Implementation of nutritional care in hospitals: A qualitative study of barriers and facilitators using implementation theory

BACKGROUND

Disease-related malnutrition is prevalent among hospitalised patients, but not all patients achieve the needed nutritional care. At a Danish University Hospital, focus has been on implementing nutritional practices based on clinical guidelines, but there is continuously variation between the wards regarding the quality of nutritional care.

AIM

The aim of this study was to identify the potential barriers and facilitators for implementation of the clinical guidelines for nutritional practices and to recommend suggestions for development of nutritional practices, using a theoretical implementation strategy.

METHOD

The design was a qualitative interview study of employees at a Danish University Hospital, using a semi-structured interview guide. The participants were nurses, nurse's assistant, nurse nutrition expert, head nurse and dieticians. We recruited 11 employees, representing eight different wards.

FINDINGS

The analysis identified six themes: (1) clear allocation of responsibilities and committed management enhances nutrition practices, (2) leadership support is essential, (3) physical settings and tools affect possibilities for action, (4) selection of equivalent staff is core, (5) teaching promotes the knowledge and skills and (6) a dietitian in the ward facilitates implementation of nutritional care. Barriers and facilitators among the themes were identified and has led to suggestions to strengthen nutritional care, based on implementation theory.

CONCLUSION

Various factors were identified as having impact on the implementation of nutrition practices and different suggestions have emerged to accommodate those factors, as well as to apply an implementation strategy to facilitate change in practice.

Measured versus estimated energy requirement in hospitalized patients

BACKGROUND & AIM

Failure to identify a patient's energy requirement has a variety of consequences both physiological and economical. Previous studies have shown that predictive formulas, including the Harris Benedict equation (HB), both over- and underestimates energy requirement in severely ill patients and healthy younger adults, compared to the golden standard, indirect calorimetry (IC). The comparison between measured and estimated energy requirements in hospitalized patients in regular wards is underreported. The aim of this study was to assess the agreement between measured energy requirements and requirements estimated by HB in the individual hospitalized patients, and to investigate whether those findings were associated with other specific patient characteristics.

METHODS

IC (n = 86) was used to measure resting energy expenditure (REE) and bioimpedance analysis (BIA) (n = 67) was used for body composition in patients admitted to Aalborg University Hospital. Furthermore, height, weight, body mass index, calf circumference, while information regarding hospital ward, vital values, dieticians estimated energy requirements and blood samples were collected in the patients' electronic medical records. Bland-Altman plots, multiple linear regression analysis, and Chi2 tests were performed.

RESULTS

On average a difference between IC compared with the HB (6.2%), dietitians' estimation (7.8%) and BIA (4.50%) was observed (p < 0.05). Association between REE and skeletal muscle mass (SMM) (R2 = 0.58, β = 149.0 kJ), body fat mass (BFM) (R2 = 0.51, β = 59.1 kJ), and weight (R2 = 0.62, β = 45.6 kJ) were found (p < 0.05). A positive association between measured REE and HB were found in the following variables (p < 0.05): CRP, age, surgical patients, and respiratory rate.

CONCLUSION

This study found a general underestimation of estimated energy expenditure compared to measured REE. A positive correlation between measured REE and SMM, BRM and weight was found. Lastly, the study found a greater association between CRP, age, surgical patients, and respiratory rate and a general greater than ±10% difference between measured and estimation of energy requirements.

Maintenance of own health after acute hospitalization - older people's experiences and perspectives on physical activity and nutrition

BACKGROUND

Studies indicate that prefrail and frail older people would like to exercise, but support from healthcare professionals is required. Knowledge regarding health maintenance in prefrail or frail older people in terms of physical training and nutrition after hospitalization is scarce.

OBJECTIVE

To explore the perspectives and experiences of prefrail and frail older people concerning physical training and nutrition one and four weeks after an acute medical hospitalization.

METHODS

Repeated individual semi-structured interviews with ten prefrail and frail older people were conducted. An inductive-deductive thematic analysis was performed.

RESULTS

Previous experiences with healthcare affected the views of the participants on training, nutrition, and health. Although the participants' knowledge about physical training was limited, they were positive about participating in training and obtaining knowledge about their condition. However, their positive intentions were not successfully achieved within four weeks. Despite positive intentions, appointments at the hospital, musculoskeletal pain, and other limitations hindered the intended training. Furthermore, changing nutritional habits seemed difficult.

CONCLUSION

The participants were positive toward participating in training and interested in knowledge addressing their condition. Nutritional habits were considered as a personal matter and difficult to change, as they had year long habits about when and how they ate. These findings indicate that a lack of dialogue about training and nutrition may contribute to lower health literacy in frail older people and may therefore affect the maintenance of health after an acute hospitalization. This suggests that physiotherapists should ensure that follow-up is discussed and planned in detail with patients before discharge.

Unintentional weight loss is reflected in worse one-year clinical outcomes among COPD outpatients

RATIONALE

Unintentional weight loss (UWL) is prevalent among patients with chronic obstructive pulmonary disease (COPD). However, little research has been done on UWL as an independent variable in terms of clinical outcome. The aim of this study was to investigate the association between BMI, UWL, and clinical outcome in terms of hospitalization, length of stay, exacerbations, mortality, and quality of life (QoL) within six months and one year in a hospital outpatient setting.

METHODS

A prospective single-center cohort study enrolled 200 patients from the COPD outpatient clinic between October 2020 and May 2021 at a Danish Hospital. At baseline, data was collected using patients' electronic journals and a quantitative questionnaire was gathered with a patient-reported UWL of 5% of body weight within three months. At six months and one-year follow-ups, data was collected using the patients' medical journals and a telephonic interview with the EQ-5D-5L and SARC-F questionnaire and the number of non-hospitalization exacerbations since inclusion. Data were analyzed using logistic and Cox hazard regression analysis.

