Systematised, Interdisciplinary Malnutrition Program for impLementation and Evaluation delivers improved hospital nutrition care processes and patient reported experiences - An implementation study

Interdisciplinary Oral Nutrition Support and Supplementation After Hip Fracture Surgery in Older Adult Inpatients: A Global Cross-Sectional Survey (ONS-STUDY)

BACKGROUND

Malnutrition predicts poor outcomes following hip fracture, affecting patient recovery, healthcare performance, and costs. Evidence-based guidelines recommend multicomponent, interdisciplinary nutrition care to improve intake, reduce complications, and enhance outcomes. This study examines global variation in oral nutrition support for older (65+ years) hip fracture inpatients.

METHODS

A global survey was conducted as part of a broader program to improve interdisciplinary nutrition care. The protocol was based on evidence-based guidelines, reviewed by experts, and piloted for validity. Recruitment used snowball sampling to achieve diversity across income levels, countries, and healthcare roles.

RESULTS

The survey (July-September 2023) recruited 308 participants from 46 countries across five global regions. Respondents primarily worked in acute teaching (57.5%) and non-teaching (17.5%) hospitals, representing medical (48.4%), nursing (28.2%), and allied health (17.9%) roles. Findings revealed a global knowledge-to-practice gap in multicomponent nutrition care, across providing high-protein/energy food and fluids (median: "half the time"), post-operative provision of oral nutritional supplements (median: "half the time") and continuation for one month with assessment (median: "not very often"), and nutritional education (median: "not very often"). Only 17.9% of respondents reported routine provision ("often" and "nearly always or always") of high-protein/energy food, supplements, and education. Substantial regional variation showed Western Pacific respondents perceiving the lowest provision across multicomponent processes. Interdisciplinary, multicomponent interventions were seen as a potential opportunity requiring further exploration.

CONCLUSIONS

Major gaps persist in implementing evidence-based, interdisciplinary, multicomponent nutrition care for older adults with hip fractures. A targeted implementation approach is the next step to addressing the knowledge-to-practice gap.

Health policy to address disease-related malnutrition: a scoping review

ABSTRACT

Background

Health policies promote optimal care, yet policies that address disease-related malnutrition (DRM) are lacking. The purpose of this study was to conduct a scoping review to identify literature on existing and planned policy to address DRM in children or adults and explore the settings, contexts and actors of DRM policy.

Methods

A search strategy comprising DRM and policy keywords was applied to eight databases on 24 February 2023. Articles that addressed DRM and policy were selected for inclusion after two independent reviews. The health policy triangle (HPT) framework (ie, actors, content, contexts and processes considerations for policy) guided data extraction and thematic analysis.

Results

A total of 67 articles were included out of the 37 196 identified. Some articles (n=14) explored established policies at the local level related to food and mealtime, nutrition care practices, oral nutritional supplement prescribing or reimbursement. Other articles gave direction or rationale for DRM policy. As part of the HPT, actors included researchers, advocacy groups and DRM champions while content pertained to standard processes for nutrition care such as screening, assessment, intervention and monitoring. Contexts included acute care and care home settings with a focus on paediatrics, adults, older adults. Processes identified were varied and influenced by the type of policy (eg, local, national, international) and its goal (eg, advocating, developing, implementing).

Discussion

There is a paucity of global DRM policy. Nutrition screening, assessment, intervention and monitoring are consistently identified as important to DRM policy. Decision makers are important actors and should consider context, content and processes to develop and mobilise DRM policy to improve nutrition care. Future efforts need to prioritise the development and implementation of policies addressing DRM.

Prospective validation of the Global Leadership Initiative on Malnutrition criteria for identifying malnutrition in hospitals: A protocol and feasibility pilot study

BACKGROUND

The aim of this study was to pilot a protocol for prospective validation of the Global Leadership Initiative on Malnutrition (GLIM) criteria in hospital patients and evaluate its feasibility and patient acceptability.

