Impact of protected mealtimes on ward mealtime environment, patient experience and nutrient intake in hospitalised patients

Nursing Home Organization Mealtimes and Staff Attitude Toward Nutritional Care: A Multicenter Observational Study

OBJECTIVES

The aims of this study were to investigate the practices of registered nurses and nurse aides at mealtimes in nursing homes (NHs) and to evaluate the attitudes of health care staff toward the nutritional care of older people.

DESIGN

This is a multicenter cross-sectional study.

SETTING AND PARTICIPANTS

The study involved a convenience sample of NH health care staff: physicians, registered nurses, and nurse aides.

METHODS

Data were collected on characteristics of the dining environment, organizational and nutritional care practices, staff-resident ratio, and staff activities during meals, using 2 questionnaires and staff attitudes were assessed with Staff Attitudes to Nutritional Nursing Care Geriatric Scale (SANN-G). Total score ranges from 18 to 90 points, with the following cutoffs: ≥72, positive attitude; ≤54, negative; and 55-71 points, neutral attitude.

RESULTS

A total of 1267 workers from 29 NHs in northern Italy participated in the study. The most common nutritional assessment tool used by nurses was the Malnutrition Universal Screening Tool. A median of 4.0 and 4.2 people (family caregivers, volunteers and staff) were present for feeding support, respectively, at lunch and dinner. A median of 2.5 and 2.0 staff members at lunch and at dinner, respectively, fed residents. Overall, 1024 health care workers responded to SANN-G of which 21.9% showed a negative attitude, 57.2% neutral, and 20.9% a positive attitude. Nurse aides (190/714) showed worse attitudes compared with registered nurses (20/204) and physicians (2/36); differences were statistically significant. Overall, the best attitudes were toward "habits," "interventions," and "individualization" of nutritional care. Staff who had received nutritional training (29.2%) had best attitudes.

CONCLUSIONS AND IMPLICATIONS

The results suggest that NHs should ensure adequate staff-resident ratio during meals, involving trained volunteers and relatives. Moreover, health professionals' knowledge and attitude toward nutritional care should be improved through continuous training.

Managing food waste in the inpatient population

INTRODUCTION

For medical students, food is rarely discussed from the clinical perspective. Yet, in hospitals reduced food intake poses the risk of malnutrition, along with increased morbidity and mortality. The issue of food waste, a cause of inadequate dietary intake and a common issue within the National Health Service, is rarely addressed. The implementation of protected mealtimes has done little to solve this. This quality improvement project aimed to reduce the average amount of inpatient food waste by 20% by May 2022.

METHODS

A standardised meal size intervention was tested. Meals were weighed before and after meal services to collect baseline and postintervention data. The percentage consumed and the percentage wasted were then calculated. Finally, the overall average of the percentage wasted across both meal services was determined.

RESULTS

Quantitative data showed a change in the average amount of food waste from 70.16% to 65.75%, a decrease of 4.41%. Survey results also found an increase of 3% in patient satisfaction with meal sizes.

CONCLUSION

Standardising meal sizes is shown to improve inpatient food waste and may serve as a starting point for healthcare providers to devise further strategies to reduce wastage in hospitals.

Dietary assessment methods for measurement of oral intake in acute care and critically ill hospitalised patients: a scoping review

Quantification of oral intake within the hospital setting is required to guide nutrition care. Multiple dietary assessment methods are available, yet details regarding their application in the acute care setting are scarce. This scoping review, conducted in accordance with JBI methodology, describes dietary assessment methods used to measure oral intake in acute and critical care hospital patients. The search was run across four databases to identify primary research conducted in adult acute or critical care settings from 1st of January 2000-15th March 2023 which quantified oral diet with any dietary assessment method. In total, 155 articles were included, predominantly from the acute care setting (n = 153, 99%). Studies were mainly single-centre (n = 138, 88%) and of observational design (n = 135, 87%). Estimated plate waste (n = 59, 38%) and food records (n = 43, 28%) were the most frequent assessment methods with energy and protein the main nutrients quantified (n = 81, 52%). Validation was completed in 23 (15%) studies, with the majority of these using a reference method reliant on estimation (n = 17, 74%). A quarter of studies (n = 39) quantified completion (either as complete versus incomplete or degree of completeness) and four studies (2.5%) explored factors influencing completion. Findings indicate a lack of high-quality evidence to guide selection and application of existing dietary assessment methods to quantify oral intake with a particular absence of evidence in the critical care setting. Further validation of existing tools and identification of factors influencing completion is needed to guide the optimal approach to quantification of oral intake in both research and clinical contexts.

