Decline in nutritional status is associated with prolonged length of stay in hospitalized patients admitted for 7 days or more: A prospective cohort study

Incidence and outcomes of in-hospital nutritional decline: A prospective observational cohort study in adult patients

BACKGROUND AND AIMS

Hospital malnutrition is associated with higher healthcare costs and worse outcomes. Only a few prospective studies have evaluated trends in nutritional status during an acute stay, but these studies were limited by the short timeframe between nutrition assessments. The aim of this study was to investigate changes in nutritional status, incidence of hospital-acquired malnutrition (HAM), and the associated risk factors and outcomes in acute adult patients admitted for >14 days.

METHODS

A prospective observational cohort study was conducted in two medical and two surgical wards in a tertiary hospital in Brisbane, Australia. Nutrition assessments were performed using the Subjective Global Assessment at baseline (day eight) and weekly until discharge. Nutritional decline was defined as a change from well-nourished to moderate/severe malnutrition (HAM) or from moderate to severe malnutrition (further decline) >14 days after admission.

RESULTS

One hundred and thirty patients were included in this study (58.5% male; median age 67.0 years (IQR 24.4), median length of stay 23.5 days (IQR 14)). At baseline, 70.8% (92/130) of patients were well-nourished. Nutritional decline occurred in 23.8% (31/130), with 28.3% (26/92) experiencing HAM. Of the patients with moderate malnutrition on admission (n = 30), 16% (5/30) continued to decline to severe malnutrition. Improvement in nutritional status from moderate and severe malnutrition to well-nourished was 18.4% (7/38). Not being prescribed the correct nutrition care plan within the first week of admission was an independent predictor of in-hospital nutritional decline or remaining malnourished (OR 2.3 (95% CI 1.0-5.1), p = 0.039). In-hospital nutritional decline was significantly associated with other hospital-acquired complications (OR 3.07 (95% CI 1.1-8.9), p = 0.04) and longer length of stay (HR 0.63 (95% CI 0.4-0.9), p = 0.044).

CONCLUSION

This study found a high rate of nutritional decline in acute patients, highlighting the importance of repeated nutrition screening and assessments during hospital admission and proactive interdisciplinary nutrition care to treat or prevent further nutritional decline.

Exploring the impact of arginine-supplemented immunonutrition on length of stay in the intensive care unit: A retrospective cross-sectional analysis

BACKGROUND

Arginine-supplemented enteral immunonutrition has been designed to optimize outcomes in critical care patients. Existing formulas may be isocaloric and isoproteic, yet differ in L-arginine content, energy distribution, and in source and amount of many other specialized ingredients. The individual contributions of each may be difficult to pinpoint; however, all cumulate in the body's response to illness and injury. The study objective was to compare health outcomes between different immunonutrition formulas.

METHODS

Real-world data from October 2015 -February 2019 in the PINC AI™ Healthcare Database (formerly the Premier Healthcare Database) was reviewed for patients with an intensive care unit (ICU) stay and ≥3 days exclusive use of either higher L-arginine formula (HAF), or lower L-arginine formula (LAF). Multivariable generalized linear model regression was used to check associations between formulas and ICU length of stay.

RESULTS

3,284 patients (74.5% surgical) were included from 21 hospitals, with 2,525 receiving HAF and 759 LAF. Inpatient mortality (19.4%) and surgical site infections (6.2%) were similar across groups. Median hospital stay of 17 days (IQR: 16) did not differ by immunonutrition formula. Median ICU stay was shorter for patients receiving HAF compared to LAF (10 vs 12 days; P<0.001). After adjusting for demographics, visit, severity of illness, and other clinical characteristics, associated regression-adjusted ICU length of stay for patients in the HAF group was 11% shorter [0.89 (95% CI: 0.84, 0.94; P<0.001)] compared to patients in the LAF group. Estimated adjusted mean ICU length of stay was 9.4 days (95% CI: 8.9, 10.0 days) for the HAF group compared to 10.6 days (95% CI: 9.9, 11.3 days) for the LAF group (P<0.001).

CONCLUSIONS

Despite formulas being isocaloric and isoproteic, HAF use was associated with significantly reduced ICU length of stay, compared to LAF. Higher arginine immunonutrition formula may play a role in improving health outcomes in primarily surgical critically ill patients.

Prevalence of the use of oral nutritional supplements among acute inpatients at risk of malnutrition and associated patient characteristics

AIM

To provide a snapshot of the current use of oral nutritional supplements, its association with inpatient characteristics, and with a focus on the role of nursing monitoring of food intake and implementing nutritional interventions for patients with low intake.

DESIGN

Retrospective cohort study.

METHODS

The study collected data from a hospital database regarding oral nutritional supplement initiation and variables of patients hospitalised in internal medicine departments, who did not receive enteral or parenteral nutrition.

RESULTS

Of the 5155 admissions, 1087 fulfilled the inclusion criteria (47% female; mean age, 72.4 ± 14.6 years; mean length of stay, 14.6 ± 11.4 days). Sufficient food intake reporting was noted in 74.6% of the patients; of these 17% had decreased intake. Oral nutritional supplements and non-oral nutritional supplements groups did not differ in terms of sex, age, length of stay, Charlson Comorbidity Index, proportion of nursing reports, and absence of intake monitoring. Oral nutritional supplements were initiated in 31.9% of patients with a Malnutrition Universal Screening Tool score ≥2 and in 34.6% with decreased food intake. On multivariable analysis, hypoalbuminemia (adjusted odds ratio, 3.70), decreased food intake (adjusted odds ratio, 3.38), Malnutrition Universal Screening Tool score ≥2 (adjusted odds ratio, 2.10), and age <70 years (adjusted odds ratio, 1.56) were significantly associated with oral nutritional supplements use.

CONCLUSION

The prevalence of oral nutritional intervention was suboptimal in patients at risk of malnutrition during acute hospitalisation, although decreased food intake and Malnutrition Universal Screening Tool score ≥2 independently increased the probability of oral nutritional supplements initiation.

RELEVANCE IN CLINICAL PRACTICE

Understanding the clinical practice and nursing impact of care management in relation to nutritional intervention can assist in reviewing and improving patient care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE IMPACT (ADDRESSING): This study informs clinical management and influences nursing practice standards related to assessing, monitoring, and managing malnutrition risk.

IMPACT

The study impacts the quality of care for patients at risk of malnutrition.

REPORTING METHOD

We adhered to the STROBE Checklist for cohort studies.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

The mode and timing of administrating nutritional treatment of critically ill elderly patients in intensive care units: a multicenter prospective study

Introduction

Critically ill patients are more susceptible to malnutrition due to their severe illness. Moreover, elderly patients who are critically ill lack specific nutrition recommendations, with nutritional care in the intensive care units (ICUs) deplorable for the elderly. This study aims to investigate nutrition treatment and its correlation to mortality in elderly patients who are critically ill in intensive care units.

Method

A multiple-center prospective cohort study was conducted in China from 128 intensive care units (ICUs). A total of 1,238 elderly patients were included in the study from 26 April 2017. We analyzed the nutrition characteristics of elderly patients who are critically ill, including initiated timing, route, ways of enteral nutrition (EN), and feeding complications, including the adverse aspects of feeding, acute gastrointestinal injury (AGI), and feeding interruption. Multivariate logistic regression analysis was used to screen out the impact of nutrition treatment on a 28-day survival prognosis of elderly patients in the ICU.

Result

A total of 1,238 patients with a median age of 76 (IQR 70-83) were enrolled in the study. The Sequential Organ Failure (SOFA) median score was 7 (interquartile range: IQR 5-10) and the median Acute Physiology and Chronic Health Evaluation (APACHE) II was 21 (IQR 16-25). The all-cause mortality score was 11.6%. The percentage of nutritional treatment initiated 24 h after ICU admission was 58%, with an EN of 34.2% and a parenteral nutrition (PN) of 16.0% in elderly patients who are critically ill. Patients who had gastrointestinal dysfunction with AGI stage from 2 to 4 were 25.2%. Compared to the survivors' group, the non-survivors group had a lower ratio of EN delivery (57% vs. 71%; p = 0.015), a higher ratio of post-pyloric feeding (9% vs. 2%; p = 0.027), and higher frequency of feeding interrupt (24% vs. 17%, p = 0.048). Multivariable logistics regression analysis showed that patients above 76 years old with OR (odds ratio) 2.576 (95% CI, 1.127-5.889), respiratory rate > 22 beats/min, and ICU admission for 24 h were independent risk predictors of the 28-day mortality study in elderly patients who are critically ill. Similarly, other independent risk predictors of the 28-day mortality study were those with an OR of 2.385 (95%CI, 1.101-5.168), lactate >1.5 mmol/L, and ICU admission for 24 h, those with an OR of 7.004 (95%CI, 2.395-20.717) and early PN delivery within 24 h of ICU admission, and finally those with an OR of 5.401 (95%CI, 1.175-24.821) with EN delivery as reference.

Conclusion

This multi-center prospective study describes clinical characteristics, the mode and timing of nutrition treatment, frequency of AGI, and adverse effects of nutrition in elderly ICU patients. According to this survey, ICU patients with early PN delivery, older age, faster respiratory rate, and higher lactate level may experience poor prognosis.

Effect of Preoperative Malnutrition Based on Albumin and BMI on Hepatocellular Carcinoma Surgery and Prediction of Risk Factors of Complications

BACKGROUND

To investigate the correlation between preoperative malnutrition and perioperative variables in patients with hepatocellular carcinoma (HCC) and to analyze the risk factors of complications after HCC resection.