METHODS

The validation protocol follows the GLIM consortium's rigorous methodological guidance. Protocol feasibility was assessed against criteria on recruitment (≥50%) and data collection completion (≥80%); protocol acceptability was assessed via patient satisfaction surveys and interviews. Adult inpatients in a tertiary hospital underwent four nutrition assessments (each by a different assessor); two Subjective Global Assessments (SGAs) and two GLIM assessments. All five GLIM criteria were assessed with bioelectrical impedance analysis used for muscle mass. Interrater reliability, criterion validity, and predictive validity were reported to detect trends.

RESULTS

All primary feasibility criteria were met (consent rate 76%; data for GLIM criterion validity collected on 83% participants). Of predictive outcome data, 100% of hospital-related data, 82% of 6-month mortality data, and 39% of 6-month health-related quality of life data were collected. The mean (SD) age of participants was 61.0 ± 16.2 years, and 51.5% were male. The median (interquartile range) length of stay and body mass index were 7 (4-15) days and 25.6 (24.2-33.0) kg/m2, respectively. GLIM criteria diagnosed 70% of the patients as malnourished vs 55% with SGA. Most patients found the data collection acceptable with minimal burden.

CONCLUSION

The methods outlined in this rigorous GLIM validation protocol are feasible to undertake in hospitals and acceptable to patients. This paper provides practical methodological guidance for future prospective GLIM validation studies.

Harnessing delegation and technology to identify and manage malnutrition in a digital hospital: An implementation study

AIMS

Delegation of nutrition care activities to Dietetic Assistants in hospitals has been identified as one innovative malnutrition model of care, but there has been limited evaluation of their roles. This study aimed to develop, implement and evaluate a new Malnutrition Model of Care embracing automated delegation and digital systems.

METHODS

The Malnutrition Model of Care was created to detect patients at risk of malnutrition (using the Malnutrition Screening Tool) and nutritional decline (via routine intake tracking at all meals and snacks). Digital systems generated automated referrals to dietetics, with protocols to support Dietetic Assistants to action these to direct care escalation to the ward dietitian. Dietetic Assistant training included simulations and clinical task instructions. Implementation evaluation was guided by the Donabedian model of quality and included a review of inpatient dietetics occasions of service, survey of Dietetic Assistant role satisfaction and task confidence, and hospital-wide cross-sectional malnutrition audit. Data was descriptively analysed.

RESULTS

During the first year of implementation, 60% of Dietetics inpatient occasions of service were completed by Dietetic Assistants, with 26% of Dietetic Assistant inpatient tasks initiated from nursing malnutrition risk screening. Most Dietetic Assistants reported adequate training and confidence in completing delegated tasks. Malnutrition prevalence was 14% with no hospital-acquired malnutrition identified. No clinical incidents were reported.

CONCLUSIONS

The Dietetic Assistant workforce and technology were harnessed to implement an innovative delegated Malnutrition Model of Care that appears to be safe and effective at managing malnutrition from preliminary evaluation. Work continues to formally assess service efficiencies, cost and patient experience.

Enhancing or impeding? The influence of digital systems on interprofessional practice and person-centred care in nutrition care systems across rehabilitation units

AIMS

Digital health transformation may enhance or impede person-centred care and interprofessional practice, and thus the provision of high-quality rehabilitation and nutrition services. We aimed to understand how different elements and factors within existing digital nutrition and health systems in subacute rehabilitation units influence person-centred and/or interprofessional nutrition and mealtime care practices through the lens of complexity science.

METHODS

Our ethnographic study was completed through an interpretivist paradigm. Data were collected from observation and interviews with patients, support persons and staff. Overall, 58 h of ethnographic field work led to observing 125 participants and interviewing 77 participants, totalling 165 unique participants. We used reflexive thematic analysis to analyse the data with consideration of complexity science.

RESULTS

We developed four themes: (1) the interplay of local context and technology use in nutrition care systems; (2) digitalisation affects staff participation in nutrition and mealtime care; (3) embracing technology to support nutrition and food service flexibility; and (4) the (in)visibility of digitally enabled nutrition care systems.