Patient Mealtime Experience: Capturing Patient Perceptions Using a Novel Patient Mealtime Experience Tool

INTRODUCTION

The aim of this study is to describe the mealtime experience using the qualitative components of the Austin Health Patient Mealtime Experience Tool (AHPMET) to complement the quantitative findings of this tool.

METHODS

A multiphase, cross-sectional study was undertaken across all sites of Austin Health (Victoria, Australia) between March 2020 and November 2021. Patient mealtime experience was measured using the AHPMET. Descriptive statistics and a deductive thematic analysis approach described the patients' mealtime experiences.

RESULTS

Questionnaire data were collected from 149 participants. Patients were most satisfied with staff interactions, and least satisfied with dimensions of food quality, specifically, flavour, presentation, and menu variety. Clinical symptoms, nutrition impact symptoms and the patient's position were barriers to consumption.

DISCUSSION

Food quality was perceived as the poorest aspect of patient satisfaction with the hospital foodservice, particularly flavour, presentation, and menu variety. Future foodservice quality improvements must prioritise improving food quality to have the greatest impact on patient satisfaction. While clinical and organisational systems have a role in improving mealtime experience and oral intake, communicating patient perceptions of the mealtime experience is critical for responding to current perceptions of hospital food quality.

CONCLUSION

Mealtime experience in the hospital has a significant impact on oral intake and patients' wider perception of hospital services. Questionnaires have been used to capture patient satisfaction with foodservice in the hospital; however, no comprehensive questionnaires including qualitative questions that capture the broader mealtime experience have been validated across different hospital settings. The tool developed through this study can be implemented in any acute and subacute health service to provide feedback and improve the mealtime experience of patients. This has the capacity to improve mealtime intake, mitigate malnutrition, and improve quality of life and patient outcomes.

Indirect Nutrition and Mobility Risks during Hospitalization: An Architectural Perspective on the nutritionDay Study Findings

Nutrition and mobility risks include complex and interrelated physiological, medical, and social factors. A growing body of evidence demonstrates that the built environment can affect patients' well-being and recovery. Nevertheless, the relationship between the built environment, nutrition, and mobility in general hospitals is largely unexplored. This study examines the implications of the nutritionDay study's results for the architectural design of hospital wards and nutrition environments. This one-day annual cross-sectional study uses online questionnaires in 31 different languages to collect ward-specific and patient-specific variables. The main findings relevant to the design of hospital wards were: (1) 61.5% of patients (n = 48,700) could walk before hospitalization and (2) this number dropped to 56.8% on nutritionDay (p < 0.0001), while the number of bedridden patients increased from 6.5% to 11.5% (p < 0.0001), (3) patients who needed more assistance had a much longer mean LOS than mobile patients, (4) mobility was associated with changes in eating, and (5) 72% of units (n = 2793) offered additional meals or snacks, but only 30% promoted a positive eating environment. The built environment may indirectly affect hospitalized patients' mobility, independence, and nutritional intake. Possible future study directions are suggested to further investigate this relationship.

