Multidisciplinary Provision of Food and Nutritional Care to Hospitalized Adult In-Patients: A Scoping Review

From Clinic to Kitchen to Electronic Health Record: The Background and Process of Building a Culinary Medicine eConsult Service

Diet plays a pivotal role in health outcomes, influencing various metabolic pathways and accounting for over 20% of risk-attributable disability adjusted life years (DALYs). However, the limited time during primary care visits often hinders comprehensive guidance on dietary and lifestyle modifications. This paper explores the integration of electronic consultations (eConsults) in Culinary Medicine (CM) as a solution to bridge this gap. CM specialists, with expertise in the intricate connections between food, metabolism, and health outcomes, offer tailored dietary recommendations through asynchronous communication within the electronic health record (EHR) system. The use of CM eConsults enhances physician-patient communication and fosters continuous medical education for requesting clinicians. The benefits extend directly to patients, providing access to evidence-based nutritional information to address comorbidities and improve overall health through patient empowerment. We present a comprehensive guide for CM specialist physicians to incorporate CM eConsults into their practices, covering the historical context of eConsults, their adaptation for CM, billing methods, and insights from the implementation at UT Southwestern Medical Center. This initiative delivers expanded access to patient education on dietary risks and promotes interprofessional collaboration to empower improved health.

Current Oncology Nutrition Care Practice in Southeast Asia: A Scoping Review

Although evidence-based nutrition care is recommended for patients with cancer, current nutrition care practices provided by nutritionists and dietitians in Southeast Asian countries are not clearly reported. The aim of this scoping review was to describe nutritionists' and dietitians' current oncology nutrition care practice within Southeast Asia by identifying access to dietetic services, tools or strategies used in providing care, and barriers and enablers to implementing nutrition care practices. Five databases (Ovid MEDLINE, Global Health, Embase, Cochrane Central Register of Controlled Trials, and Proquest) were searched through structured search strategies, in addition to strategic searching of grey literature. A total of 4261 sources of evidence were retrieved. After full-text screening, 18 studies from Southeast Asian countries met the inclusion criteria and were included in this review. The provision and reporting of nutrition care practices provided by nutritionists and dietitians were limited. Access to dietetic services, including nutritional screening tools and reason to be referred, were varied within studies. Barriers and enablers to nutrition care provision were unique and related to each country's specific resources and guidelines. In summary, there was varied reporting of nutrition care practices provided to patients with cancer in Southeast Asia and a lack of clarity on the actual standardized processes. Future research is warranted to further explore the barriers and enablers to providing nutrition care by local nutritionists and dietitians in Southeast Asia.

Managing food waste in the inpatient population

INTRODUCTION

For medical students, food is rarely discussed from the clinical perspective. Yet, in hospitals reduced food intake poses the risk of malnutrition, along with increased morbidity and mortality. The issue of food waste, a cause of inadequate dietary intake and a common issue within the National Health Service, is rarely addressed. The implementation of protected mealtimes has done little to solve this. This quality improvement project aimed to reduce the average amount of inpatient food waste by 20% by May 2022.

METHODS

A standardised meal size intervention was tested. Meals were weighed before and after meal services to collect baseline and postintervention data. The percentage consumed and the percentage wasted were then calculated. Finally, the overall average of the percentage wasted across both meal services was determined.

RESULTS

Quantitative data showed a change in the average amount of food waste from 70.16% to 65.75%, a decrease of 4.41%. Survey results also found an increase of 3% in patient satisfaction with meal sizes.

CONCLUSION

Standardising meal sizes is shown to improve inpatient food waste and may serve as a starting point for healthcare providers to devise further strategies to reduce wastage in hospitals.

A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review

INTRODUCTION

Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand.

METHODS

A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel.

RESULTS

Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan.

CONCLUSION

We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.

Improving physician documentation for malnutrition: A sustainable quality improvement initiative

This study compares documentation and reimbursement rates before and after provider education in nutritional status documentation. Our study aimed to evaluate accurate documentation of nutrition status between registered dietitian nutritionists and licensed independent practitioners before and after the implementation of a dietitian-led Nutrition-Focused Physical Exam intervention at an academic medical center in the southeastern US. ICD-10 codes identified patients from 10/1/2016-1/31/2018 with malnutrition. The percentage of patients with an appropriate diagnosis of malnutrition and reimbursement outcomes attributed to malnutrition documentation were calculated up to 24 months post-intervention. 528 patients were analyzed. Pre-intervention, 8.64% of patients had accurate documentation compared to 46.3% post-intervention. Post-intervention, 68 encounters coded for malnutrition resulted in an estimated $571,281 of additional reimbursement, sustained at 6, 12, 18, and 24 months. A multidisciplinary intervention improved physician documentation accuracy of malnutrition status and increased reimbursement rates.

