Sustained benefits of a community dietetics intervention designed to improve oral nutritional supplement prescribing practices

Background: Healthcare professionals working in the community do not always prescribe oral nutritional supplements (ONS) according to best practice guidelines for the management of malnutrition. The present study aimed to determine the impact of a community dietetics intervention on ONS prescribing practices and expenditure 1 year later. Methods: The intervention involved general practitioners (GPs), practice nurses, nurses in local nursing homes and community nurses. It comprised an education programme together with the provision of a new community dietetics service. Changes in health care professionals’ nutrition care practices were determined by examining community dietetics records. ONS prescribing volume and expenditure on ONS were assessed using data from the Primary Care Reimbursement Service of the Irish Health Service Executive. Results: Seven out of 10 principal GPs participated in the nutrition education programme. One year later, screening for malnutrition risk was better, dietary advice was provided more often, referral to the community dietetics service improved and ONS were prescribed for a greater proportion of patients at ‘high risk’ of malnutrition than before (88% versus 37%; P < 0.001). There was a trend towards fewer patients being prescribed ONS (18% reduction; P = 0.074) and there was no significant change in expenditure on ONS by participating GPs (3% reduction; P = 0.499), despite a 28% increase nationally by GPs on ONS. Conclusions: The community dietetics intervention improved ONS prescribing practices by GPs and nurses, in accordance with best practice guidelines, without increasing expenditure on ONS during the year after intervention.     

Critical Role of Nutrition in Improving Quality of Care

The current era of healthcare delivery, with its focus on providing high‐quality, affordable care, presents many challenges to hospital‐based health professionals. The prevention and treatment of hospital malnutrition offer a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and treat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute posthospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reduce complication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patients who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following 6 principles: (1) create an institutional culture where all stakeholders value nutrition, (2) redefine clinicians’ roles to include nutrition care, (3) recognize and diagnose all malnourished patients and those at risk, (4) rapidly implement comprehensive nutrition interventions and continued monitoring, (5) communicate nutrition care plans, and (6) develop a comprehensive discharge nutrition care and education plan.     

Screening for malnutrition among nursing home residents — a comparative analysis of the Mini Nutritional Assessment, the Nutritional Risk Screening, and the Malnutrition Universal Screening Tool

Background

The European Society for Clinical Nutrition and Metabolism (ESPEN) has recommended the Mini Nutritional Assessment (MNA®), the Nutritional Risk Screening 2002 (NRS), and the Malnutrition Universal Screening Tool (MUST) for nutritional screening in various settings and age groups. While in recent years all three tools have been applied to nursing home residents, there is still no consensus on the most appropriate screening tool in this specific setting.

Aim

The present study aims at comparing the MNA, the NRS, and the MUST with regard to applicability, categorization of nutritional status, and predictive value in the nursing home setting.

Method

MNA, NRS, and MUST were performed on 200 residents from two municipal nursing homes in Nuremberg, Germany. Follow-up data on infection, hospitalization, and mortality were collected after six and again after twelve months.

Results

Among 200 residents (mean age 85.5 ±7.8 years) the MNA could be completed in 188 (94.0%) and the NRS and MUST in 198 (99.0%) residents. The prevalence of ‘malnutrition’ according to the MNA was 15.4%. The prevalence of ‘risk of malnutrition’ (NRS) and ‘high risk of malnutrition’ (MUST), respectively, was 8.6% for both tools. The individual categorization of nutritional status showed poor agreement between NRS and MUST on the one hand and MNA on the other. For all tools a significant association between nutritional status and mortality was demonstrated during follow-up as classification in ‘malnourished’, respectively ‘high risk of malnutrition’ or ‘nutritional risk’, was significantly associated with increased hazard ratios. However, the MNA showed the best predictive value for survival among well-nourished residents.

Conclusion

The evaluation of nutritional status in nursing home residents by MNA, NRS, and MUST shows significant differences. This observation may be of clinical relevance as nutritional intervention is usually based on screening results. As the items of the MNA reflect particularities of the nursing home population, this tool currently appears to be the most suitable one in this setting.     

