Improving Patient Nutrition and Hydration in Hospital

Patient nutrition and hydration are often overlooked by doctors when patients are admitted acutely to hospital. This has been an established problem for many years despite evidence about the clinical and financial costs of neglecting this area. In a recent study, one in three patients admitted to a care home or hospital were either malnourished or at risk. Patients who are admitted to hospital may be malnourished for many reasons, including poor appetite, swallowing difficulties and reduced cognitive ability. When a patient is admitted to hospital, adequate fluid and nutrition should be addressed. There are many reasons why malnutrition is important. It is associated with increased morbidity and mortality, and a two to three-fold increased risk of post-op complications. It may delay wound healing and puts the patient at increased risk of pressure ulcers and wound infections. Malnutrition also leads to impairment of the body's immune system and will prolong hospital stay by three days on average with a 50% increased readmission rate amongst this group of patients. Dehydration and 'over' hydration are common in the hospital setting but the subsequent morbidity and mortality is rarely recognised. Patients in hospital are on one hand at risk of developing acute kidney injury, whilst on the other hand at risk of acute pulmonary oedema.

NICE recommend that screening for malnutrition is carried out on all hospital in-patients on admission, usually this is carried out in the form of the 'MUST' charts. According to NICE, nutritional support should be considered in the following groups:

• BMI <18 .5="" li="">
• Unintentional weight loss >10% within past 3-6 months
• BMI <20 3-6="" 5="" and="" greater="" in="" li="" loss="" months="" past="" than="" the="" unintentional="" weight="">
• People who have eaten little or nothing for more than 5 days or are likely to eat little or nothing for the next 5 days or longer
• People with poor absorptive capacity, high nutrient losses, or increased nutritional needs from causes such as catabolism

Admission to hospital provides a vital opportunity for intervention, but what can be done? The first step is to identify patients at risk. To achieve this, there needs to be increased recognition and awareness from all staff (medical and nursing). Maximising normal food intake needs to be encouraged. If appetite is reduced, oral nutritional supplement drinks can be used in the short term. Refer the patient to the hospital dietician for assessment. If oral nutrition is inadequate or impossible, enteral tube feeding or IV nutrition need to be considered (although these procedures carry risk - ie. misplaced NG tubes).

With regards to IV fluids, this is often inadequate and from my experience tends to be quite hap-hazard in hospitals. One problem is the lack of routine and careful fluid balance assessment by senior clinicians and the reliance on the most junior doctors with the least experience to carry out this task. Decisions on IV fluids are often left to out of hours, when the doctor on-call doesn't know the patient or their fluid requirements and is asked to 'write up more fluids' without much thought due to time pressure.

Ways in which we can improve our practice in order to benefit our patients include implementing the current NICE guidelines and auditing compliance with them. Senior clinicians and managers also need to share responsibility in this area. A simple measure, such as a ward round checklist could be used to improve fluids and nutrition. Staff should encourage patients to eat and drink, with assistance provided to those who need it. 'Protected meal-times' and red-trays to identify those patients with increased need for help are good ideas. Improving patient education is also an important consideration. So in summary, nutrition and hydration in hospital patients is an important, often neglected area and now is the time to address the problems which I've highlighted.