Implementation of nutritional screening tools, nutritional assessment tools, and diagnostic criteria for malnutrition in convalescent rehabilitation wards: A nationwide survey.

BACKGROUND & AIMS: The utilization of recommended nutritional assessment measures in rehabilitation settings remains unclear. This study explored methods for identifying nutritional disorders using data from a nationwide survey conducted in convalescent rehabilitation wards. METHODS: This cross-sectional study analyzed the annual survey, including methods for identifying malnutrition, the risk of malnutrition, and overnutrition in Kaifukuki (convalescent) rehabilitation wards. Methods identifying malnutrition and risk of malnutrition were grouped into nutritional screening tools (NSTs), nutritional assessment tools (NATs), diagnostic criteria for malnutrition (DCM), and suboptimal methods (e.g., hypoalbuminemia). NSTs, NATs, and DCM were further categorized as "acceptable tools." The association between applying acceptable tools, hospital-based data (e.g., the number of beds), and ward-based data (e.g., assessor for nutritional status) was analyzed by logistic regression analysis with multiple imputations. RESULTS: In total, 885 hospitals with Kaifukuki rehabilitation wards responded to the survey, and 754 hospitals were included in the analysis. Registered dietitians assessed the nutritional status in 88% of the hospitals, whereas other professionals (e.g., nurses) evaluated the nutritional status in the remainder. NSTs (e.g., Mini Nutritional Assessment Short-Form), NATs (e.g., Subjective Global Assessment), DCM (e.g., Global Leadership Initiative on Malnutrition criteria), and suboptimal tools were used in 13.1%, 5.4%, 4.8%, and 74.6% of cases, respectively. Most hospitals used acceptable measures (e.g., body mass index) for overnutrition (91.2%). Multiple logistic regression analysis showed that assessments by registered dietitians (adjusted odds ratio[OR]: 2.20.95% confidence interval[CI]: 1.09-4.45) and hospital-owned food services, a proxy for limited clinical practice time of dietitians, were associated with a low likelihood of implementing acceptable measures (adjusted OR: 0.64, 95%CI: 0.43-0.97). CONCLUSIONS: Acceptable malnutrition measures, including the NSTs, NATs, and DCM, have not been widely applied in convalescent rehabilitation settings. The implementation of recommended tools for identifying malnutrition may be promoted when registered dietitians assess the patients' nutritional status.

Risk of Weight Loss in Adult Patients and the Effect of Staffing Registered Dietitians in Kaifukuki (Convalescent) Rehabilitation Wards: A Retrospective Analysis of a Nationwide Survey.

There is scarce evidence regarding the risk of weight loss and the effect of having registered dietitians (RDs) on staff in rehabilitation wards on weight loss. We aimed to examine the effects of RDs in Kaifukuki (convalescent) rehabilitation wards (KRWs) on the prevention of weight loss in adult patients. Data from 2-year nationwide annual surveys on KRWs in Japan were retrospectively analysed. Weight loss was defined as loss of ≥5% weight during the KRW stay. Risk of weight loss in class 1 KRWs (obligated to provide nutrition care) was compared with that in class 2-6 KRWs (not obligated). Risk of weight loss in class 2-6 KRWs with RDs was compared to those without. Overall, 17.7% of 39,417 patients lost weight. Class 1 KRWs showed a lower risk of weight loss than class 2-6 KRWs (17.3% vs. 18.5%, p = 0.003). KRWs with RDs showed a significantly lower incidence of weight loss than those without RDs (16.1% vs. 18.8%, p = 0.015). Class 1 KRWs and exclusively staffed RDs were independently associated with lower odds of weight loss (odds ratio = 0.915 and 0.810, respectively). Approximately 18% of KRW patients lost weight, and having RDs on staff can lower the risk of weight loss.

Assignment of Registered Dietitians and Other Healthcare Professionals Positively Affects Weight Change of Underweight Patients in Convalescent (Kaifukuki) Rehabilitation Wards: A Secondary Analysis of a Nationwide Survey.