Self‐Screening for Malnutrition Risk in Outpatient Inflammatory Bowel Disease Patients Using the Malnutrition Universal Screening Tool (MUST)

Background and Aims: Malnutrition is common in patients with inflammatory bowel disease (IBD) and is associated with poor outcomes. Our aim is to determine if patient self‐administered malnutrition screening using the malnutrition universal screening tool (MUST) is reliable by comparing patient scores with those derived from the healthcare practitioner (HCP), the gold standard. Methods: We conducted a prospective validation study at a tertiary Canadian academic center that included 154 adult outpatients with IBD. All patients with IBD completed a self‐administered nutrition screening assessment using the MUST score followed by an independent MUST assessment performed by HCPs. The main outcome measure was chance‐corrected agreement (κ) of malnutrition risk categorization. Results: For patient‐administered MUST, the chance‐corrected agreement κ (95% confidence interval [CI]) was 0.83 (0.74–0.92) when comparing low‐risk and combined medium‐ and high‐risk patients with HCP screening. Weighted κ analysis comparing all 3 risks groups yielded a κ (95% CI) of 0.85 (0.77–0.93) between patient and HCP screening. All patients were able to screen themselves. Overall, 96% of patients reported the MUST questionnaire as either very easy or easy to understand and to complete. Conclusion: Self‐administered nutrition screening in outpatients with IBD is valid using the MUST screening tool and is easy to use. If adopted, this tool will increase utilization of malnutrition screening in hectic outpatient clinic settings and will help HCPs determine which patients require additional nutrition support.     

Factors for Effective Identification of Patients at Nutritional Risk in Clinical Practice: Thematic Analysis of Qualitative Research

IntroductionDespite the high prevalence of malnutrition in patients at all levels of healthcare, early prevention and treatment of malnourished patients are often neglected and overlooked in clinical practice. The aim of this systematic literature review was to identify the factors considered most important by healthcare professionals in the identification and treatment of malnourished patients or those at risk of malnutrition.MethodsA systematic literature review of qualitative research was conducted. Documents published in scientific journals in English from 2011 to 2021 were searched in the PubMed (MEDLINE), CINAHL and ProQuest databases. The results were analysed with a thematic analysis of qualitative research findings.ResultsFrom the search set of 1010 results, 7 sources were included in the final analysis. Factors identified by health professionals as important in the identification and treatment of malnourished patients in clinical practice were grouped into five themes: unclear organizational structure; indefinite structure of nutritional care; poor continuity of nutritional care; lack of knowledge and skills of health professionals; lack of time and human resources.ConclusionsHealth policy must provide resources for nutritional care for patients at all levels of health care on the initiative of the highest professional bodies at the state level. To improve the nutritional care of patients in clinical practice, the management of health care institutions must promote and enable the professional and organizational establishment of clinical nutrition as a regular medical activity of the institution, develop clinical nutritional pathways, and promote evidence-based clinical practice and interprofessional collaboration.     

Relationship between Nutritional Screening Tools and GLIM in Complicated IBD Requiring Surgery

Background: Accurate identification of malnutrition and preoperative nutritional care in Inflammatory Bowel Disease (IBD) surgery is mandatory. There is no validated nutritional screening tool for IBD patients. We developed a novel nutritional screening tool for IBD patients requiring surgery and compared it with other tools. Methods: we included 62 consecutive patients scheduled for elective surgery. The IBD Nutritional Screening tool (NS-IBD) was developed to screen patients for further comprehensive assessment. NRS-2002, MUST, MST, MIRT, SaskIBD-NR are compared with the new test. All screening tests were subsequently related to new GLIM criteria. Results: according to GLIM criteria, 25 (40%) IBD patients were malnourished (15 CD and 10 UC, 33% vs. 63%, p = 0.036). Stage 1 malnutrition was reported in ten patients, while stage 2 was detected in 15 patients. The comparison of each nutritional risk tool with GLIM criteria showed sensitivity of 0.52, 0.6, 0.6, 0.84, 0.84 and 0.92 for SASKIBD-NR, MUST, MST, NRS-2002, MIRT, and the new NS-IBD, respectively. Conclusions: in IBD, currently adopted nutritional screening tools are characterized by a low sensitivity when malnutrition diagnosis is performed with recent GLIM criteria. Our proposed tool to detect malnutrition performed the best in detecting patients that may require nutritional assessment and preoperative intervention.     