CONCLUSIONS

While digital systems enhance the visibility and flexibility of nutrition care systems in some instances, they may also reduce the ability to customise nutrition and mealtime care and lead to siloing of nutrition-related activities. Our findings highlight that the introduction of digital systems alone may be insufficient to enable interprofessional practice and person-centred care within nutrition and mealtime care and thus should be accompanied by local processes and workflows to maximise digital potential.

Oral Nutritional Supplementation in Older Adults with a Hip Fracture-Findings from a Bi-National Clinical Audit

BACKGROUND/OBJECTIVES

Evidence-based guidelines and care standards recommend offering oral nutrition supplements to all older adults with hip fracture, not just those already malnourished. This study aimed to identify the proportion of inpatients in a sample of hospitals in two countries that were provided with oral nutritional supplementation (ONS) following a hip fracture and to identify factors associated with ONS provision.

METHODS

An analysis of prospectively collected data from a bi-national Hip Fracture Registry nutrition sprint and registry audit data limited to older adults (≥65 years) undergoing surgical intervention for a fractured hip from 1 to 31 August 2021. Multivariable logistic regression was used to identify factors associated with providing ONS.

RESULTS

Patient-level data was available for 385 older adults (median 85 years; 60.5% female) admitted to twenty-nine hospitals. Less than half (n = 47.3%) of the audited inpatients were provided ONS. After adjusting for covariates, ONS was more likely to be provided to older adults who were identified as malnourished on formal testing (OR 11.92; 95%CI 6.57, 21.69). Other factors associated with prescription of ONS included those who did not have a preoperative medical assessment (OR 2.26; 95%CI 1.19, 4.27) or were cognitively impaired (OR 1.83; 95%CI 1.01, 3.32), severely frail, or terminally ill (OR 3.17; 95%CI 1.10, 9.17).

CONCLUSIONS

ONS was provided in line with evidence-based recommendations for less than half of the older adults with a hip fracture in 29 hospitals in two countries. A structured approach to implementation may be required to reduce complications and improve outcomes for all older adults after a hip fracture, not just those assessed as cognitively impaired, frail, and/or malnourished.

Dietetics student contribution to addressing malnutrition in residential aged care facilities

AIMS

To test a model of malnutrition screening and assessment conducted by dietetics students on placement in residential aged care facilities. The secondary aim was to identify possible facilitators and barriers to the implementation of the model.

METHOD

The type 1 hybrid effectiveness-implementation trial study design and reporting outcomes were developed using the Consolidated Framework for Implementation Research. An innovative placement model was developed, where students on voluntary placement visited three residential aged care facilities to identify residents at risk of malnutrition using currently available screening tools for older people. Students completed malnutrition assessments for all residents using the subjective global assessment tool.

RESULTS

Thirty-two students participated; 31 completed all three sessions, with malnutrition screening completed for 207 residents and malnutrition assessment for 187 residents (July and September 2022). Based on the subjective global assessment, 31% (n = 57) of residents were mildly/moderately malnourished, and 3% (n = 5) were severely malnourished. The Innovation Domain of the Framework was the most important consideration before implementation.

CONCLUSION

Whilst previous research documented student learning opportunities in residential aged care facilities, this study provides the first available evidence of the direct contribution students can make to the health of aged care residents through malnutrition screening and assessment. The model enables students to conduct malnutrition screening and assessment feasibly and efficiently in facilities that do not routinely collate and act on these data. With a limited nursing aged care workforce to undertake this vital task, the potential role of student dietitians to fulfil this role must be considered.

Lost in Transition: Insights from a Retrospective Chart Audit on Nutrition Care Practices for Older Australians with Malnutrition Transitioning from Hospital to Home

Care transitions from hospital to home for older adults with malnutrition present a period of elevated risk; however, minimal data exist describing the existing practice. This study aimed to describe the transition of nutrition care processes provided to older adults in a public tertiary hospital in Australia. A retrospective chart audit conducted between July and October 2022 included older (≥65 years), malnourished adults discharged to independent living. Dietetic care practices (from inpatient to six-months post-discharge) were reported descriptively. Of 3466 consecutive admissions, 345 (10%) had a diagnosis of malnutrition documented by the dietitian and were included in the analysis. The median number of dietetic visits per admission was 2.0 (IQR 1.0-4.0). Nutrition-focused discharge plans were inconsistently developed and documented. Only 10% of patients had nutrition care recommendations documented in the electronic discharge summary. Post-discharge oral nutrition supplementation was offered to 46% and accepted by 34% of the patients, while only 23% attended a follow-up appointment with dietetics within six months of hospital discharge. Most patients who are seen by dietitians and diagnosed with malnutrition appear lost in transition from hospital to home. Ongoing work is required to explore determinants of post-discharge nutrition care in this vulnerable population.