METHODS

All patients who underwent hepatectomy because of HCC in the First Affiliated Hospital of Chongqing Medical University from June 1, 2018, to December 1, 2021, were analyzed retrospectively. Preoperative malnutrition was defined as body mass index (BMI) < 18.5 kg/m2 or serum albumin level < 3.5 g/dL within 30 days before operation.

RESULTS

A total of 415 patients with HCC hepatectomy were included, and 75 (18.1%) were classified as malnutrition group. In the malnutrition group, blood loss (662.1 ± 748.1 VS 404.6 ± 681.9, P = 0.002), transfusion rate (36.0% VS 13.5%, P < 0.001), postoperative hospital stays (13.3 ± 9.6 VS 10.1 ± 4.2, P < 0.001), 30-day postoperative mortality (4.0 VS 0.6%, P = 0.043), complications rate (68% VS 34.8%, P < 0.001), and severe complication rate (17.3% VS 2.4%, P < 0.001) were significantly higher than those in the well-nourished group. Multivariate analysis showed that age (HR 1.037, 95% CI 1.015-1.059, P = 0.001), preoperative malnutrition (HR 2.933, 95% CI 1.515-5.679, P = 0.001), simultaneous cholecystectomy (HR 2.004, 95% CI 1.168-3.440, P = 0.012), cirrhosis (HR 4.997, 95% CI 2.864-8.718, P < 0.001), and transfusion (HR 5.166, 95% CI 2.272-11.748, P < 0.001) were independent risk factors for postoperative complications. In addition, preoperative malnutrition (HR 8.209, 95% CI 2.711-24.864, P < 0.001) and operation time (HR 1.088, 95% CI 1.003-1.103, P = 0.004) were independent risk factors for severe complications.

CONCLUSION

Preoperative malnutrition can adversely affect the outcome of HCC resection. For patients with advanced age, cirrhosis, and malnutrition, preoperative planning is very important, and we should be more careful during the operation to avoid transfusion caused by bleeding and not to carry out preventive cholecystectomy, which are helpful to reduce the occurrence of postoperative complications.

Community-Based Nutrition Risk Screening in Older Adults (COMRISK): An Exploration of the Experience of Being Screened and Prevalence of Nutrition Risk in Alberta, Canada

The objectives of this feasibility study were to measure the prevalence of nutrition risk in community-dwelling older adults (CDOA, ages ≥ 65 years) and explore the perspectives of CDOA of the acceptability, value, and effectiveness of nutrition risk screening in primary care and community settings. Using the Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN)© eight-item tool (n = 276), results indicated that moderate and high nutrition risks affected 50 per cent and 8 per cent, respectively, of those screened. Interviewees (n = 16) agreed that screening is acceptable, important, and valuable (Theme One). Effectiveness was unclear, as only 3 of 16 respondents recalled being told their nutrition risk status. When articulating nutrition-related issues, a food security theme, expressed in the third person, was prominent (Theme Two). Screening for nutrition risk and receiving nutrition information in community-based settings are acceptable to CDOA and medically necessary, as evidenced by the high proportion of CDOA at moderate-high nutrition risk.

Malnutrition screening tool use in a New Zealand hospital: Reliability and rates of malnutrition screening on admission

AIMS

This research aimed to assess the rate and reliability of routine nurse-completed malnutrition screening and report the prevalence of malnutrition risk on admission to Christchurch Hospital.

METHODS

Student dietitians administered the Malnutrition Screening Tool to patients in three speciality wards within 48 h of admission. Student dietitians' Malnutrition Screening Tool scores were compared against documented nurse-completed Malnutrition Screening Tool scores. Data were analysed using descriptive statistics, Fisher's exact test, and Cohen's kappa tests (interrater reliability ⱪ). A p-value <0.05 was considered statistically significant.

RESULTS

Student dietitians, using the Malnutrition Screening Tool, screened 360 (96%) of 377 eligible patients while nurses screened 332 (88%) patients. Student dietitians and nurses screened 119 patients (33%) and 63 patients (18%) respectively at risk of malnutrition. There was fair agreement (ⱪ = 0.311) in Malnutrition Screening Tool total scores between nurses and student dietitians. There was a significant difference in the proportion of patients screened at risk of malnutrition between nurses and student dietitians (p < 0.0001).

CONCLUSION

Malnutrition risk remains high in acute care settings. Nurses were less likely to screen patients as at risk of malnutrition than student dietitians. Regular support and training in using Malnutrition Screening Tool may help improve the rate and reliability of routine malnutrition screening.

"More2Eat" in patients at nutritional risk during hospital stay lowers the risk of three-month mortality

BACKGROUND & AIMS

Malnutrition is a common problem among hospitalized patients due to increased nutrient requirements and reduced food intake or uptake of nutrients. The aim of this prospective cohort study was to investigate the association of nutritional risk status (at or not at risk by NRS-2002) as well as energy and protein intake, use of oral nutritional supplements (ONS) and snack meals in at risk patients during hospitalization and adverse outcomes (length of stay (LOS), readmissions and mortality) at three-months follow-up.

METHODS

Data were collected at baseline and at three-months follow-up in patients hospitalized at 31 units at a Danish University Hospital. Diet records were performed at baseline by using the nurses' quartile nutrition recording methods. Data about disease and clinical outcomes were collected from electronic medical records at baseline and three-months follow-up.

RESULTS

A total of 318 patients were included. Patients at nutritional risk (n = 149, 47%) had higher risk of longer LOS (≥20 days (OR = 4.24 [1.81;9.95] and ≥30 days OR = 2.50 [1.22;5.14])), having one readmission (OR = 1.86 [1.15;3.01]) and death (OR = 2.56 [1.27;5.20]) compared to patients not at nutritional risk (n = 169, 53%). A longer LOS was associated with patients who achieved ≥75% of energy and protein requirements, consumed snack meals incl. and excl. oral nutritional supplements. Readmissions in patients at nutritional risk during the three-months were not associated with food intake during the index hospitalization. Mortality was observed in 43 of the 318 (13.5%) hospitalized patients. A lower mortality was associated with increased energy and protein intake in patients at nutritional risk.

CONCLUSIONS

The results of this study indicate a longer LOS, higher readmission rate and increased mortality in patients at nutritional risk compared to patients not at risk. Patients at nutritional risk had lower risk of three-month mortality and longer LOS during index hospitalization with increased energy and protein intake. Readmissions in patients at nutritional risk were not affected by food intake. The association of nutritional risk with poorer outcomes indicates that good nutritional care including constant attention to food-intake during hospitalization can be beneficial regarding mortality.

Canadian Nutrition Society Dialogue on disease-related malnutrition: a commentary from the 2022 Food For Health Workshop

This commentary represents a dialogue on key aspects of disease-related malnutrition (DRM) from leaders and experts from academia, health across disciplines, and several countries across the world. The dialogue illuminates the problem of DRM, what impact it has on outcomes, nutrition care as a human right, and practice, implementation, and policy approaches to address DRM. The dialogue allowed the germination of an idea to register a commitment through the Canadian Nutrition Society and the Canadian Malnutrition Task Force in the UN/WHO Decade of Action on Nutrition to advance policy-based approaches for DRM. This commitment was successfully registered in October 2022 and is entitled CAN DReaM (Creating Alliances Nationally for Policy in Disease-Related Malnutrition). This commitment details five goals that will be pursued in the Decade of Action on Nutrition. The intent of this commentary is to record the proceedings of the workshop as a stepping stone to establishing a policy-based approach to DRM that is relevant in Canada and abroad.

Impact of the Prognostic Nutritional Index on Postoperative Outcomes in Patients Undergoing Heart Surgery

Background Malnutrition is associated with adverse outcomes in patients undergoing cardiac surgery. The prognostic nutritional index (PNI) is a validated tool for assessing nutritional status in cardiovascular diseases. This study aims to evaluate the prognostic value of PNI in heart surgery patients, including mortality rate, length of hospital and ICU stays, and infection rate, while investigating correlations with demographic and clinical characteristics. Methods A retrospective cross-sectional study was conducted in King Fahad Armed Forces Hospital in Jeddah, Saudi Arabia. Data from electronic medical records of patients undergoing heart surgery between 2019 and 2021 were retrospectively reviewed. The study involved patients with valvular heart disease, including those requiring concomitant procedures. Statistical analysis was conducted using t-tests, logistic regression, and Kaplan-Meier survival curve analysis. Results This study included 264 individuals with a mean age of 56.48±12.11 years. The prevalence of low PNI was 50.80% and high PNI was 49.20%. No significant differences in PNI levels were found between individuals with various clinical conditions, except for target vessel revascularization. The mortality rate was slightly higher in the low PNI group, but not statistically significant. Significant differences in laboratory findings were observed between high and low PNI groups. Individuals with low PNI had longer hospital stays. Conclusion Lower PNI levels consistently correlate with longer hospital stays and higher morbidity and mortality rates, suggesting the potential importance of PNI and other nutritional markers in assessing risk and predicting outcomes in cardiac surgery patients.

