Aspects of protected mealtimes are associated with improved mealtime energy and protein intakes in hospitalized adult patients on medical and surgical wards over 2 years

Feeding Assistance Skill Score: development and verification of reliability and validity

PURPOSE

Feeding assistance should be safe and improve the assisted individual's ability to feed, yet objective tools for evaluating these skills are lacking. This study focuses on developing a tool for assessing feeding assistance skills.

METHODS

A group consisting of 25 experts employed the Delphi method to achieve a consensus on the essential items necessary for assessing feeding assistance skills. Subsequently, a draft score using a three-point scale was developed. To test the reliability of the draft scores, a group of 20 patients and 20 nurses was matched to record a meal assistance scene, which were independently evaluated by three raters. We computed the AC1 statistic to assess both intra- and inter-rater reliability, and further examined correlations between the Feeding Assistance Skill Score (FASS) scores and outcome items to verify validity.

RESULTS

Initially, an 18-item draft score was generated using the Delphi method. Subsequently, seven items were omitted from the intra- or inter-rater reliability analysis. Furthermore, after discussion, researchers removed one item that assessed food cognition, because the agreement score between the two items was 91%. Finally, the 10-item FASS was developed, showing a correlation with dietary intake upon validation.

CONCLUSIONS

We successfully developed a scoring system for peer evaluation of feeding assistance skills. Future studies should aim to validate the FASS. The implementation of the FASS aims to assess the effectiveness of feeding assistance training and care quality, potentially improving safety and satisfaction for those receiving feeding assistance.

Mealtimes matter: Measuring the hospital mealtime environment and care practices to identify opportunities for multidisciplinary improvement

AIMS

Hospital inpatients often eat poorly and report barriers related to mealtime care. This study aimed to measure and describe the mealtime environment and care practices across 16 acute wards in a tertiary hospital to identify opportunities for improvement.

METHODS

A prospective cross-sectional audit was undertaken over a two-month period in 2021. A structured audit tool was used at one breakfast, lunch and dinner on each ward to observe the mealtime environment (competing priorities, lighting, tray table clutter) and care practices (positioning, tray within reach, mealtime assistance). Data were analysed descriptively (%, count), with analyses by meal period and ward to identify variation in practices.

RESULTS

A total of 892 observations were completed. Competing priorities (59%), poor lighting (43%) and cluttered tray tables (41%) were common. Mealtime assistance was required by 300 patients (33.6%; 5.9% eating assistance, 27.7% set-up assistance) and was provided within 10 min for 203 (66.7%) patients. A total of 54 patients (18.0%) did not receive the required assistance. We observed 447 (50.2%) patients lying in bed at meal delivery, with 188 patients (21.1%) sitting in a chair. Competing priorities, poor lighting, poor patient positioning and delayed assistance were worse at breakfast. Mealtime environments and practices varied between wards.

CONCLUSION

This audit demonstrates opportunities to improve mealtimes in our hospital. Variation between wards and meal periods suggest that improvements need to be tailored to the ward-specific barriers and enablers. Dietitians are ideally placed to lead a collaborative approach alongside the wider multidisciplinary team to improve mealtime care and optimise intake.

Impact of a surgical ward breakfast buffet on nutritional intake in postoperative patients: A prospective cohort pilot study

BACKGROUND

An early return to normal intake and early mobilization enhances postoperative recovery. However, one out of six surgical patients is undernourished during hospitalization and approximately half of the patients eat 50% or less of the food provided to them. We assessed the use of newly introduced breakfast buffets in two wards for gastrointestinal and oncological surgery and determined the impact on postoperative protein and energy intake.

METHODS

A prospective pilot cohort study was conducted to assess the impact of the introduction of breakfast buffets in two surgical wards. Adult patients had the opportunity to choose between an attractive breakfast buffet and regular bedside breakfast service. Primary outcomes were protein and energy intake during breakfast. We asked patients to report the type of breakfast service and breakfast intake in a diary over a seven-day period. Prognostic factors were used during multivariable regression analysis.

RESULTS

A total of 77 patients were included. The median percentage of buffet use per patient during the seven-day study period was 50% (IQR 0-83). Mean protein intake was 14.7 g (SD 8.4) and mean energy intake 332.3 kcal (SD 156.9). Predictors for higher protein intake included the use of the breakfast buffet (β = 0.06, p = 0.01) and patient weight (β = 0.13, p = 0.01). Both use of the breakfast buffet (β = 1.00, p = 0.02) and Delirium Observation Scale scores (β = -246.29, p = 0.02) were related to higher energy intake.