Are Malnourished Inpatients Treated by Dietitians Active Participants in Their Nutrition Care? Findings of an Exploratory Study of Patient-Reported Measures across Nine Australian Hospitals

BACKGROUND

Inpatient malnutrition is a key determinant of adverse patient and healthcare outcomes. The engagement of patients as active participants in nutrition care processes that support informed consent, care planning and shared decision making is recommended and has expected benefits. This study applied patient-reported measures to identify the proportion of malnourished inpatients seen by dietitians that reported engagement in key nutrition care processes.

METHODS

A subset analysis of a multisite malnutrition audit limited to patients with diagnosed malnutrition who had at least one dietitian chart entry and were able to respond to patient-reported measurement questions.

RESULTS

Data were available for 71 patients across nine Queensland hospitals. Patients were predominantly older adults (median 81 years, IQR 15) and female (n = 46) with mild/moderate (n = 50) versus severe (n = 17) or unspecified severity (n = 4) malnutrition. The median length of stay at the time of audit was 7 days (IQR 13). More than half of the patients included had two or more documented dietitian reviews. Nearly all patients (n = 68) received at least one form of nutrition support. A substantial number of patients reported not receiving a malnutrition diagnosis (n = 37), not being provided information about malnutrition (n = 30), or not having a plan for ongoing nutrition care or follow-up (n = 31). There were no clinically relevant trends between patient-reported measures and the number of dietitian reviews or severity of malnutrition.

CONCLUSIONS

Malnourished inpatients seen by dietitians across multiple hospitals almost always receive nutritional support. Urgent attention is required to identify why these same patients do not routinely report receiving malnutrition diagnostic advice, receiving information about being at risk of malnutrition, and having a plan for ongoing nutrition care, regardless of how many times they are seen by dietitians.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients’ preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients’ preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient’s specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Qualitative analysis of the implementation of a hospital room service in a large metropolitan hospital: foundations for transformation

INTRODUCTION AND AIMS

Room service is a hospital meal service model with demonstrated improved nutrition intake, reduced wastage and cost benefits in some settings compared with traditional models. However, uptake across public hospital settings appears low; the underlying reasons require exploration. In 2019, room service was introduced in a Queensland Hospital and Health Service site. The aim of this article is to identify the barriers and enablers to implementing room service to provide recommendations for future implementation of this model.

METHODS

The current qualitative descriptive study utilized semistructured interviews with project members and key stakeholders involved in implementation of the room service meal delivery model at the Prince Charles Hospital (Queensland, Australia). A convenience sample of participants were recruited. Interviews explored project experiences from commencement to completion, barriers and enablers to implementation, strategies to overcome challenges and recommendations for implementation at other sites. Interviews were coded to identify themes and subthemes.

RESULTS

Nine participants were interviewed. Key themes with associated subthemes were (1) foundations of transformation, (2) navigating implementation and (3) embedding sustainable practices.

CONCLUSION

The current study adds rich information to understand factors that support the implementation of a room service model in a large public hospital. Future implementation of room service should not only consider measuring quantifiable outcomes, but also the importance of qualitative descriptive studies surveying project members and key stakeholders to further explore experiences, barriers and enablers to implementation and develop strategies to overcome challenges to assist further sites implement this model.

