Nutritional care of medical inpatients: a health technology assessment

Proximity and information sharing in hospitals and nursing homes: Development of an instrument assessing health personnel's perceptions of proximity and information sharing with kitchen personnel

Healthcare services are becoming increasingly specialized, potentially hampering interprofessional care. To provide holistic treatment and care, different professions and departments need to share information. Healthcare services also include support services, such as institutional food services, and health personnel and kitchen personnel need to share information about food and patients to serve food adapted to the patients' nutritional needs. Healthcare institutions mainly use formal information-sharing systems, but informal communication is considered more suitable for exchanging complex information. Physical and social proximity may facilitate informal information sharing across different professions and units. We aimed to develop and test an instrument for assessing health personnel's perceptions of physical and social proximity to, and information-sharing practices with, kitchen personnel and to describe associations between physical and social proximity and information-sharing practices. A survey questionnaire measuring proximity and information-sharing practices was developed and distributed to 368 health personnel. Scale analyses were performed to test the psychometric properties of the measures included in the questionnaire. MANOVA and regression analyses were run to assess associations between proximity and information-sharing practices. The results indicated reasonable validity of the measures, and both physical and social proximity were associated with increased informal information sharing.

Strategies for Incorporating Lifestyle Medicine in Everyday Hospital Practice

Cardiovascular disease and its associated risk factors such as hypertension, obesity, and diabetes are contributing to a large portion of morbidity, mortality, and health care costs in the United States. Diet and lifestyle education have been shown to be beneficial in reducing cost, mortality, and morbidity associated with these diseases. However, the lack of implementation of diet and lifestyle tools into clinical practices and into hospital systems leaves much room for improvement. Obstacles such as poor physician education, financial concerns, patient preference, and social resistance to change have made it difficult to promote healthy lifestyle and nutrition practices throughout all aspects of health systems. Some hospital systems and hospital-based clinical practices have had important successes in creating prevention clinic models, implementing plant-based menus in their hospital systems, and incorporating intensive rehabilitation programs that will pave the way for more future change. This review describes the current deficits, obstacles, and innovative strategies for implementing lifestyle medicine into hospital systems.

Lack of focus on nutrition and documentation in nursing homes, home care- and home nursing: the self-perceived views of the primary care workforce

Background

Malnutrition is a comprehensive challenge for the nursing home, home care- and home nursing sector. Nutritional care and the subsequent documentation are a common and multifaceted healthcare practice that requires that the healthcare professionals possess complex combinations of competencies in order to deliver high-quality care and treatment. The purpose of this study was to investigate how a varied group of healthcare professionals’ perceive their own competencies within nutrition and documentation and how organizational structures influence their daily work and the quality of care provided.

Methods

Two focus groups consisting of 14 healthcare professionals were conducted. The transcribed focus group interviews was analyzed using the qualitative content analysis approach.

Results

Six categories were identified: 1) Lack of uniform and systematic communication affect nutritional care practices 2) Experience-based knowledge among the primary workforce influences daily clinical decisions, 3) Different attitudes towards nutritional care lead to differences in the quality of care 4) Differences in organizational culture affect quality of care, 5) Lack of clear nutritional care responsibilities affect how daily care is performed and 6) Lack of clinical leadership and priorities makes nutritional care invisible.

Conclusions

The six categories revealed two explanatory themes: 1) Absent inter- and intra-professional collaboration and communication obstructs optimal clinical decision-making and 2) quality deterioration due to poorly-established nutritional care structure. Overall, the two themes explain that from the healthcare professionals’ point of view, a visible organization that allocates resources as well as prioritizing and articulating the need for daily nutritional care and documentation is a prerequisite for high-quality care and treatment. Furthermore, optimal clinical decision making among the healthcare professionals are compromised by imprecise and unclear language and terminology in the patients’ healthcare records and also a lack of clinical guidelines and standards for collaboration between different healthcare professionals working in nursing homes, home care or home nursing.

