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Ten Cate D, Dikken J, Ettema RGA, Schoonhoven L, Schuurmans MJ. Development of a microlearning intervention regarding nursing nutritional care for older adults: A multi-methods study. NURSE EDUCATION TODAY 2023; 120:105623. [PMID: 36459951 DOI: 10.1016/j.nedt.2022.105623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 09/18/2022] [Accepted: 11/03/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Nutritional care for older adults provided by hospital and home care nurses and nursing assistants is suboptimal. This is due to several factors including professionals' lack of knowledge and low prioritisation. Affecting these factors may promote nurses' and nursing assistants' behavioral change and eventually improve nutritional care. To increase the likelihood of successfully targeting these factors, an evidence-based educational intervention is needed. OBJECTIVES To develop an educational intervention for hospital and home care nurses and nursing assistants to promote behaviour change by affecting factors that influence current behaviour in nutritional care for older adults. In this paper, we describe the intervention development process. DESIGN A multi-methods approach using literature and expert input. SETTINGS Hospital and home care. PARTICIPANTS Older adults, nurses, nursing assistants, experts, and other professionals involved in nutritional care. METHODS The educational intervention was based on five principles: 1) interaction between intervention and users, 2) targeting users on both individual and team level, 3) supporting direct and easy transfer to the workplace, and continuous learning, 4) facilitating learning within an appropriate period, and 5) fitting with the context. Consistent with these principles, the research team focussed on developing a microlearning intervention and they established consensus on seven features of the intervention: content, provider, mode of delivery, setting, recipient, intensity, and duration. RESULTS The intervention consisted of 30 statements about nursing nutritional care for older adults, which nurses and nursing assistants were asked to confirm or reject, followed by corresponding explanations. These can be presented in a snack-sized way, this means one statement per day, five times a week over a period of six weeks through an online platform. CONCLUSIONS Based on a well-founded and comprehensive procedure, the microlearning intervention was developed. This intervention has the potential to contribute to nursing nutritional care for older adults.
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Affiliation(s)
- Debbie Ten Cate
- Research Group Proactive Care for Older People, Utrecht University of Applied Sciences, Heidelberglaan 7, 3584 CS Utrecht, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands.
| | - Jeroen Dikken
- Faculty of Health, Nutrition and Sport, The Hague University of Applied Sciences, Johanna Westerdijkplein 75, 2521 EN The Hague, the Netherlands.
| | - Roelof G A Ettema
- Research Group Personalized Integrated Care, Institute for Nursing Studies, Utrecht University of Applied Sciences, Heidelberglaan 7, 3584 CS Utrecht, the Netherlands.
| | - Lisette Schoonhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, University Road, Southampton SO17 1BJ, United Kingdom.
| | - Marieke J Schuurmans
- Education Center, UMC Utrecht Academy, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands.
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Ford KL, Prado CM, Weimann A, Schuetz P, Lobo DN. Unresolved issues in perioperative nutrition: A narrative review. Clin Nutr 2022; 41:1578-1590. [PMID: 35667274 DOI: 10.1016/j.clnu.2022.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 12/23/2022]
Abstract
Surgical patients are at an increased risk of negative outcomes if they are malnourished or at risk of malnutrition preoperatively. Optimisation of nutritional status should be a focus throughout the perioperative continuum to promote improved surgical outcomes. Enhanced Recovery after Surgery (ERAS) protocols are increasingly applied in the surgical setting but are not yet widespread. This narrative review focused on areas of perioperative nutrition that are perceived as controversial or are lacking in agreement. A search for available literature was conducted on 1 March 2022 and relevant high-quality articles published since 2015 were considered for inclusion. Most malnutrition screening tools are not specific to the surgical population except for the Perioperative Nutrition Screen (PONS) although more large-scale initiatives are needed to improve the prevalence of preoperative nutrition screening. Poor muscle health is common in patients with malnutrition and further exacerbates negative health outcomes indicating that prevention, detection and treatment is of high importance in this population. Although a lack of consensus remains for who should receive preoperative nutritional therapy, evidence suggests a positive impact on muscle health. Additionally, postoperative nutritional support benefits surgical outcomes, with some patients requiring enteral and/or parenteral feeding routes and showing benefit from immunonutrition. The importance of nutrition extends beyond the time in hospital and should remain a priority post-discharge. The impact of individual or personalised nutrition based on select patient characteristics remains to be further investigated. Overall, the importance of perioperative nutrition is evident in the literature despite select ongoing areas of contention.
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Affiliation(s)
- Katherine L Ford
- Human Nutrition Research Unit, Department of Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, Canada
| | - Carla M Prado
- Human Nutrition Research Unit, Department of Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, Canada
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Leipzig, Germany
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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Barriers and Enablers to Delegating Malnutrition Care Activities to Dietitian Assistants. Nutrients 2022; 14:nu14051037. [PMID: 35268008 PMCID: PMC8912543 DOI: 10.3390/nu14051037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 01/27/2023] Open
Abstract
Delegation of malnutrition care to dietitian assistants can positively influence patient, healthcare, and workforce outcomes. However, nutrition care for hospital inpatients with or at risk of malnutrition remains primarily individually delivered by dietitians—an approach that is not considered sustainable. This study aimed to identify barriers and enablers to delegating malnutrition care activities to dietitian assistants. This qualitative descriptive study was nested within a broader quality assurance activity to scale and spread systematised and interdisciplinary malnutrition models of care. Twenty-three individual semi-structured interviews were completed with nutrition and dietetic team members across seven hospitals. Inductive thematic analysis was undertaken, and barriers and enablers to delegation of malnutrition care to dietitian assistants were grouped into four themes: working with the human factors; balancing value and risk of delegation; creating competence, capability, and capacity; and recognizing contextual factors. This study highlights novel insights into barriers and enablers to delegating malnutrition care to dietitian assistants. Successful delegation to dietitian assistants requires the unique perspectives of humans as individuals and in their collective healthcare roles, moving from words to actions that value delegation; engaging in processes to improve competency, capability, and capacity of all; and being responsive to climate and contextual factors.
