The Norwegian Directorate of Health recommends malnutrition screening tool (MST) for all adults

Healthcare professionals' experience with nutritional care beyond formal quality systems - A qualitative study

BACKGROUND

Numerous formal strategies, screening tools, and interventions have been used to prevent malnutrition in long-term care patients. Despite these efforts, the proportion of screened patients is low, and a large proportion are malnourished. Previous research has revealed that healthcare professionals use a broad approach in their nutritional care but has also emphasised the need for further investigation into these approaches.

OBJECTIVE

To explore how healthcare professionals working in long-term care experience and apply nutritional care.

DESIGN

A descriptive, exploratory, qualitative design containing 240 h of participant observation, 12 focus groups and 2 individual interviews.

SETTING(S)

Twelve nursing homes and home care units in three Norwegian municipalities.

PARTICIPANTS

Participant observation of interactions between healthcare professionals and patients. Forty-three registered nurses participated in focus group or individual interviews.

METHODS

The data were analysed using inductive thematic analysis.

RESULTS

The analysis identified three themes: The first theme, limited significance of nutritional screening, showed that healthcare professionals experienced the limited value of nutritional screening, as it often did not capture patients' nutritional challenges. They also perceived nutritional screening as unsuitable for patients at the end of their lives, those with overweight-related complications, or undergoing rehabilitation. In addition, nutritional screening was perceived as something healthcare professionals did for their managers or administrators, not because it was crucial to providing good nutritional care. The second theme, provision of individualised food, captures the healthcare professionals' efforts in adapting and preparing food according to the patient's preferences. Facilitation to enable patients to make individual food choices and the use of food cards or lists were two approaches to individualising nutrition care. The third theme, making meals more than about food, elucidated how healthcare professionals used meals to help patients cope with their situations and experience social belonging. Conversations about or around meals were used to provide patients with a sense of belonging to their past or present situation. The meals were also used as a diversion strategy for patients with unrest, as arenas for daily activity training, and for meaningful social interactions between patients around the tables.

CONCLUSIONS

Nutritional screening and prevention of malnutrition are only one part of healthcare professionals' nutritional care. Individualised food and meals that create coping, a sense of belonging, and social experiences are equally important parts of their care. Emphasising healthcare professional's person-centred approach to nutritional care would be beneficial, as it could strengthen and further develop long-term nutritional care services.

The role of the nutrition in malnourished cancer patients: Revisiting an old dilemma

BACKGROUND & AIMS

GLIM definition of malnutrition is recognised all over the world and, when is referring to cancer, it specifies that weight or muscle loss are associated with an inflammatory status. However, the real-world practice shows that GLIM definition cannot encompass all the wide and heterogenous clinical presentations of cancer patients with malnutrition, which involves many other drivers beyond inflammation. Moreover, placing an excessive emphasis on the inflammation can overshadow, in the clinical practice, the role of the nutritional support in malnourished cancer patients. The aim of this paper is not to criticize the rationale of the GLIM definition of cancer cachexia, but to show the complexity and heterogeneity of malnutrition of cancer patients and reasons why nutritional support should deserve such a better consideration among the oncologists.

METHODS

Literature pertinent to pathophysiology of malnutrition of cancer patients is scrutinised and reasons for the frequent underuse of nutritional support are critically analysed.

RESULTS

The appraisal of the literature shows that there are various pathophysiological patterns of malnutrition among cancer patients and inflammatory markers are not universally present in weight-losing cancer patients. Inflammation alone does not account for weight loss in all cancer patients and factors other than inflammation can drive hypophagia and weight loss, and hypophagia appears to be a primary catalyst for weight loss. Furthermore, malnutrition may be the consequence of the presence of several Nutrition Impact Symptoms or of the oncologic therapy. The nutritional support may fail to show benefits in malnourished cancer patients because the golden standard to validate a therapy relies on RCT, but it is ethically impossible to have an unfed control group of malnourished patients. Furthermore, nutritional interventions often fell short of the optimal standards, adherence to treatment plans was often poor, nutritional support was mainly reserved for very advanced patients and the primary endpoints of the studies on nutritional support were sometimes unrealistic.

CONCLUSION

There is a gap between the suggestion of the guidelines which advocate the use of nutritional support to improve the compliance of patients facing intensive oncologic treatments or to prevent an early demise when patients enter a chronic phase of slow nutritional deterioration, and the poor use of nutrition in the real-world practice. This requires a higher level of awareness of the oncologists concerning the reasons for the lacking evidence of efficacy of the nutritional support and an understanding of its potential contribute to improve the outcome of the patients. Finally, this paper calls for a change of the oncologist's approach to the cancer patient, from only focusing on the cure of the tumour to taking care of the patient as a whole.

Malnutrition in cancer patients: Causes, consequences and treatment options

Cancer patients are at a high risk of malnutrition and disease-associated catabolic derangements. It is important to differentiate between 'simple' - voluntary or involuntary - caloric restriction with protein-sparing ketogenic metabolic adaptation and cachexia, characterized by the combination of weight loss and dysmetabolism, most prominently systemic inflammation. While both conditions result in the sacrifice of fat and protein stores and thus impact on treatment tolerance, complication rates and survival, the presence of metabolic derangements is especially dangerous by straining multiple organ functions. To avoid underdiagnosing and undertreating malnutrition, all cancer patients should be routinely screened for nutritional risk. At-risk patients require comprehensive assessment for contributing and treatable causes and, if available, multi-professional efforts to improve food intake, support anabolism, alleviate distress and antagonize pro-inflammatory processes. In curative settings, anabolic support should accompany or even precede anticancer treatments. Prehabilitation before major surgery, has been studied extensively, including muscle training as well as nutritional and/or psychological support. Recent meta-analyses report a consistent benefit on functional capacity and possible improvement in postoperative complications and length of hospital stay. In palliative settings, prevailing catabolic derangements require careful assessment of the individual constellation of disturbed functions and an empathic evaluation of benefits and risks of nutritional interventions. This is of special relevance in patients with an expected survival of less than a few months. Due to the complex interactions of mechanical, metabolic and psychological factors, multi-professional teams should be involved.

