Validity and reliability of the new Canadian Nutrition Screening Tool in the ‘real-world’ hospital setting

Validity of nutrition screening tools for risk of malnutrition among hospitalized adult patients: A systematic review and meta-analysis

BACKGROUNDS & AIMS

Malnutrition is prevalent among hospitalized patients in developed countries, contributing to negative health outcomes and increased healthcare costs. Timely identification and management of malnutrition are crucial. The lack of a universally accepted definition and standardized diagnostic criteria for malnutrition has led to the development of various screening tools, each with varying validity. This complicates early identification of malnutrition, hindering effective intervention strategies. This systematic review and meta-analysis aimed to identify the most valid and reliable nutritional screening tool for assessing the risk of malnutrition in hospitalized adults.

METHODS

A systematic literature search was conducted to identify validation studies published from inception to November 2023, in the Pubmed/MEDLINE, Embase, and CINAHL databases. This systematic review was registered in INPLASY (INPLASY202090028). The risk of bias and quality of included studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2). Meta-analyses were performed for screening tools accuracy using the symmetric hierarchical summary receiver operative characteristics models.

RESULTS

Of the 1646 articles retrieved, 60 met the inclusion criteria and were included in the systematic review, and 21 were included in the meta-analysis. A total of 51 malnutrition risk screening tools and 9 reference standards were identified. The meta-analyses assessed four common malnutrition risk screening tools against two reference standards (Subjective Global Assessment [SGA] and European Society for Clinical Nutrition and Metabolism [ESPEN] criteria). The Malnutrition Universal Screening Tool (MUST) vs SGA had a sensitivity (95% Confidence Interval) of 0.84 (0.73-0.91), and specificity of 0.85 (0.75-0.91). The MUST vs ESPEN had a sensitivity of 0.97 (0.53-0.99) and specificity of 0.80 (0.50-0.94). The Malnutrition Screening Tool (MST) vs SGA had a sensitivity of 0.81 (0.67-0.90) and specificity of 0.79 (0.72-0.74). The Mini Nutritional Assessment-Short Form (MNA-SF) vs ESPEN had a sensitivity of 0.99 (0.41-0.99) and specificity of 0.60 (0.45-0.73). The Nutrition Universal Screening Tool-2002 (NRS-2002) vs SGA had a sensitivity of 0.76 (0.58-0.87) and specificity of 0.86 (0.76-0.93).

CONCLUSIONS

The MUST demonstrated high accuracy in detecting malnutrition risk in hospitalized adults. However, the quality of the studies included varied greatly, possibly introducing bias in the results. Future research should compare tools within a specific patient population using a valid and universal gold standard to ensure improved patient care and outcomes.

A survey of preoperative surgical nutrition practices, opinions, and barriers across Canada

Malnutrition is prevalent among surgical candidates and associated with adverse outcomes. Despite being potentially modifiable, malnutrition risk screening is not a standard preoperative practice. We conducted a cross-sectional survey to understand healthcare professionals' (HCPs) opinions and barriers regarding screening and treatment of malnutrition. HCPs working with adult surgical patients in Canada were invited to complete an online survey. Barriers to preoperative malnutrition screening were assessed using the Capability Opportunity Motivation-Behaviour model. Quantitative data were analyzed using descriptive statistics and qualitative data were analyzed using summative content analysis. Of the 225 HCPs surveyed (n = 111 dietitians, n = 72 physicians, n = 42 allied HCPs), 96%-100% agreed that preoperative malnutrition is a modifiable risk factor associated with worse surgical outcomes and is a treatment priority. Yet, 65% (n = 142/220; dietitians: 88% vs. physicians: 40%) reported screening for malnutrition, which mostly occured in the postoperative period (n = 117) by dietitians (n = 94). Just 42% (48/113) of non-dietitian respondents referred positively screened patients to a dietitian for further assessment and treatment. The most prevalent barriers for malnutrition screening were related to opportunity, including availability of resources (57%, n = 121/212), time (40%, n = 84/212) and support from others (38%, n = 80/212). In conclusion, there is a gap between opinion and practice among surgical HCPs pertaining to malnutrition. Although HCPs agreed malnutrition is a surgical priority, the opportunity to screen for nutrition risk was a great barrier.

Prehabilitation: Who can benefit?

Prehabilitation is an intervention that occurs between cancer diagnosis and the start of an acute treatment. It involves physical, nutritional, and psychological assessments to establish a baseline functional level and provide targeted interventions to improve a person's health and prevent future impairments. Prehabilitation has been applied to surgical oncology and has shown positive results at improving functional capacity, reducing hospital stay, decreasing complications, and enhancing health-related quality of life. The importance of collaboration between various healthcare professionals and the implementation of multimodal interventions, including exercise training, nutrition optimization, and emotional support is discussed in this manuscript. The need for screening and assessment of conditions such as sarcopenia, frailty, or low functional status in order to identify patients who would benefit the most from prehabilitation is vital and should be a part of all prehabilitation programs. Exercise and nutrition play complementary roles in prehabilitation, enhancing anabolism and performance. However, in the presence of malnutrition and sarcopenia, exercise-related energy expenditure without sufficient protein intake can lead to muscle wasting and further deterioration of functional capacity, thus special emphasis on nutrition and protein intake should be made in these cases. Finally, the challenges and the need for a paradigm shift in perioperative care are discussed to effectively implement personalized prehabilitation programs.

Optimizing care of patients undergoing cardiac surgery using a digital platform and a multidisciplinary team approach

OBJECTIVE

Restrictions to care access during the pandemic along with the increasing complexity of patients awaiting cardiac surgery provides unique challenges for care delivery. The University of Ottawa Heart Institute has developed a novel multidisciplinary digital platform, the Prehab Automated Follow-Up (AFU) Program, which delivers patient/caregiver teaching regarding risk factor mitigation, tracks patient symptoms, and screens for optimization using best practice guidelines. This study was conducted to quantify patient outcomes following initiation of the AFU Program.

METHODS

Patients awaiting elective cardiac surgery are enrolled and screened via automated telephone conversation, according to best practice guidelines, and a Short Form-12 preoperative assessment. Following this screen, patients are referred for an in-person assessment by an appropriate multidisciplinary team member; namely, a diabetes specialist, physiotherapist, dietitian, smoking cessation counselor, social worker, vocational counselor, and/or psychologist.

RESULTS

Since initiation in February 2021, the AFU Program has enrolled more than 1237 patients with 508 multidisciplinary team referrals prompted by the AFU screening platform. Before program initiation, there were no multidisciplinary team referrals for preoperative optimization. Compared with patients treated between February 2020 and February 2021, there was a 2.5% decrease in hospital readmission rate within 30 days of surgery, a 0.6-day shorter hospital stay, and a 2.5% decrease in surgical site infection.

CONCLUSIONS

Our cardiac surgery AFU Program reduced adverse health outcomes for patients by identifying and optimizing risk factors that increased quality of patient care. The AFU Program provides patient/caregiver engagement through educational support and multidisciplinary team counseling.

Preoperative frailty screening, assessment and management

PURPOSE OF REVIEW

To highlight the importance of frailty assessment in thoracic surgery patients.