CONCLUSION

Introduction of a breakfast buffet on a surgical ward was associated with higher protein and energy intake and it could be a promising approach to optimizing such intake in surgical patients. Large, prospective and preferably randomized studies should confirm these findings.

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.

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.

Evidence-Based Analysis of Protected Mealtime Policies on Patient Nutrition and Care

Malnutrition in hospitalized patients remains a significant problem. Protected Mealtimes is a complex, inter-professional ward-based intervention that was first introduced in the United Kingdom to address this issue. Now implemented internationally, the approach still remains in key policy documents including the National Health Service Essence of Care. This review aims to synthesize the nutrition, satisfaction and quality of life patient/resident outcomes that arise from the implementation of Protected Mealtimes in hospitals and residential aged care facilities and to consider fidelity issues that have been reported in previous research. A defined search strategy was implemented in seven databases to identify full text papers of original research that evaluated Protected Mealtimes implementation. After screening, data were extracted from eight studies (7 quantitative and 1 qualitative study) that were conducted in hospitals. There was no research identified from the aged care sector. There were few positive outcomes that resulted from Protected Mealtimes implementation, many fidelity issues with the intervention were reported. It is apparent that Protected Mealtimes provide few, if any, benefits for hospitalized patients. It is a complex, multi-pronged initiative that has limited fidelity and limited outcomes. As such, we recommend that disinvestment by policy makers for hospitals should be considered, with the implementation of other evidence based mealtime initiatives. We provide no recommendation for disinvestment in the aged care sector, since the approach has not been evaluated against any of the eligible outcomes of this review.

Acute stroke patients not meeting their nutrition requirements: Investigating nutrition within the enriched environment

BACKGROUND & AIMS

Malnutrition is common after stroke. We investigated the impact of environmental enrichment strategies on dietary intake and rates of malnutrition in an acute stroke unit.

METHODS

We performed a before-after study. In standard care, meals were delivered to participants' rooms whilst in the enriched environment, communal meals with assistance were offered and nutritional intake reminders were placed at the patient bedside. Nutrition supplementation was provided to both groups if indicated. Breakfast and lunch meals were directly observed while remaining intake was calculated using food charts. Nutrition requirements were calculated for energy (ratio method), protein (1 g/kg) and proportion of requirements met. Malnutrition was assessed using the Subjective Global Assessment and body weight. ANCOVA adjusting for stroke severity was used to determine between group differences. Stepwise multivariable logistic regression was performed to assess predictors of nutritional outcomes, adjusting for intervention group, demographic, clinical and baseline nutritional factors.

RESULTS

Neither standard care (n = 30, age 76.0yrs ± SD12.8) nor enriched environment (n = 30, age 76.7yrs ± SD12.1, p = 0.84) met daily requirements for energy (70.7% ± SD16.8 vs. 70.7% ± SD17.3, p = 0.94) or protein intake (73.2% ± SD18.6 vs. 69.8% ± SD17.3, p = 0.70). Mean body weight dropped: standard care 0.92 kg ± SD2.47 vs. enriched 0.64 kg ± SD3.12 (p = 0.53) and malnutrition increased: standard care 3.3%-26.6% vs. enriched 6.6%-13.3% (p = 0.07). Predictors of malnutrition on discharge in logistic regression models were: length of stay (p < 0.01) and protein (p < 0.01) or energy intake (p = 0.02).

CONCLUSIONS

Acute stroke patients were not meeting nutritional requirements and losing body weight. The enriched environment showed no effect on nutritional intake. Malnutrition was associated with lower energy and protein intakes and increased length of stay.

The Currently Available Literature on Inpatient Foodservices: Systematic Review and Critical Appraisal

BACKGROUND

An adequate hospital foodservice is important to optimize protein and energy intake and to maintain or improve a patient's nutritional status. Key elements that define an optimal foodservice have yet to be identified.

OBJECTIVES

To systematically describe the effects of published foodservice interventions on nutrition and clinical outcomes and determine which elements should be considered essential. Secondly, to describe the outcome measures used in these studies and evaluate their relevance and validity to guide future research.

METHODS

PubMed, Embase, the Cochrane Library, and the Web of Science databases were searched. Studies that included assessment of nutrition and/or clinical outcomes of hospital foodservice up to December 2017 were eligible. The details of the subject population, the type of intervention, and the effects on reported outcomes were extracted from each study.

