Indications for Clinical NutritionView more
Food and proper nutrition intake are fundamental to good health and resistance to disease.
In the majority of hospital patients, high quality hospital food sufficiently meets the dietary needs. However, more than 50 percent of patients in the hospital do not eat their entire meal.1 This type of insufficient dietary intake can lead to deterioration of nutritional status. In the case of surgical patients undergoing major surgery, the avoidance of any nutritional therapy bears a risk for underfeeding during the postoperative period. Considering that malnutrition and underfeeding represent risk factors for postoperative complications, nutrition support involving oral nutritional supplements (ONS), enteral tube feeding, and/or parenteral nutrition becomes indispensable.2
Hospital malnutrition impacts patients of all ages and is not restricted to one health care setting.2 Hospital malnutrition and the risk of malnutrition are common in many hospital wards, including geriatrics, oncology, surgery, internal medicine, and gastroenterology.3
To counteract hospital malnutrition and its deleterious consequences, such as poor wound healing, infections, and complications, timely identification of impaired nutritional status and rapid initiation of effective clinical nutrition treatment are crucial for patients in nutritional risk groups.4
The steps in good nutritional care include:
When addressing hospital malnutrition, the choice of clinical nutrition support depends on the patient’s clinical state.
Enteral nutrition (EN), including ONS and tube feeding via nasogastric, nasoenteral or percutaneous tubes, and parenteral nutrition (PN), including supplemental PN and total PN, are the major types of clinical nutrition support.
EN and PN, or a combination of both may be indicated according to the outcome of a formal nutrition assessment.4
To read more about the different types of clinical nutrition support, please click here.
Clinical trials have shown that adequate clinical nutrition improves patient outcomes by:
Published evidence5 has shown that administration of supplemental PN in post-acute critically ill patients who fail to reach ≥60% of the targeted nutrition delivery with EN
improves the cumulative energy balance,
reduces the risk of healthcare-associated infections (HR 0.65, 95% CI 0.43–0.97; p=0.0338).
The effect of perioperative total PN in surgical patients showed to depend especially on the patient’s constitution. Whereas patients categorized as either borderline or mildly malnourished had no demonstrable benefit from total PN, severely malnourished patients experienced fewer noninfectious complications, and no concomitant increase in infectious complications.10
By improving patient health, clinical nutrition reduces the burden on health care resources, delivering economic benefits coming from shorter hospital stays, fewer readmissions, and lowered cost of care:
Pradelli et al. 2017 performed a cost-effectiveness analysis based on previous study data from Heidegger et al. 20135 (supplemental PN being associated with reduced nosocomial infections) and could demonstrate that optimization of energy provision by nutritional support was - in addition to the benefit in clinical outcome – also a cost-saving strategy.21
The British Association for Parenteral and Enteral Nutrition undertook a cost analysis of the use of ONS in hospitals in the UK. Data was extracted from randomized controlled trials (RCTs) of ONS versus standard care. The pooled results from the analysis suggested that ONS can produce a net cost saving and be cost-effective in selected patient groups (such as patients undergoing gastrointestinal surgery).11
A prospective observational study from Zhang et al. 2017 performed in surgical and medical gastroenterology wards revealed that nutrition support (EN and PN) was associated with fewer infectious complications and shorter length of stay in patients at nutritional risk. The cost of nutrition support was completely offset due to cost savings arising from lower length of hospital stay and reduced infectious complications.12
Nutritional support (especially EN) was beneficial in patients at risk of malnutrition, resulting in a lower complication rate.8 In a multicenter, prospective cohort study, implementation of nutritional support (EN and PN) already preoperatively was found to be associated with a lower complication rate and with a shorter postoperative hospital length of stay (LOS), so that overall hospital LOS was not prolonged by the preoperative intervention. 13
Hospital malnutrition is a serious problem all over the world, in both developed and developing nations.
In hospitalized patients, throughout different patient groups and across varied settings, the estimated prevalence of hospital malnutrition varies. In Asia alone, the figure ranges from 22 to 56%.14-20
The use of clinical nutrition is a vital opportunity to improve care and outcomes for patients.