malnutrition is present in 1855% of hospitalized patients ( sorensen et al . , 2008 ; imoberdorf et al . ,
studies show that nutritional support to undernourished patients and those at nutritional risk is advantageous ( stratton and elia , 2007 ) .
european guidelines state that provision of tailored food should be an integral part of patient care ( council of europe , 2002 ; kondrup et al .
, 2003a , 2003b ; norwegian directorate of health , 2009 ) . however , nutrition is often not given priority in clinical practice ( mowe et al .
insufficient knowledge and low commitment among nurses and physicians result in an insufficient focus on nutritional aspects of care ( kondrup et al . , 2002 ; bavelaar et al . , 2008 ;
dietary parameters are seldom monitored during hospital stays ; neither are they described in patients ' medical records or discharge summaries ( bavelaar et al . , 2008 ; meijers et al . , 2009
it is a great challenge to implement nutritional guidelines in hospitals ( llido , 2006 ; mowe et al . , 2006 , 2008 ; bavelaar et al . , 2008 ;
the goals were to increase professional awareness of the importance of nutritional care and to provide proper nutritional care to patients with such needs . to achieve these goals ,
it was considered necessary to develop guidelines , tools and skills , and to educate nurses and physicians in basic clinical nutrition .
responsibilities were defined and a professional framework was established ( figure 1 ) to implement these aspects of nutritional care .
an important factor was to increase the flexibility of the food services , leading to the provision of more tempting and nourishing food according to patient needs .
the aim of the present study was , by using repeated point prevalence surveys , to evaluate whether the implementation of a new strategy had positive effects on nutritional care in the hospital .
we performed a prospective quality improvement program implementing nutritional guidelines through the dedicated nutritional network ( figure 1 ) . repeated point prevalence surveys over 2 years made it possible to assess whether practice changed over time
the seven further surveys were conducted in 51 departments between june 2008 and november 2009 .
patients were excluded if they were admitted for bariatric surgery , day - surgery or other day - care procedure .
the barriers to proper nutritional care identified by the council of europe ( council of europe , 2002 ) were taken into account when the nutritional campaign was carried out .
health care professionals , kitchen staff , patients ' representatives and the hospital management were involved in workshops or the network .
the nutritional network included 130 physicians , nurses and nurse assistants , and were organized in three levels ( figure 1 ) .
they were educated for 2 days in basic clinical nutrition and were then responsible for introducing the guidelines to their units .
other amenities included interactive tools like website , e - course in clinical nutrition and dedicated forms in electronic patient journal system . at 0800 hours on the day of registration , administrative patient 's data ( name , date of birth , sex and hospital ward )
the patients were first included ( supplementary information sheet 1 , appendix 1 ) , then screened according to the nutrition risk screening 2002 ( nrs 2002 ) ( supplementary information sheet 2 , appendix 1 ) .
if total score was 3 , additional questions about nutritional support were answered ( supplementary information sheet 3 , appendix 1 ) .
this was measured as the proportion of patients screened , proportion of patients at nutritional risk with a nutritional plan , that is , who were either under treatment or for whom treatment was planned , and the proportion of patients seen by a dietician .
we used the proportion of patients coded with the diagnoses for under nutrition according to the international statistical classification of diseases and related health problems ( icd-10 ) e44 or e46 ( world health organization , 2010 ) to assess the participation by physicians .
statistical evaluation included a descriptive analysis , and estimations of prevalence of undernutrition at each survey and the proportion of patients who underwent nutritional treatment .
version 9.1 and spss version 17.0 ( spss inc . , chicago , il , usa ) .
this study was part of a quality improvement project and was exempted from review by regional committee for medical and health research ethics .
the patients were not asked to give informed consent , as they were not subject to any experimental interventions .
the barriers to proper nutritional care identified by the council of europe ( council of europe , 2002 ) were taken into account when the nutritional campaign was carried out .
health care professionals , kitchen staff , patients ' representatives and the hospital management were involved in workshops or the network .
the nutritional network included 130 physicians , nurses and nurse assistants , and were organized in three levels ( figure 1 ) .
they were educated for 2 days in basic clinical nutrition and were then responsible for introducing the guidelines to their units .
other amenities included interactive tools like website , e - course in clinical nutrition and dedicated forms in electronic patient journal system .
at 0800 hours on the day of registration , administrative patient 's data ( name , date of birth , sex and hospital ward ) were transferred to a dedicated database .