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Laur C, Bell J, Valaitis R, Ray S, Keller H. The role of trained champions in sustaining and spreading nutrition care improvements in hospital: qualitative interviews following an implementation study. BMJ Nutr Prev Health 2021; 4:435-446. [PMID: 35028514 PMCID: PMC8718867 DOI: 10.1136/bmjnph-2021-000281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/13/2021] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
- NNEdPro Global Centre for Nutrition and Health, St John's Innovation Centre, Cambridge, UK
| | - Jack Bell
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Renata Valaitis
- Knowledge Development and Exchange Hub, Renison University College, Waterloo, Ontario, Canada
| | - Sumantra Ray
- NNEdPro Global Centre for Nutrition and Health, St John's Innovation Centre, Cambridge, UK
- School of Biomedical Sciences, Ulster University, Ulster, UK
- School of the Humanities and Social Sciences, University of Cambridge, Cambridge, UK
| | - Heather Keller
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
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Identifying Low Value Malnutrition Care Activities for De-Implementation and Systematised, Interdisciplinary Alternatives-A Multi-Site, Nominal Group Technique Approach. Nutrients 2021; 13:nu13062063. [PMID: 34208675 PMCID: PMC8234755 DOI: 10.3390/nu13062063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 01/07/2023] Open
Abstract
Malnutrition risk is identified in over one-third of inpatients; reliance on dietetics-delivered nutrition care for all “at-risk” patients is unsustainable, inefficient, and ineffective. This study aimed to identify and prioritise low-value malnutrition care activities for de-implementation and articulate systematised interdisciplinary opportunities. Nine workshops, at eight purposively sampled hospitals, were undertaken using the nominal group technique. Participants were asked “What highly individualised malnutrition care activities do you think we could replace with systematised, interdisciplinary malnutrition care?” and “What systematised, interdisciplinary opportunities do you think we should do to provide more effective and efficient nutrition care in our ward/hospital?” Sixty-three participants were provided five votes per question. The most voted de-implementation activities were low-value nutrition reviews (32); education by dietitian (28); assessments by dietitian for patients with malnutrition screening tool score of two (22); assistants duplicating malnutrition screening (19); and comprehensive, individualised nutrition assessments where unlikely to add value (15). The top voted alternative opportunities were delegated/skill shared interventions (55), delegated/skill shared education (24), abbreviated malnutrition care processes where clinically appropriate (23), delegated/skill shared supportive food/fluids (14), and mealtime assistance (13). Findings highlight opportunities to de-implement perceived low-value malnutrition care activities and replace them with systems and skill shared alternatives across hospital settings.
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Rushton A, Young A, Keller H, Bauer J, Bell J. Delegation Opportunities for Malnutrition Care Activities to Dietitian Assistants-Findings of a Multi-Site Survey. Healthcare (Basel) 2021; 9:healthcare9040446. [PMID: 33920280 PMCID: PMC8068993 DOI: 10.3390/healthcare9040446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/29/2021] [Accepted: 04/08/2021] [Indexed: 01/04/2023] Open
Abstract
Approximately one-third of adult inpatients are malnourished with substantial associated healthcare burden. Delegation frameworks facilitate improved nutrition care delivery and high-value healthcare. This study aimed to explore knowledge, attitudes, and practices of dietitians and dietitian assistants regarding delegation of malnutrition care activities. This multi-site study was nested within a nutrition care implementation program, conducted across Queensland (Australia) hospitals. A quantitative questionnaire was conducted across eight sites; 87 dietitians and 37 dietitian assistants responded and descriptive analyses completed. Dietitians felt guidelines to support delegation were inadequate (agreement: <50% for assessment/diagnosis, care coordination, education, and monitoring and evaluation); dietitian assistants perceived knowledge and guidelines to undertake delegated tasks were adequate (agreement: >50% food and nutrient delivery, education, and monitoring and evaluation). Dietitians and dietitian assistants reported confidence to delegate/receive delegation (dietitian agreement: >50% across all care components; dietitian assistant agreement: >50% for assessment/diagnosis, food and nutrient delivery, education, monitoring and evaluation). Practice of select nutrition care activities were routinely performed by dietitians, rather than assistants (p < 0.001 across all nutrition care components). The process for care delegation needs to be improved. Clarity around barriers and enablers to delegation of care prior to implementing reforms to the current models of care is key.
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Affiliation(s)
- Alita Rushton
- Department of Nutrition and Dietetics, The Prince Charles Hospital, Chermside, QLD 4032, Australia;
| | - Adrienne Young
- School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, QLD 4072, Australia; (A.Y.); (J.B.)