Controlling Nutritional Status (CONUT) Score as a Predictive Marker in Hospitalized Frail Elderly Patients

The Controlling Nutritional Status (CONUT) score is a simple screening tool able to detect altered nutritional status as well as to predict clinical adverse outcomes in specific populations. No data are available in frail patients. This study aims to investigate the predictive role of the CONUT score on mortality and length of stay (LOS) in frail patients admitted to an Internal Medicine Department. We consecutively enrolled 246 patients aged 65 years or older, divided into two groups based on frailty status. The two groups were further divided according to low (<5) or high (≥5) CONUT score. Length of stay (LOS) was higher in frail patients than not-frail patients, as well as in the frail group with high CONUT scores compared to the frail group with low CONUT scores. Multiple linear regression showed an increase of 2.1 days for each additional point to the CONUT score. In-hospital mortality was higher in frail compared to not-frail patients, but it did not differ between frail patients with high CONUT scores and frail patients with low CONUT scores. An analysis of the survival curve for 30-day mortality showed a higher mortality rate for frail/high-CONUT-score patients as compared to the not-frail/low-CONUT-score group. The CONUT score shows high prognostic value for higher LOS-but not mortality-in the clinical setting of internal medicine departments for old frail patients.

Association of Nutritional Risk Index With Continuous Flow Left Ventricular Assist Device Complications

BACKGROUND

Studies revealing the relationship between major surgery outcomes and nutritional parameters are increasing daily. Publications demonstrating the relationship between early postoperative success and surgical complications in patients with chronic heart failure and continuous flow left ventricular assist device (cf-LVAD) are limited. The vast majority of patients with advanced chronic heart failure are cachexic, and the reason for this is multifactorial. The aim of this study is to investigate the link between the modified nutritional risk index (NRI) and 6-month survival and complication rates in patients with a cf-LVAD.

METHODS

This study included statistical analysis of NRI and postoperative parameters of 456 patients with advanced heart failure who had cf-LVAD implantation between 2010 and 2020.

RESULTS

The results of this study showed a statistically significant difference between mean NRI values and postoperative parameters such as 6-month survival (P = .001), right ventricular failure (P = .003), infection (P = .001), driveline infection (P = .000), and sepsis (P = .000).

CONCLUSIONS

This study revealed that 6-month postoperative complications and mortality rates of patients with advanced heart failure in patients with cf-LVAD are closely related to malnutrition status. In these patients, nutrition specialist use would be beneficial both preoperatively and postoperatively to increase surveillance and reduce postoperative complications.

Effects of obesity on short-term mortality in patients with acute heart failure under different nutritional status

BACKGROUND

Increased body mass index (BMI) is associated with better survival in patients with acute heart failure (AHF), which is a paradoxical phenomenon. However, it is unclear whether different nutritional status affects this association.

METHODS

1325 patients with AHF from the Medical Information Mart for Intensive Care III database were retrospectively included. Nutritional status was assessed by serum albumin (SA) and prognostic nutritional index (PNI). Patients were divided into High-SA (≥ 3.5 g/dL) and Low-SA groups (< 3.5 g/dL), and they also were divided into High-PNI (≥ 38) and Low-PNI groups (< 38). Propensity-score matching (PSM) was used to control for the effect of baseline confounding factors, multifactor regression model was adopted to assess the association of nutritional status, BMI, and outcomes in AHF patients.

RESULTS

Of the 1325 patients (mean age 72.4 ± 13.1 years), 52.1% (n = 690) were male, 13.1% (n = 173) died in hospital and 23.5% (n = 311) died within 90 days. Before PSM, after adjusting for potential confounders, in the High-SA population, compared with the under/normal BMI group, overweight and obesity were negatively correlated with 90-day mortality, with adjusted hazard ratios (HR) of 0.47, 95% confidence interval (CI) (0.30-0.74), P = 0.001; HR 0.45, 95%CI (0.28-0.72), P = 0.001, respectively. However, this correlation was much attenuated in the Low-SA group (overweight BMI: HR 1.06, 95%CI 0.75-1.50, P = 0.744; obese BMI: HR 0.86, 95%CI 0.59-1.24, P = 0.413). After PSM, those who were overweight or obese in the High-SA group had a 50-58% reduction in 90-day risk of death, while the protective effect disappeared in the Low-SA group (HR 1.09, 95% CI 0.70-1.71; HR 1.02, 95%CI 0.66 - 0.59). Similarly, results were similar in analyses using PNI as a nutritional assessment criterion.

CONCLUSION

Overweight or Obesity was associated with lower short-term mortality in well-nourished AHF patients, whereas this association was significantly attenuated or even disappeared in malnourished patients. Therefore, further research is needed for weight loss recommendations for malnourished obese patients with AHF.

In-hospital malnutrition among adult patients in a national referral hospital in Indonesia

BACKGROUND/OBJECTIVES

Malnutrition during hospitalization is linked to increased morbidity and mortality, but there are insufficient studies observing clinical factors contributing to weight loss during hospitalization in Indonesia. This study was therefore undertaken to determine the rate of weight loss during hospitalization and the contributing factors.

SUBJECTS/METHODS

This was a prospective study involving hospitalized adult patients aged 18-59 yrs, conducted between July and September 2019. Body weight measurement was taken at the time of admission and on the last day of hospitalization. The factors studied were malnutrition at admission (body mass index < 18.5 kg/m2), immobilization, depression (Beck Depression Inventory-II Indonesia), polypharmacy, inflammatory status (neutrophil-lymphocytes ratio; NLR), comorbidity status (Charlson Comorbidity Index; CCI), and length of stay.

RESULTS

Totally, 55 patients were included in the final analysis, with a median age of 39 (18-59 yrs) yrs. Of these, 27% had malnutrition at admission, 31% had a CCI score > 2, and 26% had an NLR value of ≥ 9. In all, 62% presented with gastrointestinal symptoms, and depression was documented in one-third of the subjects at admission. Overall, we recorded a mean weight loss of 0.41 kg (P = 0.038) during hospitalization, with significant weight loss observed among patients hospitalized for 7 days or more (P = 0.009). The bivariate analysis revealed that inflammatory status (P = 0.016) was associated with in-hospital weight loss, while the multivariate analysis determined that the contributing factors were length of stay (P < 0.001) and depression (P = 0.019).

CONCLUSIONS

We found that inflammatory status of the patient might influence the incidence of weight loss during hospitalization, while depression and length of stay were independent predictors of weight loss during hospitalization.

The Hospital Food Experience Questionnaire Predicts Adult Patient Food Intake

Purpose: Describe food/beverage intake among all patients and those with low meal intake and determine if the Hospital Food Experience Questionnaire (HFEQ), or its shorter version (HFEQ-sv), predicts food intake while considering patient (e.g., gender) and hospital characteristics (e.g., foodservice model).Methods: Cross-sectional study of 1087 adult patients from 16 hospitals in Ontario, Canada. The valid and reliable HFEQ assessed patients' meal quality perceptions. Visual estimation determined overall meal and food/beverage intake using the Comstock method. Binary logistic regressions tested the association between patient and hospital characteristics and whether HFEQ or HFEQ-sv scores added utility in predicting overall meal intake (≤50% vs. ≥75%).Results: Approximately 29% of patients consumed ≤50% of their meal. Models assessing patient and hospital characteristics and either the HFEQ or the HFEQ-sv were significant (LRT(43) = 72.25, P = 0.003; LRT(43) = 93.46, P < 0.001). Men and higher HFEQ or HFEQ-sv scores demonstrated significantly higher odds of ≥75% meal consumption. Considering HFEQ or HFEQ-sv scores explained greater variance in meal intake and resulted in better model fits.Conclusions: The HFEQ and HFEQ-sv predict patient meal intake when adjusting for covariates and add utility in understanding meal intake. Either version can be confidently used to support menu planning and food delivery to promote food intake.

Quantifying care delivery team influences on the hospitalization outcomes of patients with multimorbidity: Implications for clinical informatics

The primary objective was to quantify the influences of care delivery teams on the outcomes of patients with multimorbidity. Electronic medical record data on 68,883 patient care encounters (i.e., 54,664 patients) were extracted from the Arkansas Clinical Data Repository. Social network analysis assessed the minimum care team size associated with improved care outcomes (i.e., hospitalizations, days between hospitalizations, and cost) of patients with multimorbidity. Binomial logistic regression further assessed the influence of the presence of seven specific clinical roles. When compared to patients without multimorbidity, patients with multimorbidity had a higher mean age (i.e., 47.49 v. 40.61), a higher mean dollar amount of cost per encounter (i.e., $3,068 v. $2,449), a higher number of hospitalizations (i.e., 25 v. 4), and a higher number of clinicians engaged in their care (i.e., 139,391 v. 7,514). Greater network density in care teams (i.e., any combination of two or more Physicians, Residents, Nurse Practitioners, Registered Nurses, or Care Managers) was associated with a 46-98% decreased odds of having a high number of hospitalizations. Greater network density (i.e., any combination of two or more Residents or Registered Nurses) was associated with 11-13% increased odds of having a high cost encounter. Greater network density was not significantly associated with having a high number of days between hospitalizations. Analyzing the social networks of care teams may fuel computational tools that better monitor and visualize real-time hospitalization risk and care cost that are germane to care delivery.

Improving Administration and Documentation of Enteral Nutrition Support Therapy in a Veteran Affairs Health Care System: Use of Medication Administration Record and Bar Code Scanning Technology

OBJECTIVES

The goal of this project was to evaluate and improve the ordering, administration, documentation, and monitoring of enteral nutrition therapies within the inpatient setting in a Veteran's Health Administration system.