The presence of malnutrition in community‐living older adults receiving home nursing services

Aim: To determine the extent of malnutrition and malnutrition risk among community‐living older people (aged 65 years and over) who are receiving care from a metropolitan home nursing service in Victoria, Australia. Method: Over a 3‐month period (May–July 2009), 235 clients aged 65 years and over from a community nursing service providing home nursing care were assessed for malnutrition using the Mini Nutritional Assessment (MNA®, Nestle, Vevey, Switzerland). Results: Thirty‐four per cent (34.5%) of clients were identified as being at risk of malnutrition, while 8.1% were found to be malnourished. There was no significant relationship between nutrition risk and gender, country of birth or living arrangements. Conclusion: Malnutrition and nutrition risk was found to be an issue among this sample of community‐living older adults who were receiving home nursing care in Victoria, Australia. In this study, just over 40% of the participants were either at risk of malnutrition or malnourished, which highlights the vulnerability of this group of older people and the need for routine nutrition screening and a targeted intervention program to address nutrition issues.     

Food provision for older people receiving home care from the perspectives of home‐care workers

Malnutrition is a significant cause of morbidity and mortality, particularly among older people. Attention has focused on the inadequacies of food provision in institutions, yet the majority suffering from malnutrition live in the community. The aim of this study was to explore barriers and facilitators to food provision for older people receiving home care. It was a qualitative exploratory study using semi‐structured interviews with nine home‐care workers in June 2013 employed by independent agencies in a large city in northern England. Data were analysed thematically, based on the principles of grounded theory. Findings showed that significant time pressures limited home‐care workers in their ability to socially engage with service users at mealtimes, or provide them with anything other than ready meals. Enabling choice was considered more important than providing a healthy diet, but choice was limited by food availability and reliance on families for shopping. Despite their knowledge of service users and their central role in providing food, home‐care workers received little nutritional training and were not involved by healthcare professionals in the management of malnutrition. Despite the rhetoric of individual choice and importance of social engagement and nutrition for health and well‐being, nutritional care has been significantly compromised by cuts to social care budgets. The potential role for home‐care workers in promoting good nutrition in older people is undervalued and undermined by the lack of recognition, training and time dedicated to food‐related care. This has led to a situation whereby good quality food and enjoyable mealtimes are denied to many older people on the basis that they are unaffordable luxuries rather than an integral component of fundamental care.     

Nutrition and dietetics in aged care

Aim: The global trends of rapid population ageing and increased risk of malnutrition among older people have a tremendous impact on nutrition care for the elderly. The present paper offers an overview of the challenging nutritional needs and problems of the elderly and explores strategies related to nutrition and dietetics to improve care for this particular segment of the population. Methods: A narrative review on monitoring malnutrition and improving food services was undertaken with reference to the literature and drawing on the experience of the author. Results: There is a wide range of problems associated with malnutrition in the elderly that have implications on strategies of intervention for addressing these problems. Conclusions: The current challenges for dietitians include identifying and monitoring the nutritional needs and malnutrition problems of the elderly, improving the quality of food services in health‐care facilities, and initiating innovative approaches to nutrition and dietetic services in the community.     