- Department of Nutrition and Dietetics, Royal Brisbane Women’s Hospital, Herston, QLD 4029, Australia
| | - Heather Keller
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, ON N2L 3G1, Canada;
| | - Judith Bauer
- School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, QLD 4072, Australia; (A.Y.); (J.B.)
| | - Jack Bell
- Department of Nutrition and Dietetics, The Prince Charles Hospital, Chermside, QLD 4032, Australia;
- School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, QLD 4072, Australia; (A.Y.); (J.B.)
- Correspondence: ; Tel.: +61-07-3139-6172
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Rushton A, Edwards A, Bauer J, Bell JJ. Dietitian assistant opportunities within the nutrition care process for patients with or at risk of malnutrition: a systematic review. Nutr Diet 2021; 78:69-85. [PMID: 33416208 DOI: 10.1111/1747-0080.12651] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 12/12/2022]
Abstract
AIM Shifting to models of care that incorporate delegation of nutrition care process actions to dietitian assistants could facilitate effective and efficient nutrition care delivery. This review aimed to determine if delegation of malnutrition care activities to dietitian assistants, when compared with routine nutrition care practices influences patient, healthcare and/or workforce outcomes for adult hospital inpatients with or at risk of malnutrition. METHODS This review was undertaken in accordance with PRISMA guidelines, with five databases (CINAHL, Medline, PsycINFO, Embase and Scopus) searched systematically for studies published up to and including February 2020. Exclusion criteria included review articles and studies conducted in community settings. RESULTS The search yielded 3431 results, with 11 studies eligible for inclusion. Across all domains of the nutrition care process, there is emerging evidence dietitian assistants may improve the delivery of nutrition care practices, patient, healthcare and workforce outcomes. Findings demonstrated various roles and scope of dietitian assistants' practice throughout the studies. Positive patient outcomes were found when dietitian assistants were part of a multi-disciplinary model of care. CONCLUSIONS Implementing delegation of components of the nutrition care process to dietitian assistants is vital in the current health climate and should be considered in a future multidisciplinary model of nutrition care. Exploration of dietitian assistant roles and opportunities are required to expand and strengthen the evidence.
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Affiliation(s)
- Alita Rushton
- Department of Nutrition and Dietetics, The Prince Charles Hospital, Chermside, Queensland, Australia.,School of Human Movement and Nutrition Sciences, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Anna Edwards
- School of Human Movement and Nutrition Sciences, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Judith Bauer
- School of Human Movement and Nutrition Sciences, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Jack J Bell
- Department of Nutrition and Dietetics, The Prince Charles Hospital, Chermside, Queensland, Australia.,School of Human Movement and Nutrition Sciences, The University of Queensland, Saint Lucia, Queensland, Australia
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Keller H, Koechl JM, Laur C, Chen H, Curtis L, Dubin JA, Gramlich L, Ray S, Valaitis R, Yang Y, Bell J. More-2-Eat implementation demonstrates that screening, assessment and treatment of malnourished patients can be spread and sustained in acute care; a multi-site, pretest post-test time series study. Clin Nutr 2020; 40:2100-2108. [PMID: 33077271 DOI: 10.1016/j.clnu.2020.09.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Malnutrition in medical and surgical inpatients is an on-going problem. More-2-Eat (M2E) Phase 1 demonstrated that improved detection and treatment of hospital malnutrition could be embedded into routine practice using an intensive researcher-facilitated implementation process. Yet, spreading and sustaining new practices in diverse hospital cultures with minimal researcher support is unknown. AIMS To demonstrate that a scalable model of implementation can increase three key nutrition practices (admission screening; Subjective Global Assessment (SGA); and medication pass (MedPass) of oral nutritional supplement) in diverse acute care hospitals to detect and treat malnutrition in medical and surgical patients. METHODS Ten hospitals participated in this pretest post-test time series implementation study from across Canada, including 21 medical or surgical units (Phase 1 original units (n = 4), Phase 1 hospital new units (n = 9), Phase 2 new hospitals and units (n = 8)). The scalable implementation model included: training champions on implementation strategies and providing them with education resources for teams; creating a self-directed audit and feedback process; and providing mentorship. Standardized audits of all patients on the study unit on an audit day were completed bi-monthly to track nutrition care activities since admission. Bivariate comparisons were performed by time period (initial, mid-term and final audits). Run-charts depicted the trajectory of change and qualitatively compared to Phase 1. RESULTS 5158 patient charts were audited over the course of 18-months. Admission nutrition screening rates increased from 50% to 84% (p < 0.0001). New Phase 1 units more readily implemented screening than Phase 2 sites, and the original Phase 1 units generally sustained screening practices from Phase 1. SGA was a sustained practice at Phase 1 hospitals including in new Phase 1 units. The new Phase 2 units improved completion of SGA but did not reach the levels of Phase 1 units (original or new). MedPass almost doubled over the time periods (7%-13% of all patients p < 0.007). Other care practices significantly increased (e.g. volunteer mealtime assistance). CONCLUSION Nutrition-care activities significantly increased in diverse hospital units with this scalable model. This heralds the transition from implementation research to sustained changes in routine practice. Screening, SGA, and MedPass can all be implemented, improve nutrition care for all patients, spread within an organization, and for the most part, sustained (and in the case of original Phase 1 units, for over 3 years) with champion leadership.
