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.

Randomised controlled trial of early prophylactic feeding vs standard care in patients with head and neck cancer.

BACKGROUND: Weight loss remains significant in patients with head and neck cancer, despite prophylactic gastrostomy and intensive dietary counseling. The aim of this study was to improve outcomes utilising an early nutrition intervention. METHODS: Patients with head and neck cancer at a tertiary hospital in Australia referred for prophylactic gastrostomy prior to curative intent treatment were eligible for this single centre randomised controlled trial. Exclusions included severe malnutrition or dysphagia. Patients were assigned following computer-generated randomisation sequence with allocation concealment to either intervention or standard care. The intervention group commenced supplementary tube feeding immediately following tube placement. Primary outcome measure was percentage weight loss at three months post treatment. RESULTS: Recruitment completed June 2015 with 70 patients randomised to standard care (66 complete cases) and 61 to intervention (56 complete cases). Following intention-to-treat analysis, linear regression found no effect of the intervention on weight loss (10.9±6.6% standard care vs 10.8±5.6% intervention, P=0.930) and this remained non-significant on multivariable analysis (P=0.624). No other differences were found for quality of life or clinical outcomes. No serious adverse events were reported. CONCLUSIONS: The early intervention did not improve outcomes, but poor adherence to nutrition recommendations impacted on potential outcomes.

CHERISH (collaboration for hospitalised elders reducing the impact of stays in hospital): protocol for a multi-site improvement program to reduce geriatric syndromes in older inpatients.

BACKGROUND: Older inpatients are at risk of hospital-associated geriatric syndromes including delirium, functional decline, incontinence, falls and pressure injuries. These contribute to longer hospital stays, loss of independence, and death. Effective interventions to reduce geriatric syndromes remain poorly implemented due to their complexity, and require an organised approach to change care practices and systems. Eat Walk Engage is a complex multi-component intervention with structured implementation, which has shown reduced geriatric syndromes and length of stay in pilot studies at one hospital. This study will test effectiveness of implementing Eat Walk Engage using a multi-site cluster randomised trial to inform transferability of this intervention. METHODS: A hybrid study design will evaluate the effectiveness and implementation strategy of Eat Walk Engage in a real-world setting. A multisite cluster randomised study will be conducted in 8 medical and surgical wards in 4 hospitals, with one ward in each site randomised to implement Eat Walk Engage (intervention) and one to continue usual care (control). Intervention wards will be supported to develop and implement locally tailored strategies to enhance early mobility, nutrition, and meaningful activities. Resources will include a trained, mentored facilitator, audit support, a trained healthcare assistant, and support by an expert facilitator team using the i-PARIHS implementation framework. Patient outcomes and process measures before and after intervention will be compared between intervention and control wards. Primary outcomes are any hospital-associated geriatric syndrome (delirium, functional decline, falls, pressure injuries, new incontinence) and length of stay. Secondary outcomes include discharge destination; 30-day mortality, function and quality of life; 6 month readmissions; and cost-effectiveness. Process measures including patient interviews, activity mapping and mealtime audits will inform interventions in each site and measure improvement progress. Factors influencing the trajectory of implementation success will be monitored on implementation wards. DISCUSSION: Using a hybrid design and guided by an explicit implementation framework, the CHERISH study will establish the effectiveness, cost-effectiveness and transferability of a successful pilot program for improving care of older inpatients, and identify features that support successful implementation. TRIAL REGISTRATION: ACTRN12615000879561 registered prospectively 21/8/2015.

Self-Determination, Optimism, Social Support, Knowledge, and Skills Have a Positive Influence on the Oral Intake of Long-Stay Acute Patients: A Qualitative Study.