RESULTS

In total, 33 studies that met inclusion criteria were identified, but only nine (27%) were rated as having sufficient methodologic quality. These nine studies concluded that various elements of a foodservice can be considered essential, including using volunteers to provide mealtime assistance, encouraging patients to choose protein-rich foods, adding protein-enriched items to the menu, replacing existing items with protein-enriched items, giving patients the ability to order food by telephone from a printed menu (room service concept), or a combination of these interventions. The interstudy heterogeneity was high for both outcome measures and methods.

CONCLUSIONS

Various foodservice interventions have the potential to improve outcome measures. Recommendations are made to facilitate future research.

The Challenge of Managing Undernutrition in Older People with Frailty

Many older people with frailty are at risk of malnutrition and poor health, yet there is evidence that improving nutrition and weight loss can reduce frailty. This will become more important as the number of older people with frailty increases worldwide in future. Identifying those at risk is challenging due to the difficulty of reaching and screening those older people most at risk, the large number of nutritional assessment tools used, and the lack of consensus on the criteria to make a diagnosis of malnutrition. The management of older people with or at risk of malnutrition should be multi-modal and multi-disciplinary, and all care staff have an important role in delivering appropriate nutritional advice and support. This paper will highlight a number of practical approaches that clinicians can take to manage malnutrition in older people with frailty in community and acute settings, including environmental changes to enhance mealtime experience, food fortification and supplementation.

Mealtime Assistance ... From Chaos to Calm: A Collaborative Best Practice Implementation Project

BACKGROUND

Providing appropriate and timely mealtime assistance to hospitalized patients should be part of a multifaceted and multidisciplinary approach to optimizing a patient's nutritional care plan.

PROBLEM

There was anecdotal evidence at the study hospital that patients did not receive adequate and/or timely assistance at mealtimes.

APPROACH

A best practice implementation project, using a proven strategy of audit, feedback, and reaudit, was used to effect practice change on an acute general medical ward.

OUTCOMES

The combined interventions of staff engagement, redesigning the model of care to reprioritize activities at mealtimes, clarifying nutritional care roles and responsibilities, introducing a protected mealtime and a novel 2-tiered colored tray system, and implementing an awareness and education program have resulted in significant improvements in mealtime assistance.

CONCLUSIONS

Success of the project is considered to be replicable and sustainable hospitalwide and more broadly.

Exploring staff perceptions and experiences of volunteers and visitors on the hospital ward at mealtimes using an ethnographic approach

AIMS AND OBJECTIVES

To explore multiple perspectives and experiences of volunteer and visitor involvement and interactions at hospital mealtimes. In addition, to understand how the volunteer and visitor role at mealtimes is perceived within the hospital system.

BACKGROUND

Mealtime assistance can improve patients' food intake and mealtime experience. Barriers to providing mealtime assistance include time pressures, staff availability and inadequate communication. Volunteers and visitors can encourage and assist patients at mealtimes. There is a lack of evidence on the relationship between hospital staff, volunteers and visitors.

DESIGN

A qualitative, ethnographic approach.

METHODS

Sixty-seven hours of fieldwork were conducted on two subacute wards within an Australian healthcare network in 2015. Mealtime practices and interactions of hospital staff, volunteers and visitors were observed. Sixty-one staff, volunteers and visitors were interviewed in 75 ethnographic and semi-structured interviews. Data were inductively and thematically analysed.

RESULTS

Three key themes emerged as follows: "help"-volunteers and visitors were considered helpful when they assisted patients at mealtimes, supported well-being and aided staff-patient communication; "hindrance"-staff perceived visitors as negative presences when they inhibited patient progress and impacted staff work practices; and "reality of practice"-visiting hours, visitor engagement in patient therapy and communication between staff, volunteers and visitors were important practical considerations of mealtime involvement.

CONCLUSIONS

The findings show how and why volunteers and visitors can be helpful and unhelpful at hospital mealtimes on subacute wards. More research on the role and contribution of volunteers and visitors on hospital wards will inform future practice in healthcare settings.

RELEVANCE TO CLINICAL PRACTICE

This healthcare organisation should continue to encourage volunteer and visitor involvement at hospital mealtimes. More effort is needed to educate visitors about patients' therapeutic goals and the importance of nutrition. The working relationship between hospital staff, volunteers and visitors should be strengthened to improve nutritional care.

Can trained volunteers improve the mealtime care of older hospital patients? An implementation study in one English hospital

OBJECTIVE

Multinational studies report undernutrition among 39% older inpatients; importantly, malnutrition risk may further increase while in hospital. Contributory factors include insufficient mealtime assistance from time-pressured hospital staff. A pilot study showed trained volunteers could safely improve mealtime care. This study evaluates the wider implementation of a mealtime assistance programme.