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Affiliation(s)
- Heather Keller
- Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Dr, Waterloo, ON N2J 0E2, Canada; Department of Kinesiology, University of Waterloo, Canada.
| | | | - Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; NNEPro Global Centre for Nutrition and Health in Cambridge, Cambridge, UK
| | - Helen Chen
- School of Public Health and Health Systems, University of Waterloo, Canada
| | - Lori Curtis
- Department of Economics, University of Waterloo, Canada
| | - Joel A Dubin
- School of Public Health and Health Systems and Department of Statistics and Actuarial Science, University of Waterloo, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Canada
| | - Sumantra Ray
- School of Humanities and Social Sciences, University of Cambridge, Cambridge, UK; NNEPro Global Centre for Nutrition and Health in Cambridge, Cambridge, UK; School of Biomedical Sciences, Ulster University, Coleraine, UK
| | - Renata Valaitis
- School of Public Health and Health Systems, University of Waterloo, Canada
| | - Yang Yang
- School of Public Health and Health Systems, University of Waterloo, Canada
| | - Jack Bell
- School of Human Movement and Nutrition Sciences, The University of Queensland, Australia; The Prince Charles Hospital, Australia
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McNicholl T, Curtis L, Dubin JA, Mourtzakis M, Nasser R, Laporte M, Keller H. Handgrip strength predicts length of stay and quality of life in and out of hospital. Clin Nutr 2019; 39:2501-2509. [PMID: 31757485 DOI: 10.1016/j.clnu.2019.11.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 09/30/2019] [Accepted: 11/03/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Handgrip strength (HGS) is a practical measure of strength and physical function that can be used to identify frailty among hospitalized patients, but its utility in this setting is unclear. To be considered useful, any functional measure needs to provide pertinent information on the patient and predict relevant outcomes such as health-care utilization (e.g., length of stay (LOS)) and patient-reported quality of life (QOL). The purpose of this study was to determine if HGS predicted LOS and QOL. A second aim was to examine the best sensitivity (SE) and specificity (SP) for predicting length of stay (>7 or >13 days) using previously published cut-points for HGS. METHODOLOGY HGS was measured on 1136 medical patients shortly after admission with a Lafayette dynamometer. QOL was assessed with the self-reported SF-12 completed with an interviewer during hospitalization and 30- days after discharge via telephone. Physical (PCS) and mental (MCS) component scores of SF-12 were calculated. A variety of covariates were assessed (e.g., nutritional status). Multivariate analyses stratified by sex were completed. RESULTS The mean LOS was 12.71 days (median = 8.00; SD = 13.20), 12.88 days (SD = 13.82) for males, and 12.58 days (SD = 12.68) for females. Lower admission HGS scores were associated with longer LOS (male X2 = 7.85, p < 0.05; female X2 = 14.9, p < 0.0001). The average quality of life scores were as follows: in hospital PCS: 34.66, MCS: 46.49; post discharge PCS: 36.17; MCS: 51.22. HGS predicted PCS during hospitalization (male X2 = 36.22, p < 0.0001; female X2 = 19.87, p < 0.0001) and post hospitalization (male X2 = 6.98, p < 0.01; female X2 = 10.99, p < 0.01). Various reference cut-points for HGS were tested against LOS, with none being considered appropriate (e.g., SE and SP both < 70) when adjusting for age and sex. CONCLUSION Admission HGS adds predictive value for both LOS and physical components of QOL and is worth pursuing in practice to identify potential frailty and the need for proactive steps to mitigate further functional decline during hospitalization. However, HGS cut-points for LOS specific to acute care patients need to be defined and tested.
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Affiliation(s)
- Tara McNicholl
- University of Waterloo, 200 University Ave. W, Waterloo, ON, N2L 3G1, Canada.
| | - Lori Curtis
- University of Waterloo, 200 University Ave. W, Waterloo, ON, N2L 3G1, Canada.
| | - Joel A Dubin
- University of Waterloo, 200 University Ave. W, Waterloo, ON, N2L 3G1, Canada.
| | - Marina Mourtzakis
- University of Waterloo, 200 University Ave. W, Waterloo, ON, N2L 3G1, Canada.
| | - Roseann Nasser
- Pasqua Hospital, 101 Dewdney Avenue, Regina, SK, S4T 1A5, Canada.
| | - Manon Laporte
- Réseau de santé Vitalité Health Network, Campbellton Regional Hospital, 189 Lily Lake Road, Campbellton, NB, E3N 3H3, Canada.
| | - Heather Keller
- University of Waterloo, 200 University Ave. W, Waterloo, ON, N2L 3G1, Canada; Schlegel-Univeristy of Waterloo Research Institute for Aging, Waterloo, ON, N2J 0E2, Canada.