BACKGROUND: Although previous research has attempted to understand the barriers and enablers of oral intake in hospitalized patients, these studies have mainly focused on short-stay inpatients and lacked a theory-driven examination of the determinants that influence dietary behavior in the hospital. OBJECTIVE: To explore and compare the factors influencing adequate and poor oral intake in long-stay acute patients (admitted >14 days). DESIGN: A qualitative descriptive study with semistructured interviews. PARTICIPANTS/SETTING: Twenty-one adult inpatients (13 men, 8 women) admitted to 2 medical and 2 surgical wards at a tertiary hospital in Brisbane, Australia, during 2022, stratified by the Subjective Global Assessment. Analysis performed Transcripts were initially deductively analyzed against the Theoretical Domains Framework, and a reflexive thematic approach was used to create overall themes. RESULTS: Of the 21 included patients (median age = 68.0 years, IQR 34 years), 11 had adequate/improved intake and 10 poor/decreased intake. Six themes were identified to have influenced oral intake in long-stay patients: self-determination to eat; nutrition impact symptoms; foodservice characteristics and processes; nutrition-related knowledge and skills; social support; and optimism, emotions, and emotion regulation. Patients with adequate/improved oral intake were characterized by an autonomous motivation to eat. They had increased awareness about their nutritional status, knowledge, and skills about food for recovery, were more optimistic, and social support was an important enabler to eating. In contrast, patients with poor/decreased oral intake perceived nutrition impact symptoms and dislike of meals as the main barriers to eating in the hospital; however, they also expressed more negative emotions, reduced coping strategies, and decreased knowledge, skills, intrinsic motivation, and capabilities to eat. Social support was present but did not enable oral intake in this patient group. CONCLUSIONS: This study provides novel insights into the factors that influenced oral intake in long-stay acute patients, highlighting the importance of patient-centered nutrition care, encompassing motivational interviewing techniques and collaboration from the multidisciplinary team to create a supportive environment that fosters autonomy and empowers patients to actively participate in their own nutrition and recovery.

A Cost-Consequence Analysis of Nutritional Interventions Used in Hospital Settings for Older Adults with or at Risk of Malnutrition.

BACKGROUND: Malnutrition is a significant and prevalent issue in hospital settings, associated with increased morbidity and mortality, longer hospital stays, higher readmission rates, and greater healthcare costs. Despite the potential impact of nutritional interventions on patient outcomes, there is a paucity of research focusing on their economic evaluation in the hospital setting. This study aims to fill this gap by conducting a cost-consequence analysis (CCA) of nutritional interventions targeting malnutrition in the hospital setting. METHODS: We performed a CCA using data from recent systematic reviews and meta-analyses, focusing on older adult patients with or at risk of malnutrition in the hospital setting. The analysis included outcomes such as 30-day, 6-month, and 12-month mortality; 30-day and 6-month readmissions; hospital complications; length of stay; and disability-adjusted life years (DALYs). Sensitivity analyses were conducted to evaluate the impact of varying success rates in treating malnutrition and the proportions of malnourished patients seen by dietitians in SingHealth institutions. RESULTS: The CCA indicated that 28.15 DALYs were averted across three SingHealth institutions due to the successful treatment or prevention of malnutrition by dietitians from 1 April 2021 to 31 March 2022, for an estimated 45,000 patients. The sensitivity analyses showed that the total DALYs averted ranged from 21.98 (53% success rate) to 40.03 (100% of malnourished patients seen by dietitians). The cost of implementing a complex nutritional intervention was USD 218.72 (USD 104.59, USD 478.40) per patient during hospitalization, with additional costs of USD 814.27 (USD 397.69, USD 1212.74) when the intervention was extended for three months post-discharge and USD 638.77 (USD 602.05, USD 1185.90) for concurrent therapy or exercise interventions. CONCLUSION: Nutritional interventions targeting malnutrition in hospital settings can have significant clinical and economic benefits. The CCA provides valuable insights into the costs and outcomes associated with these interventions, helping healthcare providers and policymakers to make informed decisions on resource allocation and intervention prioritization.

Incidence and outcomes of in-hospital nutritional decline: A prospective observational cohort study in adult patients.

