Lack of focus on nutrition and documentation in nursing homes, home care- and home nursing: the self-perceived views of the primary care workforce.

BACKGROUND: Malnutrition is a comprehensive challenge for the nursing home, home care- and home nursing sector. Nutritional care and the subsequent documentation are a common and multifaceted healthcare practice that requires that the healthcare professionals possess complex combinations of competencies in order to deliver high-quality care and treatment. The purpose of this study was to investigate how a varied group of healthcare professionals' perceive their own competencies within nutrition and documentation and how organizational structures influence their daily work and the quality of care provided. METHODS: Two focus groups consisting of 14 healthcare professionals were conducted. The transcribed focus group interviews was analyzed using the qualitative content analysis approach. RESULTS: Six categories were identified: 1) Lack of uniform and systematic communication affect nutritional care practices 2) Experience-based knowledge among the primary workforce influences daily clinical decisions, 3) Different attitudes towards nutritional care lead to differences in the quality of care 4) Differences in organizational culture affect quality of care, 5) Lack of clear nutritional care responsibilities affect how daily care is performed and 6) Lack of clinical leadership and priorities makes nutritional care invisible. CONCLUSIONS: The six categories revealed two explanatory themes: 1) Absent inter- and intra-professional collaboration and communication obstructs optimal clinical decision-making and 2) quality deterioration due to poorly-established nutritional care structure. Overall, the two themes explain that from the healthcare professionals' point of view, a visible organization that allocates resources as well as prioritizing and articulating the need for daily nutritional care and documentation is a prerequisite for high-quality care and treatment. Furthermore, optimal clinical decision making among the healthcare professionals are compromised by imprecise and unclear language and terminology in the patients' healthcare records and also a lack of clinical guidelines and standards for collaboration between different healthcare professionals working in nursing homes, home care or home nursing. The findings of this study are beneficial to support organizations within these settings with strategies focusing on increasing nutritional care and documentation competencies among the healthcare professionals. Furthermore, the results advocate for the daily involvement and support of leaders and managers in articulating and structuring the importance of nutritional care and treatment and the subsequent documentation.

Nutritional Follow-Up after Discharge Prevents Readmission to Hospital - A Randomized Clinical Trial.

OBJECTIVE: To compare the effects of two individualized nutritional follow-up intervention strategies (home visit or telephone consultation) with no follow-up, with regard to acute readmissions to hospital at two points in time, 30 and 90 days after discharge from hospital. DESIGN: Randomized clinical trial with two intervention groups and one control group, and monitoring on readmission at 30 and 90 days after discharge. SETTING: Intervention in the participants' homes after discharge from hospital. PARTICIPANTS: Inclusion: Malnourished geriatric patients and patients at risk of malnutrition (MNA<24), aged 75 years and older, living at home and alone. Exclusion: Nursing home residents and patients with terminal illnesses or cognitive impairment. Randomization: Upon discharge, the patients were stratified according to nutritional status (MNA), and assigned to one of three groups: 'home visit', 'telephone', or 'control' group. INTERVENTION: Individualized nutritional counselling of the patient and the patient's daily home carer by a clinical dietician one, two, and four weeks after discharge from hospital. The counselling was either in-person at the patient's homes, or over the telephone. All patients received a diet plan on discharge. The control group received standard care, but no follow-up after discharge. MEASUREMENTS: Information on readmissions to hospital and mortality at 30 and 90 days after discharge was obtained from electronic patient records. Intention-to-treat (ITT) and per-protocol (PP) analyses were carried out. RESULTS: Two-hundred and eight participants were randomized, 73 to home visits, 68 to the telephone consultation group, and 67 to the control group. The mean age of the participants was 86.1 years. Home visit participants had a lower risk of readmission to hospital compared to control participants at 30 days after discharge (HR=0.4; 95% CI: 0.2-0.9, p=0.03) and 90 days after discharge (HR=0.4; 95% CI: 0.2-0.8, p<0.01). No significant difference was detected between the telephone consultation group and the control group, at either 30 days (HR=0.6, 95% CI: 0.3-1.3, p=0.18) or 90 days after discharge (HR=0.7, 95% CI: 0.4-1.3, p=0.23). The PP analysis revealed that the risk of readmission was significantly lower in the home visit group compared to the control group and the telephone consultation group compared to the control group, and this was evident at 30 days as well as at 90 days after discharge. CONCLUSION: An individualized nutritional follow-up performed as home visits seems to reduce readmission to hospital 30 and 90 days after discharge. Intervention by telephone consultations may also prevent readmission, but only among participants who receive the full intervention.

ESPEN Guidelines on Enteral Nutrition: Cardiology and pulmonology.

These guidelines are intended to give evidence-based recommendations for the use of enteral nutrition (EN) in patients with chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD). They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They have been discussed and accepted in a consensus conference. EN by means of oral nutritional supplements (ONS) or tube feeding (TF) enables nutritional intake to be maintained or increased when normal oral intake is inadequate. No data are yet available concerning the effects of EN on cachexia in CHF patients. However, EN is recommended to stop or reverse weight loss on the basis of physiological plausibility. In COPD patients, EN in combination with exercise and anabolic pharmacotherapy has the potential to improve nutritional status and function. Frequent small amounts of ONS are preferred in order to avoid postprandial dyspnoea and satiety as well as to improve compliance.

Early Nutritional Follow-Up after Discharge Prevents Deterioration of ADL Functions in Malnourished, Independent, Geriatric Patients Who Live Alone - A Randomized Clinical Trial.

OBJECTIVES: To compare the effects of two nutritional follow-up interventions with regard to preventing short-term deterioration in ADL, and to compare their effects on physical function, emotional health, and health-related quality of life. DESIGN: Randomized clinical trial with two intervention groups and one control group, and a follow-up period of eight weeks. SETTING: Intervention in the participants' homes after discharge from hospital. PARTICIPANTS: Inclusion: Malnourished geriatric patients and patients at risk of malnutrition (MNA<24), aged 75 years and older, living at home and alone. Exclusion: Nursing home residents and patients with terminal illnesses or cognitive impairment. Randomization: At discharge, the patients were assigned to one of three groups: 'home visit', 'telephone consultation', or 'control' group. INTERVENTION: Individually tailored nutritional counselling of the patient and the patient's daily home carer by a clinical dietician one, two, and four weeks after discharge from hospital. The counselling was either in-person at the patients' homes, or by telephone. The control group received no follow-up after discharge. MEASUREMENTS: Primary outcome: Change in ADL (Barthel-100 score) at discharge and eight weeks later. SECONDARY OUTCOMES: Change in physical performance (handgrip strength, 30-sec. chair stand test, CAS), quality of life and depression measurements (SF-36, Depression List, Geriatric Depression Score), and Avlund mobility-tiredness score (Mob-T). RESULTS: Two-hundred and eight participants were randomized, 73 to home visits and 68 to telephone consultations. The control group comprised 67 patients. The mean age of the participants was 86.1 years. At eight weeks after discharge, 157 completed the follow-up (home visit 52, telephone consultation 51, and control group 54). The mean age of these patients was 85.8 years. More patients in the home visit group improved or maintained their ADL (96%), compared to the telephone (75%) and control groups (72%), p<0.01. No difference was detected among the groups with regard to physical measurements, health-related quality of life, and emotional health. CONCLUSION: Early nutritional follow-up after discharge, performed as home visits, prevents deterioration of ADL in malnourished, independent, geriatric patients who live alone and thereby preserves their independence.