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Laur C, Bell J, Valaitis R, Ray S, Keller H. 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. BMC Health Serv Res 2018; 18:930. [PMID: 30509262 PMCID: PMC6278089 DOI: 10.1186/s12913-018-3748-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/21/2018] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Celia Laur
- Faculty of Applied Health Sciences, University of Waterloo, Waterloo, Canada
| | - Jack Bell
- School of Human Movement and Nutrition Sciences, The University of Queensland and The Prince Charles Hospital, Chermside, Australia
| | - Renata Valaitis
- Faculty of Applied Health Sciences, University of Waterloo, Waterloo, Canada
| | - Sumantra Ray
- NNEdPro Global Centre for Nutrition and Health, St. John’s Innovation Centre, Cambridge, UK
| | - Heather Keller
- Faculty of Applied Health Sciences, University of Waterloo, Waterloo, Canada
- Schlegel-University of Waterloo Research Institute for Aging, University of Waterloo, Waterloo, Canada
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Curtis LJ, Valaitis R, Laur C, McNicholl T, Nasser R, Keller H. Low food intake in hospital: patient, institutional, and clinical factors. Appl Physiol Nutr Metab 2018; 43:1239-1246. [DOI: 10.1139/apnm-2018-0064] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In-hospital malnutrition and inadequate food intake have been associated with negative outcomes (e.g., prolonged length of stay, readmission, mortality, and increased hospital costs). Studies examining the factors associated with low food intake in hospital, commonly defined as the consumption of ≤50% of meals, have produced mixed results. We examined the correlates of food intake including patient socioeconomic, demographic, and health characteristics, institutional factors, and common clinical strategies in 1129 medical patients from 5 Canadian hospitals. Low food intake was found in 35% of patients (41% of females and 29% of males) (p < 0.001). In multivariate analyses, sex, socioeconomic status, demographics, and diagnoses were not significantly related to food intake. Patients assessed as malnourished (subjective global assessment (SGA) B/C) (odds ratio (OR), 2.41; p = 0.003) or as not at risk of malnutrition (OR, 1.67; p = 0.040) were more likely to have low intake when compared with those assessed as well nourished (SGA A). Patient reports of mealtime challenges (OR, 2.70; p < 0.001) and barriers to food intake (OR, 1.11; p = 0.008) were positively related to low intake throughout the study sample. Higher 12-Item Short Form Health Survey Mental Component Summary scores were related to better food intake (OR, 0.98; p < 0.001). Clinical strategies such as between-meal snacks lowered the likelihood of low food intake (OR, 0.55; p = 0.037), whereas a group of “other strategies” increased the odds (OR, 2.77; p = 0.001). These results offer a better understanding of the correlates of in-hospital low food intake. The conclusion discusses some avenues for improving food intake in the clinical setting, such as better mealtime monitoring and a reduction in barriers to food intake.
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Affiliation(s)
- Lori J. Curtis
- Department of Economics, University of Waterloo, 200 University Avenue, Waterloo, ON N2L 3G1, Canada
| | - Renata Valaitis
- Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Celia Laur
- Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Tara McNicholl
- Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Roseann Nasser
- Nutrition and Food Services, Pasqua Hospital, Saskatchewan Health Authority, Regina, SK S4T 1A5, Canada
| | - Heather Keller
- Schlegel–UW Research Institute for Aging and Department of Kinesiology, University of Waterloo, Waterloo, ON N2L 3G1, Canada
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Young AM, Keller HH, Barnes R, Bell JJ. Clinicians as novice facilitators: a SIMPLE case study. J Health Organ Manag 2018; 33:78-92. [PMID: 30859913 DOI: 10.1108/jhom-03-2018-0071] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to advance understanding about the facilitation process used in complex implementation projects, by describing the function of novice clinician facilitators, and the barriers and enablers they experience, while implementing a new model of care for managing hospital malnutrition. DESIGN/METHODOLOGY/APPROACH Semi-structured interviews were undertaken with local facilitators ( n=7) involved in implementing The SIMPLE Approach (Systematised Interdisciplinary Malnutrition Pathway Implementation and Evaluation) in six hospitals in Queensland, Australia. Facilitator networks and training supported the clinicians acting as novice facilitators. FINDINGS Key functions of the facilitator role were building relationships and trust; understanding the problem and stimulating change through data; negotiating and implementing the change; and measuring, sharing and reflecting on success. "Dedicated role, time and support" was identified as a theme encompassing the key barriers and enablers to successful facilitation. PRACTICAL IMPLICATIONS When implementing complex interventions within short project timelines, it is critical that novice clinician facilitators are given adequate and protected time within their role, and have access to regular support from peers and experienced facilitators. With these structures in place, facilitators can support iterative improvements through building trust and relationships, co-designing strategies with champions and teams and developing internal capacity for change. ORIGINALITY/VALUE This case study extends the knowledge about how facilitation works in action, the barriers faced by clinicians new to working in facilitator roles, and highlights the need for an adapt-to-fit approach for the facilitation process, as well as the innovation itself.
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Affiliation(s)
- Adrienne M Young
- Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Herston, Australia.,School of Exercise and Nutrition Sciences, Faculty of Health, Queensland University of Technology , Kelvin Grove, Australia
| | - Heather H Keller
- Faculty of Applied Health Sciences, University of Waterloo , Waterloo, Canada.,Schlegel-University of Waterloo Research Institute for Aging, University of Waterloo , Waterloo, Canada
| | | | - Jack J Bell
- School of Human Movement and Nutrition Sciences, Faculty of Health and Behavioural Sciences, University of Queensland , Herston, Australia.,Allied Health Research Collaborative, Prince Charles Hospital, Chermside, Australia
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13
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Keller HH, Xu Y, Dubin JA, Curtis L, Laur CV, Bell J. Improving the standard of nutrition care in hospital: Mealtime barriers reduced with implementation of the Integrated Nutrition Pathway for Acute Care. Clin Nutr ESPEN 2018; 28:74-79. [PMID: 30390896 DOI: 10.1016/j.clnesp.2018.09.075] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/24/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Poor food intake is common in hospital patients and is associated with adverse patient and healthcare outcomes; diverse mealtime barriers to intake often undermine clinical nutrition care. AIM This study determines whether implementation of locally adaptable nutrition care activities as part of uptake of the Integrated Nutrition Pathway for Acute Care (INPAC) reduced mealtime barriers and improved other patient outcomes (e.g. length of stay; LOS) when considering other covariates. METHODS 1250 medical patients from 5 Canadian hospitals were recruited for this before-after time series design. Mealtime barriers were tallied with the Mealtime Audit Tool after a meal, while proportion of the meal consumed was assessed with the My Meal Intake Tool. Implementation of new standard care activities occurred over 12 months and three periods (pre-, early, and late) of implementation were compared. Regression analyses determined the effect of time period while adjusting for key covariates. RESULTS Mealtime barriers were reduced over time periods (Period 1 = 2.5 S.D. 2.1; Period 3 = 1.8 S.D. 1.7) and site differences were noted. This decrease was statistically significant in regression analyses (-0.28 per time period; 95% CI -0.44, -0.11). Within and across site changes were also observed over time in meal intake and LOS; however, after adjusting for covariates, time period of implementation was not significantly associated with these outcomes. DISCUSSION Mealtime barriers can be reduced and sustained by implementing improved standard care procedures for patients. The More-2-Eat study provides an example of how to implement changes in practice to support the prevention and treatment of malnutrition. TRIAL REGISTRATION Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.