The findings of this study are beneficial to support organizations within these settings with strategies focusing on increasing nutritional care and documentation competencies among the healthcare professionals. Furthermore, the results advocate for the daily involvement and support of leaders and managers in articulating and structuring the importance of nutritional care and treatment and the subsequent documentation.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4450-1) contains supplementary material, which is available to authorized users.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Nutrition Status Related to Clinical Improvement in AFB-Positive Pulmonary Tuberculosis Patients in Primary Health Centres in Medan, Indonesia

BACKGROUND:

Tuberculosis (TB) remains a major public issue in Indonesia, including in North Sumatra province. Despite reported good efficacy of TB treatment in the region, the success of treatment depends on many factors, including nutritional status.

AIM:

To determine the relationship between Body Mass Index and Albumin level with sputum conversion in AFB-positive pulmonary TB patients.

METHODS:

The study was done in two primary health centres in Medan between October and November 2018. A total of 39 newly diagnosed TB patients with confirmed AFB-positive were included in the study. Participants received TB treatment according to the national guidelines.

RESULTS:

The proportion of participants with below normal, normal and above normal BMI status were 13 (33.3%), 21 (53.9%) and 5 (12.8%), respectively. Level of albumin was determined as normal in 25 participants (64.1%), and the remaining as low. Normal BMI status was significantly associated with increased albumin level (p < 0.05). At 2 months follow-up, the sputum conversion was observed in 24 individuals (61.5%), and the conversion was significantly associated with normal BMI and/or normal albumin level (p < 0.05).

CONCLUSION:

We concluded that nutritional status is an important factor in the success of TB treatment.

Are energy and protein requirements met in hospital?

BACKGROUND

Malnutrition is a problem within hospitals, which impacts upon clinical outcomes. The present audit assesses whether a hospital menu meets the energy and protein standards recommended by the British Dietetic Association's (BDA) Nutrition and Hydration Digest and determines the contribution of oral nutrition supplements (ONS) and additional snacks.

METHODS

Patients in a UK South West hospital were categorised as 'nutritionally well' or 'nutritionally vulnerable' in accordance with their Malnutrition Universal Screening Tool score. Energy and protein content of food selected from the menu ('menu choice'), menu food consumed ('hospital intake') and total food consumed including snacks ('overall intake') were calculated and compared with the standards.

RESULTS

In total, 93 patients were included. For 'nutritionally well' patients (n = 81), energy and protein standards were met by 11.1% and 33.3% ('menu choice'); 7.4% and 22.2% ('hospital intake'); and 14.8% and 28.4% ('overall intake'). For 'nutritionally vulnerable' patients (n = 12), energy and protein standards were met by 0% and 8.3% ('menu choice'); 0% and 8.3% ('hospital intake'); and 8.3% and 16.7% ('overall intake'). Ten percent of patients consumed ONS. Patients who consumed hospital snacks (34%) were more likely to meet the nutrient standards (P ≤ 0.001).

CONCLUSIONS

The present audit demonstrated that most patients are not meeting the nutrient standards recommended by the BDA Nutrition and Hydration Digest. Recommendations include the provision of energy/protein-dense snacks, as well as menu, offering ONS where clinically indicated, in addition to training for staff. A food services dietitian is ideally placed to lead this, forming a vital link between patients, caterers and clinical teams.

Effectiveness and efficacy of nutritional therapy: A systematic review following Cochrane methodology

BACKGROUND & AIMS

Disease-related malnutrition has deleterious consequences on patients' outcome and healthcare costs. The demonstration of improved outcome by appropriate nutritional management is on occasion difficult. The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed the Nutrition Education Study Group (ESPEN-NESG) to increase recognition of nutritional knowledge and support in health services.