BACKGROUND AND AIMS: Hospital malnutrition is associated with higher healthcare costs and worse outcomes. Only a few prospective studies have evaluated trends in nutritional status during an acute stay, but these studies were limited by the short timeframe between nutrition assessments. The aim of this study was to investigate changes in nutritional status, incidence of hospital-acquired malnutrition (HAM), and the associated risk factors and outcomes in acute adult patients admitted for >14 days. METHODS: A prospective observational cohort study was conducted in two medical and two surgical wards in a tertiary hospital in Brisbane, Australia. Nutrition assessments were performed using the Subjective Global Assessment at baseline (day eight) and weekly until discharge. Nutritional decline was defined as a change from well-nourished to moderate/severe malnutrition (HAM) or from moderate to severe malnutrition (further decline) >14 days after admission. RESULTS: One hundred and thirty patients were included in this study (58.5% male; median age 67.0 years (IQR 24.4), median length of stay 23.5 days (IQR 14)). At baseline, 70.8% (92/130) of patients were well-nourished. Nutritional decline occurred in 23.8% (31/130), with 28.3% (26/92) experiencing HAM. Of the patients with moderate malnutrition on admission (n = 30), 16% (5/30) continued to decline to severe malnutrition. Improvement in nutritional status from moderate and severe malnutrition to well-nourished was 18.4% (7/38). Not being prescribed the correct nutrition care plan within the first week of admission was an independent predictor of in-hospital nutritional decline or remaining malnourished (OR 2.3 (95% CI 1.0-5.1), p = 0.039). In-hospital nutritional decline was significantly associated with other hospital-acquired complications (OR 3.07 (95% CI 1.1-8.9), p = 0.04) and longer length of stay (HR 0.63 (95% CI 0.4-0.9), p = 0.044). CONCLUSION: This study found a high rate of nutritional decline in acute patients, highlighting the importance of repeated nutrition screening and assessments during hospital admission and proactive interdisciplinary nutrition care to treat or prevent further nutritional decline.

A Conceptual Study on Characterizing the Complexity of Nutritional Interventions for Malnourished Older Adults in Hospital Settings: An Umbrella Review Approach.

INTRODUCTION: Malnutrition is a widespread and intricate issue among hospitalized adults, necessitating a wide variety of nutritional strategies to address its root causes and repercussions. The primary objective of this study is to systematically categorize nutritional interventions into simple or complex, based on their resource allocation, strategies employed, and predictors of intervention complexity in the context of adult malnutrition in hospital settings. METHODS: A conceptual evaluation of 100 nutritional intervention studies for adult malnutrition was conducted based on data from a recent umbrella review (patient population of mean age > 60 years). The complexity of interventions was categorized using the Medical Research Council 2021 Framework for Complex Interventions. A logistic regression analysis was employed to recognize variables predicting the complexity of interventions. RESULTS: Interventions were divided into three principal categories: education and training (ET), exogenous nutrient provision (EN), and environment and services (ES). Most interventions (66%) addressed two or more of these areas. A majority of interventions were delivered in a hospital (n = 75) or a hospital-to-community setting (n = 25), with 64 studies being classified as complex interventions. The logistic regression analysis revealed three variables associated with intervention complexity: the number of strategies utilized, the targeted areas, and the involvement of healthcare professionals. Complex interventions were more likely to be tailored to individual needs and engage multiple healthcare providers. CONCLUSIONS: The study underlines the importance of considering intervention complexity in addressing adult malnutrition. Findings advocate for a comprehensive approach to characterizing and evaluating nutritional interventions in future research. Subsequent investigations should explore optimal balances between intervention complexity and resource allocation, and assess the effectiveness of complex interventions across various settings, while considering novel approaches like telehealth.

Incidence and criteria used in the diagnosis of hospital-acquired malnutrition in adults: a systematic review and pooled incidence analysis.

