Implementation of nutrition risk screening using the Malnutrition Universal Screening Tool across a large metropolitan health service.

BACKGROUND: A standardised nutrition risk screening (NRS) programme with ongoing education is recommended for the successful implementation of NRS. This project aimed to develop and implement a standardised NRS and education process across the adult bed-based services of a large metropolitan health service and to achieve a 75% NRS compliance at 12 months post-implementation. METHODS: A working party of Monash Health (MH) dietitians and a nutrition technician revised an existing NRS medical record form consisting of the Malnutrition Universal Screening Tool and nutrition management guidelines. Nursing staff across six MH hospital sites were educated in the use of this revised form and there was a formalised implementation process. Support from Executive Management, nurse educators and the Nutrition Risk Committee ensured the incorporation of NRS into nursing practice. Compliance audits were conducted pre- and post-implementation. RESULTS: At 12 months post-implementation, organisation-wide NRS compliance reached 34.3%. For those wards that had pre-implementation NRS performed by nursing staff, compliance increased from 7.1% to 37.9% at 12 months (P < 0.001). The improved NRS form is now incorporated into standard nursing practice and NRS is embedded in the organisation's 'Point of Care Audit', which is reported 6-monthly to the Nutrition Risk Committee and site Quality and Safety Committees. CONCLUSIONS: NRS compliance improved at MH with strong governance support and formalised implementation; however, the overall compliance achieved appears to have been affected by the complexity and diversity of multiple healthcare sites. Ongoing education, regular auditing and establishment of NRS routines and ward practices is recommended to further improve compliance.

Can the Mini Nutritional Assessment (MNA) Be Used as a Nutrition Evaluation Tool for Subacute Inpatients over an Average Length of Stay?

OBJECTIVE: The prevalence of malnutrition in subacute inpatient settings has been reported to be 30-50%. While there are a number of nutrition evaluation tools which have been validated to diagnose malnutrition, the use of a validated nutrition evaluation tool to measure changes in nutritional status during an average length of stay for a subacute inpatient has not yet been tested. This study aims to determine the potential of the full MNA (full Mini Nutritional Assessment) and MNA (Mini Nutritional Assessment Short Form) scores to measure change in nutritional status over an average subacute inpatient stay (21 days). DESIGN: A prospective observational study. SETTING: The study was performed in three Rehabilitation and Geriatric Evaluation and Management (GEM) wards of the Kingston Centre, Monash Health, Melbourne, Australia. PARTICIPANTS: All patients ≥65 years admitted to these wards with an expected length of stay of at least 14 days were considered for inclusion in this study. MEASUREMENTS: Nutritional status was assessed on admission using the full MNA as part of usual dietetic care and patients were provided with nutrition intervention/diet therapy based on full MNA classification. Full MNA score (0-30), MNA score (0-14), anthropometry (weight and height) and nutritional biochemistry (serum albumin, transthyretin and C-reactive protein) were compared between admission and day 20.5 ± 2.4. RESULTS: Mean age (± SD) of 83 ± 7 years, n=114. For those patients diagnosed at risk of malnutrition or malnourished (n=103), there were significant increases in full MNA score (1.8 ± 2.4, p<0.001), MNA score (0.9 ± 1.7, p<0.001), weight (0.6 ± 2.5 kg, p=0.017) and serum albumin (1.4 ± 4.4 g/L, p=0.003) over the study period. All four of the full MNA domain sub-scores, also increased significantly in those patients diagnosed at risk of malnutrition or malnourished (n=103): anthropometric assessment (p<0.001), dietary assessment (p<0.001), general status assessment (p=0.019) and self-perceived health and nutrition states (p=0.033). CONCLUSION: Both the MNA and full MNA can be used to evaluate nutrition progress within the subacute inpatient setting over a three week time period, thereby providing clinicians with feedback on a patient's nutrition progress and assisting with ongoing care planning. Due to its ease of use and shorter time required to complete, the MNA may be the preferred nutrition evaluation tool in this setting.

Nutritional consequences of modified vertical gastroplasty in obese subjects.

