Combating hospital malnutrition: Dietitian-led quality improvement initiative

Muscle quality and major adverse cardiovascular events in post-acute myocardial infarction: A prospective cohort study

BACKGROUND & AIMS

Functional muscle quality, as assessed through the muscle quality index (MQI), represents a contemporary method to measure the capacity to generate force. Despite its potential, the prognostic significance of MQI remains uncertain in various clinical conditions, particularly among patients following acute myocardial infarction (AMI). In light of this, our study sought to evaluate the prognostic relevance of MQI concerning major adverse cardiovascular events (MACE) in patients following AMI.

METHODS AND RESULTS

This is a secondary analysis of a prospective cohort study that included subjects aged ≥20 years from a Cardiovascular Unit Hospital. Functional muscle quality was estimated using MQI, defined as the ratio of handgrip strength (HGS) to muscle mass (MM) derived from bioelectrical impedance analysis. The outcomes included prolonged length of hospital stay, new adverse cardiovascular events (AMI, stroke and hospital readmission for unstable angina), and cardiovascular mortality. A composite score comprising all adverse events over the 1-year follow-up was calculated and defined as MACE. This study included 163 patients, with a median age of 61 years (IQ: 54-69 years), and the majority consisted of males (76.1%). Individual components of the functional muscle quality (HGS and MM) were not associated with any of the adverse outcomes. Only MQI was associated mortality over the 1-year follow-up. For each increase in MQI, the hazard of mortality decreases: adjusted HR: 0.08 (95% CI 0.01-0.84).

CONCLUSION

Functional muscle quality assessed by the MQI may be a valuable clinical predictor of 1-year cardiovascular mortality in patients hospitalized post-AMI.

ESPEN practical guideline: Nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and healthcare costs.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

The 2023 update adheres to the standard operating procedures for ESPEN guidelines. We undertook a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g., published guidelines), until July 12th, 2022. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (including SIGN grading), which was followed by submission to Delphi voting. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

RESULTS

32 recommendations (7× A, 11× B, 10× O and 4× GPP), which encompass different aspects of nutritional support were included from the scientific guideline including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated practical guideline offers an evidence-based nutritional approach to polymorbid medical inpatients and may improve their outcomes.

ESPEN guideline on nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting.

RESULTS

From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.

Setting goals with patients at risk of malnutrition: A focus group study with clinical dietitians

OBJECTIVE

Setting goals collaboratively with patients is a key aspect in shared decision-making (SDM) in malnutrition interventions. The aim, therefore, was to gain an understanding of clinical dietitians' reflections regarding the process of goal-setting with patients at risk of malnutrition.

METHODS

Six semi-structured audio-recorded focus group discussions were held with registered dietitians (n = 29) from primary healthcare and hospitals in Sweden. Focus group transcripts were analysed thematically to find patterns in the data and identify themes.

RESULTS

Dietitians expressed striving to explore patients' narratives, capabilities, and resources before deciding on goals. They described different strategies in counseling patients and a lack of patient participation in the goal-setting. They emphasized the difficulties of setting feasible goals due to discrepancies between their clinically-oriented goals and patients' personal goals.

CONCLUSION

Findings highlight a gap in the process of setting goals for patients at risk of malnutrition, where patients' participation was lacking. Education in SDM, and strategies and tools to support dietitians in involving patients in goal-setting, are required to bridge the gap and promote person-centeredness.

PRACTICE IMPLICATIONS

Findings may be further used to develop tools and strategies, and design studies on the implementation of and education in SDM and goal-setting for malnutrition interventions.

Physicians' Knowledge of Clinical Nutrition Discipline in Riyadh Saudi Arabia

Background: Nutrition plays a major role in the prevention and management of diet-related disease. With the absence of clinical nutrition dietitians, physicians are considered responsible for prescribing nutritional support. Identifying weaknesses in nutritional knowledge among Saudi physicians may provide guidance to improve their nutritional knowledge. Methods: A cross-sectional study that used an anonymous electronic questionnaire to investigate physicians’ knowledge of the clinical nutrition discipline. In addition to demographics, the questionnaire consisted of 15 questions covering six areas in the clinical nutrition discipline (macro- and micronutrients, nutrition and chronic diseases, nutrition and metabolic diseases, nutrition care process, nutrition support therapy, and research). For continuous variables, independent t-tests and one-way ANOVA were used. Results: A total of 332 had completed the questionnaire and were included in the study. Most of the physicians were Saudi (87%), male (73.5%), aged between 26 and 35 years (63.3%), and without health problems (56.3%). The mean score of the physicians’ knowledge was 5.3 ± 1.97 out of 15. Physicians who reported that they received some sort of nutritional training or course (M = 5.57, SD = 2.08) scored significantly more than physicians who did not (M = 5.10, SD = 1.86); t(330) = −2.174, p = 0.30. Conclusions: Nutrition should be reinforced as an important component of continuing medical education. There is a need for hiring more dietitians in health care settings in Saudi Arabia as an integral part of a multidisciplinary team delivering medical care services.

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.

Can COVID-19 be a risk for cachexia for patients during intensive care? Narrative review and nutritional recommendations

Although increased weight, and particularly obesity, has been associated with a more severe clinical course of COVID-19 and risk of fatality, the course of the illness can lead to prolonged length of stay. Changes in nutritional status and weight loss during hospitalisation are largely reported in some populations, but still not explored in COVID-19 patients. Considering that patients with COVID-19 show an increased inflammatory response, other signs and symptoms, which can lead to weight and muscle loss, should be monitored. The aim of this article was to establish possible connections between COVID-19, prolonged hospitalisation and muscle wasting, as well as to propose nutritional recommendations for the prevention and treatment of cachexia, through a narrative review. Identification of risk and presence of malnutrition should be an early step in general assessment of all patients, with regard to more at-risk categories including older adults and individuals suffering from chronic and acute disease conditions, such as COVID-19. The deterioration of nutritional status, and consequently cachexia, increases the risk of mortality and needs to be treated with attention as other complications. There is, however, little hard evidence of nutritional approaches in assisting COVID-19 treatment or its management including cachexia.