Individual-Level Variables Associated with Self-Efficacy in Nutritional Care for Older People among Italian Nurses: A Multicenter Cross-Sectional Study

Malnutrition in older people is still an unsolved issue. Clinical nurses have a key role in malnutrition prevention. This study aims to describe the individual-level variables associated with self-efficacy in nutrition care for older adults among nurses. A cross-sectional descriptive observational study was performed involving nurses from four northern Italy hospitals. The self-efficacy scale for nursing nutrition care (SE-NNC) and Multiple linear regression (MLR) models were used, enrolling 305 nurses. The mean SE-NNC total score was 53.3 ± 19.7. Considering the three dimensions of the SE-NNC, mean scores were 45.9 ± 21.7 for boosting knowledge, 55.4 ± SD = 20.3 for assessment and evidence utilization, and 57.7 ± 21.1 for care delivery. To be a younger nurse, working in a chronic care setting, and being male were associated with a higher level of self-efficacy, both considering the SE-NNC total score and its dimensions. Working in acute care settings and being an older nurse was associated with lower nursing self-efficacy in nutrition care for older adults.

Hospital Services to Improve Nutritional Intake and Reduce Food Waste: A Systematic Review

BACKGROUND AND AIMS

Patients' nutritional intake is a crucial issue in modern hospitals, where the high prevalence of disease-related malnutrition may worsen clinical outcomes. On the other hand, food waste raises concerns in terms of sustainability and environmental burden. We conducted a systematic review to ascertain which hospital services could overcome both issues.

METHODS

A systematic literature search following PRISMA guidelines was conducted across MEDLINE, Web of Science, and Scopus for randomised controlled trials (RCTs) and observational studies comparing the effect of hospital strategies on energy intake, protein intake, and plate/food waste. The quality of included studies was assessed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane Risk of Bias tool from the Cochrane Handbook for Systematic Reviews of Interventions for RCTs.

RESULTS

Nineteen studies were included, assessing as many hospital strategies such as food service systems-including catering and room service-(n = 9), protected mealtimes and volunteer feeding assistance (n = 4), food presentation strategies (n = 3), nutritional counseling and education (n = 2), plant-based proteins meal (n = 1). Given the heterogeneity of the included studies, the results were narratively analysed.

CONCLUSIONS

Although the results should be confirmed by prospective and large sample-size studies, the personalisation of the meal and efficient room service may improve nutritional intake while decreasing food waste. Clinical nutritionist staff-especially dietitians-may increase food intake reducing food waste through active monitoring of the patients' nutritional needs.

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.

Nutritional care of older people: Investigating nurses' attitudes in medical and surgical units

Background: Malnutrition in older people in hospitals leads to negative patient outcomes. Nurses often underestimate the problem, showing negative attitudes.Aims: To compare nurses' attitudes towards nutritional care of older people in surgical and medical wards. Design: Multicentre cross-sectional survey, conducted in January 2015.Methods: All nurses in surgical and medical wards in 10 hospitals in northern Italy were surveyed using the Staff Attitudes to Nutritional Nursing Care Geriatric Scale (SANN-G scale).Results: 799 out of 1,293 questionnaires were returned (61.8%). 23.2% (185) had a negative attitude, 56.6%(452) had a neutral attitude, and 20.2%(162), positive. Multivariate analysis showed no significant differences between medical and surgical wards (OR = 1.298; CI95% = .883-1.886, p = .18).Conclusions: It is necessary to raise nurses' awareness of poor nutritional care in both settings. More research is needed within the barriers to nutritional care.Impact statement: Strategies such as education and more clearly defined nutritional responsibilities are needed to improve nurses' attitudes.

During Hospitalization, Older Patients at Risk for Malnutrition Consume <0.65 Grams of Protein per Kilogram Body Weight per Day

BACKGROUND

Malnutrition is prevalent in hospitalized patients. To support muscle maintenance in older and chronically ill patients, a protein intake of 1.2-1.5 g/kg/d has been recommended during hospitalization. We assessed daily protein intake levels and distribution in older patients at risk for malnutrition during hospitalization.

