Written by Eilis Hogan
During my clinical placement on a medical ward many patients had complaints about the hospital food. I noticed a lot of these patients had family members bring them in food during visiting hours. If this was happening surely there would be people on the ward who do not have the opportunity for family members to bring food in for them due to financial hardship or being in hospital away from their hometown. If this were the case then surely these patients would begin to suffer from malnourishment over time. My question was developed after hearing and reading about the change to the hospital food in order to save money for budget cuts in the media (Goodwin, 2016). I was sure that this would incur more costs that it could save. Firstly I wanted to know if malnutrition was a problem in New Zealand and Australian hospitals and then if it causes increased length of stay and incurs greater hospital costs.
There has been lots of research performed around malnutrition; particularly this review will look at malnutrition in acute care settings of adults over 65 years of age in New Zealand and Australia, with particular interest to the impact malnutrition has on the length of stay and hospital costs. This review will focus on three main themes that are immediately evident in the literature. These themes are: the extent of the problem in New Zealand and Australia, the increase on length of hospital stay, the increase of health care costs. It will then look into the solutions that can be put into practice and how we can begin to minimise the problem of malnutrition in acute care hospitals in New Zealand and Australia.
Does malnutrition have an impact on the length of inpatient stay and hospital costs in acute care of adults over 65 years of age in New Zealand and Australia?
I formed my question based around the PECOT model (Whitehead, 2013). The PECOT model forms the foundation for a question and it ensures that you define your population, exposure, comparison/control, outcome and time. The population is adults over 65 years of age in New Zealand and Australia. When I began my initial literature search I found vast amounts of information and I was able to narrow my review down to a specific age group. I choose the 65 and over age group, as I know that they are a particularly vulnerable age group. This was also the age group that I had the most experience with during this particular placement. The exposure that I am looking at is malnutrition, I will look at articles that discuss the prevalence of malnutrition and the effects it has on length of stay and cost of hospitalisation. The comparison group will be those with a similar diagnosis who do not experience an extended stay in hospital. By comparing to someone with a similar diagnosis we are able to find out how much malnutrition extends hospital stay for while controlling for confounding due to different diagnoses having different hospital stay times without malnutrition. The outcome I will look at is the length of extended hospital stay. This will tell me if malnutrition does in fact have an effect on hospital stay and if it is an increased length of stay will also incur greater hospital costs. The time period I looked at was the length of time the patients are in acute hospital care. This review focuses on malnutrition in acute care therefore only the time while in hospital is relevant.
Firstly it is important to understand what the broad issues surrounding the food that can be delivered in hospital are that there is a finite amount of money allocated in the budget to run a hospital and there is only a certain percentage of that allocated towards food. When budget cuts are experienced food is one of the areas that needs to be looked at to see how money can be saved to ensure it is still within budget. The importance of quality food and its impact on overall patient outcomes during their planning stages in any proposal for changes to the food services needs to be considered. After a lengthy proposal and planning processes the DHB in question implemented a new food service that outsourced its food using a frozen service so it is able to save money. Patient outcomes and the potential of malnutrition needs to be considered and it is important to understand whether the changes to food services affect the patient outcomes. Malnutrition is a problem that is very common in New Zealand and is often overlooked (Dunne, 2009).
Malnutrition of older adults in acute hospital settings throughout New Zealand and Australia is a problem that is often overlooked. Malnutrition is defined as, a deficiency, or imbalance of energy that results in quantifiable effects on the body (Elia, 2000). The prevalence of malnutrition in New Zealand and Australian hospitals is reported to be 30% (Agarwal, Ferguson, Banks, Batterham, Bauer, Capra & Isenring, 2011). There are a number of barriers that seem to be causing this problem. Walton, Williams and Tapsell (2012) investigated the top barriers of which they found the top five were; lack of feeding assistance, lack of flexibility of food service, lack of choice due to special diet, boredom due to length of stay and limited variety. This search is backed up by Naithani, Welan, Thomas, Gulliford and Morgan’s (2008) study who found that overall patients were satisfied with the food quality, although they experienced hunger during their time in hospital due to difficulties accessing food. The barriers were identified to belong to one of three groups: organisational barriers; physical barriers; and environmental factors. Naithani et al. (2008) conclude that these barriers remain in place, as patients are often hesitant to ask for help, which results in staff continuing to be unaware of the barriers.