This study aimed to verify the relationship between assignment of professional registered dietitians (RDs) and other healthcare professionals and body weight or functional outcome in underweight patients. This was a secondary analysis of the nation-wide survey data from Kaifukuki (convalescent) rehabilitation wards (KRWs). Data of patients aged ≥20 y with disabilities and body mass index (BMI) <18.5 kg/m2 and who were discharged from 1,099 KRWs were analyzed. The primary outcome was BMI at discharge. Secondary outcomes were Functional Independence Measure (FIM) at discharge and returning to home. Patients were divided into two groups: those in KRWs with ≥1 or <1 dedicated RD per ward (KRW/RD+ and KRW/RD-, respectively). Of 5,843 eligible participants (female, 63%; median age, 82 y; hip/vertebral/knee fracture, 47%; stroke, 34%; disuse syndrome secondary to acute illness, 11%; others, 8%), 1,288 and 4,555 were from the KRW/RD+ and KRW/RD- groups, respectively. At discharge, KRW/RD+ patients had higher FIM (93 vs. 90) and BMI (17.1 vs. 17.0 kg/m2) than did KRW/RD- patients. Multivariable analysis showed that assignment of dedicated RDs (B=0.213, 95% confidence interval [CI], 0.036-0.389), number of nurses (B=0.023, 95% CI, 0.003-0.043), and daily rehabilitation dose were significantly associated with changes in body weight. Furthermore, these factors positively affected BMI at discharge. Number of nurses and rehabilitation dose correlated with FIM, but assignment of RDs did not correlate with FIM. In conclusion, assignment of RDs, nurses, and sufficient rehabilitation dose may contribute to BMI gain. Nurses and daily rehabilitation dose may positively affect functional recovery.

Weight gain is associated with improvement in activities of daily living in underweight rehabilitation inpatients: a nationwide survey.

We retrospectively analysed large-scale, nationwide data from the Kaifukuki (convalescent) Rehabilitation Ward (KRW) survey of 2015. Patients were classified into two groups based on changes in body mass index (BMI) during their KRW stay: increased BMI and non-increased BMI. The primary outcome was motor functional independence measure (FIM) score at discharge, and the secondary outcomes were motor FIM gain and full oral intake at discharge. We analysed 4605 patients (64% women; mean age, 79.3 years). Of these patients, 1128 and 3477 were classified into the increased and non-increased groups, respectively. Multivariate analysis showed that BMI increases were independently associated with motor FIM scores at discharge (partial regression coefficient = 1.165; 95% confidence interval, 0.671-1.659) and motor FIM gains, although BMI increase was not associated with full oral intake. Thus, increasing body weight might lead to activities of daily life improvement in underweight patients undergoing post-acute rehabilitation.

Malnutrition risk predicts recovery of full oral intake among older adult stroke patients undergoing enteral nutrition: Secondary analysis of a multicentre survey (the APPLE study).

BACKGROUND & AIMS: Whether malnutrition risk correlates with recovery of swallowing function of convalescent stroke patients is unknown. This study was conducted to clarify whether malnutrition risks predict achievement of full oral intake in convalescent stroke patients undergoing enteral nutrition. METHODS: We conducted a secondary analysis of 466 convalescent stroke patients, aged 65 years or over, who were undergoing enteral nutrition. Patients were extracted from the "Algorithm for Post-stroke Patients to improve oral intake Level; APPLE" study database compiled at the Kaifukuki (convalescent) rehabilitation wards. Malnutrition risk was determined by the Geriatric Nutritional Risk Index as follows: severe (<82), moderate (82 to <92), mild (92 to <98), and no malnutrition risks (≥98). Swallowing function was assessed by Fujishima's swallowing grade (FSG) on admission and discharge. The primary outcome was achievement of full oral intake, indicated by FSG ≥ 7. Binary logistic regression analysis was performed to identify predictive factors, including malnutrition risk, for achieving full oral intake. Estimated hazard risk was computed by Cox's hazard model. RESULTS: Of the 466 individuals, 264 were ultimately included in this study. Participants with severe malnutrition risk showed a significantly lower proportion of achievement of full oral intake than lower severity groups (P = 0.001). After adjusting for potential confounders, binary logistic regression analysis showed that patients with severe malnutrition risk were less likely to achieve full oral intake (adjusted odds ratio: 0.232, 95% confidence interval [95% CI]: 0.047-1.141). Cox's proportional hazard model revealed that severe malnutrition risk was an independent predictor of full oral intake (adjusted hazard ratio: 0.374, 95% CI: 0.166-0.842). Compared to patients who did not achieve full oral intake, patients who achieved full oral intake had significantly higher energy intake, but there was no difference in protein intake and weight change. CONCLUSION: Severe malnutrition risk independently predicts the achievement of full oral intake in convalescent stroke patients undergoing enteral nutrition.