Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Nutrition
Published in: BMC Nutrition 1/2017

Open Access 01-12-2017 | Study protocol

More-2-Eat: evaluation protocol of a multi-site implementation of the Integrated Nutrition Pathway for Acute Care

Authors: Heather Keller, Celia Laur, Renata Valaitis, Jack Bell, Tara McNicholl, Sumantra Ray, Joseph Murphy, Stephanie Barnes, for the More-2-Eat team

Published in: BMC Nutrition | Issue 1/2017

Login to get access

Abstract

Background

Nutrition care in hospitals is often haphazard, and malnourished patients are not always readily identified and do not receive the care they require. The Integrated Nutrition Pathway for Acute Care (INPAC) is an algorithm designed to improve the prevention, detection and treatment of malnutrition in medical and surgical patients. More-2-Eat is an evaluation of the implementation of INPAC care activities (e.g. screening) in five diverse medical units from different hospitals in Canada. The primary purpose is to understand how tailored implementation affects INPAC uptake and factors that impact this implementation. The principal outcome is a toolkit that can provide guidance to others.

Methods

This participatory action research uses a before-after time series design to address several research questions focused on implementation and uptake of INPAC (e.g., Does the implementation of INPAC improve the detection of malnutrition? Do nutrition care related knowledge, attitudes and practices scores of unit staff change with the implementation of INPAC?). A six-month developmental phase where baseline data were collected is followed by a twelve-month implementation phase and a three-month sustainability phase. Qualitative and quantitative data are collected concurrently, and to address key research questions, these data are merged. Quantitative data are collected on-site by trained local dietitians and include chart audits of nutrition care practices and a more detailed assessment of recruited patients on quality of life, disability, frailty, food intake and barriers to food intake. Thirty-day post discharge follow up for these patients occurs by researchers via a telephone interview at three time points within baseline and implementation phases, to ascertain the same and other outcomes (e.g. readmission to hospital). Qualitative data include focus groups and key informant interviews completed by researchers, monthly teleconferences among the sites and site-completed forms that track implementation activities. Resource utilization of dietitian time for various care activities (e.g. assessment) and staff time to assist patients at mealtimes is also collected.

Discussion

More-2-Eat provides an example of how implementation can be tailored when a care algorithm is embedded into routine practice. The project also highlights important learning points with respect to data collection and techniques to support implementation.