RESULTS

A total of 187 patients were eligible for follow-up (mean age 69.2 years, 43.9% males, median BMI 26.8 kg/m2), and the prevalence of UWL was 13.4%. UWL was associated with an almost trifold risk of >five days stay (OR = 2.94, p = 0.021). Additionally, UWL was associated with a worse QoL. A higher risk of exacerbation was found in the underweight patients (OR = 4.94, p = 0.014). No significant difference in mortality was found.

CONCLUSION

UWL as a solitary factor is associated with increased hospital length of stay and a worse QoL. The results provide further evidence that implementation of regular screening for UWL in addition to BMI might be beneficial to include in international COPD guidelines for outpatient settings.

"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.

A 1-year follow-up study in patients with idiopathic pulmonary fibrosis regarding adverse outcomes to unintended weight loss

OBJECTIVES

Malnutrition in pulmonary fibrosis may influence clinical outcomes negatively. This project aimed to investigate if weight, unintended weight loss (UWL) at baseline and weight development, and signs of sarcopenia measured by the strength, assistance with the walking, rising from a chair, climbing stairs, and falls questionnaire (SARC-F) are associated with hospital admissions and mortality for idiopathic pulmonary fibrosis outpatients in ≤1 y as well as referral to pulmonary rehabilitation.

METHODS

At baseline, prevalence of weight and UWL were sought in a cross-sectional questionnaire study, consecutively, including 100 patients in an outpatient clinic. Medical records were sought for time from diagnosis and comorbidities. One year after inclusion weight, UWL and SARC-F were collected by phone interviews, and medical records were revisited for clinical outcomes.

RESULTS

Of the 100 patients, two patients died and seven were lost to follow-up. The prevalence of UWL increased within the year (10-13%), and the amount of UWL increased (9.1-11.8 kg). Patients with a UWL at baseline had a significantly higher risk of mortality (odds ratio = 29.8; P = 0.037). UWL at baseline was associated with risk of hospital admissions (odds ratio = 14.7; P = 0.009). Based on the results from SARC-F, 20.9% have signs of sarcopenia. UWL at follow-up was associated with the risk of sarcopenia by SARC-F. Patients with risk of sarcopenia and those with body mass index ≥30 kg/m² were to a higher degree offered pulmonary rehabilitation; however, participation was low.

CONCLUSIONS

UWL at baseline was significantly associated with risk of hospital admissions and mortality in ≤1 y in idiopathic pulmonary fibrosis outpatients. Patients with signs of sarcopenia and body mass index ≥30 kg/m² were most often referred to pulmonary rehabilitation.

Are nutritional sufficiency of ≥75% energy and protein requirements relevant targets in patients at nutritional risk? - A one month follow-up study

BACKGROUND & AIM

Nutrient intake in patients at nutritional risk was recorded with the aim of reaching at least 75% of estimated requirements for energy and protein. However, the cutoff at 75% has only been sparsely investigated. The aim of this study was to re-evaluate the 75% cutoff of estimated energy and protein requirements among patients at or not at nutritional risk in relation to 30-day mortality and readmissions.

METHODS

A 30-day follow-up study was performed among hospitalized patients in 31 units at a Danish University Hospital. Data was collected using the nurses' quartile nutrition registration method and electronic patient journals. All patients were screened using the NRS-2002 and classified as either at nutritional risk (NRS-2002, score ≥3) or not at nutritional risk (NRS-2002, score <3). Energy and protein requirements were estimated using weighted Harris-Benedict equation and 1.3 g/kg/day, respectively.

RESULTS

In total, 318 patients were included in this study. Patients at nutritional risk were older, lower BMI, male, more comorbidities and a longer primary length of stay compared to patients not at nutritional risk (p < 0.05). After 30-day follow-up, mortality was higher among patients at risk (9.5% vs. 2.0%, p < 0.05). Patients at nutritional risk showed increased risk of mortality if they did not achieve 75% of estimated requirements (energy: OR = 8.08 [1.78; 36.79]; protein: OR = 3.40 [0.74; 15:53]). Furthermore, predicted probability of mortality decreased with increased energy and protein intakes. No significant associations were found for readmissions achieving 75% of estimated energy or protein requirements. A cutoff of 76-81% for energy and 58-62% for protein was equivalent with accepting a 6-8% mortality rate.

CONCLUSION

The results of this study indicate that an energy intake ≥75% of estimated requirement among patients at nutritional risk has a preventative effect regarding mortality within one month, but not for readmissions.

Management of acute mesenteric ischaemia: Results of a worldwide survey

BACKGROUND

Acute mesenteric ischaemia (AMI) is a condition with high mortality. This survey assesses current attitudes and practices to manage AMI worldwide.

METHODS

A questionnaire survey about the practices of diagnosing and managing AMI, endorsed by several specialist societies, was sent to different medical specialists and hospitals worldwide. Data from individual health care professionals and from medical teams were collected.

RESULTS

We collected 493 individual forms from 71 countries and 94 team forms from 34 countries. Almost half of respondents were surgeons, and most of the responding teams (70%) were led by surgeons. Most of the respondents indicated that diagnosis of AMI is often delayed but rarely missed. Emergency revascularisation is often considered for patients with AMI but rarely in cases of transmural ischaemia (intestinal infarction). Responses from team hospitals with a dedicated special unit (14 team forms) indicated more aggressive revascularisation. Abdominopelvic CT-scan with intravenous contrast was suggested as the most useful diagnostic test, indicated by approximately 90% of respondents. Medical history and risk factors were thought to be more important in diagnosis of AMI without transmural ischaemia, whereas for intestinal infarction, plasma lactate concentrations and surgical exploration were considered more useful. In elderly patients, a palliative approach is often chosen over extensive bowel resection. There was a large variability in anticoagulant treatment, as well as in timing of surgery to restore bowel continuity.