Despite advances in identifying malnutrition at hospital admission, decline in nutritional status of well-nourished patients can be overlooked. The aim of this systematic review was to investigate the incidence of hospital-acquired malnutrition (HAM), diagnostic criteria and health-related outcomes. PubMed, CINAHL, Embase and Cochrane Library were searched up to July 2021. Studies were included if changes in nutritional status was assessed with a validated nutrition assessment tool in acute and subacute adult (≥18 yrs) hospitalised patients. A random-effects method was used to pool the incidence proportion of HAM in prospective studies. The certainty of evidence was appraised using the Grading of Recommendation Assessment, Development and Evaluation system. We identified 12 observational cohort studies (10 prospective and 2 retrospective), involving 35,324 participants from acute (9 studies) and subacute settings (3 studies). Retrospective studies reported a lower incidence of HAM (<1.4%) than prospective studies (acute: 9-38%; subacute: 0-7%). The pooled incidence of HAM in acute care was 25.9% (95% confidence interval (CI): 17.3-34.6). Diagnostic criteria varied, with use of different nutrition assessment tools and timeframes for assessment (retrospective studies: >14 days; prospective studies: ≥7 days). Nutritional decline is probably associated with longer length of stay and higher 6-month readmission (moderate certainty of evidence) and may be association with higher complications and infections (low certainty of evidence). The higher incidence of HAM in the acute setting, where nutritional assessments are conducted prospectively, highlights the need for consensus regarding diagnostic criteria and further studies to understand the impact of HAM.

An Umbrella Review and Meta-analysis of Interventions, Excluding Enteral and Parenteral Nutrition, Initiated in the Hospital for Adults with or at Risk of Malnutrition.

BACKGROUND: Multiple systematic reviews and meta-analyses (SRMAs) on various nutritional interventions in hospitalized patients with or at risk of malnutrition are available, but disagreements among findings raise questions about their validity in guiding practice. OBJECTIVES: We conducted an umbrella review (a systematic review of systematic reviews in which all appropriate studies included in SRMAs are combined) to assess the quality of reviews, identify the types of interventions available (excluding enteral and parenteral nutrition), and re-analyze the effectiveness of interventions. METHODS: The databases MEDLINE/PubMed, CINAHL, Embase, The Cochrane Library, and Google Scholar were searched. AMSTAR-2 was used for quality assessment and GRADE for certainty of evidence. Updated meta-analyses with risk of bias (ROB) by Cochrane ROB 2.0 were performed. Pooled effects were reported as relative risk (RR), with zero-events and publication bias adjustments, and trial sequential analysis (TSA) performed for mortality, readmissions, complications, length of stay, and quality of life. RESULTS: A total of 66 randomized controlled trials were cited by the 19 SRMAs included in this umbrella review, and their data extracted and analyzed. Most clinical outcomes were discordant with variable effect sizes in both directions. In trials with low ROB, interventions targeting nutritional intake reduce mortality at 30 d (15 studies, n: 4156, RR: 0.72, 95% CI: 0.55, 0.94, P: 0.02, I2: 6%, Certainty: High), 6 mo (27 studies, n: 6387, RR: 0.81, 95% CI: 0.71, 0.92, P = 0.001, I2: 4%, Certainty: Moderate), and 12 mo (27 studies, n: 6387, RR: 0.80, 95% CI: 0.67, 0.95, P: 0.01, I2: 33%, Certainty: Moderate), with TSA verifying an adequate sample size and robustness of the meta-analysis. CONCLUSION: Existing evidence is sufficient to show that nutritional intervention is effective for mortality outcomes at 30 d, 6 mo, and 12 mo. Future clinical trials should focus on the effect of nutritional interventions on other clinical outcomes. TRIAL REGISTRATION NUMBER: The protocol is registered on PROSPERO (CRD42022341031).

Are Malnourished Inpatients Treated by Dietitians Active Participants in Their Nutrition Care? Findings of an Exploratory Study of Patient-Reported Measures across Nine Australian Hospitals.

BACKGROUND: Inpatient malnutrition is a key determinant of adverse patient and healthcare outcomes. The engagement of patients as active participants in nutrition care processes that support informed consent, care planning and shared decision making is recommended and has expected benefits. This study applied patient-reported measures to identify the proportion of malnourished inpatients seen by dietitians that reported engagement in key nutrition care processes. METHODS: A subset analysis of a multisite malnutrition audit limited to patients with diagnosed malnutrition who had at least one dietitian chart entry and were able to respond to patient-reported measurement questions. RESULTS: Data were available for 71 patients across nine Queensland hospitals. Patients were predominantly older adults (median 81 years, IQR 15) and female (n = 46) with mild/moderate (n = 50) versus severe (n = 17) or unspecified severity (n = 4) malnutrition. The median length of stay at the time of audit was 7 days (IQR 13). More than half of the patients included had two or more documented dietitian reviews. Nearly all patients (n = 68) received at least one form of nutrition support. A substantial number of patients reported not receiving a malnutrition diagnosis (n = 37), not being provided information about malnutrition (n = 30), or not having a plan for ongoing nutrition care or follow-up (n = 31). There were no clinically relevant trends between patient-reported measures and the number of dietitian reviews or severity of malnutrition. CONCLUSIONS: Malnourished inpatients seen by dietitians across multiple hospitals almost always receive nutritional support. Urgent attention is required to identify why these same patients do not routinely report receiving malnutrition diagnostic advice, receiving information about being at risk of malnutrition, and having a plan for ongoing nutrition care, regardless of how many times they are seen by dietitians.

