Exploring hospital mealtime experiences of older inpatients, caregivers and staff using photovoice methods.

AIM: To gather and understand the experience of hospital mealtimes from the perspectives of those receiving and delivering mealtime care (older inpatients, caregivers and staff) using photovoice methods to identify touchpoints and themes to inform the co-design of new mealtime interventions. METHODS: This study was undertaken on acute care wards within a single metropolitan hospital in Brisbane, Australia in 2019. Photovoice methods involved a researcher accompanying 21 participants (10 older patients, 5 caregivers, 4 nurses and 2 food service officers) during a mealtime and documenting meaningful elements using photographs and field notes. Photo-elicitation interviews were then undertaken with participants to gain insight into their experience. Data were analysed using inductive thematic analysis, involving a multidisciplinary research team including a consumer. RESULTS: Themes were identified across the three touchpoints: (1) preparing for the meal (the juggle, the anticipation), (2) delivering/receiving the meal (the rush, the clutter and the wait) and (3) experiencing the meal (the ideal, pulled away and acceptance). Despite a shared understanding of the importance of meals and shared vision of 'the ideal' mealtime, generally this was a time of tension, missed cares and dissatisfaction for staff, patients and caregivers. There was stark contrast in some aspects of mealtime experience, with simultaneous experiences of 'the rush' (staff) and 'the wait' (patients and caregivers). There was an overwhelming sense of acceptance and lack of control over change from all. CONCLUSIONS: This study identified themes during hospital mealtimes which have largely gone unaddressed in the design of mealtime interventions to date. This research may provide a framework to inform the future co-design of mealtime interventions involving patients, caregivers and multidisciplinary staff, centred around these key touchpoints. PRACTICE IMPLICATIONS: Mealtimes are experienced differently by patients, caregivers, nurses and food service officers across three key touchpoints: preparing for, delivering/receiving and experiencing the meal. Improving mealtime experiences therefore necessitates a collaborative approach, with co-designed mealtime improvement programs that include specific interventions focusing each touchpoint. Our data suggest that improvements could focus on reducing clutter, clarifying mealtime roles and workflows and supporting caregiver involvement. IMPACT: What problem did the study address? Mealtimes are the central mechanism to meet patients' nutritional needs in hospital; however, research consistently shows that many patients do not eat enough to meet their nutritional requirements and that they often do not receive the mealtime assistance they require. Interventions to improve hospital mealtimes have, at best, shown only modest improvements in nutritional intake and mealtime care practices. Gaining deeper insight into the mealtime experience from multiple perspectives may identify new opportunities for improvement. What were the main findings? Patients, caregivers and staff have shared ideals of comfort, autonomy and conviviality at mealtimes, but challenges of complex teamwork and re-prioritisation of mealtimes in the face of prevailing power hierarchies make it difficult to achieve this ideal. There are three discrete touchpoints (preparing for, delivering/receiving and experiencing the meal) that require different approaches to improvement. Our data suggests a need to focus improvement on reducing clutter, clarifying mealtime roles and workflows and supporting caregivers. Where and on whom will the research have an impact? The research provides a framework for multidisciplinary teams to begin co-designing improvements to mealtime care to benefit patients, caregivers and staff, while also providing a method for researchers to understand other complex care situations in hospital. REPORTING METHOD: This manuscript is written in adherence with the Standards for Reporting Qualitative Research. PATIENT OR PUBLIC CONTRIBUTION: Patients and caregivers were involved in the conception and design of the study through their membership of the hospital mealtime reference group. A consumer researcher (GP) was involved in the team to advise on study conduct (i.e. recruitment methods and information), data analysis (i.e. coding transcripts), data interpretation (i.e. review and refinement of themes) and manuscript writing (i.e. review and approval of final manuscript).

Use and safety of enteral nutrition protocols in acute care: A scoping review of literature and retrospective audit of practice.

