Managing Patients in the Hospital Setting

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

[97] Center for Substance Abuse Treatment (US). Improving Cultural Competence. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2014 (Treatment Improvement Protocol (TIP) Series, No. 59) 1, Introduction to Cultural Competence. Available from: https:// www.ncbi.nlm.nih.gov/books/

[98] DeWalt DA, Malone RM, Bryant ME, Kosnar MC, Corr KE, Rothman RL. A heart failure self-management program for patients of all literacy levels: A randomised, control trial. BMC Health Services Research.

[99] Rothman R, De Walt D, Malone R, Bryant B, Shintqani A, Crigler B, et al. Influence of patient literacy on the effectiveness of a primary care-based diabetes management program. Journal of the American Medical Association.

NBK248431/

2006;**6**(30):1-10

2004;**292**(14):1711-1716

**34**

**37**

**Chapter 3**

**Abstract**

*Donnette Wright*

mortality and morbidity.

obesity paradox, hospital mortality

**1. Global epidemiology and trends in malnutrition**

Nutrition and Hospital Mortality,

Nutrition has a strong positive linear relationship with hospitalisation, recovery and death. Nutritional status serves as an independent predictor of hospital morbidity and mortality. There is an ensuing academic debate concerning the role and magnitude of nutrition in modifying health outcomes and the strategies that are to be employed to ensure nutritional adequacy. Professional, skill, knowledge and experience are important correlates that may modify patient outcomes, but hospitals continue to be under-resourced even in developed states. It is imperative that current standards, recommendations and policies be examined with the view to aligning the appropriate needs and services to realise positive gains with hospital

**Keywords:** nutritional adequacy, malnutrition, undernutrition, nutritional support,

The incidence of malnutrition has expanded exponentially over the last three decades. At either ends of the nutritional spectrum, malnutrition is concerning to health care professionals and transcends the economic status worldwide, affecting both developed and developing countries. According to the World Health Organization, the incidence of malnutrition is declining among children but remains at critical levels. In 2017, globally there were 151 million children under 5 years of age who were stunted, 51 million children classified as wasted and 38 million children who were overweight. Alternatively, The WHO identifies that global adult undernutrition examined using low body-mass index (BMI) as a proxy has decreased from 13.8% in 1975 to 8.8% in 2014; corresponding levels for women are 14.6 and 9.7%. Conversely, the incidence of malnutrition on the other extreme (overnutrition) was identified as being 1.9 billion among adults (accounting for 38% of the global adult population). Malnutrition has been defined as a health condition where there is an imbalance in the body's supply and usage of energy, protein and other vital nutrients resulting in discernible physiological changes and clinical health outcomes [1]. The epidemiology of malnutrition is difficult to track due to the expansive nature of the definition. Many studies reference malnutrition as undernutrition concerning only weight but the umbrella term also includes conditions of micronutrient deficiencies such as iron, calcium, vitamin A, vitamin D, magnesium, iodine, and vitamin B12 which are the leading deficiencies globally. Moreover, overnutrition including overweight and obesity is often not classified as malnutrition, but the concept encompasses these states of nutrition

Morbidity and Health Outcomes

#### **Chapter 3**

## Nutrition and Hospital Mortality, Morbidity and Health Outcomes

*Donnette Wright*

#### **Abstract**

Nutrition has a strong positive linear relationship with hospitalisation, recovery and death. Nutritional status serves as an independent predictor of hospital morbidity and mortality. There is an ensuing academic debate concerning the role and magnitude of nutrition in modifying health outcomes and the strategies that are to be employed to ensure nutritional adequacy. Professional, skill, knowledge and experience are important correlates that may modify patient outcomes, but hospitals continue to be under-resourced even in developed states. It is imperative that current standards, recommendations and policies be examined with the view to aligning the appropriate needs and services to realise positive gains with hospital mortality and morbidity.

**Keywords:** nutritional adequacy, malnutrition, undernutrition, nutritional support, obesity paradox, hospital mortality

#### **1. Global epidemiology and trends in malnutrition**

The incidence of malnutrition has expanded exponentially over the last three decades. At either ends of the nutritional spectrum, malnutrition is concerning to health care professionals and transcends the economic status worldwide, affecting both developed and developing countries. According to the World Health Organization, the incidence of malnutrition is declining among children but remains at critical levels. In 2017, globally there were 151 million children under 5 years of age who were stunted, 51 million children classified as wasted and 38 million children who were overweight. Alternatively, The WHO identifies that global adult undernutrition examined using low body-mass index (BMI) as a proxy has decreased from 13.8% in 1975 to 8.8% in 2014; corresponding levels for women are 14.6 and 9.7%. Conversely, the incidence of malnutrition on the other extreme (overnutrition) was identified as being 1.9 billion among adults (accounting for 38% of the global adult population). Malnutrition has been defined as a health condition where there is an imbalance in the body's supply and usage of energy, protein and other vital nutrients resulting in discernible physiological changes and clinical health outcomes [1]. The epidemiology of malnutrition is difficult to track due to the expansive nature of the definition. Many studies reference malnutrition as undernutrition concerning only weight but the umbrella term also includes conditions of micronutrient deficiencies such as iron, calcium, vitamin A, vitamin D, magnesium, iodine, and vitamin B12 which are the leading deficiencies globally. Moreover, overnutrition including overweight and obesity is often not classified as malnutrition, but the concept encompasses these states of nutrition

#### **Figure 1.**

*The global burden of disease. Source: Ritchie and Roser [2].*

and is important in the public health predictions for non-communicable diseases. Nutritional deficiencies are ranked in the top 20 leading worldwide disease and disability burden in 2016, according to the Institute of Health Metrics Evaluation [2], and is a pivotal global concern (see **Figure 1**).

The prevalence of malnutrition in hospitalised adults has been extensively reported in the international literature and varies between 13 and 78% among acute-care patients [3]. Reports pertaining to Latin America describe adult specific values with a much narrower range, with prevalence levels in hospitalised adults totalling 20–50% [4]. The variability in data may be due to tautology of the term, the assessment criteria and variations in institutions. Nevertheless, the impact on health outcomes are consistent across studies.

#### **2. Outcomes of malnutrition**

The effects of malnutrition are extensive and include delayed recovery and prolonged hospital stay, increased risk of morbidity and mortality, increased general practitioner visits, and an increased probability of admission to tertiary care facilities [3]. Correspondingly, other literature supports these data and reports that poor nutritional states are associated with increased morbidity and mortality, increased length of hospitalisation, more frequent re-admissions, increased infectious and non-infectious clinical complications and increased healthcare costs [4].

Hospital admissions, duration of hospitalisation and the economic burden of malnutrition have been studied extensively. Contemporary evidence points to a disparity in the length-of-stay (LOS) of adequately-nourished patients when compared with malnourished patients. South African data points to an observation that malnourished patients' LOS approximates 4½ days, which was 43% longer than the stay of the well-nourished patients. Earlier evidence identified an even

**39**

**Table 1.**

*Source: Adapted from WHO (1995, 2000, 2004).*

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes*

wider variance between the two states of nutrition, where malnourished patients had demonstrably significantly higher incidence of complications (27.0 vs. 16.8%), increased mortality (12.4 vs. 4.7%), longer LOS (mean of 16.7 vs. 10.1 days) and increased hospital costs [5]. Congruently, Canadian based assessments have also found that malnutrition directly contributes to lengthy hospital stay. After controlling for demographic, socioeconomic, and disease-related factors and treatment, malnutrition at admission was independently associated with prolonged LOS [6]. It was estimated that nutritionally at-risk patients have a fourfold increased cost of hospital care when compared with well-nourished patients in part due to their delay in recovery and the protraction of their hospitalisation. Moreover, in the United Kingdom in 2009, health costs associated with malnutrition was quantified as being

Though undernutrition is a public health issue that undermines the health outcomes of hospitalised patients, malnutrition in the form of overnutrition is also a complex public health challenge with debilitating impact on clinical outcomes and hospitalisations. Worldwide, at least 2.8 million people die each year because of overweight or obesity, and an estimated 35.8 million (2.3%) of global disability adjusted life years (DALYs) are caused by overweight or obesity [7, 8]. Weight related malnutrition is classified by several organisations including CDC, UNICEF [9] and WHO. The World Health Organization's classification is made using weight

Current epidemiological data provide concerning evidence of the global expansion of overnutrition. While substantial work has been undertaken to curtail the incidence of undernutrition which has improved over the last decade, there has been a significant increase in the incidence of overnutrition with corresponding increases in the prevalence of non-communicable diseases and poor quality of life.

**)**

23.00–24.99

27.50–29.99

32.50–34.99

37.50–39.99

**Principal cut-off points Additional cut-off points**

**Classification BMI (kg/m2**

Underweight **<18.50 <18.50** Severe thinness <16.00 <16.00 Moderate thinness 16.00–16.99 16.00–16.99 Mild thinness 17.00–18.49 17.00–18.49 Normal range 18.50–24.99 18.50–22.99

Overweight ≥25.00 ≥25.00 Pre-obese 25.00–29.99 25.00–27.49

Obese ≥30.00 ≥30.00 Obese class I 30.00–34.99 30.00–32.49

Obese class II 35.00–39.99 35.00–37.49

Obese class III ≥40.00 ≥40.00

*International classification of adult underweight, overweight and obesity using to BMI.*

*DOI: http://dx.doi.org/10.5772/intechopen.84282*

at least £13 billion annually [3].

and height indices and is outlined in **Table 1**.

#### *Nutrition and Hospital Mortality, Morbidity and Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.84282*

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

and is important in the public health predictions for non-communicable diseases. Nutritional deficiencies are ranked in the top 20 leading worldwide disease and disability burden in 2016, according to the Institute of Health Metrics Evaluation

The prevalence of malnutrition in hospitalised adults has been extensively reported in the international literature and varies between 13 and 78% among acute-care patients [3]. Reports pertaining to Latin America describe adult specific values with a much narrower range, with prevalence levels in hospitalised adults totalling 20–50% [4]. The variability in data may be due to tautology of the term, the assessment criteria and variations in institutions. Nevertheless, the impact on

The effects of malnutrition are extensive and include delayed recovery and prolonged hospital stay, increased risk of morbidity and mortality, increased general practitioner visits, and an increased probability of admission to tertiary care facilities [3]. Correspondingly, other literature supports these data and reports that poor nutritional states are associated with increased morbidity and mortality, increased length of hospitalisation, more frequent re-admissions, increased infectious and

Hospital admissions, duration of hospitalisation and the economic burden of malnutrition have been studied extensively. Contemporary evidence points to a disparity in the length-of-stay (LOS) of adequately-nourished patients when compared with malnourished patients. South African data points to an observation that malnourished patients' LOS approximates 4½ days, which was 43% longer than the stay of the well-nourished patients. Earlier evidence identified an even

non-infectious clinical complications and increased healthcare costs [4].

[2], and is a pivotal global concern (see **Figure 1**).

*The global burden of disease. Source: Ritchie and Roser [2].*

health outcomes are consistent across studies.

**2. Outcomes of malnutrition**

**38**

**Figure 1.**

wider variance between the two states of nutrition, where malnourished patients had demonstrably significantly higher incidence of complications (27.0 vs. 16.8%), increased mortality (12.4 vs. 4.7%), longer LOS (mean of 16.7 vs. 10.1 days) and increased hospital costs [5]. Congruently, Canadian based assessments have also found that malnutrition directly contributes to lengthy hospital stay. After controlling for demographic, socioeconomic, and disease-related factors and treatment, malnutrition at admission was independently associated with prolonged LOS [6]. It was estimated that nutritionally at-risk patients have a fourfold increased cost of hospital care when compared with well-nourished patients in part due to their delay in recovery and the protraction of their hospitalisation. Moreover, in the United Kingdom in 2009, health costs associated with malnutrition was quantified as being at least £13 billion annually [3].

Though undernutrition is a public health issue that undermines the health outcomes of hospitalised patients, malnutrition in the form of overnutrition is also a complex public health challenge with debilitating impact on clinical outcomes and hospitalisations. Worldwide, at least 2.8 million people die each year because of overweight or obesity, and an estimated 35.8 million (2.3%) of global disability adjusted life years (DALYs) are caused by overweight or obesity [7, 8]. Weight related malnutrition is classified by several organisations including CDC, UNICEF [9] and WHO. The World Health Organization's classification is made using weight and height indices and is outlined in **Table 1**.

Current epidemiological data provide concerning evidence of the global expansion of overnutrition. While substantial work has been undertaken to curtail the incidence of undernutrition which has improved over the last decade, there has been a significant increase in the incidence of overnutrition with corresponding increases in the prevalence of non-communicable diseases and poor quality of life.


#### **Table 1.**

*International classification of adult underweight, overweight and obesity using to BMI.*

The increase in the rates of obesity and overweight status is not only evident in developing and Agrarian societies but is also featured prominently in industrial societies. **Figure 2** provides a summary of the status of obesity and overweight in WHO regions in 2015 Global Health Observatory data. The WHO makes an even more stark comparison of developing and developing countries, the Organisation suggests that the prevalence of elevated body mass index increases with the income level of countries up to upper middle-income levels. The prevalence of overweight in high income and upper middle-income countries was more than twofold greater than that of low and lower middle-income countries.

Overweight and obesity influence health outcomes and hospitalisation. The prevalence of obesity is high among patients with type 2 diabetes and this may result in the omission of nutritional assessments for these patients [10]. Current evidence also identifies positive health outcomes associated with obesity in specialised admitted patients. European data provide evidence of lower in-hospital mortality and length of ICU stay in overweight and morbidly obese critically ill patients and is consistent with earlier studies that reported better clinical outcomes for critically ill patients with increased BMI [11]. The factors that underpin the physiological benefits of increased BMI in critically ill patients are related to the adequacy of metabolic substrates, the increased capacity for catabolism and increased energy reserves. However, the explanatory factors of improved mortality rates in ICU has not been well examined and many others have been advanced including differences in adipokines and inflammatory mediators, such as leptin and interleukin-10, secreted by fat cells, which are thought to have attenuative inflammatory properties thereby theoretically improving survival during critical illness. Another credible explanation is that persons with higher BMI may have lower severity of illness than their normal BMI counterparts through intangible means [11]. The nutritional status of ICU patients provides an interesting counterpoint to general hospital admissions, however global data on the epidemiology of obesity among patients admitted to ICUs remains limited. Yet, such data are important to understand the possible regional variability of the burden imposed by obesity on outcome and utilisation of healthcare resources. Correspondingly, other European evidence supports this report and identified a concept called the "obesity paradox" where a seemingly negative health condition (overnutrition) is associated with a

**Figure 2.**

*Global overweight status. Source: [7], concerning WHO regions for Africa, Americas, Eastern Mediterranean, Europe and South East Asia Regions and WHO Western Pacific Region.*

**41**

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes*

positive clinical outcome (reduced hospital length of stay). Shorter hospital stay was reported in populations other than critically ill patients. Parissis et al., [12] found that patients with chronic heart failure, who also had higher BMI had associ-

Alternatively, and much more common are the negative health outcomes associated with overnutrition. There is a strong positive linear relationship between obesity, overweight and the incidence of non-communicable diseases. There is an analogous increase in the prevalence of comorbidities in tandem with BMI particularly concerning arterial hypertension, diabetes mellitus, and dyslipidaemia. Moreover, current evidence identified that overweight/obese patients represented most of Acute Heart Failure cases, as well as had a higher prevalence of non-

cardiovascular comorbidities [12]. Furthermore, North American statistics provide evidence of an inverse near-linear relationship with in-hospital mortality and BMI [12]. Moreover, overnutrition is associated with an increased risk of worsened health status in diabetic patients. The evidence points to poor glycaemic control for

The paradigm of malnutrition is considerable, and the concept is linked with many factors. These determinants are usually categorised as clinical and social. **Figure 3** provides a summary of the determinants and correlates of malnutrition. There are six major physiological factors that are described as influential on malnutrition statuses among people. According to Triantafillidis et al. [14] the six main physical determinants of malnutrition, particularly undernutrition, are:

1.Decrease in oral intake due to primary physiological changes or secondary to

a.Restrictive diets such as low carb, very low carbohydrate diets (VLCD), low

b.Therapeutic fasting related primarily to presenting health condition such as in gastrointestinal disorders like Crohn's and ulcerative colitis and with bowel prep before gastrointestinal surgeries, or due to diarrhoea, abdominal

c.Alteration in taste due to drugs, vitamin and mineral deficiencies including

b.Rectorrhagia (rectal bleeding without faeces)/hematochezia (bleeding with

in zinc deficiency, and with proinflammatory mediators

2.Gastrointestinal losses which impair energy and nutrient balances

d.Protein-losing enteropathy (disease of the small intestine)

d.Anorexigenous effect of proinflammatory cytokines

obese diabetics when compared to normal weight diabetics [10].

**3. Correlates and determinants of malnutrition**

*DOI: http://dx.doi.org/10.5772/intechopen.84282*

ated lower in-hospital mortality.

health effects

a.Diarrhoea

stools)

fat, veganism among others

pain, nausea, and vomiting

c.Loss of mucus and electrolytes

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.84282*

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

than that of low and lower middle-income countries.

The increase in the rates of obesity and overweight status is not only evident in developing and Agrarian societies but is also featured prominently in industrial societies. **Figure 2** provides a summary of the status of obesity and overweight in WHO regions in 2015 Global Health Observatory data. The WHO makes an even more stark comparison of developing and developing countries, the Organisation suggests that the prevalence of elevated body mass index increases with the income level of countries up to upper middle-income levels. The prevalence of overweight in high income and upper middle-income countries was more than twofold greater

Overweight and obesity influence health outcomes and hospitalisation. The prevalence of obesity is high among patients with type 2 diabetes and this may result in the omission of nutritional assessments for these patients [10]. Current evidence also identifies positive health outcomes associated with obesity in specialised admitted patients. European data provide evidence of lower in-hospital mortality and length of ICU stay in overweight and morbidly obese critically ill patients and is consistent with earlier studies that reported better clinical outcomes for critically ill patients with increased BMI [11]. The factors that underpin the physiological benefits of increased BMI in critically ill patients are related to the adequacy of metabolic substrates, the increased capacity for catabolism and increased energy reserves. However, the explanatory factors of improved mortality rates in ICU has not been well examined and many others have been advanced including differences in adipokines and inflammatory mediators, such as leptin and interleukin-10, secreted by fat cells, which are thought to have attenuative inflammatory properties thereby theoretically improving survival during critical illness. Another credible explanation is that persons with higher BMI may have lower severity of illness than their normal BMI counterparts through intangible means [11]. The nutritional status of ICU patients provides an interesting counterpoint to general hospital admissions, however global data on the epidemiology of obesity among patients admitted to ICUs remains limited. Yet, such data are important to understand the possible regional variability of the burden imposed by obesity on outcome and utilisation of healthcare resources. Correspondingly, other European evidence supports this report and identified a concept called the "obesity paradox" where a seemingly negative health condition (overnutrition) is associated with a

*Global overweight status. Source: [7], concerning WHO regions for Africa, Americas, Eastern Mediterranean,* 

*Europe and South East Asia Regions and WHO Western Pacific Region.*

**40**

**Figure 2.**

positive clinical outcome (reduced hospital length of stay). Shorter hospital stay was reported in populations other than critically ill patients. Parissis et al., [12] found that patients with chronic heart failure, who also had higher BMI had associated lower in-hospital mortality.

Alternatively, and much more common are the negative health outcomes associated with overnutrition. There is a strong positive linear relationship between obesity, overweight and the incidence of non-communicable diseases. There is an analogous increase in the prevalence of comorbidities in tandem with BMI particularly concerning arterial hypertension, diabetes mellitus, and dyslipidaemia. Moreover, current evidence identified that overweight/obese patients represented most of Acute Heart Failure cases, as well as had a higher prevalence of noncardiovascular comorbidities [12]. Furthermore, North American statistics provide evidence of an inverse near-linear relationship with in-hospital mortality and BMI [12]. Moreover, overnutrition is associated with an increased risk of worsened health status in diabetic patients. The evidence points to poor glycaemic control for obese diabetics when compared to normal weight diabetics [10].

#### **3. Correlates and determinants of malnutrition**

The paradigm of malnutrition is considerable, and the concept is linked with many factors. These determinants are usually categorised as clinical and social. **Figure 3** provides a summary of the determinants and correlates of malnutrition.