METHODS

To obtain the best available evidence on the potential effects of malnutrition on morbidity, mortality and hospital stay; cost of malnutrition; effect of nutritional treatment on outcome parameters and pharmaco-economics of nutritional therapy, a systematic review of the literature was performed following Cochrane methodology, to answer the following key questions: Q1) Is malnutrition an independent predictive factor for readmission within 30 days from hospital discharge? Q2) Does nutritional therapy reduce the risk of readmission within 30 days from hospital discharge? Q3) Is nutritional therapy cost-effective/does it reduce costs in hospitalized patients? and Q4) Is nutritional therapy cost effective/does it reduce costs in outpatients?

RESULTS

For Q1 six of 15 identified observational studies indicated that malnutrition was predictive of re-admissions, whereas the remainder did not. For Q2 nine randomized controlled trials and two meta-analyses gave non-conclusive results whether re-admissions could be reduced by nutritional therapy. Economic benefit and cost-effectiveness of nutritional therapy was consistently reported in 16 identified studies for hospitalized patients (Q3), whereas the heterogeneous and limited corresponding data on out-patients (Q4) indicated cost-benefits in some selected sub-groups.

CONCLUSIONS

This result of this review supports the use of nutritional therapy to reduce healthcare costs, most evident from large, homogeneous studies. In general, reports are too heterogeneous and overall of limited quality for conclusions on impact of malnutrition and its treatment on readmissions.

Protein and energy intake improved by breakfast intervention in hospital

BACKGROUND/AIM

Undernutrition affects about 40% of patients in hospitals. Ordinary food is recommended as the first choice to prevent and correct undernutrition. Meanwhile, sufficient intake, especially regarding protein, is difficult to reach, in patients at nutritional risk. The aim of this study was to improve protein intake at breakfast to at least 20% of total daily requirement or at least 20 g.

METHODS

A protein rich breakfast including 20 g of protein was served in the departments of heart and lung surgery and vascular surgery for three months. Nutrition intake was registered before and after intervention.

RESULTS

Food intake records were collected from 32 and 30 patients respectively, mean age 69 (SD 8) years. At breakfast, protein intake was improved from 14% of individual requirements to 22% (p<0.001) and energy intake was improved from 18% to 25% (p=0.01). Total amount of protein intake for breakfast was increased from 14 g to 20 g (p<0.002). Total daily protein intake increased from 64% to 77% (p=0.05) and total energy intake from 76% to 99% (p<0.01) of requirements.

CONCLUSION

Protein and energy intake for surgical patients at breakfast as well as total daily intake was significantly increased to meet recommended average level for minimum individually measured requirements.

Selected nutrients and their implications for health and disease across the lifespan: a roadmap

Worldwide approximately two billion people have a diet insufficient in micronutrients. Even in the developed world, an increasing number of people consume nutrient-poor food on a regular basis. Recent surveys in Western countries consistently indicate inadequate intake of nutrients such as vitamins and minerals, compared to recommendations. The International Osteoporosis Foundation’s (IOF) latest figures show that globally about 88% of the population does not have an optimal vitamin D status. The Lancet’s “Global Burden of Disease Study 2010” demonstrates a continued growth in life expectancy for populations around the world; however, the last decade of life is often disabled by the burden of partly preventable health issues. Compelling evidence suggests that improving nutrition protects health, prevents disability, boosts economic productivity and saves lives. Investments to improve nutrition make a positive contribution to long-term national and global health, economic productivity and stability, and societal resilience.

Introducing the patient's perspective in hospital health technology assessment (HTA): the views of HTA producers, hospital managers and patients

BACKGROUND

The recent establishment of health technology assessment (HTA) units in University hospitals in the Province of Quebec (Canada) provides a unique opportunity to foster increased participation of patients in decisions regarding health technologies and interventions at the local level. However, little is known about factors that influence whether the patient's perspective is taken into consideration when such decisions are made.

OBJECTIVE

To explore the practices, perceptions and views of the various HTA stakeholders concerning patient involvement in HTA at the local level.

METHOD

Data were collected using semi-structured interviews with 24 HTA producers and hospital managers and two focus groups with a total of 13 patient representatives.