METHODS

An interdisciplinary team of clinicians reviewed the literature for best practices and revised the process for enteral nutrition support for hospitalized veterans. Interventions included training staff, revising workflows to include scanning patients and products, including enteral nutrition orders within the medication administration record (MAR), and using the existing bar code medication administration system for administration, documentation, and monitoring. Baseline and postprocess improvement outcomes over a year period were collected and analyzed for quality improvement opportunities.

RESULTS

Before process change, only 60% (33/55) of reviewed enteral nutrition orders were documented and 40% (22/55) were not documented in the intake flowsheet of the electronic health record. In the year after adding enteral nutrition therapies to the MAR and using bar code scanning, a total of 3807 enteral nutrition products were evaluated. One hundred percent of patients were bar code scanned, 3106/3807 (82%) products were documented as given, 447/3807 (12%) were documented as held (with comments), 12/3807 (<1%) were documented as missing/unavailable, and 242/3807 (6%) were documented as refused.

CONCLUSIONS

Inclusion of enteral nutrition order sets on the MAR and using bar code scanning technology resulted in sustained improvements in safety, administration, and documentation of enteral therapies for hospitalized veterans.

Incidence and criteria used in the diagnosis of hospital-acquired malnutrition in adults: a systematic review and pooled incidence analysis

Despite advances in identifying malnutrition at hospital admission, decline in nutritional status of well-nourished patients can be overlooked. The aim of this systematic review was to investigate the incidence of hospital-acquired malnutrition (HAM), diagnostic criteria and health-related outcomes. PubMed, CINAHL, Embase and Cochrane Library were searched up to July 2021. Studies were included if changes in nutritional status was assessed with a validated nutrition assessment tool in acute and subacute adult (≥18 yrs) hospitalised patients. A random-effects method was used to pool the incidence proportion of HAM in prospective studies. The certainty of evidence was appraised using the Grading of Recommendation Assessment, Development and Evaluation system. We identified 12 observational cohort studies (10 prospective and 2 retrospective), involving 35,324 participants from acute (9 studies) and subacute settings (3 studies). Retrospective studies reported a lower incidence of HAM (<1.4%) than prospective studies (acute: 9-38%; subacute: 0-7%). The pooled incidence of HAM in acute care was 25.9% (95% confidence interval (CI): 17.3-34.6). Diagnostic criteria varied, with use of different nutrition assessment tools and timeframes for assessment (retrospective studies: >14 days; prospective studies: ≥7 days). Nutritional decline is probably associated with longer length of stay and higher 6-month readmission (moderate certainty of evidence) and may be association with higher complications and infections (low certainty of evidence). The higher incidence of HAM in the acute setting, where nutritional assessments are conducted prospectively, highlights the need for consensus regarding diagnostic criteria and further studies to understand the impact of HAM.

HOMEFOOD Randomised Trial - Six-Month Nutrition Therapy in Discharged Older Adults Reduces Hospital Readmissions and Length of Stay at Hospital Up to 18 Months of Follow-Up

BACKGROUND

Malnutrition is frequently observed in older adults and is associated with hospital readmissions, length of stay (LOS), and mortality in discharged patients.

OBJECTIVE

The aim of this study was to investigate effects of six-month nutrition therapy on hospital readmissions, LOS, mortality and need for long-term care residence 1-, 6-, 12- and 18-months post-discharge in older Icelandic adults.

DESIGN

Secondary analysis of a randomized controlled trial.

PARTICIPANTS

Participants (>65 years) were randomised into intervention (n=53) and control (n=53) before discharge from a geriatric unit.

INTERVENTION

The intervention group received nutrition therapy based on the Nutrition Care Process, including home visits, phone calls, freely delivered energy- and protein-rich foods and supplements for six months after hospital discharge.

MEASUREMENTS

The Icelandic electronic hospital registry was accessed to gain information on emergency room visits (ER), hospital readmissions, LOS, mortality and need for long-term care residence.

RESULTS

The intervention group had a lower proportion of participants with at least one readmission compared to control (1 month: 1.9% vs 15.8%, P=0.033; 6 months: 25.0% vs 46.2%, P=0.021; 12 months: 38.5% vs 55.8%, P=0.051; and 18 months: 51.9% vs 65.4%, P=0.107). There was also a lower total number of readmissions per participant (1 month: 0.02 vs 0.19, P=0.015; 6 month: 0.33 vs 0.77, P=0.014; 0.62 vs 1.12, P=0.044) and a shorter LOS (1 month: 0.02 vs 0.92, P=0.013; 6 months: 2.44 vs 13.21; P=0.006; 12 months: 5.83 vs 19.40, P=0.034; 18 months: 10.42 vs 26.00, P=0.033) in the intervention group. However, there were no differences between groups in ER visits, mortality and need for long-term care residence.

CONCLUSION

A six-month nutrition therapy in older Icelandic adults discharged from hospital reduced hospital readmissions and shortens LOS at the hospital up to 18-months post-discharge. However, it did neither affect mortality, ER, nor need of long-term care residence in this group.

Implementation of an electronic solution to improve malnutrition identification and support clinical best practice

BACKGROUND

Routine malnutrition risk screening of patients is critical for optimal care and comprises part of the National Australian Hospital Standards. Identification of malnutrition also ensures reimbursement for hospitals to adequately treat these high-risk patients. However, timely, accurate screening, assessment and coding of malnutrition remains suboptimal. The present study aimed to investigate manual and digital interventions to overcome barriers to malnutrition identification for improvements in the hospital setting.

METHODS

Retrospective reporting on malnutrition identification processes was conducted through two stages: (1) manual auditing intervention and (2) development of a digital solution - the electronic malnutrition management solution (eMS). Repeated process audits were completed at approximately 6-monthly intervals through both stages between 2016 and 2019 and the results were analysed. In Stage 2, time investment and staff adoption of the digital solution were measured.

RESULTS

Overall, the combined effect of both regular auditing and use of the eMS resulted in statistically significant improvements across all six key measures: patients identified (97%-100%; p < 0.001), screened (68%-95%; p < 0.001), screened within 24 h (51%-89%; p < 0.001), assessed (72%-95%; p < 0.001), assessed within 24 h (66%-93%; p < 0.001) and coded (81%-100%; p = 0.017). The eMS demonstrated a reduction in screening time by over 60% with user adoption 100%. Data analytics enabled automated, real-time auditing with a 95% reduction in time taken to audit.

CONCLUSIONS

A single digital solution for management of malnutrition and automation of auditing demonstrated significant improvements where manual or combinations of manual and electronic systems continue to fall short.

Cost-Effectiveness Analysis of Standardized Clinical Nutrition Diagnosis and Treatment Pathway in Patients with Pulmonary Infection

Objective

From the perspective of economics, this study discusses the value of establishing a standardized clinical nutrition diagnosis and treatment pathway in the diagnosis and treatment of pulmonary infection and provides a reference for optimizing the diagnosis and treatment pathway of pulmonary infection.

Methods

The patients who received the nutrition diagnosis and treatment pathway intervention in 2017 were counted as the routine group and were subdivided into the conventional intervention group (C1) and conventional control group (C2) according to whether the standardized nutrition therapy was applied or not. The patients who received the nutrition diagnosis and treatment pathway intervention in 2020 were counted as the experimental group and were subdivided into the experimental intervention group (T1) and the experimental control group (T2) according to whether standardized intervention was applied or not. The total hospitalization expenses, average daily hospitalization cost, nutrition support expenses, plasma albumin before and after nutrition support, readmission, and other indicators of all patients were recorded and compared. The cost-effectiveness ratio (CER), incremental cost-effectiveness ratio (ICER), and cost-effectiveness threshold for cost-effectiveness analysis were adopted.

Results

Compared with the C2 group, the C1 group had higher total hospitalization expenses, average daily hospitalization expenses, nutritional support expenses, and plasma albumin improvement rate and lower readmission rate (P < 0.001). Compared with the T2 group, the T1 group had higher total hospitalization cost, average daily hospitalization expenses, nutritional support expenses, and plasma albumin improvement rate and lower readmission rate (P < 0.001). Taking the improvement rate of plasma albumin as the effect index, compared with the C1 group, the T1 group has less investment cost and better effect, and the ICER is negative (below the cost-effect threshold). And taking the readmission rate as the effective index, compared with the C1 group, the T1 group invested less cost and had a better effect, and the ICER was negative (below the cost-effect threshold).

Conclusion

For the patients with pulmonary infection, whether the improvement rate of plasma albumin or the readmission rate is used as the impact index, the standardized nutrition diagnosis and treatment pathway in 2020 is more economical than the nonstandardized nutrition diagnosis and treatment pathway.

Delayed gastric emptying after classical Whipple or pylorus-preserving pancreatoduodenectomy: a randomized clinical trial (QUANUPAD)

PURPOSE

Pylorus-preserving pancreatoduodenectomy (PPPD) has been the gold standard for pancreatic head lesion resection for several years. Some studies have noted that it involves more delayed gastric emptying (DGE) than classical Whipple (i.e., pancreatoduodenectomy with antrectomy). Our working hypothesis was that the classical Whipple has a lower incidence of DGE. We aimed to compare the incidence of DGE among pancreatoduodenectomy techniques.

METHODS

This pragmatic, randomized, open-label, single-center clinical trial involved patients who underwent classical Whipple (study group) or PPPD (control group). Gastric emptying was clinically evaluated using scintigraphy. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria. The secondary endpoints were postoperative morbidity, length of hospital stay, anthropometric measurements, and nutritional status.

