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

It is well established that the prevalence of malnutrition in hospitals is high [1–7], yet little has been done systematically to improve the nutrition care of patients during and post hospitalization [8]. A study conducted by the Canadian Malnutrition Task Force found that 45% of patients on medical or surgical wards who stayed more than 2 days were malnourished on admission [3]. Malnutrition often goes undetected [9], which is concerning as it increases mortality, length of stay, and risk of re-admission, even when considering other important covariates such as age, sex, socioeconomic and disease-related characteristics [3, 10–15]. Malnutrition also increases hospital costs [5, 16, 17] and in Canada, this is by approximately $2000CDN per malnourished patient when compared to a well nourished patient [18]. Research has also shown that many patients experience barriers to food intake, such as interrupted meals, or inability to open packages, leading to deterioration of their nutritional status while in hospital [19–21]. Unidentified malnutrition on admission and iatrogenic or worsening of malnutrition increases length of stay and also affects patients after discharge, including an increased likelihood of readmission [3, 11, 19, 22, 23].

Due to the ongoing high prevalence of malnutrition and the pursuit of patient centered care, there is growing focus on the need to build awareness to make improvements and change the culture of nutrition care in hospital [8, 9, 19, 24]. Currently, prevalence rates at admission remain high and research has shown that the lack of a systematic approach to nutrition care in hospitals may exacerbate the issue [25–27]. Keller et al. discovered that many nutrition care practices in Canadian hospitals (including diagnosis, treatment and monitoring) were haphazard [9]. This suggests a need for multi-faceted, systematic approaches to nutrition care and malnutrition management [4, 9, 25, 27, 28].

To address the high prevalence, under-diagnosis and under-treatment of malnutrition in acute care patients, the evidence and consensus based Integrated Nutrition Pathway for Acute Care (INPAC) was developed and face validated [9]. The ultimate goal of the pathway is to enhance patient nutrition care and change practice to ultimately improve clinical outcomes of patients [9]. The algorithm outlines steps for detection, treatment and monitoring of malnutrition and food intake among acute care patients and is based on the concept that nutrition care in hospital is multidisciplinary, with all members of the team, including the patient and family, potentially taking on key roles (i.e. nursing can screen; physicians can institute non-volitional feeding; patients can self report barriers to food intake). INPAC focuses on the following activities: i) nutrition screening on admission using a valid, easy to complete nutrition screening tool, such as the Canadian Nutrition Screening Tool, [CNST] [29]; ii) timely and efficient nutrition assessment using the subjective global assessment (SGA) for patients identified to be at risk [30], iii) standard nutrition care strategies (for all patients) that overcome common barriers, thus promoting food intake, iv) advanced nutrition care strategies (e.g. supplements, snacks) for those with SGA score of mild to moderately malnourished, v) timely comprehensive dietitian assessment and individualized treatments for those severely malnourished, vi) food monitoring to identify need for further nutrition interventions, and vii) connecting/referring malnourished patients to community services as they transition out of hospital.

The More-2-Eat (M2E) project demonstrates how INPAC activities can be implemented in five diverse hospitals (one medical unit/hospital) in four provinces across Canada. The aim of M2E is to monitor how each site implements INPAC, including the steps they take, the resources used etc. M2E details can be found in the protocol [31]. Prior to INPAC implementation, baseline chart audits of INPAC activities were conducted to understand current nutrition practices. This paper summarizes these baseline results of the M2E INPAC audit to identify and compare current nutrition care practices in the five medical units, and thus identify gaps in care for targeting and tailoring of INPAC implementation.

The M2E study is a multi-site participatory action research project with a pre-post time series design. The baseline data collected for this analysis was cross-sectional, over a 4-week period. Hospitals were selected based on their willingness to change nutrition care practices as presented through a request for proposal process reviewed by Canadian and international implementation experts. Each site is led by a site champion(s), supported by a local Research Associate(s) (RAs). RAs were hospital staff (dietitians and nurses) seconded to the project for data collection. RAs received in-person training regarding data collection methods based on a detailed study procedures manual [31].

In line with other literature, these results indicate that there is a gap in current and best nutrition care practice in Canadian hospitals [9, 24, 27, 35, 36]. A systematic best practice pathway, such as INPAC, is needed to help identify those patients that might need additional nutrition intervention and ensure dietitians are seeing the patients most in need of their specialized services [9]. Research has shown that hospital staff recognize the need to create effective systems to ensure quality nutrition care, yet it is challenging to put this into regular practice [37, 38].

Results also indicate that there are many statistically significant differences between M2E sites in terms of patient demographics, diagnoses and nutrition care practices. This emphasizes the importance of hospitals completing a needs assessment to determine the most important nutrition care areas to address in their setting. It also highlights the need for the intervention to be adaptable to each individual setting and tailored to meet local priorities. Research has shown that flexible and adaptable interventions have better uptake and increased chances for success [39]. In terms of screening (usually completed by nursing staff or diet clerks), less than half of patients were screened for malnutrition risk at admission. This is consistent with other research indicating that nutrition screening rates are generally poor, ranging from 42% of patients [36] to 64% [10]. Three of the five hospital sites were routinely screening, with only two having relatively good completion rates (76 and 66% of patients) and using validated tools. Many barriers to screening have been identified in the literature, including lack of time, low priority among staff, uncertainty in using existing tools, and not having a simple screening tool embedded into routine practice [38, 40]. The third site (Site C), with a low coverage of screening at 26% of patients, required a long, cumbersome nutrition screening form, which likely affected their success rate with this care activity. Even though screening was in place in these three hospitals, a positive screen only lead to a dietitian assessment in 64% of patients identified to be at risk, raising the question of purpose and ethics of screening if it is not connected to a diagnosis to confirm malnutrition [41]. Screening initiatives need to be coupled with rapid diagnosis, and as suggested by INPAC, this can be facilitated with SGA.