RESULTS

Patient representatives generally showed considerable interest in being involved in HTA. Our findings support the hypothesis that the patient perspective contributes to a more accurate and contextualized assessment of health technologies and produces HTA reports that are more useful for decision makers. They also suggest that participation throughout the assessment process could empower patients and improve their knowledge. Barriers to patient involvement in HTA at the local level are also discussed as well as potential strategies to overcome them.

DISCUSSION AND CONCLUSION

This study contributes to knowledge that could guide interventions in favour of patient participation in HTA activities at the local level. Experimenting with different patient involvement strategies and assessing their impact is needed to provide evidence that will inform future interventions of this kind.

[Hospital food: proposals for qualification of the Food and Nutrition Service, evaluated by the scientific community]

The scope of this paper is to validate proposals used to qualify hospital food by the Brazilian scientific community. An electronic questionnaire was applied to clinical nutrition professionals registered on the Lattes Platform (Brazilian database of institutions and researchers' curricula in the areas of Science and Technology). The questionnaire incorporated a Likert scale and had spaces for comments. The themes dealt with patient participation, the nutritional and sensory quality of hospital diets, and planning and goals of the Hospital Food and Nutrition Service (HFNS). The questionnaire also asked for the top five priorities for a HFNS. Proposals with total or partial adherence equal to or greater than 70% were considered to be approved. All proposals had total adherence equal to or greater than 70%. The proposal that had minimal adherence (70%) was the one that proposed that nutritional intervention must be arranged by mutual agreement with the patient. The proposal that had maximal adherence (93%) was the one advocating that there must be statistical control on diets prescribed by the HFNS. The most cited priorities referred to infrastructure and training of human resources (40%), the quality of hospital food (27%) and the nutritional status of the patient.

Introducing patients' and the public's perspectives to health technology assessment: A systematic review of international experiences

Objectives:The aim of this study was to review international experiences of patient or public involvement in the field of health technology assessment (HTA).

Methods:A systematic review of the scientific literature was conducted. A literature search was performed across nine databases. Other literature was identified through citation tracking, government websites (HTA agencies), and Internet search engines. Characteristics of the studies, description of the activities related to patient or public involvement, impact of these activities on the HTA process, and factors facilitating or limiting involvement were abstracted independently by two reviewers.

Results:A total of 1,441 potentially relevant papers were identified by the main search strategy. Among these, seventeen papers met the inclusion criteria; other search strategies identified seven additional documents. The findings reveal that patient or public involvement in HTA activities was reported in two domains, research and HTA process. In the research domain, patients are consulted to gather evidence about their perspectives, experiences, or preferences about a health technology. These perspectives could add key dimensions to the evaluation of health technologies that might otherwise be overlooked. In the domain of the HTA process, patients or public representatives participate in different stages of this process: prioritization, evidence assessment, or dissemination of findings.

Conclusions:There are few published examples of experiences involving patients and the public in HTA. These examples show that patients' or the public's perspectives could add important dimensions to the evaluation of health technologies. However, there is a need to develop more systematic approaches to considering patients' and the public's perspectives in HTA.

A review of the evidence for the impact of improving nutritional care on nutritional and clinical outcomes and cost

BACKGROUND

The association between malnutrition and poor clinical outcome is well-established, yet most research has focussed on the role of artificial nutritional support in its management. More recently, emphasis has been placed on the provision of adequate nutritional care, including nutritional screening and the routine provision of food and drink. The aim of this literature review is to establish the evidence for the efficacy of interventions that might result in improvements in nutritional and clinical outcomes and costs.

METHODS

A structured literature review was conducted investigating the role of nutritional care interventions in adults, and their effects on nutritional and clinical outcomes and costs, in all healthcare settings. Ten databases were searched electronically using keywords relating to nutritional care, patient outcomes and healthcare costs. High quality trials were included where available.

RESULTS

Two hundred and ninety-seven papers were identified and reviewed. Of these, only two randomised, controlled trials and six other trials were identified that addressed the major issues. A further 99 addressed some aspects of the provision of nutritional care, although very few formally evaluated nutritional or clinical outcomes and costs.