The development and pilot evaluation of a nutrition education intervention programme for pregnant teenage women (food for life)

Background A healthy diet in pregnancy is important for both maternal and infant health but this may be difficult to achieve particularly for groups such as teenage pregnant women, many of whom are from disadvantaged backgrounds. To our knowledge this is the first report of a practical nutrition education programme for this group in the UK. Method An intervention was designed incorporating seven informal food preparation sessions, which allowed opportunities for discussion of nutritional, and other topics (e.g. food safety and well‐being in pregnancy). Midwives in a community centre setting led the sessions. The acceptability of the package to participants and midwives was recorded and pre‐ and post‐intervention data collected on sociodemographic details, dietary intake (using an eating‐habits questionnaire and a 24‐h dietary recall) and cooking skills. Results The midwives found the package easy to follow and use. The 16 (of the 120 invited) women who attended found the courses helpful but objective evaluation of dietary intake was not possible because of poor compliance. Conclusions The nutrition education programme was favourably received by midwives and the women who participated. However recruitment was problematic and alternative methods of delivering and evaluating such a package should be investigated.     

Addressing Malnutrition in Hospitalized Adults

Established guidelines and standardized protocols exist to assist clinicians in effectively addressing disease‐related malnutrition in hospitalized adults. The goals of this treatment vary according to the disease state and the severity of the malnutrition. In starvation‐related malnutrition, the goal of nutrition therapy is to restore healthy levels of lean body mass and body fat. For chronic disease‐related malnutrition, the goals of treatment are to maintain and improve lean body mass and body fat. In acute‐disease‐related malnutrition, the goals of nutrition therapy are to support vital organ function and preserve the host response through the acute episode. The success of addressing malnutrition in hospitalized patients depends not just on the nutrition therapy selected, but also on the timely and appropriate application of guidelines and protocols by the clinicians dedicated to caring for malnourished patients. Coordination of nutrition care among providers is highly desirable, and usually includes a multidisciplinary team of clinicians typically comprising a physician, nurse, dietitian, and pharmacist. For greatest success, this attention to recognizing and addressing malnutrition begins at admission and continues beyond discharge to the community. When addressing malnutrition in hospitalized patients, oral feeding through diet enrichment or oral nutrition supplementation (ONS) is the first line of defense. ONS has consistently been demonstrated to provide nutrition, clinical, functional, and economic benefits to malnourished patients in both individual trials and meta‐analyses. In an era when the cost of healthcare is rising as the population ages, addressing malnutrition in hospitalized patients is an important priority.     

Nurses’ elicitation of patient error as a practice in training end‐stage renal patients in automated home peritoneal dialysis

As part of a reorganisation of the delivery of health care in Denmark therapies for chronic medical conditions are moved out of hospitals and disease‐specific patient education programmes instituted to train patients to assume responsibility for treating their disease at home, that is, perform tasks and functions traditionally done by healthcare professionals. Drawing on video‐recordings (90:25h) from a programme for self‐management of end‐stage renal disease through automated home peritoneal dialysis, the study employs conversation analysis to examine nurses’ instructional practices for providing patients with the necessary knowledge, skill and competences. Showing training to rely on an error‐based monitoring strategy, the study demonstrates that rather than solely waiting for random errors to emerge, nurses on occasion steer patients towards specific errors to bring about particular instructional opportunities. Surprising given the seriousness of the therapy, this elicitation of error is shown to reflect a deliberate instructional choice; nurses promote select errors to impart patients with an understanding of the procedural logic behind the therapy and medical technology. The study argues that training patients for chronic disease self‐management and providing them with a proficiency level, normally associated with certified professionals, necessitates pushing patients beyond what is strictly accurate and exposing them to medically delicate events.     

