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Researches Health System

 Vũ Thị Minh Hạnh, Phan Hồng Vân, Trần Thị Hồng Cẩm, Hoàng Mỹ Hạnh, 

Trần Vũ Hiệp, Vũ Thị Mai Anh, Hoàng Ly Na
Place of publication: Health Strategy and Policy Institute 
National Institute of  Nutrition
Year of publication:   2011
Formulation and operation of a hospital-based dietary nutrition network is necessary to improve the quality of care, cut down length of hospital stay, and help relieve the overcrowding situation at hospitals, especially central facilities. Having in place a hospital-based dietary nutrition network is also one of the key components of the draft action plan for 2011-2015 of the National nutrition strategy and Child malnutrition control project. To provide recommendations for the formulation and operation of this network, the Health Strategy and Policy Institute conducted a study on “Patients’ nutrition care needs and responsiveness of central hospitals”.
1. Illustrate the present status of nutrition care for inpatients in select central general hospitals and specialized hospitals;
2. Identify inpatients’ nutrition care needs and responsiveness of central hospitals;
3. Recommend strategies contributing to improve hospital-based nutrition care and dietary management.
Methodology: Cross-sectional study, purposive sampling
Survey site: Selecting purposively 4 provincial general hospitals and 1specialized hospital at the central level. 
Data collection methods: (i) Collection and analysis of secondary data; (ii) Use of statistic forms to gather information from the hospitals across key indicators; (iii) In-depth interview: with hospital leaders, leaders of Nutrition departments/Centers, physicians providing hands-on nutritional consultation/counseling for patients; (iv) Focus group discussion: groups of responsible departmental leaders, groups of consultation/treatment/counseling staff and nutritional service providers; (v) Semi-structured interviews with 324 inpatients in the 5 hospitals.  
Key findings 
1. All the surveyed hospitals had a Nutrition department or center and hospital-based dietary nutrition network functioning in and operating activities as specified in Circular 08. Membership of the network were  representatives from all therapeutic departments in the hospitals. A vertical technical assistance role in the area of clinical nutrition has been maintained by central general hospitals. 
All the hospitals provided therapeutic meals as required by the Ministry of Health. Counseling, communication and education on nutrition care for patients started at an early stage. Therapeutic physicians’ awareness on the importance of nutrition care in treatment was increasingly improved. 
It has not been, however, mandatory for nutritionists to take part in joint consultation yet. 
2. Nutritional care and dietary management for inpatients 
- Not a large proportion of patients received height and weight measurement at admission: 50% having body weight measured; 37% having height measured; 45% being asked about diet; 34% of the patients having not receiving nutritional examination at admission.
+ Rate of poor patients received body weight measurement at admission was much higher  than better-off patients.
+ Patients with health insurance cards received more weight measurement than out-of-pocket patients.
+ Patients at Hue Hospital and K Hospital received more weight measurement than at admission at the other surveyed hospitals.
- 58% of the patients received dietary counseling based on medical condition; 18% others on how to calculate calorie intake and nutrition; 33% on healthy diet; 30% on meals timing; 30% on the right ways to eat ; while 22% of the patients received no instructions and advice on therapeutic diets.
- Medical doctors in charge were the main nutritional counselors for inpatients (59%); followed by nurses (30%), medical doctors at  Consulting room (11%), while nutritionists accounted for only 4%.
- 50% of the patients received no weighing during the treatment cycle.
- Nutritional information sources: 66% from physicians in charge; 14% from nurses; only 1% from nutritionists; about 4% from families, fellow patients, or the media. More than 15% of the patients received  no information.
- Quality of nutritional counseling by physicians in charge, by nurses and nutritionists: The rates of respondents rated as very good/good was 89%, 78% and 100% respectively. 
- Counseling attitude of the physicians in charge: 75% of the respondents rated it as dedicated and enthusiastic; 24% as normal and acceptable; 0.5% as neglectful and cursory. As for nurses: 59% rated it as dedicated, enthusiastic; 39% as normal; 2% as neglectful, cursory. As for nutritionists, 100% of the respondents rated it as dedicated and enthusiastic. 
- Nutritional counseling approach: 44% of the physicians provided patients with standard diet, based on which the patients would determine their own diet. 22% of the patients were provided with menus to prepare their own foods. 26% of the patients are provided with illness-based meals. 2% of the patients received general advice only on kinds of food in line with their medical conditions.  
- 75% of the patients received bed-side nutritional advice; 17% through patient meetings; 4% from the hospital counseling room; more than 4% from manuals and media.
- The existing daily food supply for inpatients was mainly provided by the hospital based on patients' medical conditions (43%), while 34% of the patients used home-prepared food and 23% of the patients used food bought by their families.
3. Patients’ perception and compliance with therapeutic nutritional diets
- 93% of the patients believed that the diet played an i important role in treatment process
- 90% of the patients complied with the counseled diet. 10% of the patients did not comply because of the following reasons: they didn’t think the diet was necessary, they did not trust physicians’ advice or felt that it was not practical or could not afford the recommended diet.
4. Inpatients’ nutrition care needs
- 40% of the patients wanted hospitals to provide on-bed meals, while 30% wanted to be provided with appropriate menu to prepare food at home. 26% of the patients wanted hospitals to have a kitchen where they could order meals in accordance with their medical conditions and tastes. 3% reported no needs.
- 46% of the patients wanted to receive nutritional advice at admission. 44% needed daily nutritional counseling while on treatment. 24% wanted to receive on-call nutritional counseling. 8% wanted to receive nutritional advice on discharge. 1% did not need any nutritional advice.
- 73% of the patients wanted to be counseled by physicians in charge, 26% by nutritionists, 19% by nurses. 
- 57% of the patients wanted to have bed-side counseling. 37% wanted advice in the patient room. 9% wanted to receive the information in patient meetings. 6% wanted advice at the nutritional counseling room. 
Regulatory framework
- For Circular 08 to be really beneficial there should be clearer regulations on who is responsible for the patient’s nutritional assessment at admission and nutritional assessment during their hospital stay. This should be made on a routine basis and included as a vital indicator of hospital evaluation. 
- It should be made obligatory that nutritionists take part in any joint consultation.
- Diets recommended by the Ministry of Health should be used as the frame, while the actual diets should be tailored to regional context. 
Education and communication
- Educational materials should be provided for patient orientation.  Health education for patients  faced difficulty Health education is currently difficult due to the lack of information materials. In addition, educational information designed by the hospitals themselves proved to be inconsistent.
- Apart from the development of the nutritionist workforce and network in hospitals in future, there should be more training for  knowledge update and awareness change on the importance of nutrition in rehabilitation for physicians and nurses, who were actually the ones providing firsthand advice and instructions on nutrition and diet to patients.
Network development
- More hospital-based dietician-nutrition workers should be recruited to effectively carry out nutritional counseling.
- Weighing and nutritional check-up instruments for severe patients are needed.
- A networked system is needed in the hospital for nutritionists to conduct firsthand nutritional management and give advice to inpatients. 
- Nutrition care at lower level hospitals should be established and developed.
Foodservice management for inpatients
- A public-private partnership, financially self-sustaining approach should be adopted to the hospital canteen for it to operate on a closely controlled service-delivery basis.
Further study
- More comprehensive studies on inpatients’ nutritional status and methods of patient’s nutritional assessment are needed.

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