of malnutrition risk calculation the following data were used&#58; the number of patients who obtained a score &#62;3 during the survey and the number of patients who were screened&#46;</p><p class="elsevierStylePara"> The nutritional screening form was filled out directly by the nutrition clinic personnel during 2012&#46; However&#44; in 2013 it became part of the residents&#8217; responsibilities&#44; as a part of the patient&#8217;s medical history&#46;</p><p class="elsevierStylePara"> Primary data collected&#44; after cleaning and cross checking&#44; was stored in a digital container created with Microsoft Office Excel&#46; The variables of interest were reduced to location statisticians &#40;average&#41; and aggregation &#40;percentages&#41; using SPSS 11&#46;0 &#40;SPSS Inc&#46;&#59; Pennsylvania&#44; United States&#41;&#46; The protocol of this study was approved by the ethics committee of the hospital&#44; MI14-003&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results </span></p><p class="elsevierStylePara"> A total of 5611 patients were screened&#44; 38&#37; of the patients admitted between July 2012 and December 2013 in all six clinical areas being evaluated&#46; In 2012 screening accomplishment was 55&#37;&#59; the clinical area with the highest rate of screening was the ICU &#40;75&#37;&#41; and the lowest orthopedics &#40;35&#37;&#41;&#46; During 2012 screening decreased considerably&#44; with an accomplishment rate of 31&#37;&#59; the clinical area with the highest rate of screening was the ICU &#40;63&#37;&#41; and the lowest was orthopedics &#40;11&#37;&#41;&#46;</p><p class="elsevierStylePara"> Very low screening execution percentages during 2013 compared with 2012 were found in two clinical areas&#58; surgery and orthopedics &#40;table 1&#41;&#46;</p><p class="elsevierStylePara"><img alt="Table 1 Percentage of satisfactory nutritional screening&#44; July 2012-December 2013&#44; University Hospital&#44; UANL" src="304v16n65-90367601fig1.jpg"></img></p><p class="elsevierStylePara"> Average prevalence of hospital malnutrition risk was 54&#37;&#44; with the highest prevalence in the ICU &#40;96&#37;&#41; and the lowest in orthopedics &#40;17&#37;&#41;&#46; An elevated prevalence was observed in surgical areas &#40;58&#37;&#41;&#44; internal medicine &#40;52&#37;&#41; and neurology &#40;49&#37;&#41; &#40;table 2&#41;&#46;</p><p class="elsevierStylePara"><img alt="Table 2 Hospital malnutrition risk prevalence&#44; July 2012-December 2013&#44; University Hospital&#44; UANL" src="304v16n65-90367601fig2.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion </span></p><p class="elsevierStylePara"> Nutritional screening accomplishment was low in 2012 as well as 2013&#44; considering it should be practiced in 100&#37; of admitted patients&#44; and during the first 24 h of admission&#46; In 2012 the screening accomplishment was higher&#44; because it was performed directly by the personnel of the nutrition clinic&#44; whilst in 2013 this activity was assumed by the residents of the different clinical areas&#44; which was linked to a reduction of 17&#37; in its execution&#46; One of the possible associated factors with this low accomplishment was the fact that this action was not a part of the routine practices of the hospital and there wasn&#8217;t an awareness of its necessity&#46;</p><p class="elsevierStylePara"> It is known that basic work teams fail at recognizing the presence of nutritional disorders or malnutrition risk in the patient&#46; The reasons can be multiple and overlap in their influence&#59; it is also possible that the different nutritional needs that may be present are difficult to recognize in everyday clinical practice&#44; especially in adult patient care&#46;</p><p class="elsevierStylePara"> In general&#44; the possible objective and subjective causes&#44; which may have affected the nutritional screening accomplishment&#44; were&#58; absence of specific form in clinical history&#44; form&#8217;s lack of completion or improper completion&#44; lack of a normalized procedure of operation which rules all activities related to nutritional screening&#44; lack of proper training&#44; lack of a multidisciplinary concept in nutritional care&#44; a possible responsibility dilution and the possible lack of conviction by the doctor of the importance of food-nutrition in normal and pathological states&#46;</p><p class="elsevierStylePara"> Nutritional education has been forgotten in medical curricular formation in a large number of countries&#44; or it is taught in a very superficial manner&#46;<span class="elsevierStyleSup">41</span> However&#44; the doctor must be trained to properly assess each patient&#8217;s nutritional risk and thus be able to request the required nutritional support in a timely manner&#46;</p><p class="elsevierStylePara"> This principle can be initially satisfied with the proper execution of nutritional screening as an essential part of the clinical history and should be performed by the doctor&#46; Even though the whole