Trial registration

Retrospectively registered ClinTrials.gov Identifier: NCT02800304 June 7, 2016.
Literature
1.
Vanderwee K, Clays E, Bocquaert I, Verhaeghe S, Lardennois M, Govert M, Defloor T. Malnutrition and nutritional care practices in hospital wards for older people. J Adv Nurs. 2010;67(4):736–46.CrossRefPubMed
2.
Corish CA, Kennedy NP. Protein-energy undernutrition in hospital in-patients. Br J Nutr. 2000;83:575–91.CrossRefPubMed
3.
Allard JP, Keller H, Jeejeebhoy KN, Laporte M, Duerksen D, Gramlich L, Payette H, Bernier P, Vesnaver E, Davidson B, Terterina A, Lou W. Malnutrition at hospital admission: contributors and impact on length of stay. A prospective cohort study from the Canadian Malnutrition Task Force. J Parenter Enteral Nutr. 2016;40(4):487–97. doi:10.​1177/​0148607114567902​.CrossRef
4.
Bell J, Bauer J, Capra S, Pulle CR. Barriers to nutritional intake in patients with acute hip fracture: time to treat malnutrition as a disease and food as a medicine? Can J Physiol Pharmacol. 2013;91:489–95.CrossRefPubMed
5.
Young AM, Mudge AM, Banks MD, Ross LJ, Daniels L. Encouraging, assisting and time to EAT: improved nutritional intake for older medical patients receiving Protected Mealtimes and/or additional nursing feeding assistance. Clin Nutr. 2013;32:543–9.CrossRefPubMed
6.
Keller H, Allard JP, Laporte M, Davidson B, Payette H, Bernier P, Jeejeebhoy K, Duerksen DR, Gramlich L. Predictors of dietitian consult on medical and surgical wards. Clin Nutr. 2015;34(6):1141–5.CrossRefPubMed
7.
Keller H, Payette H, Allard J, Jeejeebhoy K, Duerksen D, Bernier P, Laporte M, Gramlich L. ‘Leaving Hospital’: nutritional status of older adults transitioning to and out of hospital, a report of the Canadian Malnutrition Task Force. J Nutr Health Aging. 2014;18(6):63.
8.
Keller H, Allard J, Vesnaver E, Laporte M, Gramlich L, Bernier P, Davidson B, Duerksen D, Jeejeebhoy K, Payette H. Barriers to food intake in acute care hospitals: a report of the Canadian Malnutrition Task Force. J Hum Nutr Diet. 2015;28(6):546–57.CrossRefPubMed
9.
Naithani S, Thomas JE, Whelan K, Morgan M, Gulliford MC. Experiences of food access in hospital. A new questionnaire measure. Clin Nutr. 2009;28(6):625–30.CrossRefPubMed
10.
Zisberg A, Shadmi E, Gur-Yaish N, Tnkikh O, Sinoff G. Hospital –associated functional decline: the role of hospitalization processes beyond individual risk factors. J Am Geriatr Soc. 2015;63:55–62.CrossRefPubMed
11.
Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011;8:514–27.CrossRefPubMedPubMedCentral
12.
Agarwal E, Ferguson M, Banks M, Batterham M, Bauer J, Capra S, Isenring E. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010. Clin Nutr. 2013;32(5):737–45.CrossRefPubMed
13.
McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. Br Med J. 1994;308(6934):945–8.CrossRef
14.
Sivakumar BS, McDermott LM, Bell JJ, Pulle CR, Jayamaha S, Ottley MC. Dedicated hip fracture service: implementing a novel model of care. ANZ J Surg. 2013;83(7–8):559–63.CrossRefPubMed
15.
Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. J Parenter Enteral Nutr. 2013;37(4):482–97.CrossRef
16.
Laur C, McCullough J, Davidson B, Keller HH. Becoming food aware in hospital: a narrative review to advance the culture of nutrition care in hospitals. Healthcare. 2015;3(2):393–407.CrossRefPubMedPubMedCentral
17.
Keller HH, Vesnaver E, Davidson B, Allard J, Laporte M, Bernier P, Payette H, Jeejeebhoy K, Duerksen D, Gramlich L. Providing quality nutrition care in acute care hospitals: perspectives of nutrition care personnel. J Hum Nutr Diet. 2014;27(2):192–202.CrossRefPubMed
18.
Keller HH, Allard J, Vesnaver E, Laporte M, Gramlich L, Bernier P, Davidson B, Duerksen D, Jeejeebhoy K, Payette H. Barriers to food intake in acute care hospitals: a report of the Canadian Malnutrition Task Force. Nutr J. 2015;19(14):63.CrossRef
19.
Duerksen DR, Keller HH, Vesnaver E, Laporte M, Jeejeebhoy K, Payette H, Gramlich L, Bernier P, Allard J. Nurses’ perceptions regarding prevalence, detection, and causes of malnutrition in Canadian hospitals: results of a Canadian Malnutrition Task Force Survey. J Parenter Enteral Nutr. 2016;40(1):100–6.CrossRef
20.
Duerksen DR, Keller HH, Vesnaver E, Allard JP, Bernier P, Gramlich L, Payette H, Laporte M, Jeejeebhoy K. Physicians’ perceptions regarding the detection and management of malnutrition in Canadian hospitals results of a Canadian malnutrition task force survey. J Parent Enteral Nutr. 2015;39(4):410–7.CrossRef