the patients were first included ( supplementary information sheet 1 , appendix 1 ) , then screened according to the nutrition risk screening 2002 ( nrs 2002 ) ( supplementary information sheet 2 , appendix 1 ) . if total score was 3 , additional questions about nutritional support were answered ( supplementary information sheet 3 , appendix 1 ) .
this was measured as the proportion of patients screened , proportion of patients at nutritional risk with a nutritional plan , that is , who were either under treatment or for whom treatment was planned , and the proportion of patients seen by a dietician .
we used the proportion of patients coded with the diagnoses for under nutrition according to the international statistical classification of diseases and related health problems ( icd-10 ) e44 or e46 ( world health organization , 2010 ) to assess the participation by physicians .
statistical evaluation included a descriptive analysis , and estimations of prevalence of undernutrition at each survey and the proportion of patients who underwent nutritional treatment .
data analysis was performed using the statistical software of sas institute inc . , version 9.1 and spss version 17.0 ( spss inc . ,
this study was part of a quality improvement project and was exempted from review by regional committee for medical and health research ethics .
the patients were not asked to give informed consent , as they were not subject to any experimental interventions .
of the total number of 5849 inpatients on the eight occasions , 666 ( 11% ) did not meet the inclusion criteria , and for 1579 patients ( 27% ) , the screening was not completed .
the proportion of patients screened increased significantly from the first to the last survey , with a range from 5477% ( figure 3 , p=0.012 ) .
the prevalence of nutritional risk was 56% at the first point prevalence survey ( january 2008 ) and varied between 3036% at the subsequent surveys ( table 1 ) .
in total 1230 patients were identified to be at nutritional risk during the eight surveys . of these ,
743 ( 60% ) , had a nutritional treatment plan . in 649 cases ( 53% ) ,
the nutritional intervention was started and in 94 cases ( 7% ) nutritional treatment was pending ( figure 2 ) .
the proportion of patients receiving a nutritional treatment plan varied between 54 and 68% , and did not increase during the eight surveys ( p=0.66 ) .
those who already received nutritional treatment varied between 47 and 59% over time , and patients at risk whose nutritional treatment was planned but had not yet commenced varied between 5 and 11% during the surveys . only 62 ( 5% ) of the patients at nutritional risk were evaluated and followed up by a dietician . during 2008 and 2009 , 1.3% of all adult , somatic inpatients at the hospital were diagnosed with malnutrition diagnoses ( e44 or e46 ) . in this study , 649 patients ( 14.3% ) of the eligible patients ( n=5183 ) were qualified for this ( at nutritional risk and have got nutritional treatment ) , and 487 ( 9.3% ) more were in need for such treatment ( at nutritional risk and did not get nutritional treatment ) .
, 2180 were identified by the four initial questions ( figure 2 ) , while the other 194 were considered not at risk according to the remaining nrs 2002 questions , giving a specificity of 92% to identify not - at - risk patients , with the first four questions .
one in three screened patients were at nutritional risk , but only half of the people at risk received nutritional treatment , with no improvement during the study period .
the strengths of this study include a large sample of patients and almost complete coverage of relevant wards and patient categories .
we used a validated screening tool and the screening data were reported by a standardised electronic form designed for this purpose .
an important limitation is that the point prevalence surveys were initiated more than 1 year after the start of the nutritional campaign , and initial changes in nutritional practice could then be undetected .
a possible limitation is that the point prevalence surveys themselves must be considered to be , at the same time , both interventions and measurements of the results of these interventions , because , as screening is supposed to improve nutritional practice , it is also a reminder of better nutritional practice .
this is supported by the fact that results from repeated point prevalence surveys of hospital infections have demonstrated improved clinical practice ( scheel and stormark , 1999 ; sartor et al . , 2005 ) .
although screening performance improved , the most important outcome , namely the proportion of patients at nutritional risk who received a nutritional treatment plan did not increase .
it could be a problem that information about patients at nutritional risk were not communicated from the nurses who did the screening to the nurses and physicians who were responsible for giving nutritional treatment .
another factor is a limited dietician service in the hospital the number of dieticians / clinical nutritionists in norwegian hospitals is among the lowest in western countries ( norwegian health directorate , 2007 ) , implying that the physicians and nurses mainly are responsible for the patients nutritional care .
nutrition has low priority in the education of medical students in norway ( norwegian directorate of health , 2007 ) and norwegian physicians and nurses reported to have less knowledge and interest for clinical nutrition than their danish and swedish colleagues ( mowe et al . , 2008 ) .
the interest in nutritional matters is lower in wards not regularly visited by dieticians ( thoresen et al . , 2008 ) .
based on the experience from this study and other recent publications ( mowe et al . , 2008 ) , we suggest that there is a scarcity of nutritional knowledge and of dieticians available .
we propose that a greater focus on nutritional education of physicians , both undergraduate and postgraduate , and an increased number of dieticians are important to improve nutritional practice . in norway ,
central health authorities have developed clinical guidelines for nutritional care in hospitals and nursing homes . performing audits of the implementation of these guidelines and economic incentives , such as diagnosis related groups reimbursement for diagnosing malnutrition , may also help improve practice .