screening process&#44; as well as its control&#44; must be responsibility of the nutrition clinic&#46;</p><p class="elsevierStylePara"> Prevalence of malnutrition risk in hospital areas where nutritional screening is performed can be considered high&#44; if compared to the rates reported in medical literature&#46;<span class="elsevierStyleSup">2-15</span> This fact demands urgent and strong actions from the hospital&#8217;s health policies&#46;</p><p class="elsevierStylePara"> There are studies that show the nutritional state deteriorating during hospitalization if there isn&#8217;t proper food&#44; nutritional and metabolic support&#46;<span class="elsevierStyleSup">21</span> On the other hand&#44; the moment of assessment of the nutritional state is also an important factor linked to malnutrition risk and presence&#46; Several studies prove the need to perform nutritional evaluations as soon as possible in hospitalized patients&#44; because they evidence a higher malnutrition risk when they are evaluated during hospitalization in comparison to the patients who are evaluated at the moment of hospital admission&#46;<span class="elsevierStyleSup">27&#44;42</span></p><p class="elsevierStylePara"> Hospital malnutrition not only alters treatment efficacy&#44; it also increases risk of complications and morbi-mortality&#44; prolongs hospital stay and increases premature re-admission rates&#44; which all affects healthcare costs negatively&#46;<span class="elsevierStyleSup">43-52</span></p><p class="elsevierStylePara"> Healthcare costs linked to hospital malnutrition have been recently calculated by the European Society of Parenteral and Enteral Nutrition at 170 billion euros a year&#46;<span class="elsevierStyleSup">38</span> Mal-nourished patients have a higher possibility of needing successive hospital admissions&#44; which may be 30-70&#37; higher than that of well-nourished patients&#46; Moreover&#44; it is well-known that nutritional intervention improves the patient&#8217;s prognosis in numerous diseases&#46; The associated expense to nutritional support was estimated to be less than 3&#37; of the total expense generated by malnutrition&#59; hence savings as a result of timely nutritional intervention are considerable&#44; especially from the reduction of hospital stay and the lower need of extended-care facilities&#46;<span class="elsevierStyleSup">38</span> Given the findings of the present study&#44; the development of standard operating procedures to organize nutritional screening processes in the hospital&#44; with the corresponding formats validated for different groups of patients &#40;children and teenagers&#44; adults&#44; elderly and babies&#41;&#59; to provide nutritional screening coverage of all clinical areas of the hospital and to all the patients who are admitted&#44; within the first 24 h&#44; in addition to the completion of the clinical history&#59; development of training courses aimed at the healthcare personnel responsible for its execution &#40;doctors&#44; residents&#44; nurses&#41;&#59; the development of a monitoring plan for nutritional screening and follow-up actions&#44; including a deep evaluation of the nutritional state of every patient detected to be at-risk of malnutrition&#44; all this in a multidisciplinary work context&#44; should be an important priority&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements </span></p><p class="elsevierStylePara"> We give special thanks to the management staff of the &#8220;Dr&#46; Jos&#233; Eleuterio Gonz&#225;lez&#8221; University Hospital of the School of Medicine of the UANL for their contribution to the development and implementation on nutritional screening&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Financing </span></p><p class="elsevierStylePara"> The authors declare that they did not receive any sponsorship to conduct this study&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interests </span></p><p class="elsevierStylePara"> The authors declare not to have any conflict of interests&#46;</p><hr></hr><p class="elsevierStylePara"> Received&#58; July 2014&#59; <br></br> Accepted&#58; September 2014</p><p class="elsevierStylePara"> &#42;Corresponding author&#58; <br></br> Consulta N<span class="elsevierStyleSup">o</span>&#46; 2&#44; Cl&#237;nica de Nutrici&#243;n&#44; <br></br> Hospital Universitario &#8220;Dr&#46; Jos&#233; Eleuterio Gonz&#225;lez&#8221;&#44; <br></br> Facultad de Medicina&#44; <br></br> Universidad Aut&#243;noma Nuevo Le&#243;n &#40;UANL&#41;&#44; <br></br> Ave&#46; Madero y Gonzalitos s&#47;n&#44; Colonia Mitras Centro&#44; <br></br> CP 64460&#44; Monterrey&#44; Nuevo Le&#243;n&#44; <br></br> M&#233;xico&#46; <span class="elsevierStyleItalic">E-mail address&#58;</span><a href="mailto&#58;patyaner&#64;hotmail&#46;com" class="elsevierStyleCrossRefs">patyaner&#64;hotmail&#46;com</a> &#40;P&#46;R&#46; &#193;ncer Rodr&#237;guez&#41;&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"> <span class="elsevierStyleItalic">Introduction&#58;</span> Hospital