AIM: Standardised enteral nutrition protocols are recommended in critical care, however their use and safety are not well described in other inpatient populations. This mixed methods study reports on the use and safety of enteral nutrition protocols for non-critically ill adults. METHODS: A scoping review of published literature was conducted. In addition a retrospective audit of practice at an Australian tertiary teaching hospital with an existing hospital-wide standardised enteral nutrition protocol was performed. Data on use, safety and adequacy of enteral nutrition prescription were collected from medical records for patients receiving enteral nutrition on acute wards (January-March 2020). RESULTS: Screening of 9298 records yielded six primary research articles. Studies were generally low quality. Published literature suggested that protocols may reduce time to enteral nutrition initiation and goal rate, and improve adequacy of nutrition provision. No adverse outcomes were reported. From the local audit of practice (105 admissions, 98 patients), enteral nutrition commencement was timely (median 0 (IQR 0-1) days from request; goal rate: median 1 (IQR 0-2) days from commencement and adequate (nil underfeeding), without prior dietitian review in 82% of cases. Enteral nutrition was commenced per protocol in 61% of instances. No adverse events, including refeeding syndrome, were observed. CONCLUSIONS: Most inpatients requiring enteral nutrition can be safely and adequately managed on enteral nutrition protocols. Evaluation of protocols outside of the critical care setting remains a gap in the literature. Standardised enteral nutrition protocols may improve delivery of nutrition to patients, whilst allowing dietitians to focus on those with specialised nutrition support needs.

Sustainability of enhanced recovery after surgery programmes in gastrointestinal surgery: A scoping review.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is an evidence-based intervention that is well-recognised across multiple surgical specialties as having potential to lead to improved patient and hospital outcomes. Little is known about sustainability of ERAS programmes. AIMS: This review aimed to describe available evidence evaluating sustainability of ERAS programmes in gastrointestinal surgery to understand: (a) how sustainability has been defined; (b) examine determinants of sustainability; (c) identify strategies used to facilitate sustainability; (d) identify adaptations to support sustainability; and (e) examine outcomes measured as indicators of sustainability of ERAS programmes. METHODS: This scoping review was conducted following the Joanna Briggs Institute's methodology. Research databases (PubMed, Embase, CINHAL) and the grey literature were searched (inception to September 2022) for studies reporting sustainability of ERAS programmes in gastrointestinal surgery. Included articles reported an aspect of sustainability (i.e., definition, determinants, strategies, adaptations, outcomes and ongoing use) at ≥2 years following initial implementation. Aspects of sustainability were categorised according to relevant frameworks to facilitate synthesis. RESULTS: The search strategy yielded 1852 records; first round screening excluded 1749, leaving 103 articles for full text review. Overall, 22 studies were included in this review. Sustainability was poorly conceptualised and inconsistently reported across included studies. Provision of adequate resources was the most frequently identified enabler to sustainability (n/N = 9/12, 75%); however, relatively few studies (n = 4) provided a robust report of determinants, with no study reporting determinants of sustainability and strategies and adaptations to support sustainability alongside patient and service delivery outcomes. CONCLUSION: Improved reporting, particularly of strategies and adaptations to support sustainability is needed. Refinement of ERAS reporting guidelines should be made to facilitate this, and future implementation studies should plan to document and report changes in context and corresponding programme changes to help researchers and clinicians sustain ERAS programmes locally.

'Life is about movement-everything that is alive moves': a mixed methods study to understand barriers and enablers to inpatient mobility from the older patient's perspective.

BACKGROUND: Mobility in hospital is important to maintain independence and prevent complications. Our multi-centre study aimed to measure mobility and identify barriers and enablers to mobility participation from the older patient's perspective. METHODS: Mixed methods study including direct observation of adult inpatients on 20 acute care wards in 12 hospitals and semi-structured interviews with adults aged 65 years or older on each of these wards. Interviews were undertaken by trained staff during the inpatient stay. Quantitative data were analysed descriptively. Qualitative data were initially coded deductively using the theoretical domains framework (TDF), with an inductive approach then used to frame belief statements. RESULTS: Of 10,178 daytime observations of 503 adult inpatients only 7% of time was spent walking or standing. Two hundred older patient interviews were analysed. Most (85%) patients agreed that mobilising in hospital was very important. Twenty-three belief statements were created across the eight most common TDF domains. Older inpatients recognised mobility benefits and were self-motivated to mobilise in hospital, driven by goals of maintaining or recovering strength and health and returning home. However, they struggled with managing pain, other symptoms and new or pre-existing disability in a rushed, cluttered environment where they did not wish to trouble busy staff. Mobility equipment, meaningful walking destinations and individualised programmes and goals made mobilising easier, but patients also needed permission, encouragement and timely assistance. CONCLUSION: Inpatient mobility was low. Older acute care inpatients frequently faced a physical and/or social environment which did not support their individual capabilities.