RECENT FINDINGS

Frailty results from an accelerated loss of functional reserve associated with ageing and leads to increased vulnerability following surgery. It is a complex and multidimensional syndrome involving physiological and psychosocial systems. Frailty is a separate entity from comorbidities and disabilities. Frailty is associated with an increased risk of complications and a higher mortality rate after thoracic surgery. Patients can easily be screened for frailty and frail patients can benefit from further assessment of all areas of frailty secondarily. Prehabilitation and rehabilitation can help limit frailty-related complications after thoracic surgery.

SUMMARY

Frailty should be part of the routine preoperative evaluation for thoracic surgery. Frailty must be considered in assessing eligibility for surgery and in planning prehabilitation and rehabilitation if necessary.

Assessment Tools of Biopsychosocial Frailty Dimensions in Community-Dwelling Older Adults: A Narrative Review

Frailty is a complex interplay between several factors, including physiological changes in ageing, multimorbidities, malnutrition, living environment, genetics, and lifestyle. Early screening for frailty risk factors in community-dwelling older people allows for preventive interventions on the clinical and social determinants of frailty, which allows adverse events to be avoided. By conducting a narrative review of the literature employing the International Narrative Systematic Assessment tool, the authors aimed to develop an updated framework for the main measurement tools to assess frailty risks in older adults, paying attention to use in the community and primary care settings. This search focused on the biopsychosocial domains of frailty that are covered in the SUNFRAIL tool. The study selected 178 reviews (polypharmacy: 20; nutrition: 13; physical activity: 74; medical visits: 0; falls: 39; cognitive decline: 12; loneliness: 15; social support: 5; economic constraints: 0) published between January 2010 and December 2021. Within the selected reviews, 123 assessment tools were identified (polypharmacy: 15; nutrition: 15; physical activity: 25; medical visits: 0; falls: 26; cognitive decline: 18; loneliness: 9; social support: 15; economic constraints: 0). The narrative review allowed us to evaluate assessment tools of frailty domains to be adopted for multidimensional health promotion and prevention interventions in community and primary care.

Demystifying Malnutrition to Improve Nutrition Screening and Assessment in Oncology

OBJECTIVE

Patients with cancer and malnutrition are more likely to experience poor treatment tolerance, prolonged length of hospital stay, and decreased quality of life. Early and sustained nutrition risk screening is the first step to tackling this patient and health care burden. Yet, malnutrition remains largely overlooked and undertreated. Malnutrition mismanagement could be indicative of a systemic misunderstanding. With this narrative review, we aimed to (1) define malnutrition, (2) address common malnutrition misconceptions, and (3) summarize nutrition recommendations for patients with cancer.

DATA SOURCES

PubMed and international clinical practice guidelines were used.

CONCLUSION

Malnutrition represents an unbalanced nutritional state that alters body composition and diminishes function. Malnutrition is not always physically obvious, and albumin is not a reliable marker of nutritional status; therefore, systematically screening all patients with a validated nutrition risk screening tool at time of cancer diagnosis, and periodically throughout treatment, is necessary to provide optimal, equitable care. Nutrition risk screening takes less than 1 minute to complete and can be completed by any health care professional. Patients that screen positive for nutrition risk should be referred to a registered nutritionist or dietitian for comprehensive nutritional assessment, diagnosis, and treatment.

IMPLICATIONS FOR NURSING PRACTICE

All health care professionals can and should be responsible for preventing and treating malnutrition. Registered nurses can actively participate in improving patient outcomes by screening patients for nutrition risk, weighing patients at every visit, referring patients to dietitians for nutrition treatment, and providing supportive medical management of nutrition impact symptoms such as nausea.

PREPARE trial: a protocol for a multicentre randomised trial of frailty-focused preoperative exercise to decrease postoperative complication rates and disability scores

INTRODUCTION

Frailty is a strong predictor of adverse postoperative outcomes. Prehabilitation may improve outcomes after surgery for older people with frailty by addressing physical and physiologic deficits. The objective of this trial is to evaluate the efficacy of home-based multimodal prehabilitation in decreasing patient-reported disability and postoperative complications in older people with frailty having major surgery.

METHODS AND ANALYSIS

We will conduct a multicentre, randomised controlled trial of home-based prehabilitation versus standard care among consenting patients >60 years with frailty (Clinical Frailty Scale>4) having elective inpatient major non-cardiac, non-neurologic or non-orthopaedic surgery. Patients will be partially blinded; clinicians and outcome assessors will be fully blinded. The intervention consists of >3 weeks of prehabilitation (exercise (strength, aerobic and stretching) and nutrition (advice and protein supplementation)). The study has two primary outcomes: in-hospital complications and patient-reported disability 30 days after surgery. Secondary outcomes include survival, lower limb function, quality of life and resource utilisation. A sample size of 750 participants (375 per arm) provides >90% power to detect a minimally important absolute difference of 8 on the 100-point patient-reported disability scale and a 25% relative risk reduction in complications, using a two-sided alpha value of 0.025 to account for the two primary outcomes. Analyses will follow intention to treat principles for all randomised participants. All participants will be followed to either death or up to 1 year.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Clinical Trials Ontario (Project ID: 1785) and our ethics review board (Protocol Approval #20190409-01T). Results will be disseminated through presentation at scientific conferences, through peer-reviewed publication, stakeholder organisations and engagement of social and traditional media.

TRIAL REGISTRATION NUMBER

NCT04221295.

Utility and Impact of the Implementation of Same-Day, Self-administered Electronic Patient-Reported Outcomes Assessments in Routine HIV Care in two North American Clinics

The PROgress study assessed the value and feasibility of implementing web-based patient-reported outcomes assessments (PROs) within routine HIV care at two North American outpatient clinics. People with HIV (PWH) completed PROs on a tablet computer in clinic before their routine care visit. Data collection included PROs from 1632 unique PWH, 596 chart reviews, 200 patient questionnaires, and 16 provider/staff questionnaires. During an initial setup phase involving 200 patients, PRO results were not delivered to providers; for all subsequent patients, providers received PRO results before the consultation. Chart review demonstrated that delivery of PRO results to providers improved patient-provider communication and increased the number of complex health and behavioral issues identified, recorded, and acted on, including suicidal ideation (88% with vs 38% without PRO feedback) and anxiety (54% with vs 24% without PRO feedback). In post-visit questionnaires, PWH (82%) and providers (82%) indicated that the PRO added value to the visit.

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.

Strategies for optimal perioperative outcomes in gastric cancer

Cancer and surgery represent a major stress on the human body. Any condition that prevents patients from tolerating the physiological stress is a risk factor for poor outcome. There is a need to identify these impairments early in the process with a simple screening, followed by assessments that provide a holistic picture of the patient. The proposed path of multimodal prehabilitation acts synergistically with enhanced recovery after surgery care to achieve optimal patient outcomes.

Prehabilitation, enhanced recovery after surgery, or both? A narrative review

This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively.

Risk Factors for Suboptimal Adherence Identified by Patient-Reported Outcomes Assessments in Routine HIV Care at 2 North American Clinics

PURPOSE

Use of patient-reported outcomes assessments (PROs) can improve patient-provider communication and focus provider attention on current health issues. This analysis examines the association between suboptimal antiretroviral therapy (ART) adherence and factors obtained through PROs among people with HIV (PWH) at 2 North American outpatient clinics.