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.

More-2-Eat implementation demonstrates that screening, assessment and treatment of malnourished patients can be spread and sustained in acute care; a multi-site, pretest post-test time series study

BACKGROUND

Malnutrition in medical and surgical inpatients is an on-going problem. More-2-Eat (M2E) Phase 1 demonstrated that improved detection and treatment of hospital malnutrition could be embedded into routine practice using an intensive researcher-facilitated implementation process. Yet, spreading and sustaining new practices in diverse hospital cultures with minimal researcher support is unknown.

AIMS

To demonstrate that a scalable model of implementation can increase three key nutrition practices (admission screening; Subjective Global Assessment (SGA); and medication pass (MedPass) of oral nutritional supplement) in diverse acute care hospitals to detect and treat malnutrition in medical and surgical patients.

METHODS

Ten hospitals participated in this pretest post-test time series implementation study from across Canada, including 21 medical or surgical units (Phase 1 original units (n = 4), Phase 1 hospital new units (n = 9), Phase 2 new hospitals and units (n = 8)). The scalable implementation model included: training champions on implementation strategies and providing them with education resources for teams; creating a self-directed audit and feedback process; and providing mentorship. Standardized audits of all patients on the study unit on an audit day were completed bi-monthly to track nutrition care activities since admission. Bivariate comparisons were performed by time period (initial, mid-term and final audits). Run-charts depicted the trajectory of change and qualitatively compared to Phase 1.

RESULTS

5158 patient charts were audited over the course of 18-months. Admission nutrition screening rates increased from 50% to 84% (p < 0.0001). New Phase 1 units more readily implemented screening than Phase 2 sites, and the original Phase 1 units generally sustained screening practices from Phase 1. SGA was a sustained practice at Phase 1 hospitals including in new Phase 1 units. The new Phase 2 units improved completion of SGA but did not reach the levels of Phase 1 units (original or new). MedPass almost doubled over the time periods (7%-13% of all patients p < 0.007). Other care practices significantly increased (e.g. volunteer mealtime assistance).

CONCLUSION

Nutrition-care activities significantly increased in diverse hospital units with this scalable model. This heralds the transition from implementation research to sustained changes in routine practice. Screening, SGA, and MedPass can all be implemented, improve nutrition care for all patients, spread within an organization, and for the most part, sustained (and in the case of original Phase 1 units, for over 3 years) with champion leadership.

COVID-19: The Inflammation Link and the Role of Nutrition in Potential Mitigation

The novel coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has engulfed the world, affecting more than 180 countries. As a result, there has been considerable economic distress globally and a significant loss of life. Sadly, the vulnerable and immunocompromised in our societies seem to be more susceptible to severe COVID-19 complications. Global public health bodies and governments have ignited strategies and issued advisories on various handwashing and hygiene guidelines, social distancing strategies, and, in the most extreme cases, some countries have adopted "stay in place" or lockdown protocols to prevent COVID-19 spread. Notably, there are several significant risk factors for severe COVID-19 infection. These include the presence of poor nutritional status and pre-existing noncommunicable diseases (NCDs) such as diabetes mellitus, chronic lung diseases, cardiovascular diseases (CVD), obesity, and various other diseases that render the patient immunocompromised. These diseases are characterized by systemic inflammation, which may be a common feature of these NCDs, affecting patient outcomes against COVID-19. In this review, we discuss some of the anti-inflammatory therapies that are currently under investigation intended to dampen the cytokine storm of severe COVID-19 infections. Furthermore, nutritional status and the role of diet and lifestyle is considered, as it is known to affect patient outcomes in other severe infections and may play a role in COVID-19 infection. This review speculates the importance of nutrition as a mitigation strategy to support immune function amid the COVID-19 pandemic, identifying food groups and key nutrients of importance that may affect the outcomes of respiratory infections.

[Assessing the implementation of a nutritional screening protocol in patients admitted to the Medicine Department of a local hospital]

Introduction

Background: the techniques for screening and nutritional intervention in hospitalized patients are a cost-effective measure. In clinical practice the problem lies in their administration. Objective: to evaluate the implementation of a nutritional screening tool in patients admitted to our Medicine Ward (M). Material and methods: a single-center, prospective, observational study in patients admitted to M. Exclusion criteria: end-stage cancer patients, inpatient stay less than 72 h, and hospital readmission of previously included patients. One out of every 2 hospital admissions was selected. We assessed the following: whether nurses performed the screening test, the Short Nutritional Assessment Questionnaire (SNAQ); the score obtained; consultations with dieticians (ICD); prescribed nutritional support; and coding of malnutrition in the discharge report. Dieticians repeated the SNAQ for one in every 3 patients. Results: during the study period 726 patients were admitted, 377 were selected, and 315 were included. The nursing staff administered the SNAQ to 93.6% of patients and malnutrition was present in 19%. Dieticians detected malnutrition in 37.8%. In 41.9% of patients with severe malnutrition an ICD was performed, whereas in 40% of them no nutritional intervention was implemented. The diagnosis of malnutrition was recorded in the discharge report of 42.1% of our cases. Conclusion: Compliance with screening test administration was good, but there is disagreement with the assessment made by dieticians. For most malnourished patients nutritional support fals to be prescribed, no ICDs are performed, and a malnutrition diagnosis is not included in the discharge report.