Effect of supplements/intensive nutrition on pressure ulcer healing: a multicentre, randomised controlled study.

OBJECTIVE: To investigate the effectiveness of an intensive nutrition intervention or use of wound healing supplements compared with standard nutritional care in pressure ulcer (PU) healing in hospitalised patients. METHOD: Adult patients with a Stage II or greater PU and predicted length of stay (LOS) of at least seven days were eligible for inclusion in this pragmatic, multicentre, randomised controlled trial (RCT). Patients with a PU were randomised to receive either: standard nutritional care (n=46); intensive nutritional care delivered by a dietitian (n=42); or standard care plus provision of a wound healing nutritional formula (n=43). Relevant nutritional and PU parameters were collected at baseline and then weekly or until discharge. RESULTS: Of the 546 patients screened, 131 were included in the study. Participant mean age was 66.1±16.9 years, 75 (57.2%) were male and 50 (38.5%) were malnourished at recruitment. Median length of stay was 14 (IQR: 7-25) days and 62 (46.7%) had ≥2 PUs at the time of recruitment. Median change from baseline to day 14 in PU area was -0.75cm2 (IQR: -2.9_-0.03) and mean overall change in Pressure Ulcer Scale for Healing (PUSH) score was -2.9 (SD 3.2). Being in the nutrition intervention group was not a predictor of change in PUSH score, when adjusted for PU stage or location on recruitment (p=0.28); it was not a predictor of PU area at day 14, when adjusted for PU stage or area on recruitment (p=0.89) or PU stage and PUSH score on recruitment (p=0.91), nor a predictor of time to heal. CONCLUSION: This study failed to confirm a significant positive impact on PU healing of use of an intensive nutrition intervention or wound healing supplements in hospitalised patients. Further research that focuses on practical mechanisms to meet protein and energy requirements is needed to guide practice.

Physical Activity Levels in Hospitalized Adults With Burn Injuries.

Physical activity behavior has not been previously described in hospitalized adults with burn injuries. This prospective, cross-sectional study used a standardized behavioral mapping protocol to observe patient behavior related to physical activity over a 12-hour period on one weekday in a quaternary referral specialist burn center. Structured observations were recorded for each of four domains: 1) patient location, 2) position, 3) activity performed, and 4) the presence of others. Observations were summarized across all participants as median (interquartile range [IQR]) proportion of time. Participants (n = 17) were predominantly male (82%) with a mean age of 44.3 (SD 15.2) years, a mean burn size of 34.9% (SD 26.7) TBSA, and a median hospital length of stay of 18 (IQR 6-49) days at time of observation. Participants spent a median of 83% (IQR 73-93) of time in their bedroom, 92% (IQR 68-97) of time in or on their bed and a median of 5% (IQR 3-13) of time mobilizing. Exercise accounted for 10% (IQR 8-17) of activity-related observations. A median of 68% (IQR 39-83) of time was spent alone. Results suggest time spent engaging in physical activity is low. Further studies are required to investigate motivators and barriers to performing physical activity in this population. This will consequently inform the development and implementation of appropriate strategies to improve physical activity behavior in this cohort.

The effects of a family-centered psychosocial-based nutrition intervention in patients with advanced cancer: the PiCNIC2 pilot randomised controlled trial.

