Update on the Integrated Nutrition Pathway for Acute Care (INPAC): post implementation tailoring and toolkit to support practice improvements

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

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

Development of the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC) using a modified Delphi technique

One in three hospitalized children have disease-related malnutrition (DRM) upon admission to hospital, and all children are at risk for further nutritional deterioration during hospital stay; however, systematic approaches to detect DRM in Canada are lacking. To standardise and improve hospital care, the multidisciplinary pediatric working group of the Canadian Malnutrition Taskforce aimed to develop a pediatric, inpatient nutritional care pathway based on available evidence, feasibility of resources, and expert consensus. The working group (n = 13) undertook a total of four meetings: an in-person meeting to draft the pathway based on existing literature and modelled after the Integrated Nutrition Pathway for Acute Care (INPAC) in adults, followed by three online surveys and three rounds of online Delphi consensus meetings to achieve agreement on the draft pathway. In the first Delphi survey, 32 questions were asked, whereas in the second and third rounds 27 and 8 questions were asked, respectively. Consensus was defined as any question/issue in which at least 80% agreed. The modified Delphi process allowed the development of an evidence-informed, consensus-based pathway for inpatients, the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC). It includes screening <24 h of admission, assessment with use of Subjective Global Nutritional Assessment (SGNA) <48 h of admission, as well as prevention, and treatment of DRM divided into standard, advanced, and specialized nutrition care plans. Research is necessary to explore feasibility of implementation and evaluate the effectiveness by integrating P-INPAC into clinical practice.

Malnutrition risk, outcomes, and costs among older adults undergoing elective surgical procedures: A retrospective cohort study

BACKGROUND

We examine here the association between malnutrition risk and adverse health outcomes among older adult patients undergoing elective surgical procedures.

METHODS

We conducted a retrospective study using linked clinical and administrative databases. Malnutrition risk was assessed prior to surgery, defined by unintentional weight loss and decreased food intake. We performed a logistic regression analysis of the primary outcome, a composite adverse outcome measure, including death, bleeding, pneumonia, and other surgical complications. We conducted Fine-Gray proportional hazard regression analysis of hospital length of stay (LOS). We performed a generalized linear regression analysis of in-hospital cost data. All regression analyses controlled for frailty, age, sex, surgical category, and comorbidities.

RESULTS

Of a total of 3457 older adult elective surgical patients (65-102 years), 310 (9.0%) screened positive for malnutrition risk. In multivariable regression analyses, malnutrition risk was associated with an increased risk of the composite adverse outcome (odds ratio [OR] = 1.74; 95% CI = 1.25-2.39), higher hospitalization costs (relative cost = 1.84; 95% CI = 1.59-2.13), and a decreased risk of discharge from the hospital (hazard ratio = 0.67; 95% CI = 0.59-0.77) compared with those who screened negative.

CONCLUSION

Older adult patients with malnutrition risk were at an increased risk of adverse surgical outcomes, had longer LOS in the hospital, and incurred higher costs of care. It is important to screen for malnutrition risk and refer older adults for dietetic consults prior to elective surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Healthcare providers' knowledge, attitude, and practice on quality of nutrition care in hospitals from a developing country: a multicenter experience

BACKGROUND

Despite the fact that malnutrition can affect both recovery and outcome in acute care patients, little is known about malnutrition in Palestine, and even less is known about the assessment of malnutrition knowledge, attitudes, and practices (M-KAP) toward healthcare providers and nutrition care quality measures in hospitalized patients. Therefore, this study aimed to evaluate the M-KAP of physicians and nurses in routine clinical care and determine the influencing factors.

METHODS

From April 1 to June 31, 2019, cross-sectional research was performed at governmental (n = 5) and non-governmental (n = 4) hospitals in the North West Bank of Palestine. Data were collected using a structured self-administered questionnaire from physicians and nurses to collect information on knowledge, attitude, and practices related to malnutrition and nutrition care, alongside sociodemographic characteristics.