CONCLUSIONS

Delayed diagnosis of AMI is common despite wide availability of an adequate imaging modality, i.e. CT-scan. Large variability in treatment approaches exists, indicating the need for updated guidelines. Increased awareness and knowledge of AMI may improve current practice until more robust evidence becomes available. Adherence to the existing guidelines may help in improving differences in treatment and outcomes.

Malnutrition in Patients With Moderate to Severe Acquired Brain Injury: Prevalence During 4 Weeks of Subacute Rehabilitation

ABSTRACT

BACKGROUND: Malnutrition is associated with high rates of complication, longer hospital stays, and increased morbidity and mortality. Malnutrition defined as undernutrition is common in patients with acquired brain injury (ABI); however, estimates vary remarkably. This study aimed to describe malnutrition at admission and after 4 weeks of subacute inpatient neurorehabilitation in patients with ABI using the new global consensus definition of malnutrition. METHODS: One hundred thirty-three patients with moderate to severe ABI consecutively admitted to a specialized neurorehabilitation hospital within a period of 4 months were screened for inclusion, of which 92 were included. Malnutrition was defined as at least 1 phenotypic criterion (weight loss, low body mass index, low muscle mass) and at least 1 etiologic criterion (reduced food intake, inflammation). Malnutrition on admission and after 4 weeks was compared using the McNemar test. RESULTS: The proportion of patients with malnutrition at admission was 42%, with more men (46%) than women (36%) fulfilling the criteria for malnutrition. The most frequent phenotypic and etiologic criteria were weight loss (56%) and inflammation (74%), respectively. During the 4 weeks of rehabilitation, the proportion of male patients fulfilling the individual criteria "weight loss" (difference, -21.4%) and "inflammation" (difference, -18.9%) decreased significantly; "low muscle mass" decreased borderline significant (difference, -8.9%), whereas "low body mass index" did not change. The proportion of female patients fulfilling individual criteria for malnutrition was stable or increased nonsignificantly. CONCLUSION: Malnutrition was common at admission to neurorehabilitation in patients with moderate to severe ABI, with more men than women fulfilling the criteria for malnutrition. The nutritional status improved after 4 weeks of rehabilitation in male patients, whereas it was largely unchanged in female patients. The results provide the basis for monitoring high-quality nutritional nursing care.

Prevalence of sarcopenia in patients with chronic intestinal failure-how are SARC-F and the EWGSOP algorithm associated before and after a physical exercise intervention

INTRODUCTION

Patients with chronic intestinal failure (IF) have a low degree of physical activity, decreased muscle mass, and decreased muscle strength, leading to a high risk of sarcopenia. We aimed to test the prevalence of sarcopenia by the use of SARC-F and EWGSOP and to investigate the association between the two at baseline and after 12 weeks of an exercise intervention.

METHODS

Thirty-one patients with chronic IF completed 12 weeks of three weekly home-based individualized exercise sessions. Body composition was measured by bioimpedance analysis and physical function by handgrip strength (HGS) and timed up-and-go (TUG). Sarcopenia was assessed by SARC-F and EWGSOP. Multiple regression analysis was used to test for the association between the two tools.

RESULTS

The prevalence of sarcopenia measured by EWGSOP was 59%. This prevalence did not change after the intervention. At baseline, 38.8% of patients were screened as at risk for sarcopenia by SARC-F. This decreased to 29.0% after the intervention (P < 0.001). A statistically significant increase was achieved in muscle mass (P = 0.017) and muscle mass index (P = 0.016). Furthermore, both TUG (P = 0.033) and HGS (P = 0.019) improved.

CONCLUSIONS

Sarcopenia is prevalent in patients with chronic IF. EWGSOP finds more patients to be at risk of sarcopenia than SARC-F but was not sufficiently sensitive to measure changes induced by the physical intervention. The significant change in SARC-F may illustrate that patients, themselves, find an improvement in self-perceived health.

Reducing Disease Activity of Inflammatory Bowel Disease by Consumption of Plant-Based Foods and Nutrients

Inflammatory bowel disease is a chronic and recurring inflammatory condition of the gastrointestinal tract encompassing ulcerative colitis and Crohn's disease. Although the pathogenesis of inflammatory bowel disease remains to be fully elucidated, environmental factors such as diet are believed to play a pivotal role in the onset and management of inflammatory bowel disease. Diet is thought to play an essential role in intestinal inflammation due to its regulatory effects on the microbiota, gut immune system, and epithelial barrier function. Although the evidence remains insufficient to draw firm conclusions on the role of specific dietary components in gastrointestinal diseases, studies have suggested that a Western diet with high intakes of total fats, omega-6 fatty acids, and meat have been associated with intestinal inflammation and relapse of inflammatory bowel disease. In contrast to a Western diet, plant-based diets often result in a reduced intake of total fats and meats and an increased intake of plant fibers which may contribute to reduced intestinal inflammation. This review critically examines the influence of plant-based dietary components on the clinical disease course of inflammatory bowel disease. Furthermore, this review discusses the benefits and possible limitations of plant-derived dietary components in the treatment of inflammatory bowel disease while addressing the principal type of disease and the anatomic site of inflammation within the gastrointestinal tract. Finally, this review points out important directions for future research on the role of diet in inflammatory bowel disease. A better understanding of the role of diet and intestinal inflammation may pave the way for novel dietary interventions and specific foods- or food supplements, which can support the treatment of inflammatory bowel disease.

