Undernutrition and patient safety

Challenges to face

Undernutrition is a considerable problem among nursing home residents and patients receiving home health care services. In nursing homes, the prevalence of undernutrition varies from 20 to 71 %, and 20–78 % of the patients are at risk of becoming undernou­rished. Among elderly patients receiving home nursing care, the prevalence of undernutrition varies from 16 to 40 %, while 20–59 % are at risk. Undernutrition leads to increased mortality, morbidity and functional impairment, increased risk of developing wounds, prolonged hospital stays and reduced quality of life. The risk of undernutrition increases with age, and some studies find that older women are more exposed than men. Cognitive impairment may represent a risk factor, but the clearest correlations have been found between undernutrition and physical deterioration and chronic disease. Moreover, people living alone may be particularly vulnerable. Additionally, routines and the way health and care services are organized may represent risks when meal rhythm and meal situations are inappropriate. Lack of competence and awareness among health personnel may also allow undernutrition to develop unnoticed.

Effects and experiences of interventions

Interventions to prevent undernutrition are sorted into the following categories: 1) Screening of nutritional risk, 2) Individualized interventions, 3) Interventions to enhance competencies, 4) Organizational interventions and 5) The package of inter­ventions for the prevention and treatment of undernutrition, recommended by the Norwegian Patient Safety Programme.

The following experiences are described for these categories:

Screening of nutritional risk: The instruments MNA, MUST and NUFFE are validated tools and deemed relevant for Norwegian nursing homes and home health care services. However, screening among patients receiving home health care services, may pose both practical and ethical challenges. Therefore, screening of nutritional risk must be seen in a holistic perspective, and the purpose must be to reveal problems that require further mapping and follow-up.

Individualized interventions: Having a nutritional plan, participation in a study-circle, use of welfare technology, receiving culturally adapted meals and individualised meal situations can improve the patient’s nutritional status and increase their food intake and well-being. In cases where individualized interventions are successful, the health personnel play a significant role in identifying risks, organizing flexible interventions and in achieving the objectives. Additionally, interventions that stimulate patients’ personal engagement, awareness and knowledge about their own activities to reach optimal nutrition can be of great significance. When it comes to possibilities for delivering individualised diets in municipal institutional services, economic factors and human resources seem to be more important than the choice of kitchen model.

Interventions to enhance competencies: Study circles for health personnel, multiprofessional collaboration, groups for networking, change agents and measures to implement national guidelines to prevent undernutrition are described in the publications. The latter is a theme of many of the development projects, and often initiated by the Centre for Development of Institutional and Home Care Services. The projects show that both knowledge and practice have a major potential for improvement. The projects report mainly positive outcomes. However, the effects appear to be short-lived and the upgrading of skills is not always traceable in practice. It is emphasized that enhancement of competencies must be a continuing process. Several of the projects end up with educational material for further use. Moreover, in cases where the knowledge of staff is measured, this is often enhanced after the project period.

Organizational interventions: Organizational interventions to prevent undernutrition described in the publications concern change, improvement and the systemizing of routines in nursing homes and home health care services. Routines that have been reviewed relate to guidelines, checklists, screening procedures, nutritional journals, collaboration with kitchen personnel and doctors, and adjustments of circadian and meal rhythm. The importance of efforts to assure documentation quality is emphasized. The change of routines is shown to contribute to the discovery of weight loss and risk of undernutrition, as well as initiate improvement measures. Managers who seek progress and focus on implementation as a continual process are extremely successful when it comes to motivating their staff.

The package of interventions for the prevention and treatment of undernutrition, recommended by the Norwegian Patient Safety Programme: It remains too early to draw conclusions about the municipalities’ efforts involving the package of interventions. The publications describe experiences from two municipalities – covering the implementation in both nursing homes and home health care services. Despite the short duration, the two pilots experienced factors of both success and barriers, indicating that the interventions are feasible with some adjustments.