Predictors of dietitian consult on medical and surgical wards

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.

Nutrition and physical activity knowledge, attitudes, and practices of inpatient cirrhosis care providers

BACKGROUND

Hospitalization is a high-risk period for cirrhosis-associated sarcopenia and frailty. This study aimed to measure the knowledge, attitudes, and practice patterns (KAP) of multidisciplinary cirrhosis providers about inhospital nutrition and physical activity care.

METHODS

We conducted an online survey of cirrhosis care providers at a combination of 38 hospitals and healthcare centres in Alberta, Canada. Analysis included descriptive statistics and content analysis.

RESULTS

Three hundred thirty-eight responses were analyzed. Across all providers, nutrition and physical activity knowledge and attitude (KA) scores were higher than practice (P) scores. Physicians had lower nutrition KA ( P = 0.010) and nutrition P ( P < 0.001) scores than nonphysicians. Previous cirrhosis-related nutrition or physical activity education was associated with higher nutrition KA ( P < 0.001), nutrition P ( P = 0.036), and physical activity P scores ( P < 0.001). Over half of the participants reported not providing patients with educational resources for nutrition or physical activity and not carrying out nutrition screening. Participant suggestions to optimize care included enhancing patient and provider education, standardizing screening and intervention processes, increasing patient-centered support, and promoting collaboration within the healthcare team. Eighty percentage of participants were willing to provide patients with resources if these were readily available.

CONCLUSION

While provider knowledge and attitudes about the importance of nutrition and physical activity in hospitalized patients with cirrhosis are reasonable, there is considerable room to optimize the delivery of best practices in this patient population. Optimization will require readily available educational and personnel resources and interdisciplinary collaboration to promote system change.

NutriSup-PPN: A pilot randomized control trial of oral nutritional supplementation (ONS) and peripheral parenteral nutrition (PPN) in canadian, malnourished, hospitalized patients

BACKGROUND & AIMS

Hospitalized malnourished patients experience poor outcomes. Our study determined the feasibility of a novel nutritional care pathway which both rapidly identifies and treats malnourished medical inpatients accounting for the obstacles in nutritional optimization. In our interventional arm, we utilize peripheral parental nutrition (PPN) followed by oral nutritional supplementation (ONS) on a composite outcome of 30 day readmission, mortality and continued admission, as well other important clinical and nutritional outcomes. The study was registered under ClinicalTrials.gov Identifier no. NCT02632630.

METHODS

NutriSUP-PPN was a 2 × 2 factorial pilot randomized trial. In two large Canadian hospitals, we recruited 100 adult patients >18 years, < 48 h from admission to a general medicine ward who were moderately or severely malnourished. Patients received: 1. PPN for 5 days and then enhanced ONS until 30 days post randomization; 2. PPN for 5 days and then standard ONS until 30 days; 3. Standard care for intravenous (IV) fluid administration for 5 days and then enhanced ONS until 30 days; 4. Standard care for IV fluid administration for 5 days and standard ONS until 30 days. Our primary outcome was a composite of 30 day readmission, continued admission and mortality.

RESULTS

There was no significant differences in the composite outcome of 30 day readmission, continued admission or mortality between any interventional group and control. We did however note a trend in the PPN + ONS arm where only 4/22 patients versus 10/24 patients (p = 0.16) in the control (no PPN, no enhanced ONS) experienced an adverse outcome which was largely driven by a reduction of readmission in the ONS + PPN arm We demonstrated feasibility in recruitment, adherence to protocol, and safety. The incidence of sepsis was greater in the PPN arm compared to control (15.5% versus 4.2%) but was not statistically significant. Improvement in nutritional status for interventional arms were not significant compared to control. However, there was a trend of improvement in preventing decline of nutritional status in both the enhanced ONS arm and PPN + enhanced ONS arm.