Lay food and health worker involvement in community nutrition and dietetics in England: roles, responsibilities and relationship with professionals

Background Community‐based food initiatives have developed in recent years with the aim of engaging previously ‘hard to reach’ groups. Lay workers engaged in community nutrition activities are promoted as a cost‐effective mechanism for reaching underserved groups. The main objective of the study was to explore perceptions and definitions of lay food and health worker (LFHW) helping roles within the context of National Health Service (NHS) community nutrition and dietetic services in order to define the conceptual and practical elements of this new role and examine the interface with professional roles. Methods Interpretive qualitative inquiry; semi‐structured interviews with LFHW and NHS professionals employed by community‐based programmes, serving ‘hard‐to‐reach’ neighbourhoods, across England. A total sampling framework was used to capture all existing and ‘fully operational’ lay food initiatives in England at the commencement of fieldwork (January 2002). Findings In total, 29 professionals and 53 LFHWs were interviewed across 15 of the 18 projects identified. Although all 15 projects shared a universal goal, to promote healthy eating, this was achieved through a limited range of approaches, characterized by a narrow, individualistic focus. Lay roles spanned three broad areas: nutrition education; health promotion; and administration and personal development. Narratives from both professionals and LFHWs indicated that the primary role for LFHWs was to encourage dietary change by translating complex messages into credible and culturally appropriate advice. Conclusions This research confirms the emerging discipline involving lay helping within the NHS and community dietetics. The primary role of LFHWs in the 15 projects involved was to support existing NHS services to promote healthy eating amongst ‘hard to reach’ communities. The activities undertaken by LFHWs are strongly influenced by professionals and the NHS. Inherent to this is a fairly narrow interpretation of health, resulting in a limited range of practice.     

Evaluation of the efficacy of nutritional screening tools to predict malnutrition in the elderly at a geriatric care hospital

BACKGROUND/OBJECTIVESMalnutrition in the elderly is a serious problem, prevalent in both hospitals and care homes. Due to the absence of a gold standard for malnutrition, herein we evaluate the efficacy of five nutritional screening tools developed or used for the elderly.SUBJECTS/METHODSElected medical records of 141 elderly patients (86 men and 55 women, aged 73.5 ± 5.2 years) hospitalized at a geriatric care hospital were analyzed. Nutritional screening was performed using the following tools: Mini Nutrition Assessment (MNA), Mini Nutrition Assessment-Short Form (MNA-SF), Geriatric Nutritional Risk Index (GNRI), Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Screening 2002 (NRS 2002). A combined index for malnutrition was also calculated as a reference tool. Each patient evaluated as malnourished to any degree or at risk of malnutrition according to at least four out of five of the aforementioned tools was categorized as malnourished in the combined index classification.RESULTSAccording to the combined index, 44.0% of the patients were at risk of malnutrition to some degree. While the nutritional risk and/or malnutrition varied greatly depending on the tool applied, ranging from 36.2% (MUST) to 72.3% (MNA-SF). MUST showed good validity (sensitivity 80.6%, specificity 98.7%) and almost perfect agreement (k = 0.81) with the combined index. In contrast, MNA-SF showed poor validity (sensitivity 100%, specificity 49.4%) and only moderate agreement (k = 0.46) with the combined index.CONCLUSIONSMNA-SF was found to overestimate the nutritional risk in the elderly. MUST appeared to be the most valid and useful screening tool to predict malnutrition in the elderly at a geriatric care hospital.     

Effect of Digital Nutrition Education Intervention on the Nutritional Knowledge Levels of Information Technology Professionals

The purpose of the study was to determine the changes in knowledge of information technology (IT) professionals after receiving a nutrition education intervention for a month. The sample comprised of 40 IT professionals (29 males and 11 females). The sample was drawn from four IT companies of Hyderabad city using random sampling techniques. The data on the general information of the subjects was collected. The data regarding the commonly accessed sources of nutrition and health information by the subjects was also obtained from the study. The intervention study group received nutrition education by distribution of the developed CD-ROMs to them followed by interactive sessions. To assess the impact of nutrition education intervention, the knowledge assessment questionnaire (KAQ) was developed and administered before and after the education programme. A significant improvement in the mean nutritional knowledge scores was observed among the total study subjects from 22.30 to 40.55 after the intervention (p < 0.05). The findings support the importance of providing professionals with nutrition knowledge to promote healthy dietary behaviors.Thus, the method of e-learning and development of CD-Rom is essential for teaching the educated groups on nutrition, physical activity and overall health education to improve their health, lifestyle and eating habits.     