Barriers and Enablers to Delegating Malnutrition Care Activities to Dietitian Assistants

Delegation of malnutrition care to dietitian assistants can positively influence patient, healthcare, and workforce outcomes. However, nutrition care for hospital inpatients with or at risk of malnutrition remains primarily individually delivered by dietitians-an approach that is not considered sustainable. This study aimed to identify barriers and enablers to delegating malnutrition care activities to dietitian assistants. This qualitative descriptive study was nested within a broader quality assurance activity to scale and spread systematised and interdisciplinary malnutrition models of care. Twenty-three individual semi-structured interviews were completed with nutrition and dietetic team members across seven hospitals. Inductive thematic analysis was undertaken, and barriers and enablers to delegation of malnutrition care to dietitian assistants were grouped into four themes: working with the human factors; balancing value and risk of delegation; creating competence, capability, and capacity; and recognizing contextual factors. This study highlights novel insights into barriers and enablers to delegating malnutrition care to dietitian assistants. Successful delegation to dietitian assistants requires the unique perspectives of humans as individuals and in their collective healthcare roles, moving from words to actions that value delegation; engaging in processes to improve competency, capability, and capacity of all; and being responsive to climate and contextual factors.

Impact of room service on nutritional intake, plate and production waste, meal quality and patient satisfaction and meal costs: A single site pre-post evaluation

AIM

Room service is a patient-focused foodservice model gaining interest in Australian hospitals following demonstrated patient and organisational benefits. This study aimed to compare nutritional intake, waste, patient satisfaction, meal costs and meal quality between a bought-in, thaw-retherm foodservice model and a cook-fresh, on-demand room service model at a large tertiary public hospital.

METHODS

A retrospective analysis of quality assurance data compared thaw-retherm to room service. Nutritional intake and plate waste were measured using a visual intake analysis tool; production waste was measured using weighted analysis methodology; patient satisfaction was measured using a validated patient satisfaction survey; meal quality was assessed using a validated meal quality audit tool, and meal costs were obtained from hospital finance reports. Independent sample t-tests or nonparametric equivalent (Mann-Whitney U-test) for continuous variables and Pearson's Chi-square for categorical data were applied for comparative purposes.

RESULTS

Average energy and protein intake, as well as percentage requirements met, improved between thaw-retherm and room service (4320 kJ/day vs 7265 kJ/day; 42.4 g/day vs 82.5 g/day; and 46% vs 80.7%; 49.9% vs 98.4%; all P < .001. Reductions in plate waste (40% vs 15%) and production waste (15% vs 5.6%, P < .001) were observed and food costs decreased by 9% with room service. Meal quality audit results improved, and patient satisfaction increased with % respondents satisfied increasing from 75.0% to 89.8% (χ² 9.985[2]; P = .007) for room service.

CONCLUSIONS

This research demonstrates significant improvements in patient and organisational outcomes with room service compared to a thaw-retherm model in a large public hospital.

Identifying Low Value Malnutrition Care Activities for De-Implementation and Systematised, Interdisciplinary Alternatives-A Multi-Site, Nominal Group Technique Approach

Malnutrition risk is identified in over one-third of inpatients; reliance on dietetics-delivered nutrition care for all “at-risk” patients is unsustainable, inefficient, and ineffective. This study aimed to identify and prioritise low-value malnutrition care activities for de-implementation and articulate systematised interdisciplinary opportunities. Nine workshops, at eight purposively sampled hospitals, were undertaken using the nominal group technique. Participants were asked “What highly individualised malnutrition care activities do you think we could replace with systematised, interdisciplinary malnutrition care?” and “What systematised, interdisciplinary opportunities do you think we should do to provide more effective and efficient nutrition care in our ward/hospital?” Sixty-three participants were provided five votes per question. The most voted de-implementation activities were low-value nutrition reviews (32); education by dietitian (28); assessments by dietitian for patients with malnutrition screening tool score of two (22); assistants duplicating malnutrition screening (19); and comprehensive, individualised nutrition assessments where unlikely to add value (15). The top voted alternative opportunities were delegated/skill shared interventions (55), delegated/skill shared education (24), abbreviated malnutrition care processes where clinically appropriate (23), delegated/skill shared supportive food/fluids (14), and mealtime assistance (13). Findings highlight opportunities to de-implement perceived low-value malnutrition care activities and replace them with systems and skill shared alternatives across hospital settings.