BACKGROUND: Gastroplasty results in a considerable reduction in food intake and dramatic weight loss. This is likely to have a nutritional impact, although it is expected that this may be minimised by good advice and supplement use. METHODS: Twenty six obese subjects were studied in detail before and after modified long vertical gastroplasty (MLVG), in a setting where comprehensive nutritional advice on symptom avoidance was readily available and multivitamin supplements advised. Nutritional intake and anthropometry were measured preoperatively and at 2, 5 (n = 22) and 12 months (n = 11) postoperatively. RESULTS: Mean weight loss was 13%, 22% and 31% of initial body weight at the respective time points. Energy intake (EI) was significantly reduced postoperatively, with the mean protein intake being only 40 g/d. At 2 months, mean intakes of iron, calcium and zinc from food were 40%, 71% and 39%, respectively, of the Australian recommended dietary intake (RDI), and iron and zinc intake remained below half the RDI at 5 months. Only regular adherence to the vitamin/mineral supplement, brought iron and calcium intakes close to RDI, but zinc remained low. Haemoglobin and serum ferritin concentrations did not alter significantly and remained within the reference range, but serum folate fell significantly between 5 months and 12 months. By 5 months, 60% of subjects never regurgitated or regurgitated less than once a week. Fresh bread was the least tolerated food. Frequency of regurgitation was not correlated with adequacy of nutrient intake. CONCLUSIONS: The results emphasise the need for regular follow-up of MLVG patients, and nutritional advice which includes diet quality as well as symptom management, and regular intake of the vitamin/mineral supplement for at least a year postoperatively. Low protein intakes, however, remain of potential long-term concern.

Use of multiple photosensitizers and wavelengths during photodynamic therapy: a new approach to enhance tumor eradication.

Several studies have examined the synergism of hyperthermia or chemotherapy agents in combination with photodynamic therapy (PDT) to enhance tumor eradication. In our unique approach to treatment, multiple photosensitizers and wavelengths were used: two photosensitizers, Photofrin II and meso-tetra-(4-sulfonatophenyl)-porphine (TPPS4), irradiated at the appropriate therapeutic wavelength for each photosensitizer. EMT-6 mammary tumors were induced in the flanks of BALB/c mice. The mice were assigned to a control group (50 mice) or treatment group (150 mice). All treatment animals and some control animals received photosensitizing drug (5 mg/kg of TPPS4, 5 mg/kg of Photofrin II, or 2.5 mg/kg of both TPPS4 and Photofrin II). All treatment animals and some control animals also received light treatment (630 nm for TPPS4 and/or 658 nm for Photofrin II). The results show that the approach using both drugs and the corresponding therapeutic wavelengths enhanced the effectiveness of PDT. This approach achieved a cure rate of up to 100%, which was, depending on the light intensity used, as much as 40% greater than the rate achieved by the approach using one drug and one wavelength. The results also show that lesser amounts of drug and/or light may be required if both drugs and wavelengths are used, thus lowering the chances of side effects common to PDT. Furthermore, the results indicate that the increased tumor kill is due to a synergistic effect of the two photosensitizers that was tested on the tumor microvasculature in the first few hours after PDT.

A structural equation model of physician productivity.

The understanding of physicians' practicing behaviors can enhance the development of active marketing strategies. The authors investigate the effects of physician characteristics on physician productivity in a hospital setting. Use of admission records, coupled with data from a survey of physicians' perceptions of hospital operations and their commitment to the study hospital, provides useful results for determining the most effective means for promoting physician satisfaction. Information from the survey can be used to forecast both the demand for various services and the likely physician response to the improvement of services and communications between physicians and administrative staff.

Sucrose versus saccharin as an added sweetener in non-insulin-dependent diabetes: short- and medium-term metabolic effects.

Seventeen non-insulin-dependent diabetic patients were randomly allocated to their usual diet supplemented daily with either 28 g sucrose or 30 g starch (isoenergetic with sucrose) and saccharin (equivalent sweetness). After 6 weeks, the supplements were reversed. No significant treatment effects were observed on fasting concentrations of blood glucose, plasma insulin or serum triglycerides, or on urinary excretion of glucose, sodium or potassium. Following a standard breakfast with either sucrose or saccharin and starch, no differences between meal responses were observed. This study demonstrates no medium-term metabolic contraindications to including a moderate amount of sucrose in the diets of patients with non-insulin-dependent diabetes mellitus.