METHODS

In this prospective, observational study, we measured actual food and food supplement consumption in patients (n = 102; age, 68 ± 14 years; hospital stay, 14 [8-28] days) at risk of malnutrition during hospitalization. Food provided by hospital meals, ONS, and snacks and the actual amount of food (not) consumed were weighed and recorded for all patients.

RESULTS

Hospital meals provided 1.03 [0.77-1.26] protein, whereas actual protein consumption was only 0.65 [0.37-0.93] g/kg/d. Protein intake at breakfast, lunch, and dinner was 10 [6-15], 9 [5-14], and 13 [9-18] g, respectively. The use of ONS (n = 62) resulted in greater energy (1.26 [0.40-1.79] MJ/d, 300 [100-430] kcal/d) and protein intake levels (11 [4-16] g/d), without changing the macronutrient composition of the diet.

CONCLUSION

Despite protein provision of ∼1.0 g/kg/d, protein intake remains well below these values (∼0.65 g/kg/d), as 30%-40% of the provided food and supplements is not consumed. Provision of ONS may increase energy and protein intake but does not change the macronutrient composition of the diet. Current nutrition strategies to achieve the recommended daily protein intake in older patients during their hospitalization are not as effective as generally assumed.

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.

Effect of a Protected Mealtime Pilot on Energy and Protein Intake in a Canadian Hospital

Purpose: In Canada, approximately 45% of hospitalized patients are moderately or severely malnourished upon admission. The protected mealtime policy was designed to address malnutrition in institutions. This pilot study aimed to provide preliminary results examining the effect of this policy on patient energy and protein intake. Methods: A 1-group, pre-post observation design was conducted in a Canadian hospital. Pre- and post-observations included the frequency and type of interruptions, type of interrupter, and patient energy and protein intake at each meal. Results: The average number and length of interruptions decreased, and the average length of mealtime assistance provided to patients (n = 12) increased in the post-observation period. Energy and protein consumption showed a slight increase during the post-observation period. Conclusion: A protected mealtime policy may be an effective policy to address malnutrition among hospitalized Canadian adults. Further studies are warranted in Canada to determine the effects and feasibility of this policy implementation.

Patient Evaluation of Food Waste in Three Hospitals in Southern Italy

In recent years, food waste has received great attention and is now considered the cause of many negative effects, including health, economic, social and environmental issues. A cross-sectional study was conducted among a sample of 762 inpatients at three hospitals of Campania region in Italy. The purpose of this study was to evaluate the amount of food waste occurring in these hospitals using a structured questionnaire and asking inpatients about the average percentage of food they had disposed of in the previous three days. The overall food wasted amounted to 41.6%. The main plates, first (pasta or rice), second plate (meat or fish), resulted in similar amounts of waste (38.5% and 39.7%, respectively). The side plate (vegetable or potatoes), however, generated the greatest amount of waste (55.0%); 40.7% of patients totally discarded this part of their meals. The type of food wastage among the three hospitals reflected similar patient behaviours, with the amount of food wasted never falling below 30%. Females tended to waste more food than males (59.1% vs. 38.2%; p = 0.000). Other variables were correlated with less food waste, such as having a good opinion of the food's quality (RR = 1.91; 95% C.I. = 1.68-2.17) and satisfaction with the foodservice in general (RR = 1.86; 95% C.I. = 1.64-2.10). Poor quality, different eating habits and the feeling of satiety were the main reasons patients gave for food waste. Our study suggests that the most promising way to reduce food waste in hospitals is to improve the quality of meals and to establish an individual, simplified and flexible meal reservation process based on specific needs and preferences.

