Impact of Facilitated Behavior Change Strategies on Food Intake Monitoring and Body Weight Measurements in Acute Care: Case Examples From the More-2-Eat Study

Spread and Scale of the Integrated Nutrition Pathway for Acute Care Across Canada: Protocol for the Advancing Malnutrition Care Program

BACKGROUND

A high proportion of patients admitted to hospital are at nutritional risk or have malnutrition. However, this risk is often not identified at admission, which may result in longer hospital stays and increased likelihood of death. The Integrated Nutrition Pathway for Acute Care (INPAC) was developed to provide clinicians with a standardized approach to prevent, detect, and treat malnutrition in hospital.

OBJECTIVE

The purpose of this study was to determine if the Advancing Malnutrition Care (AMC) program can be used to spread and scale-up improvements to nutrition care in Canadian hospitals.

METHODS

A prospective, longitudinal, mixed methods design is proposed to evaluate the spread and scale of INPAC best practices across Canadian hospitals using a mentor-champion model. Purposive and snowball sampling are used to recruit mentors and hospital champions to participate in the AMC program. Mentors are persons with experience improving nutrition care in a clinical setting and champions are health care providers with a commitment to implementing best care practices. Mentors and champions are trained digitally on their roles and activities. Mentors meet with champions in their area monthly to support them with making practice change. Champions created a site implementation team to target practice change in a specific area related to malnutrition care and use AMC program-specific tools and resources to implement improvements and collect site information through quarterly audits of patient charts to track implementation of nutrition care best practices. An online community of practice is held every 3-4 months to provide further implementation resources and foster connection between mentors and champions at a national level. A prospective evaluation will be conducted to assess the impact of the program and explore how it can be sustainably spread and scaled across Canada. Semistructured interviews will be used to gain a deeper understanding of mentor and champion experiences in the program. The capabilities, opportunities, and motivations of behavior model will be used to evaluate behavior change and the Kirkpatrick 4-level framework will facilitate assessment of barriers to change. Aggregated chart audits will assess the impact of implemented care practices. Descriptive analyses will be used to describe baseline mentor and champion and hospital characteristics and mentor and champion experiences; Friedman test will describe these changes over time. Directed content analysis will guide interpretation of interview data.

RESULTS

Data collection began in September 2022 and is anticipated to end in June 2025, at which time data analysis will begin.

CONCLUSIONS

Evaluation of the AMC program will strengthen decision-making, future programming, and will inform program changes that reflect implementation of best practices in nutrition care while supporting regional mentors and hospital champions. This work will address the sustainability of AMC and the critical challenges related to hospital-based malnutrition, ultimately improving nutrition care for patients across Canada.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/62764.

Hospital Food Service Strategies to Improve Food Intakes among Inpatients: A Systematic Review

This review aims to identify hospital food service strategies to improve food consumption among hospitalized patients. A systematic search that met the inclusion and exclusion criteria was manually conducted through Web of Science and Scopus by an author, and the ambiguities were clarified by two senior authors. The quality assessment was separately conducted by two authors, and the ambiguities were clarified with all the involved authors. Qualitative synthesis was used to analyze and summarized the findings. A total of 2432 articles were identified by searching the databases, and 36 studies were included. The majority of the studies applied menu modifications and meal composition interventions (n = 12, 33.3%), or included the implementation of the new food service system (n = 8, 22.2%), protected mealtimes, mealtime assistance and environmental intervention (n = 7, 19.4%), and attractive meal presentation (n = 3, 8.3%). Previous studies that used multidisciplinary approaches reported a significant improvement in food intake, nutritional status, patient satisfaction and quality of life (n = 6, 16.7%). In conclusion, it is suggested that healthcare institutions consider applying one or more of the listed intervention strategies to enhance their foodservice operation in the future.

The role of trained champions in sustaining and spreading nutrition care improvements in hospital: qualitative interviews following an implementation study

BACKGROUND

Many patients are already malnourished when admitted to hospital. Barriers and facilitators to nutrition care in hospital have been identified and successful interventions developed; however, few studies have explored how to sustain and spread improvements. The More-2-Eat phase 1 study involved five hospitals across Canada implementing nutrition care improvements, while phase 2 implemented a scalable model using trained champions, audit and feedback, a community of practice with external mentorship and an implementation toolkit in 10 hospitals (four continuing from phase 1). Process measures showed that screening and assessment from phase 1 were sustained for at least 4 years. The objective of this study was to help explain how these nutrition care improvements were sustained and spread by understanding the role of the trained champions, and to confirm and expand on themes identified in phase 1.

METHODS

Semistructured telephone interviews were conducted with champions from each phase 2 hospital and recordings transcribed verbatim. To explore the champion role, transcripts were deductively coded to the 3C model of Concept, Competence and Capacity. Phase 2 transcripts were also deductively coded to themes identified in phase 1 interviews and focus groups.

RESULTS

Ten interviews (n=14 champions) were conducted. To sustain and spread nutrition care improvements, champions needed to understand the Concepts of change management, implementation, adaptation, sustainability and spread in order to embed changes into routine practice. Champions also needed the Competence, including the skills to identify, support and empower new champions, thus sharing the responsibility. Capacity, including time, resources and leadership support, was the most important facilitator for staying engaged, and the most challenging. All themes identified in qualitative interviews in phase 1 were applicable 4 years later and were mentioned by new phase 2 hospitals. There was increased emphasis on audit and feedback, and the need for standardisation to support embedding into current practice.

CONCLUSION

Trained local champions were required for implementation. By understanding key concepts, with appropriate and evolving competence and capacity, champions supported sustainability and spread of nutrition care improvements. Understanding the role of champions in supporting implementation, spread and sustainability of nutrition care improvements can help other hospitals when planning for and implementing these improvements.

TRIAL REGISTRATION NUMBER

NCT02800304, NCT03391752.

Trends and Novel Research in Hospital Nutrition Care: A Narrative Review of Leading Clinical Nutrition Journals

Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.