BACKGROUND: Malnutrition in advanced cancer patients is common but limited and inconclusive data exists on the effectiveness of nutrition interventions. Feasibility and acceptability of a novel family-based nutritional psychosocial intervention were established recently. The aims of this present study were to assess the feasibility of undertaking a randomised controlled trial of the latter intervention, to pilot test outcome measures and to explore preliminary outcomes. METHODS: Pilot randomised controlled trial recruiting advanced cancer patients and family caregivers in Australia and Hong Kong. Participants were randomised and assigned to one of two groups, either a family-centered nutritional intervention or the control group receiving usual care only. The intervention provided 2-3 h of direct dietitian contact time with patients and family members over a 4-6-week period. During the intervention, issues with nutrition impact symptoms and food or eating-related psychosocial concerns were addressed through nutrition counselling, with a focus on improving nutrition-related communication between the dyads and setting nutritional goals. Feasibility assessment included recruitment, consent rate, retention rate, and acceptability of assessment tools. Validated nutritional and quality of life self-reported measures were used to collect patient and caregiver outcome data, including the 3-day food diary, the Patient-Generated Subjective Global Assessment Short Form, the Functional Assessment Anorexia/Cachexia scale, Eating-related Distress or Enjoyment, and measures of self-efficacy, carers' distress, anxiety and depression. RESULTS: Seventy-four patients and 54 family caregivers participated in the study. Recruitment was challenging, and for every patient agreeing to participate, 14-31 patients had to be screened. The consent rate was 44% in patients and 55% in caregivers. Only half the participants completed the trial's final assessment. The data showed promise for some patient outcomes in the intervention group, particularly with improvements in eating-related distress (p = 0.046 in the Australian data; p = 0.07 in the Hong Kong data), eating-related enjoyment (p = 0.024, Hong Kong data) and quality of life (p = 0.045, Australian data). Energy and protein intake also increased in a clinically meaningful way. Caregiver data on eating-related distress, anxiety, depression and caregiving burden, however, showed little or no change. CONCLUSIONS: Despite challenges with participant recruitment, the intervention demonstrates good potential to have positive effects on patients' nutritional status and eating-related distress. The results of this trial warrant a larger and fully-powered trial to ascertain the effectiveness of this intervention. TRIAL REGISTRATION: The trial was registered with the Australian & New Zealand Clinical Trials Registry, registration number ACTRN12618001352291 .

Exploring the highs and lows of very low carbohydrate high fat diets on weight loss and diabetes- and cardiovascular disease-related risk markers: A systematic review.

AIM: Very low carbohydrate high fat diets (VLCHF) are increasingly popular for weight loss and diabetes management, but the risk implications of long-term adherence to a high-fat-diet remain unclear, especially in high-risk populations. This review aimed to examine adherence, weight loss, diabetes- and cardiovascular disease (CVD)-related risk markers in adults consuming VLCHF diets. METHODS: Online databases were searched for randomised controlled trials ≥3 months duration that met a pre-defined macronutrient prescription: VLCHF ≤25%E carbohydrate, >35%E fat; low fat (LF) ≥45%E carbohydrate, ≤30%E fat; and reported energy, saturated fat (SFA), weight, blood glucose, cholesterol and blood pressure (BP). Studies were excluded if the macronutrient prescription was not targeted (n = 32); not met (n = 17) or not reported (n = 13). RESULTS: Eight studies included: 1217 commenced; 922 completed overweight and obese adults. Diets were isocaloric moderately energy-restricted, closely monitored with ongoing support from dietitians, physicians, and/or nurses. Four studies reported non-adherence beyond 3 months (n = 3) and 6 months (n = 1) despite interventions of 12, 15 and 24 months. VLCHF diets were high in fat and SFA (fat 49%-56%E; SFA 11%-21%E) compared to LF diets (fat 13%-29%E; SFA 5%-11%E). All groups achieved significant weight loss and improvements in BP and blood glucose. LDL-C reduction favoured LF, P < .05; increased HDL-C and reduced triglyceride levels favoured VLCHF, P < .05. CONCLUSIONS: VLCHF and LF diets with moderate energy restriction demonstrate similar weight loss and improvements to BP to 3 months. However, adherence is likely poor without intensive support from health professionals. Dietary SFA should be monitored to ensure recommended intakes, but longer-term studies with high adherence are required to confirm the level of CVD-risk and potential harms.

Secondary-prevention behaviour-change strategy for high-risk patients: Benefits for all classes of body mass index.

