MINISTER VARADKAR HAS clearly put his weight behind improving hospital menus since Michelin star chef Oliver Dunne highlighted the appalling food his wife was served during a stint in hospital. I applaud both Oliver and the Minister for finally taking up the challenge of tackling what had become accepted as an almost inevitable part of the hospital experience.
The media also deserves credit for playing the long game and keeping the topic in the spotlight, making it harder for press officers to handle in the age old, tried and trusted manner: ie, craft a statement that gives the impression of action but falls short of a commitment that any senior individual or department might later be tied to.
Unfortunately, whilst laudable and long awaited, the furore around inedible, fatty food has overshadowed a far more serious issue that puts patients’ lives and health at risk and that food alone, irrespective of how delicious or appetising, may have little or no impact in addressing.
The silent problem of disease-related malnutrition
Disease-related malnutrition, which can be clinically advanced even in patients with normal body weight, remains a major cause of avoidable complications and an independent risk factor for conditions that are generally associated with poor quality care: pressure sores, hospital acquired infections, longer length of stay and higher readmission rates.
Despite this, little has been done to address the underlying problems that are well known to the Department of Health and experts within the HSE: lack of nutrition education within medical curriculum, inadequate training of health professionals on nutritional care, lack of specific quality standards that are a basic requirement for health providers and the absence of any requirement to implement nutrition screening or care pathways, despite evidence that they work and are cost effective.
Failure to implement ‘good nutritional care’ guidelines
At a major two day conference last week attended by over 300 health professions, the failure by hospitals to implement ‘good nutritional care’ guidelines issued by the Department of Health in 2009 was cited as an example of the lack of priority placed on safeguarding patients from avoidable – and in some cases life-threatening – risks.
The conference, hosted by the Irish Society of Clinical Nutrition and Metabolism (IrSPEN), devoted its first half-day session to a multidisciplinary policy seminar to develop a consensus for urgent action to tackle the major deficits in the nutritional care provided in many hospitals, and the lack of services and resources for managing patients that require far more specialised nutrition support including intravenous nutrition.
With a theme of ‘Time to Act’ reflecting the consensus amongst both Irish and international experts that healthcare providers are not doing enough to prioritise nutrition – despite overwhelming evidence that the problem is a major issue costing an estimated €1.4billion in Ireland each year – delegates and invited representatives from the HSE and HIQA heard that patients with malnutrition (which may require as little as 5% weight loss over three months or 10% within six months in a person with an underlying chronic illness) are nearly twice as likely to end up in hospital compared with someone who is eating well or receiving supplementary nutrition.
Furthermore, unless hospitals are screening every patient on admission to hospital, (the vast majority of Irish hospitals are not doing so) these patients will not receive appropriate nutritional care; will have a threefold greater chance of getting a hospital acquired infection; spend at least 30% longer in hospital; and be nearly twice as likely to be readmitted to hospital after discharge.
Will action finally replace words?
The seminar, featuring world expert Professor Marinos Elia and leading health economist Professor Charles Normand was opened by Professor John Reynolds who as a leading cancer surgeon who is widely published on clinical nutrition, is the chairman of IrSPEN. The HSE Quality Improvement Division was represented on the agenda to announce their plans to lead an initiative to improve nutrition and hydration, giving some hope to attendees that, finally, action will replace words and encourage hospital managers to embed good nutritional care into their systems and procedures alongside improvements that chef Oliver Dunne can manage to stimulate through his efforts to drive change.
Speaking about the baffling failure of healthcare providers to commit the necessary resources to tackle the problem, Professor Elia presented updated findings from a new costing report that shows that malnourished patients in England cost between three and four times MORE to manage than non-malnourished patients. He presented evidence from systematic reviews that nutrition supplementation of patients identified by screening programmes reduced risks of complications, length of stay and readmission rates, leading to substantial cost savings, concluding ‘the more we treat, the more we save’.
Reducing the length of stay
If this sounds too simple, a presentation by Elaine Bradley, clinical nurse manager at Beaumont hospital only reinforced the message when she reported on a pilot programme to introduce nutrition screening, which was conducted last year in selected medical and surgical wards. Even though compliance to screening was far from perfect, the initiative was able to drive a reduction in length of stay of 1.6 days on the surgical ward and three days on the medical ward, higher than the hospital average of 0.8 days and translating into a potential cost saving of €1,550-€3,000 per patient.
If Minister Varadkar had been available to open the conference this week and heard the speakers, he might also have been affected by presentations given by Ben O’ Connor, a double lung transplant patient with cystic fibrosis who had undergone an oesophagectomy and depended on ongoing nutrition support, and by Professor Billy Bourke, a consultant paediatric gastroenterologist at Our Lady’s hospital in Crumlin.
No action has been taken to improve the situation
Professor Bourke expressed his extreme frustration at the ongoing battles he has every time he wants to send a child with intestinal failure home on total parenteral nutrition, despite the major cost savings and improved quality of life for this small but highly complex group of children that may never be able to eat normally.
Advocating yet again for an adult specialist service for patients with intestinal failure that he can transition from his specialist unit in Crumlin once these children reach 18 years of age, he told the audience that parents were now reluctant to leave the Crumlin service and he fully understood their fears.
When this issue was highlighted by the press in the last two months, a HSE spokesperson that spoke to the press indicated that they have no plans to resolve the issue. Professor Bourke’s concluding remarks were that, after 15 years of setting up his service, no action has been taken to improve the situation and it was unprecedented for a developed economy to be without an adult service (there is one in Northern Ireland).
Expressing disappointment that he was probably talking to the converted and that the messages were falling on deaf ears, he quickly exited the building without waiting for lunch to look after a ‘very sick’ little boy that needed his care.
Niamh Rice is an independent Consultant in nutrition and medical affairs and Director of IrSPEN. The views expressed in this piece are hers alone.
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