Good nutritional practice in hospitals during an 8-year period: The impact of accreditation

Implementation of nutritional care in hospitals: A qualitative study of barriers and facilitators using implementation theory

BACKGROUND

Disease-related malnutrition is prevalent among hospitalised patients, but not all patients achieve the needed nutritional care. At a Danish University Hospital, focus has been on implementing nutritional practices based on clinical guidelines, but there is continuously variation between the wards regarding the quality of nutritional care.

AIM

The aim of this study was to identify the potential barriers and facilitators for implementation of the clinical guidelines for nutritional practices and to recommend suggestions for development of nutritional practices, using a theoretical implementation strategy.

METHOD

The design was a qualitative interview study of employees at a Danish University Hospital, using a semi-structured interview guide. The participants were nurses, nurse's assistant, nurse nutrition expert, head nurse and dieticians. We recruited 11 employees, representing eight different wards.

FINDINGS

The analysis identified six themes: (1) clear allocation of responsibilities and committed management enhances nutrition practices, (2) leadership support is essential, (3) physical settings and tools affect possibilities for action, (4) selection of equivalent staff is core, (5) teaching promotes the knowledge and skills and (6) a dietitian in the ward facilitates implementation of nutritional care. Barriers and facilitators among the themes were identified and has led to suggestions to strengthen nutritional care, based on implementation theory.

CONCLUSION

Various factors were identified as having impact on the implementation of nutrition practices and different suggestions have emerged to accommodate those factors, as well as to apply an implementation strategy to facilitate change in practice.

Poor performance in nutrition risk screening may have serious consequences for hospitalized patients

BACKGROUND AND AIM

Finding patients at nutrition risk and securing sufficient nutritional intake, is vital to decrease risk of adverse outcomes and all-cause mortality. The aims of this study were therefore to investigate the prevalence of patients being screened for nutrition risk, to determine nutritional coverage in at-risk patients and assess the prevalence of readmissions and mortality within 30 days.

METHODS

A one-day cross-sectional study was performed at Herlev Hospital, Denmark in June 2019. Patients >18 y and hospitalized for ≥4 days were enrolled. Exclusion criteria were admission to the intensive, palliative, acute medical or maternal ward. If a patient was not screened by the ward a clinical dietitian screened the patient. Patients found to be at nutrition-risk underwent a 24-h dietary recall to assess energy and protein intake. Data on length of stay, readmissions, and mortality within 30 days were collected from the hospital patient register.

RESULTS

In total 197 (F:52%) patients were included. Median (IQR) age 74y (65-81). At the audit day n = 76 (39%) had a primary screening, and n = 42 (21%) were screened within 24 h. A NRS-2002-score ≥ 3 was found in 111 patients (63%). At-risk patients were more likely to be readmitted within 30 days (45% vs. 27%, p = 0.024) and had a higher mortality within 30 days after discharge (23% vs. 10%., p = 0.0285). In patients at nutrition risk 23% covered ≥75% of their energy- and protein requirement the last 24 h. More patients covered their energy- and protein-need if they were supplemented with enteral and/or parenteral nutrition fully or partly (63% vs. 15%, p < 0.001 or had been in contact with a clinical dietitian during the admission (33% vs. 15%, p = 0.0337. There were no differences in prevalence of readmissions and mortality between those patients at nutrition risk, who covered their energy and protein need and those who did not.

CONCLUSIONS

The results demonstrate that the current nutritional care process is inadequate and may have serious consequences for hospitalized patients. Further effort is needed on the awareness of screening patients and how to fulfil their requirements during hospitalization. An abstract with part of the results has been accepted as a poster to ESPEN 2020.

Nutrition care quality indicators in hospitals and nursing homes: A systematic literature review and critical appraisal of current evidence

OBJECTIVE

Quality indicators (QIs) can be used to assess and improve the quality of care in health care institutions. Although QIs about nutrition care in hospitals and nursing homes have been used in studies, no systematic catalogue exists to date. This systematic literature review identifies nutrition care QIs in hospitals and nursing homes and maps them according to QI type, stakeholder level and nutrition care theme. We also assess the level of consensus between studies and critically appraise the QIs presented therein based on two conceptual frameworks.