RESULTS

A total of 84 patients were randomized (42 per group). DGE incidence was 50% (20/40, 95% confidence interval (95% CI): 35-65%) in the study group and 62% (24/39, 95% CI: 46-75%) in the control group (p = 0.260). No differences were observed between both groups regarding postoperative morbidity or length of hospital stay. Anthropometric measurements at 6 months post-surgery: triceps fold measurements were 12 mm and 16 mm (p = 0.021). At 5 weeks post-surgery, triceps fold measurements were 13 mm and 16 mm (p = 0.020) and upper arm circumferences were 26 cm and 28 cm (p = 0.030). No significant differences were observed in nutritional status.

CONCLUSION

DGE incidence and severity did not differ between classical Whipple and PPPD. Some anthropometric measurements may indicate a better recovery with PPPD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03984734.

LOSS et al.Nutrition as a risk for mortality and functionality in critically ill older adultsNutrition as a risk for mortality and functionality in critically ill older adults

BACKGROUND & AIMS

There is no specific recommendation for nutrition therapy for critically ill older adults. However, targeting caloric and protein balance and avoiding fasting could improve outcomes in this high-risk nutritional population. This study aimed to evaluate the associations between nutrition and mortality/functionality in critically ill older patients.

METHODS

Single-center retrospective observational study of critically ill patients aged 65 years or older. We extracted data from the dietician evaluations about calories, proteins, and the type of diet (fasting, oral, enteral, parenteral) prescribed in the first week of intensive care unit admission. Primary outcomes were intrahospital mortality and independence and functional capacity evaluated after hospital discharge.

RESULTS

Out of the 2,043 patients screened, 533 were included in the study. Most patients were men (52.1%), with a median age of 73 (68-78) years. Overall, the intrahospital mortality rate was 53.8%. SAPS-3, albumin, C-reactive protein, and surgical patients were independently associated with fasting in a multivariate analysis. The multivariate regression analyses showed that SAPS-3, albumin, and fasting were independently associated with mortality. Each fasting day increases the risk of mortality by 16.7%. Also, independence and functional capacity were not related to nutritional prescription.

CONCLUSION

Older adults (65 years or older) constitute a fragile population in which nutritional breaks were associated with increased hospital mortality. Furthermore, a prospective clinical trial is necessary to establish the best strategy to feed this population. This article is protected by copyright. All rights reserved.

Malnutrition Screening and Assessment

Malnutrition is a serious problem with a negative impact on the quality of life and the evolution of patients, contributing to an increase in morbidity, length of hospital stay, mortality, and health spending. Early identification is fundamental to implement the necessary therapeutic actions, involving adequate nutritional support to prevent or reverse malnutrition. This review presents two complementary methods of fighting malnutrition: nutritional screening and nutritional assessment. Nutritional risk screening is conducted using simple, quick-to-perform tools, and is the first line of action in detecting at-risk patients. It should be implemented systematically and periodically on admission to hospital or residential care, as well as on an outpatient basis for patients with chronic conditions. Once patients with a nutritional risk are detected, they should undergo a more detailed nutritional assessment to identify and quantify the type and degree of malnutrition. This should include health history and clinical examination, dietary history, anthropometric measurements, evaluation of the degree of aggression determined by the disease, functional assessment, and, whenever possible, some method of measuring body composition.

Recommendations for nutritional assessment across clinical practice guidelines: A scoping review

BACKGROUND & AIMS

CPGs propose several methods and criteria to perform nutritional assessment, a key process to determine the type and severity of malnutrition, which generates variability in clinical practice and outcomes. The aim of the study was to describe the criteria considered by clinical practice guidelines (CPGs) for nutritional assessment.

METHODS

We performed a scoping review systematically searching in PubMed, Trip Database, Google Scholar, and Google, until November 5, 2021. We included all CPGs mentioning tools or criteria for nutritional assessment in adults from the general population or with any specific pathology or condition. Two authors independently reviewed and decided on study selection and data extraction.

RESULTS

We included 18 CPGs (12 elaborated in Europe). The CPGs recommended heterogeneous criteria for nutritional assessment: 16/18 CPGs included at least one body composition parameter (e.g., loss of muscle mass, loss of subcutaneous fat), 15/18 included history related to dietary intake, 15/18 included clinical history (e.g., weight loss), 10/18 included anthropometric measurement (e.g., low body mass index [BMI]), 11/18 included biochemical criteria (e.g., albumin, C-reactive protein), 8/18 included physical examination (e.g., fluid retention, sarcopenia, loss of subcutaneous fat), 8/18 included functional test (e.g., decreased handgrip strength), and 1/18 included catabolic state. Also, 9/18 CPGs mentioned a tool for nutritional assessment, the Subjective Global Assessment (SGA) the most common (8/18). None of the CPGs justified the inclusion of any of the tools or criteria they mentioned.

CONCLUSIONS

The CPGs mentioned heterogeneous criteria for nutritional assessment. The most commonly mentioned criteria were decreased food intake, loss of muscle mass, weight loss, and low BMI. The most mentioned tool was the SGA. None of the CPGs provided a clear rationale for using certain criteria or tools for nutritional assessment.

The Association between Nutritional Status and Length of Hospital Stay among Patients with Hypertension

Background: Nutritional status is related to the prognosis and length of hospital stay (LOS) of patients with hypertension (HT). This study aimed to assess how nutritional status and body mass index (BMI) affect LOS for patients with hypertension. Method: We performed a retrospective analysis of 586 medical records of patients who had been admitted to the Institute of Heart Diseases of the University Clinical Hospital in Wroclaw, Poland. Results: A total of 586 individuals were included in the analysis. Individuals who were at a nutritional risk represented less than 2% of the study population, but more than 60% were overweight or obese. The mean BMI was 28.4 kg/m² (SD: 5.16). LOS averaged 3.53 days (SD = 2.78). In the case of obese individuals, hospitalisation lasted for 3.4 ± 2.43 days, which was significantly longer than for patients of normal weight. For underweight patients, hospitalisation lasted for 5.14 ± 2.27 days, which was also significantly longer than for those in other BMI categories (p = 0.017). The independent predictors of shorter hospitalisations involved higher LDL concentration (parameter of regression: −0.015) and HDL concentration (parameter of regression: −0.04). Conclusions: The study revealed that with regard to the nutritional status of hypertensive patients, being either underweight or obese was associated with longer LOS. Additional factors that related to prolonged LOS were lower LDL and HDL levels and higher CRP concentrations.

Oral condition as a predictor of risk for malnutrition during hospitalization: A cross-sectional study

BACKGROUND

Malnutrition and poor oral health are common conditions in patients in the hospital. Both conditions are associated with poor systemic health. The present study aimed to assess the relationship between the oral condition and the nutrition status of individuals admitted to a large tertiary hospital.

METHODS

This cross-sectional study evaluated 364 patients who received a comprehensive dental examination at their hospital bed. An examiner recorded visible plaque index, gingival bleeding index, plaque retentive factors, probing depth, clinical attachment loss, bleeding on probing, number of existing teeth, and prosthesis use. Medical status was assessed by the Charlson Comorbidity Index. The nutrition status was evaluated by the Subjective Global Assessment. Crude and adjusted prevalence ratios were estimated by Poisson regression analysis with robust variance.

RESULTS

Patients with moderate to severe malnutrition presented worse oral hygiene (55.83 ± 25.16 vs 64.90 ± 24.28; P < 0.001), more gingival inflammation (24.31 ± 24.13 vs 33.43 ± 27.36; P < 0.001), higher levels of attachment loss (4.22 ± 1.81 vs 4.80 ± 1.83; P < 0.001), and a lower mean number of teeth (14.58 ± 7.45 vs 10.94 ± 6.85; P < 0.001) than patients without malnutrition. In the multivariable analysis, the number of teeth and higher comorbidity index were associated with malnutrition.

CONCLUSIONS

Poor oral health and medical condition were associated with malnutrition in this single-institution study, and oral condition may be considered an indicator of malnutrition in patients in the hospital. The implications of this study include the need to raise awareness among health professionals of the importance of oral health and nutrition status in adults.

Malnutrition in Hospitalized Old Patients: Screening and Diagnosis, Clinical Outcomes, and Management

Malnutrition in hospitalized patients heavily affects several clinical outcomes. The prevalence of malnutrition increases with age, comorbidities, and intensity of care in up to 90% of old populations. However, malnutrition frequently remains underdiagnosed and undertreated in the hospital. Thus, an accurate screening to identify patients at risk of malnutrition or malnourishment is determinant to elaborate a personal nutritional intervention. Several definitions of malnutrition were proposed in the last years, affecting the real frequency of nutritional disorders and the timing of intervention. Diagnosis of malnutrition needs a complete nutritional assessment, which is often challenging to perform during a hospital stay. For this purpose, various screening tools were proposed, allowing patients to be stratified according to the risk of malnutrition. The present review aims to summarize the actual evidence in terms of diagnosis, association with clinical outcomes, and management of malnutrition in a hospital setting.