PATIENTS AND METHODS

Immediately before a clinic visit, PWH completed self-administered PROs. Unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated from logistic regression models to identify sociodemographic and health-related factors (satisfaction with ART, difficulty meeting housing costs, depression, intimate partner violence, risk of malnutrition, smoking status, alcohol use, and substance use) associated with suboptimal adherence (defined as self-reporting <95% or <80% adherence). Multiple imputation was performed to account for missing data in the multivariate analyses.

RESULTS

Of 1632 PWH, 1239 (76%) responded to the adherence assessment; of these, 268 (22%) and 106 (9%) reported <95% and <80% adherence, respectively. Of 1580 PWH who responded, 354 (22%) were dissatisfied with their HIV medication. Of responding PWH, 19% reported moderate-to-severe depression, 23% indicated they were at risk of malnutrition, 34% were current smokers, and 62% reported substance use in the past 3 months. Dissatisfaction with ART was significantly associated with <95% and <80% adherence in the unadjusted analysis (unadjusted OR [95% CI], 3.38 [2.51-4.56] and 4.26 [2.82-6.42], respectively) and adjusted analysis (adjusted OR [95% CI], 2.76 [1.91-4.00] and 3.28 [1.95-5.52], respectively); significance remained after multiple imputation. In adjusted analyses, no risk of malnutrition was significantly associated with reduced odds of <95% adherence after multiple imputation (adjusted OR [95% CI], 0.714 [0.511-0.997]); no other factors were associated with <95% or <80% adherence.

CONCLUSION

These results suggest that implementation of PROs evaluating treatment satisfaction may provide value to adherence management in routine HIV care.

Safety and impact of peripheral parenteral nutrition on nutrient delivery in patients with nutrition risk: A prospective observational study

BACKGROUND

Malnutrition is common in hospitalized patients and strategies to improve energy and protein intake have a positive impact on outcome. Despite early evidence suggesting the usefulness of peripheral parenteral nutrition (PPN), its adoption has been hampered by concerns regarding safety and efficacy. This study addresses this issue.

METHODS

This prospective observational study was performed in medical and surgical inpatients in who were screened for nutrition risk and assessed using Subjective Global Assessment (SGA). Data captured included nutrition status, energy and protein requirements, intravenous access, indications for PPN, use of supplemental micronutrients, and disposition of patients on PPN.

RESULTS

Ninety-eight patients were recruited from two centers over 8 months. The average age was 61.5 years, the mean Charlson Comorbidity Index was 4.21 (±3.09), 52% were male, and 48% were admitted to medicine, whereas 52% were admitted to surgery. Thirty-three percent of patients were SGA C, 44% were SGA B, and 19% were SGA A. Twenty-seven percent of patients had cancer. The average length of hospital stay was 22 days. The main indications for PPN were gastrointestinal tract dysfunction (72%) and postsurgical status (16%). PPN provided an average of 1296 kcal (±191) and 46 g of protein (±7). Intravenous access complications in patients receiving PPN did not occur in excess of expected. Almost 40% of patients required transition to central PN.

CONCLUSIONS

PPN is a safe, effective way to deliver supplemental protein, energy, and micronutrients to malnourished patients and supports transition to other modes of nutrition care.

Dietary intake and characteristics in persons with multiple sclerosis

BACKGROUND

Despite growing interest in diet and dietary interventions in persons with multiple sclerosis (PwMS), few studies have examined dietary intake and characteristics within this population. The objectives of this study were to prospectively describe and compare nutrition assessment parameters related to the diet, including daily food intake, nutrient intake, eating behaviours, and other dietary characteristics (i.e., specific diets, food preparation, and food security) between PwMS and controls without multiple sclerosis (MS).

METHODS

This study used a cross-sectional design in 60 PwMS and 60 matched controls. All participants completed a 3-day food intake record and questionnaires. Dietary intake was analysed with and without supplements using ESHA Food Processor SQL. Differences in dietary intake by group and supplement intake were examined using mixed-model ANOVAs.

RESULTS

There were differences in average daily micronutrient intake between groups for vitamins D, B12, and C, omega 3 fatty acids, and phosphorous. Through supplement use, PwMS consumed significantly more vitamin D, omega 3 fatty acids, vitamin B12, vitamin C, magnesium, manganese, and zinc than controls. There was no difference in dietary behaviours or other dietary characteristics between groups.

CONCLUSIONS

Results suggest that dietary intake was similar in persons with and without MS. The few differences in dietary intake between groups were mostly accounted for by supplement intake in PwMS. Further studies are needed to continue exploring dietary intake in PwMS.

From clinical guidelines to practice: The nutrition elements for enhancing recovery after colorectal surgery

The Enhanced Recovery After Surgery (ERAS) Care System improves patient outcomes. The ERAS Protocol describes multimodal, evidence-based processes that are bundled into >20 care elements, and the ERAS Implementation Program provides strategies to guide the successful adoption of the care elements. Although formal training is essential to implement ERAS correctly, with this article we aim to bridge the gap between the nutritionally relevant care elements of the protocol and their implementation for colorectal surgery. This article also describes how dietitians can support optimal patient outcomes by playing an active role in implementing, monitoring, and evaluating ERAS practices.

Feasibility of implementing a same-day electronic screening tool for clinical assessment to measure patient-reported outcomes for eliciting actionable information on adherence to HIV medication and related factors in a busy Canadian urban HIV clinic

BACKGROUND

An optimal adherence to antiretroviral therapy (ART) is fundamental for suppression of HIV viral load and favourable treatment outcomes. Patient-reported outcomes (PROs) are effective tools for improving patient-provider communication and focusing providers' awareness on current health problems. The objectives of this analysis were (1) to determine the feasibility of implementing an electronic screening tool to measure PROs in a Canadian HIV clinic to obtain information on ART adherence and related factors and (2) to determine the factors related to sub-optimal adherence.

METHODS

This implementation research with a convenience sample of 600 people living with HIV (PLWH) was conducted in a busy, academic, urban HIV clinic in Toronto, Canada. PLWH were approached to participate in PRO assessments just prior to their in-clinic appointments, including health-related domains such as mental health, housing, nutrition, financial stress and medication adherence, and responses were summarized on a single sheet available for providers to review. Feasibility of implementing PROs was assessed by quantifying response rate, completion rate, time taken and participation rate. Medication adherence was elicited by self-report of the percentage of prescribed HIV medications taken in the last month. Unadjusted and adjusted odds ratios were estimated from logistic regression models to identify factors associated with adherence of <95%.

RESULTS

Of the 748 PLWH invited to participate, 692 (participation rate: 92.5%) completed the PRO assessments as standard of care in clinic. Of these, 600 consented to the use of their PRO results for research and were included in this analysis. The average response rate to the ART-related questions was 96.8% and mean completion rate was 95.5%. The median time taken to complete the assessment was 12.0 (IQR = 8.4-17.3) min, adjusted 8.7 (IQR = 7.2-10.8) min. 445 (74.9%) of participants were male, and 153 (26.2%) reported dissatisfaction with ART. 105 (19.7%) of the PLWH reported ART adherence of <95%. Multivariable logistic regression identified the following risk factors for sub-optimal adherence: dissatisfaction with ART (OR = 2.30, 95% CI 1.38-3.83), not having a family doctor or not visiting a family doctor in last year (OR = 1.69, 95% CI 1.02-2.79).

CONCLUSION

Collecting self-reported health information from PLWH through PROs in a busy urban clinic was feasible and can provide relevant information to healthcare providers on issues related to adherence. This has a potential to help in individualizing ambulatory care.