Personalized exercise intervention in HPN patients - A feasibility study

BACKGROUND

Physical health status may be predictive of readmissions, psychological health and mortality in patients with short bowel syndrome.

AIMS

This study aimed to investigate the feasibility and effect of an individualized exercise intervention and secondary, oral nutrition intake counseling on Timed-Up-and-Go (TUG) and 30 s Chair Stand Test (CST) as well as body-composition and EuroQol (EQ)-5D-5L, in patients with chronic intestinal failure (IF) type III receiving HPN and/or fluid therapy.

METHODS

A 12-week individualized exercise intervention consisting on three weekly home based sessions, and nutrition counselling focusing on protein intake and reducing high stoma output, was performed. Weekly follow-up by phone was done on motivation to exercise.

RESULTS

The study invited 71 patients, 44 accepted the invitation (62%), 37(52%) were included, and 31 (84%) completed the intervention. The exercise intervention was well tolerated. TUG improved from 8.9(SD 5.5) to 7.7(SD 3.8) (p = 0.033). CST improved by four repetitions (<0.001∗). A statistical, however not clinically relevant improvement was seen in muscle mass. No improvement was seen in (EQ)-5D-5L total, but insignificantly (p = 0.055) for physical function only. Protein intake improved by 10.6 g/day (p = 0.008).

CONCLUSIONS

A 12 weeks individualized exercise intervention showed very feasible and beneficial in HPN patients. Physical function improved statistically and clinically, and oral protein intake improved. QoL overall did not improve, however COVID-19 was an uninvited partner throughout the study period, which may have influenced general QoL. As only 62% accepted the invitation to participate, home based exercise intervention may not apply to all patients.

Signs of dysphagia and associated outcomes regarding mortality, length of hospital stay and readmissions in acute geriatric patients: Observational prospective study

BACKGROUND AND AIMS

Dysphagia is a prevalent disorder in acute geriatric patients. This observational prospective study aimed at investigating adverse clinical outcomes linked to signs of dysphagia, including mortality, length of hospital stay (LOS), readmissions, among patients aged ≥ 65 years at a Danish acute medical unit (AMU).

METHODS

Signs of dysphagia were assessed using bedside screening tools including the Eating Assessment Tool (EAT-10), a 30 mL Water Swallowing Test (WST) and the Gugging Swallowing Screen tool (GUSS), as described in the preceding cross-sectional study. Data for the follow-up was twice retrieved from electronic medical charts 30 days and 90 days after the patients' primary admission to the hospital. Statistical analysis included non-parametric tests of independence and proportional hazards modelling.

RESULTS

444 patients were recruited, 334 of whom completed the dysphagia screening with 144 (43.1 %) showing signs of dysphagia. Patients with signs of dysphagia, compared to those without, experienced higher mortality after 30 days (12.5 % vs. 1.6 %, p < 0.001) and 90 days (21.5 % vs. 5.8 %, p < 0.001), longer LOS (median [Q1; Q3]: 4 [2; 8] vs. 3 [1; 6] days, p = 0.004), more total hospital days (THD) during both the 30-day and 90-day follow-up (for 90d: median [Q1; Q3]: 6 [2.25; 12] vs. 4 [2; 9] days, p = 0.007), but no significant difference in frequency of readmissions. Multivariate proportional hazards modelling revealed signs of dysphagia, low performance status and high comorbidity to be independent risk factors for mortality. High comorbidity and low hemoglobin, but not signs of dysphagia, were revealed as independent risk factors for readmission.

CONCLUSION

Dysphagia is a notable risk factor linked to increased mortality and length of hospital stay (LOS) for acute geriatric patients in general, not just those suffering from stroke, head and neck cancer or neurodegenerative diseases. Further research is needed to investigate the effectiveness and feasibility of systematic dysphagia screening within this population.

Healthcare professionals' experiences with practice for managing disease-related malnutrition in general practice and proposals for improvement: A qualitative study

BACKGROUND & AIM

Disease-related malnutrition is prevalent in all healthcare settings, including general practice, and is associated with negative consequences for the individual and the community. The aim of this study was to investigate general practitioners and general practice nurses' perceptions of how they manage disease-related malnutrition, and their view on introducing an early intervention against disease-related malnutrition.

METHODS

Content analysis was used to analyse individual semi-structured interviews with the general practitioners (n = 9) and five focus group interviews with the general practice nurses (n = 21) from five general practices in Denmark.

RESULTS

General practice has no tradition for detection of disease-related malnutrition and find that they rarely see patients with unintended weight loss. Nutritional guidance is to a low degree and only randomly performed. Furthermore, most of the health professionals do not have access to nutritional guidance material for patients and lack information about patients' nutrition, when patients when patients receive treatment in the hospital. Suggestions for improvement were handouts with pictures and including nutritional status as a standard in the communication from hospital to general practice. An early intervention against unintended weight loss in specific groups was found feasible. Barriers and facilitators were seen as lack of time, lack of educational opportunities and skills. A financial incentive from the health authorities, and interventions adapted to the individual general practice were among suggested facilitators.

CONCLUSION

Disease-related malnutrition was rarely recognised and managed in general practice. The health professionals found they lacked means to perform nutritional guidance to patients with unintended weight loss. However, the health professionals had suggestions for improvement for an early intervention including handouts for patients. Further research on implementation of early intervention against unintended weight loss in general practice is needed.

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.

Efforts targeted malnutrition among children with cerebral palsy in care homes and hospitals: A qualitative exploration study

INTRODUCTION

Children with cerebral palsy (CP) are at risk of becoming malnourished. Malnutrition risk increases with increased gross motor function classification. The present study aimed to investigate and explore existing nutritional efforts and practice among staff in Danish hospitals and care homes working with children with CP.