, 2003a , 2003b ; norwegian directorate of health , 2009 and the hospitals local guidelines ) as the first step to individualized nutritional treatment .
nutritional screening is one of several time - consuming procedures in a busy hospital and may be easy to neglect . by using the four opening questions in nrs 2002 we identified 92% of the patients not at nutritional risk .
as all at - risk patients are screened positive on these first four questions of nrs 2002 , there will be no patients at risk who are not detected .
the proportion of patients classified to be at nutritional risk , would increase from 34 to 40% when using only the four initial questions .
the prevalence of patients at nutritional risk is similar to previous european studies ( rasmussen et al . , 2006 ; sorensen et al . , 2008
; lucchin , 2009 ) but lower than the 44% , shown by a previous norwegian study ( oppedal et al . , 2010 ) .
the difference can be due to a bias in our study because 1579 patients ( 27% ) eligible for screening were not screened .
the healthiest patients may have a higher likelihood of being screened , because it can be difficult to weight bedridden patients and patients in wheelchairs .
it is also a challenge to obtain reliable information about previous weight and food intake from certain patients , for example , with delirium and dementia .
it has been reported that patients without anthropometric information in the medical records have higher morbidity , mortality and length of stay ( stratton et al .
this study was not designed to assess patient outcomes or improvements in food provided to the patients , but there might have been some general improvement in nutrition in the hospital owing to better and more flexible food services .
the point prevalence surveys were easy to perform owing to previous experience with similar surveys on infections .
it is a suitable method to draw attention to a common and serious problem in health care and it should be considered as a national quality indicator in clinical nutrition .
implementation of nutritional guidelines in this university hospital improved the screening performance , which is an important element in better nutritional care , but did not increase the proportion of patients who received nutritional treatment .
one of the three patients was at nutritional risk , but only half of them got nutritional treatment . in order to improve practice , we suggest using only the four initial screening questions in nrs 2002 to identify patients not at risk .
we also suggest better education in nutritional care for physicians and nurses , and more dieticians employed to achieve more knowledge about nutrition audits of implementation of guidelines performed by health authorities , better accordance between the screening tool and the icd-10 criteria and specific reimbursement for diagnosing malnutrition may also improve practice .
we propose repeated point prevalence surveys to become a national quality indicator in clinical nutrition .
 background / objectives : malnutrition is present in 2050% of hospitalized patients , and nutritional care is a challenge . the aim was to evaluate whether the implementation of a nutritional strategy would influence nutritional care performance in a university hospital.subjects/methods:this was a prospective quality improvement program implementing guidelines for nutritional care , with the aim of improving nutritional practice . the nutrition risk screening ( nrs ) 2002 was used . 
 point prevalence surveys over 2 years to determine whether nutritional practice had improved.results:in total , 3604 ( 70% ) of 5183 eligible patients were screened and 1230 ( 34% ) were at nutritional risk . 
 only 53% of the at - risk patients got nutritional treatment and 5% were seen by a dietician . 
 the proportion of patients screened increased from the first to the eighth point prevalence survey ( p=0.012 ) , but not the proportion of patients treated ( p=0.66 ) . 
 the four initial screening questions in nrs 2002 identified 92% of the patients not at nutritional risk.conclusions:implementation of nutritional guidelines improved the screening performance , but did not increase the proportion of patients who received nutritional treatment . 
 point prevalence surveys were useful to evaluate nutritional practice in this university hospital . in order to improve practice , we suggest using only the four initial screening questions in nrs 2002 to identify patients not at risk , better education in nutritional care for physicians and nurses , and more dieticians employed . 
 audit of implementation of guidelines , performed by health authorities , and specific reimbursement for managing nutrition may also improve practice . 
Introduction
Materials and methods
Implementing of guidelines
The point prevalence surveys
Outcomes
Statistics
Ethics
Results
Discussion
Conclusion
Supplementary Material