Nutrition Care Process Model Approach to Surgical Prehabilitation in Oncology

The nutrition care process is a standardized and systematic method used by nutrition professionals to assess, diagnose, treat, and monitor patients. Using the nutrition care process model, we demonstrate how nutrition prehabilitation can be applied to the pre-surgical oncology patient.

Identifying Low Value Malnutrition Care Activities for De-Implementation and Systematised, Interdisciplinary Alternatives-A Multi-Site, Nominal Group Technique Approach

Malnutrition risk is identified in over one-third of inpatients; reliance on dietetics-delivered nutrition care for all “at-risk” patients is unsustainable, inefficient, and ineffective. This study aimed to identify and prioritise low-value malnutrition care activities for de-implementation and articulate systematised interdisciplinary opportunities. Nine workshops, at eight purposively sampled hospitals, were undertaken using the nominal group technique. Participants were asked “What highly individualised malnutrition care activities do you think we could replace with systematised, interdisciplinary malnutrition care?” and “What systematised, interdisciplinary opportunities do you think we should do to provide more effective and efficient nutrition care in our ward/hospital?” Sixty-three participants were provided five votes per question. The most voted de-implementation activities were low-value nutrition reviews (32); education by dietitian (28); assessments by dietitian for patients with malnutrition screening tool score of two (22); assistants duplicating malnutrition screening (19); and comprehensive, individualised nutrition assessments where unlikely to add value (15). The top voted alternative opportunities were delegated/skill shared interventions (55), delegated/skill shared education (24), abbreviated malnutrition care processes where clinically appropriate (23), delegated/skill shared supportive food/fluids (14), and mealtime assistance (13). Findings highlight opportunities to de-implement perceived low-value malnutrition care activities and replace them with systems and skill shared alternatives across hospital settings.

The complexities of approaching nutrition in inflammatory bowel disease: current recommendations and future directions

Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis predispose patients to malnutrition due to a combination of increased basal metabolic rate, decreased oral intake, and increased nutritional losses and malabsorption. Malnutrition is common, affecting up to 75% of patients with Crohn's disease and 62% of patients with ulcerative colitis, and is associated with worse disease prognosis, higher complication rates, decreased quality of life, and increased mortality risk. It is imperative to screen patients with IBD for malnutrition to assess those at increased risk and treat accordingly to prevent progression and complications. This literature review provides an overall approach to optimizing nutrition in IBD, focusing on the assessment for the diagnosis of malnutrition, management of macro- and micronutrient deficiencies, and identification of areas for future study.

Wound Bed Preparation 2021

GENERAL PURPOSE

To present the 2021 update of the Wound Bed Preparation paradigm.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will: 1. Apply wound assessment strategies. 2. Identify patient concerns about wound care. 3. Select management options for healable, nonhealable, and maintenance wounds.

Malnourished lung cancer patients have poor baseline functional capacity but show greatest improvements with multimodal prehabilitation

OBJECTIVE

The objective is to characterize the presence of malnutrition, examine the association between malnutrition and baseline functional capacity (FC), and the extent to which patients benefit from preoperative multimodal prehabilitation in patients undergoing lung resection for cancer.

METHODS

Data from 162 participants enrolled in multimodal prehabilitation or control before lung cancer surgery were analyzed. Malnutrition was measured using the Patient-Generated Subjective Global Assessment (PG-SGA) according to triage levels: low-nutrition-risk (PG-SGA 0-3), moderate-nutrition-risk (4-8) and high-nutrition-risk (≥9). Baseline differences in FC, measured by the 6-minute walk test (6MWT), were compared. Factorial analysis of covariance (ANCOVA) was conducted to examine the effect of nutrition status and intervention on mean change in 6MWT preoperatively.

RESULTS

51.2% patients were considered low-nutrition-risk, 37.7% moderate-nutrition-risk, and 11.1% high-nutrition-risk. Low-nutrition-risk patients had significantly higher 6MWT at baseline (mean of 484 m [standard deviation (SD) = 88]) compared with moderate-nutrition-risk (432 m [SD = 107], P = .005) and high-nutrition-risk groups (416 m [SD = 90], P = .022). The adjusted mean change in 6MWT between prehabilitation vs control was 18.1 (95% confidence interval, 3.8 to 32.3) vs 5.6 m (-14.1 to 25.4) in low-nutrition-risk (P = .309), 28.5 (11 to 46) vs -4 m (-31.3 to 23.4) in moderate-nutrition-risk (P = .053), and 58.9 (16.7 to 101.2) vs -39.7 m (-80.2 to 0.826) in high-nutrition-risk group (P = .001).

CONCLUSIONS

Lung cancer patients at high-nutrition-risk awaiting surgery had significantly lower baseline FC compared with low-nutrition-risk patients but experienced significant improvements in preoperative FC upon receiving multimodal prehabilitation.

A Pragmatic Non-Randomized Trial of Prehabilitation Prior to Cancer Surgery: Study Protocol and COVID-19-Related Adaptations

Background

Experimental data highlight the potential benefits and health system cost savings related to surgical prehabilitation; however, adequately powered randomized controlled trial (RCT) data remain nascent. Emerging prehabilitation services may be informed by early RCT data but can be limited in informing real-world program development. Pragmatic trials emphasize external validity and generalizability to understand and advise intervention development and implementation in clinical settings. This paper presents the methodology of a pragmatic prehabilitation trial to complement emerging phase III clinical trials and inform implementation strategies.

Methods

This is a pilot pragmatic clinical trial conducted in a large academic hospital in Toronto, Ontario, Canada to assess feasibility of clinical implementation and derive estimates of effectiveness. Feasibility data include program referral rates, enrolment and attrition, intervention adherence and safety, participant satisfaction, and barriers and facilitators to programming. The study aims to receive 150 eligible referrals for adult, English-speaking, preoperative oncology patients with an identified indication for prehabilitation (e.g., frailty, deconditioning, malnutrition, psychological distress). Study participants undergo a baseline assessment and shared-decision making regarding the intervention setting: either facility-based prehabilitation or home-based prehabilitation. In both scenarios, participants receive an individualized exercise prescription, stress-reduction psychological support, nutrition counseling, and protein supplementation, and if appropriate, smoking cessation program referrals. Secondary objectives include estimating intervention effects at the week prior to surgery and 30 and 90 days postoperatively. Outcomes include surgical complications, postoperative length of stay, mortality, hospital readmissions, physical fitness, psychological well-being, and quality of life. Data from participants who decline the intervention but consent for research-related access to health records will serve as comparators. The COVID-19 pandemic required the introduction of a 'virtual program' using only telephone or internet-based communication for screening, assessments, or intervention was introduced.

Conclusion

This pragmatic trial will provide evidence on the feasibility and viability of prehabilitation services delivered under usual clinical conditions. Study amendments due to the COVID-19 pandemic are presented as strategies to maintain prehabilitation research and services to potentially mitigate the consequences of extended surgery wait times.

Scored-GLIM as an effective tool to assess nutrition status and predict survival in patients with cancer

BACKGROUND & AIMS

The Global Leadership Initiative on Malnutrition (GLIM) released new universal criteria for diagnosing and grading malnutrition, and calls for further investigations not only in different clinical setting but also in GLIM itself including reference value, combination and weight of different GLIM criteria. This study aimed to weigh the GLIM criteria and develop a scored-GLIM system, and then validate as well as evaluate its application in nutritional assessment and survival prediction for patients with cancer.