21.
Sahyoun NR, Akobundu U, Coray K, Netterville L. Challenges in the delivery of nutrition services to hospital discharged older adults: the community connections demonstration project. J Nutr Elder. 2009;28:127–42.CrossRefPubMed
22.
23.
Leistra E, van Bokhorst-de van der Schueren MAE, Visser M, van der Hout A, Languis AE, Kruizenga HM. Systematic screening for undernutrition in hospitals: predictive factors for success. Clin Nutr. 2013;33(3):495–501.CrossRefPubMed
24.
van Asselt DZ, van der Cammen TJ, Disselhorst LG, Janse A, Lonterman-Monasch S, Maas HA, Popescu ME, Schölzel-Dorenbos CJ, Sipers WM, Veldhoven CM, Wijnen HH. Assessment and treatment of malnutrition in Dutch geriatric practice: consensus through a modified Delphi study. Age Ageing. 2012;41(3):399–404.CrossRefPubMed
25.
26.
Schindler K, Pernicka E, Laviano A, Howard P, Schütz T, Bauer P, Grecu I, Jonkers C, Kondrup J, Ljungqvist O, Mouhieddine M. How nutritional risk is assessed and managed in European hospitals: a survey of 21,007 patients findings from the 2007–2008 cross-sectional nutritionDay survey. Clin Nutr. 2010;29(5):552–9.CrossRefPubMed
27.
Holst M, Rasmussen H. Nutrition therapy in the transition between hospital and home: an investigation of barriers. J Nutr Metab. 2013. doi:10.​1155/​2013/​463751.
28.
29.
Hoekstra JC, Goosen JHM, de Wolf GS, Verheyen CCPM. Effectiveness of multidisciplinary nutritional care on nutritional intake, nutritional status and quality of life in patients with hip fractures: a controlled prospective cohort study. Clin Nutr. 2011;30:455–61.CrossRefPubMed
30.
31.
Omidvari AH, Vali Y, Murray SM, Wonderling D, Rashidan A. Nutritional screening for improving professional practice for patient outcomes in hospital and primary care settings. Cochrane Database Syst Rev. 2013;(6):CD005539. doi:10.​1002/​14651858.​CD005539.​pub2.
32.
Brotherton A, Simmonds N, Stroud M. Malnutrition Matters: Meeting quality standards in nutritional care. A toolkit for clinical commissioning groups and providers in England. 2nd ed. Redditch: BAPEN; 2012.
33.
Raynaud-Simon A, Revel-Delhom C, Hébuterne X. Clinical practice guidelines from the French Health High Authority: nutritional support strategy in protein-energy malnutrition in the elderly. Clin Nutr. 2011;30:312–9.CrossRefPubMed
34.
Mudge AM, Ross LJ, Young AM, Isenring EA, Banks MD. Helping understand nutritional gaps in elderly (HUNGER): a prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients. Clin Nutr. 2011;30:320–5.CrossRefPubMed
35.
Hickson M, Connolly A, Whelan K. Impact of protected mealtimes on ward mealtime environment, patient experience and nutrient intake in hospitalised patients. J Hum Nutr Diet. 2011;24(4):370–4.CrossRefPubMed
36.
Block L, Morgan-Gouveia M, Levine RB, Cayea D. We could have done a better job: a qualitative study of medical student reflections on safe hospital discharge. J Am Geriatr Soc. 2014;62(6):1147.CrossRefPubMed
37.
38.
Laporte M, Keller H, Payette H, Allard JP, Duerksen DR, Bernier P, Jeejeebhoy K, Gramlich L, Vesnaver E, Teterina A. Validity and reliability of the new Canadian Nutrition Screening tool in the ‘real-world’ hospital setting. Eur J Clin Nutr. 2015;69(5):558–64.CrossRefPubMed
39.
Detsky AS, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN. What is subjective global assessment of nutritional status? J Parenter Enteral Nutr. 1987;11(1):8–13.CrossRef
40.
Persson MD, Brismar KE, Katzarski KS, Nordenström J, Cederholm TE. Nutritional status using mini nutritional assessment and subjective global assessment predict mortality in geriatric patients. J Am Geriatr Soc. 2002;50(12):1996–2002.CrossRefPubMed
41.
42.
McCullough J, Keller H. MMIT: My Meal Intake Tool (MMIT) - A valid food intake monitoring assessment for acute care hospital patients. J Nutr Health Aging. 2016. doi:10.​1007/​s12603-016-0859-y.
43.
Laur C, Marcus H, Ray S, Keller HH. Measuring hospital staff’s knowledge, attitudes and practices with respect to quality nutrition care. Healthcare. 2016;6:79.CrossRef
44.
Farrer K, Donaldson E, Blackett B, Lloyd H, Forde C, Melia D, Lal S. Nutritional screening of elderly patients: a health improvement approach to practice. J Hum Nutr Diet. 2014;27:184–91.CrossRefPubMed
45.