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Affiliation(s)
- Heather H Keller
- University of Waterloo, 200 University Ave W., Waterloo, ON, N2L3G1, Canada; Schlegel-University of Waterloo Research Institute for Aging, Waterloo, ON, N2J 0E2, Canada.
| | - Yingying Xu
- University of Waterloo, 200 University Ave W., Waterloo, ON, N2L3G1, Canada
| | - Joel A Dubin
- University of Waterloo, 200 University Ave W., Waterloo, ON, N2L3G1, Canada
| | - Lori Curtis
- University of Waterloo, 200 University Ave W., Waterloo, ON, N2L3G1, Canada
| | - Celia V Laur
- University of Waterloo, 200 University Ave W., Waterloo, ON, N2L3G1, Canada
| | - Jack Bell
- The University of Queensland & The Prince Charles Hospital, Rode Road, Chermside, QLD, 4032, Australia
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McNicholl T, Dubin JA, Curtis L, Mourtzakis M, Nasser R, Laporte M, Keller H. Handgrip Strength, but Not 5-Meter Walk, Adds Value to a Clinical Nutrition Assessment. Nutr Clin Pract 2018; 34:428-435. [PMID: 30288776 DOI: 10.1002/ncp.10198] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Decreased physical functioning is associated with malnutrition and common in acute care patients; determining loss of function is often considered part of a comprehensive nutrition assessment. Handgrip strength (HGS) and 5-meter timed walk (5m) are functional measures used in a variety of settings. This analysis sought to determine which functional measure could be added to a hospital nutrition assessment, based on its feasibility and capacity to discriminate patient subgroups. METHODS Eligible medical patients (no delirium/dementia, admitted from community; n = 1250), recruited from 5 hospitals that participated in a previous multisite action research study, provided data on demographics, HGS, 5m, nutrition status, perceived disability, and other characteristics. RESULTS Significantly more patients (z = 17.39, P < .00001) were able to complete HGS than 5m (92% versus 43%, respectively). Median HGS was 28.0 kg for men and 14.7 kg for women. Of patients who completed the 5m, mean completion time was 8.98 seconds (median, 6.79 seconds, SD = 6.59). 5m and HGS scores were significantly worse with patient-perceived disability (z = -9.56, t = 10.69, respectively; P < .0001; 95% confidence interval [CI], [7.33, 10.63]; [1.76, 3.18]). HGS was associated with nutrition status (t = 4.13, P < .001; 95% CI [2.02, 5.67]), although it showed poor validity as a single nutrition indicator. CONCLUSIONS These data indicate that HGS is a more useful functional measure than 5m when added to a hospital nutrition assessment. Determination of HGS cutpoints to identify low strength in acute care patients will promote its use.
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Affiliation(s)
- Tara McNicholl
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
- David Braley Health Sciences Centre, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Joel A Dubin
- Department of Statistics and Actuarial Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Lori Curtis
- Department of Economics, University of Waterloo, Waterloo, Ontario, Canada
| | - Marina Mourtzakis
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Roseann Nasser
- Nutrition and Food Services, Pasqua Hospital, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Manon Laporte
- Department of Clinical Nutrition, Vitalité Health Network, Campbellton Regional Hospital, New Brunswick, Canada
| | - Heather Keller
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
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Bell JJ, Young A, Hill J, Banks M, Comans T, Barnes R, Keller HH. Rationale and developmental methodology for the SIMPLE approach: A Systematised, Interdisciplinary Malnutrition Pathway for impLementation and Evaluation in hospitals. Nutr Diet 2018; 75:226-234. [PMID: 29436107 DOI: 10.1111/1747-0080.12406] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/18/2017] [Accepted: 12/20/2017] [Indexed: 11/28/2022]
Abstract
AIM Changing population demographics, service demands, and healthcare provider expectations suggest that a shift is required regarding how malnutrition care is managed in hospitals. The present study aims to build the reason for required change, and to describe the process used to develop a model for managing malnutrition for implementation across six Queensland hospitals. METHODS A cross-sectional survey of approaches to managing malnutrition in Queensland public hospitals, and development of a new model of care (guided by Knowledge-to-Action Framework and qualitative interviews) for testing within a broader implementation program. RESULTS Twenty-three surveys were distributed with 21 completed by metropolitan (n = 11), regional (n = 8), and rural/remote (n = 2) settings. Substantial within and across site variance was observed, with care processes focused towards highly individualised, dietitian delivered care. Some early adopter sites demonstrated systematic, interdisciplinary or delegated malnutrition care processes; however, the latter was rarely or never undertaken in eight sites. A model for the Systematised, Interdisciplinary Malnutrition Pathway for impLementation and Evaluation (SIMPLE) in hospitals was drafted based on identified contemporary models and supporting literature. A mixed-methods approach combined survey data with structured interviews conducted in six sites, purposively sampled for maximal variation to iteratively refine the model. Consensus for implementation of the final model was achieved across site clinicians, leaders, and governance structures. CONCLUSIONS Systematised, delegated, and interdisciplinary nutrition care activities are realistic in at least some settings. A model is now available to provide interdisciplinary care. Next steps including testing implementation will determine if this interdisciplinary model improves malnutrition care delivered in hospitals.