Indicators of nutritional risk in hospital inpatients: a narrative review

Malnutrition is common in the acute care setting. Despite the existence of a plethora of screening tools, many malnourished patients remain undiagnosed and untreated, in part due to competing responsibilities for screening staff, under- or over-referral to dietetics services, and inadequate dietetics resources. Better identification of patients at risk of malnutrition would enable optimised care provision and streamlined care pathways. This narrative review of reviews aimed to collate and synthesise literature documenting nutritional risk factors in adult hospital inpatients, to generate a comprehensive list of nutritional risk indicators from high methodological quality review articles. Six electronic databases were searched (Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, Embase and Scopus) using a systematic search strategy. Three researchers screened the resulting 5889 citations, identifying 59 reviews summarising original studies that investigated associations between indicators and measures of malnutrition, undernutrition or nutritional risk. After quality appraisal by two researchers, using the American Dietetic Association Quality Criteria Checklist for Review Articles, seven reviews were classified as high quality, identifying fifty-seven unique indicators of nutritional risk (disease status/condition – twenty-three; eating/appetite/digestion – twelve; type of diet – five; cognition/psychology/social factors – five; medication-related – two; miscellaneous – ten). This is the first comprehensive list of nutritional risk factors in adult hospital inpatients, derived from only the highest methodological quality reviews. This list contributes to the development of practice and evidence-informed systems-level approaches to the identification of nutritional risk in the acute care setting.

Risk factors for malnutrition among hospitalized gastroenterological patients

Background/Aim. Risk factors for malnutrition of patients during hospitalization have not been precisely deter-mined. The aim of the study was to determine these factors in hospitalized gastroenterological patients. Methods. Nutritional status (NS) of 650 gastroenterological patients was assessed at the hospital admission and at discharge by the six parameters: unintentional weight loss, lymphocyte count, serum albumin concentration, body mass index, triceps skinfold thickness, and mid-upper arm muscle circumference. The influence on NS at discharge was tested for ten factors: gender, age, affected organ, the nature, severity, and complications of the disease, the length of hospitalization, mobility worsening during hospitalization, Karnofsky score, and NS on admission. Primary and secondary risk factors were defined among the factors significantly influencing malnutrition. Results. Seven factors were found to be the independent predictors for malnutrition in hospitalized gastroenterological patients. NS at admission was considered as a primary risk factor (Forward: Wald multivariate logistic regression analysis, p < 0.001 for five applied assessment parameters). The other six factors, obtained in the evaluation according to 1-3 assessment parameters, were considered as secondary risk factors: severe disease activity, malignancy, the existence of complications, male gender, hospitalization > 14 days, and mobility worsening during the hospitalization (Forward: Wald multivariate logistic regression analysis, p from 0.001 to 0.027). Conclusion. There are seven risk factors for malnutrition among gastroenterological patients during hospitalization. Timely nutritional support in these patients can prevent the development of intrahospital malnutrition and its negative influence on the clinical outcome.

Key approaches to diagnosing malnutrition in adults

Nutrition assessment is used to describe nutrition status-related nutrition problems and their causes, one of which includes malnutrition. Four malnutrition diagnostic tools are currently in use today in adults: Subjective Global Assessment, the Mini Nutritional Assessment, the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition malnutrition consensus characteristics, and the Global Leadership Initiative on Malnutrition criteria. The aim of this article is to provide sufficient background of these methodologies to assist clinicians in choosing their approach in diagnosing malnutrition. There is substantial overlap between the criteria included in these malnutrition diagnostic approaches. A desired goal is to identify a core data set in order to evaluate malnutrition prevalence globally and to assess the impact of nutrition interventions on nutrition and clinical outcomes.

Ageing rate of older adults affects the factors associated with, and the determinants of malnutrition in the community: a systematic review and narrative synthesis

BACKGROUND

Malnutrition negatively impacts on health, quality of life and disease outcomes in older adults. The reported factors associated with, and determinants of malnutrition, are inconsistent between studies. These factors may vary according to differences in rate of ageing. This review critically examines the evidence for the most frequently reported sociodemographic factors and determinants of malnutrition and identifies differences according to rates of ageing.

METHODS

A systematic search of the PubMed Central and Embase databases was conducted in April 2019 to identify papers on ageing and poor nutritional status. Numerous factors were identified, including factors from demographic, food intake, lifestyle, social, physical functioning, psychological and disease-related domains. Where possible, community-dwelling populations assessed within the included studies (N = 68) were categorised according to their ageing rate: 'successful', 'usual' or 'accelerated'.

RESULTS

Low education level and unmarried status appear to be more frequently associated with malnutrition within the successful ageing category. Indicators of declining mobility and function are associated with malnutrition and increase in severity across the ageing categories. Falls and hospitalisation are associated with malnutrition irrespective of rate of ageing. Factors associated with malnutrition from the food intake, social and disease-related domains increase in severity in the accelerated ageing category. Having a cognitive impairment appears to be a determinant of malnutrition in successfully ageing populations whilst dementia is reported to be associated with malnutrition within usual and accelerated ageing populations.

CONCLUSIONS

This review summarises the factors associated with malnutrition and malnutrition risk reported in community-dwelling older adults focusing on differences identified according to rate of ageing. As the rate of ageing speeds up, an increasing number of factors are reported within the food intake, social and disease-related domains; these factors increase in severity in the accelerated ageing category. Knowledge of the specific factors and determinants associated with malnutrition according to older adults' ageing rate could contribute to the identification and prevention of malnutrition. As most studies included in this review were cross-sectional, longitudinal studies and meta-analyses comprehensively assessing potential contributory factors are required to establish the true determinants of malnutrition.

Investigating the patient food experience: Understanding hospital staffs' perspectives on what leads to quality food provision in Ontario hospitals

BACKGROUND

Food quality influences patient food satisfaction, which may subsequently affect food intake and recovery, influencing hospital costs. The present qualitative study aimed to gain an understanding of hospital staff/volunteers experiences of serving food in Ontario hospitals, perceptions of food quality and challenges to quality food provision.

METHODS

Sixteen Ontario hospitals participated. Semi-structured interviews (n = 64 participants) and focus groups (n = 24; 150 participants) were conducted. Transcripts were analysed using inductive thematic analysis.

RESULTS

Four themes emerged: (1) Providing Good Quality Food (e.g., attributes that comprise the construct of meal quality, patients' expectations and desires from meals); (2) Individualising the Food and Mealtime Experience (e.g., processes to identify and cater to patients' needs and preferences); (3) Acknowledging Organisational Constraints (e.g., staffing, budget, etc.); and (4) Innovating Beyond Constraints (e.g., identifying innovation within potential modifiable and unmodifiable organisational constraints).

CONCLUSIONS

Serving meals in hospital is complex because of organisational and patient factors; however, current efforts to serve quality food despite these complexities were uncovered in our investigation. Discussions highlighted current practices that promote food quality and strategies for improvement. Improving food quality and the hospital meal experience can support food intake and patient outcomes, as well as reduce waste and hospital associated costs. The findings can be used to support quality improvement measures aiming to serve high quality food that meets patients' expectations and nutritional needs.

Prognostic nutritional index and the risk of acute kidney injury in patients with acute coronary syndrome

OBJECTIVE

Recent studies have linked malnutrition with undesirable outcomes in cardiovascular diseases. However, the underlying mechanism is unknown. Contrast-induced acute kidney injury (CI-AKI) increased cardiovascular mortality after percutaneous coronary intervention (PCI). This study hypothesizes that prognostic nutritional index (PNI) plays a role in the development of CI-AKI in patients with acute coronary syndrome undergoing emergency PCI.

METHODS

This study enrolled 551 patients. PNI was determined as 10× serum albumin (g/dL)+0.005×total lymphocyte count (mm3). CI-AKI was characterized as the increase in serum creatinine ≥0.3 mg/dL level within 48 h after PCI. Patients were classified as either CI-AKI (+) or CI-AKI (-).

RESULTS

CI-AKI has occurred in 72 of 551 patients (13.1%). PNI was significantly lower in the CI-AKI (+) group than in the CI-AKI (-) group (44.4±6.6 versus 47.2±5.8, p<0.001, respectively). Multivariate logistic regression analysis showed that PNI [odds ratio, OR: 1.631, 95% confidence interval (CI): 1.168-2.308, p=0.02] and estimated glomerular filtration rate (OR: 3.26, 95%CI 1.733-6.143, p<0.001) were independent risk factors for CI-AKI.

CONCLUSIONS

PNI is an independent risk factor for CI-AKI. The development of CI-AKI may be the mechanism responsible for the relationship between poor nutritional status and adverse cardiac events.

A multimodal nutritional intervention after discharge improves quality of life and physical function in older patients - a randomized controlled trial

BACKGROUND

Many older hospitalized patients are at nutritional risk or malnourished and the nutritional condition is often further impaired during hospitalization. When discharged to own home, a "Nutrition Gap" often occurs, causing inadequate dietary intake, and potentially impeded recovery. Previously, cross-sectorial studies of single component nutritional intervention have shown a limited effect on clinically relevant outcomes. We hypothesized that a multimodal nutritional intervention is necessary to elicit a beneficial effect on clinically relevant outcomes.

METHODS

A randomized controlled trial was performed for a period of 16 weeks. At discharge, the intervention group (IG) received dietetic counselling including a recommendation of daily training, an individual nutrition plan and a package containing foods and drinks covering dietary requirements for the next 24 h. Further, a goodie-bag containing samples of protein-rich milk-based drinks were provided. Information regarding recommendations of nutritional therapy after discharge was systematically and electronically communicated to the municipality. The dietician performed telephone follow-ups on day 4 and 30 and a home visit at 16 weeks. The control group (CG) received standard treatment. The primary outcome was readmissions within 6 month, secondary outcomes were Length of Stay (LOS), Health Related Quality of Life (EQ-5D-3L), nutritional status, physical function (30s-CST) and mortality. This trial was registered under ClinicalTrials.gov Identifier no. NCT03488329.

