Need for the Integrated Nutrition Pathway for Acute Care (INPAC): gaps in current nutrition care in five Canadian hospitals

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.

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

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

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.

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.

Development of a new tool to monitor and identify inadequate oral intake in hospital

BACKGROUND

There is a need for quick and easy methods to monitor nutritional intake in hospital and identify patients with poor intake. Food record charts are often used in clinical practice, with low levels of accuracy and completion. This study aims to describe the development and evaluate the performance of a new tool to estimate energy and protein intake and identify poor nutritional intake amongst adult hospital patients.

METHODS

Ninety trays were sampled and assessed independently using the new tool 'Meal Intake Points' and a weighed (reference) method. The performance was tested by measuring association (Spearman's correlation), agreement (proportion of meals within specified limits of reference method), and sensitivity and specificity to identify poor energy and protein intake.

RESULTS

This new tool achieved very strong association for energy estimates (r = .91) and strong association for protein estimates (r = .86). Estimates for energy and protein were within 450 kJ and 4.5 g of the reference method in 77.8% and 62.2% of meals, respectively. It also displayed excellent performance as a screening tool (sensitivity 100%; specificity 76%-80%). Minor revision of the original tool was needed to optimise performance.

CONCLUSIONS

Meal Intake Points accurately estimates energy and protein intake and identifies patients with poor nutritional intake, providing a clinically relevant tool for use in hospitals to monitor intake and identify patients for proactive nutrition support. Further validation studies are needed to determine its performance in clinical practice and whether it is useful in predicting hospital-acquired malnutrition.

Delegation Opportunities for Malnutrition Care Activities to Dietitian Assistants-Findings of a Multi-Site Survey

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.

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.

Dietitian assistant opportunities within the nutrition care process for patients with or at risk of malnutrition: a systematic review

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.

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.

Low food intake in hospital: patient, institutional, and clinical factors

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.

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

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.