Effectiveness of dietary counseling with or without nutrition supplementation in hospitalized patients who are malnourished or at risk of malnutrition: A systematic review and meta-analysis.

BACKGROUND: Nutrition support is associated with improved survival and nonelective hospital readmission rates among malnourished medical inpatients; however, limited evidence supporting dietary counseling is available. We intend to determine the effect of dietary counseling with or without oral nutrition supplementation (ONS), compared with standard care, on hospitalized adults who are malnourished or at risk of malnutrition. METHODS: We searched MEDLINE/PubMed, CINAHL, Embase, Scopus, The Cochrane Library, and Google Scholar for studies listed from January 1, 2011, to August 31, 2021. Meta-analysis was performed to obtain pooled risk ratios (RRs) and 95% CIs to estimate the effect. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of the evidence. RESULTS: Sixteen studies were identified. Compared with standard care, dietary counseling with or without ONS probably does not reduce inpatient rates of 30-day mortality (RR = 1.24; 0.60-2.55; I2 = 45%; P = 0.56; moderate certainty), slightly reduces 6-month mortality (RR = 0.83; 0.69-1.00; I2 = 16%; P = 0.06; high certainty), reduces complications (RR = 0.85; 0.73-0.98; I2 = 0%; P = 0.03; high certainty), and may slightly reduce readmission (RR = 0.83; 0.66-1.03; I2 = 55%; P = 0.10; low certainty) but may not reduce length of stay (mean difference: -0.75 days; -1.66-0.17; I2 = 70%; P = 0.11; low certainty). Intervention may result in slight improvements in nutrition status/intake and weight/body mass index (low certainty). CONCLUSIONS: There is an increase in the certainty of evidence regarding the positive impact of dietary counseling on outcomes. Future studies should standardize and provide details/frequencies of counseling methods and ONS adherence to determine dietary counseling effectiveness.

Nutritional therapy in patients with acute pancreatitis requiring critical care unit management: a prospective observational study in Australia and New Zealand.

OBJECTIVE: To determine nutritional therapy practices of patients with severe acute pancreatitis (defined as those receiving critical care management in an intensive care unit or high-dependency unit) in Australia and New Zealand with focus on the choice of enteral nutrition or parenteral nutrition. DESIGN: Prospective observational multicentered study performed at 40 sites in Australia and New Zealand over 6 months. SETTING: Intensive care units or high-dependency units within Australia and New Zealand. PATIENTS: Those with severe acute pancreatitis diagnosed by elevated lipase and/or amylase. Patients with chronic pancreatitis were excluded. MEASUREMENTS: The primary outcome was the proportion of patients who received enteral nutrition, parenteral nutrition, or concurrent enteral nutrition/parenteral nutrition. Secondary outcomes included other aspects of nutritional therapy and the severity and clinical outcomes of acute pancreatitis. MEASUREMENTS AND MAIN RESULTS: We enrolled 121 patients and 117 were analyzed. The mean age was 61 (sd 17) years and 53% were men. Enteral nutrition was delivered to 58 (50%; 95% confidence interval [CI], 41-59%) and parenteral nutrition to 49 (42%; 95% CI, 33-51%) patients. Parenteral nutrition was more frequently used as the initial therapy (58%; 95% CI, 49-67%) than enteral nutrition (42%; 95% CI, 33-51%). The most common reason for parenteral nutrition prescription was the treating doctor's preference (60%). Enteral nutrition (74%) was more often used than parenteral nutrition (40%) on any individual study day. Concurrent enteral nutrition and parenteral nutrition occurred in 28 (24%) patients on 14% of days. Complications of acute pancreatitis requiring critical care unit management were observed in 45 (39%) patients. The median (interquartile range) duration of intensive care unit and hospital stay were 5 (2-10) and 19 (9-31) days, respectively. The hospital mortality rate was 15% (95% CI, 8-21%), and there was a tendency toward higher mortality for patients who only received parenteral nutrition than for those who only received enteral nutrition (28% vs. 7%, p=.06). CONCLUSIONS: For patients with acute pancreatitis requiring critical care unit management in Australian and New Zealand intensive care units, enteral nutrition is used most commonly, but parenteral nutrition is more often used as the initial route of nutritional therapy. Given that clinical practice guidelines currently recommend enteral nutrition as the initial route of nutritional therapy in severe acute pancreatitis, improved education about and dissemination of these guidelines seems warranted.