DESIGN

A total of 3547 patients in the primary cohort and 415 patients in the validation cohort were included in the study. Patients' nutritional status were retrospectively assessed using the GLIM criteria. Kaplan-Meier survival curves and multivariate Cox regression analyses were performed to analyze the association between nutritional status and overall survival (OS). A nomogram was produced to quantify the GLIM criteria and develop the scored-GLIM system. C-index, receiver operating characteristic (ROC) curve and calibration curve analyses were performed to validate the predictive accuracy and discriminatory capacity of the scored-GLIM. Finally, a decision curve was applied to assess the clinical utility of the scored-GLIM system.

RESULTS

In the primary cohort, 70.3% of patients were diagnosed as malnutrition. The malnutrition severity grading according to the GLIM criteria were associated with the prognosis of patients with cancer (HR 1.42, 1.23 to 1.65 for moderate malnutrition; HR 1.80,1.84 to 2.09 for severe malnutrition). The weight of each GLIM criteria was calculated, and unintentional weight loss was the most determining factor acting upon mortality (HR 1.82, 1.64 to 2.10 for stage II and HR 1.50, 1.31 to 1.73 for stage I). A nomogram was constructed by four factors of GLIM to weigh the GLIM criteria. The areas under the ROC curve were 65.3 (1-year ROC) and 65.5 (3-year ROC), and the C-index was 0.62, and the calibration curves fitted well. Decision curve analysis demonstrated the clinical usefulness of the scored-GLIM system.

CONCLUSION

The accuracy and net clinical benefit of scored-GLIM system were similar to scored-PG-SGA but higher than GLIM both in nutrition assessment and in survival prediction for patients with cancer. These findings, along with its time-savings advantages over scored-PG-SGA, suggest scored-GLIM be a better nutritional assessment tool.

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

AIM

Shifting to models of care that incorporate delegation of nutrition care process actions to dietitian assistants could facilitate effective and efficient nutrition care delivery. This review aimed to determine if delegation of malnutrition care activities to dietitian assistants, when compared with routine nutrition care practices influences patient, healthcare and/or workforce outcomes for adult hospital inpatients with or at risk of malnutrition.

METHODS

This review was undertaken in accordance with PRISMA guidelines, with five databases (CINAHL, Medline, PsycINFO, Embase and Scopus) searched systematically for studies published up to and including February 2020. Exclusion criteria included review articles and studies conducted in community settings.

RESULTS

The search yielded 3431 results, with 11 studies eligible for inclusion. Across all domains of the nutrition care process, there is emerging evidence dietitian assistants may improve the delivery of nutrition care practices, patient, healthcare and workforce outcomes. Findings demonstrated various roles and scope of dietitian assistants' practice throughout the studies. Positive patient outcomes were found when dietitian assistants were part of a multi-disciplinary model of care.

CONCLUSIONS

Implementing delegation of components of the nutrition care process to dietitian assistants is vital in the current health climate and should be considered in a future multidisciplinary model of nutrition care. Exploration of dietitian assistant roles and opportunities are required to expand and strengthen the evidence.

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.

The Anthropometric Assessment With the Bioimpedance Method Is Associated With the Prognosis of Cirrhotic Patients

BACKGROUND/AIM

The bioimpedance analysis (BIA) can provide anthropometric data on patients. The aim of the study is to evaluate the clinical relevance of these automatically obtained values.

PATIENTS AND METHODS

We studied the arm circumference (AC) and arm muscle circumference (AMC) of 197 histologically proven cirrhotic patients. The BIA-based anthropometric data were compared to the manually measured data. In addition, we evaluated whether or not the BIA-based anthropometric data were associated with the prognosis of the patients.

RESULTS

The data of %AC and %AMC obtained using the two methods were well correlated (p<0.001) with relatively inconspicuous differences (approximately 6.0% for %AC and 16.0% for %AMC). The data of %AC and %AMC obtained from the BIA method were significantly associated with the prognosis of the patients.

CONCLUSION

The BIA-based anthropometric data were associated with the direct measurement data and related to the prognosis of cirrhotic patients.

More-2-Eat implementation demonstrates that screening, assessment and treatment of malnourished patients can be spread and sustained in acute care; a multi-site, pretest post-test time series study

BACKGROUND

Malnutrition in medical and surgical inpatients is an on-going problem. More-2-Eat (M2E) Phase 1 demonstrated that improved detection and treatment of hospital malnutrition could be embedded into routine practice using an intensive researcher-facilitated implementation process. Yet, spreading and sustaining new practices in diverse hospital cultures with minimal researcher support is unknown.

AIMS

To demonstrate that a scalable model of implementation can increase three key nutrition practices (admission screening; Subjective Global Assessment (SGA); and medication pass (MedPass) of oral nutritional supplement) in diverse acute care hospitals to detect and treat malnutrition in medical and surgical patients.

METHODS

Ten hospitals participated in this pretest post-test time series implementation study from across Canada, including 21 medical or surgical units (Phase 1 original units (n = 4), Phase 1 hospital new units (n = 9), Phase 2 new hospitals and units (n = 8)). The scalable implementation model included: training champions on implementation strategies and providing them with education resources for teams; creating a self-directed audit and feedback process; and providing mentorship. Standardized audits of all patients on the study unit on an audit day were completed bi-monthly to track nutrition care activities since admission. Bivariate comparisons were performed by time period (initial, mid-term and final audits). Run-charts depicted the trajectory of change and qualitatively compared to Phase 1.

RESULTS

5158 patient charts were audited over the course of 18-months. Admission nutrition screening rates increased from 50% to 84% (p < 0.0001). New Phase 1 units more readily implemented screening than Phase 2 sites, and the original Phase 1 units generally sustained screening practices from Phase 1. SGA was a sustained practice at Phase 1 hospitals including in new Phase 1 units. The new Phase 2 units improved completion of SGA but did not reach the levels of Phase 1 units (original or new). MedPass almost doubled over the time periods (7%-13% of all patients p < 0.007). Other care practices significantly increased (e.g. volunteer mealtime assistance).

CONCLUSION

Nutrition-care activities significantly increased in diverse hospital units with this scalable model. This heralds the transition from implementation research to sustained changes in routine practice. Screening, SGA, and MedPass can all be implemented, improve nutrition care for all patients, spread within an organization, and for the most part, sustained (and in the case of original Phase 1 units, for over 3 years) with champion leadership.

Clinical measurement properties of malnutrition assessment tools for use with patients in hospitals: a systematic review

Background

The use of malnutrition outcome measures (OM) by registered dietitians (RD) with inpatients in hospitals has increased promoting the achievement of nutritional care goals and supporting decision-making for the allocation of nutritional care resources in hospitals. There are 3 commonly used OMs: Subjective Global Assessment (SGA), Patient Generated-Subjective Global Assessment (PG-SGA) and Mini Nutritional Assessment (MNA). The purpose of this current study was to systematically review the evidence of the clinical measurement properties of malnutrition assessment tools for use with patients admitted in hospitals.

Methods

MEDLINE, Cinahl, EMBASE, and PubMed were searched for articles published between 2000 and 2019. Research articles were selected if they established reliability, validity, and responsiveness to change properties of the SGA, PG-SGA and MNA tools, were written in English, and used any of these OMs as an outcome measure. Abstracts were not considered. The risk of bias within studies was assessed using the Quality Appraisal for Clinical Measurement Study (QA-CMS).