AIM: Research is needed to support the long-term benefits of lifestyle interventions for management of high-risk patients with different BMI classifications. This prospective multicentre study assessed two-year outcomes of hospital-referred patients (BMI 25-61 kg/m2 ) attending a dietitian-led multidisciplinary Healthy Eating and Lifestyle Behaviour-Change Program in group or individual formats in hospital outpatient settings. METHODS: Bodyweight, quality of life (Short Form-12) and intuitive eating (Intuitive Eating Scale) data were collected at pre-intervention, post-intervention and 2 years. Outcomes were reported in BMI classes. RESULTS: At pre-intervention (n = 493), 11% had pre-obesity, 25% obesity class I, 30% obesity class II and 34% obesity class III. Characteristics of participants with available data at post-intervention (n = 290) and 2 years (n = 178) were comparable (P > .05). Significant mean weight loss was seen at post-intervention (-2.0 ± 0.4 kg, P < .001, n = 290) and 2 years (-4.3 ± 0.5 kg, P < .001, n = 178). All BMI classes had significant weight losses (P < .05). Participants with higher obesity (classes II and III) had greater improvements in mental quality of life (P < .05) and initial weight reductions (P < .05) than those with lower classes. However, those with obesity class I had the greatest long-term weight reductions and significant improvements in physical quality of life at 2 years (P < .05). All BMI classes reported similar improvements in intuitive eating. No effect was found for differences in intervention format, duration or setting (P > .05). CONCLUSIONS: The results support dietitian-led multidisciplinary lifestyle interventions for multidisciplinary management of high-risk patients of all BMI classes.

Implementation science approaches to enhance uptake of complex interventions in surgical settings.

Achieving practice change in the complex healthcare environment is difficult. Effective surgical care requires coordination of services across the continuum of care, involving interdisciplinary collaboration across multiple units, with systems and processes that may not connect effectively. Principles of enhanced recovery after surgery (ERAS) are increasingly being incorporated into facility policies and practice, but the literature reports challenges with both initial adherence and mid- to long-term sustainability. Greatest adherence is typically observed for the intraoperative elements, which are within the control of a single discipline, with poorest adherence reported for postoperative processes occurring in the complex ward environment. Using ERAS as an example, this perspective piece describes the challenges associated with implementation of complex interventions in the surgical setting, highlighting the value that implementation science approaches can bring to practice change initiatives and providing recommendations as to suggested course of action for effective implementation.

EXploring practice gaps to improve PERIoperativE Nutrition CarE (EXPERIENCE Study): a qualitative analysis of barriers to implementation of evidence-based practice guidelines.

BACKGROUND/OBJECTIVES: Aligning care with best practice-such as Enhanced Recovery After Surgery (ERAS) guidelines-may improve patient outcomes. However, translating research into practice is challenging and implementation science literature emphasises the importance of understanding barriers and enablers specific to the local context and clinicians. This study aimed to explore staff perceptions about barriers and enablers to practice change aligning with nutrition-related recommendations from ERAS guidelines. SUBJECTS/METHODS: A qualitative study using a maximum variation sampling method. Clinicians involved in care of patients admitted to two general surgical wards consented to participate in semi-structured interviews. Framework analysis was undertaken using the integrated Promoting Action on Research Implementation in Health Services framework to identify a priori and emergent themes. RESULTS: From interviews with 13 clinicians (two surgical consultants, one registrar, one intern; one anaesthetist; two nurse unit managers, one surgical nurse coordinator, three nurses; two dietitians), three major themes were identified: (a) complexity of the context (e.g., unpredictable theatre times, requirement for flexibility and large, multidisciplinary workforce); (b) strong decision-making hierarchy, combined with lack of knowledge, confidence or authority of junior and non-surgical staff to implement change; and (c) poor communication and teamwork (within and between disciplines). These barriers culminate in practice where default behaviours are habit, and the view that achieving clinical consensus is challenging. CONCLUSIONS: This study highlights the necessity for a multifaceted implementation approach that simplifies the process, flattens the power differential and facilitates communication and teamwork. Other facilities may consider these findings when implementing similar practice change interventions.

Prospective application of an implementation framework to improve postoperative nutrition care processes: Evaluation of a mixed methods implementation study.