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Affiliation(s)
- Jack J Bell
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia.,Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Adrienne Young
- Department of Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Exercise and Nutrition Science, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jan Hill
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Merrilyn Banks
- Department of Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Exercise and Nutrition Science, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Tracy Comans
- Metro North Hospital and Health Service District and Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
| | | | - Heather H Keller
- Faculty of Applied Health Sciences, University of Waterloo, Waterloo, Ontario, Canada.,Schlegel-University of Waterloo Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
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Nutrition Care after Discharge from Hospital: An Exploratory Analysis from the More-2-Eat Study. Healthcare (Basel) 2018; 6:healthcare6010009. [PMID: 29361696 PMCID: PMC5872216 DOI: 10.3390/healthcare6010009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/08/2018] [Accepted: 01/17/2018] [Indexed: 12/21/2022] Open
Abstract
Many patients leave hospital in poor nutritional states, yet little is known about the post-discharge nutrition care in which patients are engaged. This study describes the nutrition-care activities 30-days post-discharge reported by patients and what covariates are associated with these activities. Quasi-randomly selected patients recruited from 5 medical units across Canada (n = 513) consented to 30-days post-discharge data collection with 48.5% (n = 249) completing the telephone interview. Use of nutrition care post-discharge was reported and bivariate analysis completed with relevant covariates for the two most frequently reported activities, following recommendations post-discharge or use of oral nutritional supplements (ONS). A total of 42% (n = 110) received nutrition recommendations at hospital discharge, with 65% (n = 71/110) of these participants following those recommendations; 26.5% (n = 66) were taking ONS after hospitalization. Participants who followed recommendations were more likely to report following a special diet (p = 0.002), different from before their hospitalization (p = 0.008), compared to those who received recommendations, but reported not following them. Patients taking ONS were more likely to be at nutrition risk (p < 0.0001), malnourished (p = 0.0006), taking ONS in hospital (p = 0.01), had a lower HGS (p = 0.0013; males only), and less likely to believe they were eating enough to meet their body’s needs (p = 0.005). This analysis provides new insights on nutrition-care post-discharge.
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17
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Keller H, Laur C, Atkins M, Bernier P, Butterworth D, Davidson B, Hotson B, Nasser R, Laporte M, Marcell C, Ray S, Bell J. Update on the Integrated Nutrition Pathway for Acute Care (INPAC): post implementation tailoring and toolkit to support practice improvements. Nutr J 2018; 17:2. [PMID: 29304866 PMCID: PMC5756381 DOI: 10.1186/s12937-017-0310-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 12/15/2017] [Indexed: 11/20/2022] Open
Abstract
The Integrated Nutrition Pathway for Acute Care (INPAC) is an evidence and consensus based pathway developed to guide health care professionals in the prevention, detection, and treatment of malnutrition in medical and surgical patients. From 2015 to 2017, the More-2-Eat implementation project (M2E) used a participatory action research approach to determine the feasibility, and evaluate the implementation of INPAC in 5 hospital units across Canada. Based on the findings of M2E and consensus with M2E stakeholders, updates have been made to INPAC to enhance feasibility in Canadian hospitals. The learnings from M2E have been converted into an online toolkit that outlines how to implement the key steps within INPAC. The aim of this short report is to highlight the updated version of INPAC, and introduce the implementation toolkit that was used to support practice improvements towards this standard.