DESIGN

Mixed methods prospective quasi-experimental study.

SETTING

Nine wards across Medicine for Older People (MOP), Acute Medical Unit, Orthopaedics and Adult Medicine departments in one English hospital.

PARTICIPANTS

Patients, volunteers, ward staff.

INTERVENTION

Volunteers trained to help patients aged ≥70 years at weekday lunchtime and evening meals.

MAIN OUTCOME MEASURES

The number of volunteers recruited, trained and their activity was recorded. Barriers and enablers to the intervention were explored through interviews and focus groups with patients, ward staff and volunteers. The total cost of the programme was evaluated.

RESULTS

65 volunteers (52 female) helped at 846 meals (median eight/volunteer, range 2-109). The mix of ages (17-77 years) and employment status enabled lunch and evening mealtimes to be covered. Feeding patients was the most common activity volunteers performed, comprising 56% of volunteer interactions on MOP and 34%-35% in other departments. Patients and nurses universally valued the volunteers, who were skilled at encouraging reluctant eaters. Training was seen as essential by volunteers, patients and staff. The volunteers released potential costs of clinical time equivalent to a saving of £27.04/patient/day of healthcare assistant time or £45.04 of newly qualified nurse time above their training costs during the study.

CONCLUSIONS

Patients in all departments had a high level of need for mealtime assistance. Trained volunteers were highly valued by patients and staff. The programme was cost-saving releasing valuable nursing time.

TRIAL REGISTRATION NUMBER

NCT02229019; Pre-results.

Comparing Hospital Staff Nutrition Knowledge, Attitudes, and Practices Before and 1 Year After Improving Nutrition Care: Results From the More-2-Eat Implementation Project

BACKGROUND

Staff play key roles in the prevention, detection, and treatment of hospital malnutrition. Understanding staff knowledge, attitudes, and practices (KAP) is important for developing and evaluating change management strategies.

METHODS

The More-2-Eat project improved nutrition care in 5 Canadian hospitals by implementing the Integrated Nutrition Pathway for Acute Care (INPAC). To understand staff views before (T1) and after 1 year of implementation (T2), a reliable KAP questionnaire, based on INPAC, was administered. T2 included questions about involvement in implementation. The mean difference between T2 and T1 responses was calculated, and t tests were used for comparisons.

RESULTS

The questionnaire was completed at T1 (n = 189) and T2 (n = 147) (unpaired); 57 staff completed both questionnaires (paired). A significant increase in total score was seen in unpaired results at T2 (from 93.6/128 [range, 51-124] to 99.5/128 [range, 54-119]; t = 5.97, P < .0001), with an increase in knowledge/attitudes (KA) (t = 2.4, P = .016) and practice (t = 3.57, P < .0001) components. There were no statistically significant changes in paired responses. Seventy percent (n = 102/147) noticed positive changes in practices, 12% (n = 18) noticed positive/negative changes, 1% (n = 1) noticed negative change, and 17% (n = 25) noticed no change. Fifty-nine percent (n = 86) felt involved in the change, and these staff had higher KA and KAP scores than those who did not feel involved.

CONCLUSION

Staff involvement is important in the implementation process for improving nutrition care.

Changing the food environment: the effect of trained volunteers on mealtime care for older people in hospital

This review will describe the evidence for changing the hospital environment to improve nutrition of older people, with particular emphasis on the role of additional mealtime assistance. Poor nutrition among older people in hospital is well recognised in many countries and is associated with poor outcomes of hospital care including increased mortality and longer lengths of stay. Factors recognised to contribute to poor dietary intake include acute illness, co-morbidities, cognitive impairment, low mood and medication. The hospital environment has also been scrutinised with reports from many countries of food being placed out of reach or going cold because time-pressured ward and catering staff often struggle to help an increasingly dependent group of patients at mealtimes. Routine screening in hospital for people at risk of under nutrition is recommended. Coloured trays and protected mealtimes are widespread although there is relatively little evidence for their impact on dietary intake. Volunteers can be trained to sfely give additional mealtime assistance including feeding to older patients on acute medical wards. They can improve the quality of mealtime care for patients and nursing staff although the evidence for improved dietary intake is mixed. In conclusion, improving the nutrition of older patients in hospital is challenging. Initiatives such as routine screening, the use of coloured trays, protected mealtimes and additional mealtime assistance can work together synergistically. Volunteers are likely to be increasingly important in an era when healthcare systems are generally limited in both financial resources and the ability to recruit sufficient nursing staff.