AIM: To describe prospective application of an implementation framework to guide and evaluate a quality improvement (QI) project to improve adherence to evidence-based postoperative diet guidelines (consistent with Enhanced Recovery After Surgery, ERAS) in older surgical patients. METHODS: A hybrid mixed methods study guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework was used. A pre-implementation audit identified gaps in nutrition-related care practices against ERAS guidelines for older surgical patients. Qualitative interviews explored barriers to practice change, informing development of the facilitated implementation strategy. Iterative facilitation interventions were identified by field notes and classified using i-PARIHS facilitator's tool-kit. Post-implementation audit measured implementation outcomes, and clinical processes and outcomes using controlled before-after comparative study. RESULTS: Implementation involved 17 discrete facilitation activities. Early postoperative diet upgrade was acceptable, well adopted (79%) and appropriate for 89% of patients. Fidelity (i.e. protocol delivered as intended) was 59%, with loss of fidelity primarily because of incorrect diet codes. Clinical processes and outcome evaluation (n = 155) compared data pre-implementation (intervention: n = 45, control: n = 27; mean age 73 (SD 6) years, 60% male) and post-implementation (intervention: n = 47, control: n = 36; mean age 74 (SD 6) years, 57% male). Patients on the intervention ward had higher odds of receiving early nutrition post-implementation (adjusted odds ratio [95% CI]: 6.5 [1.9-22.4], P = 0.01). CONCLUSIONS: Prospective application of an implementation framework supported planning and successful implementation in this QI project. Multi-level evaluation of facilitation strategies, implementation outcomes, and clinical processes and outcomes helps to understand areas of success and continuing challenges.

Use of hand grip strength in nutrition risk screening of older patients admitted to general surgical wards.

AIM: Hand grip strength (HGS) has been proposed as an indicator of nutritional status that is objective, requires minimal assessor training and is quick to administer, making it attractive for use in the acute setting. This study aimed to determine the discriminatory ability of impaired HGS to screen for malnutrition in an older hospital population and assess the added value of combining this with existing screening tools. METHODS: Measures were undertaken during acute admission in patients ≥65 years admitted to general surgical wards. Impaired HGS was defined as a mean value below the lower limit of the 95% CI of population norms and observed HGS standardised as a percentage of this value. Nutritional risk was assessed using the Malnutrition Screening Tool (MST) and malnutrition defined as Patient-Generated Subjective Global Assessment (PG-SGA) rating B or C. Discriminatory ability of impaired HGS to identify malnourished patients was tested using the area under the receiver operating characteristic curve (AUC). RESULTS: Seventy-five patients (mean age: 74.0 (SD 6.7) years, 60% male) were recruited. Impaired HGS did not accurately identify malnutrition (AUC (95% CI): 0.41 (0.25-0.58), P < 0.001), nor did it improve discriminatory ability of the MST (AUC (95% CI), MST: 0.83 (0.71-0.95), P = 0.32; MST/HGS combined: 0.68 (0.51-0.86), P = 0.035). CONCLUSIONS: HGS was not found to be suitable in screening older inpatients for malnutrition during admission to surgical wards. As such, screening for nutrition risk using an existing validated tool to identify patients for further in-depth nutritional assessment by an appropriately trained clinician remains the preferred method.

Enhanced Recovery After Surgery as an auditing framework for identifying improvements to perioperative nutrition care of older surgical patients.

Older patients are at increased risk of malnutrition and reduced physical function. Using Enhanced Recovery After Surgery (ERAS) guidelines as an auditing framework, this study aimed to determine adherence of nutrition care to perioperative best practice in older patients. A single researcher retrieved data via chart review. Seventy-five consenting patients ≥65 years (median 72 (range 65-95) years, 61% male) admitted postoperatively to general surgical wards were recruited. Sixty per cent had a primary diagnosis of cancer and 51% underwent colorectal resection. Seventeen per cent and 4% of patients met fasting targets of 2-4 h for fluid and 6-8 h for food, respectively. Fifty-five per cent were upgraded to full diet by first postoperative day. Nil received preoperative carbohydrate loading. Minimally invasive surgery (p = 0.01) and no anastomosis formation (p = 0.05) were associated with receiving ERAS-concordant nutrition care. This study highlights areas for improvement in perioperative nutrition care of older patients at our facility.