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Affiliation(s)
- Heather Keller
- Schlegel-University of Waterloo Research Institute for Aging; Department of Kinesiology, University of Waterloo, Waterloo, ON Canada
| | - Celia Laur
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON Canada
| | | | - Paule Bernier
- Ordre professionnel des diététistes du Québec, Montreal, QC Canada
| | | | | | - Brenda Hotson
- Winnipeg Regional Health Authority, Winnipeg, MB Canada
| | | | - Manon Laporte
- Réseau de santé Vitalité Health Network, Campbellton Regional Hospital, Campbellton, NB Canada
| | | | - Sumantra Ray
- NNEdPro Global Centre for Nutrition and Health (Affiliated with: Cambridge University Health Partners, Wolfson College Cambridge and the British Dietetic Association), St John’s Innovation Centre, Cowley Road, Cambridge, UK
| | - Jack Bell
- School of Human Movement and Nutrition Sciences, The University of Queensland &, The Prince Charles Hospital, Brisbane, Australia
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Laur CV, Keller HH, Curtis L, Douglas P, Murphy J, Ray S. Comparing Hospital Staff Nutrition Knowledge, Attitudes, and Practices Before and 1 Year After Improving Nutrition Care: Results From the More-2-Eat Implementation Project. JPEN J Parenter Enteral Nutr 2017; 42:786-796. [PMID: 28792864 DOI: 10.1177/0148607117718493] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 06/06/2017] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Celia V Laur
- Faculty of Applied Health Science, University of Waterloo, Waterloo, ON, Canada.,NNEdPro Global Centre for Nutrition and Health (affiliated with Cambridge University Health Partners, Wolfson College Cambridge, and the British Dietetic Association), St John's Innovation Centre, Cambridge, United Kingdom
| | - Heather H Keller
- Schlegel-University of Waterloo Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Lori Curtis
- Department of Economics, University of Waterloo, Waterloo, Ontario, Canada
| | - Pauline Douglas
- NNEdPro Global Centre for Nutrition and Health (affiliated with Cambridge University Health Partners, Wolfson College Cambridge, and the British Dietetic Association), St John's Innovation Centre, Cambridge, United Kingdom
| | - Joseph Murphy
- The Ottawa Hospital
- L'Hôpital d'Ottawa, Ottawa, Ontario, Canada
| | - Sumantra Ray
- NNEdPro Global Centre for Nutrition and Health (affiliated with Cambridge University Health Partners, Wolfson College Cambridge, and the British Dietetic Association), St John's Innovation Centre, Cambridge, United Kingdom
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Laur C, Valaitis R, Bell J, Keller H. Changing nutrition care practices in hospital: a thematic analysis of hospital staff perspectives. BMC Health Serv Res 2017; 17:498. [PMID: 28724373 PMCID: PMC5518103 DOI: 10.1186/s12913-017-2409-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 06/27/2017] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Celia Laur
- Department of Applied Health Science, University of Waterloo, 200 University Ave, Waterloo, ON, N2L 3G1, Canada
| | - Renata Valaitis
- Department of Applied Health Science, University of Waterloo, 200 University Ave, Waterloo, ON, N2L 3G1, Canada
| | - Jack Bell
- School of Human Movement and Nutrition Sciences, The University of Queensland &, The Prince Charles Hospital, Rode Road, Chermside, QLD, 4032, Australia
| | - Heather Keller
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, ON, Canada. .,Department of Kinesiology University of Waterloo, 200 University Ave, Waterloo, N2L 3G1, ON, Canada.
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Valaitis R, Laur C, Keller H, Butterworth D, Hotson B. Need for the Integrated Nutrition Pathway for Acute Care (INPAC): gaps in current nutrition care in five Canadian hospitals. BMC Nutr 2017; 3:60. [PMID: 32153840 PMCID: PMC7050887 DOI: 10.1186/s40795-017-0177-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/06/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Malnutrition is common in hospitalized patients and is associated with increased mortality, length of stay, and risk of re-admission. The consensus based Integrated Nutrition Pathway for Acute Care (INPAC) was developed and validated to enhance patients' nutrition care and improve clinical outcomes. As part of the More-2-Eat project (M2E), five hospitals implemented INPAC activities (e.g. screening) in a single medical unit. The purpose of this paper is to demonstrate the care gaps with respect to INPAC activities on these five units prior to implementation. Results were used as part of a needs assessment on each unit, demonstrating where nutrition care could be improved and tailoring of implementation was required. METHODS Cross-sectional data was collected by site research associates (RAs) using a standardized audit form once per week for 4 weeks. The audit contents were based on the INPAC algorithm. All medical charts of patients on the study unit on the day of the audit were reviewed to track routine nutrition care activities (e.g. screening). Data was descriptively displayed with REDCap™ and analyzed using R Studio software. RESULTS Less than half of patients (249/700, 36%) were screened for malnutrition at admission. Of those screened, 36% (89/246) were at risk for malnutrition yet 36% (32/89) of these patients did not receive a dietitian assessment. Also, 21% (33/157) of patients who were not screened at risk were assessed. At least one barrier to food intake was noted in 85% of patient medical charts, with pain, constipation, nausea or vomiting being the most common. Many of these barriers were addressed through INPAC standard nutrition care strategies that removed the barrier (e.g. 41% were provided medication for nausea). Advanced nutrition care strategies to improve intake were less frequently recorded (39% of patients). CONCLUSION These results highlight the current state of nutrition care and areas for improvement regarding INPAC activities, including nutrition screening, assessment, and standard and advanced nutrition care strategies to promote food intake. The results also provided baseline data to support buy-in for INPAC implementation in each M2E study unit. TRIAL REGISTRATION Retrospectively registered ClinTrials.gov Identifier: NCT02800304, June 7, 2016.
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Affiliation(s)
- Renata Valaitis
- University of Waterloo, 200 University Ave W., Waterloo, ON N2L3G1 Canada
| | - Celia Laur
- University of Waterloo, 200 University Ave W., Waterloo, ON N2L3G1 Canada
| | - Heather Keller
- University of Waterloo, 200 University Ave W., Waterloo, ON N2L3G1 Canada
- Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Drive, Waterloo, Canada
| | - Donna Butterworth
- Concordia Hospital, 1095 Concordia Ave., Winnipeg, MB R2K 3S8 Canada
| | - Brenda Hotson
- Winnipeg Regional Health Authority, GG435 820 Sherbrook St., Winnipeg, MB R3A 1R9 Canada
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