RESULTS

A total of 405 physicians and nurses were participated in the study. Only 56% of participants strongly agreed that nutrition was important, only 27% strongly agreed that there should be nutrition screening, only 25% felt food helped with recovery, and around 12% felt nutrition as part of their job. Approximately 70% of participants said they should refer to a dietitian, but only 23% knew how and only 13% knew when. The median knowledge/attitude score was 71, with an IQR ranging from 65.00 to 75.00, and the median practice score was 15.00 with an IQR of 13.00-18.00. The mean knowledge attitude practice score was 85.62 out of 128 with SD (9.50). Respondents who worked in non-governmental hospitals showed higher practice scores (p < 0.05), while staff nurses and ICU workers showed the highest practice score (p < 0.001). Respondents with younger age categories, working in non-governmental hospitals in the ICU as practical and staff nurses, showed the highest KAP score (p < 0.05). Significance positive correlations were found between respondents' knowledge/attitude and practice scores regarding the quality of nutrition care in hospitals (r = 0.384, p value < 0.05). In addition, the result also revealed that almost half of respondents believed that the most important barriers to inadequate intake of food at the bedside are related to food appearance, taste, and aroma of meals served (58.0%).

CONCLUSIONS

The research revealed that inadequate knowledge was perceived as a barrier to effective nutrition care to the patient. Many beliefs and attitudes do not always translate into practice. Although the M-KAP of physicians and nurses is lower than in some other countries/studies, it highlights a strong need for more nutrition professionals in the hospital and increasing nutrition education to improve nutrition care in hospitals in Palestine. Furthermore, establishing a nutrition task force in hospitals elaborated by dietitians as the unique nutrition care provider will assure to implementation of a standardized nutrition care process.

Demystifying Malnutrition to Improve Nutrition Screening and Assessment in Oncology

OBJECTIVE

Patients with cancer and malnutrition are more likely to experience poor treatment tolerance, prolonged length of hospital stay, and decreased quality of life. Early and sustained nutrition risk screening is the first step to tackling this patient and health care burden. Yet, malnutrition remains largely overlooked and undertreated. Malnutrition mismanagement could be indicative of a systemic misunderstanding. With this narrative review, we aimed to (1) define malnutrition, (2) address common malnutrition misconceptions, and (3) summarize nutrition recommendations for patients with cancer.

DATA SOURCES

PubMed and international clinical practice guidelines were used.

CONCLUSION

Malnutrition represents an unbalanced nutritional state that alters body composition and diminishes function. Malnutrition is not always physically obvious, and albumin is not a reliable marker of nutritional status; therefore, systematically screening all patients with a validated nutrition risk screening tool at time of cancer diagnosis, and periodically throughout treatment, is necessary to provide optimal, equitable care. Nutrition risk screening takes less than 1 minute to complete and can be completed by any health care professional. Patients that screen positive for nutrition risk should be referred to a registered nutritionist or dietitian for comprehensive nutritional assessment, diagnosis, and treatment.

IMPLICATIONS FOR NURSING PRACTICE

All health care professionals can and should be responsible for preventing and treating malnutrition. Registered nurses can actively participate in improving patient outcomes by screening patients for nutrition risk, weighing patients at every visit, referring patients to dietitians for nutrition treatment, and providing supportive medical management of nutrition impact symptoms such as nausea.

Dietitians’ Perspectives on the Coordination and Continuity of Nutrition Care for Malnourished or Frail Clients: A Qualitative Study

Malnutrition and frailty are common conditions that impact overall health and function. There is limited research exploring the barriers and enablers to providing coordinated nutrition care to malnourished or frail clients in the community (including transitions from hospital). This study aimed to explore dietitians’ experiences and perspectives on providing coordinated nutrition care for frail and malnourished clients identified in the community or being discharged from hospital. Semi-structured interviews with clinical/acute, community, and aged care dietitians across Australia and New Zealand were conducted. Interviews were 23–61 min long, audio recorded and transcribed verbatim. Data were analysed using inductive thematic analysis. Eighteen dietitians participated in interviews, including five clinical, eleven community, and two residential aged care dietitians. Three themes, describing key factors influencing the transition and coordination of nutrition care, emerged from the analysis: (i) referral and discharge planning practices, processes, and quality; (ii) dynamics and functions within the multidisciplinary team; and (iii) availability of community nutrition services. Guidelines advising on referral pathways for malnourished/frail clients, improved communication between acute and community dietitians and within the multidisciplinary team, and solutions for community dietetic resource shortages are required to improve the delivery of coordinated nutrition care to at-risk clients.