METHODS

Ten qualitative interviews were generated with multidisciplinary staff working in hospital wards, care homes and Neuro Pediatric Team (NPT). Analysis was inspired by Braun and Clarke's thematic analysis.

RESULTS

The analysis generated the following six themes: Weighing and anthropometric measurements; Existing nutritional evaluation and intervention in practice; Cross-sectoral communication and interdisciplinarity; Involvement of the children's parents; Knowledge and professional intuition; and Time and priority. Weighing is the most common nutritional evaluation, supplemented by weight/height curves in the NPT. No actual screening is performed. In care homes without healthcare staff, the nutritional focus primarily regards the meal and how the children are able to eat. In care homes with health staff, as well as hospital departments, the focus is primarily on weight. Written communication is a necessity for the nutritional collaboration around the child to work, but collaboration between IT-systems are lacking. Interdisciplinarity and parental involvement are key components for managing nutrition issues among children with CP. The specialist dietitian was much required, but difficult to reach.

CONCLUSIONS

Despite the great focus on nutrition and nutritional status among children with CP in all of the inquired contexts, existing efforts for assessment reveal primarily on weight and intuition. No actual screening is performed. Collaboration between sectors and professionals is challenged by lacking IT-systems and systematic procedures.

The perspectives of health professionals in Denmark on physical exercise and nutritional interventions for acutely admitted frail older people during and after hospitalisation

Frailty is associated with several negative health outcomes, such as readmissions to hospital. Physical exercise, including strength training and nutritional optimisation are essential parts of documented interventions for frail older people in preventing or minimising frailty. Further knowledge is necessary to ensure feasible and successful interventions encompassing both physical exercise and nutritional optimisation. The aim of this qualitative study was to investigate the perspectives of health professionals on which factors may affect interventions, including physical exercise and nutrition, for frail older people in relation to discharge after acute admission to hospital. Data were gathered in two semi-structured focus groups, totalling 11 health professionals working with frail older people in a Danish university hospital and a municipality. The sampling of participants was purposive and the interviews were facilitated by a semi-structured interview guide. Data were analysed applying a six-step data-driven thematic analysis. Findings showed that health professionals experienced working with nutritional optimisation and physical exercise within a frail older population as challenging, and they mostly used extrinsic motivation, such as incentives, deals or intensified messages, as external factors in their approaches as to affect specific behaviours. A discourse on the importance of activity- and functional training was prevalent, while diverging perspectives were present in relation to strength training, which was considered less feasible or meaningful in a community-dwelling setting. Organisational barriers such as communication between sectors and time limitations affected negatively the work of health professionals, as they hindered co-ordinated and adequate interventions from the health professionals. Findings and theory-based knowledge indicate that health professionals should work towards a person-centred approach, which includes goal-setting, to improve physical training and nutritional interventions for frail older people. Furthermore, health professionals may need more support in order to incorporate strength training in interventions. In addition to this, improved co-ordination between sectors is warranted.

Feasibility of a multimodal intervention on malnutrition in patients with lung cancer during primary anti-neoplastic treatment

BACKGROUND

Wasting of body mass and skeletal muscle frequently develops in patients with cancer and is associated with impaired functional ability and poor clinical outcome and quality of life. This study aimed to evaluate the feasibility and explore the effect of a multimodal intervention targeting nutritional status in patients with non-small cell lung cancer receiving primary anti-neoplastic treatment. Additionally, predictive and prognostic factors of gaining skeletal muscle were explored.

METHODS

This was a single-centre multimodal intervention trial using a historical control group. The multimodal intervention involved fish oil intake (2 g of eicosapentaenoic acid or docosahexaenoic acid daily), regular dietary counselling and unsupervised physical exercise twice weekly during the first three cycles of primary anti-neoplastic treatment. Feasibility was assessed through recruitment rate, completion rate and compliance rate with the intervention. Differences in skeletal muscle, body weight, and physical function between the intervention and historical control groups were analysed. Factors contributing to increased skeletal muscle were explored using univariate and multivariate ordinal logistic regression analyses.

RESULTS

The recruitment and completion rates were 0.48 (n = 59/123) and 0.80 (n = 46/59), respectively. The overall compliance rate with all five individual interventions was 0.60 (n = 28/47). The individual compliance rates were 0.81 (n = 38/47) with fish oil intake, 0.94 (n = 44/47) with energy intake, 0.98 (n = 46/47) with protein intake, 0.51 (n = 24/47) with resistance exercise and 0.57 (n = 27/47) with aerobic exercise. No mean differences in skeletal muscle, body weight, or physical function were found between the intervention and control groups. However, a larger proportion of patients in the intervention group gained skeletal muscle (p < 0.02). The identified contributing factors of muscle gain were weight gain (OR, 1.3; p = 0.01), adherence to treatment plan (OR, 4.6; p = 0.02), stable/partial response (OR, 3.3; p = 0.04) and compliance to the intervention (OR, 7.4; p = 0.01). Age, sex, tumour stage, performance status, treatment type and baseline cachexia did not predict muscle gain.

CONCLUSION

This three-dimensional intervention in patients with lung cancer undergoing primary anti-neoplastic treatment was feasible and increased the proportion of patients gaining skeletal muscle. Dietary counselling and fish oil use were useful strategies. The motivation for conducting unsupervised physical intervention was low. Clinical trials.gov identifier: NCT04161794.

Unintended weight loss in hematology outpatients - Work to do

BACKGROUND

Malnutrition frequently occurs in hematology diseases and may threaten the course of treatment and patient outcomes. While screening for nutritional risk is often done in hospitalized patients, it is rarely described in the outpatient setting. Hematology patients are often followed in outpatient settings before hospitalization and for a longer time after.