CONCLUSION

There are signals in our data, which suggest that the combination of PPN with ONS may improve both clinical and nutritional outcomes compared to PPN or ONS alone. We posit that a large, multi-center, definitive randomized control trial is now justified to determine if PPN for up to 5 days along with 30 days of ONS, versus standard of care, will improve a composite outcome of death, continued admission, and readmission at 30 days. However, because PPN was associated with a non-statistically significant increase in episodes of sepsis, future studies should ensure that sepsis episodes are well documented and monitored closely by the data safety monitoring board.

High Turnover in Clinical Dietetics: A Descriptive Analysis

Purpose: To identify key attributes of Canadian clinical registered dietitian (RD) jobs associated with high rates of turnover.Methods: Managers of clinical RDs in Canada were eligible to complete a survey on the topic of turnover in clinical RD positions. Specifically, key details were sought regarding positions with the highest and lowest turnover in each manager's portfolio.Results: High turnover (HT) positions turned over an average of 4.0 times in a 5-year period in contrast to 0.3 times in low turnover (LT) positions. Resignation was the top reason for turnover in both HT and LT positions. HT and LT positions were of analogous full-time equivalent, had comparable caseloads, and served clients/patients with similar diagnoses including diabetes and neurological conditions.Conclusions: There is significant variation in the frequency of turnover across positions in clinical dietetics in Canada. What differentiates HT positions from LT positions remains unclear. More research is required to guide managers seeking to balance turnover and preclude uneven nutrition care quality across units and programs.

Canadian Nationwide Survey on Pediatric Malnutrition Management in Tertiary Hospitals

Background: Disease-associated malnutrition (DAM) is common in hospitalized children. This survey aimed to assess current in-hospital practices for clinical care of pediatric DAM in Canada. Methods: An electronic survey was sent to all 15 tertiary pediatric hospitals in Canada and addressed all pillars of malnutrition care: screening, assessment, treatment, monitoring and follow-up. Results: Responses of 120 health care professionals were used from all 15 hospitals; 57.5% were medical doctors (MDs), 26.7% registered dietitians (RDs) and 15.8% nurses (RNs). An overarching protocol for prevention, detection and intervention of pediatric malnutrition was present or “a work in progress”, according to 9.6% of respondents. Routine nutritional screening on admission was sometimes or always performed, according to 58.8%, although the modality differed among hospitals and profession. For children with poor nutritional status, lack of nutritional follow-up after discharge was reported by 48.5%. Conclusions: The presence of a standardized protocol for the clinical assessment and management of DAM is uncommon in pediatric tertiary care hospitals in Canada. Routine nutritional screening upon admission has not been widely adopted. Moreover, ongoing nutritional care of malnourished children after discharge seems cumbersome. These findings call for the adoption and implementation of a uniform clinical care pathway for malnutrition among pediatric hospitals.

An appealing meal: Creating conditions for older persons' mealtimes - a focus group study with healthcare professionals

BACKGROUND

Healthcare professionals' knowledge and attitudes may have an impact on older persons' nutritional status. Therefore, it is important to explore different healthcare professionals' perspectives on older persons' meals.

AIM

The aim of this study was to describe healthcare professionals' understanding of and views on the mealtime experience of older persons in municipal care.

METHODS

Seven focus group discussions with various healthcare professionals (nurse assistants, registered nurses and occupational therapists) (n = 52) working in nursing homes and/or home care for older persons were conducted and analysed using interpretive description. The COREQ checklist was used for reporting the findings.

RESULTS

The results revealed a striving to create conditions for an appealing meal, regardless of profession. This overall theme, 'An appealing meal - creating conditions for older persons' mealtimes', consisted of four sub-themes: 'Food is crucial', 'The mealtime as a social interaction', 'Identifying the individual older person's needs' and 'Integrating different perspectives of meal-related situations among the team'.

CONCLUSION

The findings show that the different professionals strive to prioritise meals in the everyday care of older persons, but at same time there is a lack of a common view on how to prioritise meal-related issues. This indicates that the care may be fragmented, being based on each professional's duties and interpretation of responsibility for older persons' meals, rather than constituting comprehensive integrated person-centred care provided by a multidisciplinary team.