Update to the pediatric Subjective Global Nutritional Assessment (SGNA)

Lack of a standardized method of identifying and defining pediatric malnutrition has led to an inability to fully understand the prevalence of and impact that malnutrition has on pediatric patients and the healthcare system. The Subjective Global Nutritional Assessment (SGNA) is an assessment tool meant to determine presence and severity of malnutrition in pediatric populations. However, the anthropometric section of the tool contains some out-dated parameters. This has limited its clinical practicality. The aim of this paper is to propose updates to the anthropometrics section of the SGNA. A retrospective analysis of 153 SGNA's performed on children aged 1 month to 16 years was completed, comparing the original SGNA results to SGNA results incorporating updated anthropometric parameters for percentiles and ideal body weight. The category of length/height for age was updated to include z score cutoffs rather than percentiles, and ideal body weight was updated to z scores for weight for length or body mass index (BMI). Two serial growth questions were updated in wording only, to reflect z score trends. The results of the analysis showed these updates would have changed the rankings of eight patients (5%) for length/height for age, and 20 patients (13%) for ideal body weight to weight for length or BMI. Adjustments to these questions did not impact the overall SGNA rating. This study shows updates to the SGNA are not expected to have a significant impact on the validity of the tool and has the potential to improve its applicability to current day practice.

The role of trained champions in sustaining and spreading nutrition care improvements in hospital: qualitative interviews following an implementation study

BACKGROUND

Many patients are already malnourished when admitted to hospital. Barriers and facilitators to nutrition care in hospital have been identified and successful interventions developed; however, few studies have explored how to sustain and spread improvements. The More-2-Eat phase 1 study involved five hospitals across Canada implementing nutrition care improvements, while phase 2 implemented a scalable model using trained champions, audit and feedback, a community of practice with external mentorship and an implementation toolkit in 10 hospitals (four continuing from phase 1). Process measures showed that screening and assessment from phase 1 were sustained for at least 4 years. The objective of this study was to help explain how these nutrition care improvements were sustained and spread by understanding the role of the trained champions, and to confirm and expand on themes identified in phase 1.

METHODS

Semistructured telephone interviews were conducted with champions from each phase 2 hospital and recordings transcribed verbatim. To explore the champion role, transcripts were deductively coded to the 3C model of Concept, Competence and Capacity. Phase 2 transcripts were also deductively coded to themes identified in phase 1 interviews and focus groups.

RESULTS

Ten interviews (n=14 champions) were conducted. To sustain and spread nutrition care improvements, champions needed to understand the Concepts of change management, implementation, adaptation, sustainability and spread in order to embed changes into routine practice. Champions also needed the Competence, including the skills to identify, support and empower new champions, thus sharing the responsibility. Capacity, including time, resources and leadership support, was the most important facilitator for staying engaged, and the most challenging. All themes identified in qualitative interviews in phase 1 were applicable 4 years later and were mentioned by new phase 2 hospitals. There was increased emphasis on audit and feedback, and the need for standardisation to support embedding into current practice.

CONCLUSION

Trained local champions were required for implementation. By understanding key concepts, with appropriate and evolving competence and capacity, champions supported sustainability and spread of nutrition care improvements. Understanding the role of champions in supporting implementation, spread and sustainability of nutrition care improvements can help other hospitals when planning for and implementing these improvements.

TRIAL REGISTRATION NUMBER

NCT02800304, NCT03391752.

Safety and impact of peripheral parenteral nutrition on nutrient delivery in patients with nutrition risk: A prospective observational study

BACKGROUND

Malnutrition is common in hospitalized patients and strategies to improve energy and protein intake have a positive impact on outcome. Despite early evidence suggesting the usefulness of peripheral parenteral nutrition (PPN), its adoption has been hampered by concerns regarding safety and efficacy. This study addresses this issue.

