Evidence-Based Analysis of Protected Mealtime Policies on Patient Nutrition and Care

The clinical advantages of making our hospitals older adult friendly

Older adults (≥65 years old), now comprise half of the inpatient population. Catering for the needs of this group requires consideration of the processes of care, the inpatient environment and care practices operating in our hospitals. Older adults are often multimorbid, more likely than older adults in the community to be malnourished and have coexistent physical and cognitive impairments. These older adults are at great risk of suffering hospital associated harms or being designated as "bed blockers", partly due to inadequate understanding of their needs, a failure of recognition or an unwillingness to address them. The adoption of older adult friendly care presents considerable opportunity to transform the manner in which care is delivered in order to mitigate avoidable harms and optimize outcomes for older adults. This review explores the nature of our older adult inpatients, the implications of older adult friendly care, the requirement for true interprofessional care, the advantages of systematic assessment which spans pre-hospital to post-hospital care and highlights specific interventions to deal with in hospital problems which differentially impair health related outcomes for older adults. As such it raises awareness of the needs of older adults under cardiological to improve outcomes for hospitalized older adults.

Exploring hospital mealtime experiences of older inpatients, caregivers and staff using photovoice methods

AIM

To gather and understand the experience of hospital mealtimes from the perspectives of those receiving and delivering mealtime care (older inpatients, caregivers and staff) using photovoice methods to identify touchpoints and themes to inform the co-design of new mealtime interventions.

METHODS

This study was undertaken on acute care wards within a single metropolitan hospital in Brisbane, Australia in 2019. Photovoice methods involved a researcher accompanying 21 participants (10 older patients, 5 caregivers, 4 nurses and 2 food service officers) during a mealtime and documenting meaningful elements using photographs and field notes. Photo-elicitation interviews were then undertaken with participants to gain insight into their experience. Data were analysed using inductive thematic analysis, involving a multidisciplinary research team including a consumer.

RESULTS

Themes were identified across the three touchpoints: (1) preparing for the meal (the juggle, the anticipation), (2) delivering/receiving the meal (the rush, the clutter and the wait) and (3) experiencing the meal (the ideal, pulled away and acceptance). Despite a shared understanding of the importance of meals and shared vision of 'the ideal' mealtime, generally this was a time of tension, missed cares and dissatisfaction for staff, patients and caregivers. There was stark contrast in some aspects of mealtime experience, with simultaneous experiences of 'the rush' (staff) and 'the wait' (patients and caregivers). There was an overwhelming sense of acceptance and lack of control over change from all.

CONCLUSIONS

This study identified themes during hospital mealtimes which have largely gone unaddressed in the design of mealtime interventions to date. This research may provide a framework to inform the future co-design of mealtime interventions involving patients, caregivers and multidisciplinary staff, centred around these key touchpoints.

PRACTICE IMPLICATIONS

Mealtimes are experienced differently by patients, caregivers, nurses and food service officers across three key touchpoints: preparing for, delivering/receiving and experiencing the meal. Improving mealtime experiences therefore necessitates a collaborative approach, with co-designed mealtime improvement programs that include specific interventions focusing each touchpoint. Our data suggest that improvements could focus on reducing clutter, clarifying mealtime roles and workflows and supporting caregiver involvement.

IMPACT

What problem did the study address? Mealtimes are the central mechanism to meet patients' nutritional needs in hospital; however, research consistently shows that many patients do not eat enough to meet their nutritional requirements and that they often do not receive the mealtime assistance they require. Interventions to improve hospital mealtimes have, at best, shown only modest improvements in nutritional intake and mealtime care practices. Gaining deeper insight into the mealtime experience from multiple perspectives may identify new opportunities for improvement. What were the main findings? Patients, caregivers and staff have shared ideals of comfort, autonomy and conviviality at mealtimes, but challenges of complex teamwork and re-prioritisation of mealtimes in the face of prevailing power hierarchies make it difficult to achieve this ideal. There are three discrete touchpoints (preparing for, delivering/receiving and experiencing the meal) that require different approaches to improvement. Our data suggests a need to focus improvement on reducing clutter, clarifying mealtime roles and workflows and supporting caregivers. Where and on whom will the research have an impact? The research provides a framework for multidisciplinary teams to begin co-designing improvements to mealtime care to benefit patients, caregivers and staff, while also providing a method for researchers to understand other complex care situations in hospital.