Culinary Medicine eConsults Pair Nutrition and Medicine: A Feasibility Pilot

The global impact of diet-sensitive disease demands innovative nutrition education for health professionals and widespread, reimbursable clinical models to apply nutrition to practice. Interprofessional collaboration across disciplines and the optimization of emerging telemedicine consultation strategies, including electronic consultation (eConsult), merge to deliver vital innovation in the delivery of nutrition-based clinical care. Aligning with an existing eConsult infrastructure in the institutional electronic health record (EHR), a physician-dietitian team developed a novel Culinary Medicine eConsult. During a pilot phase, the service was introduced to primary care clinicians, and a response algorithm for eConsults was created. During the 12-month pilot phase, the Culinary Medicine team completed 25 eConsults from 11 unique primary care clinicians with a 76% (19/25) insurance reimbursement rate. Topics varied from dietary strategies for preventing and managing common metabolic diseases to specific dietary influences on microbiome health and disease flares. Requesting clinicians reported time saved in their clinic encounters and high patient satisfaction with expert nutrition guidance. EConsults in Culinary Medicine promote the integration of interprofessional nutrition care into existing clinical structures and empower enhanced access to the vital domain of dietary health. EConsults deliver timely answers to clinical questions and create opportunities for further innovation in care delivery as communities, health systems, and payors seek solutions to the growing burden of diet-sensitive diseases.

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.

Prevalence of hospital-acquired malnutrition and modifiable determinants of nutritional deterioration during inpatient admissions: A systematic review of the evidence

BACKGROUND

Malnutrition affects between 20% and 50% of hospital inpatients on admission, with further declines expected during hospitalisation. This review summarises the existing literature on hospital-acquired malnutrition that examines the magnitude of nutritional deterioration amongst adult inpatients and identifies preventable barriers to optimising nutrition support during episodes of care.

METHODS

A systematic review was conducted to answer the question: Among adult hospital inpatients, the presence of which modifiable factors contribute to hospital-acquired malnutrition? A database search was conducted between the 24 April and 30 June 2020 using CINAHL, MEDLINE, Scopus and PubMed databases according to a protocol registered with PROSPERO (CD42020182728). In addition, issues of the 10 top clinical nutrition journals published during the period of from 1 April 2015 to 30 March 2020 were hand-searched.

RESULTS

Fifteen articles were eligible for inclusion from a total of 5944 retrieved abstracts. A narrative synthesis of evidence was completed because of the high level of heterogeneity in methodologies. Nutritional deterioration is common among previously well-nourished and nutritionally compromised patients, with studies reporting that 10%-65% of patients experienced nutritional decline. Frequently reported barriers were mealtime interruptions, meal dissatisfaction, procedure-related fasting, effects of illness or treatment, chewing difficulties, poor appetite and malnutrition as a low clinical priority.

CONCLUSIONS

The findings of this review support the need for routine nutritional risk screening throughout each hospital admission with hospital-acquired malnutrition affecting up to 65% of inpatients. Clear establishment of the roles and responsibilities of each member within multidisciplinary healthcare teams in the provision of nutrition care and cost-benefit analyses are recommended to demonstrate the effectiveness of changes to models of care.

Preliminary Evidence on the Effectiveness of a Multidisciplinary Nutritional Support for Older People with Femur Fracture at an Orthogeriatric Unit in Spain

To describe the nutritional and functional changes that occurred in older patients with a femur fracture following a dietary intervention and oral nutritional support implemented at an orthogeriatric unit in Aragon, Spain. Open-label, prospective study. Patients were consecutively recruited and arranged into three groups based on their CONtrolling NUTritional (CONUT^®) score and nutritional needs. Nutritional status was assessed while in hospital, and at 45-, 100- and 180-days post-hospital discharge. One hundred and sixty-nine patients [mean age: 86 years (SD ± 5.48)] were recruited (July 2017 to January 2020). At admission, 53.3% were at risk of malnutrition; 26.6% were malnourished; 20.1% were well-nourished. Variable proportions of malnourished patients at admission were well-nourished 45-, 100-, and 180-days post-discharge. CONUT^® and Barthel index correlations showed that as nutritional status enhanced, patients gained functionality. Dietary interventions and nutritional support may help restoring the nutritional and functional status of older patients with a femur fracture.