Changing nutrition care practices in hospital: a thematic analysis of hospital staff perspectives

Background

Many patients are admitted to hospital and are already malnourished. Gaps in practice have identified that care processes for these patients can be improved. Hospital staff, including management, needs to work towards optimizing nutrition care in hospitals to improve the prevention, detection and treatment of malnutrition. The objective of this study was to understand how staff members perceived and described the necessary ingredients to support change efforts required to improve nutrition care in their hospital.

Methods

A qualitative study was conducted using purposive sampling techniques to recruit participants for focus groups (FG) (n = 11) and key informant interviews (n = 40) with a variety of hospital staff and management. Discussions based on a semi-structured schedule were conducted at five diverse hospitals from four provinces in Canada as part of the More-2-Eat implementation project. One researcher conducted 2-day site visits over a two-month period to complete all interviews and FGs. Interviews were transcribed verbatim while key points and quotes were taken from FGs. Transcripts were coded line-by-line with initial thematic analysis completed by the primary author. Other authors (n = 3) confirmed the themes by reviewing a subset of transcripts and the draft themes. Themes were then refined and further detailed. Member checking of site summaries was completed with site champions.

Results

Participants (n = 133) included nurses, physicians, food service workers, dietitians, and hospital management, among others. Discussion regarding ways to improve nutrition care in each specific site facilitated the thought process during FG and interviews. Five main themes were identified: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team.

Conclusions

Hospital staff need a reason to change their nutrition care practices and a significant change driver is perceived and experienced benefit to the patient. Participants described key ingredients to support successful change and specifically engaging the interdisciplinary team to effect sustainable improvements in nutrition care.

Trial registration

Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.

The efficacy of Protected Mealtimes in hospitalised patients: a stepped wedge cluster randomised controlled trial

BACKGROUND

Protected Mealtimes is an intervention developed to address the problem of malnutrition in hospitalised patients through increasing positive interruptions (such as feeding assistance) whilst minimising unnecessary interruptions (including ward rounds and diagnostic procedures) during mealtimes. This clinical trial aimed to measure the effect of implementing Protected Mealtimes on the energy and protein intake of patients admitted to the subacute setting.

METHODS

A prospective, stepped wedge cluster randomised controlled trial was undertaken across three hospital sites at one health network in Melbourne, Australia. All patients, except those receiving end-of-life care or not receiving oral nutrition, admitted to these wards during the study period participated. The intervention was guided by the British Hospital Caterers Association reference policy on Protected Mealtimes and by principles of implementation science. Primary outcome measures were daily energy and protein intake. The study was powered to determine whether the intervention closed the daily energy deficit between estimated intake and energy requirements measured as 1900 kJ/day in the pilot study for this trial.

RESULTS

There were 149 unique participants, including 38 who crossed over from the control to intervention period as the Protected Mealtimes intervention was implemented. In total, 416 observations of 24-hour food intake were obtained. Energy intake was not significantly different between the intervention ([mean ± SD] 6479 ± 2486 kJ/day) and control (6532 ± 2328 kJ/day) conditions (p = 0.88). Daily protein intake was also not significantly different between the intervention (68.6 ± 26.0 g/day) and control (67.0 ± 25.2 g/day) conditions (p = 0.86). The differences between estimated energy/protein requirements and estimated energy/protein intakes were also limited between groups. The adjusted analysis yielded significant findings for energy deficit: (coefficient [robust 95% CI], p value) of -1405 (-2354 to -457), p = 0.004. Variability in implementation across aspects of Protected Mealtimes policy components was noted.

CONCLUSIONS

The findings of this trial mirror the findings of other observational studies of Protected Mealtimes implementation where nutritional intakes were observed. Very few positive improvements to nutritional intake have been identified as a result of Protected Mealtimes implementation. Instead of this intervention, approaches with a greater level of evidence for improving nutritional outcomes, such as mealtime assistance, other food-based approaches and the use of oral nutrition support products to supplement oral diet, should be considered in the quest to reduce hospital malnutrition.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12614001316695 ; registered 16th December 2014.

Comparing Computerised Dietary Analysis with a Ready Reckoner in a Real World Setting: Is Technology an Improvement?

