There is increasing awareness of the detrimental health impact of frailty on older adults and of the high prevalence of malnutrition in this segment of the population. Experts in these 2 arenas need ...to be cognizant of the overlap in constructs, diagnosis, and treatment of frailty and malnutrition. There is a lack of consensus regarding the definition of malnutrition and how it should be assessed. While there is consensus on the definition of frailty, there is no agreement on how it should be measured. Separate assessment tools exist for both malnutrition and frailty; however, there is intersection between concepts and measures. This narrative review highlights some of the intersections within these screening/assessment tools, including weight loss/decreased body mass, functional capacity, and weakness (handgrip strength). The potential for identification of a minimal set of objective measures to identify, or at least consider risk for both conditions, is proposed. Frailty and malnutrition have also been shown to result in similar negative health outcomes and consequently common treatment strategies have been studied, including oral nutritional supplements. While many of the outcomes of treatment relate to both concepts of frailty and malnutrition, research questions are typically focused on the frailty concept, leading to possible gaps or missed opportunities in understanding the effect of complementary interventions on malnutrition. A better understanding of how these conditions overlap may improve treatment strategies for frail, malnourished, older adults.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Screening for nutrition risk in community-dwelling older adults increases the likelihood of early intervention to improve nutritional status, with short screening tools preferred. SCREEN-II-AB is a ...valid 8-item tool. The current study determines whether SCREEN-III, a proposed 3-item version, adequately classifies nutrition risk in comparison.
Baseline data from the Canadian Longitudinal Study on Aging were used. Seventy-two percent (n = 24,456) of eligible participants (>55 years, complete SCREEN-II-AB) were included. Sensitivity and specificity of various SCREEN-III values compared with SCREEN-II-AB risk determined a nutrition risk cut-point and the proportion misclassified (False-) was calculated. Construct validity was tested against a composite variable summarizing outcomes associated with nutrition risk (e.g., self-reported health, hospitalization) using logistic regression adjusted for individual factors (e.g., marital status).
A SCREEN-III cut-point of <22 performed best on sensitivity (0.83 95% CI = 0.82, 0.84) and specificity (0.73 95% CI = 0.72, 0.74) compared to SCREEN-II-AB (Cramer's V = 0.53). Of those at-risk using SCREEN-II-AB, 16.7% were misclassified as False(-) by SCREEN-III. The False(-) group did not differ significantly from the True(-) group. Based on SCREEN-III, 45.3% of individuals were at nutrition risk, 44% of whom reported the outcome composite. SCREEN-III nutrition risk was associated with greater odds of the outcome composite compared to those not at-risk (OR = 1.40, 95% CI = 1.33, 1.48, P < 0.0001).
The proposed version of SCREEN-III demonstrated construct validity, but misclassification of risk may be problematic; further validation of a 3-item version is recommended.
Improving the detection and treatment of malnourished patients in hospital is needed to promote recovery.
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.
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.
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.
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.
Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.
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.
Sustainability science is an emerging area within implementation science. There is limited evidence regarding strategies to best support the continued delivery and sustained impact of evidence-based ...interventions (EBIs). To build such evidence, clear definitions, and ways to operationalize strategies specific and/or relevant to sustainment are required. Taxonomies and compilations such as the Expert Recommendations for Implementing Change (ERIC) were developed to describe and organize implementation strategies. This study aimed to adapt, refine, and extend the ERIC compilation to incorporate an explicit focus on sustainment. We also sought to classify the specific phase(s) of implementation when the ERIC strategies could be considered and applied.
We used a two-phase iterative approach to adapt the ERIC. This involved: (1) adapting through consensus (ERIC strategies were mapped against barriers to sustainment as identified
the literature to identify if existing implementation strategies were sufficient to address sustainment, needed wording changes, or if new strategies were required) and
(2) preliminary application of this sustainment-explicit ERIC glossary (strategies described in published sustainment interventions were coded against the glossary to identify if any further amendments were needed). All team members independently reviewed changes and provided feedback for subsequent iterations until consensus was reached. Following this, and utilizing the same consensus process, the Exploration, Preparation, Implementation and Sustainment (EPIS) Framework was applied to identify when each strategy may be best employed across phases.
Surface level changes were made to the definitions of 41 of the 73 ERIC strategies to explicitly address sustainment. Four additional strategies received deeper changes in their definitions. One new strategy was identified:
. Application of the EPIS identified that at least three-quarters of strategies should be considered during preparation and implementation phases as they are likely to impact sustainment.
A sustainment-explicit ERIC glossary is provided to help researchers and practitioners develop, test, or apply strategies to improve the sustainment of EBIs in real-world settings. Whilst most ERIC strategies only needed minor changes, their impact on sustainment needs to be tested empirically which may require significant refinement or additions in the future.