REPORTING METHOD

This manuscript is written in adherence with the Standards for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

Patients and caregivers were involved in the conception and design of the study through their membership of the hospital mealtime reference group. A consumer researcher (GP) was involved in the team to advise on study conduct (i.e. recruitment methods and information), data analysis (i.e. coding transcripts), data interpretation (i.e. review and refinement of themes) and manuscript writing (i.e. review and approval of final manuscript).

Improving nutrition care and diet intake for hospitalised older people at risk of malnutrition through a nurse-driven mealtime assistance bundle

BACKGROUND

Poor dietary intake is common in hospitalised older people. A targeted mealtime intervention is needed to improve nutrition care and dietary intake, especially for those at risk of malnutrition.

OBJECTIVES

This quality improvement project designed, implemented and evaluated a mealtime assistance bundle consisting of care measures driven by the hospital nursing team. The aims were to improve the mealtime care process to promote dietary intake of the hospitalised older people and to improve nursing staff's knowledge, attitude and practice in malnutrition.

METHODS

This project adopted a pre-post design, targeting older people aged 65 years and above, who were admitted to a general medical unit in a regional hospital in Singapore. A mealtime assistance bundle consisting of seven care measures, using the acronym CANFEED, was implemented for older adults at risk of malnutrition. Outcome measures on the amount of dietary intake during meals through chart reviews and surveys of nursing staff using Malnutrition Knowledge, Attitudes and perceived Practices (M-KAP) questionnaire were performed before and after implementation.

RESULTS

There were fewer older adults with poor intake in the post-implementation group than the pre-implementation group. Among those at risk of malnutrition, older adults in the post-implementation group had higher average intake of all provided meals as well as the protein-dense main dish. Significant improvements were noted in the total scores rated by the nursing staff in both the Knowledge-Attitude subscale and Practice subscale of the M-KAP questionnaire.

CONCLUSIONS

Integrating a nurse-driven mealtime assistance bundle into usual care may have positive outcomes on nutritional intake of hospitalised older people at risk of malnutrition, and on knowledge, attitude and practice of hospital nurses in nutrition care.

IMPLICATIONS FOR PRACTICE

Nurses play a critical role in nutrition care for hospitalised older people. Continuing efforts to improve nutritional intake of hospitalised older people should focus on staff education, building a multidisciplinary food-promoting culture and patient, family and community empowerment. More efficient clinical processes incorporating information technology with the EMR to support better nutrition care of the hospitalised older people are needed.

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.

Impact of a surgical ward breakfast buffet on nutritional intake in postoperative patients: A prospective cohort pilot study

BACKGROUND

An early return to normal intake and early mobilization enhances postoperative recovery. However, one out of six surgical patients is undernourished during hospitalization and approximately half of the patients eat 50% or less of the food provided to them. We assessed the use of newly introduced breakfast buffets in two wards for gastrointestinal and oncological surgery and determined the impact on postoperative protein and energy intake.

METHODS

A prospective pilot cohort study was conducted to assess the impact of the introduction of breakfast buffets in two surgical wards. Adult patients had the opportunity to choose between an attractive breakfast buffet and regular bedside breakfast service. Primary outcomes were protein and energy intake during breakfast. We asked patients to report the type of breakfast service and breakfast intake in a diary over a seven-day period. Prognostic factors were used during multivariable regression analysis.

RESULTS

A total of 77 patients were included. The median percentage of buffet use per patient during the seven-day study period was 50% (IQR 0-83). Mean protein intake was 14.7 g (SD 8.4) and mean energy intake 332.3 kcal (SD 156.9). Predictors for higher protein intake included the use of the breakfast buffet (β = 0.06, p = 0.01) and patient weight (β = 0.13, p = 0.01). Both use of the breakfast buffet (β = 1.00, p = 0.02) and Delirium Observation Scale scores (β = -246.29, p = 0.02) were related to higher energy intake.

CONCLUSION

Introduction of a breakfast buffet on a surgical ward was associated with higher protein and energy intake and it could be a promising approach to optimizing such intake in surgical patients. Large, prospective and preferably randomized studies should confirm these findings.