There are six major physiological factors that are described as influential on malnutrition statuses among people. According to Triantafillidis et al. [14] the six main physical determinants of malnutrition, particularly undernutrition, are:

	- a.Restrictive diets such as low carb, very low carbohydrate diets (VLCD), low fat, veganism among others
	- b.Therapeutic fasting related primarily to presenting health condition such as in gastrointestinal disorders like Crohn's and ulcerative colitis and with bowel prep before gastrointestinal surgeries, or due to diarrhoea, abdominal pain, nausea, and vomiting
	- c.Alteration in taste due to drugs, vitamin and mineral deficiencies including in zinc deficiency, and with proinflammatory mediators
	- d.Anorexigenous effect of proinflammatory cytokines
	- a.Diarrhoea
	- b.Rectorrhagia (rectal bleeding without faeces)/hematochezia (bleeding with stools)
	- c.Loss of mucus and electrolytes
	- d.Protein-losing enteropathy (disease of the small intestine)
	- a.Increase in resting energy expenditure due to inflammation, fever, and sepsis
	- b.Enhanced fat oxidation
	- a.Inflammatory states
	- b.Increased basal oxidative metabolism—including during fever
	- c.Infectious complications-with activated immune response
	- d.Postsurgery with substantial tissue repair
	- a.Corticosteroids and calcium reabsorption
	- b.Corticosteroids and protein catabolism—influencing turnover and nitrogen balance
	- c.Salazopyrin and folate absorption
	- d.Methotrexate and folates
	- e.Cholestyramine and fat-soluble vitamins
	- f. Antimicrobials esp. cephalosporins and vitamin K; inhibit endogenous metabolism and intestinal absorption
	- g.Antisecretors and iron
	- a.Reduction of the absorptive surface due to intestinal resection and enteric fistulas and high output fistulas
	- b.Blind loops and bacterial overgrowth
	- c.Poor absorption of bile salts in ileitis or resection

d.Mucosal inflammation and inflammatory diseases [14]

Alternately, the determinants of overnutrition are fewer and varies widely from those resulting in undernutrition, however the concept of energy and food intake is consistent across malnutrition categories. There are definitive proponents of obesity

**43**

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes*

development. It is documented that increased consumption of energy dense foods which are correspondingly poor in micronutrients, greater than physiologic demand will lead to weight accumulation, shifting the beam of the pendulum from balance to excess [10]. North American data identifies biological, behavioural and social contributors of obesity, insomuch as Lifshitz and Lifshitz [15] proposes that the

7.Structural environmental changes creating an obesogenic environment

The factors increasing the risk of malnutrition exist for malnourished states central to as well as external to hospitalisation. Though the factors outlined hitherto contributes significantly to hospital-based malnutrition, the unique concept of hospitalisations worsens the risk and the incidence of malnutrition. In secondary care facilities malnutrition, and more frequently undernutrition, develops as a result of insufficient energy and nutrient intake, impaired digestion/absorption/

*DOI: http://dx.doi.org/10.5772/intechopen.84282*

causes of obesity are multifactorial, they include:

*Factors influencing malnutrition. Source: Bapat et al. [13], p. 2.*

4.An environmental susceptibility to gain weight

8.Abundance of high-caloric density, low-quality food

1.A genetic predisposition

5.Increased energy intake

6.Reduced energy expenditures

9.Food selection/preparation

10. National and international food policies

3.Health status and disease burden

2.Hormonal activity

**Figure 3.**

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.84282*

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

a.Increase in resting energy expenditure due to inflammation, fever, and

4.Increase in nutritional requirements due to increase substrate requirement for macro and micronutrients with subsequent switch from anabolism to

5.Drug interactions limiting absorption, digestion and usage of essential micro-

b.Corticosteroids and protein catabolism—influencing turnover and nitrogen

f. Antimicrobials esp. cephalosporins and vitamin K; inhibit endogenous

6.Gastrointestinal or support organ structural dysfunction resulting in poor

a.Reduction of the absorptive surface due to intestinal resection and enteric

Alternately, the determinants of overnutrition are fewer and varies widely from those resulting in undernutrition, however the concept of energy and food intake is consistent across malnutrition categories. There are definitive proponents of obesity

b.Increased basal oxidative metabolism—including during fever

c.Infectious complications-with activated immune response

d.Postsurgery with substantial tissue repair

nutrients—vitamins, minerals and electrolytes

a.Corticosteroids and calcium reabsorption

e.Cholestyramine and fat-soluble vitamins

metabolism and intestinal absorption

fistulas and high output fistulas

b.Blind loops and bacterial overgrowth

c.Poor absorption of bile salts in ileitis or resection

d.Mucosal inflammation and inflammatory diseases [14]

c.Salazopyrin and folate absorption

d.Methotrexate and folates

g.Antisecretors and iron

absorption of nutrients

3.Metabolic disorders which interferes with energy balance

sepsis

catabolism

balance

b.Enhanced fat oxidation

a.Inflammatory states

**42**

#### **Figure 3.** *Factors influencing malnutrition. Source: Bapat et al. [13], p. 2.*

development. It is documented that increased consumption of energy dense foods which are correspondingly poor in micronutrients, greater than physiologic demand will lead to weight accumulation, shifting the beam of the pendulum from balance to excess [10]. North American data identifies biological, behavioural and social contributors of obesity, insomuch as Lifshitz and Lifshitz [15] proposes that the causes of obesity are multifactorial, they include:


The factors increasing the risk of malnutrition exist for malnourished states central to as well as external to hospitalisation. Though the factors outlined hitherto contributes significantly to hospital-based malnutrition, the unique concept of hospitalisations worsens the risk and the incidence of malnutrition. In secondary care facilities malnutrition, and more frequently undernutrition, develops as a result of insufficient energy and nutrient intake, impaired digestion/absorption/

utilisation or loss of nutrients due to illness or trauma through wounds, fistulas, or excreta as well increased metabolic demands during illness, recovery, and physiological response [4]. There remains no consensus on the definition of malnutrition, especially undernutrition, with a profusion of criteria possibly explaining some of the inconsistencies in the prevalence rates reported in the literature. Generally, unintentional weight loss >5% in a short period of time (over 3–6 months) and decreased food intake are among the definitive parameters of undernutrition [4]. Consistent with the challenges in defining malnutrition, so too is there challenge in delineating all the factors that correlate with malnutrition, particularly undernutrition.

Supportive evidence precedes these assertions and describe the causes of "disease-related malnutrition" as being inclusive of insufficient food/nutrient intake, impaired nutrient digestion and absorption and increased requirements for nutrients with increased losses (e.g., from wounds, malabsorption) and catabolism [1]. While other evidence points to a strong social link, where nutritional status at hospital admission is said to be compounded by primary malnutrition mainly reflecting poor socioeconomic conditions, and secondary malnutrition usually influenced by the impact of degenerative, terminal and chronic diseases [16].

Acute malnutrition takes place in a few weeks to months, it primarily affects lean body stores and is usually managed effectively to prevent permanent impact, especially in children. It occurs in a range of instances including during emergencies, seasonally and endemically [17]. These situations usually contribute to undernutrition through severe restrictions to nutrient and energy supply. In the former case, hospital-based emergencies may result in medium term therapeutic fasts, while in countries which rely heavily on agriculture and have variable weather pattern, food security may be critically impacted creating a unique form of dietary restriction. In undernutrition, there is a greater risk of death which is related not only to the infection but also to the loss of muscle mass with concordant limits to immunity and primary metabolic functions. Fat stores, which are used up in cases of undernutrition without infection, may also play a role in survival and regulate bone linear growth [17].

#### **4. At risk groups**

In as much as malnutrition is debilitating and associated with severe health outcomes, there are vulnerable groups for which malnutrition, particularly undernutrition, is more likely to affect and by extension more probable to result in death. The literature suggest that malnutrition is a problem in many different disease groups, including cancer (5–80%), neurology (4–66%), surgical/critical illness (0–100%), respiratory disease (5–60%), gastrointestinal and liver disease (3–100%), HIV/ AIDS (8–98%) and renal disease (10–72%) [1]. Over a similar period in Cuba the rates of undernutrition were alarming 41.2% were classified as undernourished and 11.1% of patients were considered severely undernourished. Malnutrition rates increased progressively with prolonged length of stay [18]. Current evidence highlights that patients who are hospitalised are at risk of developing iatrogenic malnutrition or hospital-based malnutrition due to several reasons. Patients admitted in hospitals, for instance after an acute exacerbation of a chronic condition, are at high risk of developing disease-related malnutrition (DRM) a consequence of loss of appetite, poor nutritional intake, and disease-related catabolism and in severe instances cachexia [19]. In addition to the clinical conditions that may predispose patients to malnutrition, age and gender are also factors which create additional risk. Children and infants with limited physiological and nutritional

**45**

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes*

health conditions/disease states and the lifecycle [20].

reserves, pregnant women who must physically meet her needs and that of a growing foetus as well as the elderly are numbered among the vulnerable, nutritionally at-risk group. Hospitalised elderly patients are particularly vulnerable to develop DRM because of poor nutritional antecedents including decreased fat free mass and impaired protein, energy, and fluid intake [19]. Consequently, care must be taken to screen, assess, manage and follow up patients who are at-risk of malnutrition in an effort to reduce the associated risk of mortality and morbidity across differing

Negative health outcomes resulting from poor nutrition is pervasive across all life stages and impacts individuals differently in each group due to physiological and developmental differences among groups. Consequently, health care professionals must be keen to ensure that the unique characteristics and risks in each group are evaluated. Therefore, international organisations such as PAHO, WHO and CDC have instituted concerted efforts, but the rates and impact of childhood malnutrition continues to be extensive. Childhood is characterized by a period of dependence, rapid growth and limited nutritional reserves accordingly, parental neglect, limited knowledge and socioeconomic capacity may negatively influence nutritional adequacy. Globally childhood malnutrition continues to be a public health problem with alarming statistics in 2015, out of the 1.5 million children who died, nearly half (45%) of these deaths resulted from malnutrition or its correlates [21]. In the Latin America and the Caribbean, the rates are more concerning with infant mortality rate being 11 per 1000 live births in Barbados [22]. Furthermore, infants and children exposed earlier and more sustainably to poor states of nutrition have a greater probability of experiencing more severe and chronic health outcomes as a result. In utero as well as cohort studies of the Latin Americas and the Caribbean and European societies suggest that foetus exposed to poor maternal nutrition, and children 0–6 months old exposed to poor nutritional profiles are more likely to be hospitalised, exhibit mental disorders such as personality and schizoid disorders and have chronic diseases including hypertension and diabetes [22, 23]. Moreover, European evidence points to greater episodes of diarrhoea, vomiting, poor recovery, longer hospital stays and greater health care costs in admitted children with body mass indices less than two standard deviations in children compared to healthy controls [24]. Nevertheless, the morbidity associated with nutritional inadequacies in children can be attenuated with early and appropriate nutritional interventions. Studies concerning the Caribbean and West African population have shown that the rate of hospitalisation and mental illness associated with poor childhood nutrition declined with nutritional supplementation in both Barbados and Mauritius [23]. Similar to the physiological impact in infancy and childhood, pregnancy and lactation create nutritional vulnerabilities for the foetus and the mother. The additional metabolic demands, nutritional requirements of the foetus and the capacity to support the organ changes coupled with emotional and physiological factors limiting dietary intake increase the risk of nutritional inadequacy in pregnancy. Current evidence suggests that it increases the risk of morbidity and mortality for both the mother and the unborn child. In Latin America, there are reports of a lack of specialised tool to examine maternal nutritional states as well as a lack of protocols to guide nutritional support and intervention [21]. In pregnancy, poor maternal weight gain, low haemoglobin levels, and impaired fasting plasma glucose levels, as well as poor maternal dietary intake and physical inactivity are important predictors of infant mortality, maternal mortality, low birth weight and poor infant

*DOI: http://dx.doi.org/10.5772/intechopen.84282*

**5. Malnutrition across the lifespan**

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.84282*

reserves, pregnant women who must physically meet her needs and that of a growing foetus as well as the elderly are numbered among the vulnerable, nutritionally at-risk group. Hospitalised elderly patients are particularly vulnerable to develop DRM because of poor nutritional antecedents including decreased fat free mass and impaired protein, energy, and fluid intake [19]. Consequently, care must be taken to screen, assess, manage and follow up patients who are at-risk of malnutrition in an effort to reduce the associated risk of mortality and morbidity across differing health conditions/disease states and the lifecycle [20].

#### **5. Malnutrition across the lifespan**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

utilisation or loss of nutrients due to illness or trauma through wounds, fistulas, or excreta as well increased metabolic demands during illness, recovery, and physiological response [4]. There remains no consensus on the definition of malnutrition, especially undernutrition, with a profusion of criteria possibly explaining some of the inconsistencies in the prevalence rates reported in the literature. Generally, unintentional weight loss >5% in a short period of time (over 3–6 months) and decreased food intake are among the definitive parameters of undernutrition [4]. Consistent with the challenges in defining malnutrition, so too is there challenge in delineating all the factors that correlate with malnutrition, particularly

Supportive evidence precedes these assertions and describe the causes of "disease-related malnutrition" as being inclusive of insufficient food/nutrient intake, impaired nutrient digestion and absorption and increased requirements for nutrients with increased losses (e.g., from wounds, malabsorption) and catabolism [1]. While other evidence points to a strong social link, where nutritional status at hospital admission is said to be compounded by primary malnutrition mainly reflecting poor socioeconomic conditions, and secondary malnutrition usually influenced by the impact of degenerative, terminal and chronic diseases [16]. Acute malnutrition takes place in a few weeks to months, it primarily affects lean body stores and is usually managed effectively to prevent permanent impact, especially in children. It occurs in a range of instances including during emergencies, seasonally and endemically [17]. These situations usually contribute to undernutrition through severe restrictions to nutrient and energy supply. In the former case, hospital-based emergencies may result in medium term therapeutic fasts, while in countries which rely heavily on agriculture and have variable weather pattern, food security may be critically impacted creating a unique form of dietary restriction. In undernutrition, there is a greater risk of death which is related not only to the infection but also to the loss of muscle mass with concordant limits to immunity and primary metabolic functions. Fat stores, which are used up in cases of undernutrition without infection, may also play a role in survival and regulate

In as much as malnutrition is debilitating and associated with severe health outcomes, there are vulnerable groups for which malnutrition, particularly undernutrition, is more likely to affect and by extension more probable to result in death. The literature suggest that malnutrition is a problem in many different disease groups, including cancer (5–80%), neurology (4–66%), surgical/critical illness (0–100%), respiratory disease (5–60%), gastrointestinal and liver disease (3–100%), HIV/ AIDS (8–98%) and renal disease (10–72%) [1]. Over a similar period in Cuba the rates of undernutrition were alarming 41.2% were classified as undernourished and 11.1% of patients were considered severely undernourished. Malnutrition rates increased progressively with prolonged length of stay [18]. Current evidence highlights that patients who are hospitalised are at risk of developing iatrogenic malnutrition or hospital-based malnutrition due to several reasons. Patients admitted in hospitals, for instance after an acute exacerbation of a chronic condition, are at high risk of developing disease-related malnutrition (DRM) a consequence of loss of appetite, poor nutritional intake, and disease-related catabolism and in severe instances cachexia [19]. In addition to the clinical conditions that may predispose patients to malnutrition, age and gender are also factors which create additional risk. Children and infants with limited physiological and nutritional

**44**

undernutrition.

bone linear growth [17].

**4. At risk groups**

Negative health outcomes resulting from poor nutrition is pervasive across all life stages and impacts individuals differently in each group due to physiological and developmental differences among groups. Consequently, health care professionals must be keen to ensure that the unique characteristics and risks in each group are evaluated. Therefore, international organisations such as PAHO, WHO and CDC have instituted concerted efforts, but the rates and impact of childhood malnutrition continues to be extensive. Childhood is characterized by a period of dependence, rapid growth and limited nutritional reserves accordingly, parental neglect, limited knowledge and socioeconomic capacity may negatively influence nutritional adequacy. Globally childhood malnutrition continues to be a public health problem with alarming statistics in 2015, out of the 1.5 million children who died, nearly half (45%) of these deaths resulted from malnutrition or its correlates [21]. In the Latin America and the Caribbean, the rates are more concerning with infant mortality rate being 11 per 1000 live births in Barbados [22]. Furthermore, infants and children exposed earlier and more sustainably to poor states of nutrition have a greater probability of experiencing more severe and chronic health outcomes as a result. In utero as well as cohort studies of the Latin Americas and the Caribbean and European societies suggest that foetus exposed to poor maternal nutrition, and children 0–6 months old exposed to poor nutritional profiles are more likely to be hospitalised, exhibit mental disorders such as personality and schizoid disorders and have chronic diseases including hypertension and diabetes [22, 23]. Moreover, European evidence points to greater episodes of diarrhoea, vomiting, poor recovery, longer hospital stays and greater health care costs in admitted children with body mass indices less than two standard deviations in children compared to healthy controls [24]. Nevertheless, the morbidity associated with nutritional inadequacies in children can be attenuated with early and appropriate nutritional interventions. Studies concerning the Caribbean and West African population have shown that the rate of hospitalisation and mental illness associated with poor childhood nutrition declined with nutritional supplementation in both Barbados and Mauritius [23].

Similar to the physiological impact in infancy and childhood, pregnancy and lactation create nutritional vulnerabilities for the foetus and the mother. The additional metabolic demands, nutritional requirements of the foetus and the capacity to support the organ changes coupled with emotional and physiological factors limiting dietary intake increase the risk of nutritional inadequacy in pregnancy. Current evidence suggests that it increases the risk of morbidity and mortality for both the mother and the unborn child. In Latin America, there are reports of a lack of specialised tool to examine maternal nutritional states as well as a lack of protocols to guide nutritional support and intervention [21]. In pregnancy, poor maternal weight gain, low haemoglobin levels, and impaired fasting plasma glucose levels, as well as poor maternal dietary intake and physical inactivity are important predictors of infant mortality, maternal mortality, low birth weight and poor infant growth and development [21]. The authors suggest that assessment, screening, follow-up and maternal care are important modulators of these outcomes.

For adolescents, the portion of the lifecycle is characterized by rapid growth and organ development, greater autonomy and independence, access to media and dietary advice. Contingent on the adolescent's support and capacity to negotiate these changes he may be at risk of developing micronutrient deficiencies such as iron and calcium, or experience macronutrient imbalances associated with obesity and wasting as well as eating disorders such as anorexia nervosa and bulimia [25]. Growth should be monitored at regular intervals throughout childhood and adolescence and should also be measured every time an adolescent visits a healthcare facility for preventive, acute, or chronic care. In children ages 2–20 years several nutritional and developmental indices should be measured as a standard procedure to identify and treat potential nutritional risks and disorders including standing height-for-age, weight-for-age, and body mass index (BMI)-for-age [26].

While adolescence malnutrition is plagued with equal risks of acute and chronic outcomes, in adulthood the risks associated with nutritional imbalances have greater links to chronic illnesses such as cardiovascular and endocrine disorders. These disorders worsen morbidity risk in nutritionally unhealthy adults through poorer quality of life and longer periods of disability adjusted life years (DALY) mainly as a result of the contribution of overweight and obesity. Similarly, underweight, using mid upper arm circumference as a proxy for assessment, has shown strong negative correlations with in-hospital mortality in adults. It accounted for a nearly (3.8) fourfold increased risk of in-hospital mortality when compared with healthy controls [27]. Other evidence points however to a protective effect of obesity on in-hospital mortality in adults where odds of death was 0.9 and 0.7 in overweight and obese patients compared to normal weight adult counterparts. Other evidence however confirmed the findings of Asiimwe [27] inasmuch as it reports that the odds of dying were higher in hospitalised undernourished adult patients [28].

Nutritional health maintenance and its sequelae of outcomes are similarly perplexing in the elderly. They have a double burden of increased micronutrient requirements such as iron, calcium, and phosphorus with a discordant reduction in the requirement for macronutrients. In the face of this conundrum, the health care provider must be careful of the nutritional prescriptions to balance macronutrient requirements to attenuate chronic disease risk as well as to maintain adequate micronutrient requirements to prevent and manage important metabolic changes associated with the physiological features of aging. Furthermore, the older adult is described as nutritionally vulnerable because he has reduced physical reserve that restricts the ability to mount a vigorous recovery when there is an acute health threat or stressor [29]. In developing as well as developed countries malnutrition is identified as an independent predictor of mortality. The mortality rate in malnourished elderly Brazilians aged between 60 and 69 years was 3.34 deaths per 1000 inhabitants, and among those aging 70 years and older, 11 deaths per 1000 inhabitants [30]. The factors contributing to the elderly's nutritional vulnerability include multiple medical conditions, and polypharmacy, physiological changes affecting intake and absorption including xerostomia, anorexia of aging and achlorhydria, obesity, and limited socioeconomic resources. Conversely, having adequate muscle mass, replete micronutrient stores, healthy dietary practices and adequate social support are protective factors against nutritional inadequacy in the elderly population [29]. Consistent across all life stages is the risk of nutritional ill health, unique to each segment of the cycle is a physiological and development paradigm that creates a distinctive risk for the individual. Critical to the successful negotiation of the life stage is the public health role that providers play, they must be equipped to

**47**

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes*

screen, assess, diagnose, and prescribe appropriate individualised plans and evaluate nutritional outcomes. It is important therefore for the health care provider to be conversant regarding the procedures for managing both elements of the spectrum

Comparable with the debate concerning the criteria for defining undernutrition, there continues to be a rigorous academic discourse surrounding the management

Though the debate is still raging, institutes such as BAPEN, ASPEN and ESPEN

For children, malnutrition-especially undernutrition may be more incestuous and accompanied by infectious diseases, worm and helminth infections and involve both macro and micronutrient deficiencies. Current evidence outlines that childhood malnutrition is a significant contributor to mortality rates of children under five. The risk of death may be attenuated by energy supply dependent on calorimet-

To effectively manage undernutrition, patients' nutritional status must be determined, and the nutritional prescription individualised based on their needs. Screening and assessment are the procedures necessary for the classification of client's nutritional status. Furthermore, nutritional risk screening is an important modulator of mortality and morbidity risk particularly in hospitalised surgical patients [35]. Current research supports this finding, as nutritional screening is described as one of the most critical initial steps in nutritional management. Many

and health professionals have advanced nutritional prescriptions linked to the energy, amino acid and electrolyte needs. Protein and energy supply in undernourished patients contribute to supporting metabolic reactions, providing substrates for immune functions and expansion of lean body reserves, while electrolytes and major minerals such as iron, sodium, phosphorus and potassium are essential for electrical and neuronal conductivity and several metabolic homeostatic reactions. Energy and protein recommendations are usually the most varied elements of the debate, nevertheless contemporary and classical evidence converges on the general recommendations for nutritional support of undernourished clients. These patients should be prescribed a diet based on the following allowances: protein, 1.1–1.5 g/kg; calories, 30–35 kcal/kg; sodium, 87–120 mEq/day; potassium, 1.1–1.5 mEq/kg; phosphorus, <17 mg/kg. Additional nutritional supports in the form of high-protein or high-protein and high-calorie supplements were also provided to individual patients whose weight was <80% of their habitual body weight, if they had more than 3 kg (5–7 lb) of weight loss in a month, and/or their serum albumin was <3.5 g/dl [31, 32]. Despite the benefits that can be accrued from nutritional support, the problem is still evident in the Low and Middle-Income countries of the Latin Americas. In eight Latin American countries (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Panama, and Peru), malnutrition was found to be prevalent among hospitalised patients and caloric intake failed to meet targeted energy delivery in 40% of hospitalised adults receiving nutrition therapy. The evidence suggested that supplemental administration of parenteral and enteral nutrition was associated with improved energy and protein delivery and

*DOI: http://dx.doi.org/10.5772/intechopen.84282*

**6. Management of malnutrition**

of malnutrition.

of undernutrition.

reduced mortality levels [33].

ric determinants and earlier antibiotic therapy [34].

**7. Nutritional screening, assessment and evaluation**

screen, assess, diagnose, and prescribe appropriate individualised plans and evaluate nutritional outcomes. It is important therefore for the health care provider to be conversant regarding the procedures for managing both elements of the spectrum of malnutrition.

### **6. Management of malnutrition**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

growth and development [21]. The authors suggest that assessment, screening, follow-up and maternal care are important modulators of these outcomes.