Summary Background Poor food intake is common in hospital patients and is associated with adverse patient and healthcare outcomes; diverse mealtime barriers to intake often undermine clinical ...nutrition care. Aim This study determines whether implementation of locally adaptable nutrition care activities as part of uptake of the Integrated Nutrition Pathway for Acute Care (INPAC) reduced mealtime barriers and improved other patient outcomes (e.g. length of stay; LOS) when considering other covariates. Methods 1250 medical patients from 5 Canadian hospitals were recruited for this before-after time series design. Mealtime barriers were tallied with the Mealtime Audit Tool after a meal, while proportion of the meal consumed was assessed with the My Meal Intake Tool. Implementation of new standard care activities occurred over 12 months and three periods (pre-, early, and late) of implementation were compared. Regression analyses determined the effect of time period while adjusting for key covariates. Results Mealtime barriers were reduced over time periods (Period 1 = 2.5 S.D. 2.1; Period 3 = 1.8 S.D. 1.7) and site differences were noted. This decrease was statistically significant in regression analyses (−0.28 per time period; 95% CI -0.44, −0.11). Within and across site changes were also observed over time in meal intake and LOS; however, after adjusting for covariates, time period of implementation was not significantly associated with these outcomes. Discussion Mealtime barriers can be reduced and sustained by implementing improved standard care procedures for patients. The More-2-Eat study provides an example of how to implement changes in practice to support the prevention and treatment of malnutrition. Trial registration Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304 , June 7, 2016.
Abstract only
The More‐2‐Eat (M2E) project aims to optimize nutrition care in Canadian hospitals through use of the Integrated Nutrition Pathway for Acute Care (INPAC). By optimizing nutrition care, ...the M2E project aims to impact performance of the healthcare system by ensuring that malnutrition and poor food intake are prevented, detected and treated, hence promoting the recovery, function and quality of life of patients, with particular attention on the needs of frail elderly.
Before making a change to nutrition culture in hospital, it is important to understand current attitudes and practices related to nutrition care from a variety of hospital staff and management perspectives. As part of baseline data collection for M2E, interviews (n=40) and focus groups (n=11) were conducted with staff and management from 5 Canadian hospitals, in 4 provinces. Thematic analysis of transcripts is currently underway and preliminary findings identify facilitators and barriers regarding incorporation of nutrition screening tools, provision of standard nutrition care, use of nutrition assessment tools, incorporation of nutrition into the discharge process, and suggestions for making change in the hospital.
Initial results indicate that communication is a problem across departments. Although communication between individuals is seen as strong, it is not always clear who is responsible for certain tasks, there are often several steps required to communicate a patient need/care, and it is not always clear how to communicate patient needs to effect change in behaviour of staff. There is also a lack of ownership regarding mealtimes, making it more difficult to make a change if no one is accountable. The staff care about nutrition and their patients, however need specific and manageable tasks which can be built into their current workload. Change should begin small and be tested for feasibility before upscaling. Incorporating all staff will be essential for this culture change.
The results of the focus groups and interviews will be summarized for each unit and presented back to them as a starting point, along with quantitative data on their current processes. Feedback of this data will be used to stimulate change in nutrition care on the unit. Understanding the facilitators, barriers and opportunities to change are essential when optimizing nutrition care in hospital.
Support or Funding Information
This research is funded by the Technology Evaluation in the Elderly Network (TVN), which is supported by the Government of Canada through the Networks of Centres of Excellence program.
There is increasing awareness of the detrimental health impact of frailty on older adults and of the high prevalence of malnutrition in this segment of the population. Experts in these 2 arenas need ...to be cognizant of the overlap in constructs, diagnosis, and treatment of frailty and malnutrition. There is a lack of consensus regarding the definition of malnutrition and how it should be assessed. While there is consensus on the definition of frailty, there is no agreement on how it should be measured. Separate assessment tools exist for both malnutrition and frailty; however, there is intersection between concepts and measures. This narrative review highlights some of the intersections within these screening/assessment tools, including weight loss/decreased body mass, functional capacity, and weakness (handgrip strength). The potential for identification of a minimal set of objective measures to identify, or at least consider risk for both conditions, is proposed. Frailty and malnutrition have also been shown to result in similar negative health outcomes and consequently common treatment strategies have been studied, including oral nutritional supplements. While many of the outcomes of treatment relate to both concepts of frailty and malnutrition, research questions are typically focused on the frailty concept, leading to possible gaps or missed opportunities in understanding the effect of complementary interventions on malnutrition. A better understanding of how these conditions overlap may improve treatment strategies for frail, malnourished, older adults.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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