METHODS

Ovid, Scopus and grey literature were searched from 1995 to 2016 including studies in English and German. Papers were considered if they presented, developed, assessed, rated or applied nutrition care QIs in hospitals or nursing homes. We used Donabedian's framework to define structure, process and outcome indicators, the WHO (World Health Organization) definition to describe stakeholder levels, and a structured table to map indicators within themes. Further, we used the Institute of Medicine (IOM) and the Organisation for Economic Cooperation and Development (OECD) frameworks' key dimensions to measure the conceptual quality of the QIs. Results are summarised and presented tabulated and narratively.

RESULTS

From 536 identified studies, 46 were included. Eight hundred and twenty-two QIs were extracted and mapped into 19 themes and 151 sub-themes. Half were process indicators (49%) and about a quarter were outcome (28%) and structure (23%) indicators, respectively. The vast majority (71%) targeted micro level, while 28% meso level and only 1% macro level information. The nutrition themes meals/mealtimes (12%), treatment (adherence) (12%), nutrition screening (7%), assessment (7%) and monitoring (7%) were most frequently covered. 69% of indicators were cited by more than one study. Most frequent framework dimensions were patient-centeredness (33%), timeliness (30%), validity (30%) and actionability/feasibility (30%).

CONCLUSION

The large number of nutrition care QIs in hospitals and nursing homes indicates the high interest in and importance of better nutrition care provision in institutions. However, the great variability indicates little consensus of the nutrition community on how to best assess and measure the quality of nutrition care. The limited methodological and conceptual validity of presented QIs and the low representation of QIs at macro and meso levels make international consensus finding complicated. Increased efforts including all stakeholder levels and using conceptual frameworks to define a limited number of key QIs with high methodological validity, actionability and stakeholder relevance are needed. Registration in clinicaltrials.gov: Identifier: NCT02820246.

Changes in nutritional routines at discharge in Scandinavia during a 10-year period: A follow-up survey

BACKGROUND AND AIMS

Time to treat malnutrition during hospital admission is limited due to short hospital stays. Therefore, nutritional care often needs to be continued after discharge from hospital. However, health care professionals' attitudes and discharge routines may not always support continuity of good nutritional practice. The aim of this study was to investigate changes in nutritional discharge routines and related attitudes in Scandinavia (Denmark, Norway, Sweden) over a 10-year period.

METHODS

A survey among doctors and nurses in Scandinavian hospitals was conducted in 2012/2014 and results were compared with an identical survey from 2004. Differences between countries were also studied.

RESULTS

Response rate in 2012/2014 survey was 25% with 2733 questionnaires returned. There was a statistically significant difference between the countries regarding proportions of respondents reporting routinely measuring patients' weight at discharge (Denmark 14% vs. Norway 4% vs. Sweden 22%, p < 0.0005). However, these proportions had increased since the 2004 survey in all countries. In Denmark and Sweden, evaluation of nutritional status at discharge was more often stated to be a standard procedure in 2012/2014 compared to 2004 (10% vs. 18%, p < 0.0005; 8% vs. 15%, p < 0.0005, respectively). A statistically significant increase was found in the proportion of Danish and Swedish participants responding that the nutritional regimens initiated during hospital stay are always included in discharge summaries (35% vs 41%, p < 0.004; 51% vs. 63%, p < 0.0005, respectively).

CONCLUSIONS

The results suggest a positive development in the nutritional discharge routines. Nevertheless, there appears to be room for improvement. Differences in the nutritional practices still exist between the Scandinavian countries.

Factors associated with the practice of nursing staff sharing information about patients' nutritional status with their colleagues in hospitals

BACKGROUND/OBJECTIVES

Nursing staff have an important role in patients' nutritional care. The aim of this study was to demonstrate how the practice of sharing a patient's nutritional status with colleagues was affected by the nursing staff's attitude, knowledge and their priority to provide nutritional care.