For adolescents, the portion of the lifecycle is characterized by rapid growth and organ development, greater autonomy and independence, access to media and dietary advice. Contingent on the adolescent's support and capacity to negotiate these changes he may be at risk of developing micronutrient deficiencies such as iron and calcium, or experience macronutrient imbalances associated with obesity and wasting as well as eating disorders such as anorexia nervosa and bulimia [25]. Growth should be monitored at regular intervals throughout childhood and adolescence and should also be measured every time an adolescent visits a healthcare facility for preventive, acute, or chronic care. In children ages 2–20 years several nutritional and developmental indices should be measured as a standard procedure to identify and treat potential nutritional risks and disorders including standing height-for-age, weight-for-age, and body mass index (BMI)-for-age [26]. While adolescence malnutrition is plagued with equal risks of acute and chronic outcomes, in adulthood the risks associated with nutritional imbalances have greater links to chronic illnesses such as cardiovascular and endocrine disorders. These disorders worsen morbidity risk in nutritionally unhealthy adults through poorer quality of life and longer periods of disability adjusted life years (DALY) mainly as a result of the contribution of overweight and obesity. Similarly, underweight, using mid upper arm circumference as a proxy for assessment, has shown strong negative correlations with in-hospital mortality in adults. It accounted for a nearly (3.8) fourfold increased risk of in-hospital mortality when compared with healthy controls [27]. Other evidence points however to a protective effect of obesity on in-hospital mortality in adults where odds of death was 0.9 and 0.7 in overweight and obese patients compared to normal weight adult counterparts. Other evidence however confirmed the findings of Asiimwe [27] inasmuch as it reports that the odds of dying were higher in hospitalised under-

Nutritional health maintenance and its sequelae of outcomes are similarly perplexing in the elderly. They have a double burden of increased micronutrient requirements such as iron, calcium, and phosphorus with a discordant reduction in the requirement for macronutrients. In the face of this conundrum, the health care provider must be careful of the nutritional prescriptions to balance macronutrient requirements to attenuate chronic disease risk as well as to maintain adequate micronutrient requirements to prevent and manage important metabolic changes associated with the physiological features of aging. Furthermore, the older adult is described as nutritionally vulnerable because he has reduced physical reserve that restricts the ability to mount a vigorous recovery when there is an acute health threat or stressor [29]. In developing as well as developed countries malnutrition is identified as an independent predictor of mortality. The mortality rate in malnourished elderly Brazilians aged between 60 and 69 years was 3.34 deaths per 1000 inhabitants, and among those aging 70 years and older, 11 deaths per 1000 inhabitants [30]. The factors contributing to the elderly's nutritional vulnerability include multiple medical conditions, and polypharmacy, physiological changes affecting intake and absorption including xerostomia, anorexia of aging and achlorhydria, obesity, and limited socioeconomic resources. Conversely, having adequate muscle mass, replete micronutrient stores, healthy dietary practices and adequate social support are protective factors against nutritional inadequacy in the elderly population [29]. Consistent across all life stages is the risk of nutritional ill health, unique to each segment of the cycle is a physiological and development paradigm that creates a distinctive risk for the individual. Critical to the successful negotiation of the life stage is the public health role that providers play, they must be equipped to

**46**

nourished adult patients [28].

Comparable with the debate concerning the criteria for defining undernutrition, there continues to be a rigorous academic discourse surrounding the management of undernutrition.

Though the debate is still raging, institutes such as BAPEN, ASPEN and ESPEN and health professionals have advanced nutritional prescriptions linked to the energy, amino acid and electrolyte needs. Protein and energy supply in undernourished patients contribute to supporting metabolic reactions, providing substrates for immune functions and expansion of lean body reserves, while electrolytes and major minerals such as iron, sodium, phosphorus and potassium are essential for electrical and neuronal conductivity and several metabolic homeostatic reactions. Energy and protein recommendations are usually the most varied elements of the debate, nevertheless contemporary and classical evidence converges on the general recommendations for nutritional support of undernourished clients. These patients should be prescribed a diet based on the following allowances: protein, 1.1–1.5 g/kg; calories, 30–35 kcal/kg; sodium, 87–120 mEq/day; potassium, 1.1–1.5 mEq/kg; phosphorus, <17 mg/kg. Additional nutritional supports in the form of high-protein or high-protein and high-calorie supplements were also provided to individual patients whose weight was <80% of their habitual body weight, if they had more than 3 kg (5–7 lb) of weight loss in a month, and/or their serum albumin was <3.5 g/dl [31, 32]. Despite the benefits that can be accrued from nutritional support, the problem is still evident in the Low and Middle-Income countries of the Latin Americas. In eight Latin American countries (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Panama, and Peru), malnutrition was found to be prevalent among hospitalised patients and caloric intake failed to meet targeted energy delivery in 40% of hospitalised adults receiving nutrition therapy. The evidence suggested that supplemental administration of parenteral and enteral nutrition was associated with improved energy and protein delivery and reduced mortality levels [33].

For children, malnutrition-especially undernutrition may be more incestuous and accompanied by infectious diseases, worm and helminth infections and involve both macro and micronutrient deficiencies. Current evidence outlines that childhood malnutrition is a significant contributor to mortality rates of children under five. The risk of death may be attenuated by energy supply dependent on calorimetric determinants and earlier antibiotic therapy [34].

#### **7. Nutritional screening, assessment and evaluation**

To effectively manage undernutrition, patients' nutritional status must be determined, and the nutritional prescription individualised based on their needs. Screening and assessment are the procedures necessary for the classification of client's nutritional status. Furthermore, nutritional risk screening is an important modulator of mortality and morbidity risk particularly in hospitalised surgical patients [35]. Current research supports this finding, as nutritional screening is described as one of the most critical initial steps in nutritional management. Many health care professional groups (ASPEN, BAPEN and ESPEN) currently recommend nutritional screening of acute care patients, either before elective admissions or within 24–48 h after emergency admissions. It is imperative to identify and classify malnourished patients promptly to prevent or counter the associated negative health outcomes. Currently, physicians and nurses assess patients on admission to hospital, and it has been suggested that they are in an ideal position to screen patients for malnutrition [3]. Moreover, clinicians suggest that nutritional status evaluation include clinical and biochemical assessments. Standard biochemical assessments should include basic serum electrolyte tests as well as serum albumin and prealbumin levels which are direct markers of lean body mass. For several authors, serum albumin level is the best prognostic indicator of nutritional status because of its ability to detect protein-energy malnutrition, which may not be accompanied by declines in body mass index and body weight or may be sub-clinical especially in the acute phases. Additionally, serum albumin level was identified a better predictor of some types of morbidity, particularly sepsis and major infections, than other types [36].

Effective nutritional management strategies include: appropriate weighing practices; documentation of weight fluctuations; monitoring of biochemical parameters and food intake; and clear malnutrition identification criteria through nutritional screening. Using nutritional experts and multidisciplinary nutritional teams is also recommended to help combat malnutrition [3].

Furthermore, there abounds a plethora of algorithms that outlines effective nutritional management procedures inclusive of screening, assessment and intervention guidelines. There are disease specific algorithms as well as population specific protocols available including guidelines from ASPEN as outlined in **Figure 4**.

Algorithms such as the one advanced by ASPEN are available and supported by hospital protocols but there remains low levels of nutritional screening and assessment particularly in resource restricted low-income countries such as Latin America and the Caribbean, the rates are troubling. In a study of 14 countries, only two were found to have national policies regarding best practices for nutrition therapy in hospitals or long-term care facilities and this data was associated with only 9% of patients who required parenteral or enteral nutrition receiving the treatment [4].

In children, several indices have been identified by health authorities including the WHO as being suitable in identifying malnutrition and its risk. Current evidence points to mid-upper-arm circumference (MUAC) providing better estimates of childhood mortality when compared with weight-for-height. Weightfor-height is unstable and variable in acute conditions affecting body water. It is

**49**

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes*

more sensitive to dehydration, such as in the case of diarrhoea, where dehydration causes weight loss with little impact on lean body mass [17], therefore MUAC which is more robust against these changes, is recommended as a more stable measure of

Consistent with the need for nutritional screening, assessment and evaluation, is the poignant value of hospitals and primary as well as tertiary care facilities being staffed with professionals knowledgeable, skilled and resourced to deliver adequate nutritional support. In stark contrast to this recommendation is the reality of the characteristics of human resources that people these institutions. In some studies, provider knowledge, understanding and data usage was identified as a barrier to optimal nutritional support [38]. In Swedish settings, limited access to nutrition related education as well as availability of training programmes were identified as having negative effects on nutritional support and management [39]. Furthermore, there is low nutrition related health literacy among health care professionals partly attributable to a weak "nutritional culture" correspondent with inadequate academic training and preparation of health care professionals [40]. This partly due to limits in

the nutritional education and training afforded to health care providers.

*"The quantity of formalized nutrition education is shrinking in the curricula of health professions, such as physicians, nurses, dietitians, and pharmacists. The current nutrition education being taught in U.S. schools of healthcare professionals does not appropriately prepare students for identification of patients at nutrition risk or management of undernourished hospitalized patients with specialized* 

While health care workers recognised the value of nutritional screening and assessment, deficiencies in their knowledge and skill limit the benefits that could be accrued from early and consistent nutritional evaluation. Coupled with individual level limitations there are also policy level challenges as well as institutional and nationally challenges in some respects [39]. In the Latin America, the culture, value, and significance of nutritional support in health care are limited even as the prevalence of malnutrition and its outcomes rise. The increased rates of community and hospital malnutrition and its morbidity and mortality risks in Latin America occur alongside a limitation in the awareness levels of providers concerning the management of disease-related malnutrition [42]. It however, represents an opportunity to improve nutrition care by increasing education and training. Healthcare administrators, clinical leaders and educators, and clinicians must first recognise the significance of nutrition to health care and then must be knowledgeable in order

Though there are inconsistencies in the proponents' views on the diagnosis and treatment of malnutrition there is consensus on the need for treatment and the value of nutritional support to health care outcomes. Current guidelines published by the European Society for Clinical Nutrition and Metabolism (ESPEN) provide primarily recommendations for nutritional therapy specific to organ/system dysfunctions and medical specialty [19]. However, large developed and developing countries fail to institute these recommendations in the abundance and the absence of adequate resources. Knowledge, experience, self-confidence, and self-efficacy may be the intangible factors constraining the implementation of these guidelines. Current evidence points to their impact on negative clinical and health outcomes

*DOI: http://dx.doi.org/10.5772/intechopen.84282*

**8. Professional and nutrition care**

*nutrition therapies…." ([41] p. 218).*

to realise the benefits of nutritional support in hospitals.

nutritional status and risk.

**Figure 4.** *Nutrition care algorithm. Source: [37], p. 17.*

more sensitive to dehydration, such as in the case of diarrhoea, where dehydration causes weight loss with little impact on lean body mass [17], therefore MUAC which is more robust against these changes, is recommended as a more stable measure of nutritional status and risk.

### **8. Professional and nutrition care**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

tions, than other types [36].

recommended to help combat malnutrition [3].

health care professional groups (ASPEN, BAPEN and ESPEN) currently recommend nutritional screening of acute care patients, either before elective admissions or within 24–48 h after emergency admissions. It is imperative to identify and classify malnourished patients promptly to prevent or counter the associated negative health outcomes. Currently, physicians and nurses assess patients on admission to hospital, and it has been suggested that they are in an ideal position to screen patients for malnutrition [3]. Moreover, clinicians suggest that nutritional status evaluation include clinical and biochemical assessments. Standard biochemical assessments should include basic serum electrolyte tests as well as serum albumin and prealbumin levels which are direct markers of lean body mass. For several authors, serum albumin level is the best prognostic indicator of nutritional status because of its ability to detect protein-energy malnutrition, which may not be accompanied by declines in body mass index and body weight or may be sub-clinical especially in the acute phases. Additionally, serum albumin level was identified a better predictor of some types of morbidity, particularly sepsis and major infec-

Effective nutritional management strategies include: appropriate weighing practices; documentation of weight fluctuations; monitoring of biochemical parameters and food intake; and clear malnutrition identification criteria through nutritional screening. Using nutritional experts and multidisciplinary nutritional teams is also

Furthermore, there abounds a plethora of algorithms that outlines effective nutritional management procedures inclusive of screening, assessment and intervention guidelines. There are disease specific algorithms as well as population specific protocols available including guidelines from ASPEN as outlined in **Figure 4**.

Algorithms such as the one advanced by ASPEN are available and supported by hospital protocols but there remains low levels of nutritional screening and assessment particularly in resource restricted low-income countries such as Latin America and the Caribbean, the rates are troubling. In a study of 14 countries, only two were found to have national policies regarding best practices for nutrition therapy in hospitals or long-term care facilities and this data was associated with only 9% of patients who required parenteral or enteral nutrition receiving the treatment [4]. In children, several indices have been identified by health authorities including the WHO as being suitable in identifying malnutrition and its risk. Current evidence points to mid-upper-arm circumference (MUAC) providing better estimates of childhood mortality when compared with weight-for-height. Weightfor-height is unstable and variable in acute conditions affecting body water. It is

**48**

**Figure 4.**

*Nutrition care algorithm. Source: [37], p. 17.*

Consistent with the need for nutritional screening, assessment and evaluation, is the poignant value of hospitals and primary as well as tertiary care facilities being staffed with professionals knowledgeable, skilled and resourced to deliver adequate nutritional support. In stark contrast to this recommendation is the reality of the characteristics of human resources that people these institutions. In some studies, provider knowledge, understanding and data usage was identified as a barrier to optimal nutritional support [38]. In Swedish settings, limited access to nutrition related education as well as availability of training programmes were identified as having negative effects on nutritional support and management [39]. Furthermore, there is low nutrition related health literacy among health care professionals partly attributable to a weak "nutritional culture" correspondent with inadequate academic training and preparation of health care professionals [40]. This partly due to limits in the nutritional education and training afforded to health care providers.

*"The quantity of formalized nutrition education is shrinking in the curricula of health professions, such as physicians, nurses, dietitians, and pharmacists. The current nutrition education being taught in U.S. schools of healthcare professionals does not appropriately prepare students for identification of patients at nutrition risk or management of undernourished hospitalized patients with specialized nutrition therapies…." ([41] p. 218).*

While health care workers recognised the value of nutritional screening and assessment, deficiencies in their knowledge and skill limit the benefits that could be accrued from early and consistent nutritional evaluation. Coupled with individual level limitations there are also policy level challenges as well as institutional and nationally challenges in some respects [39]. In the Latin America, the culture, value, and significance of nutritional support in health care are limited even as the prevalence of malnutrition and its outcomes rise. The increased rates of community and hospital malnutrition and its morbidity and mortality risks in Latin America occur alongside a limitation in the awareness levels of providers concerning the management of disease-related malnutrition [42]. It however, represents an opportunity to improve nutrition care by increasing education and training. Healthcare administrators, clinical leaders and educators, and clinicians must first recognise the significance of nutrition to health care and then must be knowledgeable in order to realise the benefits of nutritional support in hospitals.

Though there are inconsistencies in the proponents' views on the diagnosis and treatment of malnutrition there is consensus on the need for treatment and the value of nutritional support to health care outcomes. Current guidelines published by the European Society for Clinical Nutrition and Metabolism (ESPEN) provide primarily recommendations for nutritional therapy specific to organ/system dysfunctions and medical specialty [19]. However, large developed and developing countries fail to institute these recommendations in the abundance and the absence of adequate resources. Knowledge, experience, self-confidence, and self-efficacy may be the intangible factors constraining the implementation of these guidelines. Current evidence points to their impact on negative clinical and health outcomes

including worsening risk of mortality and morbidity as a consequence of undertreatment of vulnerable hospitalised patients.

Significantly, developed and emerging societies are plagued with malnutrition and its consequences as well as institutional and provider level incompetencies to manage the spiralling problem. The burden is more severe in resource restricted countries. To attenuate the negative effects of malnutrition developing countries should employ the following strategies:


### **9. Conclusion**

The global incidence of malnutrition is significant. Nutritional inadequacies directly impact hospital morbidity and mortality rates, worsening death for the most parts and to a lesser extent obesity has been linked to a protective effect. The condition severely diminishes quality of life for individuals of all ages. Health care providers through their capacity and responsibility to screen, assess and intervene serve as critical modulators of malnutrition outcomes. Nevertheless, their attenuative capacity is severely restricted through limited nutrition health related culture, training, education and resource limitations. Notwithstanding the significant challenges, countries and health care institutions must recognise the role nutrition plays in morbidity and mortality and institute effective action, including training and education, as well as policy and resource provision in order to stymie the negative impact of nutrition on morbidity and mortality.

**51**

**Author details**

Donnette Wright

West Indies

provided the original work is properly cited.

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes*

*DOI: http://dx.doi.org/10.5772/intechopen.84282*

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

The UWI School of Nursing, Mona, University of the West Indies, Jamaica,

\*Address all correspondence to: donnette.wright02@uwimona.edu.jm

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.84282*

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

treatment of vulnerable hospitalised patients.

should employ the following strategies:

opment and recovery

malnutrition risk

**9. Conclusion**

to guide health care practitioners

the use of nutritional treatment protocols

updates for all members of the health care team

statistics concerning nutritional management

impact of nutrition on morbidity and mortality.

including worsening risk of mortality and morbidity as a consequence of under-

Significantly, developed and emerging societies are plagued with malnutrition and its consequences as well as institutional and provider level incompetencies to manage the spiralling problem. The burden is more severe in resource restricted countries. To attenuate the negative effects of malnutrition developing countries

1.Evaluate, adopt and customise appropriate nutritional management algorithms

2.Institute appropriate national and institutional policies to guide and support

3.Assess the training and educational needs of the health care teams

4.Organise regular and contemporary education/training procedures and

5.Engender a culture of nutritional significance and value to health care devel-

6.Reinforce nutritional evaluation and follow-up during and post hospitalisation

7.Adopt international primary and public health strategies to minimize primary

8.Support the documentation of unique nutritional support procedures and the

The global incidence of malnutrition is significant. Nutritional inadequacies directly impact hospital morbidity and mortality rates, worsening death for the most parts and to a lesser extent obesity has been linked to a protective effect. The condition severely diminishes quality of life for individuals of all ages. Health care providers through their capacity and responsibility to screen, assess and intervene serve as critical modulators of malnutrition outcomes. Nevertheless, their attenuative capacity is severely restricted through limited nutrition health related culture, training, education and resource limitations. Notwithstanding the significant challenges, countries and health care institutions must recognise the role nutrition plays in morbidity and mortality and institute effective action, including training and education, as well as policy and resource provision in order to stymie the negative

**50**

### **Author details**

Donnette Wright The UWI School of Nursing, Mona, University of the West Indies, Jamaica, West Indies

\*Address all correspondence to: donnette.wright02@uwimona.edu.jm

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

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[2] Ritchie H, Roser M. Micronutrient Deficiency. 2018. Published online at OurWorldInData.org. Retrieved from: https://ourworldindata.org/ micronutrient-deficiency

[3] van Tonder E, Gardner L, Cressey S, Tydeman-Edwards R, Gerber K. Adult malnutrition: Prevalence and use of nutrition-related quality indicators in South African public-sector hospitals. South African Journal of Clinical Nutrition. 2017;**32**(1):1-7

[4] Correia MIT, Perman MI, Waitzberg DL. Hospital malnutrition in Latin America: A systematic review. Clinical Nutrition. 2017;**36**(4):958-967

[5] Correia MIT, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clinical Nutrition. 2003;**22**(3):235-239

[6] Allard JP, Keller H, Jeejeebhoy KN, Laporte M, Duerksen DR, Gramlich L, et al. Malnutrition at hospital admission—Contributors and effect on length of stay: A prospective cohort study from the Canadian Malnutrition Task Force. Journal of Parenteral and Enteral Nutrition. 2016;**40**(4):487-497

[7] World Health Organization. Global Health Observatory (GHO) Data. 2016. Child Mortality and Causes of Death. Geneva: WHO; 2016

[8] WHO, UNICEF, Mathers C. Global strategy for women's, children's and adolescents' health (2016-2030). Organization. 2017;**2016**(9)

[9] UNICEF/WHO/World Bank Group. Joint child malnutrition estimates: Key findings of the 2017 edition. 2017. Retrieved from: http://www.who.int/ news-room/commentaries/detail/ double-duty-actions-for-endingmalnutrition-within-a-decade

[10] Yildirim ZG, Uzunlulu M, Caklili OT, Mutlu HH, Oguz A. Malnutrition rate among hospitalized patients with type 2 diabetes mellitus. Progress in Nutrition. 2018;**20**(2):183-188

[11] Sakr Y, Alhussami I, Nanchal R, Wunderink RG, Pellis T, Wittebole X, et al. Being overweight is associated with greater survival in ICU patients: Results from the intensive care over nations audit. Critical Care Medicine. 2015;**43**(12):2623-2632

[12] Parissis J, Farmakis D, Kadoglou N, Ikonomidis I, Fountoulaki E, Hatziagelaki E, et al. Body mass index in acute heart failure: Association with clinical profile, therapeutic management and in-hospital outcome. European Journal of Heart Failure. 2016;**18**(3):298-305

[13] Bapat PR, Satav AR, Husain AA, Shekhawat SD, Kawle AP, Chu JJ, et al. Differential levels of alpha-2-macroglobulin, haptoglobin and sero-transferrin as adjunct markers for TB diagnosis and disease progression in the malnourished tribal population of Melghat, India. PLoS One. 2015;**10**(8):e0133928

[14] Triantafillidis JK, Vagianos C, Papalois AE. The role of enteral nutrition in patients with inflammatory bowel disease: Current aspects. BioMed Research International. 2015;**2015**:1-13

[15] Lifshitz F, Lifshitz JZ. Globesity: The root causes of the obesity epidemic in the USA and now worldwide. Pediatric Endocrinology Reviews: PER. 2014;**12**(1):17-34

**53**

1-21

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes*

PT, et al. Childhood malnutrition and maltreatment are linked with personality disorder symptoms in adulthood: Results from a Barbados

lifespan cohort. Psychiatry Research. 2018;**269**:301-308

2015;**34**(1):53-59

[24] Hecht C, Weber M, Grote V, Daskalou E, Dell'Era L, Flynn D, et al. Disease associated malnutrition correlates with length of hospital stay in children. Clinical Nutrition.

[25] Garber AK, Machen VI, Park CC, Peebles R. Changing approaches to refeeding malnourished patients with eating disorders: Results of an International Survey. Journal of Adolescent Health. 2018;**62**(2):S100

[26] Becker P, Carney LN, Corkins MR, Monczka J, Smith E, Smith SE, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators recommended for the identification and documentation

(undernutrition). Nutrition in Clinical

[27] Asiimwe SB. Simplifications of the mini nutritional assessment short-form are predictive of mortality among hospitalized young and middle-aged adults. Nutrition. 2016;**32**(1):95-100

[28] Cereda E, Klersy C, Hiesmayr M, Schindler K, Singer P, Laviano A, et al. Body mass index, age and in-hospital mortality: The Nutrition Day multinational survey. Clinical Nutrition.

[29] Starr KNP, McDonald SR, Bales CW. Nutritional vulnerability in older adults: A continuum of concerns. Current Nutrition Reports.

Matijasevich A, Menezes PR. Factors

2017;**36**(3):839-847

2015;**4**(2):176-184

[30] Damião R, Santos ÁDS,

of pediatric malnutrition

Practice. 2015;**30**(1):147-161

*DOI: http://dx.doi.org/10.5772/intechopen.84282*

[16] Goiburu ME, Jure Goiburu MM, Bianco H, Ruiz Díaz J, Alderete F, Palacios MC, et al. The impact of malnutrition on morbidity, mortality and length of hospital stay in trauma patients. Nutrición Hospitalaria.

[17] de Pee S, Grais R, Fenn B, Brown R, Briend A, Frize J, et al. Prevention of acute malnutrition: Distribution of special nutritious foods and cash, and addressing underlying causes—What to recommend when, where, for whom, and how. Food and Nutrition Bulletin.

