Celia Laur is a PhD candidate at the University of Waterloo, a member of the CPSI Knowledge Translation/Implementation Science Faculty, and core member of the More-2-Eat (M2E) implementation project that aimed to improve nutrition care in Canadian hospitals.
Celia, can you tell us a bit about your project
Nutrition is an important part of recovery in hospital, making it a patient safety issue. M2E was designed to work with hospitals to improve their nutrition care such as by adding a nutrition screening and assessment process so that those at risk are seen by a dietitian and receive appropriate nutrition care throughout their stay. In M2E, 5 Canadian hospitals worked with researchers at the University of Waterloo to improve the nutrition care provided on one unit for a year. All five sites are now conducting nutrition screening, and dietitians are using a standardized assessment that allows them to triage patients and focus in on those patients most in need of their time. Some hospitals also introduced ways to decrease barriers to food intake such as by introducing mealtime volunteers to make sure that patients could reach their meal and have what they need to eat. Other sites focused on monitoring how much a patient was eating, determining why intake was poor, and putting into place changes that would support food intake for the patient. Overall, the M2E project supported hospitals to meet the nutrition needs of their patients, and encourages other hospitals to do the same.
M2E is led by Professor Heather Keller, who is based at the University of Waterloo, and is the Schlegel Research Chair in Nutrition and Aging. Professor Keller is co-chair of the Canadian Malnutrition Task Force, which conducted a large study outlining the prevalence of malnutrition and barriers to food intake in Canadian hospitals.
Why did you choose to tackle the issue of Malnutrition?
45% of people who stay 2 or more days in hospital in Canada are malnourished, and two thirds of these individuals leave hospital still malnourished [1]. All patients, malnourished or not, should receive appropriate nutrition care to support their recovery, making nutrition an important patient safety issue. Malnutrition has been shown to independently increase mortality, length of stay, and risk of readmission, affecting patient flow and, ultimately, healthcare costs [1-3]. In Canada, a malnourished patient's cost of hospital care was approximately $2000 more than a well-nourished patient's care [2]. Food is an important part of our lives, and in hospital it can support recovery, making nutrition care a crucial part of the hospital stay.
Why is this approach innovative?
For many years, people have been discussing the issue of malnutrition in hospital, but few attempts have been made to fix the problem. Pilots have been conducted, but few projects aimed to address the overall issues, or to change the nutrition culture of a hospital. M2E took that research and expert opinion about what should happen, and then worked with the hospitals to make a difference, support the nutrition care needs of patients, working towards improving the nutrition culture in hospital.
What was one major learning you had from working on this project?
Improving nutrition care in hospital is possible.
Because of More-2-Eat, all five sites are screening at least 70% of patients on admission, and 100% of patients identified as severely malnourished are receiving appropriate care [4]. Over the year, use of nutrition care strategies to support malnourished or at risk patients (providing nutrient dense diets, oral nutritional supplements, preferred foods, etc.) increased from 31% to 61% over the course of the year [4]. A staff survey showed that 70% of staff noticed a positive change in nutrition care on their unit [5]. Interviews with hospital staff and management show what staff think about how changes to nutrition care should be made [6]. Results are on their way regarding the impact on length of stay, barriers to food intake, ways to keep the change going, and more.
Can others tap into this program, can they replicate your success?
Yes, we strongly encourage others to learn from the M2E hospitals and become a champion in their own setting. Everyone can be involved. In M2E, the 5 sites started with the Integrated Nutrition Pathway for Acute Care (INPAC) and worked towards implementing the components of INPAC. INPAC outlines a pathway for the identification, prevention, treatment, and monitoring of malnutrition [7]. The INPAC is designed to be a flexible guide, aimed at meeting the needs of the hospital or unit to benefit the patients. What we learned in M2E about what and how to implement INPAC is available in an online toolkit that anyone can access and use. There is also an online e-mail group that anyone can join that has people from across Canada discussing what they are doing in their hospital, while seeking advice from others going through the same process. Change is possible and we encourage you to get involved.
Where can people go to learn more?
For more information, the toolkit is available here: http://m2e.nutritioncareincanada.ca/
More information about the Canadian Malnutrition Task Force is available here: http://nutritioncareincanada.ca/
More-2-Eat is funded by the Canadian Frailty Network.
References:
(1) 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 effect on length of stay. A prospective cohort study from the Canadian Malnutrition Task Force. J Parenter Enteral Nutrition 2016;40(4):doi: 10.1177/0148607114567902.
(2) Curtis LJ, Bernier P, Jeejeebhoy K, Allard J, Duerksen D, Gramlich L, et al. Costs of hospital malnutrition. Clinical Nutrition 2016 Sep.
(3) Pamela L Ramage-Morin, Heather Gilmour, Michelle Rotermann. Nutritional risk, hospitalization and mortality among community-dwelling Canadians aged 65 or older. Health Reports 2017 Sep 1,;28(9):17.
(4) Keller H, Valaitis R, McNicholl T, Laur C, Xu Y, Dubin J, et al. Successful Multi-Site Implementation of Nutrition Risk Screening and Assessment Triage in Medical Inpatients: The More-2-Eat Study. ESPEN Conference Abstract 2017.
(5) Laur CV, Keller HH, Curtis L, Douglas P, Murphy J, Ray S. Comparing Hospital Staff Nutrition Knowledge, Attitudes, and Practices Before and 1 Year After Improving Nutrition Care: Results From the More-2-Eat Implementation Project. JPEN J Parenter Enteral Nutr 2017.
(6) Laur CV, Valaitis R, Bell J, Keller HH. Changing nutrition care practices in hospital: a thematic analysis of hospital staff perspectives. BMC Health Services Research 2017;17(498).
(7) Keller HH, McCullough J, Davidson B, Vesnaver E, Laporte M, Gramlich L, Allard J, Bernier P, Duerksen D, Jeejeebhoy K. The Integrated Nutrition Pathway for Acute Care (INPAC): Building consensus with a modified Delphi. . Nutr J 2015;19(14):63.