Evaluation of dietetic advice for modification of cardiovascular disease risk factors in renal transplant recipients.

OBJECTIVE: To investigate the effect of dietitian involvement in a multidisciplinary lifestyle intervention comparing risk factor modification for cardiovascular disease with standard posttransplant care in renal transplant recipients (RTR) with abnormal glucose tolerance (AGT). DESIGN: Randomized controlled trial. SETTING: Hospital outpatient department. PATIENTS: Adult RTR with AGT. INTERVENTION: RTR with AGT were randomized to a lifestyle intervention that consisted of either regular consultations with the dietitian and multidisciplinary team or standard care. MAIN OUTCOME MEASURES: Dietary intake, physical activity (PA) levels, cardiorespiratory fitness (CF), and anthropometry. RESULTS: Total fat and percent saturated fat intake rates were significantly lower in the intervention group as compared with the control group at 2-year follow-up, 54 g (16 to 105 g) versus 65 g (34 to 118 g), P = .01 and 10% (5% to 17%) versus 13% (4% to 20%), P = .05., respectively. There was a trend for an overweight (but not obese) individual to lose more weight in the intervention group (4% loss vs. a gain of 0.25% at the 2-year follow-up). Overall, RTR were significantly less fit than age- and gender-matched controls, mean peak oxygen uptake was 19.42 ± 7.09 mL/kg per minute versus 28.35 ± 8.80 mL/kg per minute, P = .000. Simple exercise advice was not associated with any improvement in total PA or CF in either group at the 2-year follow-up. CONCLUSION: Dietary advice can contribute to healthier eating habits and a trend for weight loss in RTR with AGT. These improvements in conjunction with multidisciplinary care and pharmacological treatment can lead to improvements in cardiovascular risk factors such as lipid profile. Simple advice to increase PA was not effective in improving CF and other measures are needed.

Systematised, Interdisciplinary Malnutrition Program for impLementation and Evaluation delivers improved hospital nutrition care processes and patient reported experiences - An implementation study.

AIM: Models of hospital malnutrition care reliant on dietitians can be inefficient and of limited effectiveness. This study evaluated whether implementing the Systematised, Interdisciplinary Malnutrition Program for impLementation and Evaluation (SIMPLE) improved hospital nutrition care processes and patientreported experiences compared with traditional practice. METHODS: A multi-site (five hospitals) prospective, pre-post study evaluated the facilitated implementation of SIMPLE, a malnutrition care pathway promoting proactive nutrition support delivered from time of malnutrition screening by the interdisciplinary team, without need for prior dietetic assessment. Implementation was tailored to local site needs and resources. Nutrition care processes delivered to inpatients who were malnourished or at-risk of malnutrition were identified across diagnosis, intervention, and monitoring domains using standardised audits from medical records, foodservice systems and patient-reported nutrition experience measures. RESULTS: Pre-implementation (n = 365) and post-implementation (n = 397) cohorts were similar for age (74 vs 73 years), gender (47.1% vs 48.6% female), and nutrition risk status (46.6% vs 45.3% at-risk). Post-implementation, at-risk participants were more likely to receive enhanced food and fluids (68.5% vs 83.9%; P < .01), nutrition information (30.9% vs 47.2%; P < .01), mealtime assistance where required (61.4% vs 77.9% P = .04), nutrition monitoring (25.2% vs 46.3%; P < .01) and care planning (17.8% vs 27.7%; P = .01). Patient-reported nutrition experience measures confirmed improved nutrition care. There was no difference in dietetic occasions of service per patient (1.51 vs 1.25; P = .83). CONCLUSIONS: Tailored SIMPLE implementation improves nutrition care processes and patient reported nutrition experience measures for at-risk inpatients within existing dietetic resources.