Improving Nutrition Care, Delivery, and Intakes Among Hospitalised Patients: A Mixed Methods, Integrated Knowledge Translation Study

Malnutrition is a common and complex problem in hospitals. This study used an integrated knowledge translation approach to develop, implement, and evaluate a multifaceted, tailored intervention to improve nutrition care, delivery, and intake among acute medical inpatients. This observational, pre-post study was conducted in a medical ward at a public hospital in Australia. The intervention was co-developed with key stakeholders and targeted three levels: individuals (nutrition intake magnets at patient bedsides), the ward (multidisciplinary hospital staff training), and the organisation (foodservice system changes). Observational data were collected pre- and post-intervention on patient demographics, food intakes, and the mealtime environment. Data were entered into SPSS and analysed using descriptive and inferential statistics. Ethical approval was gained through the hospital and university ethics committees. A total of 207 patients were observed; 116 pre- and 91 post-intervention. After intervention implementation, patients' mean energy and protein intakes (in proportion to their estimated requirements) were significantly higher and the number of patients eating adequately doubled (p < 0.05). In summary, a multifaceted, pragmatic intervention, tailored to the study context and developed and implemented alongside hospital staff and patients, seemed to be effective in improving nutrition practices and patient nutrition intakes on an acute medical ward.

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.

Protein Intake Falls below 0.6 g•kg-1•d-1 in Healthy, Older Patients Admitted for Elective Hip or Knee Arthroplasty

OBJECTIVE

Hospitalization is generally accompanied by changes in food intake. Patients typically receive hospital meals upon personal preference within the framework of the food administration services of the hospital. In the present study, we assessed food provision and actual food and snack consumption in older patients admitted for elective hip or knee arthroplasty.

DESIGN

A prospective observational study.

SETTING

Orthopedic nursing ward of the Maastricht University Medical Centre+.

PARTICIPANTS

In the present study, n=101 patients (age: 67±10 y; hospital stay: 6.1±1.8 d) were monitored during hospitalization following elective hip or knee arthroplasty.

MEASUREMENTS

Energy and protein provided by self-selected hospital meals and snacks, and actual energy and protein (amount, distribution, and source) consumed by patients was weighed and recorded throughout 1-6 days.

RESULTS

Self-selected meals provided 6.5±1.5 MJ•d-1, with 16, 48, and 34 En% provided as protein, carbohydrate, and fat, respectively. Self-selected hospital meals provided 0.75±0.16 and 0.79±0.21 g•kg-1•d-1 protein in males and females, respectively. Actual protein consumption averaged merely 0.59±0.18 and 0.50±0.21 g•kg-1•d-1, respectively. Protein consumption at breakfast, lunch, and dinner averaged 16±8, 18±9, and 20±6 g per meal, respectively.

CONCLUSIONS

Though self-selected hospital meals provide patients with ~0.8 g•kg-1•d-1 protein during short-term hospitalization, actual protein consumption falls well below 0.6 g•kg-1•d-1 with a large proportion (~32%) of the provided food being discarded. Alternative strategies are required to ensure maintenance of habitual protein intake in older patients admitted for elective orthopedic surgery.

Malnutrition Screening and Assessment in Hospitalised Older People: a Review

Malnutrition (undernutrition) remains one of the most serious health problems for older people worldwide. Many factors contribute to malnutrition in older people, including: loss of appetite, polypharmacy, dementia, frailty, poor dentition, swallowing difficulties, social isolation, and poverty. Malnutrition is common in the hospital setting, yet often remains undetected by medical staff. The objective of this review is to compare the validity and reliability of Nutritional Screening Tools (NSTs) for older adults in the hospital setting. We also provide an overview of the various nutritional screening and assessment tools used to identify malnutrition in hospitalised older adults. These include: Subjective Global Assessment (SGA), the Mini Nutritional Assessment (MNA), MNA-short form (MNA-SF), Malnutrition Universal Screening Tool (MUST), Simplified Nutritional Appetite Questionnaire (SNAQ), Geriatric Nutrition Risk Index (GNRI) and anthropometric measurements. The prevalence and outcomes of malnutrition in hospitalised older adults are also addressed.

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.

Process evaluation of implementing Protected Mealtimes under clinical trial conditions

AIM

To evaluate the implementation of Protected Mealtimes and contrast the findings with implementation fidelity.