2006;**21**(5):604-610

2015;**36**(1\_suppl1):S24-S29

[18] Penié JB, Cuban Group for the Study of Hospital Malnutrition. State of malnutrition in Cuban hospitals. Nutrition. 2005;**21**(4):487-497

[19] Bounoure L, Gomes F, Stanga Z, Keller U, Meier R, Ballmer P, et al. Detection and treatment of medical inpatients with or at-risk of malnutrition: Suggested procedures based on validated guidelines. Nutrition. 2016;**32**(7-8):790-798

[20] Cederholm T, Bosaeus I, Barazzoni R, Bauer J, Van Gossum A, Klek S, et al. Diagnostic criteria for malnutrition— An ESPEN consensus statement. Clinical Nutrition. 2015;**34**(3):335-340

[21] LaMontagne M, Miller B, Falcone T. Development and implementation of a nutritional-risk screening procedure for pregnant mothers in a Honduran community hospital system. 2017;**587**:

[22] Hock RS, Bryce CP, Waber DP, McCuskee S, Fitzmaurice GM, Henderson DC, et al. Relationship between infant malnutrition and childhood maltreatment in a Barbados lifespan cohort. Vulnerable Children and Youth Studies. 2017;**12**(4):304-316

[23] Hock RS, Bryce CP, Fischer L, First MB, Fitzmaurice GM, Costa

*Nutrition and Hospital Mortality, Morbidity and Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.84282*

[16] Goiburu ME, Jure Goiburu MM, Bianco H, Ruiz Díaz J, Alderete F, Palacios MC, et al. The impact of malnutrition on morbidity, mortality and length of hospital stay in trauma patients. Nutrición Hospitalaria. 2006;**21**(5):604-610

[17] de Pee S, Grais R, Fenn B, Brown R, Briend A, Frize J, et al. Prevention of acute malnutrition: Distribution of special nutritious foods and cash, and addressing underlying causes—What to recommend when, where, for whom, and how. Food and Nutrition Bulletin. 2015;**36**(1\_suppl1):S24-S29

[18] Penié JB, Cuban Group for the Study of Hospital Malnutrition. State of malnutrition in Cuban hospitals. Nutrition. 2005;**21**(4):487-497

[19] Bounoure L, Gomes F, Stanga Z, Keller U, Meier R, Ballmer P, et al. Detection and treatment of medical inpatients with or at-risk of malnutrition: Suggested procedures based on validated guidelines. Nutrition. 2016;**32**(7-8):790-798

[20] Cederholm T, Bosaeus I, Barazzoni R, Bauer J, Van Gossum A, Klek S, et al. Diagnostic criteria for malnutrition— An ESPEN consensus statement. Clinical Nutrition. 2015;**34**(3):335-340

[21] LaMontagne M, Miller B, Falcone T. Development and implementation of a nutritional-risk screening procedure for pregnant mothers in a Honduran community hospital system. 2017;**587**: 1-21

[22] Hock RS, Bryce CP, Waber DP, McCuskee S, Fitzmaurice GM, Henderson DC, et al. Relationship between infant malnutrition and childhood maltreatment in a Barbados lifespan cohort. Vulnerable Children and Youth Studies. 2017;**12**(4):304-316

[23] Hock RS, Bryce CP, Fischer L, First MB, Fitzmaurice GM, Costa

PT, et al. Childhood malnutrition and maltreatment are linked with personality disorder symptoms in adulthood: Results from a Barbados lifespan cohort. Psychiatry Research. 2018;**269**:301-308

[24] Hecht C, Weber M, Grote V, Daskalou E, Dell'Era L, Flynn D, et al. Disease associated malnutrition correlates with length of hospital stay in children. Clinical Nutrition. 2015;**34**(1):53-59

[25] Garber AK, Machen VI, Park CC, Peebles R. Changing approaches to refeeding malnourished patients with eating disorders: Results of an International Survey. Journal of Adolescent Health. 2018;**62**(2):S100

[26] Becker P, Carney LN, Corkins MR, Monczka J, Smith E, Smith SE, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition). Nutrition in Clinical Practice. 2015;**30**(1):147-161

[27] Asiimwe SB. Simplifications of the mini nutritional assessment short-form are predictive of mortality among hospitalized young and middle-aged adults. Nutrition. 2016;**32**(1):95-100

[28] Cereda E, Klersy C, Hiesmayr M, Schindler K, Singer P, Laviano A, et al. Body mass index, age and in-hospital mortality: The Nutrition Day multinational survey. Clinical Nutrition. 2017;**36**(3):839-847

[29] Starr KNP, McDonald SR, Bales CW. Nutritional vulnerability in older adults: A continuum of concerns. Current Nutrition Reports. 2015;**4**(2):176-184

[30] Damião R, Santos ÁDS, Matijasevich A, Menezes PR. Factors

**52**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

[9] UNICEF/WHO/World Bank Group. Joint child malnutrition estimates: Key findings of the 2017 edition. 2017. Retrieved from: http://www.who.int/ news-room/commentaries/detail/ double-duty-actions-for-endingmalnutrition-within-a-decade

[10] Yildirim ZG, Uzunlulu M, Caklili OT, Mutlu HH, Oguz A. Malnutrition rate among hospitalized patients with type 2 diabetes mellitus. Progress in Nutrition. 2018;**20**(2):183-188

[11] Sakr Y, Alhussami I, Nanchal R, Wunderink RG, Pellis T, Wittebole X, et al. Being overweight is associated with greater survival in ICU patients: Results from the intensive care over nations audit. Critical Care Medicine.

[12] Parissis J, Farmakis D, Kadoglou N,

Hatziagelaki E, et al. Body mass index in acute heart failure: Association with clinical profile, therapeutic management and in-hospital outcome. European Journal of Heart Failure.

[13] Bapat PR, Satav AR, Husain AA, Shekhawat SD, Kawle AP, Chu JJ, et al. Differential levels of alpha-2-macroglobulin, haptoglobin and sero-transferrin as adjunct markers for TB diagnosis and disease progression in the malnourished tribal population

of Melghat, India. PLoS One.

[14] Triantafillidis JK, Vagianos C, Papalois AE. The role of enteral

nutrition in patients with inflammatory bowel disease: Current aspects. BioMed Research International. 2015;**2015**:1-13

[15] Lifshitz F, Lifshitz JZ. Globesity: The root causes of the obesity epidemic

Pediatric Endocrinology Reviews: PER.

in the USA and now worldwide.

2015;**10**(8):e0133928

2014;**12**(1):17-34

2015;**43**(12):2623-2632

2016;**18**(3):298-305

Ikonomidis I, Fountoulaki E,

**References**

[1] Meier R, Stratton R. Basic concepts

[2] Ritchie H, Roser M. Micronutrient Deficiency. 2018. Published online at OurWorldInData.org. Retrieved from: https://ourworldindata.org/

[3] van Tonder E, Gardner L, Cressey S, Tydeman-Edwards R, Gerber K. Adult malnutrition: Prevalence and use of nutrition-related quality indicators in South African public-sector hospitals. South African Journal of Clinical

[4] Correia MIT, Perman MI, Waitzberg DL. Hospital malnutrition in Latin America: A systematic review. Clinical

in nutrition: Epidemiology of malnutrition. European e-Journal of Clinical Nutrition and Metabolism.

2008;**3**(4):e167-e170

micronutrient-deficiency

Nutrition. 2017;**32**(1):1-7

Nutrition. 2017;**36**(4):958-967

2003;**22**(3):235-239

Geneva: WHO; 2016

[5] Correia MIT, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clinical Nutrition.

[6] Allard JP, Keller H, Jeejeebhoy KN, Laporte M, Duerksen DR, Gramlich L, et al. Malnutrition at hospital admission—Contributors and effect on length of stay: A prospective cohort study from the Canadian Malnutrition Task Force. Journal of Parenteral and Enteral Nutrition. 2016;**40**(4):487-497

[7] World Health Organization. Global Health Observatory (GHO) Data. 2016. Child Mortality and Causes of Death.

[8] WHO, UNICEF, Mathers C. Global strategy for women's, children's and adolescents' health (2016-2030). Organization. 2017;**2016**(9)

associated with risk of malnutrition in the elderly in south-eastern Brazil. Revista Brasileira de Epidemiologia. 2017;**20**:598-610

[31] Fleischmann E, Teal N, Dudley J, May W, Bower JD, Salahudeen AK. Influence of excess weight on mortality and hospital stay in 1346 hemodialysis patients. Kidney International. 1999;**55**(4):1560-1567

[32] Park J, Ahmadi SF, Streja E, Molnar MZ, Flegal KM, Gillen D, et al. Obesity paradox in end-stage kidney disease patients. Progress in Cardiovascular Diseases. 2014;**56**(4):415-425

[33] Vallejo KP, Martínez CM, Adames AAM, Fuchs-Tarlovsky V, Nogales GCC, Paz RER, et al. Current clinical nutrition practices in critically ill patients in Latin America: A multinational observational study. Critical Care. 2017;**21**(1):227

[34] Trehan I, Goldbach HS, LaGrone LN, Meuli GJ, Wang RJ, Maleta KM, et al. Research article (New England Journal of Medicine) antibiotics as part of the management of severe acute malnutrition. Malawi Medical Journal. 2016;**28**(3):123-130

[35] Schwegler I, Von Holzen A, Gutzwiller JP, Schlumpf R, Mühlebach S, Stanga Z. Nutritional risk is a clinical predictor of postoperative mortality and morbidity in surgery for colorectal cancer. British Journal of Surgery. 2010;**97**(1):92-97

[36] Alves A, Panis Y, Mathieu P, Mantion G, Kwiatkowski F, Slim K. Postoperative mortality and morbidity in French patients undergoing colorectal surgery: Results of a prospective multicenter study. Archives of Surgery. 2005;**140**(3):278-283

[37] Mueller C, Compher C, Ellen DM, American Society for Parenteral and Enteral Nutrition (ASPEN) Board of

Directors. ASPEN clinical guidelines: Nutrition screening, assessment, and intervention in adults. Journal of Parenteral and Enteral Nutrition. 2011;**35**(1):16-24

[38] Martin L, de van der Schueren MA, Blauwhoff-Buskermolen S, Baracos V, Gramlich L. Identifying the barriers and enablers to nutrition care in head and neck and esophageal cancers: An international qualitative study. Journal of Parenteral and Enteral Nutrition. 2016;**40**(3):355-366

[39] Duerksen DR, Keller HH, Vesnaver E, Laporte M, Jeejeebhoy K, Payette H, et al. Nurses' perceptions regarding the prevalence, detection, and causes of malnutrition in Canadian hospitals: Results of a Canadian Malnutrition Task Force Survey. Journal of Parenteral and Enteral Nutrition. 2016;**40**(1):100-106

[40] Donini LM, Leonardi F, Rondanelli M, Banderali G, Battino M, Bertoli E, et al. The domains of human nutrition: The importance of nutrition education in academia and medical schools. Frontiers in Nutrition. 2017;**4**:2

[41] Sacks GS. The shrinking of formalized nutrition education in health professions curricula and postgraduate training. Journal of Parenteral and Enteral Nutrition. 2017;**41**(2):217-225

[42] Correia MI, Hegazi RA, Diaz-Pizarro Graf JI, Gomez-Morales G, Fuentes Gutiérrez C, Goldin MF, et al. Addressing disease-related malnutrition in healthcare: A Latin American perspective. Journal of Parenteral and Enteral Nutrition. 2016;**40**(3):319-325

**55**

**Chapter 4**

**Abstract**

multidisciplinary teams

**1. Introduction**

Improving the Quality of Care in

Surgery: The Role of Guidelines,

*Joseph Martin Plummer, Mark S. Newnham and Timothy Henry*

Today's surgical environment is a complex multifaceted one that has eroded the traditional doctor patient relationship. Increasingly a discerning public expects surgery to be efficiently performed and be free of complications. Decisions about choosing a doctor are now data driven and the health system must adapt accordingly in order to attract patients. The streamlining of the patient: treatment: outcome continuum can be made better with the use of various standard operating procedures such as the use of guidelines, protocols and checklists with a multidisciplinary team where all stakeholders are actively engaged. This is especially important in developing countries for the potential savings in lives and finances. Still the need for individualization and good clinical judgment remains. The basis of all our decisions however must be evidence-based, and once applied in the best interest of the patient will benefit health care systems. There is good evidence that this is the case, and the only limitation currently is the lack of more widespread implementation.

Medical knowledge is increasing at an exponential pace and as such standard of care applicable a decade ago may not necessarily apply today, depending on the condition and the level of evidence supporting the change. Patients now have access to a wide range of information, proportionate on their resources, motivation and level of education. In fact they can be seen no longer as 'patients' but 'clients' who are consumers and shoppers of care. As such they expect that their doctors will be professional, compassionate and with up-to-date knowledge and skills, providing at least a basic standard of care that *guarantees* a good outcome. The duty of a certain standard is owed to the public by the doctors, nurses, administrators, and all other members of

the health team irrespective of the patient's resources, social class or religion.

Oftentimes there is a gap in new medical knowledge and its translation to clinical practice, and on average this can take up to a decade [1, 2]. The consequences of these evidence-to-practice gaps are potentially significant, with risk of mortality, morbidity and significant healthcare and financial impact. Importantly, once there is

Protocols, Checklist and the

**Keywords:** quality of surgery, guidelines, checklists and protocols,

Multidisciplinary Team

#### **Chapter 4**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

Directors. ASPEN clinical guidelines: Nutrition screening, assessment, and intervention in adults. Journal of Parenteral and Enteral Nutrition.

[38] Martin L, de van der Schueren MA, Blauwhoff-Buskermolen S, Baracos V, Gramlich L. Identifying the barriers and enablers to nutrition care in head and neck and esophageal cancers: An international qualitative study. Journal of Parenteral and Enteral Nutrition.

[39] Duerksen DR, Keller HH, Vesnaver E, Laporte M, Jeejeebhoy K, Payette H, et al. Nurses' perceptions regarding the prevalence, detection, and causes of malnutrition in Canadian hospitals: Results of a Canadian Malnutrition Task Force Survey. Journal of Parenteral and Enteral Nutrition. 2016;**40**(1):100-106

[40] Donini LM, Leonardi F, Rondanelli M, Banderali G, Battino M, Bertoli E, et al. The domains of human nutrition: The importance of nutrition education in academia and medical schools. Frontiers in Nutrition. 2017;**4**:2

formalized nutrition education in health professions curricula and postgraduate training. Journal of Parenteral and Enteral Nutrition. 2017;**41**(2):217-225

[41] Sacks GS. The shrinking of

[42] Correia MI, Hegazi RA, Diaz-Pizarro Graf JI, Gomez-Morales G, Fuentes Gutiérrez C, Goldin MF, et al. Addressing disease-related malnutrition

in healthcare: A Latin American perspective. Journal of Parenteral and Enteral Nutrition. 2016;**40**(3):319-325

2011;**35**(1):16-24

2016;**40**(3):355-366

associated with risk of malnutrition in the elderly in south-eastern Brazil. Revista Brasileira de Epidemiologia.

[31] Fleischmann E, Teal N, Dudley J, May W, Bower JD, Salahudeen AK. Influence of excess weight on mortality and hospital stay in 1346 hemodialysis patients. Kidney International. 1999;**55**(4):1560-1567

[32] Park J, Ahmadi SF, Streja E, Molnar MZ, Flegal KM, Gillen D, et al. Obesity paradox in end-stage kidney disease patients. Progress in Cardiovascular Diseases. 2014;**56**(4):415-425

[33] Vallejo KP, Martínez CM, Adames AAM, Fuchs-Tarlovsky V, Nogales GCC, Paz RER, et al. Current clinical nutrition practices in critically ill patients in Latin America: A multinational observational study. Critical Care. 2017;**21**(1):227

[34] Trehan I, Goldbach HS, LaGrone LN, Meuli GJ, Wang RJ, Maleta KM, et al. Research article (New England Journal of Medicine) antibiotics as part of the management of severe acute malnutrition. Malawi Medical Journal.

2016;**28**(3):123-130

2010;**97**(1):92-97

[35] Schwegler I, Von Holzen A, Gutzwiller JP, Schlumpf R, Mühlebach S, Stanga Z. Nutritional risk is a clinical predictor of postoperative mortality and morbidity in surgery for colorectal cancer. British Journal of Surgery.

[36] Alves A, Panis Y, Mathieu P, Mantion G, Kwiatkowski F, Slim K. Postoperative mortality and morbidity in French patients undergoing colorectal surgery: Results of a prospective multicenter

study. Archives of Surgery. 2005;**140**(3):278-283

[37] Mueller C, Compher C, Ellen DM, American Society for Parenteral and Enteral Nutrition (ASPEN) Board of

2017;**20**:598-610

**54**

## Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist and the Multidisciplinary Team

*Joseph Martin Plummer, Mark S. Newnham and Timothy Henry*

### **Abstract**

Today's surgical environment is a complex multifaceted one that has eroded the traditional doctor patient relationship. Increasingly a discerning public expects surgery to be efficiently performed and be free of complications. Decisions about choosing a doctor are now data driven and the health system must adapt accordingly in order to attract patients. The streamlining of the patient: treatment: outcome continuum can be made better with the use of various standard operating procedures such as the use of guidelines, protocols and checklists with a multidisciplinary team where all stakeholders are actively engaged. This is especially important in developing countries for the potential savings in lives and finances. Still the need for individualization and good clinical judgment remains. The basis of all our decisions however must be evidence-based, and once applied in the best interest of the patient will benefit health care systems. There is good evidence that this is the case, and the only limitation currently is the lack of more widespread implementation.

**Keywords:** quality of surgery, guidelines, checklists and protocols, multidisciplinary teams

#### **1. Introduction**

Medical knowledge is increasing at an exponential pace and as such standard of care applicable a decade ago may not necessarily apply today, depending on the condition and the level of evidence supporting the change. Patients now have access to a wide range of information, proportionate on their resources, motivation and level of education. In fact they can be seen no longer as 'patients' but 'clients' who are consumers and shoppers of care. As such they expect that their doctors will be professional, compassionate and with up-to-date knowledge and skills, providing at least a basic standard of care that *guarantees* a good outcome. The duty of a certain standard is owed to the public by the doctors, nurses, administrators, and all other members of the health team irrespective of the patient's resources, social class or religion.

Oftentimes there is a gap in new medical knowledge and its translation to clinical practice, and on average this can take up to a decade [1, 2]. The consequences of these evidence-to-practice gaps are potentially significant, with risk of mortality, morbidity and significant healthcare and financial impact. Importantly, once there is a concerted effort to improve quality in clinical care, gradually over time we will see improved results [3, 4] across the spectrum of quality outcomes. For example there is evidence that cancer outcome can be improved by up to 30% with optimum application of best evidence with a 10% reduction in cancer mortality if the evidence for best practice was used.

Confronted with overwhelming evidence that substantial harm was being done to the public due to inadequate patient safety and the failure to practice using the best currently available evidence, the World Health Assembly (WHA) mandated the WHO to take a lead in setting global norms and standards and supporting countries in preparing patient safety policies and practices [5]. In 2008 the WHO choose the 'safety of surgical care' for its second Global Patient Safety Challenge. This Safe Surgery Saves Lives Program brought together surgeons, gynecologists, anesthetists, ward and theater nurses, operating theater managers, patient advocates, infection control experts and biomedical engineers to identify opportunities to improve the safety of surgical patients [6]. The groups were tasked with considering four pillars for improved outcome: infection prevention, anesthetic safety, teamwork and communication and measurement of surgical capacity and outcomes. It has been a decade since the launch of this mandate and although the measures identified were not new, they certainly brought into focus the importance of clinical practice guidelines, checklists and protocols as tools available to improve the quality of surgical care. Increasingly more recently especially with the importance of a multimodal approach to the treatment of cancers, an additional area of focus to improve the quality of surgical care is the role of multidisciplinary rounds.

The process for the successful systems improvement was divided into three stages: teaching, which has a widely variable performance rate; mandates/regulations, which results in modest level of performance improvement; and systemization including data feedback loops, coaching, and checklists, which result in high reliability [7]. Once implemented, this improvement is noticeable both at 'well-performing' hospitals and 'worse-performing' hospitals [8] and would have a substantial impact in achieving more from the limited spending allocated annually in the national budget to healthcare. This is because meaningful implementation of these safety measures occurs when there is a shift in the mindset of the surgeon from solo practitioners (autonomous cowboys) to a team-based or 'pit crew' approach. Dr. Gawande [7] noted that this change in the operating room involves humility, discipline, and teamwork. He emphasized three critical pause points for surgery as identified by the checklist: before the induction of anesthesia, before the incision in the skin, and before the patient leaves the operating room (OR). Whereas the purpose of the checklist was to help the OR team remember important details that may be missed during an operation, it certainly encourages teamwork and communication.

#### **2. The scope of the problem**

Surgical care is essential in improving population health. It is estimated that there is one operation performed annually for every 25 human beings alive [9]. With this volume there is a great potential source for a public health crisis. Globally perioperative mortality has declined significantly over the past 50 years, with the greatest decline in developed countries. It is in developing countries where avoidable surgical complications disproportionately account for a large proportion of preventable medical injuries and deaths globally [10]. A surgical complication is any undesirable, unintended and direct result of an operation affecting the patient that would not have occurred had the operation gone well as could reasonably be hoped [11]. Whereas complications of medical care may occur as a consequence of

**57**

*Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist…*

reduction in the number of unexpected deaths in American hospitals [15].

clearly demonstrating the need to improve safety in this setting [16, 17].

complications (74.3%) was in low-income or middle-income countries [22].