METHODS

This prospective observational study was performed in medical and surgical inpatients in who were screened for nutrition risk and assessed using Subjective Global Assessment (SGA). Data captured included nutrition status, energy and protein requirements, intravenous access, indications for PPN, use of supplemental micronutrients, and disposition of patients on PPN.

RESULTS

Ninety-eight patients were recruited from two centers over 8 months. The average age was 61.5 years, the mean Charlson Comorbidity Index was 4.21 (±3.09), 52% were male, and 48% were admitted to medicine, whereas 52% were admitted to surgery. Thirty-three percent of patients were SGA C, 44% were SGA B, and 19% were SGA A. Twenty-seven percent of patients had cancer. The average length of hospital stay was 22 days. The main indications for PPN were gastrointestinal tract dysfunction (72%) and postsurgical status (16%). PPN provided an average of 1296 kcal (±191) and 46 g of protein (±7). Intravenous access complications in patients receiving PPN did not occur in excess of expected. Almost 40% of patients required transition to central PN.

CONCLUSIONS

PPN is a safe, effective way to deliver supplemental protein, energy, and micronutrients to malnourished patients and supports transition to other modes of nutrition care.

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

AIM

Models of hospital malnutrition care reliant on dietitians can be inefficient and of limited effectiveness. This study evaluated whether implementing the Systematised, Interdisciplinary Malnutrition Program for impLementation and Evaluation (SIMPLE) improved hospital nutrition care processes and patientreported experiences compared with traditional practice.

METHODS

A multi-site (five hospitals) prospective, pre-post study evaluated the facilitated implementation of SIMPLE, a malnutrition care pathway promoting proactive nutrition support delivered from time of malnutrition screening by the interdisciplinary team, without need for prior dietetic assessment. Implementation was tailored to local site needs and resources. Nutrition care processes delivered to inpatients who were malnourished or at-risk of malnutrition were identified across diagnosis, intervention, and monitoring domains using standardised audits from medical records, foodservice systems and patient-reported nutrition experience measures.

RESULTS

Pre-implementation (n = 365) and post-implementation (n = 397) cohorts were similar for age (74 vs 73 years), gender (47.1% vs 48.6% female), and nutrition risk status (46.6% vs 45.3% at-risk). Post-implementation, at-risk participants were more likely to receive enhanced food and fluids (68.5% vs 83.9%; P < .01), nutrition information (30.9% vs 47.2%; P < .01), mealtime assistance where required (61.4% vs 77.9% P = .04), nutrition monitoring (25.2% vs 46.3%; P < .01) and care planning (17.8% vs 27.7%; P = .01). Patient-reported nutrition experience measures confirmed improved nutrition care. There was no difference in dietetic occasions of service per patient (1.51 vs 1.25; P = .83).

CONCLUSIONS

Tailored SIMPLE implementation improves nutrition care processes and patient reported nutrition experience measures for at-risk inpatients within existing dietetic resources.

Consensus-Based Nutrition Care Pathways for Hospital-to-Community Transitions and Older Adults in Primary and Community Care

BACKGROUND

Practical guidance for providers on preventing, detecting, and treating malnutrition in primary care (PC) and the community is limited. The purpose of this study was to develop nutrition care pathways for adult patients (aged ≥18 years) transitioning from hospital to community and community-dwelling older adults (aged ≥65 years) who are at risk for malnutrition.

METHODS

A review of best-practice nutrition evidence and guidelines published between 2009 and 2019 was performed using PubMed and CINAHL. Findings were summarized into two draft care pathways by the Primary Care Working Group of the Canadian Malnutrition Task Force. Diverse stakeholders (n = 21) reviewed and suggested revisions at a 1-day meeting. Revisions were made and an online survey was conducted to determine the relevance and importance of discrete care practices, and to establish consensus for which practices should be retained in the pathways. Providers (e.g., dietitians, physicians, nurses; n = 291) across healthcare settings completed the survey. Consensus on relevance and importance of practices was set at ≥80%.