Rasmussen HH, Kondrup J, Staun M, Ladfoged K, Lindorff K, Mørch Jørgensen L, Jakobsen J, Kristensen H, Wengler A. A method for implementation of nutritional therapy in hospitals. Clin Nutr. 2006;25:515–23.CrossRefPubMed
46.
Bell JJ, Bauer JD, Capra S, Pulle RC. Multidisciplinary, multi-modal nutritional care in acute hip fracture inpatients–Results of a pragmatic intervention. Clin Nutr. 2014;33(6):1101–7.CrossRefPubMed
47.
Stoopendaal A, Bal R. Conferences, tablecloths and cupboards: How to understand the situatedness of quality improvements in long-term care. Soc Sci Med. 2013;78:78–85.CrossRefPubMed
48.
Ellen ME, Leon G, Bouchard G, Ouimet M, Grimschaw JM, Lavis JN. Barriers, facilitators and views about next steps to implementing supports for evidence-informed decision-making in health systems: a qualitative study. Implement Sci. 2014;8:179.CrossRef
49.
Moore J, Mascarenhas A, Marquez C, Almaawiy U, Chan W-H, D’Souza J, Liu B, Straus SE. Mapping barriers and intervention activities to behavior change theory for guide for adapting a multisite educational intervention: Mobilization of Vulnerable Elders in Ontario (MOVE ON), a multi-site implementation intervention in acute-care hospitals. Implement Sci. 2014;9:160.CrossRefPubMedPubMedCentral
50.
Doyle C, Howe C, Woodcock T, Myron R, Phekoo K, McNicholas C, Safer J, Bell D. Making change last: applying the NHS institute for innovation and improvement sustainability model to healthcare improvement. Implement Sci. 2013;8:127.CrossRefPubMedPubMedCentral
51.
Leykum LK, Pugh JA, Lanham HJ, Harmon J, McDaniel Jr RR. Implementation research design: integration participatory action research into randomized controlled trials. Implement Sci. 2009;4:69.CrossRefPubMedPubMedCentral
52.
Patton MQ. Developmental evaluation: applying complexity concepts to enhance innovation and use. 1st ed. New York: Guilford Press; 2011.
53.
Bell JJ, Rossi T, Bauer JD, Capra S. Developing and evaluating interventions that are applicable and relevant to inpatients and those who care for them; a multi-phase, pragmatic action research approach. BMC Med Res Methodol. 2014;14:98.CrossRefPubMedPubMedCentral
54.
Ray S, Laur C, Douglas P, Rajput-Ray M, van der Es M, Redmond J, Eden T, Sayegh M, Minns L, Griffin K, McMillan C. Nutrition education and leadership for improved clinical outcomes: training and supporting junior doctors to run ‘Nutrition Awareness Weeks’ in three NHS hospitals across England. BMC Med Educ. 2014;14:1.CrossRef
55.
Simpson KM, Porter K, McConnell ES, Colon-Emeric C, Daily KA, Stalzer A, Anderson RA. Tool for evaluating research implementation challenges: a sense-making protocol for addressing implementation challenges in complex research settings. Implement Sci. 2013;8:2.CrossRefPubMedPubMedCentral
56.
Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. Thousand Oaks: Sage Publications; 2007.
57.
Benzer JK, Beehler S, Cramer IE, Mohr DC, Charns MP, Burgess Jr JF. Between and within-site variation in qualitative implementation research. Implement Sci. 2013;8:4.CrossRefPubMedPubMedCentral
58.
Meyers DC, Durlak JA, Wansersman A. The Quality Implementation Framework. A synthesis of critical steps in the implementation process. Am J Community Psychol. 2012;50:462–80.CrossRefPubMed
59.
Nadeem E, Olin SS, Campbell Hill L, Eaton Hoagwood K, McCue HS. Understanding the components of quality improvement collaboratives: a systematic literature review. Milbank Q. 2013;91(2):354–94.CrossRefPubMedPubMedCentral
60.
Ijkema R, Langelaan M, van de Steeg L, Wagner C. What impedes and what facilitates a quality improvement project for older hospitalized patients? Int J Qual Health Care. 2014;26(1):41–8.CrossRefPubMed
61.
McCormack B, Rycroft-Malone J, DeCorby K, Hutchinson AM, Bucknall T, Kent B, Schultz A, Snelgrove-Clarke E, Stetler C, Titler M, Wallin L, Wilson V. A realist review of interventions and strategies to promote evidence-informed healthcare: a focus on change agency. Implement Sci. 2013;8:107.CrossRefPubMedPubMedCentral
62.
Laur C, Keller H. Implementing best practice in hospital multidisciplinary nutritional care: an example of using the knowledge-to-action process for a research program. J Multidiscip Healthc. 2015;8:463–72.CrossRefPubMedPubMedCentral
63.
McMormack B, McCarthy G, Wright J, Coffey A, Slater P. Development of the Context Assessment Index (CAI). Ulster: University of Ulster; 2008.
64.
65.