Ready reckoners are used in the clinical setting as a tool for the estimation of nutrient intake. With increasing opportunities for nutrition research, ready reckoners may provide for a more rapid analysis of nutritional intake than computerised methods, often seen as the gold standard for nutritional analysis. This research aimed to determine the level of agreement between ready reckoner and computerised dietary analysis through a secondary analysis of clinical trial data. Participant food intakes were estimated by trained observers using the one-quarter method. Daily energy and protein intake were estimated by the healthcare network ready reckoner and computerised dietary analysis. Agreement between methods was tested using t-tests, correlations and Bland-Altman plots. A correlation between analysis methods was observed (r = 0.9086 energy, r = 0.8700 protein). Wide limits of agreement were observed for both energy and protein intake. Compared with the computerised method, ready reckoner analysis underestimated energy intake by 600 kJ and protein intake by 5 g. Mean energy and protein intake calculated by each method was significantly different (p < 0.0001 energy; p < 0.0001 protein). No time differences between analysis methods were observed. In the clinical setting, practitioners should be aware of the variability of a ready reckoner compared to computerised dietary analysis. Further investigation into the acceptability of ready reckoners as a reliable method of nutrient intake determination, particularly for analysis of nutrition research, is required.

Protected Mealtimes in hospitals and nutritional intake: Systematic review and meta-analyses

OBJECTIVES

Protected Mealtimes is an intervention developed to address the problem of malnutrition, particularly in the hospital setting. The intervention aims to provide interruption-free time to eat during a hospital admission, thus supporting increased nutritional intake. This review aimed to determine the impact of Protected Mealtimes on the nutritional intake of hospitalised patients.

DESIGN

The review was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42015023423) and followed the PRISMA guidelines. Meta-analyses were conducted of energy and protein intake.

DATA SOURCES

Seven databases were searched to identify relevant publications: Ovid MEDLINE, Embase, CINAHL Plus, PsycInfo, Scopus, Cochrane Library (including NHS economic evaluations), and NICE clinical guidelines. A supplementary internet search of Google and Google Scholar was undertaken. The search terms protect* AND (mealtime* OR "meal time*") were used for all searches.

REVIEW METHODS

Eligible studies were original research where Protected Mealtimes was implemented in hospitals and nutritional intake measured. Studies were selected for inclusion following a systematic process of identification, screening and eligibility assessment. Two authors completed the screening and eligibility assessment, and quality assessment of included studies. The Quality Criteria Checklist for Primary Research was used to evaluate the quality of each study, whilst the overall body of evidence was assessed using the GRADE approach. One author extracted data and ran the meta-analyses, these were verified by a second author.

RESULTS

Database and hand searching yielded 150 papers for consideration; the final review library was seven studies where nutritional intake of patients had been evaluated before and after the introduction of Protected Mealtimes. No clinical trials of the intervention were identified. The meta-analyses of energy and protein intake in four observational studies found no effect in favour of Protected Mealtimes implementation. The GRADE of evidence was rated as very low.

CONCLUSIONS

Given the small number of observational studies and the quality of evidence on the effect of the intervention on nutritional intake, we conclude that there is insufficient evidence for widespread implementation of Protected Mealtimes in hospitals. More research including clinical trials, with subgroup reporting of patients' nutritional status and estimated energy requirements are needed to further understand the merits of this complex healthcare intervention.

Quality Nutrition Care: Measuring Hospital Staff's Knowledge, Attitudes, and Practices

Understanding the knowledge, attitudes, and practices (KAP) of hospital staff is needed to improve care activities that support the detection/prevention/treatment of malnutrition, yet quality measures are lacking. The purpose was to develop (study 1) and assess the administration and discriminative potential (study 2) of using such a KAP measure in acute care. In study 1, a 27-question KAP questionnaire was developed, face validated (n = 5), and tested for reliability (n = 35). Kappa and Intraclass Correlation (ICC) were determined. In study 2, the questionnaire was sent to staff at five diverse hospitals (n = 189). Administration challenges were noted and analyses completed to determine differences across sites, professions, and years of practice. Study 1 results demonstrate that the knowledge/attitude (KA) and the practice (P) subscales are reliable (KA: ICC = 0.69 95% CI 0.45-0.84, F = 5.54, p < 0.0001; P: ICC = 0.84 95% CI 0.68-0.92, F = 11.12, p < 0.0001). Completion rate of individual questions in study 2 was high and suggestions to improve administration were identified. The KAP mean score was 93.6/128 (range 51-124) with higher scores indicating more knowledge, better attitudes and positive practices. Profession and years of practice were associated with KAP scores. The KAP questionnaire is a valid and reliable measure that can be used in needs assessments to inform improvements to nutrition care in hospital.