CONCLUSIONS

This review reveals a serious lack of evidence to support interventions designed to improve nutritional care, in particular with reference to their effects on nutritional and clinical outcomes and costs. The review suggests that screening alone may be insufficient to achieve beneficial effects and thus more research is required to determine the most cost-effective interventions in each part of the nutritional care pathway, in a variety of healthcare settings and across all age ranges, to impact upon nutritional and clinical outcomes.

Effect of changed organisation of nutritional care of Danish medical inpatients

Background

Many patients are undernourished during hospitalisation. The clinical consequences of this include lassitude, an increased risk of complications and prolonged convalescence. The aim of the study is 1) to implement a new organisation with a focus on improving the quality of the nutritional care of medical inpatients at risk of undernutrition, and 2) to investigate the effect of the intervention.

Methods

Social and healthcare assistants are educated to the higher level of nutritional and healthcare assistants to provide nutritional care in daily practice to undernourished medical inpatients. The effect of the intervention is investigated before and five months after the employment of the nutritional and healthcare assistants. Data are obtained from structured interviews with patients and staff, and the amount of ordered and wasted food is recorded.

Results

Patients regard the work of the nutritional and healthcare assistant as very important for their recovery and weight gain: the assistant takes care of the individual patient's nutritional requirements and wishes, and she imparts knowledge to the patient about optimum nutrition. Staff members benefit from the knowledge and dedication of the nutritional and healthcare assistant and from her work; the staff is often too busy with other nursing tasks to make it a priority to ensure that patients who are nibblers get sufficient nutrition. The choices of food from the production kitchen are utilised to a higher degree, and more of the food is eaten by the patients. Before the intervention, a 20% increase in ordered food in relation to the food budget is found. During the intervention a 20% decrease in ordered food in relation to the food budget is found, and food wastage decreases from 55% to 18% owing to the intervention.

Conclusion

The job function of the nutritional and healthcare assistants on the medical wards is of great value to patients, nursing staff members and the production kitchen. The quality of the nutritional care of undernourished patients increases significantly, and a considerable optimisation of resources in the production and ordering of food takes place. Hospitals can benefit from implementation of the present organisational model if they focus on improving the quality of the nutritional care of weak and elderly inpatients and on optimisating the use of resources.

Do recommendations for institutional food service result in better food service? A study of compliance in Danish hospitals and nursing homes from 1995 to 2002-2003

BACKGROUND

Since 1995, significant efforts by authorities and researchers have been directed towards addressing the nutritional problems in Danish hospitals and nursing homes.

AIM

The purpose of this study was to investigate whether the increased focus on nutritional problems in patients and nursing home residents has resulted in measurable progress.

DESIGN

A questionnaire-based study was carried out among foodservice managers in Danish hospitals (n=96) and nursing homes (n=898) in 1995 and 2002/3 (n=90) and (n=682), respectively. The study used compliance with selected issues in the official Danish recommendations for institutional food service as an indicator for progress. The issues included: using nutrient calculated recipes/menus, offering menu choice options, using feedback routines on acceptability of menus, maintaining nutritional steering committees, employing food and nutrition contact persons, employing official recommendations and offering choice between three different menu energy levels.

RESULTS

Hospitals had a higher compliance compared to nursing homes. In 1995, this was the case for all questions asked and differences were statistically significant. Also in 2002/3, hospitals had a higher compliance, except in the case of established feedback routines. Differences were statistically significant. The results indicate that nutritional care is higher on the agenda in hospital, than in nursing homes. However, very little progress can be seen in compliance when results are analysed over the 8-year period. The only progress for nursing homes was that more homes had implemented feedback routines on acceptability of food service in 2002/3 than in 1995. The difference was statistically significant. For hospitals, however, no progress was found between 1995 and 2002/3.

CONCLUSION

The attempts to improve the nutritional status of hospital patients and nursing home residents seem to have failed. Still, the initiatives taken to improve the situation seem relevant. Especially the nursing homes might benefit from advantage of these experiences.