AIMS

The primary aim of this study was to investigate the prevalence of nutritional risk measured by unintended weight loss within three months and reduced food intake within one week among patients in a hematology outpatient clinic. The second purpose was to investigate the two variables as a quick initial screening tool.

METHODS

All patients visiting the outpatient clinic within one week were invited to participate in this study, designed as a questionnaire-based cross-sectional study, consisting of nine questions. Descriptive statistical analyses, chi² test and simple logistic regression analyses were performed.

RESULTS

Of the 219 included patients, 23.7% had an unintended weight loss of mean 13.7% of body weight within the last three months and 13.2% had eaten less than usual within the past week. Patients who had significantly increased odds for unintended weight loss were >80 years of age [CI95%: 1274; 6084], patients visiting for examinations [CI95%: 1.105; 7.227], patients visiting for treatment [CI95%: 1.383; 6598] and patients visiting as part of a course of investigations [CI95%: 1.112; 34.184] as well as patients who had eaten less [CI95%: 2.731; 14.224]. Patients visiting the outpatient clinic for examination had significantly increased odds of having eaten less [CI95%: 1.783; 14.629].

CONCLUSIONS

Based on the statistical analyses, almost one fourth of the patients had a significant unintended weight loss, about 15% had reduced food intake and only 7.8% had both unintended weight loss and reduced food intake. These results indicate that unintended weight loss can be used as a quick screening tool to identify and detect patients at risk of malnutrition and that guidelines should be drawn up for managing patients at nutritional risk in hematology outpatient clinics.

High risk of disease-related malnutrition in gastroenterology outpatients

OBJECTIVE

Disease-related malnutrition (DRM) in hospitalized patients is known to have significant negative impact on clinical outcomes. Meanwhile, DRM in gastroenterology outpatients is scarcely investigated. The aim of this study was to investigate the prevalence of unintentional weight loss (UWL) and reduced food intake (RFI) as contributors to the risk of DRM in outpatients. Furthermore, the aim was to investigate if UWL may be used as initial screening for DRM, based on the correlation between UWL and RFI.

METHODS

All outpatients visiting the clinics for Medical and Surgery Gastroenterology, Aalborg University Hospital, Denmark, during 1 wk in September 2018, were invited to participate. Data regarding UWL within the past 3 mo, RFI the past week, and nutritional impact symptoms (NIS) were collected in this questionnaire-based cross-sectional study. Descriptive analysis, χ² test, and multiple logistic regression analysis were used for statistics.

RESULTS

Out of 348 eligible patients, 346 were included at the medical clinic (n = 170) and surgery clinic (n = 176). UWL occurred in 26%, with a mean weight loss of 7.1 kg (standard deviation [SD] 5.2), and 24% had RFI. A significantly increased risk of UWL was identified in patients with body mass index <18.5 kg/m² (odds ratio 6.1; confidence interval 2.0-18.7; P = 0.003). NIS were more common in the medical clinic. The main self-reported reasons for NIS affecting UWL were lack of appetite (15% versus 12%), pain (14% versus 8%), and nausea (12% versus 3%).

CONCLUSIONS

One in four outpatients experienced UWL to an extent that may have a significant negative impact on clinical outcome. A firm correlation was found between UWL and RFI. Thus, based on this superficial study, UWL may be used as initial screening for protein-energy malnutrition in the medical and surgery gastroenterology outpatient setting. The impact on clinical outcome and of early nutritional intervention in these settings need to be investigated.

Protein and energy intake improved by in-between meals: An intervention study in hospitalized patients

BACKGROUND/AIM

Disease related malnutrition is a major problem in hospitals. Malnutrition in hospitalized patients is caused by many factors. Among these factors are decreased appetite and early satiety, and reaching nutritional requirements in nutritional risk patients is a challenge when using ordinary energy and protein dense food. The aim of this study was to examine if total protein and energy intake in medical and surgical patients at nutritional risk could be improved by protein fortified and energy rich in-between meals.

METHODS

An assortment of fortified in-between meals including 10 g of protein was developed based on patient preferences and served in the Departments of Lung Medicine and Abdominal Surgery for a period of three months. Nutrition intake was recorded before and after intervention.

RESULTS

Food intake records were collected from a total of 92 patients, (46 before and 46 after intervention). The total amount of protein intake per in-between meal was increased from 2,6 g to 10,3 g. Total daily protein intake increased from 49% to 88% (p < 0.00) and total energy intake from 74% to 109% (p < 0.00) of requirements.

CONCLUSION

Protein and energy intake for surgical and medical patients at in-between meals as well as total daily intake increased significantly. Recommended average level for individually measured requirements was reached.

Acute intestinal failure: International multicenter point-of-prevalence study

BACKGROUND & AIMS

Intestinal failure (IF) is defined from a requirement or intravenous supplementation due to failing capacity to absorb nutrients and fluids. Acute IF is an acute, potentially reversible form of IF. We aimed to identify the prevalence, underlying causes and outcomes of acute IF.

METHODS

This point-of-prevalence study included all adult patients hospitalized in acute care hospitals and receiving parenteral nutrition (PN) on a study day. The reason for PN and the mechanism of IF (if present) were documented by local investigators and reviewed by an expert panel.