Exploring Norwegian homecare healthcare professionals' perceptions of risk and the link to high-quality care: a qualitative multiple case study

OBJECTIVES

Homecare is a critical component of the ongoing restructuring of healthcare worldwide, given the shift from institution- to home-based care. The homecare evidence base still contains significant gaps: There is a lack of knowledge regarding quality and safety work and interventions. This study explores how home healthcare professionals perceive and use the concept of risk to guide them in providing high-quality healthcare while maintaining resilience.

DESIGN

The study design is a qualitative multiple case study. The phenomena explored were risk perception, sensemaking and adaptations of care delivered to patients in their homes. Inductive content analysis was conducted.

SETTING

The study was conducted in three Norwegian municipalities. Each municipality was defined as a single case.

PARTICIPANTS

Interviews with healthcare professionals were performed both individually and in focus groups of three to five persons. 19 interviews with 35 informants were conducted: 11 individual semistructured interviews and 8 focus groups.

RESULTS

Four themes were identified: 'professionalism is constantly prioritising and aligning care based on here-and-now observations' 'teamwork feels safe and enhances quality' 'taking responsibility for system risk' and 'reluctantly accepting the extended expectations from society'.

CONCLUSIONS

To make sense of risk when aspiring for high-quality care in everyday work, the healthcare professionals in this sample mainly used their clinical gaze, gut feeling and experience to detect subtle changes in the patients' condition. Assessing risk information, not only individually but also as a team, was reportedly crucial for high-quality care. Healthcare professionals emphasised the well-being, safety and soundness of the patients when acting on risk information. They felt obliged to act on their gut feeling, moral compass and clinical understanding of quality.

Systematic Review and Meta-Analysis: Malnutrition and In-Hospital Death in Adults Hospitalized with COVID-19

BACKGROUND

Malnutrition and increased malnutrition risk are frequently identified in hospitalized adults. The increase in hospitalization rates during the COVID-19 pandemic was accompanied by the documentation of adverse hospitalization outcomes in the presence of certain co-morbidities, including obesity and type 2 diabetes. It was not clear whether the presence of malnutrition increased in-hospital death in patients hospitalized with COVID-19.

OBJECTIVES

To estimate the effect of malnutrition on in-hospital mortality in adults hospitalized with COVID-19; and secondarily, to estimate the prevalence of malnutrition in adults hospitalized with malnutrition during the COVID-19 pandemic.

METHODS

EMBASE, MEDLINE, PubMed, Google Scholar, and Cochrane Collaboration databases were queried using the search terms malnutrition and COVID-19 and hospitalized adults and mortality. Studies were reviewed using the 14-question Quality Assessment Tool for Studies with Diverse Designs (QATSDD) (questions appropriate for quantitative studies). Author names; date of publication; country; sample size; malnutrition prevalence; malnutrition screening/diagnostic method; number of deaths in malnourished patients; and number of deaths in adequately nourished patients were extracted. Data were analyzed using MedCalc software v20.210 (Ostend, Belgium). The Q and I² tests were calculated; a forest plot was generated, and the pooled odds ratio (OR) with 95% confidence intervals (95%CI) were calculated using the random effects model.

RESULTS

Of the 90 studies identified, 12 were finally included in the meta-analysis. In the random effects model, malnutrition or increased malnutrition risk increased odds of in-hospital death by more than three-fold: OR 3.43 (95% CI 2.549-4.60), p < 0.001. The pooled prevalence estimate for malnutrition or increased malnutrition risk was 52.61% (95% CI 29.50-75.14%).

DISCUSSION AND CONCLUSIONS

It is clear that malnutrition is an ominous prognostic sign in patients hospitalized with COVID. This meta-analysis, which included studies from nine countries on four continents with data from 354,332 patients, is generalizable.

Harmonization and standardization of malnutrition screening for all adults - A systematic review initiated by the Norwegian Directorate of Health

BACKGROUND & AIMS

The Norwegian Directorate of Health has identified a need to harmonize and standardize the malnutrition screening practice in Norwegian hospitals and primary health care settings, in order to provide a seamless communication of malnutrition screening along the patient pathway. Our aim was to perform a systematic review of the validity and reliability of screening tools used to identify risk of malnutrition across health care settings, diagnoses or conditions and adult age groups, as a first step towards a national recommendation of one screening tool.

METHODS

A systematic literature search for articles evaluating validity, agreement, and reliability of malnutrition screening tools, published up to August 2020, was conducted in: MEDLINE, Embase, APA PsycInfo, Cinahl, Cochrane Databases, Web of Science, Epistemonikos, SveMed+, and Norart. The systematic review was registered in PROSPERO (CRD42022300558). For critical appraisal of each included article, the Quality Criteria Checklist by The Academy of Nutrition and Dietetics was used.

RESULTS

The review identified 105 articles that fulfilled the inclusion and exclusion criteria. The most frequently validated tools were Mini Nutritional Assessment short form (MNA), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and Nutritional Risk Screening 2002 (NRS-2002). MNA, MST and NRS-2002 displayed overall moderate validity, and MUST low validity. All four tools displayed low agreement. MST and MUST were validated across health care settings and age groups. In general, data on reliability was limited.

CONCLUSIONS

The screening tools MST and NRS-2002 displayed moderate validity for the identification of malnutrition in adults, of which MST is validated across health care settings. In addition, MNA has moderate validity for the identification of malnutrition in adults 65 years or older.