RESULTS

We included 191 patients (IG: n = 93). No significant difference was seen in readmissions within 6 month (IG: 45% vs. CG: 45%, Risk Ratio (RR): 0.96 0.71-1.31, p = 0.885). At the 16-weeks follow-up more patients in the IG reached at least 75% of energy and protein requirements (82% vs. CG: 61%, p = 0,007). The energy (kcal) and protein intake (g) per kg was significantly higher in the IG (26.4 kcal/kg (±7.4) vs. 22.6 (±7.4), p = 0.0248) (1.1 g/kg (±0.3) vs. 0.9 g/kg (±0.3). Furthermore, significant lower weight loss was seen in IG (0.7 (±4.3) vs. -1.4 (±3.6), p = 0.002). A significant and clinically relevant difference was found in the EQ-5D-3L VAS-score (IG: mean 61.6 ± 16.2 vs. CG: 53.3 ± 19.3, p = 0.011) (Δ14.3 (±15.5) vs. Δ5.6 (±17.2), p = 0.002). A significant difference in mean 30s-CST in IG was also found (7.2 (±4.3) vs. 5.3 (±4.1), p = 0.010). The improvements in physical function were of clinical relevance in both groups, but significantly higher in the IG (Δ4.2 (±4.4) vs. Δ2.2 (±2.5), p = 0.008). In fact, 86% in IG experienced improvements in the 30s-CST compared with 68% in the CG (p = 0.022). LOS was found to be lower at all time points, however not significant (30 days: -3 (-8.5 to 2.5), p = 0.276, 16 weeks: -4 (-10.2 to 2.2, p = 0.204), 6 months: -3 (-9.3 to 3.3, p = 0346)). All-cause mortality was not different between groups, however RR showed a non-significantly 47% reduction at day 30 (0.53 (0.14-2.05, p = 0.499)) and a 17% reduction at 16 weeks (0.83 (0.40-1.73, p = 1.000)) in IG. Per protocol (PP) analysis revealed a non-significant decrease of 32% in readmission at 6 months (RR: 0.68 (0.42-1.08), p = 0.105).

CONCLUSION

The present study, using a multimodal nutritional approach, revealed no significant effect on readmissions however a significant positive effect on nutritional status, quality of life and physical function was found. The improvements in quality of life and physical function were of clinical relevance. No significant effect was found on LOS and mortality.

Predictors of recovery in children aged 6-59 months with uncomplicated severe acute malnutrition: a multicentre study

OBJECTIVE

To identify predictors of recovery in children with uncomplicated severe acute malnutrition (SAM).

DESIGN

This is a secondary data analysis from an individual randomised controlled trial, where children with uncomplicated SAM were randomised to three feeding regimens, namely ready-to-use therapeutic food (RUTF) sourced from Compact India, locally prepared RUTF or augmented home-prepared foods, under two age strata (6-17 months and 18-59 months) for 16 weeks or until recovery. Three sets of predictors that could influence recovery, namely child, family and nutritional predictors, were analysed.

SETTING

Rural and urban slum areas of three states of India, namely Rajasthan, Delhi and Tamil Nadu.

PARTICIPANTS

In total, 906 children (age: 6-59 months) were analysed to estimate the adjusted hazard ratio (AHR) using the Cox proportional hazard ratio model to identify various predictors.

RESULTS

Being a female child (AHR: 1·269 (1·016, 1·584)), better employment status of the child's father (AHR: 1·53 (1·197, 1·95)) and residence in a rental house (AHR: 1·485 (1·137, 1·94)) increased the chances of recovery. No hospitalisation (AHR: 1·778 (1·055, 2·997)), no fever, (AHR: 2·748 (2·161, 3·494)) and ≤ 2 episodes of diarrhoea (AHR: 1·579 (1·035, 2·412)) during the treatment phase; availability of community-based peer support to mothers for feeding (AHR: 1·61 (1·237, 2·097)) and a better weight-for-height Z-score (WHZ) at enrolment (AHR: 1·811 (1·297, 2·529)) predicted higher chances of recovery from SAM.

CONCLUSION

The probability of recovery increases in children with better WHZ and with the initiation of treatment for acute illnesses to avoid hospitalisation, availability of peer support and better employment status of the father.

Health information technology to improve care for people with multiple chronic conditions

OBJECTIVE

To review evidence regarding the use of Health Information Technology (health IT) interventions aimed at improving care for people living with multiple chronic conditions (PLWMCC) in order to identify critical knowledge gaps.

DATA SOURCES

We searched MEDLINE, CINAHL, PsycINFO, EMBASE, Compendex, and IEEE Xplore databases for studies published in English between 2010 and 2020.

STUDY DESIGN

We identified studies of health IT interventions for PLWMCC across three domains as follows: self-management support, care coordination, and algorithms to support clinical decision making.

DATA COLLECTION/EXTRACTION METHODS

Structured search queries were created and validated. Abstracts were reviewed iteratively to refine inclusion and exclusion criteria. The search was supplemented by manually searching the bibliographic sections of the included studies. The search included a forward citation search of studies nested within a clinical trial to identify the clinical trial protocol and published clinical trial results. Data were extracted independently by two reviewers.

PRINCIPAL FINDINGS

The search yielded 1907 articles; 44 were included. Nine randomized controlled trials (RCTs) and 35 other studies including quasi-experimental, usability, feasibility, qualitative studies, or development/validation studies of analytic models were included. Five RCTs had positive results, and the remaining four RCTs showed that the interventions had no effect. The studies address individual patient engagement and assess patient-centered outcomes such as quality of life. Few RCTs assess outcomes such as disability and none assess mortality.

CONCLUSIONS

Despite a growing body of literature on health IT interventions or multicomponent interventions including a health IT component for chronic disease management, current evidence for applying health IT solutions to improve care for PLWMCC is limited. The body of literature included in this review provides critical information on the state of the science as well as the many gaps that need to be filled for digital health to fulfill its promise in supporting care delivery that meets the needs of PLWMCC.

Malnutrition diagnoses and associated outcomes in hospitalized patients: United States, 2018

In the US, malnutrition is prevalent among hospitalized patients and is associated with higher morbidity, mortality, and healthcare costs when compared with those without malnutrition. Over time, national data have indicated the rate of coded malnutrition diagnoses among hospital discharges rising over time, and more current data on demographic and clinical characteristics of these patients are needed. Data on malnutrition discharges from the 2018 Healthcare Cost and Utilization Project (HCUP)-the most recent nationally representative data-were examined and compared with earlier HCUP findings. Based on International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, 8.9% of all US non-maternal, non-neonatal hospital discharges in 2018 had a coded diagnosis of malnutrition (CDM). From this 2018 data, those with a CDM were older, had longer lengths of stay, and incurred higher costs, as compared with those without a CDM. Higher readmission rates and higher inpatient mortality were also observed in this group. These findings provide more recent demographic and clinical evidence for standardized malnutrition diagnostic and interventional programs to treat and/or prevent this condition.

Prognostic impact of malnutrition in elderly patients with acute myocardial infarction

We aimed to investigate the prevalence and the prognostic impact of malnutrition using the geriatric nutritional risk index (GNRI) in elderly patients with acute myocardial infarction (AMI). We investigated 130 consecutive patients aged ≥ 75 years who were discharged following successful primary coronary intervention between March 2009 and December 2016. The mean age of the patients was 81.5 ± 5.0 years, and 55.4% of them were male. At discharge, the patients' nutritional statuses were evaluated using the GNRI, which were calculated as follows: 14.89 × serum albumin (g/dL) + 41.7 × body mass index/22. The patients were divided into two groups, a low GNRI group (GNRI < 92) with nutrition-related risk and a high GNRI group (GNRI ≥ 92) without nutrition-related risk. The mean GNRI score of all patients was 95.2 ± 11.0, and 46 patients (35.4%) had a low GNRI score. During the mean follow-up of 1030 ± 850 days, the all-cause mortality was significantly higher in the low GNRI group than in the high GNRI group (32.6% vs. 13.1%, p < 0.001), while the event rates of AMI recurrence and hospitalization due to heart failure did not differ significantly between the two groups. Multivariate Cox proportional analysis revealed that low GNRI was a modest but independent predictor of mortality (hazard ratio, 0.94; 95% confidence interval 0.90-0.98; p = 0.01). Among elderly patients with AMI, malnutrition assessed using the GNRI was often encountered and was an independent predictor of long-term mortality.

Prolonged hospital length of stay in pediatric trauma: a model for targeted interventions

BACKGROUND

In this study, trauma-specific risk factors of prolonged length of stay (LOS) in pediatric trauma were examined. Statistical and machine learning models were used to proffer ways to improve the quality of care of patients at risk of prolonged length of stay and reduce cost.

METHODS

Data from 27 hospitals were retrieved on 81,929 hospitalizations of pediatric patients with a primary diagnosis of trauma, and for which the LOS was >24 h. Nested mixed effects model was used for simplified statistical inference, while a stochastic gradient boosting model, considering high-order statistical interactions, was built for prediction.

RESULTS

Over 18.7% of the encounters had LOS >1 week. Burns and corrosion and suspected and confirmed child abuse are the strongest drivers of prolonged LOS. Several other trauma-specific and general pediatric clinical variables were also predictors of prolonged LOS. The stochastic gradient model obtained an area under the receiver operator characteristic curve of 0.912 (0.907, 0.917).