RELEVANCE TO CLINICAL PRACTICE

To enhance older persons' mealtimes, we need to map how mealtimes are valued and implemented in clinical practice and approached in healthcare professionals' education. Education on older person's nutritional needs should be team-based, and not focus on the perspective of a single profession.

High turnover in clinical dietetics: a qualitative analysis

BACKGROUND

Relationships between dietitians and other healthcare providers can impact the degree to which patient care is collaborative; inefficient communication can lead to suboptimal care. It takes time for multidisciplinary team members to build collaborative, trusting relationships. For this reason, frequent dietitian turnover is of concern. Consequences include fewer referrals to clinical dietetic services and limited provider continuity. The characteristics of clinical dietetic jobs associated with high turnover have not been identified. We predicted that managers would identify disease prestige as having an impact. In this study, we aimed to explore: 1) characteristics of clinical dietetic jobs associated with the highest turnover, and 2) consequences of high turnover on patients and managers of clinical dietitians.

METHODS

Research assistants conducted semi-structured interviews with ten managers of clinical dietitians in the Canadian public healthcare system. We employed a constant comparative approach to thematic analysis. We classified themes related to turnover as either avoidable or unavoidable.

RESULTS

Sub-themes under avoidable turnover included lack of manager support, growth opportunities, burnout/workload, tension/conflict and hours of work. Sub-themes under unavoidable turnover included life-stage/life-events and geography. We also identified themes related to consequences of turnover, including: burnout/workload, client/patient impact, tension/conflict, cost and gap-specific. As predicted, prestige was perceived as playing a role in triggering dietitian turnover. Managers observed high turnover resulting in low provider continuity and limiting patient access to dietitians.

CONCLUSIONS

Managers of publicly-employed dietitians identified many factors as contributing to high turnover. Future prospective research, incorporating the objective measure of turnover and multi-method analysis of work characteristics and work setting, would be of value in the identification of characteristics of clinical dietetic jobs associated with high turnover and the consequences of high turnover on patients and managers of these staff.

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

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

Predictors of Dietitian Referrals in Hospitals

Dietitian involvement has considerable benefits for hospitalized patients, resulting in better health outcomes and improved quality of life. However, dietitian referral routines are often inappropriate in hospitals. The aim of this study was to identify predictors for dietitian referrals in hospitalized patients. This study was performed on data collected in an annually conducted cross-sectional study (in the years 2017, 2018, 2019). A standardized questionnaire was used to collect data, and logistic regression and a generalized estimating equation (GEE) model were used to calculate the associations between the patient characteristics and dietitian referrals. In the final GEE model, the following predictors for dietitian referrals remained significant: diabetes diagnosis (OR 1.80), cancer diagnosis (OR 1.76), digestive disease diagnosis (OR 2.03), presence of a pressure injury (OR 1.58), risk of malnutrition based on body mass index (BMI) and weight loss (OR 1.72), risk of malnutrition based on the malnutrition universal screening tool (MUST) (2.55), and the application of any malnutrition screening at admission to hospital (2.20). Total dietitian referral rate was 16.8%. The highest rate of dietitian referrals was found in patients with a risk of malnutrition (37%). This study included a large sample of hospitalized adult patients and revealed a low dietitian referral rate among these patients. These results indicate that dietitian involvement in hospitalized patients with nutrition-related conditions urgently needs to be improved.

The role of the dietitian in the management of malnutrition in the elderly: A systematic review of current practices

AIM

The prevalence of age-related malnutrition is increasing in almost all Western countries. Because of their expertise, dietitians should have a central role in the management of malnutrition. This review aimed to synthesise the literature on the role of the dietitian in the management of malnutrition in the elderly in comparison with other health professionals.

METHODS

In November 2018, a search of Embase, Medline Ovid, Cinahl Ebscohost, Cochrane Central, Web of Science and Google Scholar was undertaken using 'dietitian', 'elderly' and 'malnutrition' as the main search terms. Qualitative and quantitative empirical research studies that focussed on the role of dietitians as the (main) subject of the study were included. Data extraction and data synthesis were performed by the three authors using a thematic synthesis approach.