BACKGROUND

Protected Mealtimes is a systems approach developed to address the issue of malnutrition in hospitalized patients. Previous studies have used a pre--post study design, with no high-quality trials previously undertaken to measure the effect of the intervention.

DESIGN

A prospective, stepped-wedge cluster randomized controlled trial was undertaken October-November 2015. This process evaluation was conducted using qualitative and quantitative methods to explain discrepancies between expected and observed clinical trial outcomes.

METHODS

Qualitative data were collected using focus groups with the healthcare team and contrasted with fidelity data. Quantitative data were collected using attendance lists, audits and observations and analysed descriptively. Concept-driven coding was undertaken using a framework derived from studies citing the Theoretical Domains Framework.

FINDINGS

Staff training in the trial protocol was viewed positively, however, not all staff attended. Staff were generally enthusiastic about Protected Mealtimes with many programme aspects successfully implemented. Limited staffing resources, particularly of nursing staff, hindered implementation. The presence of trial observers affected staff morale by increasing feelings of stress and anxiety.

CONCLUSION

Process data allowed challenges for the implementation of Protected Mealtimes under clinical trial conditions to be described. Given our inability to implement the trial protocol fully due to the complexity of the mealtime environment and the lack of efficacy on nutritional intake, alternative approaches should be considered to resolve the problem of hospital malnutrition.

Mealtime interruptions, assistance and nutritional intake in subacute care

Protected mealtimes is an initiative to support increased nutritional intake for all hospitalised patients, particularly those who are malnourished. The increased focus on maximising independence of patients in the subacute setting may provide a supportive environment for implementing these strategies. The aim of the present study was to gain insight into subacute ward practices at mealtimes under usual conditions (i.e. at baseline) where no protected mealtimes policy was implemented. Participants were patients aged ≥65 years recruited from subacute care facilities at a large healthcare network in Victoria, Australia. Participants were observed at mealtimes and mid meals (i.e. morning tea, afternoon tea and supper) to determine daily energy and protein intake, provision of mealtime assistance and mealtime interruptions. Almost all participants received assistance when it was needed, with positive and negative interruptions experienced by 56.2% and 76.2% of participants, respectively. There was an energy deficit of approximately 2 MJ per day between average intake and estimated requirements. In conclusion, mealtime practices were suboptimal, with particularly high rates of negative interruptions. Protected mealtimes is one strategy that may improve the mealtime environment to support patients' dietary intake. Prospective studies are needed to evaluate its implementation and effects.

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.

Raising a beautiful swan: a phenomenological-hermeneutic interpretation of health professionals' experiences of participating in a mealtime intervention inspired by Protected Mealtimes

The British concept named Protected Mealtimes is known for stopping all non-acute activities and giving health professionals an opportunity to focus on providing patients their meals without being interrupted or disturbed. PM involves a cultural and behavioural change in the clinical setting, since health professionals are asked to adjust their daily routines. This study investigate how health professionals experience participating in a mealtime intervention inspired by the concept of Protected Mealtimes and intend to change mealtime practices. Three focus group interviews was conducted and included a total of 15 interdisciplinary staff members. After transcribing the interviews, the text material was analysed and interpreted in a three-methodological-step process inspired by the French philosopher Paul Ricoeur. In the analysis and interpretation three themes was identified. The themes were: (1) a chance towards a new and better scene; (2) a step towards a more neurologically friendly environment; and (3) a renewed view of the neurological patients. This study concludes that to the health professionals, the intervention was meaningful in several ways because it created structure during mealtimes and emphasized the importance of creating a calm environment for both patients and health professionals. The intervention was described as an eye-opening and well-regarded event in the field of neurological care that facilitated community, and reflections on nursing care and professional identity were expressed.

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.

Novel, Family-Centered Intervention to Improve Nutrition in Patients Recovering From Critical Illness: A Feasibility Study

BACKGROUND

Critically ill patients are at increased risk of developing malnutrition-related complications because of physiological changes, suboptimal delivery, and reduced intake. Strategies to improve nutrition during critical illness recovery are required to prevent iatrogenic underfeeding and risk of malnutrition. The purpose of this study was to assess the feasibility and acceptability of a novel family-centered intervention to improve nutrition in critically ill patients.