Clinical practice guidelines are evidence-based recommendations for the treatment of patients with specific problems. Guidelines are developed by groups that combine people with expertise in conducting systematic reviews and health economic analyses, with those with the expertise in the clinical area (from health professionals and patients) [1]. The uptake of clinical practice guidelines has been inconsistent despite their potent to improve the quality of care and patient outcome. The WHO recommends that for each problem to be addressed by the development

**3. Guidelines, checklist and protocols**

of guidelines, the following steps should be taken:

a.Define the specific issue to be addressed by the guidelines

b.Undertake a systematic review of the evidence available

all stakeholders for feedback before a final version.

c.Develop recommendations linked to the strength of evidence

d.Draft guidelines and for each recommendation it is best to list "highly recommended", 'recommended' or 'suggested'. These should be shared initially with

both the illness and the treatment, in general its regarded as 'a complication' when it was not caused by the underlying disease [12]. This 'complication' is perhaps better labeled 'an adverse event' which is defined as an unintended injury caused by medical management rather than by the underlying disease or condition of the patient [13]. In developed countries up to 17% of all inpatient surgeries will have a major complication [14]. Nearly 30% of all adverse events were as a result of negligence, and these events were much higher in the elderly. Often complications occur as a result of errors of commission or acts of omission. While accepting that 'To err is human', the Institute of Medicine in recognizing this fatal flaw still called for a 50%

The WHO estimates that 7 million surgical patients suffer significant surgical complications and 1 million die during or immediately after surgery and akin this to the maternal and neonatal survival crisis with its suggested public health intervention and educational campaign in an attempt to improve surgical safety and quality of care [5]. The surgical mortality in developing countries is 10 times higher than developed nations [9] and deaths attributed to anesthesia are 1000-fold higher,

Its estimated that 8 million amendable deaths occurred in 2015, with 96% in low and middle income countries. The value of lost output resulted in a projected cumulative loss of \$11.2 trillion in these countries during 2015–2030, with a potential economic output loss of up to 2.6% of gross domestic product (GDP) in low-income countries by 2030 [18]. Quality of care in surgery has garnered increased attention both globally, regionally and nationally [5, 19–21]. For example the introduction of guidelines for preoperative investigations for elective surgery in 2012 at the Queen Elizabeth Hospital in Barbados resulted in savings of US \$40,745.50 per year, mainly due to a significant reduction in the number of full blood count and chest X-ray tests that were ordered [20]. There is therefore a strong ethical and economic case for promoting is can be reduced with the implementation of evidence-based best practice in developing countries. Following the implementation of the WHO SSC, evidence suggests it is particularly effective in a resource-poor setting. The largest decrease in

*DOI: http://dx.doi.org/10.5772/intechopen.84658*

#### *Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist… DOI: http://dx.doi.org/10.5772/intechopen.84658*

both the illness and the treatment, in general its regarded as 'a complication' when it was not caused by the underlying disease [12]. This 'complication' is perhaps better labeled 'an adverse event' which is defined as an unintended injury caused by medical management rather than by the underlying disease or condition of the patient [13]. In developed countries up to 17% of all inpatient surgeries will have a major complication [14]. Nearly 30% of all adverse events were as a result of negligence, and these events were much higher in the elderly. Often complications occur as a result of errors of commission or acts of omission. While accepting that 'To err is human', the Institute of Medicine in recognizing this fatal flaw still called for a 50% reduction in the number of unexpected deaths in American hospitals [15].

The WHO estimates that 7 million surgical patients suffer significant surgical complications and 1 million die during or immediately after surgery and akin this to the maternal and neonatal survival crisis with its suggested public health intervention and educational campaign in an attempt to improve surgical safety and quality of care [5]. The surgical mortality in developing countries is 10 times higher than developed nations [9] and deaths attributed to anesthesia are 1000-fold higher, clearly demonstrating the need to improve safety in this setting [16, 17].

Its estimated that 8 million amendable deaths occurred in 2015, with 96% in low and middle income countries. The value of lost output resulted in a projected cumulative loss of \$11.2 trillion in these countries during 2015–2030, with a potential economic output loss of up to 2.6% of gross domestic product (GDP) in low-income countries by 2030 [18]. Quality of care in surgery has garnered increased attention both globally, regionally and nationally [5, 19–21]. For example the introduction of guidelines for preoperative investigations for elective surgery in 2012 at the Queen Elizabeth Hospital in Barbados resulted in savings of US \$40,745.50 per year, mainly due to a significant reduction in the number of full blood count and chest X-ray tests that were ordered [20]. There is therefore a strong ethical and economic case for promoting is can be reduced with the implementation of evidence-based best practice in developing countries. Following the implementation of the WHO SSC, evidence suggests it is particularly effective in a resource-poor setting. The largest decrease in complications (74.3%) was in low-income or middle-income countries [22].

#### **3. Guidelines, checklist and protocols**

Clinical practice guidelines are evidence-based recommendations for the treatment of patients with specific problems. Guidelines are developed by groups that combine people with expertise in conducting systematic reviews and health economic analyses, with those with the expertise in the clinical area (from health professionals and patients) [1]. The uptake of clinical practice guidelines has been inconsistent despite their potent to improve the quality of care and patient outcome. The WHO recommends that for each problem to be addressed by the development of guidelines, the following steps should be taken:


*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

practice was used.

a concerted effort to improve quality in clinical care, gradually over time we will see improved results [3, 4] across the spectrum of quality outcomes. For example there is evidence that cancer outcome can be improved by up to 30% with optimum application of best evidence with a 10% reduction in cancer mortality if the evidence for best

Confronted with overwhelming evidence that substantial harm was being done to the public due to inadequate patient safety and the failure to practice using the best currently available evidence, the World Health Assembly (WHA) mandated the WHO to take a lead in setting global norms and standards and supporting countries in preparing patient safety policies and practices [5]. In 2008 the WHO choose the 'safety of surgical care' for its second Global Patient Safety Challenge. This Safe Surgery Saves Lives Program brought together surgeons, gynecologists, anesthetists, ward and theater nurses, operating theater managers, patient advocates, infection control experts and biomedical engineers to identify opportunities to improve the safety of surgical patients [6]. The groups were tasked with considering four pillars for improved outcome: infection prevention, anesthetic safety, teamwork and communication and measurement of surgical capacity and outcomes. It has been a decade since the launch of this mandate and although the measures identified were not new, they certainly brought into focus the importance of clinical practice guidelines, checklists and protocols as tools available to improve the quality of surgical care. Increasingly more recently especially with the importance of a multimodal approach to the treatment of cancers, an additional area of focus to improve the quality of surgical care is the role of multidisciplinary rounds. The process for the successful systems improvement was divided into three stages: teaching, which has a widely variable performance rate; mandates/regulations, which results in modest level of performance improvement; and systemization including data feedback loops, coaching, and checklists, which result in high reliability [7]. Once implemented, this improvement is noticeable both at 'well-performing' hospitals and 'worse-performing' hospitals [8] and would have a substantial impact in achieving more from the limited spending allocated annually in the national budget to healthcare. This is because meaningful implementation of these safety measures occurs when there is a shift in the mindset of the surgeon from solo practitioners (autonomous cowboys) to a team-based or 'pit crew' approach. Dr. Gawande [7] noted that this change in the operating room involves humility, discipline, and teamwork. He emphasized three critical pause points for surgery as identified by the checklist: before the induction of anesthesia, before the incision in the skin, and before the patient leaves the operating room (OR). Whereas the purpose of the checklist was to help the OR team remember important details that may be missed during an operation, it certainly encourages teamwork and communication.

Surgical care is essential in improving population health. It is estimated that there is one operation performed annually for every 25 human beings alive [9]. With this volume there is a great potential source for a public health crisis. Globally perioperative mortality has declined significantly over the past 50 years, with the greatest decline in developed countries. It is in developing countries where avoidable surgical complications disproportionately account for a large proportion of preventable medical injuries and deaths globally [10]. A surgical complication is any undesirable, unintended and direct result of an operation affecting the patient that would not have occurred had the operation gone well as could reasonably be hoped [11]. Whereas complications of medical care may occur as a consequence of

**56**

**2. The scope of the problem**

e.Finally the guidelines should be tested through pilot evaluations with appropriate feedback and a full dissemination strategy implemented.

The use of guidelines usually covers common surgical problems and brings together the evidence and risks/benefits considerations for certain recommendations such that the best decisions can be made. There is still some individuality that is left to the managing team. Oftentimes guidelines are cumbersome documents of multiple pages and interpretation and implementation is made easier by a one-page summary document in simple easy to understand wording and should be readily available to all areas where patients are cared for.

Guidelines differ somewhat from protocols and checklists as here the adopted strategy should be strictly adhered to. The checklist was adapted from the field of aviation, where it was developed in response to a crash after investigations revealed the crash was as a result of a pilot failing to perform one of the steps necessary for safe takeoff [23]. Another similar area is Formula 1 racing where a high level of teamwork, focus and performance lead by team leader is necessary for optimal outcome. Meticulous training and practice is required for ideal F1 pit stop. It takes significant resources to change behavior and incorporate its use into routine daily practice [6, 7, 23]. In adjusted analysis, the use of and compliance with a checklist-based safety system was associated with a more than a 30 percent decrease in mortality and morbidity respectively [24, 25]. The decrease in surgical adverse events after implementation of checklists seems to be greater in developing countries [26] but even in well performing systems in developed countries stand to improve [27], proving that even highly skilled operating room teams need tools to help them achieve optimal results. Still it is in the low and middle income countries that the checklist use is not universally promoted or implemented, suggesting an opportunity for advocacy and education in the use of this safety tool [6].

It has been shown that the communication failures are common, affecting up to 30% of interactions in the operating room [28] and the use of a checklist may prevent more than half of the communication failures from occurring [29] by orienting the team to the individual patient, alerting each member to potential complications and encouraging team members to voice concerns when they notice an error occurring [30]. The proper use of the checklist may be a marker for teamwork and cooperation within the operating room. This calls into question whether it is the improved teamwork or the checklist. While it may be difficult to be absolutely sure of the underlying reasons for the use of checklists and improved patient outcomes, and while it is accepted that the checklist culture improves the safety culture within an institution, a firm sense of commitment is necessary, as it may become a routine activity of checking off boxes without actually driving behavior change or improvement, giving a false sense of security [31, 32]. The lack of benefit after the widespread implementation of a checklist in a hospital system is well documented and may in fact represent a more 'real world' situation [33] but also speaks to the need sometimes to modify these instruments to suite the local population.

Protocols are a set of standardized orders governing the management of a surgical problem and as such represent another means of attempting quality improvement in surgery. The development and introduction of standardized enhanced recovery and fast-track protocols in the preoperative management of surgical patients occurred over 20 years ago [34] and is well known for the benefits of reduce length of hospital stay, infection rates and costs as evidenced by various publications [35, 36]. A well-executed enhanced recovery protocol requires a multi-disciplinary team buy-in (both medical personnel and administration) and the active participation of both the patient and family. The pillars of this successful program will include the principles of carbohydrate loading, early feeding, early

**59**

*Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist…*

and non-gastrointestinal surgery with maintenance of the gains [38–40].

ambulation, goal-directed fluid therapy, and opiate-sparing analgesics. Newer anesthetic techniques, minimally invasive surgery and an emphasis on greater patient education will reduce the physiologic stress of surgical trauma and therefore less organ dysfunction. The ERAS protocols also uses evidence-based adjustments in the use of nasogastric tubes, drains, urinary catheters, preoperative bowel preparation and the use of antibiotics [37]. Although they were popularized with colorectal surgery, they have now been extended to a wide spectrum of other gastrointestinal

The multidisciplinary approach is a concept that has been around for at least 50–60 years [41]. In fact the theoretical concept is revolutionary and as the base of medical knowledge increases the role of the single "super doctor" is now becoming obsolete. Daily hundreds of new articles filled with research done by even larger numbers of medically trained personnel enter the world of medicine. The National Health Service (NHS) defines this concept as follows: "A multidisciplinary approach involves drawing appropriately from multiple disciplines to explore problems outside of normal boundaries and reach solutions based on a new understanding of complex situations" [42]. This definition in itself is very broad but at least offers a framework in which to operate. There are some definitions used for defining the concept of the Multidisciplinary Team (MDT). According to the NHS in the UK, "a Multidisciplinary Team Meeting is defined as a care activity, a care activity referring to an individualized point of care service for patients." Furthermore, a MDT meeting is defined as, "…a meeting of the group of professionals from one or more clinical disciplines who together make decisions regarding recommended treatment of individual patients. Multidisciplinary Teams may specialize in certain conditions, such as Cancer. Clinical decisions are made based on reviews of clinical documentation such as case notes, test results, diagnostic imaging, etc. The patient may or may

According to specialist opinion across many surgical fields, the role of multidisciplinary teams is integral in improving patient quality care as it relates to time to time to diagnosis and treatment. There is also an economic benefit as there would be less requests for unnecessary tests therefore improving resource management [44]. In fact although there is much evidence that these multidisciplinary systems are effective in improving different parameters as it relates to different fields in medicine, the very definition of a multidisciplinary team itself is lacking. Not only is a standardized definition lacking but there is no well defined, internationally recognized set of criteria that can be used to determine if the "MDT" being assessed in each study is operating at a certain standard. It is therefore reasonable to assume that the evidence may not always point in the accurate direction due to the assessment of possibly "substandard" multidisciplinary teams littering the pool of literature. This being said, there is still overwhelming support for the use of these teams in recent literature and this is most certainly a positive indicator considering

As mentioned before there are many advantages to the use of MDTs in clinical practice however many obstacles to their effective implementation remain. The one to one traditional clinician:patient interaction is lacking in many ways and MDTs seek to fill those gaps. One of the most obvious advantages is the sharing of knowledge across specialties. This leads to new perspectives on patient care and improved resource management as it relates to patient investigations. The multidisciplinary team meeting is a learning opportunity for specialists and this increases their

*DOI: http://dx.doi.org/10.5772/intechopen.84658*

**4. Multidisciplinary meetings**

not be present [43].

the previous point.

*Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist… DOI: http://dx.doi.org/10.5772/intechopen.84658*

ambulation, goal-directed fluid therapy, and opiate-sparing analgesics. Newer anesthetic techniques, minimally invasive surgery and an emphasis on greater patient education will reduce the physiologic stress of surgical trauma and therefore less organ dysfunction. The ERAS protocols also uses evidence-based adjustments in the use of nasogastric tubes, drains, urinary catheters, preoperative bowel preparation and the use of antibiotics [37]. Although they were popularized with colorectal surgery, they have now been extended to a wide spectrum of other gastrointestinal and non-gastrointestinal surgery with maintenance of the gains [38–40].

#### **4. Multidisciplinary meetings**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

ate feedback and a full dissemination strategy implemented.

available to all areas where patients are cared for.

e.Finally the guidelines should be tested through pilot evaluations with appropri-

The use of guidelines usually covers common surgical problems and brings together the evidence and risks/benefits considerations for certain recommendations such that the best decisions can be made. There is still some individuality that is left to the managing team. Oftentimes guidelines are cumbersome documents of multiple pages and interpretation and implementation is made easier by a one-page summary document in simple easy to understand wording and should be readily

Guidelines differ somewhat from protocols and checklists as here the adopted strategy should be strictly adhered to. The checklist was adapted from the field of aviation, where it was developed in response to a crash after investigations revealed the crash was as a result of a pilot failing to perform one of the steps necessary for safe takeoff [23]. Another similar area is Formula 1 racing where a high level of teamwork, focus and performance lead by team leader is necessary for optimal outcome. Meticulous training and practice is required for ideal F1 pit stop. It takes significant resources to change behavior and incorporate its use into routine daily practice [6, 7, 23]. In adjusted analysis, the use of and compliance with a checklist-based safety system was associated with a more than a 30 percent decrease in mortality and morbidity respectively [24, 25]. The decrease in surgical adverse events after implementation of checklists seems to be greater in developing countries [26] but even in well performing systems in developed countries stand to improve [27], proving that even highly skilled operating room teams need tools to help them achieve optimal results. Still it is in the low and middle income countries that the checklist use is not universally promoted or implemented, suggesting an

opportunity for advocacy and education in the use of this safety tool [6].

sometimes to modify these instruments to suite the local population.

Protocols are a set of standardized orders governing the management of a surgical problem and as such represent another means of attempting quality improvement in surgery. The development and introduction of standardized enhanced recovery and fast-track protocols in the preoperative management of surgical patients occurred over 20 years ago [34] and is well known for the benefits of reduce length of hospital stay, infection rates and costs as evidenced by various publications [35, 36]. A well-executed enhanced recovery protocol requires a multi-disciplinary team buy-in (both medical personnel and administration) and the active participation of both the patient and family. The pillars of this successful program will include the principles of carbohydrate loading, early feeding, early

It has been shown that the communication failures are common, affecting up to 30% of interactions in the operating room [28] and the use of a checklist may prevent more than half of the communication failures from occurring [29] by orienting the team to the individual patient, alerting each member to potential complications and encouraging team members to voice concerns when they notice an error occurring [30]. The proper use of the checklist may be a marker for teamwork and cooperation within the operating room. This calls into question whether it is the improved teamwork or the checklist. While it may be difficult to be absolutely sure of the underlying reasons for the use of checklists and improved patient outcomes, and while it is accepted that the checklist culture improves the safety culture within an institution, a firm sense of commitment is necessary, as it may become a routine activity of checking off boxes without actually driving behavior change or improvement, giving a false sense of security [31, 32]. The lack of benefit after the widespread implementation of a checklist in a hospital system is well documented and may in fact represent a more 'real world' situation [33] but also speaks to the need

**58**

The multidisciplinary approach is a concept that has been around for at least 50–60 years [41]. In fact the theoretical concept is revolutionary and as the base of medical knowledge increases the role of the single "super doctor" is now becoming obsolete. Daily hundreds of new articles filled with research done by even larger numbers of medically trained personnel enter the world of medicine. The National Health Service (NHS) defines this concept as follows: "A multidisciplinary approach involves drawing appropriately from multiple disciplines to explore problems outside of normal boundaries and reach solutions based on a new understanding of complex situations" [42]. This definition in itself is very broad but at least offers a framework in which to operate. There are some definitions used for defining the concept of the Multidisciplinary Team (MDT). According to the NHS in the UK, "a Multidisciplinary Team Meeting is defined as a care activity, a care activity referring to an individualized point of care service for patients." Furthermore, a MDT meeting is defined as, "…a meeting of the group of professionals from one or more clinical disciplines who together make decisions regarding recommended treatment of individual patients. Multidisciplinary Teams may specialize in certain conditions, such as Cancer. Clinical decisions are made based on reviews of clinical documentation such as case notes, test results, diagnostic imaging, etc. The patient may or may not be present [43].

According to specialist opinion across many surgical fields, the role of multidisciplinary teams is integral in improving patient quality care as it relates to time to time to diagnosis and treatment. There is also an economic benefit as there would be less requests for unnecessary tests therefore improving resource management [44]. In fact although there is much evidence that these multidisciplinary systems are effective in improving different parameters as it relates to different fields in medicine, the very definition of a multidisciplinary team itself is lacking. Not only is a standardized definition lacking but there is no well defined, internationally recognized set of criteria that can be used to determine if the "MDT" being assessed in each study is operating at a certain standard. It is therefore reasonable to assume that the evidence may not always point in the accurate direction due to the assessment of possibly "substandard" multidisciplinary teams littering the pool of literature. This being said, there is still overwhelming support for the use of these teams in recent literature and this is most certainly a positive indicator considering the previous point.

As mentioned before there are many advantages to the use of MDTs in clinical practice however many obstacles to their effective implementation remain. The one to one traditional clinician:patient interaction is lacking in many ways and MDTs seek to fill those gaps. One of the most obvious advantages is the sharing of knowledge across specialties. This leads to new perspectives on patient care and improved resource management as it relates to patient investigations. The multidisciplinary team meeting is a learning opportunity for specialists and this increases their

exposure to evidence-based protocols and guidelines from other disciplines. One cannot fail to mention that the patient perceives this as having the benefit of a second opinion and in addition to improving the clinical intervention through consultation, may improve their perception of the quality of care they are receiving. There are also several reasons to explain the difficulty in integrating the use of multidisciplinary teams as a routine part of patient care. The ambiguity of who is needed at these meetings may lead to having not enough, or too many clinicians attending the meetings. It is an investment of time that may not be perceived as effective by some. There is an additional structure required to maintain these meetings which would mean more finances poured into human resources. If no dedicated staff for this purpose is chosen then the question of which existing department would be responsible for holding multidisciplinary meetings for which subset of patients [45].

According to the WHO in February 2015, cancer is a leading cause of morbidity and mortality worldwide, with approximately 14 million new cases and 8.2 million cancer-related deaths reported in 2012 [46]. Great interest has been generated in the application of the use of multidisciplinary teams toward the management of patients with potentially high risk and major cancer surgery [47]. In 2012, the NHS published a retrospective cohort study where breast cancer survival in intervention and non-intervention groups not treated by an MDT were compared with intervention and non-intervention groups treated by an MDT. This study found a significant decrease in mortality among the intervention group for those treated by an MDT [48]. Another example of the benefit of this application is in a retrospective cohort study done by Stephens MR et al. where a cohort of patients for R0 oesophagectomy treated by an MDT was compared with a cohort of patients treated by six individual general surgeons. A statistically significant difference in major parameters was found. Operative mortality (5.7% vs. 26%, chi2 = 8.22, P = 0.004), 5-year survival (52%vs. 10%, chi2 = 15.05, P = 0.0001) and rate of open and closed laparotomy and thoracotomy all had statistically significant improvements [49]. This is one of the very few pieces of available publications providing evidence of the utility of MDTs in high risk surgery and although encouraging, there is still more need for evidence as it relates to specific compositions of MDTs as the results may differ based on the specialists involved in the planning of these cases.

Some professionals are of the belief that a multidisciplinary team should be available for all surgical cases in order to improve the outcomes of all surgical patients who seek tertiary care. It is important to note that this may not always be an efficient use of resources. For instance, in 2015, Chien-Chou Pan et al. explored the survival rates of patients treated by an MDT for stage III and IV non-small cell lung cancer had statistically significantly higher survival rates than those not treated by an MDT. For those with stages I and II, the survival rates did not differ significantly [50]. This is an example that supports the use of multidisciplinary teams for high risk cases as the benefits may only be worth the risk in these cases.

Although the little evidence emerging thus far is in support of the implementation of MDTs, the favorable results may be partly due to flaws in study design, various biases in enrollment of participants for these studies and other factors associated with the presence of the MDT itself. For example, because this is a relatively newly explored concept, there is a lack of randomized controlled trials. Doing such studies would also raise ethical concerns especially as the MDT is already viewed by many as a higher standard of patient care and denying a patient this resource when available may be seen as questionable morally. Patients enrolled for studies for MDTs may be dependent on the referring physician and it may be reasonable to assume persons who are more likely to survive from further intervention would be in the majority of those referred to an MDT. It is also important not to forget that when a patient is referred to an MDT, they may have several investigations

**61**

**5. Conclusions**

*Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist…*

Identify relevant interventions Systematic review of the literature

**Targets/goals Suggested intervention** Establish baseline practice at the local institution Audit of current practice

expedited that would have otherwise not have been done or would have taken longer to be completed. These factors are all important to consider in interpretation

Overall, it is evident that the presence of the multidisciplinary team has been beneficial for specific patient populations. Whether this benefit is directly as a result of the team itself or the associated factors such as decreased time to investigations or other similar factors may not necessarily be of significant concern. As this topic continues to be explored in the literature and is also being applied in increasing numbers of patient care institutions, we will continue to learn about the utility of these teams both in a general sense and as it relates to more specific patient

Identify barriers to implementation Interviews & surveys: surgeons, nurse anesthetists,

residents, physicians

opinion incorporated

Modified Delphi method, both evidence & expert

Providing optimal care to patients based on the best evidence is difficult as the half-life of knowledge is estimated to be approximately 3–5 years therefore it is very difficult for physicians to keep up with the medical literature. Multiple strategies are often required to make changes and provide optimal care. Knowledge translation is a dynamic and iterative process that includes synthesis and dissemination of the best available evidence in an ethically sound manner to improve health, provide more effective health services and products and strengthen the healthcare system. It requires collaboration between multiple stakeholders and multifaceted interventions such as audits and feedback, reminders, educational strategies, decision aids and standardized orders. Physicians usually play a leading role in implementation as they are usually opinion leaders. Additionally they are well respected and trusted by all members of the health care team. Especially in developing countries where there is a lot to be gained some answers may lie outside the physician or hospital. Measures such as legislation, public education and advocacy, revision of the medical curriculum, patient handbooks and other health promotional material may all have a role in eliciting change in behavior. Varying committed members of the health care team may have to assume the role of the opinion leader or 'champion'. Recommendations are more likely to be followed if they are simple, inclusive, with a high level of evidence but are more likely to succeed with an evaluative component

The modern surgical environment is complex with multiple components perhaps too much to be considered for any one individual. The dynamic nature of medical knowledge in an environment of an informed patient dictates that consumers

of increased survival rates seen in the existing literature.