malnutrition risk has prevalence values of 20&#37;-50&#37;&#44; and it is a major health problem in the health institutions worldwide&#46;</p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Objective&#58;</span> To assess the accomplishment of nutritional screening and the prevalence of hospital malnutrition risk in a University Hospital&#46;</p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Materials and methods&#58;</span> A retrospective analysis was carried out with nutritional screening&#44; using primary data from six clinical areas obtained in the period between July 2012 and December 2013&#46; According to previous results in Mexican health institutions and considering a mean malnutrition risk prevalence of 50&#37;&#44; it was calculated that a sample size of 3200 subjects was required for the assessment of valid risk values&#46; Patients with values &#8805;3 on the Nutritional Risk Screening &#40;NRS&#44; 2002&#41; were classified as carriers of nutritional risk&#46;</p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Results&#58;</span> A total of 5611 patients &#40;38&#37; of all patients admitted&#41; were studied&#46; The rate of screening declined from 55&#37; in 2012 to 31&#37; in 2013&#46; During the whole period&#44; 3034 patients were classified with risk of malnutrition &#40;54&#37; prevalence&#41;&#46;</p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Conclusions&#58;</span> The prevalence of hospital malnutrition risk was high&#46; The accomplishment of the nutritional screening was deficient&#44; and declined between 2012 and 2013&#46; The lack of nutritional screening does not meet the vital care requirements of hospitalized patients and prevents the timely treatment of those at malnutrition risk&#46;</p>"
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                        0 => array:2 [
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                          "autores" => array:3 [
                            0 => "Lobo T&#225;ner G"
                            1 => "Ru&#237;z L&#243;pez MD"
                            2 => "P&#233;rez de la Cruz AJ&#46;"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medcli.2008.06.008"
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Article information

ISSN: 16655796
Original language: English

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	18	0	18
2024 October	137	16	153
2024 September	231	30	261
2024 August	158	24	182
2024 July	123	18	141
2024 June	115	19	134
2024 May	135	12	147
2024 April	163	21	184
2024 March	184	15	199
2024 February	230	24	254
2024 January	241	26	267
2023 December	190	19	209
2023 November	246	41	287
2023 October	264	48	312
2023 September	168	20	188
2023 August	145	23	168
2023 July	139	17	156
2023 June	161	31	192
2023 May	147	35	182
2023 April	157	29	186
2023 March	138	14	152
2023 February	85	24	109
2023 January	86	15	101
2022 December	73	15	88
2022 November	111	24	135
2022 October	130	31	161
2022 September	150	43	193
2022 August	106	25	131
2022 July	103	25	128
2022 June	100	18	118
2022 May	105	43	148
2022 April	111	42	153
2022 March	117	37	154
2022 February	124	29	153
2022 January	152	20	172
2021 December	145	37	182
2021 November	116	26	142
2021 October	220	31	251
2021 September	213	33	246
2021 August	118	30	148
2021 July	122	32	154
2021 June	74	20	94
2021 May	107	27	134
2021 April	362	78	440
2021 March	194	43	237
2021 February	126	18	144
2021 January	144	27	171
2020 December	127	31	158
2020 November	107	24	131
2020 October	49	12	61
2020 September	67	22	89
2020 August	78	17	95
2020 July	64	15	79
2020 June	116	28	144
2020 May	129	28	157
2020 April	96	42	138
2020 March	149	16	165
2020 February	175	42	217
2020 January	114	23	137
2019 December	95	29	124
2019 November	94	18	112
2019 October	107	19	126
2019 September	143	35	178
2019 August	77	19	96
2019 July	79	17	96
2019 June	120	33	153
2019 May	199	47	246
2019 April	113	21	134
2019 March	84	12	96
2019 February	57	22	79
2019 January	27	8	35
2018 December	26	1	27
2018 November	37	7	44
2018 October	41	8	49
2018 September	18	4	22
2018 August	22	6	28
2018 July	14	5	19
2018 June	14	4	18
2018 May	24	3	27
2018 April	22	2	24
2018 March	23	2	25
2018 February	16	0	16
2018 January	25	1	26
2017 December	17	0	17
2017 November	19	3	22
2017 October	13	0	13
2017 September	8	8	16
2017 August	12	3	15
2017 July	21	2	23
2017 June	34	17	51
2017 May	40	4	44
2017 April	27	2	29
2017 March	29	47	76
2017 February	18	1	19
2017 January	13	1	14
2016 December	17	2	19
2016 November	18	4	22
2016 October	27	2	29
2016 September	8	0	8
2016 August	13	2	15
2016 July	21	9	30
2016 June	71	29	100
2016 May	50	18	68
2016 April	47	15	62
2016 March	119	28	147
2016 February	60	33	93
2016 January	68	27	95
2015 December	65	15	80
2015 November	58	25	83
2015 October	58	26	84
2015 September	54	15	69
2015 August	114	16	130
2015 July	87	16	103
2015 June	59	17	76
2015 May	131	41	172
2015 April	76	26	102
2015 March	58	16	74
2015 February	64	21	85
2015 January	83	21	104
2014 December	42	15	57

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