RESULTS

Three themes emerged from the coding and synthesis of the 21 included studies. The first theme demonstrates that other health professionals' time for, and knowledge of, screening policies negatively affects the role of the dietitian. The second theme demonstrates that the importance of nutritional care is acknowledged. However, this does not always imply familiarity with dietetics nor does it always mean that other health professionals think involving dietitians is worth the effort. The third theme demonstrates that issues of workload appeared to be especially important in crossing or guarding role boundaries.

CONCLUSIONS

The role of dietitians in managing age-related malnutrition is not always clear and coherent. Therefore, how dietitians shape their role to provide optimal management of malnutrition in the elderly is open to debate.

Food Service Workers: Reliable Assessors of Food Intake in Hospitalized Patients

Early detection of malnutrition in hospitalized patients is of paramount importance. As poor food intake is a marker of malnutrition risk, a simple and accurate method to monitor intake is valuable. This quality assurance project aimed to determine if food service workers (FSW) were able to provide accurate estimates of patient intakes through visually assessing meal trays at an acute care hospital. FSW conducted visual estimates of patient trays after meals using the meal plate pictorial rating scale adapted from the My Meal Intake Tool and translated their estimates into one of 5 consumption levels (0%, 25%, 50%, 75%, or 100%). A total of 401 patient meal estimates were validated using the food weighing method. Spearman's correlations between percent calories consumed (determined by weight) and estimates by FSW were 0.624 (n = 137, P < 0.001), 0.771 (n = 134, P < 0.001), and 0.829 (n = 130, P < 0.001), for breakfast, lunch, and supper, respectively. Paired Wilcoxon tests and the Kruskal-Wallis H test showed that accuracy varied for breakfast, lunch, and supper. The overall sensitivity and specificity of FSW for detecting patient intake ≤50% was 81% and 88%, respectively. These findings identify that FSW can accurately estimate patient intake, contributing an important marker for the detection of malnutrition.

Pre-operative nutrition and the elective surgical patient: why, how and what?

Pre-operative nutrition therapy is increasingly recognised as an essential component of surgical care. The present review has been formatted using Simon Sinek's Golden Circle approach to explain 'why' avoiding pre-operative malnutrition and supporting protein anabolism are important goals for the elective surgical patient, 'how' peri-operative malnutrition develops leading in part to a requirement for pre-operative anabolic preparation, and 'what' can be done to avoid pre-operative malnutrition and support anabolism for optimal recovery.

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.

Multi-site implementation of nutrition screening and diagnosis in medical care units: Success of the More-2-Eat project

BACKGROUND

Improving the detection and treatment of malnourished patients in hospital is needed to promote recovery.

AIM

To describe the change in rates of detection and triaging of care for malnourished patients in 5 hospitals that were implementing an evidence-based nutrition care algorithm. To demonstrate that following this algorithm leads to increased detection of malnutrition and increased treatment to mitigate this condition.

METHODS

Sites worked towards implementing the Integrated Nutrition Pathway for Acute Care (INPAC), including screening (Canadian Nutrition Screening Tool) and triage (Subjective Global Assessment; SGA) to detect and diagnose malnourished patients. Implementation occurred over a 24-month period, including developmental (Period 1), implementation (Periods 2-5), and sustainability (Period 6) phases. Audits (n = 36) of patient health records (n = 5030) were conducted to identify nutrition care practices implemented with a variety of strategies and behaviour change techniques.

RESULTS

All sites increased nutrition screening from Period 1, with three achieving the goal of 75% of admitted patients being screened by Period 3, and the remainder achieving a rate of 70% by end of implementation. No sites were conducting SGA at Period 1, and sites reached the goal of a 75% completion rate or referral for those identified to be at nutrition risk, by Period 3 or 4. By Period 2, 100% of patients identified as SGA C (severely malnourished) were receiving a comprehensive nutritional assessment. In Period 1, the nutrition diagnosis and documentation by the dietitian of 'malnutrition' was a modest 0.37%, increasing to over 5% of all audited health records. The overall use of any Advanced Nutrition Care practices increased from 31% during Period 1 to 63% during Period 6.