MATERIALS AND METHODS

A 3-phase, prospective cohort feasibility study was conducted in 4 intensive care units (ICUs) across 2 countries. Intervention feasibility was determined by patient eligibility, recruitment, and retention rates. The acceptability of the intervention was assessed by participant perspectives collected through surveys. Participants included family members of the critically ill patients and ICU and ward healthcare professionals (HCPs).

RESULTS

A total of 75 patients and family members, as well as 56 HCPs, were enrolled. The consent rate was 66.4%, and 63 of 75 (84%) of family participants completed the study. Most family members (53/55; 98.1%) would recommend the nutrition education program to others and reported improved ability to ask questions about nutrition (16/20; 80.0%). Family members viewed nutrition care more positively in the ICU. HCPs agreed that families should partner with HCPs to achieve optimal nutrition in the ICU and the wards. Health literacy was identified as a potential barrier to family participation.

CONCLUSION

The intervention was feasible and acceptable to families of critically ill patients and HCPs. Further research to evaluate intervention impact on nutrition intake and patient-centered outcomes is required.

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.

The Impact of Trained Volunteer Mealtime Assistants on Dietary Intake and Satisfaction with Mealtime Care in Adult Hospital Inpatients: A Systematic Review

BACKGROUND

Malnutrition is common in hospital inpatients and is associated with increased morbidity and mortality. Insufficient assistance at mealtimes can contribute to this and therefore trained volunteer mealtime assistants may be of benefit.

OBJECTIVES

To identify and review the current evidence for the impact of trained volunteer mealtime assistants on dietary intake and satisfaction with mealtime care in adult hospital inpatients.

METHODS

A systematic search of Medline, Embase and CINAHL was conducted to identify relevant articles. Articles of any methodology were considered. Quality assessment and data extraction were carried out by two reviewers independently.

PARTICIPANTS

Participants were inpatients in a hospital setting, including rehabilitation units. Participants in long term care facilities were excluded.

INTERVENTION

Articles that examined the effect of trained volunteer mealtime assistants on nutritional outcomes or satisfaction with mealtime care were included.

RESULTS

5576 articles were identified, of which 14 were included in the review. Nine were small research studies and five were quality improvement initiatives. The quality of eight studies was moderate, with one study being of lower quality. Eight articles reported dietary intake and seven demonstrated an improvement, with protein intakes at volunteer mealtimes increasing by 4.3g-10.1g and energy intakes by 44-105kcal. Ten articles reported positive staff, patient and volunteer feedback. No adverse events were reported.

CONCLUSION

There is evidence from small studies and improvement projects that trained volunteer mealtime assistants are safe and improve satisfaction with mealtime care in hospital inpatients, although evidence for an effect on dietary intake was less consistent. Larger studies with robust methodology are required to confirm this.

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.

Assisted or Protected Mealtimes? Exploring the impact of hospital mealtime practices on meal intake

AIMS

To evaluate the impact of mealtime practices (meal time preparation, assistance and interruptions) on meal intake of inpatients in acute hospital wards.

BACKGROUND

It is common for patients to eat poorly while in hospital, related to patient and illness factors and possibly mealtime practices. Few studies have quantified the impact of mealtime practices on the meal intake of hospital patients.

DESIGN

Cross-sectional study.

METHODS

Structured observations were conducted at 601 meals across four wards (oncology, medical and orthopaedic and vascular surgical) during 2013. Each ward was observed by two dietitians and/or nurses for two breakfasts, lunches and dinners over 2 weeks. Data were collected on patient positioning, mealtime assistance, interruptions and meal intake (visual estimate of plate waste). Associations between mealtime practices and 'good' intake (prospectively defined as ≥75% of meal) were identified using chi-squared tests.