RESULTS

One hundred twenty-eight resources were identified and used to develop the draft pathways. Survey participants assigned ratings of ≥80% for relevance and importance for all nutrition care practices, except community service providers monitoring patient weight and appetite.

CONCLUSION

These evidence- and consensus-based nutrition pathways offer guidance to healthcare and service providers on how to deliver nutrition care during hospital-to-community transitions for malnourished adult patients and community-dwelling older adults at risk for malnutrition. These pathways are flexible for diverse PC and community models.

Nutritional Care of the Older Patient with Fragility Fracture: Opportunities for Systematised, Interdisciplinary Approaches Across Acute Care, Rehabilitation and Secondary Prevention Settings

Nutritional care of the older patient with fragility fracture is complex. Diagnostic difficulties, multi-morbidities and interdependencies and social complexities all contribute to the wicked problem of malnutrition. Whilst many settings have attempted to address malnutrition through highly specialised care, increasing evidence supports the role of systematised, interdisciplinary approaches across acute care, rehabilitation and secondary prevention settings. Consequently, this chapter is devoted to highlighting why a SIMPLE approach to malnutrition should underpin the nutritional care of the older patient with fragility fracture, regardless of setting or healthcare provider.

S Screen for nutrition risk

I Interdisciplinary assessment

M Make the diagnosis (es)

P Plan with the patient

L impLement interventions

E Evaluate ongoing care requirements

Trends and Novel Research in Hospital Nutrition Care: A Narrative Review of Leading Clinical Nutrition Journals

Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.

The Role of Preoperative Parenteral Nutrition

Malnutrition is associated with poor surgical outcomes, and therefore optimizing nutritional status preoperatively is very important. The purpose of this paper is to review the literature related to preoperative parenteral nutrition (PN) and to provide current evidence based guidance. A systemic online search of PubMed, Medline, and Cochrane Databases from January 1990 to February 2020 was done. Sixteen studies were included in this narrative review, including four meta-analyses and twelve clinical trials. The majority of studies have demonstrated benefits of preoperative PN on postoperative outcomes, including reduced postoperative complications (8/10 studies) and postoperative length of stay (3/4 studies). Preoperative PN is indicated in malnourished surgical patients who cannot achieve adequate nutrient intake by oral or enteral nutrition. It can be seen that most studies showing benefits of preoperative PN often included patients with upper gastrointestinal cancer and inflammatory bowel disease (10/12 studies), which gastrointestinal problems are commonly seen and enteral nutrition may be not feasible. When preoperative PN is indicated, adequate energy and protein should be provided, and patients should receive at least seven days of PN prior to surgery. The goal of preoperative PN is not weight regain, but rather repletion of energy, protein, micronutrients, and glycogen stores. Complications associated with preoperative PN are rarely seen in previous studies. In order to prevent and mitigate the potential complications such as refeeding syndrome, optimal monitoring and early management of micronutrient deficiencies is required.

Perceptions on Use of the Subjective Global Assessment Before and After It Became Part of Regular Practice

BACKGROUND

Subjective global assessment (SGA) is a standardized diagnostic tool for malnutrition and identifies those who would benefit from nutrition treatment. SGA has been validated in several patient populations; however, implementation in clinical practice is inconsistent. The objective of this study was to understand and contrast the perceptions on use of SGA before and after it became a regular practice for hospital dietitians.

METHODS

The More-2-Eat implementation project provided the opportunity to undertake this qualitative study, as 5 hospitals adopted INPAC (Integrated Nutrition Pathway for Acute Care), which includes the use of SGA. Between 2015 and 2018, interviews were conducted with dietitians at baseline (n = 9), a year after implementation (n = 18), and a year after project completion (n = 6). Thematic analysis was conducted.