Further, malnutrition was an uncommon nutrition diagnosis when a nutrition assessment was completed yet diagnoses of weight loss and poor intake were common. This may suggest a hesitancy by dietitians to diagnose malnutrition in the Canadian health care system, and potentially the incorporation of SGA into their practice will have a positive impact. Of interest was the high proportion of specialized nutrition care in the form of prescribed diets beyond the regular diet. As dietitians completed a comprehensive assessment in 28% of cases, which may have lead to a diet prescription, this suggests that diet is routinely manipulated by physicians, nurses and Speech Language Pathologists (SLP) and there is an opportunity for further dietitian involvement with some of the more restrictive diet prescriptions.

Recording patients’ body weight at admission (48%) appears to be a more common practice compared to monitoring body weight (18%) during patients’ hospital stay. Results from the Canadian 2010-2011 nutrition Day survey found similar rates of body weights being recorded on admission, although the numbers are increasing (52% in 2010, 67% in 2011) [42]. It is also unclear if the weights recorded at admission in this baseline sample were actual, estimated, or reported, as this was not always indicated in the documentation. The potential variability between these weights can have a significant effect on recommendations for a variety of specialists including pharmacists who prescribe medication based on body weight, occupational therapists who need weights for ordering assistive devices, as well as others. Additionally, research shows that emphasis also needs to be placed on monitoring body weight throughout hospital stay. Collins and colleagues [43] found that nutrition classification declined for 10.3% of hospital patients during their stay. Yet, the Nutrition Care Day Survey indicated that heights and weights were not routinely measured nor were patients monitored for further weight loss during hospital stay [10]. Results from this study also indicate that more attention needs to be placed not only on getting measured weights at admission, but also monitoring weight change over time, particularly in longer stay patients. The INPAC highlights the importance of both care activities.

Research has shown that having food intake of 50% or less during the first week of the hospital admission is significantly associated with a longer length of stay even when adjusting for other important covariates including nutritional status [3]. Low food intake appears to be common in hospital patients, where 57% of Canadian patients consumed less than half of their meal on the day of the nutritionDay survey [42]. This is an important consideration as few M2E sites were monitoring food intake and using this data to change interventions. Challenges in identification of low food intake by hospital staff may contribute to poor rates of monitoring and hence inaction to improve food intake. By increasing food intake monitoring amongst staff, it could lead to supportive actions to improve food intake. Using a process to quickly and accurately identify how much is consumed and have low intake (50% or less) trigger an action is recommended within INPAC [9]. The My Meal Intake Tool (MMIT), completed by patients may be a strategy to support monitoring of food intake [44].

Understanding patient-reported barriers to food intake is necessary to address low food intake in hospital. Many barriers to food intake were identified by staff in all sites, which corroborate findings from other research [19, 23]. The Nutrition Care in Canadian Hospitals (NCCH) study identified numerous barriers in the areas of illness (poor appetite, nausea, pain), eating difficulties (difficulty opening packages, inability to reach meal trays) and organizational barriers (not receiving help to eat, missing meals due to tests) [19]. Barriers identified by the sites in this study were most commonly medically based (e.g. nausea) indicating that other barriers identified in the NCCH study were either not as readily recognized by staff and/or were less frequently addressed or that these barriers were not issues for these sites. The Mealtime Audit Tool (MAT) standardizes the process of monitoring intake and addressing barriers, ultimately improving nutrition care [21].

Standard nutrition care strategies were common among the 5 sites and there appears to be good alignment between care strategies to address the most commonly reported barriers to food intake. For instance, pain is the top reported barrier while pain control was the most common standard nutrition care strategy. However, baseline results also suggest that advanced nutrition care strategies were under-utilized. For example, use of small amounts (e.g. 60 mls) of nutrient dense ONS with medication delivery was low compared to other strategies such as specialized diets and/or supplements given during or between meals. Supplements provided tend to be high-energy, high protein, milkshakes or ONS, however, there is a concern about waste which could be minimized with increased use of the small amount of supplement [45]. This highlights an area for practice improvement.

Results from INPAC audits provide a snapshot of the nutrition care that is being provided on a single medical unit in five Canadian hospitals. Although this sample is not representative of the Canadian context, it provides for the first time, estimates on nutrition care activities beyond screening, which only occurred in ~35% of all patients. Identified nutrition risk was not always followed by an assessment and the proportion of patients seeing a dietitian was relatively low considering the documented level of malnutrition in hospital. Malnutrition was rarely chosen as a nutrition diagnosis, and appears to be underrepresented considering the prevalence of risk. Low rates of food intake monitoring that led to a change in intervention among sites identifies an additional gap in nutrition care. The high use of prescribed diets suggests a need for nutrition care practices that require better coordination with nutrition professionals. Audits also identified strengths of current nutrition care, such as the consideration of key barriers and their follow-through with strategies. Food appears to be the focus for much of the advanced nutrition care strategies provided in these medical units. INPAC audits have provided a strong foundation for making change within the M2E sites. Similar needs assessment is recommended for others choosing to embark on quality improvements to nutrition care, as local data are powerful to stimulating change [46].