Gort M, Broekhuis M, Regts G. How teams use indicators for quality improvement- a multiple-case study on the use of multiple indicators on multidisciplinary cancer teams. Soc Sci Med. 2013;96:69–77.CrossRefPubMed
66.
Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Casell W, Robinson N. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26:13–24.CrossRefPubMed
67.
Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.CrossRefPubMedPubMedCentral
68.
Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Sci. 2012;7(1):37.
69.
Phillips CJ, Marshall AP, Chaves NJ, Jankelowitz SK, Lin IB, Loy CT, Rees G, Sakzewski L, Thomas S, To TP, Wilkinson SA, Michie S. Experiences of using the Theoretical Domains Framework across diverse clinical environments: a qualitative study. J Multidiscip Healthc. 2015;8:139–46.PubMedPubMedCentral
70.
Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, Finch T, Kennedy A, Mair F, O’Donnell C, Nio Ong B, Rapley T, Rogers A, May C. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med. 2010;8:63.CrossRefPubMedPubMedCentral
71.
Langley GJ, Moen RD, Nola KM, Noal TW, Norman CL, Provost LP. The improvement guide. 2nd ed. San Francisco: Jossey- Bass; 2009.
72.
Berta W, Ginsburg L, Gilbart E, Lemieux-Charles L, Davis D. What, why, and how care protocols are implemented in Ontario nursing homes. Can J Aging. 2013;32(1):73–85.CrossRefPubMed
73.
Holstein JA, Gubrium JF. The active interview. Thousand Oaks: Sage Publications; 1995.CrossRef
74.
Patton MQ. Qualitative research and evaluation methods. 3rd ed. Thousand Oaks: Sage Publication; 2002.
75.
Miles MB, Huberman AM, Saldana J. Qualitative data analysis: a methods sourcebook. 3rd ed. Thousand Oaks: Sage Publishing; 2014.
76.
Brennan SE, Bosch M, Buchan H, Greene SE. Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments. Implement Sci. 2012;7:121.CrossRefPubMedPubMedCentral
77.
78.
Roberts HC, Denison HJ, Martin HJ, Patel HP, Syddall H, Cooper C, Sayer AA. A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach. Age Ageing. 2011;40(4):423–9.CrossRefPubMed
79.
Nagi SZ. An epidemiology of disability among adults in the United States. Milbank Q. 1976;54:439–46.CrossRef
80.
Ware JE, Kosinski M, Turner-Bowker DM, Gandek B. How to score version 2 of the SF-12 health survey (with a supplement documenting version 1). QualityMetric Incorporated; 1995.
81.
Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O’Brien MA, Johansen M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;6:CD000259.
82.
Ivers NM, Sales A, Colquhoun H, Michie S, Roy R, Francis JJ, Grimshaw JM. No more ‘business as usual’ with audit and feedback interventions: towards an agenda for a reinvigorated intervention. Implement Sci. 2014;9:14.CrossRefPubMedPubMedCentral
83.
Metadata
Title
More-2-Eat: evaluation protocol of a multi-site implementation of the Integrated Nutrition Pathway for Acute Care
Authors
Heather Keller
Celia Laur
Renata Valaitis
Jack Bell
Tara McNicholl
Sumantra Ray
Joseph Murphy
Stephanie Barnes
for the More-2-Eat team
Publication date
01-12-2017
Publisher
BioMed Central
Published in
BMC Nutrition / Issue 1/2017
Electronic ISSN: 2055-0928
DOI
https://doi.org/10.1186/s40795-017-0127-5

Other articles of this Issue 1/2017

BMC Nutrition 1/2017 Go to the issue

Research article

Treatment outcome and associated factors of severe acute malnutrition among 6–59 months old children in Debre Markos and Finote Selam hospitals, Northwest Ethiopia: a retrospective cohort study

Research article

Folate, vitamin B12, ferritin and haemoglobin levels among women of childbearing age from a rural district in South India

Research article

Predictors of anemia in pregnant women residing in rural areas of the Oromiya region of Ethiopia

Research article

High magnitude of under nutrition among HIV infected adults who have not started ART in Tanzania--a call to include nutrition care and treatment in the test and treat model

Research article

National pattern of grain products consumption among Canadians in association with body weight status

Research article

A systematic review of complementary feeding practices in South Asian infants and young children: the Bangladesh perspective
Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin
Prof. Florian Limbourg
Prof. Anoop Chauhan
Developed by: Springer Medicine
Obesity Clinical Trial Summary

At a glance: The STEP trials

Read more

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine
Image Credits