**4.1 What are the barriers to implementation?**

and with rewards and disincentives.

populations (**Table 1**).

*DOI: http://dx.doi.org/10.5772/intechopen.84658*

Develop guidelines and protocols based on

*Implementation of guidelines/checklist/protocols.*

evidence and consensus

**Table 1.**

*Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist… DOI: http://dx.doi.org/10.5772/intechopen.84658*


#### **Table 1.**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

exposure to evidence-based protocols and guidelines from other disciplines. One cannot fail to mention that the patient perceives this as having the benefit of a second opinion and in addition to improving the clinical intervention through consultation, may improve their perception of the quality of care they are receiving. There are also several reasons to explain the difficulty in integrating the use of multidisciplinary teams as a routine part of patient care. The ambiguity of who is needed at these meetings may lead to having not enough, or too many clinicians attending the meetings. It is an investment of time that may not be perceived as effective by some. There is an additional structure required to maintain these meetings which would mean more finances poured into human resources. If no dedicated staff for this purpose is chosen then the question of which existing department would be responsible for holding multidisciplinary meetings for which subset of patients [45].

According to the WHO in February 2015, cancer is a leading cause of morbidity and mortality worldwide, with approximately 14 million new cases and 8.2 million cancer-related deaths reported in 2012 [46]. Great interest has been generated in the application of the use of multidisciplinary teams toward the management of patients with potentially high risk and major cancer surgery [47]. In 2012, the NHS published a retrospective cohort study where breast cancer survival in intervention and non-intervention groups not treated by an MDT were compared with intervention and non-intervention groups treated by an MDT. This study found a significant decrease in mortality among the intervention group for those treated by an MDT [48]. Another example of the benefit of this application is in a retrospective cohort study done by Stephens MR et al. where a cohort of patients for R0 oesophagectomy treated by an MDT was compared with a cohort of patients treated by six individual general surgeons. A statistically significant difference in major parameters was found. Operative mortality (5.7% vs. 26%, chi2 = 8.22, P = 0.004), 5-year survival (52%vs. 10%, chi2 = 15.05, P = 0.0001) and rate of open and closed laparotomy and thoracotomy all had statistically significant improvements [49]. This is one of the very few pieces of available publications providing evidence of the utility of MDTs in high risk surgery and although encouraging, there is still more need for evidence as it relates to specific compositions of MDTs as the results may differ based on the

Some professionals are of the belief that a multidisciplinary team should be available for all surgical cases in order to improve the outcomes of all surgical patients who seek tertiary care. It is important to note that this may not always be an efficient use of resources. For instance, in 2015, Chien-Chou Pan et al. explored the survival rates of patients treated by an MDT for stage III and IV non-small cell lung cancer had statistically significantly higher survival rates than those not treated by an MDT. For those with stages I and II, the survival rates did not differ significantly [50]. This is an example that supports the use of multidisciplinary teams for high

Although the little evidence emerging thus far is in support of the implementation of MDTs, the favorable results may be partly due to flaws in study design, various biases in enrollment of participants for these studies and other factors associated with the presence of the MDT itself. For example, because this is a relatively newly explored concept, there is a lack of randomized controlled trials. Doing such studies would also raise ethical concerns especially as the MDT is already viewed by many as a higher standard of patient care and denying a patient this resource when available may be seen as questionable morally. Patients enrolled for studies for MDTs may be dependent on the referring physician and it may be reasonable to assume persons who are more likely to survive from further intervention would be in the majority of those referred to an MDT. It is also important not to forget that when a patient is referred to an MDT, they may have several investigations

risk cases as the benefits may only be worth the risk in these cases.

specialists involved in the planning of these cases.

**60**

*Implementation of guidelines/checklist/protocols.*

expedited that would have otherwise not have been done or would have taken longer to be completed. These factors are all important to consider in interpretation of increased survival rates seen in the existing literature.

Overall, it is evident that the presence of the multidisciplinary team has been beneficial for specific patient populations. Whether this benefit is directly as a result of the team itself or the associated factors such as decreased time to investigations or other similar factors may not necessarily be of significant concern. As this topic continues to be explored in the literature and is also being applied in increasing numbers of patient care institutions, we will continue to learn about the utility of these teams both in a general sense and as it relates to more specific patient populations (**Table 1**).

#### **4.1 What are the barriers to implementation?**

Providing optimal care to patients based on the best evidence is difficult as the half-life of knowledge is estimated to be approximately 3–5 years therefore it is very difficult for physicians to keep up with the medical literature. Multiple strategies are often required to make changes and provide optimal care. Knowledge translation is a dynamic and iterative process that includes synthesis and dissemination of the best available evidence in an ethically sound manner to improve health, provide more effective health services and products and strengthen the healthcare system. It requires collaboration between multiple stakeholders and multifaceted interventions such as audits and feedback, reminders, educational strategies, decision aids and standardized orders. Physicians usually play a leading role in implementation as they are usually opinion leaders. Additionally they are well respected and trusted by all members of the health care team. Especially in developing countries where there is a lot to be gained some answers may lie outside the physician or hospital. Measures such as legislation, public education and advocacy, revision of the medical curriculum, patient handbooks and other health promotional material may all have a role in eliciting change in behavior. Varying committed members of the health care team may have to assume the role of the opinion leader or 'champion'. Recommendations are more likely to be followed if they are simple, inclusive, with a high level of evidence but are more likely to succeed with an evaluative component and with rewards and disincentives.

#### **5. Conclusions**

The modern surgical environment is complex with multiple components perhaps too much to be considered for any one individual. The dynamic nature of medical knowledge in an environment of an informed patient dictates that consumers

of health care in a globalized world expect the best outcome. A multidisciplinary approach using the best available evidence is just the first step in knowledge translation. The entire health system may need to change. This is the active process of implementation among the multiple stakeholders that will be necessary to effect change. The combination of a multidisciplinary team using guidelines or protocols aided by checklists is one way of ensuring quality in the surgical health care system. Consideration can also be given to a rewards and disincentives packages as we seek to change behavior. Of course, once implemented and with appropriate audits, we should see positive results, that is, improved quality care. We recognize that this is a dynamic process, with active monitoring of the literature for emerging/changing evidence, and revisions at designated intervals as necessary.

### **Author details**

Joseph Martin Plummer\*, Mark S. Newnham and Timothy Henry Department of Surgery, Radiology, Anesthesia and Intensive Care, University of the West Indies, Kingston, Jamaica

\*Address all correspondence to: joseph.plummer02@uwimona.edu.jm

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**63**

*Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist…*

Improvement Program: An evaluation of all hospitals. Annals of Surgery.

[10] Bainbridge D, Martin J, Arango M,

[9] Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: A modelling strategy based on available data. Lancet. 2008;**372**:139-144

Cheng D. Evidence-based perioperative clinical outcomes research (EPiCOR) group. Lancet.

[11] Sokol DK, Wilson J. What is a surgical complication. World Journal of

[12] Gross M. Reporting complications on a general surgical service. Canadian Journal of Surgery. 2000;**43**(2):86

[13] Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. The New England Journal of Medicine. 1991;**324**(6):370-376

[14] Treadwell JR, Lucas S, Tsou AY. Surgical checklists: A systematic review of impacts and implementation.

[15] Russell T. Safety and quality improvement in surgical practice. Annals of Surgery. 2006;**244**(5):

[16] Ouro-Bang'na Maman AF, Tomta K, Ahouangbévi S, Chobli M. Deaths associated with anaesthesia in Togo, West Africa. Tropical Doctor.

[17] Li G, Warner M, Lang BH, Huang L, Sun LS. Epidemiology

BMJ Quality and Safety. 2014;**23**(4):299-318

653-655

2005;**35**:220-222

2012;**380**(9847):1075-1081

Surgery. 2008;**32**(6):942-944

2009;**250**(3):363-376

*DOI: http://dx.doi.org/10.5772/intechopen.84658*

[2] Schmid O, Chalmers L, Berexnicki L.

Evidence-to-practice gaps in the management of community-dwelling Australian patients with ischaemic heart disease. Journal of Clinical Pharmacy and Therapeutics. 2015;**40**(4):398-403

[3] Ingraham AH, Cohen ME, Billimoria KY, Dimick JB, Richards KE, et al. Association of surgical care improvement project infection-related process measure compliance with risk-adjusted outcomes: Implications for quality measurement. Journal of the American College of Surgeons.

[4] Cohen ME, Liu Y, Ko CY, Hall BL. Improved surgical outcomes for ACS NSQIP hospitals over time: Evaluation of hospitals cohorts with up to 8 years of participation. Annals of Surgery.

[5] World Alliance for Patient Safety. WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Geneva: World

[7] Gawande AA. From cowboys to pit crews: Patient focused care starts with a team approach. In: ACS Clinical Congress News; Wed Oct 24. 2018. p. 1. Available from: ACSCNEWS.ORG

[8] Hall BL, Hamilton BH, Richards K, Billimoria KY, Cohen ME, Ko CY. Does surgical quality in the American College of Surgeons National Surgery Quality

2010;**211**(6):705-714

2016;**263**(2):267-273

Health Organization; 2009

[6] Weiser TG, Haynes AB. Ten years of the surgical safety checklist. British Journal of Surgery.

Jul 2018;**105**(8):927-929

[1] Alderson P, Tan T. The use of Cochrane reviews in NICE clinical guidelines. Cochrane Database of Systematic Reviews. 9 Aug 2011;**12**:ED000032. DOI: 10.1002/14651858.ED000032

**References**

*Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist… DOI: http://dx.doi.org/10.5772/intechopen.84658*

#### **References**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

evidence, and revisions at designated intervals as necessary.

of health care in a globalized world expect the best outcome. A multidisciplinary approach using the best available evidence is just the first step in knowledge translation. The entire health system may need to change. This is the active process of implementation among the multiple stakeholders that will be necessary to effect change. The combination of a multidisciplinary team using guidelines or protocols aided by checklists is one way of ensuring quality in the surgical health care system. Consideration can also be given to a rewards and disincentives packages as we seek to change behavior. Of course, once implemented and with appropriate audits, we should see positive results, that is, improved quality care. We recognize that this is a dynamic process, with active monitoring of the literature for emerging/changing

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Joseph Martin Plummer\*, Mark S. Newnham and Timothy Henry Department of Surgery, Radiology, Anesthesia and Intensive Care,

\*Address all correspondence to: joseph.plummer02@uwimona.edu.jm

**62**

**Author details**

provided the original work is properly cited.

University of the West Indies, Kingston, Jamaica

[1] Alderson P, Tan T. The use of Cochrane reviews in NICE clinical guidelines. Cochrane Database of Systematic Reviews. 9 Aug 2011;**12**:ED000032. DOI: 10.1002/14651858.ED000032

[2] Schmid O, Chalmers L, Berexnicki L. Evidence-to-practice gaps in the management of community-dwelling Australian patients with ischaemic heart disease. Journal of Clinical Pharmacy and Therapeutics. 2015;**40**(4):398-403

[3] Ingraham AH, Cohen ME, Billimoria KY, Dimick JB, Richards KE, et al. Association of surgical care improvement project infection-related process measure compliance with risk-adjusted outcomes: Implications for quality measurement. Journal of the American College of Surgeons. 2010;**211**(6):705-714

[4] Cohen ME, Liu Y, Ko CY, Hall BL. Improved surgical outcomes for ACS NSQIP hospitals over time: Evaluation of hospitals cohorts with up to 8 years of participation. Annals of Surgery. 2016;**263**(2):267-273

[5] World Alliance for Patient Safety. WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Geneva: World Health Organization; 2009

[6] Weiser TG, Haynes AB. Ten years of the surgical safety checklist. British Journal of Surgery. Jul 2018;**105**(8):927-929

[7] Gawande AA. From cowboys to pit crews: Patient focused care starts with a team approach. In: ACS Clinical Congress News; Wed Oct 24. 2018. p. 1. Available from: ACSCNEWS.ORG

[8] Hall BL, Hamilton BH, Richards K, Billimoria KY, Cohen ME, Ko CY. Does surgical quality in the American College of Surgeons National Surgery Quality

Improvement Program: An evaluation of all hospitals. Annals of Surgery. 2009;**250**(3):363-376

[9] Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: A modelling strategy based on available data. Lancet. 2008;**372**:139-144

[10] Bainbridge D, Martin J, Arango M, Cheng D. Evidence-based perioperative clinical outcomes research (EPiCOR) group. Lancet. 2012;**380**(9847):1075-1081

[11] Sokol DK, Wilson J. What is a surgical complication. World Journal of Surgery. 2008;**32**(6):942-944

[12] Gross M. Reporting complications on a general surgical service. Canadian Journal of Surgery. 2000;**43**(2):86

[13] Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. The New England Journal of Medicine. 1991;**324**(6):370-376

[14] Treadwell JR, Lucas S, Tsou AY. Surgical checklists: A systematic review of impacts and implementation. BMJ Quality and Safety. 2014;**23**(4):299-318

[15] Russell T. Safety and quality improvement in surgical practice. Annals of Surgery. 2006;**244**(5): 653-655

[16] Ouro-Bang'na Maman AF, Tomta K, Ahouangbévi S, Chobli M. Deaths associated with anaesthesia in Togo, West Africa. Tropical Doctor. 2005;**35**:220-222

[17] Li G, Warner M, Lang BH, Huang L, Sun LS. Epidemiology of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology. 2009;**110**:759-765

[18] Alkire BC, Peters AW, Shrime MG, Meara JG. The economic consequences of mortality amendable to high-quality health care in low and middle-income countries. Health Affairs (Millwood). 2018;**37**(6):988-996

[19] Rogers SO. The holy grail of surgical quality improement: Process measures of risk-adjusted outcomes? The American Surgeon. 2006;**72**(11):1046-1050

[20] Nicholls J, Gaskin PS, Ward J, Areti YK. Guidelines for preoperative investigations for elective surgery at Queen Elizabeth Hospital: Effects on practices, outcomes, and costs. Journal of Clinical Anesthesia. 2016;**35**:176-189

[21] Plummer JM, Williams N, Leake PA, Ferron-Boothe D, Meeks-Aitken N, Mitchell DI, et al. Surgical quality in colorectal cancer. Annals of Medicine and Surgery (London). 2015;**5**:52-56

[22] Vivekanantham S, Ravindran RP, Shanmugarajah K, Maruthappu M, Shalhoub J. Surgical safety checklists in developing countries. International Journal of Surgery. 2014;**12**(1):2-6

[23] Gawande A. The Checklist Manifesto: How to Get Things Right. 1st ed. New York, NY: Metropolitan Books; 2010

[24] de Vries EN, Prins HA, Crolla RM, den Outer AJ, van Andel G, van Helden SH, et al. Effect of a comprehensive surgical safety system on patients outcome. The New England Journal of Medicine. 2010;**363**:1928-1937

[25] Birkmeyer JD. Strategies for improving surgical quality-checklists and beyond. The New England Journal of Medicine. 2010;**363**:1963-1965

[26] de Jager E, McKenna C, Bartlett L, Gunnarsson R, Ho YH. Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: A systematic literature review of 25 studies. World Journal of Surgery. 2016;**40**(8):1842-1858

[27] Haynes AB, Edmondson L, Lipsitz SR, Molina G, Neville BA, Singer SJ, et al. Mortality trends after a voluntary checklist-based surgical safety collaborative. Annals of Surgery. 2017;**266**:923-929

[28] Hu YY, Arriaga AF, Peyre SE, Corso KA, Roth EM, Greenberg CC. Deconstructing intraoperative communication failures. The Journal of Surgical Research. 2012;**177**(1):37-42

[29] Hendrickson SE, Wadhera RK, Elbardissi AW, Wiegmann DA, Sundt TM. 3rd development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. Journal of the American College of Surgeons. 2009;**208**(6):1115-1123

[30] Pugel AE, Simianu VV, Flum DR, Dellinger EP. Use of surgical checklist ti improve communication and reduce complications. Journal of Infection and Public Health. 2015;**8**(3):219-225

[31] Levy SM, Senter CE, Hawkins RB, Zhao JY, Doody K, Kao LS, et al. Implementing a surgical checklist: More than ckecking a box. Surgery. 2012;**152**(3):331-336

[32] Putman LR, Levy SM, Sajid M, Bubuisson DA, Rogers NB, Kao LS, et al. Multifaceted interventions improve adherence to the surgical checklist. Surgery. 2014;**156**(2):336-344

[33] Ubach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklist in Ontario, Canada. The New England Journal of Medicine. 2014;**370**(11):1029-1038

**65**

*Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist…*

28, 2018]

[42] England.nhs.uk. 2018. Available from: https://www.england.nhs.uk/ wp-content/uploads/2015/01/mdt-devguid-flat-fin.pdf [Accessed: November

[43] Supporting Information: Multidisciplinary Team Meeting [Internet]. Datadictionary.nhs.uk. 2018. Available from: https://www. datadictionary.nhs.uk/data\_dictionary/

nhs\_business\_definitions/m/ multidisciplinary\_team\_meeting\_ de.asp?shownav=1 [Accessed:

November 28, 2018]

[44] Güler SA, Cantürk

10.5152/UCD.2014.2724

2003;**12**:i25-i28

[45] Carter S, Garside P, Black A. Multidisciplinary team working, clinical networks, and chambers; opportunities to work differently in the NHS. BMJ Quality & Safety.

[46] World Health Organization

[47] Ziabari Y, Wigmore T, Kasivisvanathan R. The

10.1093/bjaed/mkx003

[49] Stephens MR, Lewis WG, Brewster AE, et al. Multidisciplinary team management is associated with improved outcomes after surgery for

(WHO). Cancer Factsheet Number 297. 2015. Available from: http://www.who. int/mediacentre/factsheets/fs297/en/

multidisciplinary team approach for high-risk and major cancer surgery. BJA Education. 2017;**17**(8):255-261. DOI:

[48] Kesson Eileen M, Allardice Gwen M, David GW, Burns Harry JG, Morrison David S. Effects of multidisciplinary team working on breast cancer survival: Retrospective, comparative, interventional cohort study of 13 722 women. BMJ. 2012;**344**:e27149

NZ. Multidisciplinary breast cancer teams and proposed standards. Ulusal cerrahi dergisi. **2014**;(1):39-41. DOI:

*DOI: http://dx.doi.org/10.5772/intechopen.84658*

"enhanced recovery" and how can I do it? Journal of Gastrointestinal Surgery.

[34] Kim BJ, Aloia TA. What is

[35] Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, et al. Consensus review of optimal preoperative care in colorectal surgery. Enhanced Recovery After Surgery (ERAS) Group recommendations. Archives of Surgery. 2009;**144**:

[36] Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z. Enhanced recovery after surgery programs versus

traditional care for colorectal surgery: Meta-analysis of randomized trials. Diseases of the Colon and Rectum.

[37] Kehlet H. Fast-track colorectal surgery. Lancet. 2008;**371**:791-793

[38] Parizh D, Ascher E, Raza Rizvi SA, Hingorani A, Amaturo M, Johnson E. Quality improvement initiative: Preventative surgical site infection protocol in vascular surgery. Vascular.

[39] Bond-Smith G, Belgaumkar AP, Davidson BR, Gurusamy KS. Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery. Cochrane Database of Systematic Reviews. 2016;**2**:CD011382

[40] Ryan SL, Sen A, Staggers K, Luerssen TG, Jea A. Texas Children's

[41] Patkar V, Acosta D, Davidson T, Jones A, Fox J, Keshtgar M. Cancer multidisciplinary team meetings: Evidence, challenges, and the role of clinical decision support technology. International Journal of Breast Cancer. 2011;**2011**:7. Article ID: 831605. DOI:

Hospital Spine Study Group. Journal of Neurosurgery. Pediatrics.

2014;**14**(3):259-265

10.4061/2011/831605

2018;**22**(1):164-171

2013;**56**(5):667-678

2018;**26**(1):47-53

961-969

*Improving the Quality of Care in Surgery: The Role of Guidelines, Protocols, Checklist… DOI: http://dx.doi.org/10.5772/intechopen.84658*

[34] Kim BJ, Aloia TA. What is "enhanced recovery" and how can I do it? Journal of Gastrointestinal Surgery. 2018;**22**(1):164-171

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

[26] de Jager E, McKenna C, Bartlett L, Gunnarsson R, Ho YH. Post-

improved by the World Health

[27] Haynes AB, Edmondson L, Lipsitz SR, Molina G, Neville BA, Singer SJ, et al. Mortality trends after a voluntary checklist-based surgical safety collaborative. Annals of Surgery.

[28] Hu YY, Arriaga AF, Peyre SE, Corso KA, Roth EM, Greenberg CC. Deconstructing intraoperative communication failures. The Journal of Surgical Research. 2012;**177**(1):37-42

[29] Hendrickson SE, Wadhera RK, Elbardissi AW, Wiegmann DA, Sundt TM. 3rd development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. Journal of the American College of Surgeons. 2009;**208**(6):1115-1123

[30] Pugel AE, Simianu VV, Flum DR, Dellinger EP. Use of surgical checklist ti improve communication and reduce complications. Journal of Infection and Public Health. 2015;**8**(3):219-225

[31] Levy SM, Senter CE, Hawkins RB, Zhao JY, Doody K, Kao LS, et al. Implementing a surgical checklist: More than ckecking a box. Surgery.

[32] Putman LR, Levy SM, Sajid M, Bubuisson DA, Rogers NB, Kao LS, et al. Multifaceted interventions improve adherence to the surgical checklist. Surgery. 2014;**156**(2):336-344

[33] Ubach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklist in Ontario, Canada. The New England Journal of Medicine. 2014;**370**(11):1029-1038

2012;**152**(3):331-336

2016;**40**(8):1842-1858

2017;**266**:923-929

operative adverse events inconsistently

Organization surgical safety checklist: A systematic literature review of 25 studies. World Journal of Surgery.

of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology. 2009;**110**:759-765

2018;**37**(6):988-996

2006;**72**(11):1046-1050

2016;**35**:176-189

[19] Rogers SO. The holy grail of surgical quality improement: Process measures of risk-adjusted outcomes? The American Surgeon.