Medical Nutrition Reimbursement in Singapore: Who Are the Patients Receiving MediFund Assistance? An Audit of Clinical Outcomes and Issues Pertaining to Reimbursement in a Public Hospital in Singapore.

BACKGROUND: Financial reimbursement (MediFund) of medical nutrition products (MNPs) was recently implemented in some of the public hospitals in Singapore for patients with financial difficulties. This study aimed to investigate the sustainability of this policy and the benefits conferred. METHODS: We performed a 1-year retrospective audit of patients in a tertiary hospital who received MediFund. Demographics, presupport and postsupport clinical outcomes, and cost of support were determined and analyzed. RESULTS: A total of 129 patients received MediFund for MNPs. The median length of financial support was 115 days (interquartile range, 37-269). Overall, body mass index increased after nutrition support (20.9 ± 5.1 vs 20.4 ± 5.3; P = .012). There was a significant decrease in the number of malnourished patients (final, 55.1% vs initial, 86.8%; P < .001) and a significant increase in 7-point subjective global assessment scores (final, 4.9 ± 1.3 vs initial, 4.1 ± 1.3; P < .001) after MNP support. MNP adherence was high for 88.5% of patients who returned for follow-up appointments. Patients who defaulted follow-up appointments were more likely to have 30-day readmission (50% vs 19.5%; P < .001) and had higher mortality rates (35.7% vs 10.3%; P < .001). Total reimbursement of S $108,960 was provided to subsidize MNPs over 1 year. CONCLUSION: Supporting patients with financial difficulties led to an improvement in their nutrition status. Regular dietitian reviews of patients and monitoring compliance to consumption of MNPs are essential to ensure patients benefit from the support.

Economic Evaluation of Nutrition Support in the Prevention and Treatment of Pressure Ulcers in Acute and Chronic Care Settings: A Systematic Review.

BACKGROUND: Recent developments in nutrition intervention indicated clinical effectiveness for pressure ulcer (PU) prevention and treatment, but it is important to assess whether they are cost-effective. The aims of this systematic review are to determine the cost-effectiveness and clinical outcomes of nutrition support in PU prevention and treatment. METHODS: A systematic search of randomized controlled trials, observational studies, and statistical models that investigated cost-effectiveness and economic outcomes for prevention and/or treatment of PUs were performed using standard literature and electronic databases. RESULTS: Fourteen studies met the inclusion criteria, which included 3 randomized controlled trials with their companion economic evaluations, 4 model-based, 2 cohort, 1 pre and post, and 1 prospective controlled trial. Risk of bias assessment for all of the uncontrolled or observational trials revealed high or serious risk of bias. Interventions that incorporated specialized nursing care appeared to be more effective in prevention and treatment of PUs, compared with single intervention studies. There is a trend of improved PU healing when additional energy/protein are provided. PU prevention ($250-$9,800) was less expensive than treatment ($2,500-$16,000). Nutrition intervention for PU prevention was cost-effective in 87.0%-99.99% of the simulation models. CONCLUSIONS: There is potential cost-saving and/or cost-effectiveness of nutrition support in the long term, as predicted by the model-based PU prevention studies in the review. Prevention of PU also appears to be more cost-effective than treatment. A multidisciplinary approach to managing PU is more likely to be cost-effective.

Home Enteral Nutrition in Singapore's Long-Term Care Homes-Incidence, Prevalence, Cost, and Staffing.