Many articles have been written on malnutrition and its effect of length of hospital stay. Malnutrition causes an increase in the length of hospital stay for older adults in New Zealand. Dunne (2008) found the malnutrition results in physical effects most notably impaired growth and development. This directly affects length of treatment and recovery time. Dunne concludes that failure to prevent malnutrition results in an increased length of stay in acute care settings. Lim, Ong, Chan, Loke, Ferguson and Daniels (2011) agree with Dunne (2008) reporting that malnutrition results in an increased length of stay, they claim that malnourished patients have a 1.5-1.7 times longer hospital stay than well-nourished patients. Current research demonstrates that malnutrition has a very significant effect on increasing length of stay in hospital (Corish & Kennedy, 1999, Agarwal, Ferguson, Banks, Batterham, Bauer, Capra & Isenring, 2012). It is evident in these articles above that the research supports the theory that malnutrition does cause an increase in length of hospital stay.
The implications of malnutrition on patient healthcare outcomes are directly related to increasing length of stay. Dunne (2008) reports that malnutrition has physical effects that can cause impaired growth and repair processes, reduction in body mass and body fat content and a reduction in strength. It is apparent that this would result in an increased need for interventions to aid recovery, which in turn would result in increasing treatment and recovery time compared to someone who was not nutritionally compromised. However, Corish and Kennedy (1999) state that the implications of malnutrition on health results in an impairment of every body system, particularly muscle weakness. This muscle weakness will result in longer recovery times therefore resulting in an increased length of hospital stay. Although these two articles contain differing information on the consequences of malnutrition on the body, they both support the theory that malnutrition causes an increase in length of hospital stay.
It is evident that malnutrition causes an increase in the cost of hospitalisation in older adults in New Zealand and Australia. Lim et al, (2011) found that there was an increase in hospitalisation cost when compared with well-nourished patients with similar diagnoses. Agarwal et al., (2012) and Banks, Graves, Bauer, and Ash, (2010) also report that malnourished patients incur greater hospital costs. It can be argued that the increase in hospital cost is a direct effect of the increase in the length of stay. The longer someone is in hospital the more it will cost due to increased use of resources. There have been budget cuts to most of the DHBs and they are all scrambling for ways to deliver the same standard of care with less money. Saving money on food can seem like a good solution which has a noticeable impact on the quality of the food; it also means that there is more chance for barriers to adequate nutrition. This is especially noticeable in the organizational barriers that initially arise with the implementation of a new food system. There have been media reports of the food not being hot enough when the patients received them (Goodwin, 2016). It is very important that more barriers like this do not arise and any that occur are overcome promptly otherwise there will be a negative impact on patient outcomes resulting in increasing hospital costs.
There is money to be saved by having a food service that reduces the barriers to adequate nutrition. By reducing the barriers to adequate nutrition length of hospital stay would not increase therefore cost of hospitalisation also would not increase. It is not only the job of the food service team to ensure that barriers to adequate nutrition are reduced. It is also the responsibility of nurses to ensure that physical barriers are reduced. Nurses need to help patients around mealtimes to ensure that they are in a comfortable position to eat, they can reach their food and utensils and there is no packaging that they are unable to open. Some patients also require further assistance with feeding due to physical disability (Naithani, et al., 2008). With a reduction in the barriers to good nutrition there should also be a reduction in the number of patients who experience malnutrition and therefore also in the costs incurred by malnutrition.
It can be argued that it will be beneficial to put such interventions into place as malnutrition adds a huge cost to the health care system due to the increased length of stay in hospital that it causes (Dunne, 2008). From the literature it is possible to distinguish the most feasible interventions to minimise malnutrition in older adults in acute care. Walton, et al. (2012) found the food interventions with the top priority to enhance nutritional support in hospitals in Australia. Walton, et al, (2012) claim that the food interventions with the best opportunity to reduce malnutrition in hospitals are; food fortification, increased assistance with packaging, meal setup and feeding support, more snacks between meals, improved variety in the menu (especially important for patients with a longer stay) and an increase in nutritional assessment tools. It is important to put these interventions into place as Agarwal, et al., (2012) found that nutritional interventions assert positive effects for patient outcomes. Therefore by putting such interventions in place to prevent malnourishment DHBs would be able to save money and put it into other areas of healthcare.
Malnutrition is a preventable health problem that has a very high prevalence in acute care of older adults in New Zealand and Australia. In order to minimise the problem of malnutrition we need to begin by increasing our understanding of where the problem lies. If we are able to reduce the extent of malnutrition we will simultaneously reduce the financial burden on our healthcare system that is caused by an increased length of stay. Malnutrition is a problem New Zealand and Australian hospitals are facing that is highly prevalent. Malnutrition results in poorer health outcomes for those who are affected by it. Malnutrition is highly preventable with screening which will lead to early detection and can result in prevention (Agarwal et al., 2012). There is an increasing awareness of the problem of malnutrition among healthcare professionals, although the extent of the problem is still widely unknown. Introducing nutritional screening would not only identify the at risk individuals but would also give health professionals greater insight into the prevalence of malnutrition in their respected fields of work. Another advantage of the implementation of nutritional screening will be that the complications that stem from malnutrition will be more visible. Screening is a very valuable tool that can lead to a great reduction in the prevalence of malnutrition through prevention.