Increased frequency and accuracy of MUST screening after use of a nutrition screening round

Background: Surveys indicate that malnutrition remains common among hospital patients (Russell & Elia, 2010). It is recommended that all patients be screened on admission and weekly (NICE, 2006). The Malnutrition Universal Screening tool (MUST) is a sensitive and specific screening measure (Kyle et al., 2006). In Homerton Hospital, the nutrition screening round (NSR) ran alongside transition of paper‐based screening onto an electronic patient record system (EPR). This study aimed to assess the effectiveness of a dietitian‐led NSR as a method of training staff to use MUST. Methods: Malnutrition screening was audited on an elderly care ward and an adult rehabilitation unit. The number of MUST scores undertaken within 24 h of admission and the frequency of weekly screening were assessed. Data gathered included the numbers of patients with accurately measured height, weight, body mass index, weight loss and acute disease effect scores. A weekly NSR was then conducted on these two wards alongside consultant ward rounds, with the dietitian carrying out nutritional care and all staff gaining practical experience of MUST by assisting with screening of each patient. After 20 weeks, screening levels were re‐audited and, at 24 weeks nursing staff took back full responsibility for MUST screening. A final audit of screening levels took place 1 month after staff on the two designated wards had taken back responsibility for screening. Results: The initial audit indicated that, of 53 patients, 26 had a paper MUST proforma present. Of 23 patients who were on the wards for >7 days who had a MUST proforma, only one was screened each week as per NICE guidelines. The 20‐week mid‐intervention audit showed that the number of patients on the wards for ≥1 week with an accurate MUST screen recorded on EPR had increased to 100%. Increased detection of malnutrition led to prompt, effective nutrition support. The final audit at 28 weeks showed sustained screening levels, with all patients on the ward for ≥1 week being accurately screened for malnutrition by ward staff alone. Discussion: The NSR appeared to target factors identified as being behind low levels of screening, including a low awareness of screening policy and poor screening skills (Porter, et al., 2009).Confidence in carrying out MUST was increased by ‘hands‐on’ training in the immediate patient environment. Perceived barriers to screening cited in other research include pressures of workload (Hodge, 2008). The NSR demonstrated that screening was not as time consuming as assumed and that it could be fitted alongside other tasks. Previous studies have suggested training might be targeted toward all clinical staff (Wong & Gandy, 2008). The NSR project supports this finding, demonstrating that the involvement of all members of the multiprofessional team is strongly conducive to embedding MUST within clinical care and as part of weekly ward routine. Conclusions: A NSR is an effective way of providing practical training in nutritional screening. A NSR raises the ward level profile of screening, encourages it to become routine practice and is a feasible method of increasing frequency of screening in line with policy to enhance patient care. References: Hodge, A. (2008) An exploratory case study of cancer nurses’ understanding and use of nutritional screening in patients diagnosed with cancer. J. Hum. Nutr. Diet. 21 , 388–389. Kyle, U.G., Kossovsky, M.P., Karsegard, V.L. & Pichard, C. (2006) Comparison of tools for nutritional assessment and screening at hospital admission: a population study. Clin. Nutr. 25 , 409–417. NICE (2006) Nutrition Support in Adults. Clinical Guideline 32. London: NICE. Porter, J., Raja, R., Cant, R. & Aroni, R. (2009) Exploring issues influencing the use of the Malnutrition Universal Screening Tool by nurses in two Australian hospitals. J. Hum. Nutr. Diet. 22 , 203–299. Russell, C. & Elia, M. (2010) Nutrition Screening Survey in the UK and Republic of Ireland in 2010. Redditch: British Association for Parenteral and Enteral Nutrition. Wong, S. & Gandy, J. (2008) An audit to evaluate the effect of staff training on the use of the Malnutrition Universal Screening Tool. J. Hum. Nutr. Diet. 21 , 405–406.