Introduction: Data on home enteral nutrition (HEN) in long-term care facilities (LTCF) in Singapore is scarce. This study aims to determine the prevalence and incidence of chewing/swallowing impairment and HEN, and the manpower and costs related. Methods: A validated cross-sectional survey was sent to all 69 LTCFs in Singapore in May 2019. Local costs (S$) for manpower and feeds were used to tabulate the cost of HEN. Results: Nine LTCFs (13.0%) responded, with a combined 1879 beds and 240 residents on HEN. An incidence rate (IR) of 15.7 per 1000 people-years (PY) and a point prevalence (PP) of 136.6 per 1000 residents were determined for HEN, and an IR of 433.0 per 1000 PY, with PP of 385.6 per 1000 residents for chewing/swallowing impairment. Only 2.5% of residents had a percutaneous endoscopic gastrostomy (PEG). The mean length of residence in LTCF was 45.9 ± 12.3 months. More than half of the residents received nasogastric tube feeding (NGT) for ≥36 months. Median monthly HEN cost per resident was S$799.47 (interquartile range (IQR): 692.11, 940.30). Nursing costs for feeding contributed to 63% of total HEN costs. Conclusions: The high usage and length of time on NGT feeding warrants exploration and education of PEG usage. A national HEN database may improve the care of LTCF residents.

A Survey of Home Enteral Nutrition Practices and Reimbursement in the Asia Pacific Region.

Literature regarding the use of home enteral nutrition (HEN) and how it is reimbursed in the Asia Pacific region is limited. This research survey aims to determine the availability of HEN, the type of feeds and enteral access used, national reimbursement policies, the presence of nutrition support teams (NSTs), and clinical nutrition education in this region. An electronic questionnaire was sent to 20 clinical nutrition societies and leaders in the Asia Pacific region in August 2017, where thirteen countries responded. Comparison of HEN reimbursement and practice between countries of different income groups based on the World Bank's data was investigated. Financial support for HEN is only available in 40% of the countries. An association was found between availability of financial support for HEN and health expenditure (r = 0.63, p = 0.021). High and middle-upper income countries use mainly commercial supplements for HEN, while lower-middle income countries use mainly blenderized diet. The presence of NSTs is limited, and only present mainly in acute settings. Sixty percent of the countries indicated an urgent need for funding and reimbursement of HEN. This survey demonstrates the varied clinical and economic situation in the Asia Pacific region. There is a lack of reimbursement, clinical support, and inadequate educational opportunities, especially for the lower-middle income countries.

Improving nutrition care and intake for older hospital patients through system-level dietary and mealtime interventions.

BACKGROUND & AIMS: Interventions such as oral nutritional supplements (ONS), fortified meals and mid-meals, feeding assistants and Protected Mealtimes have shown some impact on nutritional intake in research studies, but embedding them in practise remains challenging. This study monitored nutritional intake of older medical inpatients as dietary and mealtime interventions were progressively implemented into routine practise. METHODS: Series of three prospectively evaluated patient cohorts allowed comparison of nutritional intake of 320 consented medical inpatients aged 65 + years: cohort 1 (2007-8), cohort 2 (2009) and cohort 3 (2013-14) as nutrition care interventions were progressively introduced and embedded. Interventions focused on 'assisted mealtimes', fortified meals and mid-meals, and ONS. Energy and protein intake were calculated from visual plate waste of individual meal and mid-meal components on day 5 of admission. Nutrition care processes were evaluated by mealtime audits of diet type, assistance and interruptions on the same day. One-way ANOVA and chi square tests were used for comparison between cohorts. RESULTS: Significant, progressive improvements in energy and protein intake were seen between cohorts (energy: cohort 1: 5073 kJ/d; cohort 2: 5403 kJ/d; cohort 3: 5989 kJ/d, p = 0.04; protein: cohort 1: 48 g/d, cohort 2: 50 g/d, cohort 3: 57 g/d, p = 0.02). Greater use of fortified meals and mid-meals and sustained improvements in mealtime assistance likely contributed to these improvements. CONCLUSIONS: Multi-faceted system-level approach to nutrition care, including changes to dietary and mealtime care processes, was associated with measureable and sustained improvements in nutritional intake of older inpatients over a seven year period.