Results

Five hundred five studies were identified, of which 34 articles were included in the final review: SGA (n = 8), PG-SGA (n = 13), and MNA (n = 13). Of the 34 studies, 8 had a quality score greater than 75%; 23 had a quality score of 40–75% and 3 studies had a quality score of less than 40%. PG-SGA was found to have excellentdiagnostic accuracy (ROC: 0.92–0.975; Sensitivity: 88.6–98%; Specificity: 82–100%), sufficient internal consistency (Cronbach’s alpha: 0.722–0.73), and strong test-retest reliability (r = 0.866). There was insufficient evidence to suggest adequate diagnostic accuracy and good inter-rater reliability for SGA. Only one study examined the minimum detectable change of MNA (MDC = 2.1).

Conclusions

The evidence of validity for the existing malnutrition assessment tools supports the use of these tools, but more studies with sound methodological quality are needed to assess the responsiveness of these OMs to detect the change in nutritional status.

[Assessing the implementation of a nutritional screening protocol in patients admitted to the Medicine Department of a local hospital]

Introduction

Background: the techniques for screening and nutritional intervention in hospitalized patients are a cost-effective measure. In clinical practice the problem lies in their administration. Objective: to evaluate the implementation of a nutritional screening tool in patients admitted to our Medicine Ward (M). Material and methods: a single-center, prospective, observational study in patients admitted to M. Exclusion criteria: end-stage cancer patients, inpatient stay less than 72 h, and hospital readmission of previously included patients. One out of every 2 hospital admissions was selected. We assessed the following: whether nurses performed the screening test, the Short Nutritional Assessment Questionnaire (SNAQ); the score obtained; consultations with dieticians (ICD); prescribed nutritional support; and coding of malnutrition in the discharge report. Dieticians repeated the SNAQ for one in every 3 patients. Results: during the study period 726 patients were admitted, 377 were selected, and 315 were included. The nursing staff administered the SNAQ to 93.6% of patients and malnutrition was present in 19%. Dieticians detected malnutrition in 37.8%. In 41.9% of patients with severe malnutrition an ICD was performed, whereas in 40% of them no nutritional intervention was implemented. The diagnosis of malnutrition was recorded in the discharge report of 42.1% of our cases. Conclusion: Compliance with screening test administration was good, but there is disagreement with the assessment made by dieticians. For most malnourished patients nutritional support fals to be prescribed, no ICDs are performed, and a malnutrition diagnosis is not included in the discharge report.

GLIM criteria has fair sensitivity and specificity for diagnosing malnutrition when using SGA as comparator

BACKGROUND & AIMS

The Global Leadership Initiative on Malnutrition (GLIM) proposed a new framework for diagnosing malnutrition based on combinations of phenotypic and etiologic criteria. The aim of this study was to compare GLIM criteria to Subjective Global Assessment (SGA) judged to be the most validated standardized assessment of malnutrition.

METHODS

This is a retrospective analysis of variables extracted from a prospective cohort study assessing malnutrition at admission, in 18 Canadian hospitals. Based on the available parameters, GLIM was compared to SGA using the following combinations of one phenotypic and one etiologic criteria: A. weight loss and low intake; B. weight loss and high C-reactive protein (CRP); C. low body mass index (BMI) and low intake; D. low BMI, high CRP. Data were not available for fat-free mass. Since all patients had acute or chronic active disease as per GLIM etiologic criterion, CRP was used as a more specific measure to define inflammation. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated. Data are expressed as mean and Clopper-Pearson exact 95% confidence interval (CI).

RESULTS

From 1022 patients in the original dataset, 784 had all considered parameters with a prevalence of malnutrition (SGA B or C) of 45.15% (CI 41.60, 48.70), where severe malnutrition (SGA C) was 11.73% (CI 9.57, 14.20). Using the available GLIM parameters with the above combinations of two-criteria, the prevalence of malnutrition was 33.29% (CI 30.00, 36.71) and severe malnutrition was 19.77% (CI 17.00, 22.70). For all criteria combinations of GLIM together versus SGA, sensitivity was 61.30% (CI 56.0, 66.4), specificity was 89.77% (CI 86.5, 92.5) and PPV was 83.14% (CI 78.0, 87.5) while NPV was 73.80 (CI 69.8, 77.5). Sensitivity was improved when only SGA C for severe malnutrition was used as the criterion (82.61%; CI 73.3, 89.7) but PPV was greatly reduced (29.12%; CI 23.7, 35.0). Similarly, when using GLIM criteria for severe malnutrition only, sensitivity improved (76.09%; CI 66.1, 84.4). Any two criteria combinations of GLIM had much poorer sensitivity with the highest being weight loss + high CRP (46.33%) with a specificity of 93.02% (PPV: 84.54%; NPV: 67.80%), while the combination of low BMI + low intake had the highest specificity (98.84%) but with a sensitivity of 15.54% (PPV 91.67%; NPV: 58.70%).

CONCLUSIONS

Based on the CMTF dataset and using SGA as the most validated tool for diagnosing malnutrition, the two criteria combinations used for GLIM in the present study had fair criterion validity for the diagnosis of malnutrition, regardless of severity status. The best combinations were weight loss and high CRP or weight loss and low intake, both having high specificity at diagnosing malnutrition but unacceptably low sensitivity, and thus were considered poor. There may be potential for the full framework to be used to diagnose malnutrition, but individual combinations of two criteria when used exclusively will miss malnourished patients, as defined by SGA.

Handgrip strength predicts length of stay and quality of life in and out of hospital

BACKGROUND

Handgrip strength (HGS) is a practical measure of strength and physical function that can be used to identify frailty among hospitalized patients, but its utility in this setting is unclear. To be considered useful, any functional measure needs to provide pertinent information on the patient and predict relevant outcomes such as health-care utilization (e.g., length of stay (LOS)) and patient-reported quality of life (QOL). The purpose of this study was to determine if HGS predicted LOS and QOL. A second aim was to examine the best sensitivity (SE) and specificity (SP) for predicting length of stay (>7 or >13 days) using previously published cut-points for HGS.

METHODOLOGY

HGS was measured on 1136 medical patients shortly after admission with a Lafayette dynamometer. QOL was assessed with the self-reported SF-12 completed with an interviewer during hospitalization and 30- days after discharge via telephone. Physical (PCS) and mental (MCS) component scores of SF-12 were calculated. A variety of covariates were assessed (e.g., nutritional status). Multivariate analyses stratified by sex were completed.

RESULTS

The mean LOS was 12.71 days (median = 8.00; SD = 13.20), 12.88 days (SD = 13.82) for males, and 12.58 days (SD = 12.68) for females. Lower admission HGS scores were associated with longer LOS (male X² = 7.85, p < 0.05; female X² = 14.9, p < 0.0001). The average quality of life scores were as follows: in hospital PCS: 34.66, MCS: 46.49; post discharge PCS: 36.17; MCS: 51.22. HGS predicted PCS during hospitalization (male X² = 36.22, p < 0.0001; female X² = 19.87, p < 0.0001) and post hospitalization (male X² = 6.98, p < 0.01; female X² = 10.99, p < 0.01). Various reference cut-points for HGS were tested against LOS, with none being considered appropriate (e.g., SE and SP both < 70) when adjusting for age and sex.

