It is alarming that 45% of Canadian adults hospitalized for two days or more are malnourished at admission.1 Malnutrition puts patients at risk for longer hospital stay, readmission and mortality.1-3 The magnitude and repercussions of malnutrition calls us to do a better job identifying and treating it in Canadian hospitals. The More-2-Eat Study provides an innovative way to address these issues.
In this post, I’m pleased to share information about this study and the experiences of some of those involved.
The More-2-Eat Study
The More-2-Eat Study, led by Professor Heather Keller and her team at the University of Waterloo, aims to address malnutrition in acute care settings using the Integrated Nutrition Pathway for Acute Care (INPAC). INPAC outlines an algorithm for identifying, preventing, treating, and monitoring malnutrition and is based on best practices (evidence and expert consensus). 4-5
In 2016, five hospital sites from four provinces were enrolled in the More-2-Eat Study and began a yearlong trial to implement INPAC within one hospital unit.
From left to right, back row: Joseph Murphy, Heather Keller, Michelle Booth, Sheila Doering, Andrea Digweed, Lina Vescio, Chelsa Marcell, Celia Laur
From left to right, front row: Shannon Cowan, Roseann Nasser, Renata Valaitis, Bridget Davidson, Stephanie Barnes
Each hospital unit evaluated their own nutrition care practices, identified gaps when compared to INPAC, and worked with the unit and hospital teams to improve practices.
All hospitals focused on implementing nutrition screening to identify patients who may be at nutrition risk, as well as using Subjective Global Assessment (SGA) to determine the nutritional status of those at risk.
Some hospitals developed ways to decrease barriers to food intake such as introducing mealtime volunteers. Others focused on monitoring patients’ food intake and tailoring strategies when intake was poor.
Sustaining and spreading change
Since the end of the study, INPAC activities have not only been sustained in the five hospitals, but also spread. For example:
- Nutrition screening has continued across all five hospital units6 and has spread throughout the hospitals
- Subjective Global Assessment (SGA) is used by all dietitians in the five hospitals6 and these dietitians are involved in training others
- The Medication Pass Nutrition Supplement Program (Med Pass), a nutritional supplement program provided to patients at risk of malnutrition, is now used in all hospitals
- Volunteer mealtime programs have continued
- Food intake monitoring processes have continued and spread8
- Body weight monitoring has continued8
A culture change is occurring
Staff and management from the More-2-Eat Study units have started to see a culture change around nutrition care since the study began in 2016.
“People are thinking about it [nutrition], know about it, feel it. There’s a presence there, and that’s maybe a start to a change in nutrition culture.” - Dietitian & Manager from a More-2-Eat Study Unit
Help address malnutrition in your hospital
Addressing malnutrition is more than just the role of the dietitian. More and more, it’s becoming our shared responsibility.
"We're all in it together. It's not just the nurse that needs to do it, it's not the healthcare aide, it's anybody coming and going in that room. Anybody can help. It's not just one person's task." - Management from a More-2-Eat Hospital
If you are concerned about malnutrition in your hospital setting, become a champion to address this issue. Gather a team including dietitians, nurses, physicians, occupational therapists, pharmacists, food service management, physical therapists, hospital management and so on, as a first step.This team is critical to implement change.
Unit staff, hospital management and a few key people need to be ready before you start making changes. Staff and management need to understand that improvement is needed, and be ready to slowly start making progress that can be measured. If the unit is not ready, change will be more difficult.
“Focus is not necessarily on big changes in how we take care of patients, but incremental improvements on how we take care of patients so that it feels like it's effective.” - Dietitian from a More-2-Eat Hospital
Resources you can use
Visit the More-2-Eat Project website to get resources, tools, change strategies and more information about how to get started in your hospital. Readiness checklists may be useful to support your decision to move forward with your team.
Consider joining the INPAC Community of Practice to get advice from others going through the same process and discuss what is being done in your hospital. Email Bridget Davidson, Director of the Canadian Malnutrition Task Force at firstname.lastname@example.org to join.
The next phase of the More-2-Eat Project
The next phase is underway, and it aims to demonstrate that implementing INPAC can be successful and sustainable without the support of research funding. This model is already partially available and includes the tool kit, an online registry (coming soon), and the community of practice.
Interested to learn more? Write a comment or question below or reach out to Bridget Davidson, on Quorum.
(1) Allard JP, Keller H, Jeejeebhoy KN, Laporte M, Duerksen DR, Gramlich L, et al. Malnutrition at Hospital Admission—Contributors and Effect on Length of Stay. Journal of Parenteral and Enteral Nutrition 2016 May;40(4):487-497.
(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, Laur C, Atkins M, Bernier P, Butterworth D, Davidson B, et al. Update on the Integrated Nutrition Pathway for Acute Care (INPAC): post implementation tailoring and toolkit to support practice improvements. Nutr J 2018 Jan;17(1).
(5) Keller H, 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. Nutrition Journal 2015;14(63).
(6) Keller H, Valaitis R, Laur C, McNicholl T, Xu Y, Dubin J, et al. Multi-site implementation of nutrition screening and diagnosis in medical care units: Success of the More-2-Eat project. Clin Nutr. 2018
(7) Keller H, Xu Y, Dubin J, Curtis L, Laur C, Bell J. Improving the standard of nutrition care in hospital: mealtime barriers reduced with implementation of the Integrated Nutrition Pathway for Acute Care. Submitted 2018.
(8) Laur C, Butterworth D, Nasser R, Bell J, Marcell C, et al. Monitoring food intake and body weight in acute care: case examples from the More-2-Eat study. Submitted 2018.