[20] Nicholls J, Gaskin PS, Ward J, Areti YK. Guidelines for preoperative investigations for elective surgery at Queen Elizabeth Hospital: Effects on practices, outcomes, and costs. Journal of Clinical Anesthesia.

[21] Plummer JM, Williams N, Leake PA, Ferron-Boothe D, Meeks-Aitken N, Mitchell DI, et al. Surgical quality in colorectal cancer. Annals of Medicine and Surgery (London). 2015;**5**:52-56

[22] Vivekanantham S, Ravindran RP, Shanmugarajah K, Maruthappu M, Shalhoub J. Surgical safety checklists in developing countries. International Journal of Surgery. 2014;**12**(1):2-6

[23] Gawande A. The Checklist

Medicine. 2010;**363**:1928-1937

[25] Birkmeyer JD. Strategies for improving surgical quality-checklists and beyond. The New England Journal of Medicine. 2010;**363**:1963-1965

Manifesto: How to Get Things Right. 1st ed. New York, NY: Metropolitan Books;

[24] de Vries EN, Prins HA, Crolla RM, den Outer AJ, van Andel G, van Helden SH, et al. Effect of a comprehensive surgical safety system on patients outcome. The New England Journal of

[18] Alkire BC, Peters AW, Shrime MG, Meara JG. The economic consequences of mortality amendable to high-quality health care in low and middle-income countries. Health Affairs (Millwood).

**64**

2010

[35] Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, et al. Consensus review of optimal preoperative care in colorectal surgery. Enhanced Recovery After Surgery (ERAS) Group recommendations. Archives of Surgery. 2009;**144**: 961-969

[36] Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z. Enhanced recovery after surgery programs versus traditional care for colorectal surgery: Meta-analysis of randomized trials. Diseases of the Colon and Rectum. 2013;**56**(5):667-678

[37] Kehlet H. Fast-track colorectal surgery. Lancet. 2008;**371**:791-793

[38] Parizh D, Ascher E, Raza Rizvi SA, Hingorani A, Amaturo M, Johnson E. Quality improvement initiative: Preventative surgical site infection protocol in vascular surgery. Vascular. 2018;**26**(1):47-53

[39] Bond-Smith G, Belgaumkar AP, Davidson BR, Gurusamy KS. Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery. Cochrane Database of Systematic Reviews. 2016;**2**:CD011382

[40] Ryan SL, Sen A, Staggers K, Luerssen TG, Jea A. Texas Children's Hospital Spine Study Group. Journal of Neurosurgery. Pediatrics. 2014;**14**(3):259-265

[41] Patkar V, Acosta D, Davidson T, Jones A, Fox J, Keshtgar M. Cancer multidisciplinary team meetings: Evidence, challenges, and the role of clinical decision support technology. International Journal of Breast Cancer. 2011;**2011**:7. Article ID: 831605. DOI: 10.4061/2011/831605

[42] England.nhs.uk. 2018. Available from: https://www.england.nhs.uk/ wp-content/uploads/2015/01/mdt-devguid-flat-fin.pdf [Accessed: November 28, 2018]

[43] Supporting Information: Multidisciplinary Team Meeting [Internet]. Datadictionary.nhs.uk. 2018. Available from: https://www. datadictionary.nhs.uk/data\_dictionary/ nhs\_business\_definitions/m/ multidisciplinary\_team\_meeting\_ de.asp?shownav=1 [Accessed: November 28, 2018]

[44] Güler SA, Cantürk NZ. Multidisciplinary breast cancer teams and proposed standards. Ulusal cerrahi dergisi. **2014**;(1):39-41. DOI: 10.5152/UCD.2014.2724

[45] Carter S, Garside P, Black A. Multidisciplinary team working, clinical networks, and chambers; opportunities to work differently in the NHS. BMJ Quality & Safety. 2003;**12**:i25-i28

[46] World Health Organization (WHO). Cancer Factsheet Number 297. 2015. Available from: http://www.who. int/mediacentre/factsheets/fs297/en/

[47] Ziabari Y, Wigmore T, Kasivisvanathan R. The multidisciplinary team approach for high-risk and major cancer surgery. BJA Education. 2017;**17**(8):255-261. DOI: 10.1093/bjaed/mkx003

[48] Kesson Eileen M, Allardice Gwen M, David GW, Burns Harry JG, Morrison David S. Effects of multidisciplinary team working on breast cancer survival: Retrospective, comparative, interventional cohort study of 13 722 women. BMJ. 2012;**344**:e27149

[49] Stephens MR, Lewis WG, Brewster AE, et al. Multidisciplinary team management is associated with improved outcomes after surgery for

**67**

**1. Introduction**

**Chapter 5**

**Abstract**

Inhospital Outcome of Elderly

in a Sub-Saharan Hospital

*Martin Lankoande, Papougnezambo Bonkoungou,* 

Elderly patients are frequently admitted in ICU with high mortality**.**

People aged 65 or 60 years and above are considered older [1], respectively, in developed countries and in Africa [1]. The world population grows older in most regions. In the year 2012, the global population reached 7 billion, and 562 (8%) millions of them were older. In 2015, the elderly rose by 55 million representing 8.5% of the world population [2]. In Africa, the rate of elderly (6.6% in 2015) will reach 9.6% in 2050 [2]. Like in other countries older people are increasing in Burkina Faso. This demographic transition increase health care needs especially healthcare facilities, policies and training. Critical patients have increased risk because of associated morbidities [3]. These people are characterized by their frailty with risk of death. This high risk met in anesthesia and intensive care raises some voice

**Keywords:** elderly, intensive care unit, mortality, Burkina Faso

*Oubian Soulemane, Ghislain Somda and Joachim Sanou*

People living more and more longer and elderly is growing and that requires change in health system including geriatric care to be innovative. The aim of this study was to analyze causes and prognosis of older patients admitted in an intensive care unit (ICU) in Sub-Sahara area. A retrospective study over 5 years of patients aged 65 years and above admitted in ICU of Yalgado Ouedraogo was carried out. Of the 2116 patients admitted in ICU, 237 (11.2%) were older. The mean age was 71.7 ± 6.1 years. Males were predominant (sex ratio = 2.4). Medical history was present in 80.6%. The Charlson mean score was 4.8 ± 1.8. Patients with coma represented 42%. Ambulatory Simplified Acute Physiologic Score (ASAPS) up to 8 was recorded in 49%. Medical diseases (60%) like nervous system (37.9%) were reported. Stroke and general surgery were the main affection. Globally treatment was based on fluid management and oxygen supply. During ICU stay, complications occurred in 37.5% like acute respiratory distress syndrome (ARDS) in 10.5%. The mean length of stay was 5.3 ± 7.4 days. The elderly mortality was 73%; those 90% died within 7 days. In multivariate analysis, shock (odds ratio: OR = 2.2, p = 0.002), severe brain trauma (OR = 9.6, p = 0.002), coma (OR 5.8 p < 0.003), surgical condition (OR = 4.2, p = 0.003), ASAPS ≥ 8 (OR = 4.3, p = 0.001), complication occurring (OR = 5.2**,** p = 0.001), and stroke (OR = 3.7, p = 0.001) were independent risk factors of death.

Patients in an Intensive Care Unit

esophageal cancer. Diseases of the Esophagus. 2006;**19**:164-171

[50] Pan CC, Kung PT, Wang YH, Chang YC, Wang ST, Tsai WC. Effects of multidisciplinary team care on the survival of patients with different stages of non-small cell lung cancer: A national cohort study. PLoS One. 2015;**10**(5):e0126547. DOI: 10.1371/ journal.pone.0126547

#### **Chapter 5**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

esophageal cancer. Diseases of the Esophagus. 2006;**19**:164-171

[50] Pan CC, Kung PT, Wang YH, Chang YC, Wang ST, Tsai WC. Effects of multidisciplinary team care on the survival of patients with different stages of non-small cell lung cancer: A national cohort study. PLoS One. 2015;**10**(5):e0126547. DOI: 10.1371/

journal.pone.0126547

**66**

## Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital

*Martin Lankoande, Papougnezambo Bonkoungou, Oubian Soulemane, Ghislain Somda and Joachim Sanou*

#### **Abstract**

People living more and more longer and elderly is growing and that requires change in health system including geriatric care to be innovative. The aim of this study was to analyze causes and prognosis of older patients admitted in an intensive care unit (ICU) in Sub-Sahara area. A retrospective study over 5 years of patients aged 65 years and above admitted in ICU of Yalgado Ouedraogo was carried out. Of the 2116 patients admitted in ICU, 237 (11.2%) were older. The mean age was 71.7 ± 6.1 years. Males were predominant (sex ratio = 2.4). Medical history was present in 80.6%. The Charlson mean score was 4.8 ± 1.8. Patients with coma represented 42%. Ambulatory Simplified Acute Physiologic Score (ASAPS) up to 8 was recorded in 49%. Medical diseases (60%) like nervous system (37.9%) were reported. Stroke and general surgery were the main affection. Globally treatment was based on fluid management and oxygen supply. During ICU stay, complications occurred in 37.5% like acute respiratory distress syndrome (ARDS) in 10.5%. The mean length of stay was 5.3 ± 7.4 days. The elderly mortality was 73%; those 90% died within 7 days. In multivariate analysis, shock (odds ratio: OR = 2.2, p = 0.002), severe brain trauma (OR = 9.6, p = 0.002), coma (OR 5.8 p < 0.003), surgical condition (OR = 4.2, p = 0.003), ASAPS ≥ 8 (OR = 4.3, p = 0.001), complication occurring (OR = 5.2**,** p = 0.001), and stroke (OR = 3.7, p = 0.001) were independent risk factors of death. Elderly patients are frequently admitted in ICU with high mortality**.**

**Keywords:** elderly, intensive care unit, mortality, Burkina Faso

#### **1. Introduction**

People aged 65 or 60 years and above are considered older [1], respectively, in developed countries and in Africa [1]. The world population grows older in most regions. In the year 2012, the global population reached 7 billion, and 562 (8%) millions of them were older. In 2015, the elderly rose by 55 million representing 8.5% of the world population [2]. In Africa, the rate of elderly (6.6% in 2015) will reach 9.6% in 2050 [2]. Like in other countries older people are increasing in Burkina Faso. This demographic transition increase health care needs especially healthcare facilities, policies and training. Critical patients have increased risk because of associated morbidities [3]. These people are characterized by their frailty with risk of death. This high risk met in anesthesia and intensive care raises some voice

around the world particularly in the UK where some actions like implementation of perioperative medicine were planned. The physician has a major role for health-care improvement for multimorbid and frail patients [4]. In Burkina Faso, intensive care services need to be implemented. Government-adopted politics and some physicians are in specialization in foreign countries. No guidelines are available on older patient care in our countries, and patients are treated like other patients. More and more older patients are admitted in ICU and most died. In order to reduce the number of deaths, more information need to be identified for a better evidence-based action. The aim of this study was to analyze causes and prognosis of older patients admitted in the ICU of Yalgado Hospital in Burkina Faso.

#### **2. Methods and materials**

#### **2.1 Setting and population**

A retrospective study was carried out among patients aged ≥65 years in the ICU of the teaching hospital Yalgado Ouedraogo over 5 years (January 1, 2011– December 31, 2015). The Yalgado Ouédraogo Hospital is 800-bedded hospital where no specialist in geriatric is available. The ICU is an 8-bedded unit and is poorly equipped. Data recorded after approval by the Ethical and Research Committee (Ethical and National Scientific Research and Technology Center, ENSRTC) include sociodemographic, comorbidities, diagnosis, causes of ICU admission, Glasgow Coma Score, the Ambulatory Simplified Acute Physiologic Score (ASAPS), Charlson Comorbidity Score, sepsis, shock on admission, length of stay (LOS), management, and outcome. The ASAPS [5] is a scale used for gravity evaluation for ICU patients. Patients were categorized into three groups of age (65–74 years or "young old," 75–84 or "old old," and >85 or oldest old).

#### **2.2 Statistical analysis**

Quantitative data were presented as mean and standard deviation. Their variations were analyzed using ANOVA test. Qualitative data are presented as numbers and percentages and variations analyzed using the chi-square test. Chi-square test helped to compare survivors to non-survivors with p ≤ 0.05. Analysis was performed with the Epidemiologic Info package 7.1.5.0.

#### **3. Results**

Among 2116 patients admitted in ICU, 237 (11.2%) were older. The mean age was 71.7 ± 6.1 years; the sex ratio was 2.4. A total of 173 deaths were observed (73%). Demographic and facility characteristics of deaths of patients are summarized in **Table 1**.

Comorbidity was identified in 80.6%. The Charlson mean score was 4.79 ± 1.83 [IC 95%; 2–12]. The mean score of Glasgow scale was 4.8 ± 1.2. Medical history and comorbidity are described in **Table 2**. Among the patients, 42% were admitted with coma. The ASAPS ≥8 was recorded as 49%. Clinical data are summarized in **Table 3**. Medical condition (60%) and nervous disease (37.9%) were the main diagnosis. Neurology disease and general surgery were the main affection by specialty (**Figure 1**). Stroke was the most frequent (27.4%) followed by peritonitis (**Table 3**). Intensive care was based on fluid, pain killers, and oxygen supply.

**69**

**Table 2.**

*Past history and comorbidity (N = 237).*

*a*

**Table 1.**

*Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital*

**Characteristic Frequency Percentage** Age (years) 65–74 years 167 70.5

Gender Male 167 70.5

Residency Urban 159 67.1

Profession Retired 48 32.6

Referral facilities District hospital 107 45.1

**Medical history Frequency Percentage** High blood pressure 120 50.6 Diabetes 56 23.6 Ulcer 15 6.3 Heart disease 9 3.8 Kidney failure 8 3.4 Stroke 4 1.7 Asthma 4 1.7 HIV/AIDS 3 1.3 Lymphoma 2 0.8 Live cancer 2 0.8 Esophagus stenosis 1 0.4 Esophagitis 1 0.4 Liver abscess 1 0.4 Goiter disease 1 0.4 None 60 25.3 Charlson score <3 25 10.5

*Teaching Hospital (YO: 8; Blaise Compaoré Hospital: 6; Sourou Sanou Hospital = 5).*

*Demographic characteristics of patients (n = 237).*

75–84 years 58 24.5 More 84 years 12 5

Female 70 29.5

Rural area 78 32.9

Housewife 37 25.2 Farmer 31 21.1 Public/private 31 21.1

Regional hospital 39 16.5 Dispensary 3 1.3 Teaching hospitala 19 8 Private hospital 69 29.1

> 4–5 139 58.6 6–7 53 22.3 ≥8 20 8.4

*DOI: http://dx.doi.org/10.5772/intechopen.84308*


*Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital DOI: http://dx.doi.org/10.5772/intechopen.84308*

#### **Table 1.**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

admitted in the ICU of Yalgado Hospital in Burkina Faso.

formed with the Epidemiologic Info package 7.1.5.0.

**2. Methods and materials**

**2.1 Setting and population**

oldest old).

**3. Results**

rized in **Table 1**.

**2.2 Statistical analysis**

around the world particularly in the UK where some actions like implementation of perioperative medicine were planned. The physician has a major role for health-care improvement for multimorbid and frail patients [4]. In Burkina Faso, intensive care services need to be implemented. Government-adopted politics and some physicians are in specialization in foreign countries. No guidelines are available on older patient care in our countries, and patients are treated like other patients. More and more older patients are admitted in ICU and most died. In order to reduce the number of deaths, more information need to be identified for a better evidence-based action. The aim of this study was to analyze causes and prognosis of older patients

A retrospective study was carried out among patients aged ≥65 years in the ICU of the teaching hospital Yalgado Ouedraogo over 5 years (January 1, 2011– December 31, 2015). The Yalgado Ouédraogo Hospital is 800-bedded hospital where no specialist in geriatric is available. The ICU is an 8-bedded unit and is poorly equipped. Data recorded after approval by the Ethical and Research Committee (Ethical and National Scientific Research and Technology Center, ENSRTC) include sociodemographic, comorbidities, diagnosis, causes of ICU admission, Glasgow Coma Score, the Ambulatory Simplified Acute Physiologic Score (ASAPS), Charlson Comorbidity Score, sepsis, shock on admission, length of stay (LOS), management, and outcome. The ASAPS [5] is a scale used for gravity evaluation for ICU patients. Patients were categorized into three groups of age (65–74 years or "young old," 75–84 or "old old," and >85 or

Quantitative data were presented as mean and standard deviation. Their variations were analyzed using ANOVA test. Qualitative data are presented as numbers and percentages and variations analyzed using the chi-square test. Chi-square test helped to compare survivors to non-survivors with p ≤ 0.05. Analysis was per-

Among 2116 patients admitted in ICU, 237 (11.2%) were older. The mean age was 71.7 ± 6.1 years; the sex ratio was 2.4. A total of 173 deaths were observed (73%). Demographic and facility characteristics of deaths of patients are summa-

Comorbidity was identified in 80.6%. The Charlson mean score was 4.79 ± 1.83 [IC 95%; 2–12]. The mean score of Glasgow scale was 4.8 ± 1.2. Medical history and comorbidity are described in **Table 2**. Among the patients, 42% were admitted with coma. The ASAPS ≥8 was recorded as 49%. Clinical data are summarized in **Table 3**. Medical condition (60%) and nervous disease (37.9%) were the main diagnosis. Neurology disease and general surgery were the main affection by specialty (**Figure 1**). Stroke was the most frequent (27.4%) followed by peritonitis (**Table 3**). Intensive care was based on fluid, pain killers, and oxygen supply.

**68**

*Demographic characteristics of patients (n = 237).*


**Table 2.** *Past history and comorbidity (N = 237).* *Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*


*a Other: anemia (n = 3), dehydratation (n = 2); b Hernia, blood disorder, ulcer, hydronephrosis, asthma, skin disease, leukemia.*

#### **Table 3.**

*Diagnosis and outcome of patients (n = 237).*

During hospitalization, complications occurred in 37.5%, and ARDS was the most frequent (10.5%). In total, 173 older patients died (73%). The length of stay was 5.3 ± 7.4 days [IC 95%; 1–58] (**Table 4**).

Most patients were between 64 and 74 years old. There was significant difference in terms of group of age, between patients with a Charlson score up to 8 versus less than 8 (p = 0.001) and those with complications occurring in ICU versus no

**71**

Diagnosis

**Figure 1.**

Gender

**Residency area**

Reference specialty (%)

Reasons for admission

*Nature of disease (n = 237).*

Age group (%)

**Characteristics All patients** 

**(N = 237)**

Female (n = 70) 70 (29.6) 46 (65.7) 24 (34.3)

Rural 78 (32.9) 62(79.5) 16(20.5)

≥ 8 57.9 58 (68.2) 76 (31.8)

ASAPS ≥8 150 (87) 13 ASAPS <8 109 (63.5) 36.6

ASAPS (mean) 7.9 ± 3.5 8.6 ± 3.5 5.8 ± 2.6 <0.001

Stroke 65 (27.4) 57 (87.69) 8 (12.31) 0.001

Age (mean; years) 71.7 ± 6.1 71.6 ± 5.9 72.1 ± 6.4 0.5

65–74 167 (70.4) 123 (73.6) 44 (26.3) 0.7 75–84 58 (24.5) 42 (72.4) 16 (27.6) 0.9 85 above 12 (5.1) 8 (66.6) 4 (33.3) 0.6

Male (n = 167) 167 (70.4) 127 (76.05) 40 (23.9) 0.1

Urban 159 (67.1) 97(61) 62(39) 0.3

Emergency service 134 (56.4) 108 (80.6) 26 (20.4) 0.001 Medicine 21 (8.8) 14 (66.6) 7(33.8) 0.4 Surgery 54 (22.8) 49 (90.7) 5(9.3) 0.003

ACS 133 (56.1) 109 (81.9) 24 (18) <0.001 Poor condition 6 (2.5) 3 (50) 3 (50) 0.3 Burn 11 (4.6) 7 (63.64) 4 (36.4) 0.4 ARDS 9 (3.8) 7 (77.7) 2 (22.2) 1 Shock 78 (32.9) 47 (60.3) 31 (39.7) 0.002 Charlson score (Median) 4.8 ± 1.8 4.6 ± 1.7 5.09 ± 2.04 0.12 ≥ 8 20 (8.4) 11 (55) 9 (45) 0.03 < 8 217 (91.6) 103 (47.4) 76 (52.6) 0.4 Glasgow coma score (mean value) 9.64 ± 4.01 8.9 ± 3.8 11.8 ± 3.6 0.03 < 8 42.06 69 (88.4) 9 (11.5) <0.001

**Non-survivors (n = 173)**

**Survivors (n = 64)**

**P value**

*Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital*

*DOI: http://dx.doi.org/10.5772/intechopen.84308*

*Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital DOI: http://dx.doi.org/10.5772/intechopen.84308*

#### **Figure 1.**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

Admission condition

Diseases

Complications

Outcomes

**Clinical data Number Percentage**

Medical condition 183 77.2 Surgical condition 54 22.8

Stroke 65 27.4 Prostate tumor 27 11.4 Sepsis 26 10.9 Trauma/burn 25 10.5 Bowel obstruction 13 5.5 Heart disease 18 2.5 Diabetic acute metabolic complications 20 8.4 Kidney failure 16 6.7 Othera 27 11.4 Total 237 100

Sepsis 25 10.5 Acute respiratory distress syndrome 38 42.7 Shock 15 6.3 Coma 19 21.3 Bed sores 8 3.4 Acute pulmonary edema 5 2.1 Pulmonary aspiration 5 2.1 Pulmonary embolism 1 0.4 Otherb 5 2.1

Death in ICU 173 73 Transfer to other ward 48 20.2 Hospital discharge with physician authorization 10 4.2 Discharge without physician authorization 6 2.5 Total 237 100

*Hernia, blood disorder, ulcer, hydronephrosis, asthma, skin disease,* 

During hospitalization, complications occurred in 37.5%, and ARDS was the most frequent (10.5%). In total, 173 older patients died (73%). The length of stay was

Most patients were between 64 and 74 years old. There was significant difference in terms of group of age, between patients with a Charlson score up to 8 versus less than 8 (p = 0.001) and those with complications occurring in ICU versus no

**70**

*a*

*leukemia.*

**Table 3.**

5.3 ± 7.4 days [IC 95%; 1–58] (**Table 4**).

*Other: anemia (n = 3), dehydratation (n = 2); b*

*Diagnosis and outcome of patients (n = 237).*

*Nature of disease (n = 237).*


#### *Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*


*ACS, alteration of consciousness; ARDS, acute respiratory distress syndrome, AAMCD, acute metabolic complication of diabetes; B SBT, severe brain trauma, COther disease, ASAPS: ambulatory simplified acute physiologic scale.*

#### **Table 4.**

*Comparison of survivors and non-survivor's patients (n = 237).*


*ACS, Alteration of consciousness; ARDS, Acute respiratory distress syndrome; ICU, Intensive care unit; ASAPS, Ambulatory simplified acute physiologic scale.*

**73**

death (**Table** 6).