How Physicians Can Assess and Address Dietary Behaviors to Reduce Chronic Disease Risk

With the growing burden of diet-related chronic disease impacting the public's health, nutrition counseling in a primary care setting is essential and can be accomplished through brief and creative approaches. This article reviews an example of a brief dietary assessment and counseling tool and counseling strategies focusing on dietary behavior changes that emphasize impact on health outcomes, ease of behavior change, and affordability. These, plus integrating office supports, are practical ways to start the conversation about improving diet quality with patients. Collaborative efforts in nutrition care, particularly through collaboration with registered dietitians, present a valuable opportunity to meet the nutrition care needs of patients. Additionally, this article reviews screening for eating disorders, food insecurity, and dietary supplement use.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients’ preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients’ preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient’s specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

'What do doctors think they need to know about nutrition?'-a qualitative study of doctors with formal nutrition training

BACKGROUND

Doctors are on the frontline of patient care and in an ideal position to provide nutritional advice, yet can feel ill-equipped to do so. The aim of this study was to explore the nutrition knowledge, skills and practice required for nutrition-competent medical graduates, and their role in providing nutrition advice and care, from the perspective of doctors with formal nutrition training.

METHODOLOGY

We conducted an exploratory qualitative research study. A purposive sample of 12 medical doctors and students with formal nutrition training across Australia participated in in-depth semi structured interviews. Data were analysed thematically.

RESULTS

There were four main themes identified: 1. Identifying the role of doctors in nutrition care; 2. Understanding the interrelatedness of the social determinants of health and nutrition status is key; 3. Optimising nutrition care through multidisciplinary collaboration; and 4. Providing evidence-based nutrition care.

CONCLUSION

This exploratory study suggests that doctors consider that nutrition competent medical graduates require skills in referring to dietitians, an understanding and application of the social determinants of health, and practise applying multidisciplinary and evidence-based nutrition care.

Interprofessional Treatment of Malnutrition and Sarcopenia by Dietitians and Physiotherapists: Exploring Attitudes, Interprofessional Identity, Facilitators, Barriers, and Occurrence

Purpose

Malnutrition and sarcopenia require dietetic and physiotherapy interventions. In this study, we aimed to compare interprofessional identity of dietitians and physiotherapists, as well as attitudes towards, facilitators and barriers for, and occurrence of interprofessional treatment of malnutrition and sarcopenia by both professions.

Methods

A cross-sectional online survey was distributed from December 4, 2021 until January 31, 2022 through an international online network platform for professionals (LinkedIn). Practitioners working as dietitian or physiotherapist in a healthcare setting were eligible for participation. Outcome measures concerned perceptions regarding shared problem domains, interprofessional treatment, attitudes towards interprofessional treatment, interprofessional identity, facilitators, and barriers. A Chi²-test, Mann–Whitney U-test, and Spearman’s Rho correlation were calculated.

Results

Data from 53 physiotherapists and 48 dietitians were included. Malnutrition is considered a shared problem domain by both professions (U = 1248.000; p = 0.858). While sarcopenia is treated by both professions (U = 1260.000; p = 0.927), physiotherapists consider sarcopenia more often a shared problem domain compared to dietitians (U = 1003.000; p = 0.044). Attitudes towards interprofessional treatment were mostly positive (73%, n = 35 and 87%, n = 46 respectively). Interprofessional identity of dietitians was lower compared to physiotherapists (median = 4.0 versus median = 4.3 respectively; U = 875.000, p = 0.007). This was explained by lower interprofessional belonging (median = 4.0 versus median = 4.8 respectively; U = 771.000, p < 0.001) and lower interprofessional commitment (median = 4.0 versus median = 4.3 respectively; U = 942.500, p = 0.023). Interprofessional identity was correlated with efficient means of communication (r = 0.30, p = 0.003) and bureaucracy (r = −0.21, p = 0.034). Other barriers reported included available time, financial compensation, interprofessional knowledge, and obtaining extra care. Most reported facilitators concerned role clarity, clarity of expertise, and willingness of others to collaborate.

Conclusion

Dietitians and physiotherapists have different interprofessional identities, but both are advocates of interprofessional treatment. Both professions mostly treat malnutrition and sarcopenia individually and have different perceptions regarding sarcopenia as shared problem domain. Facilitators were mainly related to clarity and commitment while barriers were mainly related to resources.