CONCLUSION

The success of this multi-site study demonstrated that implementation of nutrition screening and diagnosis is feasible and leads to appropriate care. INPAC promotes efficiency in nutrition care while minimizing the risk of missing malnourished patients.

TRIAL REGISTRATION

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

The My Meal Intake Tool (M-MIT): Validity of a Patient Self- Assessment for Food and Fluid Intake at a Single Meal

OBJECTIVES

Hospital malnutrition is an under-recognized issue that leads to a variety of adverse outcomes, especially for older adults. Food/fluid intake (FFI) monitoring in hospital can be used to identify those who are improving and those who need further treatment. Current monitoring practices such as calorie counts are impractical for all patients and a patient-completed tool, if valid, could support routine FFI monitoring. The aim of this research was to determine whether the patient-completed My Meal Intake Tool (M-MIT) can accurately represent FFI at a single meal.

DESIGN

Cross-sectional, multi-site.

SETTING

Four acute care hospitals in Canada.

PARTICIPANTS

120 patients (65+ yrs, adequate cognition).

MEASUREMENTS

Participants completed M-MIT for a single meal. Food and fluid waste was visually estimated by a research dietitian at each hospital. Sensitivity (Se), specificity (Sp) and overall agreement were calculated for both food and fluid intake by comparing M-MIT and dietitian estimations to determine criterion validity of M-MIT. Patient and research dietitian comments were used to make revisions to the M-MIT.

RESULTS

Using a cut-point of ≤50% intake, Se was 76.2% and 61.9% and Sp was 74.0% and 80.5% for solid and fluids respectively (p<0.001). M-MIT identified a greater proportion of participants (37.2%) as having low FFI (≤50%) than dietitians (25.0%), as well as a greater proportion identified with low fluid intake (28.3% vs. 24.6%). Modest revisions were made to improve the tool.

CONCLUSION

This study has demonstrated initial validity of M-MIT for use in older patients with adequate cognition. Use of M-MIT could promote FFI monitoring as a routine practice to make clinical decisions about care.

Comparing Hospital Staff Nutrition Knowledge, Attitudes, and Practices Before and 1 Year After Improving Nutrition Care: Results From the More-2-Eat Implementation Project

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.

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

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.

The Integrated Nutrition Pathway for Acute Care (INPAC): Building consensus with a modified Delphi

Background

Malnutrition is commonly underdiagnosed and undertreated in acute care patients. Implementation of current pathways of care is limited, potentially as a result of the perception that they are not feasible with current resources. There is a need for a pathway based on expert consensus, best practice and evidence that addresses this crisis in acute care, while still being feasible for implementation.

Methods

A modified Delphi was used to develop consensus on a new pathway. Extant literature and other resources were reviewed to develop an evidence-informed background document and draft pathway, which were considered at a stakeholder meeting of 24 experts. Two rounds of an on-line Delphi survey were completed (n = 28 and 26 participants respectively). Diverse clinicians from four hospitals participated in focus groups to face validate the draft pathway and a final stakeholder meeting confirmed format changes to make the pathway conceptually clear and easy to follow for end-users. Experts involved in this process were researchers and clinicians from dietetics, medicine and nursing, including management and frontline personnel.

Results

80 % of stakeholders who were invited, participated in the first Delphi survey. The two rounds of the Delphi resulted in consensus for all but two minor components of the Integrated Nutrition Pathway for Acute Care (INPAC). The format of the INPAC was revised based on the input of focus group participants, stakeholders and investigators.

Conclusions

This evidence-informed, consensus based pathway for nutrition care has greater depth and breadth than prior guidelines that were commonly based on systematic reviews. As extant evidence for many best practices is absent, the modified Delphi process has allowed for consensus to be developed based on better practices. Attention to feasibility during development has created a pathway that has greater implementation potential. External validation specifically with practitioner groups promoted a conceptually easy to use format. Test site implementation and evaluation is needed to identify resource requirements and demonstrate process and patient reported outcomes resulting from embedding INPAC into clinical practice.