RESULTS

Themes before SGA adoption included a desire for a malnutrition diagnosis and care planning; lacking comfort in use of SGA; and reflecting on SGA training needs. After a year of implementing INPAC and a year after project completion, themes described becoming a better clinician; allowing dietitians to see the right people, sooner; recognizing the variability in the treatment path for mildly/moderately malnourished (SGA B) patients; improving overall efficiency in delivery of care; and establishing policy and procedures to sustain and spread use of SGA.

CONCLUSION

Initially, dietitians were hesitant to use SGA. Adoption through a focused implementation study and experience with implementation of SGA changed these perceptions. Understanding these perceptions before and after use may support adoption of this useful diagnostic tool.

The Sustain and Spread Framework: strategies for sustaining and spreading nutrition care improvements in acute care based on thematic analysis from the More-2-Eat study

BACKGROUND

Successful improvements in health care practice need to be sustained and spread to have maximum benefit. The rationale for embedding sustainability from the beginning of implementation is well recognized; however, strategies to sustain and spread successful initiatives are less clearly described. The aim of this study is to identify strategies used by hospital staff and management to sustain and spread successful nutrition care improvements in Canadian hospitals.

METHODS

The More-2-Eat project used participatory action research to improve nutrition care practices. Five hospital units in four Canadian provinces had one year to improve the detection, treatment, and monitoring of malnourished patients. Each hospital had a champion and interdisciplinary site implementation team to drive changes. After the year (2016) of implementing new practices, site visits were completed at each hospital to conduct key informant interviews (n = 45), small group discussions (4 groups; n = 10), and focus groups (FG) (11 FG; n = 71) (total n = 126) with staff and management to identify enablers and barriers to implementing and sustaining the initiative. A year after project completion (early 2018) another round of interviews (n = 12) were conducted to further understand sustaining and spreading the initiative to other units or hospitals. Verbatim transcription was completed for interviews. Thematic analysis of interview transcripts, FG notes, and context memos was completed.

RESULTS

After implementation, sites described a culture change with respect to nutrition care, where new activities were viewed as the expected norm and best practice. Strategies to sustain changes included: maintaining the new routine; building intrinsic motivation; continuing to collect and report data; and engaging new staff and management. Strategies to spread included: being responsive to opportunities; considering local context and readiness; and making it easy to spread. Strategies that supported both sustaining and spreading included: being and staying visible; and maintaining roles and supporting new champions.

CONCLUSIONS

The More-2-Eat project led to a culture of nutrition care that encouraged lasting positive impact on patient care. Strategies to spread and sustain these improvements are summarized in the Sustain and Spread Framework, which has potential for use in other settings and implementation initiatives.

TRIAL REGISTRATION

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

Impact of Facilitated Behavior Change Strategies on Food Intake Monitoring and Body Weight Measurements in Acute Care: Case Examples From the More-2-Eat Study

BACKGROUND

Assessing and monitoring food intake and body weight of all hospital patients is considered part of "best practice" nutrition care. This study presents case examples describing the impact of behavior change strategies on embedding these 2 monitoring processes in hospitals.

METHODS

Four hospital medical units that participated in the More-2-Eat implementation study to improve nutrition care focused on improving food intake and/or weight monitoring practices. The percentage of admitted patients who received these care practices were tracked through chart audits over 18 months. Implementation progress and behavior change strategies were documented through interviews, focus groups, scorecards, and monthly telephone calls. Case examples are explored using mixed methods.

RESULTS

Of the 4 units, 3 implemented food intake monitoring. One provided food service workers the opportunity to record food intake, with low intake discussed by an interdisciplinary team during bedside rounds (increased from 0% to 97%). Another went from 0% to 61% of patients monitored by introducing a new form ("environmental restructuring") reminding staff to ask patients about low intake. A third unit increased motivation to improve documentation of low intake and improved from 3% to 95%. Two units focused on regularity of body weight measurement. One unit encouraged a team approach and introduced 2 weigh days/week (improved from 14% to 63%), while another increased opportunity by having all patients weighed on Saturdays (improved from 11% to 49%).

CONCLUSION

Difficult-to-change nutrition care practices can be implemented using diverse and ongoing behavior change strategies, staff input, a champion, and an interdisciplinary team.