One of the ways to detect those at risk of malnutrition is screening. We need to implement nutrition screening on admission to hospital so that we are able to detect patients who are at risk. Nutritional screening also needs to be conducted periodically after admission so that anyone who begins to increase in risk can be found. Following nutritional screening, we will know the patients who are at higher risk of becoming malnourished. The next step with this new knowledge will be to form nutritional care plans for patients who are found to be at risk of malnutrition after screening (Dunne, 2009). The nutritional care plan needs to cover several areas. Individual needs, which includes food allergies and cultural beliefs around food. Environmental factors that relate to eating meals in a protected environment that promotes healthy eating behaviours. Appropriate preparation so that the patient is able to feel comfortable while eating their meal. Finally, it is important to have good communication among staff, it is vital that everyone is aware of who the most vulnerable individuals are so that the treatment plan can be followed after change of shift (Dunne, 2009) well documented evidence of plans are paramount to smooth continuity of care over time. If there is going to be a reduction of malnutrition in New Zealand hospital the implementation of screening and well-documented care planning is the platform for success.
This review looked at the prevalence of malnutrition in older adults in New Zealand and Australia. It paid particular interest to the impact malnutrition has on the length of stay and the hospital costs that are incurred due to malnutrition. This review discovered that malnutrition has a prevalence of 30% in New Zealand and Australia. Malnutrition causes an increase in length of stay by 1.5-1.7 times that of a person with a similar diagnosis without malnutrition. Malnutrition results in greater hospital costs due to the increased length of stay. The three main themes that were discussed were: the extent of the problem in New Zealand and Australia, the increase on length of hospital stay, the increase of health care costs. There are solutions that can be put into practice so we can begin to minimise the problem of malnutrition in acute care hospitals in New Zealand and Australia. These are to begin routine nutrition screening and then when the high-risk patients are detected a plan can be put in place to minimise the chances of malnutrition happening.
Agarwal, E., Ferguson, M., Banks, M., Batterham, M., Bauer, J., Capra, S., & Isenring, E. (2012). Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: Results from the Nutrition Care Day Survey 2010. Clinical Nutrition, 32: 737-745. http://dx.doi.org/10.1016/j.clnu.2012.11.021
Agarwal, E., Ferguson, M., Banks, M., Batterham, M., Bauer, J., Capra, S., & Isenring, E. (2011). Nutritional status and dietary intake of acute care patients: Results from the Nutrition Care Day Survey 2010. Clinical Nutrition,31(1): 41-47.
Corish, C., & Kennedy, N. (1999). Protein-energy undernutrition in hospital in-patients. British Journal of Nutrition, 83: 575-591.
Dunne, A. (2008). Malnutrition and the older adult: care planning and management. British Journal of Nursing,17(20): 1269-1273.
Dunne, A. (2009). Management of malnutrition in older people within the hospital setting. British Journal of Nursing, 18(17): 1030-1034.
Elia, M. (2000). Guidelines for Detection and Management of Undernutrition in the Community. A report by the Malnutrition Advisory Group. BAPEN, Redditch.
Lim, S., Ong, K., Chan, Y., Loke, W., Ferguson, M., & Daniels, L. (2011). Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clinical Nutrition,31: 345-350.
Goodwin, E. (2016, February 16). Hospital food ‘not hot’ but ‘will improve’. Otago Daily Times. Retrieved from: http://www.odt.co.nz/news/dunedin/372987/hospital-food-was-not-hot-will-improve#sthash.YDbgkq5y.dpuf
Naithani, S., Whelan, K., Thomas, J., Gulliford, M., & Morgan, M. (2008). Hospital inpatients’ experiences of access to food: a qualitative interview and observational study. Health Expectations,11: 294-303.
Walton, K., Williams, P., & Tapsell L. (2012). Improving food services for elderly, long-stay patients in Australian hospitals: Adding food fortification, assistance with packaging and feeding assistance. Nutrition & Dietetics; 69: 137-144.
Whitehead, D. (2013). Identifying research ideas, questions, statement & hypotheses. In Z. Schineider, D. Whitehead, G. LoBionda-Wood, & J. Haber. Nursing and midwifery research methods and appraisal for evidence-based practice (4th ed.). (p.57-76) Sydney, Australia: Mosby/Elsevier