Professor Keller presented a poster detailing the More-2-Eat (M2E) project and the multi-level data collection that will be used to evaluate this implementation program at the recent Researching Complex Interventions in Health: The State of the Art in Exeter, United Kingdom.
Title
More-2-Eat: Testing the implementation of the Integrated Nutrition Pathway for Acute Care in Canadian hospitals.
Authors
- Heather Keller
- Celia Laur
Key message
Changing hospital nutrition care requires an interdisciplinary, complex intervention. More-2-Eat will identify and test the processes required for the implementation of a nutrition care improvement, how it is sustained and the resource implications required for scaling up.
Introduction
- Forty-five percent of patients admitted to a medical or surgical ward in Canadian hospitals are malnourished.1
- Malnutrition has been shown to increase mortality, length of stay, and risk of readmission, affecting patient flow and health care costs.1,2
- The Integrated Nutrition Pathway for Acute Care (INPAC) is an evidence-informed, consensus based algorithm designed to promote the detection, treatment and monitoring of malnutrition.
- The M2E project is the implementation of INPAC in five hospitals across Canada.
Aim
To optimize nutrition care in hospitals, and thus 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.
Measures
Site survey – Describes the numbers and roles of staff specific to nutrition care on the unit, as well as procedures (e.g. meal deliver system) that could influence food provision and mealtime experiences, resource costs (e.g. ONS oral nutrition supplements costs, human resources), etc.
Scorecard – Completed at each site implementation meeting to track Plan-Do-Study-Act (PDSA) topics and other implementation activities.
Dietitian workload – Includes referrals to the registered dietician (RD), and their time for assessment, treatment and monitoring.
INPAC Audit Form – To track progress towards fidelity with the INPAC algorithm.
Canadian Nutrition Screening Tool (CNST) – A two question screening tool which assesses risk of malnutrition.
Subjective Global Assessment (SGA) – An assessment tool to determine if the patient is classified as:
- well nourished
- moderately or suspected of being malnourished
- severely malnourished
My Meal Intake Tool (M-MIT) – Assesses intake of fluids and food provided at a single meal, as well as reasons for poor consumption.
Mealtime Audit Tool (MAT) – Determines barriers to food intake and patient perceptions of a single meal.
Patient demographic and health information:
- quality of life (QOL)
- Nagi Disability Scale
- five meter walk
- hand grip strength
- nutrition care
Tracking food and mealtime assistance for patients – Mealtime resources used by selected patients are tracked on a single day. This will include volunteer, family and staff time needed to assist with feeding, set up for the meal, etc., for this specific patient.
Thirty day post discharge follow-up contact – Follow-up questions regarding a variety of measures (SF-12 short form - 12 health survey, QOL, Nagi Disability Scale, community resources accessed, etc.).
Knowledge, Attitudes and Practice (KAP) survey – A reliable survey administered to hospital staff regarding malnutrition in their hospital.
Focus groups/staff or management interview – Conducted to determine barriers to INPAC implementation and sustainability.
Phases of More-2-Eat
Developmental phase
May to December 2015
Purpose
To focus on building readiness by creating clinical education materials, training key site staff, equipping the site implementation team and collecting baseline data to identify the problem.
Measures
- Site survey
- Dietitian workload
- INPAC Audit (~600 patients)
- KAP staff survey (~150)
- Focus groups/staff or management interviews (~10 groups/100 staff)
- Direct patient assessment (n=200)
- CNST SGA
- M-MIT
- MAT
- Patient demographic and health information
- Tracking food and mealtime assistance for patients
- Thirty day post discharge follow-up
Testing and implementation phase
December 2015 to December 2016
Purpose
To focus on mentoring site teams in their Plan-Do-Study-Act (PDSA) cycles to test and implement the INPAC, monitor change processes, and collect data to determine change in care processes and patient reported outcomes.
Measures
- Scorecard
- Dietitian workload
- INPAC Audit Form (~3600 patients)
- Direct patient assessment (n=1200)
- CNST SGA
- M-MIT
- MAT
- Patient demographic and health information
- Tracking food and mealtime assistance for patients
- Thirty day post discharge follow-up contact (at four to five months and eleven to twelve months)
Sustainability phase
January 2017 to April 2017
Purpose
To focus on continuation of INPAC components with minimal supports and finalize INPAC Implementation Toolkit.
Measures
- Site survey
- INPAC Audit Form
- KAP staff survey (n=150)
- Focus groups/staff or management interview (~10 groups/ 100 staff)
Summary of the More-2-Eat project
- M2E is designed to test and implement all aspects of the INPAC in five diverse hospitals in four provinces of Canada.
- M2E utilises the Knowledge-to-Action process, Plan-Do-Study-Act (PDSA) cycles, and an overarching Model for Improvement and Quality Implementation Framework.
- Staff will be educated regarding malnutrition (prevalence, barriers, cost, etc.), the INPAC, and tips for implementation.
- Patient education materials will be created regarding the importance of treating ‘food as medicine’.
- Data collection is qualitative and quantitative at the site, unit, staff, and patient levels, including audits of INPAC component, as well as patient reported outcomes (e.g. food intake).
- The primary outcome of M2E is the INPAC Implementation Toolkit.
References
-
Allard JP, Keller H, Jeejeebhoy, KN, Laporte M, Duerksen DR, Gramlich L et al. Malnutrition at hospital admission-contributors and effect of length of stay: A prospective cohort study from the Canadian Malnutrition Task Force. J Parenter Enteral Nutr. 2015;[Epub ahead of print]. Back to paragraph
- Russell CA, Elia M. Nutrition screening surveys in hospitals in the UK, 2007-2011. BAPEN; 2014. Back to paragraph
- Keller H, McCullough J, Davidson B, Vesnaver E, Laporte M, Gramlich L, et al. The Integrated Nutrition Pathway for Acute Care (INPAC): Building consensus with a modified Delphi. Nutrition Journal 2015; Unpublished.
- Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26(1):13-24.
- Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;31(7):50.
- Laur C, McCollough J, Davidson B, Keller H. Becoming food aware in hospital: A narrative review to advance the culture of nutrition care in hospitals. Healthcare 2015; Unpublished.
- Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014;23(4):290-8.
- Canadian Patient Safety Institute. Improvement Frameworks: Getting Started Kit. 2011; Available at: http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Interventions-default.aspx.