CONCLUSIONS

The high performance of the machine learning model coupled with statistical inference from the mixed effects model provide an opportunity for targeted interventions to improve quality of care of trauma patients likely to require long length of stay.

IMPACT

Targeted interventions on high-risk patients would improve the quality of care of pediatric trauma patients and reduce the length of stay. This comprehensive study includes data from multiple hospitals analyzed with advanced statistical and machine learning models. The statistical and machine learning models provide opportunities for targeted interventions and reduction in prolonged length of stay reducing the burden of hospitalization on families.

Body composition measures may help target fundamental nutritional nursing efforts in rehabilitating patients with acquired brain injury

Aim

To illuminate using body composition measurements for malnutrition measured by Bio Impedance Analysis (BIA), as opposed to body mass index (BMI), and discuss benefits and burdens for fundamental nursing care.

Design

A second analysis of a prospective, descriptive cohort study, targeting fundamental nursing care elements.

Methods

This postevaluation study explored data from a prospective, descriptive cohort study, which consecutively included 92 patients admitted for neurorehabilitation care. Measures of nutritional status were BMI and FFMI. Chi‐Square test and Multivariable logistic regression were used.

Results

Body composition measures rather than BMI contributed to target individual nutritional nursing care as this measure detected more patients at potential risk of malnutrition and indicated minor changes in the nutritional state. Transitions from being malnourished to a normal nutritional status occurred in 29% using the BMI definition while it was the case in 40% of individuals with malnutrition defined by the body composition.

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.

Nutritional care of older people: Investigating nurses' attitudes in medical and surgical units

Background: Malnutrition in older people in hospitals leads to negative patient outcomes. Nurses often underestimate the problem, showing negative attitudes.Aims: To compare nurses' attitudes towards nutritional care of older people in surgical and medical wards. Design: Multicentre cross-sectional survey, conducted in January 2015.Methods: All nurses in surgical and medical wards in 10 hospitals in northern Italy were surveyed using the Staff Attitudes to Nutritional Nursing Care Geriatric Scale (SANN-G scale).Results: 799 out of 1,293 questionnaires were returned (61.8%). 23.2% (185) had a negative attitude, 56.6%(452) had a neutral attitude, and 20.2%(162), positive. Multivariate analysis showed no significant differences between medical and surgical wards (OR = 1.298; CI95% = .883-1.886, p = .18).Conclusions: It is necessary to raise nurses' awareness of poor nutritional care in both settings. More research is needed within the barriers to nutritional care.Impact statement: Strategies such as education and more clearly defined nutritional responsibilities are needed to improve nurses' attitudes.

Putting quality food on the tray: Factors associated with patients' perceptions of the hospital food experience

INTRODUCTION

Perceptions of hospital meal quality can influence patient food intake. Understanding what patients prioritise and what they think of current meals can support menu development. The present study assessed patients' food and food-related priorities for hospital meals and their sensory experience using the Hospital Food Experience Questionnaire (HFEQ). Factors independently associated with the HFEQ were determined.

METHODS

Cross-sectional study (n = 1087 patients; 16 Ontario hospitals). Patients completed the HFEQ at a single meal. Descriptive statistics determined the importance of food traits and ratings of a served meal using 22 HFEQ questions (five-point Likert scales, total score 110). Bivariate and multivariable linear regression tested the association between patient and hospital characteristics and HFEQ score.

RESULTS

Most food traits were rated as 'important' (4) or 'very important' (5) by two-thirds or more of patients. Patients typically rated served meal items as 'good' (4). Mean HFEQ score was 90.60 (SD 10.83) and was associated with patient and hospital traits in multivariable analyses (F_42,556  = 2.34, p < 0.001). Older and woman-identifying patients were more likely to have a higher score. Foodservice models were associated with HFEQ. Cold-plated rethermed food resulted in the lowest HFEQ. Local food use > 10% was associated with lower HFEQ score, whereas larger hospitals had a higher score.

CONCLUSIONS

Patients prioritised taste, freshness and food that met their dietary needs. Meal sensory ratings were average. A gap exists between what patients want in hospital meals and what they receive. Attention to patient demographics and food delivery that retains sensory properties and supports choice may increase HFEQ score.

Hospital Food Experience Questionnaire (HFEQ): Reliable, valid and predicts food intake in adult patients

BACKGROUND & AIMS

Low food intake is a primary contributor to iatrogenic hospital malnutrition and can be influenced by perceptions of poor food quality. Valid and reliable tools to assess the food experience of hospital patients are lacking. This study aimed to determine the internal reliability, convergent construct and predictive validity of the new Hospital Food Experience Questionnaire (HFEQ) and to methodically derive and test a shortened version of the questionnaire (HFEQ-sv).

METHODS

Data from a multi-site study on 1087 patients from 16 Ontario hospitals were used. The HFEQ was developed to assess the importance of food (n = 6) and food-related (n = 10) traits using a 5-point Likert scale anchored by "not important" (1) and "very important" (5), and ratings of a single meal served (n = 7) using a 5-point Likert scale anchored by "very poor" (1) and "very good" (5). Food intake at the same meal was assessed using visual estimation (0%, 25%, 50%, 75%, 100%). Internal reliability was determined using Cronbach's alpha, and principal components analysis (PCA). Convergent validity was assessed using ordinal logistic regression with a single question on patients' overall meal quality rating. Cross validation was conducted in an attempt to shorten the questionnaire and binary logistic regression determined predictive validity with food intake.

RESULTS

The HFEQ demonstrated good internal reliability (α = .86), and all but one of the questionnaire items clustered together in PCA, revealing 5 factors. Subscales and the total HFEQ demonstrated convergent validity, with the importance of food taste, choice, easy-to-open packaging, easy-to-eat food and local food provision, in addition to meal ratings of taste, appearance, texture, temperature and combination of food served being associated with the overall meal quality rating (p < .050). These items became the basis for the HFEQ-sv, which was found to independently predict food intake (LRT(42) = 142.17, p < .001).

CONCLUSIONS

The HFEQ is internally reliable, demonstrates convergent validity with the construct of meal quality and predicts food intake. The 11-item HFEQ-sv promotes feasibility. The HFEQ has potential to be used globally to benchmark and quantify the patient food experience in hospital, contributing to quality improvement strategies that will support food intake among patients.

The effects of implementation of a stepwise algorithmic protocol for nutrition care process in gastro-intestinal surgical children in Pediatric Intensive Care Unit (PICU)

INTRODUCTION

Malnutrition is known as one of the major health problems among critically ill children; optimum nutrition support is considered as a therapeutic strategy to improve clinical outcomes and minimize the length of Pediatric Intensive Care Unit (PICU) staying as well as its costs. Implementation of an algorithmic protocol can result in the upgrade of the quality of nutrition support system in PICU.

METHOD

In this study, we developed a stepwise algorithmic nutrition care protocol for PICU patients in two phases as follows: a critical review of past literature and an expert discussion panel. The final structured protocol includes three following steps for the nutrition care process: 1) Initial nutrition screening and assessment, 2) Nutritional intervention and 3) Nutritional monitoring. Pre and post-implementation audits were carried out in a 23 bed medical/surgical PICU in a children's hospital affiliated to Mashhad University of Medical Sciences over two 4-week periods to evaluate the impact of the algorithm implementation. The post-implementation audit was performed by passing 12 weeks from the protocol implementation. Critically ill children aged between 1month and 10 years, and PICU length of stay>24 h who were in post gastrointestinal surgery state, were enrolled.

RESULTS

Totally, 34 eligible critically ill gastrointestinal surgical children in post-implementation audit were compared with 30 patients with similar eligibility criteria in the pre-implementation audit. Notably, there were no significant differences in gender, median age, length of PICU stay, and mechanical ventilation requirement in the two audits. The comparison of our pre and post-implementation audits showed a significant increase in the proportion of energy delivery goal achievement following performing our intervention (56.7%, and 85.3%, for pre and post-implementation audits, respectively; p-value = 0.01).Additionally, time of achieving energy and protein goals were significantly decreased (5.5 vs. 3 days; p-value = 0.008 and 4 vs 3 days; p-value = 0.002, for energy and protein delivery goal achievements, respectively).

CONCLUSION

The implementation of the algorithm have significantly improved the adequacy ratio of energy delivery and also decreased the time to achieve the goal in energy and protein intake among critically ill children in post-gastrointestinal state. In this regard, further prospective studies are needed for continuing the evaluation of the algorithm implementation outcomes in critically ill children with different surgical and internal underlying diseases.

Harnessing Stakeholder Perspectives and Experience to Address Nutrition Risk in Community-Dwelling Older Adults

Community-dwelling, older adults have a high prevalence of nutrition risk but strategies to mitigate this risk are not routinely implemented. Our objective was to identify opportunities for the healthcare system and community organizations to combat nutrition risk in this population in the jurisdiction of Alberta, Canada. An intersectoral stakeholder group that included patient representatives was convened to share perspectives and experiences and to identify problems in need of solutions using a design thinking approach. Results: Two main themes emerged from the workshop: (1) lack of awareness and poor communication of the importance of nutrition risk between healthcare providers and from healthcare providers to patients and (2) the necessity to work in partnerships comprised of patients, community organizations, healthcare providers and the health system. Conclusion: Improving awareness, prevention and treatment of malnutrition in community-dwelling older adults requires intersectoral cooperation between patients, healthcare providers and community-based organizations.