**Table 6.**

*ambulatory simplified acute physiologic scale.*

*Risk factors for ICU mortality of elderly patients.*

**4. Discussion**

and poor equipment of ICU.

*Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital*

Medical condition without coma Reference

No Reference

**Diagnosis Adjusted OR (CI 95%) p**

Surgery 4.2 [2.4–10.3] 0.003 Coma at admission 2.9 [1.6–5.4] 0.001 Coma in ICU 5.8 [2.3–14.6] 0.001 Shock during admission 2.2 [1.6–4.0] 0.002 ASAPS ≥8 4.3 [1.1–8.5] 0.001 Stroke 3.7 [1.6–8.7] 0.001 Severe brain trauma 9.6 [1.2–75.1] 0.02 Complications in ICU 0.001

Yes 5.2 [2.4–11.3] 0.001

complications occurring (p = 0.01) (**Table 5**). In multivariate analysis, surgery, coma, shock, stroke, and severe brain trauma were independent risks factors of

*ACS, alteration of consciousness; ARDS, acute respiratory distress syndrome; ICU, intensive care unit; ASAPS,* 

Older patients accounted for 11.2% of ICU admission. This rate is comparable to the 10% of Owojuyigbe et al. [6] findings in Nigeria but less than the findings in the United States (42–52%). Better health-care system organization, life expectancy improvement explains high prevalence in developed countries. In Burkina Faso, the elderly accounted 2.4% of the population [7]. Elderly mortality (73%) is high compared to Belayachi et al. [8] reports (44.7%) in Morocco and Wade et al. [9] (42.8%) at Senegal. The high mortality reported in developing countries compared to developed countries may be due to inadequate care, late consultation, poverty,

The mean age (71.7) in this study was comparable to Owojuyigbe et al. [6] report (73 years) and Belayachi et al. [8] report (72 years). In Porto, Abelha et al. [10] reported 64.1 years. The age varies according to regions and studies. Patients were mostly males, but there is no correlation between gender and outcome in this study. In other studies, [8], [10] report similar finding, while Fowler et al. reported higher mortality with female patient [11]. In this study, the majority lives in urban area (67.1%) and was retired (32.6%). Patients were referred from district hospital (45.1%). In Burkina Faso, district hospitals are so far to the National Referral Hospital, and patients travel so far in poor condition that causes delay to care and worsens prognosis. In our study, 49.4% had high Charlson comorbidity score. Older patients have many comorbidities which reduce their capability, increase disability, decrease quality of life, and increase risk of death [12]. In the literature, it has been reported that the pooled mortality risk for elderly people with multimorbidity was high compared with those with one chronic disease or none [12, 13]. Alteration of consciousness was found in 56.1% and shock in 32.9%. Our findings were comparable to those reported by Vosylius et al. [14]. ASAPS ≥8 was recorded in 49%. The

*DOI: http://dx.doi.org/10.5772/intechopen.84308*

#### **Table 5.**

*Comparison of patients according to age group (n = 237).*

*Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital DOI: http://dx.doi.org/10.5772/intechopen.84308*


#### **Table 6.**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

Peritonitis 22 (9.3) 18 (81.82) 4 (18.18) 0.4 AMCDA 20 (8.4) 10 (50) 10 (50) 0.01 SBTB 19 (8) 18 (94.74) 1 (5.26) 0.02 Bowel obstruction 13 (5.5) 7 (53.85) 6 (46.15) 0.1 Burn 10 (4.2) 6 (60) 4 (40) 0.4 Severe infection 10 (4.2) 8 (80) 2 (2) 0.7 Prostatic adenoma 9 (3.8) 5 (55.56) 4 (44.44) 0.2 Heart disease 6 (2.5) 4 (66.67) 2 (33.33) 0.6 Prostatic cancer 5 (2.1) 1 (20) 4 (80) 0.01 Inguinal hernia 5 (2.1) 3 (60) 2 (40) 0.6 OtherC 53 (22.4) 36 (67.92) 17 (32.0) 0.1

Yes = 89 89 (37.5) 80 (89.9) 9 (10.1) <0.001

Mechanical ventilation 2 (0.8) 2 (100) 0 Ki = 0.7 Length of stay (mean) 5.3 ± 7.4 5.2 ± 8 5.5 ± 5.1 0.8 *ACS, alteration of consciousness; ARDS, acute respiratory distress syndrome, AAMCD, acute metabolic complication of* 

*SBT, severe brain trauma, COther disease, ASAPS: ambulatory simplified acute physiologic scale.*

Age (mean; years) 68.3 ± 2.8 78.2 ± 2.5 86.6 ± 1.6 <0.001

Male (n = 167) 118 40 9 0.9

ACS 92 33 6 0.9 Poor condition 68 26 5 0.6 Burn 7 2 1 0.7 ARDS 13 6 0 0.4 Shock 11 4 2 0.4 Charlson score 4.5 5.1 6.3 0.001 ≥ 8 12 5 3 0.1

Glasgow score (mean) 9.7 ± 4.02 9.4 ± 4.1 8.8 ± 3.5 0.6 < 8 12 5 3 0.1

ASAPS (Mean) 7.9 ± 3.8 8.08 ± 2.9 8.1 ± 2.7 0.9 ASAPS ≥8 65 25 8 0.1 ASAPS <8 77 22 4 0.4 Complications in ICU 0.01 Yes = 89 65 19 5 0.6

Mechanical ventilation 2 0 0 0.6 Length of stay (LOS) 5.3 ± 6.8 5.6 ± 9.2 2.7 ± 2.2 0.4 Death 123 (73.6) 42 (72.4) 8 (66.6) 0.2 *ACS, Alteration of consciousness; ARDS, Acute respiratory distress syndrome; ICU, Intensive care unit; ASAPS,* 

**75–84 years n = 58 (24.5%)** **Over 84 years n = 12 (5.1%)**

**P value**

No = 148 148 (62.5) 93 (62.8) 55 (37.2)

**n = 167 (70.4%)**

Female (n = 70) 49 18 3

< 8 155 53 9

≥ 8 155 53 9

No = 148 102 39 7

**Non-survivors (n = 173)**

**Survivors (n = 64)**

**P value**

**(N = 237)**

**Characteristics All patients** 

*Comparison of survivors and non-survivor's patients (n = 237).*

**Variables 65–74 years**

Complications occurred in ICU

*diabetes; B*

**Table 4.**

Gender

Reasons for admission

**72**

**Table 5.**

*Ambulatory simplified acute physiologic scale.*

*Comparison of patients according to age group (n = 237).*

*Risk factors for ICU mortality of elderly patients.*

complications occurring (p = 0.01) (**Table 5**). In multivariate analysis, surgery, coma, shock, stroke, and severe brain trauma were independent risks factors of death (**Table** 6).

#### **4. Discussion**

Older patients accounted for 11.2% of ICU admission. This rate is comparable to the 10% of Owojuyigbe et al. [6] findings in Nigeria but less than the findings in the United States (42–52%). Better health-care system organization, life expectancy improvement explains high prevalence in developed countries. In Burkina Faso, the elderly accounted 2.4% of the population [7]. Elderly mortality (73%) is high compared to Belayachi et al. [8] reports (44.7%) in Morocco and Wade et al. [9] (42.8%) at Senegal. The high mortality reported in developing countries compared to developed countries may be due to inadequate care, late consultation, poverty, and poor equipment of ICU.

The mean age (71.7) in this study was comparable to Owojuyigbe et al. [6] report (73 years) and Belayachi et al. [8] report (72 years). In Porto, Abelha et al. [10] reported 64.1 years. The age varies according to regions and studies. Patients were mostly males, but there is no correlation between gender and outcome in this study. In other studies, [8], [10] report similar finding, while Fowler et al. reported higher mortality with female patient [11]. In this study, the majority lives in urban area (67.1%) and was retired (32.6%). Patients were referred from district hospital (45.1%). In Burkina Faso, district hospitals are so far to the National Referral Hospital, and patients travel so far in poor condition that causes delay to care and worsens prognosis. In our study, 49.4% had high Charlson comorbidity score. Older patients have many comorbidities which reduce their capability, increase disability, decrease quality of life, and increase risk of death [12]. In the literature, it has been reported that the pooled mortality risk for elderly people with multimorbidity was high compared with those with one chronic disease or none [12, 13]. Alteration of consciousness was found in 56.1% and shock in 32.9%. Our findings were comparable to those reported by Vosylius et al. [14]. ASAPS ≥8 was recorded in 49%. The

delay to consult and care worsens patient condition. Medical condition was the main diagnosis, and stroke was most frequent (27.4%) followed by peritonitis. Our findings are different with Belayachi et al. [8] who found that respiratory infections were most predominant. Diagnoses vary according to study, social environment, and countries [6, 8, 11, 14].

Advanced age alone does not preclude successful outcome [9]. In multivariate analysis, independent risk factors were surgical conditions, coma, shock during admission, ASAPS ≥8, stroke, and severe brain trauma. These findings are comparable to literature reports [9, 3, 15]. There is no difference between age groups in terms of mortality. The mean LOS was short, while 46.6% of patients died within 3 days and 90% of patient died within a week. For patients over 84 years, LOS was shorter, and inhospital mortality was less than in patients aged less than 84 years. The family usually refuse care and discharge once a poor outcome is pronounced. This explains the relatively low mortality rate and short stay of this group of

age. Elderly patients living in rural area die more than those in urban area, but this rate is not significant. The overall poor outcomes may be due to late consultation and poor quality of care due to the inadequate facilities and equipment and lack of medications due to poverty. Even most of our patients live in urban area and was retired care are not generally provided continuously because of financial barrier. Retired people do not have insurance in public hospital but only in private sector which does not have ICU. Delay to consultation may be related to limited education, traditional healing practice, poverty, and poor transportation. In Africa elderly consider conventional medicine as for infant and their family geriatric disease is associated to end of live. That sometime delay use of conventional medicine. The LOS was short in our study compared to other study (Belayachi et al. [8], 6.6 days; Fuchs et al., 9 days), but some authors found a longer LOS (12.9–23 days) [10, 16]. In our study mortality was high (73%) compared to literature [10, 11, 14, 15]. Comorbidity, frailty, low number of physicians and nurses, insufficiency of skills, lack of equipment, and insurance are some hypotheses to explain mortality. Geriatric training implementation, a good follow-up, and perioperative medicine implementation can reduce admission in ICU. In order to improve elderly care, we need to make policies, sensitize people for early consultation, and implement universal health coverage. Our study showed that most patients have comorbidities. Multimorbidity is especially common among older adults, and its negative consequences include higher disability, decrease in quality of life, and increased risk of death. The insufficiency of follow-up, limitation of skills on geriatric care, and insufficiency of hospital equipment increase risk of death.

Most of the people of Burkina Faso live in the rural area and are farmers. Cultural and financial barriers are most important in this area where people practice traditional healing because they consult later to modern health services. Diagnosis is mostly performed at an advanced condition where treatment is compromised. So the universal health coverage is not implemented, and people have to make direct payment before care. Even with most people who are living in the urban area and retried, the social security of our country does not give possibility of prepayment but only reimbursement and this situation delay care. In response to the recommendations of the World Health Organization and United Nations Assembly on Aging, our country made policies and defines laws to protect older people in the year 2015, but these laws are still unimplemented because of the lack of decree. By promoting specialization in geriatry, implementation of policies protecting older people, Burkina Faso government demonstrated a will to promote elderly well-being and health care. The national program of social protection of older people initiated in 2016 will improve health care with a better follow, universal health promotion. In the particular case of intensive care services, the national society of anesthesiology must implement perioperative medicine course. More commitment and investment

**75**

provided the original work is properly cited.

3 Distric Hôpital of Gayérie, Burkina Faso

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*, Papougnezambo Bonkoungou2

, Oubian Soulemane1

,

*Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital*

sentativeness for the population, and we cannot generalize these findings.

geriatric center can allow improved care for a low rate of death.

are needed to enhance of the elderly care. This study has limitations due to retrospective character and long-term outcome data missing. The impact of hospitalization, biologic abnormality, the APACHE, and SOFA score on outcome was not evaluated. This study showed that most of those who live in urban area raise an issue of repre-

Older patients were frequently admitted in the ICU of Yalgado hospital. Patients are mostly "young old" but have comorbidities. Patients were admitted with the serious condition. LOS was short which indirectly means poor management with early death. Mortality is high. The main factors of death are shock, severe brain trauma, coma, surgical condition, complication occurring, and stroke. The public must be sensitized to consult early and respect medical advices. Health-care worker must improve their skills and adapted care to older people. The implementation of

*DOI: http://dx.doi.org/10.5772/intechopen.84308*

**5. Conclusions**

**Conflict of interest**

**Notes/thanks/other declarations**

Thanks to Dr. Ghislain for data collection.

and Joachim Sanou<sup>2</sup>

2 Teaching Hospital Yalgado Ouedraogo, Burkina Faso

\*Address all correspondence to: m.hamtaani@gmail.com

1 Regional Hospital of Koudougou, Burkina Faso

None.

**Author details**

Ghislain Somda3

Martin Lankoande1

*Inhospital Outcome of Elderly Patients in an Intensive Care Unit in a Sub-Saharan Hospital DOI: http://dx.doi.org/10.5772/intechopen.84308*

are needed to enhance of the elderly care. This study has limitations due to retrospective character and long-term outcome data missing. The impact of hospitalization, biologic abnormality, the APACHE, and SOFA score on outcome was not evaluated. This study showed that most of those who live in urban area raise an issue of representativeness for the population, and we cannot generalize these findings.

#### **5. Conclusions**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

and countries [6, 8, 11, 14].

mortality rate and short stay of this group of

insufficiency of hospital equipment increase risk of death.

delay to consult and care worsens patient condition. Medical condition was the main diagnosis, and stroke was most frequent (27.4%) followed by peritonitis. Our findings are different with Belayachi et al. [8] who found that respiratory infections were most predominant. Diagnoses vary according to study, social environment,

Advanced age alone does not preclude successful outcome [9]. In multivariate analysis, independent risk factors were surgical conditions, coma, shock during admission, ASAPS ≥8, stroke, and severe brain trauma. These findings are comparable to literature reports [9, 3, 15]. There is no difference between age groups in terms of mortality. The mean LOS was short, while 46.6% of patients died within 3 days and 90% of patient died within a week. For patients over 84 years, LOS was shorter, and inhospital mortality was less than in patients aged less than 84 years. The family usually refuse care and discharge once a poor outcome is pronounced. This explains the relatively low

age. Elderly patients living in rural area die more than those in urban area, but this rate is not significant. The overall poor outcomes may be due to late consultation and poor quality of care due to the inadequate facilities and equipment and lack of medications due to poverty. Even most of our patients live in urban area and was retired care are not generally provided continuously because of financial barrier. Retired people do not have insurance in public hospital but only in private sector which does not have ICU. Delay to consultation may be related to limited education, traditional healing practice, poverty, and poor transportation. In Africa elderly consider conventional medicine as for infant and their family geriatric disease is associated to end of live. That sometime delay use of conventional medicine. The LOS was short in our study compared to other study (Belayachi et al. [8], 6.6 days; Fuchs et al., 9 days), but some authors found a longer LOS (12.9–23 days) [10, 16]. In our study mortality was high (73%) compared to literature [10, 11, 14, 15]. Comorbidity, frailty, low number of physicians and nurses, insufficiency of skills, lack of equipment, and insurance are some hypotheses to explain mortality. Geriatric training implementation, a good follow-up, and perioperative medicine implementation can reduce admission in ICU. In order to improve elderly care, we need to make policies, sensitize people for early consultation, and implement universal health coverage. Our study showed that most patients have comorbidities. Multimorbidity is especially common among older adults, and its negative consequences include higher disability, decrease in quality of life, and increased risk of death. The insufficiency of follow-up, limitation of skills on geriatric care, and

Most of the people of Burkina Faso live in the rural area and are farmers. Cultural

and financial barriers are most important in this area where people practice traditional healing because they consult later to modern health services. Diagnosis is mostly performed at an advanced condition where treatment is compromised. So the universal health coverage is not implemented, and people have to make direct payment before care. Even with most people who are living in the urban area and retried, the social security of our country does not give possibility of prepayment but only reimbursement and this situation delay care. In response to the recommendations of the World Health Organization and United Nations Assembly on Aging, our country made policies and defines laws to protect older people in the year 2015, but these laws are still unimplemented because of the lack of decree. By promoting specialization in geriatry, implementation of policies protecting older people, Burkina Faso government demonstrated a will to promote elderly well-being and health care. The national program of social protection of older people initiated in 2016 will improve health care with a better follow, universal health promotion. In the particular case of intensive care services, the national society of anesthesiology must implement perioperative medicine course. More commitment and investment

**74**

Older patients were frequently admitted in the ICU of Yalgado hospital. Patients are mostly "young old" but have comorbidities. Patients were admitted with the serious condition. LOS was short which indirectly means poor management with early death. Mortality is high. The main factors of death are shock, severe brain trauma, coma, surgical condition, complication occurring, and stroke. The public must be sensitized to consult early and respect medical advices. Health-care worker must improve their skills and adapted care to older people. The implementation of geriatric center can allow improved care for a low rate of death.

#### **Conflict of interest**

None.

#### **Notes/thanks/other declarations**

Thanks to Dr. Ghislain for data collection.

#### **Author details**

Martin Lankoande1 \*, Papougnezambo Bonkoungou2 , Oubian Soulemane1 , Ghislain Somda3 and Joachim Sanou<sup>2</sup>


\*Address all correspondence to: m.hamtaani@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[13] Hanlon P, Nicholl BI, Jani BD, Lee D, Mcqueenie R, Mair FS. Articles frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: A prospective analysis of 493 737 UK Biobank participants. The Lancet Public Health [Internet];**3**(7):e323-e332. DOI: 10.1016/S2468-2667(18)30091-4

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[15] Ghavarskhar F, Matlabi H, Gharibi F, Sertyesilisik B. Architecture | review article. A systematic review to compare residential care facilities for older people in developed countries: Practical implementations for Iran. Cogent Social Sciences [Internet]. 2018;**4**:1-21. DOI: 10.1080/23311886.2018.1478493

[16] Stein FDC. Prognostic factors in elderly patients admitted in the intensive care unit. 2009;**21**(1):255-261

**76**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

in an intensive care unit in Dakar, Senegal. Medecine et Sante Tropicales.

[10] Abelha F, Maia P, Landeiro N, Neves A, Barros H. Determinants of outcome in patients admitted to a surgical intensive care unit. 2007:135-143

[11] Fowler RA, Sabur N, Li P, Juurlink DN, Pinto R, Hladunewich MA, et al. Sex- and age-based differences in the delivery and outcomes of critical care. Canadian Medical Association Journal (CMAJ). 2009;**177**(12):1513-1519

[12] Olaya B, Domènech-abella J, Victoria M, Lara E, Félix F, Rico-uribe LA, et al. All-cause mortality and multimorbidity in older adults: The role of social support and loneliness. Experimental Gerontology [Internet]. 2017;**99**(March):120-126. DOI:

[13] Hanlon P, Nicholl BI, Jani BD, Lee D, Mcqueenie R, Mair FS. Articles frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: A prospective analysis of 493 737 UK Biobank participants. The Lancet Public Health [Internet];**3**(7):e323-e332. DOI: 10.1016/S2468-2667(18)30091-4

[14] Vosylius S, Sipylaite J, Ivaskevicius J. Determinants of outcome in elderly patients admitted to the intensive care unit. Age Ageing. 2005;**34**(2):157-162

[15] Ghavarskhar F, Matlabi H, Gharibi F, Sertyesilisik B. Architecture | review article. A systematic review to compare residential care facilities for older people in developed countries: Practical implementations for Iran. Cogent Social Sciences [Internet]. 2018;**4**:1-21. DOI: 10.1080/23311886.2018.1478493

[16] Stein FDC. Prognostic factors in elderly patients admitted in the intensive care unit. 2009;**21**(1):255-261

10.1016/j.exger.2017.10.001

2012;**22**(2):223-224

**References**

March 2016

2014;**9**(4):1-11

Loi. 2016

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[2] Bureau USC. An Aging World: 2015 International Population Reports.

[3] Fuchs L, Novack V, Mclennan S, Celi LA, Baumfeld Y, Park S, et al. Trends in severity of illness on ICU admission and mortality among the elderly. PLoS One.

[4] Burkina Faso AN. Loi n°024-2016/an.

[5] Dia NM, Diallo I, Manga NM, Diop SA, Fortes-Deguenonvo L, Lakhe NA, et al. Intérêt de l'indice de gravité simplifié ambulatoire (IGSA) appliqué à des patients admis dans l'unité de soins intensifs (USI) d'un service de pathologie infectieuse à Dakar. Bulletin de la Societe de Pathologie

Exotique. 2015;**108**(3):175-180

[6] Owojuyigbe AM, Adenekan AT, Babalola RN, Adetoye AO, Olateju SOA, Akonoghrere UO. Pattern and Outcome of Elderly Admissions into the Intensive Care Unit (ICU) of a Low Resource Tertiary Hospital. East and Central African Journal of Surgery. 2016;**21**(2):40-46. ISSN: 2073-9990

[7] INSD; Burkina Faso. La population

[8] Belayachi J, El M, Dendane T, Abidi K, Abouqal R, Zeggwagh AA. Factors predicting mortality in elderly patients admitted to a Moroccan medical intensive care unit. Southern African Journal of Critical Care. 2018;**28**(1):1-12

[9] Barsaoui S, Siaka K, Ouattara A, Soro D, Okon JB, Assi C, et al. Devenir des sujets âgés en réanimation à Dakar (Sénégal) Outcome of elderly patients

du Burkina Faso. 2009

## *Edited by Jasneth Mullings, Camille-Ann Thoms-Rodriguez, Affette M. McCaw-Binns and Tomlin Paul*

This book examines experiences in resource-limited settings, including Low- and Middle-Income Countries (LMICs) and covers a mix of strategies to reduce hospital mortality in these settings. These include population-level and clinical interventions such as health literacy; clinical management guidelines around nutrition; guidelines and protocols for a multi-disciplinary team approach for surgical care; and improving hospital outcomes for elderly patients.

The authors argue that robust quality-of-care systems, driven by evidence-based models/frameworks, are relevant in the matrix of solutions. Clinicians, health administrators, policy makers, academics, and students of public health and related disciplines should critically examine these strategies, inclusive of policy and programmatic interventions to reduce hospital mortality across the demographic spectrum in LMICs and other resource-limited settings.

Published in London, UK © 2019 IntechOpen © dzika\_mrowka / iStock

Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs) and Resource-Limited Settings

Strategies to Reduce Hospital

Mortality in Lower and

Middle Income Countries

(LMICs) and Resource-

Limited Settings

*Edited by Jasneth Mullings, Camille-Ann Thoms-Rodriguez,* 

*Affette M. McCaw-Binns and Tomlin Paul*