RESULTS

Sitting up for the meal was associated with good intake, compared with lying in bed. Timely mealtime assistance (within 10 minutes) was associated with good intake, compared with delayed or no assistance. Mealtime interruptions had no impact on intake. Forty percent of patients (n = 241) ate half or less of their meal, with 10% (n = 61) eating none of the meal provided.

CONCLUSION

Timely mealtime assistance and positioning for the meal may be important factors that facilitate intake among hospital patients, while mealtime interruptions appeared to have no impact on intake. To improve intake of older inpatients, mealtime programmes should focus on 'assisted mealtimes' rather than only Protected Mealtimes.

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

BACKGROUND/OBJECTIVES

Protected mealtimes programs aim to improve inpatient intakes. Yet its efficacy has not yet been established. We aimed to determine which patient-related factors and aspects of protected mealtimes, for example, mealtime assistance and meal within reach, were associated with energy and protein intakes of adult inpatients on medical and surgical wards.

SUBJECTS/METHODS

Patient characteristics and dietary intake data were collected at main meals over 2 years. Proportions of individual foods and drinks consumed were visually estimated and converted to nutrients using averaged ready reckoner data. Mealtime factors associated with energy and protein intakes were determined using multivariate linear hierarchical regression analyses.

RESULTS

Over 2 years, mealtime nutrient intakes of 798 inpatients were calculated ((63 ± 19) years, 52% male). Average intakes at main meals were 1419 ± 614 kJ and 15 ± 7 g protein. Inpatient intakes were significantly associated with gender, age, season, stopping or refusing a meal, time until discharge and eating at dinner (B = -829-222 kJ, B = -8.8 to 2.2 g protein, P = 0.000-0.032). Protected mealtimes program implementation was not associated with inpatient intake (P=0.094-0.157). However, aspects of protected mealtimes were associated with intake. This included requiring and documenting the need for mealtime assistance, introduction of mealtime volunteers, time to eat and appropriate positioning during mealtimes (B = 177-296 kJ, B = 0.07-3.9 g protein, P=0.000-0.014, R(2) = 0.148-0.154). In those specifically requiring mealtime assistance, inpatient protein intake was associated with mealtime volunteers and appropriate positioning (B = 4.1-4.4 g protein, P = 0.013-0.026, R(2) = 0.197).

CONCLUSIONS

Aspects of protected mealtimes were associated with improved intake. Identifying these achievable aspects during planning and ensuring successful implementation of protected mealtimes may be critical for optimizing acute inpatient intake.

Becoming Food Aware in Hospital: A Narrative Review to Advance the Culture of Nutrition Care in Hospitals

The Nutrition Care in Canadian Hospitals (2010-2013) study identified the prevalence of malnutrition on admission to medical and surgical wards as 45%. Nutrition practices in the eighteen hospitals, including diagnosis, treatment and monitoring of malnourished patients, were ad hoc. This lack of a systematic approach has demonstrated the need for the development of improved processes and knowledge translation of practices aimed to advance the culture of nutrition care in hospitals. A narrative review was conducted to identify literature that focused on improved care processes and strategies to promote the nutrition care culture. The key finding was that a multi-level approach is needed to address this complex issue. The organization, staff, patients and their families need to be part of the solution to hospital malnutrition. A variety of strategies to promote the change in nutrition culture have been proposed in the literature, and these are summarized as examples for others to consider. Examples of strategies at the organizational level include developing policies to support change, use of a screening tool, protecting mealtimes, investing in food and additional personnel (healthcare aides, practical nurses and/or diet technicians) to assist patients at mealtimes. Training for hospital staff raises awareness of the issue, but also helps them to identify their role and how it can be modified to improve nutrition care. Patients and families need to be aware of the importance of food to their recovery and how they can advocate for their needs while in hospital, as well as post-hospitalization. It is anticipated that a multi-level approach that promotes being "food aware" for all involved will help hospitals to achieve patient-centred care with respect to nutrition.