RESULTS

Twenty-three hospitals (19 university, 4 regional) with a total capacity of 16,356 acute care beds and 1237 intensive care unit (ICU) beds participated in this study. On the study day, 338 patients received PN (21 patients/1000 acute care beds) and 206 (13/1000) were categorized as acute IF. The categorization of reason for PN was revised in 64 cases (18.9% of total) in consensus between the expert panel and investigators. Hospital mortality of all study patients was 21.5%; the median hospital stay was 36 days. Patients with acute IF had a hospital mortality of 20.5% and median hospital stay of 38 days (P > 0.05 for both outcomes). Disordered gut motility (e.g. ileus) was the most common mechanism of acute IF, and 71.5% of patients with acute IF had undergone abdominal surgery. Duration of PN of ≥42 days was identified as being the best cut-off predicting hospital mortality within 90 days. PN ≥ 42 days, age, sepsis and ICU admission were independently associated with 90-day hospital mortality.

CONCLUSIONS

Around 2% of adult patients in acute care hospitals received PN, 60% of them due to acute IF. High 90-day hospital mortality and long hospital stay were observed in patients receiving PN, whereas presence of acute IF did not additionally influence these outcomes. Duration of PN was associated with increased 90-day hospital mortality.

Intestinal failure in adults: Recommendations from the ESPEN expert groups

BACKGROUND & AIMS

Intestinal failure (IF) is defined as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". Functionally, it may be classified as type I acute intestinal failure (AIF), type II prolonged AIF and type III chronic intestinal failure (CIF) The ESPEN Workshop on IF was held in Bologna, Italy, on 15-16 October 2017 and the aims of this document were to highlight the current state of the art and future directions for research in IF.

METHODS

This paper represents the opinion of experts in the field, based on current evidence. It is not a formal review, but encompasses the current evidence, with emphasis on epidemiology, classification, diagnosis and management.

RESULTS

IF is the rarest form of organ failure and can result from a variety of conditions that affect gastrointestinal anatomy and function adversely. Assessment, diagnosis, and short and long-term management involves a multidisciplinary team with diverse expertise in the field that aims to reduce complications, increase life expectancy and improve quality of life in patients.

CONCLUSIONS

Both AIF and CIF are relatively rare conditions and most of the published work presents evidence from small, single-centre studies. Much remains to be investigated to improve the diagnosis and management of IF and future studies should rely on multidisciplinary, multicentre and multinational collaborations that gather data from large cohorts of patients. Emphasis should also be placed on partnership with patients, carers and government agencies in order to improve the quality of research that focuses on patient-centred outcomes that will help to improve both outcomes and quality of life in patients with this devastating condition.

Factors affecting patient and nursing staff adherence to an integrated physical activity and nutritional intervention targeting functional decline on an acute medical ward: a qualitative study

BACKGROUND

Medical patients are particularly at risk of developing complications during and after hospitalization, due to impaired nutritional intake, physical inactivity, or immobilization. Evaluations of implementation studies on health-promoting interventions for medical patients in hospitals are scarce. The aim of this study was to identify factors affecting the adherence of patients and staff to an integrated physical activity and nutritional intervention on a medical ward.

METHODS

Two focus group interviews were conducted: one with patients and another with staff. Three individual telephone interviews were conducted, as three patients were not available at the time of the group interview. An inductive thematic analysis was fundamental to the findings of the study.

FINDINGS

Nine themes describe factors affecting adherence to integrated physical activity and nutrition intervention. Positive factors described by the patients were new knowledge and insight, and that they felt seen and believed in, which made a significant difference to their motivation. The nursing staff felt that the intervention provided important knowledge related to daily practice, prevented bad consciences due to time issues, and that they experienced happier and more active patients. Both staff and patients found that the approaches of the physiotherapist and the dietician positively changed their behavior, however staff members experienced limited resources as a barrier, and a lack of knowledge seemed to hinder full integration of the intervention. Patients reported that their illness situation, "being on their own," and failure to negotiate a shared goal with the project staff were barriers to adherence.

CONCLUSIONS

Both the nursing staff and patients described positive experiences with the integration of a multifaceted health promotion intervention on physical activity and nutrition, however the nursing staff did not fully participate in the intervention and patient adherence differed; particularly, it tended to diminish when the patients were expected to act on their own.

ESPEN guidelines on definitions and terminology of clinical nutrition

BACKGROUND

A lack of agreement on definitions and terminology used for nutrition-related concepts and procedures limits the development of clinical nutrition practice and research.

OBJECTIVE

This initiative aimed to reach a consensus for terminology for core nutritional concepts and procedures.

METHODS

The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a consensus group of clinical scientists to perform a modified Delphi process that encompassed e-mail communication, face-to-face meetings, in-group ballots and an electronic ESPEN membership Delphi round.

RESULTS

Five key areas related to clinical nutrition were identified: concepts; procedures; organisation; delivery; and products. One core concept of clinical nutrition is malnutrition/undernutrition, which includes disease-related malnutrition (DRM) with (eq. cachexia) and without inflammation, and malnutrition/undernutrition without disease, e.g. hunger-related malnutrition. Over-nutrition (overweight and obesity) is another core concept. Sarcopenia and frailty were agreed to be separate conditions often associated with malnutrition. Examples of nutritional procedures identified include screening for subjects at nutritional risk followed by a complete nutritional assessment. Hospital and care facility catering are the basic organizational forms for providing nutrition. Oral nutritional supplementation is the preferred way of nutrition therapy but if inadequate then other forms of medical nutrition therapy, i.e. enteral tube feeding and parenteral (intravenous) nutrition, becomes the major way of nutrient delivery.

CONCLUSION

An agreement of basic nutritional terminology to be used in clinical practice, research, and the ESPEN guideline developments has been established. This terminology consensus may help to support future global consensus efforts and updates of classification systems such as the International Classification of Disease (ICD). The continuous growth of knowledge in all areas addressed in this statement will provide the foundation for future revisions.

