Benefits of family mealtimes for nursing home residents: protecting mealtimes may similarly benefit elderly inpatients

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.

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.

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.

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.

Hospital inpatients' experiences of access to food: a qualitative interview and observational study

BACKGROUND

Hospital surveys indicate that overall patients are satisfied with hospital food. However undernutrition is common and associated with a number of negative clinical outcomes. There is little information regarding food access from the patients' perspective.

PURPOSE

To examine in-patients' experiences of access to food in hospitals.

METHODS

Qualitative semi-structured interviews with 48 patients from eight acute wards in two London teaching hospitals. Responses were coded and analysed thematically using NVivo.

RESULTS

Most patients were satisfied with the quality of the meals, which met their expectations. Almost half of the patients reported feeling hungry during their stay and identified a variety of difficulties in accessing food. These were categorized as: organizational barriers (e.g. unsuitable serving times, menus not enabling informed decision about what food met their needs, inflexible ordering systems); physical barriers (not in a comfortable position to eat, food out of reach, utensils or packaging presenting difficulties for eating); and environmental factors (e.g. staff interrupting during mealtimes, disruptive and noisy behaviour of other patients, repetitive sounds or unpleasant smells). Surgical and elderly patients and those with physical disabilities experienced greatest difficulty accessing food, whereas younger patients were more concerned about choice, timing and the delivery of food.

CONCLUSIONS

Hospital in-patients often experienced feeling hungry and having difficulty accessing food. These problems generally remain hidden because staff fail to notice and because patients are reluctant to request assistance.

Dysphagia: implications for older people

This review opens with an outline definition of dysphagia, its causes, and why it is vital that people involved in the health care of older people should be aware of it. A brief consideration of prevalence is followed by an overview of assessment options. We conclude with a section on management.