CONCLUSION

Admission HGS adds predictive value for both LOS and physical components of QOL and is worth pursuing in practice to identify potential frailty and the need for proactive steps to mitigate further functional decline during hospitalization. However, HGS cut-points for LOS specific to acute care patients need to be defined and tested.

A review of the validity of malnutrition screening tools used in older adults in community and healthcare settings - A MaNuEL study

BACKGROUND

Older adults are at increased risk of malnutrition compared to their younger counterparts. Malnutrition screening should be conducted using a valid malnutrition screening tool. An aim of the Healthy Diet for a Healthy Life (HDHL) Joint Programming Initiative (JPI) 'Malnutrition in the Elderly Knowledge Hub' (MaNuEL) was to review the reported validity of existing malnutrition screening tools used in older adults.

METHODS

A literature search was conducted to identify validation studies of malnutrition screening tools in older populations in community, rehabilitation, residential care and hospital settings. A database of screening tools was created containing information on how each tool was validated.

RESULTS

Seventy-four articles containing 119 validation studies of 34 malnutrition screening tools used in older adults were identified across the settings. Twenty-three of these tools were designed for older adults. Sensitivity and specificity ranged from 6 to 100% and 12-100% respectively. Seventeen different reference standards were used in criterion validation studies. Acceptable reference standards were used in 68 studies; 38 compared the tool against the Mini Nutritional Assessment-Full Form (MNA-FF), 16 used clinical assessment by a nutrition-trained professional and 14 used the Subjective Global Assessment (SGA). Twenty-five studies used inappropriate reference standards. Predictive validity was measured in 14 studies and was weak across all settings.

CONCLUSIONS

Validation results differed significantly between tools, and also between studies using the same tool in different settings. Many studies have not been appropriately conducted, leaving the true validity of some tools unclear. Certain tools appear to be more valid for use in specific settings.

Association of the Trauma of Hospitalization With 30-Day Readmission or Emergency Department Visit

IMPORTANCE

Trauma of hospitalization refers to the depersonalizing and stressful experience of a hospital admission and is hypothesized to increase the risk of readmission after discharge.

OBJECTIVES

To characterize the trauma of hospitalization by measuring patient-reported disturbances in sleep, mobility, nutrition, and mood among medical inpatients, and to examine the association between these disturbances and the risk of unplanned return to hospital after discharge.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study enrolled participants between September 1, 2016, and September 1, 2017, at 2 academic hospitals in Toronto, Canada. Participants were adults admitted to the internal medicine ward for more than 48 hours. Participants were interviewed before discharge using a standardized questionnaire to assess sleep, mobility, nutrition, and mood. Responses for each domain were dichotomized as disturbance or no disturbance. Disturbance in 3 or 4 domains (the upper tertile) was considered high trauma of hospitalization, and disturbance in 0 to 2 domains (the lower 2 tertiles) was considered low trauma.

MAIN OUTCOME AND MEASURES

The primary outcome was readmission or emergency department visit within 30 days of discharge. The association between trauma of hospitalization and the primary outcome was examined using logistic regression, adjusted for age; sex; length of stay; Charlson Comorbidity Index Score; Laboratory-Based Acute Physiology Score; and baseline disturbances in sleep, mobility, nutrition, and mood.

RESULTS

A total of 207 patients participated, of whom 82 (39.6%) were women and 125 (60.4%) were men, with a mean (SD) age of 60.3 (16.8) years. Among the 207 participants, 75 (36.2%) reported sleep disturbance, 162 (78.3%) reported mobility disturbance, 114 (55.1%) reported nutrition disturbance, and 48 (23.2%) reported mood disturbance. Nearly all participants (192 [92.8%]) described a disturbance in at least 1 domain, and 61 participants (29.5%) had high trauma exposure. A statistically significant 15.8% greater absolute risk of readmission or emergency department visit was found in participants with high trauma (37.7%; 95% CI, 25.9%-51.1%) compared with those with low trauma (21.9%; 95% CI, 15.7%-29.7%), which remained statistically significant after adjusting for baseline characteristics (adjusted odds ratio, 2.52; 95% CI, 1.24-5.17; P = .01) and propensity score matching (odds ratio, 2.47; 95% CI, 1.11-5.73; P = .03).

CONCLUSIONS AND RELEVANCE

Disturbances in sleep, mobility, nutrition, and mood were common in medical inpatients; such trauma of hospitalization may be associated with a greater risk of 30-day readmission or emergency department visit after hospital discharge.

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

In-hospital malnutrition and inadequate food intake have been associated with negative outcomes (e.g., prolonged length of stay, readmission, mortality, and increased hospital costs). Studies examining the factors associated with low food intake in hospital, commonly defined as the consumption of ≤50% of meals, have produced mixed results. We examined the correlates of food intake including patient socioeconomic, demographic, and health characteristics, institutional factors, and common clinical strategies in 1129 medical patients from 5 Canadian hospitals. Low food intake was found in 35% of patients (41% of females and 29% of males) (p < 0.001). In multivariate analyses, sex, socioeconomic status, demographics, and diagnoses were not significantly related to food intake. Patients assessed as malnourished (subjective global assessment (SGA) B/C) (odds ratio (OR), 2.41; p = 0.003) or as not at risk of malnutrition (OR, 1.67; p = 0.040) were more likely to have low intake when compared with those assessed as well nourished (SGA A). Patient reports of mealtime challenges (OR, 2.70; p < 0.001) and barriers to food intake (OR, 1.11; p = 0.008) were positively related to low intake throughout the study sample. Higher 12-Item Short Form Health Survey Mental Component Summary scores were related to better food intake (OR, 0.98; p < 0.001). Clinical strategies such as between-meal snacks lowered the likelihood of low food intake (OR, 0.55; p = 0.037), whereas a group of “other strategies” increased the odds (OR, 2.77; p = 0.001). These results offer a better understanding of the correlates of in-hospital low food intake. The conclusion discusses some avenues for improving food intake in the clinical setting, such as better mealtime monitoring and a reduction in barriers to food intake.

A comparison of hospital-acquired pressure injuries in intensive care and non-intensive care units: a multifaceted quality improvement initiative

Hospital-acquired pressure injuries (HAPI) are a significant cause of morbidity and mortality, and represent a major health concern worldwide. Patients suffering from HAPI report a poor quality of life on several dimensions of health. Moreover, HAPI is reported to lengthen in-hospital stay in the acute setting, posing significant healthcare resource utilisations and costs. Given the clinical and economic burden of HAPI, recent best practice guidelines provide recommendations to reduce the prevalence of pressure injuries. Humber River Hospital (HRH), a large community hospital in Toronto, Canada, has a daily census of approximately 500 patients. The aim of this project was to reduce the prevalence of HAPI within the intensive care unit (ICU) and non-ICU setting at HRH within a 1-year period. Using the International Pressure Injury/Ulcer Prevalence (IPUP) Survey we established a baseline prevalence of HAPI of 27.6% (n=315) for non-ICU and 30% for ICU (n=33) patients at our institution in 2015. Using the Plan-Do-Study-Act (PDSA) method for quality improvement, we implemented a multifaceted approach aimed at improving equipment, digital documentation and education on risk assessment, prevention and treatment strategies. Over multiple PDSA cycles, our prevalence of HAPI reduced to 16% for non-ICU patients with no changes to the HAPI prevalence in ICU patients in 2016. Sustainability continues with HAPI prevalence currently at 10% in 2017 for non-ICU patients, which outperforms the Canadian prevalence (13.7%) by census size for 2017. However, the prevalence of HAPI in the ICU increased to 45% in 2017 despite multiple quality improvement initiatives, suggesting critically ill patients represent a unique challenge for reducing HAPI for these patients at our institution.

