Nutritional Screening and Treatment of Malnutrition at a Haematological Ward - An economical perspective
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When a patient is admitted to the hospital he or she should be screened for malnutrition within the first 24 hours. If the patient is identified as being at risk, appropriate treatment should be given, and then the patient receives the appropriate ICD-10 code for malnutrition at discharge. This tells us that malnutrition has been treated, and should ensure that the ward receives reimbursement for the treatment given. The Norwegian health authorities gave the recommendations for prevention and treatment of hospital malnutrition in 2009, but are these guidelines being followed in clinical practice? Malnutrition is present in 19% - 60% of hospitalized patients, depending on the population under study and the screening tools used. Malnutrition is known to increase morbidity and length of stay (LOS), and therefore result in increased health care and hospital costs. It is estimated that it is possible to save an annual amount of 800 million Norwegian kroner, by identifying and treating malnutrition in Norwegian hospitals. Aims: The aim of this study was to evaluate the screening routines and nutritional treatment given at a haematology ward in a Norwegian university hospital, to evaluate if better routines can have an economic impact based on identification and coding for malnutrition, length of stay, and nutritional treatment. Methods: The thesis had a retrospective part where the above mentioned outcomes were studied, and a prospective part to evaluate the impacts of an intervention consisting of an instructive course. The routines for nutritional screening and treatment were evaluated by collecting data from the electronic medical record. The intervention was aimed towards the nurses. They received guidance and lectures on screening and nutritional treatment. Results: Medical records of 302 patients were retrospectively evaluated during two periods. 137 patients in the first period, and 165 patients in the second. In the first period no patients were screened for malnutrition, while 15 (9%) were screened in the second period (p under 0.001). There was not a significant difference in routines for coding malnutrition (8 in the first, 12 in second. P-value = 0, 651), and hence no difference in potential reimbursement. A significant decrease in LOS was observed, from a median of 5 to 4 days (p = 0,015), which was estimated to give a potential reduction of costs equivalent to NOK 7 289 350.00 annually. There was no significant difference in patients receiving nutritional treatment, individual nutritional plan or referral to clinical dietician. At the same time there was no significant difference in the kind of nutritional treatment given (parenteral nutrition, enteral nutrition, and oral nutritional supplements). Conclusions: An intervention consisting of an instructive course, with relevant lectures and training nurses in screening, resulted in a significant increase of screened patients. The intervention had no impact on routines for the coding of malnutrition, and the diagnosis related group (DRG) reimbursement for malnutrition. LOS was reduced, and this could potentially result in reduced costs. Our study indicates that the routines for nutritional screening are deficient, and that there is still room for improvement of nutritional routines at the haematology ward.