SUBJECTS/METHODS

The participants were 492 nursing staff. We obtained participants' demographic data, the practice of sharing patients' nutritional information and information about participants' knowledge, attitude and priority of providing nutritional care by the questionnaire. We performed partial correlation analyses and linear regression analyses to describe the relationship between the total scores of the practice of sharing patients' nutritional information based on their knowledge, attitude and priority to provide nutritional care.

RESULTS

Among the 492 participants, 396 nursing staff (80.5%) completed the questionnaire and were included in analyses. Mean±s.d. of total score of the 396 participants was 8.4±3.1. Nursing staff shared information when they had a high nutritional knowledge (r=0.36, P<0.01) and attitude (r=0.13, P<0.05); however, their correlation coefficients were low. In the linear regression analyses, job categories (β=-0.28, P<0.01), knowledge (β=0.33, P<0.01) and attitude (β=0.10, P<0.05) were independently associated with the practice of sharing information. Nursing staff's priority to provide nutritional care practice was not significantly associated with the practice of sharing information.

CONCLUSIONS

Knowledge and attitude were independently associated with the practice of sharing patients' nutrition information with colleagues, regardless of their priority to provide nutritional care. An effective approach should be taken to improve the practice of providing nutritional care practice.

Barriers to accurately measuring patients' dietary intake in hospitals using the visual estimation method

Purpose Visual estimation, an easy-to-perform technique, is commonly used in hospitals to assess dietary intake in patients. The authors performed a qualitative study where the authors interviewed nurses and dietitians about their perceptions of barriers to accurately measuring patients' dietary intake in hospitals using the visual estimation method. The paper aims to discuss these issues. Design/methodology/approach Ten dietitians and ten clinical nurses responded to 30-minute individual interviews in Tokyo, Japan, in September 2014. Each interview was conducted using a common protocol of open-ended questions focusing on the challenges of the visual estimation method and barriers to accurately measuring patients' dietary intake as part of their routine work. The tape-recorded interviews were transcribed and analyzed based on grounded theory. Findings Five main categories emerged: hospitals, meals, colleagues, raters, and patients. Various individual barriers such as skill, attitude, knowledge, and others that had not been considered in previous studies also emerged. External barriers that were out of the raters' control, such as shortage of time, human resources, financial ability, and others, emerged from the "hospitals" category. Research limitations/implications Research participants were all females and many of them had less than ten years of experience. Practical implications In addition to standardizing the visual estimation process, medical staff need to overcome various other internal and external barriers to accurate measurements. Originality/value This is the first study to articulate some important barriers that influence reliability and validity when measuring patients' dietary intake by visual estimation methods in typical clinical settings.

Nutrition impact symptoms, handgrip strength and nutritional risk in hospitalized patients with gastroenterological and liver diseases

OBJECTIVE

Malnutrition is common among patients with diseases of the liver and gastrointestinal tract. Nutritional intake may be negatively affected by nutrition impact symptoms (NIS). Therefore, the aims were to assess: 1) the prevalence of NIS in this group of patients and 2) the relationship between NIS and nutritional status as well as nutritional risk.

MATERIAL AND METHODS

We performed a cross-sectional study among patients with liver disease, inflammatory bowel disease, cancer or pancreatitis. Nutritional risk was assessed by the NRS-2002. Nutritional status was assessed by body mass index (BMI) and handgrip strength (HGS), which were both measured within 5 days after admission. NIS were assessed by the Eating Symptoms Questionnaire (ESQ) and the Disease-Related Appetite Questionnaire (DRAQ).

RESULTS

In total, 126 patients were included (women 39%) with a mean BMI of 24 ± 5 kg/m(2). The prevalence of low HGS was 38%, and the prevalence of those at nutritional risk was 58%. The number of NIS reported by 50% of the patients were 4 or more in the ESQ and 5 or more in the DRAQ. Patients who were both at nutritional risk and had a low HGS more frequently reported difficulties swallowing, poor appetite, feeling full after having one-fourth of the meal and food tasting bad.

CONCLUSIONS

NIS that preclude food intake are very frequent among patients with diseases of the liver and gastrointestinal tract. Specific NIS are associated with low HGS, weight loss and being at nutritional risk.