Optimizing protein and energy intake in hospitals by improving individualized meal serving, hosting and the eating environment

OBJECTIVE

Optimizing protein and energy intake by food in nutritional risk patients is difficult. The aim of this study was to improve the ≥75% of energy and protein requirements. We would like to see nurses take on the role of hosting the nutritional-risk patients, including focusing on bringing nutrition to the forefront in the collaboration between nurses and patients.

METHODS

This was an interventional study that included patients admitted to the Departments of Infectious Diseases, Hematology, and Heart-Lung Surgery in a baseline and follow-up investigation. It included 24-h food intake registrations (FRs) for 3 d consecutively, a questionnaire, and a semistructured patient interview. The interventions included in this study helped to improve the eating environment and serving, integrated nutrition into the nurse-patient welcome interview, and targeted individual preferences and challenges for eating.

RESULTS

The study comprised 76 24-h FRs at baseline and 108 FRs at follow-up. The total group had improved food intake; 75% of individual energy requirements were met by (67.6% vs. 40%; P = 0.036) and the Heart-Lung Surgery group (85.7 vs. 38.5; P = 0.036). This was not reflected for protein (NS). Energy intake improved for the entire group, albeit not significantly (P = 0.862). Patients reported being happy with the interventions regarding individualized food serving, nurse communication, and improved meal environments.

CONCLUSION

Only insignificant improvements to overall energy intake were seen in two of the three departments and in the overall group, and no statistical or clinically significant improvements to protein intake were observed. The relative risk of meeting 75% of energy requirements was improved in the overall group and in patients in the Department of Heart-Lung Surgery. This did not include the meeting of protein requirements. Improvements were welcomed by patients and staff. Focus on individualized nutrition from the nursing staff also improved.

Protein and energy intake improved by breakfast intervention in hospital

BACKGROUND/AIM

Undernutrition affects about 40% of patients in hospitals. Ordinary food is recommended as the first choice to prevent and correct undernutrition. Meanwhile, sufficient intake, especially regarding protein, is difficult to reach, in patients at nutritional risk. The aim of this study was to improve protein intake at breakfast to at least 20% of total daily requirement or at least 20 g.

METHODS

A protein rich breakfast including 20 g of protein was served in the departments of heart and lung surgery and vascular surgery for three months. Nutrition intake was registered before and after intervention.

RESULTS

Food intake records were collected from 32 and 30 patients respectively, mean age 69 (SD 8) years. At breakfast, protein intake was improved from 14% of individual requirements to 22% (p<0.001) and energy intake was improved from 18% to 25% (p=0.01). Total amount of protein intake for breakfast was increased from 14 g to 20 g (p<0.002). Total daily protein intake increased from 64% to 77% (p=0.05) and total energy intake from 76% to 99% (p<0.01) of requirements.

CONCLUSION

Protein and energy intake for surgical patients at breakfast as well as total daily intake was significantly increased to meet recommended average level for minimum individually measured requirements.

Comparison of complications associated with peripherally inserted central catheters and Hickman™ catheters in patients with intestinal failure receiving home parenteral nutrition. Six-year follow up study

BACKGROUND & AIM

Patients with intestinal failure (IF) are dependent on parenteral nutrition delivered through central access such as Hickman™ catheters. The peripherally inserted central catheter (PICC) is becoming increasingly popular for the purpose. The aim of the present study was to compare complication rates between the two types of catheters.

PATIENTS AND METHODS

Over a six-year period (2008-2014), we included 136 patients with IF receiving home parenteral nutrition (HPN). These patients had a total of 295 catheters (169 Hickman™ catheters and 126 PICCs). Data were collected by reviewing their medical records. Incidences are given per 1000 catheter days. Data are given as means ± standard deviation (SD) and compared using independent student's t-tests, Mann-Whitney-Wilcoxon, and X(2)-tests. A survival analysis for time to the first infection was conducted using Cox regression.

RESULTS

The total number of catheter days was 54,912 days for Hickman™ catheters (mean dwell time 325 ± 402) and 15,974 days for PICCs (mean dwell time 127 ± 121), respectively. The incidence of catheter-related blood stream infection (CRBSI) per 1000 catheter days was significantly lower for Hickman™ catheters compared to PICCs (0.56 vs. 1.63, p < 0.05). The mean time to first CRBSI was significantly shorter for PICCs compared to Hickman™ catheters (84 ± 94 days vs. 297 ± 387 days, p < 0.05), which was confirmed with a cox analysis corrected for age and gender. A total of 75 catheters were removed due to CRBSI, 49 Hickman™ catheters and 26 PICCs respectively. In addition, PICCs were more often removed due to local infection/phlebitis and mechanical causes (p < 0.001).

CONCLUSION

We found a higher risk and shorter time to first CRBSI in PICCs compared to Hickman catheters supporting that PICCs should mainly be chosen for planned HPN up to 3-6 months. We therefore conclude that the choice of catheter must still be determined on an individual basis.

Advances in clinical nutrition in GI surgery

This review addresses recent relevant advances to clinical nutrition regarding gastrointestinal disease surgery. Medline Ovid, EMBASE and Central were searched systematically in April 2014. Inclusion criteria were randomized controlled trials, non-randomized controlled trials and observational studies evaluating nutritional support in gastrointestinal surgery published within 5 years. The review included 56 relevant studies. Themes were: nutrition screening and risk factors predict outcome; preoperative nutritional support; shortening fasting periods and including carbohydrate solutions; early nutrition after surgery; immune modulating nutrition; synbiotics, growth hormone, omega-3 and oral, enteral and parenteral nutrition in combination. Screening for nutritional risk is profound, with special focus on dietary intake in the past week. Age and severity of disease need to be included in the screening system. Patients at severe nutritional risk benefit from nutritional therapy before surgery. New standards are developing quickly and clinical guidelines on surgery should include updated knowledge within clinical nutrition.