Handgrip Strength, but Not 5-Meter Walk, Adds Value to a Clinical Nutrition Assessment

BACKGROUND

Decreased physical functioning is associated with malnutrition and common in acute care patients; determining loss of function is often considered part of a comprehensive nutrition assessment. Handgrip strength (HGS) and 5-meter timed walk (5m) are functional measures used in a variety of settings. This analysis sought to determine which functional measure could be added to a hospital nutrition assessment, based on its feasibility and capacity to discriminate patient subgroups.

METHODS

Eligible medical patients (no delirium/dementia, admitted from community; n = 1250), recruited from 5 hospitals that participated in a previous multisite action research study, provided data on demographics, HGS, 5m, nutrition status, perceived disability, and other characteristics.

RESULTS

Significantly more patients (z = 17.39, P < .00001) were able to complete HGS than 5m (92% versus 43%, respectively). Median HGS was 28.0 kg for men and 14.7 kg for women. Of patients who completed the 5m, mean completion time was 8.98 seconds (median, 6.79 seconds, SD = 6.59). 5m and HGS scores were significantly worse with patient-perceived disability (z = -9.56, t = 10.69, respectively; P < .0001; 95% confidence interval [CI], [7.33, 10.63]; [1.76, 3.18]). HGS was associated with nutrition status (t = 4.13, P < .001; 95% CI [2.02, 5.67]), although it showed poor validity as a single nutrition indicator.

CONCLUSIONS

These data indicate that HGS is a more useful functional measure than 5m when added to a hospital nutrition assessment. Determination of HGS cutpoints to identify low strength in acute care patients will promote its use.

Development and application of a scoring system to rate malnutrition screening tools used in older adults in community and healthcare settings - A MaNuEL study

RATIONALE

Many malnutrition screening tools are used to screen for risk of malnutrition in older adults. An aim of the Joint Programming Initiative (JPI) 'A Healthy Diet for a Healthy Life' (HDHL) MalNutrition in the ELderly Knowledge hub (MaNuEL) is to devise recommendations on the best tools to screen for risk of malnutrition in older adults in community and healthcare settings across Europe. The aim of this paper was to develop and apply a scoring system to rate malnutrition screening tools.

METHODS

Using a targeted literature search strategy, 48 malnutrition screening tools used to screen for risk of malnutrition in older adults were identified across community, rehabilitation, residential care and hospital settings. Criteria to rate each tool were developed; these were based on published evidence and expert opinion. These criteria were translated into a scoring system.

RESULTS

The scoring system had three equally weighted sections; validation, parameters and practicability, and was applied to all 48 tools. Overall, the highest scoring tools per setting for screening for risk of malnutrition in older adults were i) DETERMINE your health checklist for the community setting; ii) the Nutritional Form for the Elderly (NUFFE) for the rehabilitation setting; iii) the Short Nutritional Assessment Questionnaire-Residential Care (SNAQ^RC) for residential care and iv) both the Malnutrition Screening Tool (MST) and the Mini Nutritional Assessment Short Form Version 1 (MNA-SF-V1) for the hospital setting.

CONCLUSION

Setting-specific tools are more appropriate for use with older adults. These findings will inform recommendations for the optimal screening of geriatric malnutrition across Europe.

Nutritional Screening Tools among Hospitalized Children: from Past and to Present

Increased awareness of the importance of nutrition among hospitalized children has increased the use of nutrition screening tool (NST). However, it is not well known the NST for hospitalized children. Therefore, the purpose of this study is to understand the past and present state of adult and child NST and discuss the pros and cons of each NST.

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.

Malnutrition in Gastrointestinal Disorders: Detection and Nutritional Assessment

All patients with significant gastrointestinal disease should be clinically assessed for protein calorie malnutrition by using the Subjective Global Assessment. Blood tests for anemia, electrolytes, calcium, phosphorus, magnesium, ferritin, vitamin B₁₂, and folate should be considered for assessment of major micronutrients. Where malabsorption or inflammatory bowel disease is diagnosed, bone mineral density using dual beam x-ray absorptiometry, 25-OH vitamin D levels, and measurement of other vitamins and trace elements should be considered. In addition, in at-risk patients, vitamin and trace element clinical deficiency syndromes should be considered during patient assessment.

Nutrition Care after Discharge from Hospital: An Exploratory Analysis from the More-2-Eat Study

Many patients leave hospital in poor nutritional states, yet little is known about the post-discharge nutrition care in which patients are engaged. This study describes the nutrition-care activities 30-days post-discharge reported by patients and what covariates are associated with these activities. Quasi-randomly selected patients recruited from 5 medical units across Canada (n = 513) consented to 30-days post-discharge data collection with 48.5% (n = 249) completing the telephone interview. Use of nutrition care post-discharge was reported and bivariate analysis completed with relevant covariates for the two most frequently reported activities, following recommendations post-discharge or use of oral nutritional supplements (ONS). A total of 42% (n = 110) received nutrition recommendations at hospital discharge, with 65% (n = 71/110) of these participants following those recommendations; 26.5% (n = 66) were taking ONS after hospitalization. Participants who followed recommendations were more likely to report following a special diet (p = 0.002), different from before their hospitalization (p = 0.008), compared to those who received recommendations, but reported not following them. Patients taking ONS were more likely to be at nutrition risk (p < 0.0001), malnourished (p = 0.0006), taking ONS in hospital (p = 0.01), had a lower HGS (p = 0.0013; males only), and less likely to believe they were eating enough to meet their body’s needs (p = 0.005). This analysis provides new insights on nutrition-care post-discharge.

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

The Integrated Nutrition Pathway for Acute Care (INPAC) is an evidence and consensus based pathway developed to guide health care professionals in the prevention, detection, and treatment of malnutrition in medical and surgical patients. From 2015 to 2017, the More-2-Eat implementation project (M2E) used a participatory action research approach to determine the feasibility, and evaluate the implementation of INPAC in 5 hospital units across Canada. Based on the findings of M2E and consensus with M2E stakeholders, updates have been made to INPAC to enhance feasibility in Canadian hospitals. The learnings from M2E have been converted into an online toolkit that outlines how to implement the key steps within INPAC. The aim of this short report is to highlight the updated version of INPAC, and introduce the implementation toolkit that was used to support practice improvements towards this standard.

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.

Nutrition Screening vs Nutrition Assessment: What's the Difference?

Screening and assessment imply different processes, with the former indicating risk factors for a deprived nutrition condition and the latter providing the nutrition diagnosis. Both should be routinely performed at hospital admission according to recommended guidelines; however, this is not the reality worldwide, and undernutrition remains highly prevalent in the hospital setting. Therefore, the objective of the current review is to delve into the principles leading to nutrition status deficiencies and how they should be addressed by screening and assessment. A critical appraisal for the reasons associated with the misunderstanding between screening and assessing is proposed without further discussing the many available screening tools while approaching some of the assessment instruments.