Presently, undernutrition still goes undetected in pediatric hospitals despite its association with poor clinical outcomes and increased annual hospital costs, thus affecting both the patient and the health care system. The reported prevalence of undernutrition in pediatric patients seeking care or hospitalized varies considerably, ranging from 2.5 to 51%. This disparity is mostly due to the diversity of the origin of populations studied, methods used to detect and assess nutritional status, as well as the lack of consensus for defining pediatric undernutrition. The prevalence among inpatients is likely to be higher than that observed for the community at large, since malnourished children are likely to have a pre-existent disease or to develop medical complications. Meanwhile, growing evidence indicates that the nutritional status of sick children deteriorates during the course of hospitalization. Moreover, the absence of systematic nutritional screening in this environment may lead to an underestimation of this condition. The present review aims to critically discuss studies documenting the prevalence of malnutrition in pediatric hospitals in developed and in-transition countries and identifying hospital practices that may jeopardize the nutritional status of hospitalized children.

BACKGROUND:Subjective global assessment (SGA) is a standardized diagnostic tool for malnutrition and identifies those who would benefit from nutrition treatment. SGA has been validated in several patient populations; however, implementation in clinical practice is inconsistent. The objective of this study was to understand and contrast the perceptions on use of SGA before and after it became a regular practice for hospital dietitians.METHODS:The More-2-Eat implementation project provided the opportunity to undertake this qualitative study, as 5 hospitals adopted INPAC (Integrated Nutrition Pathway for Acute Care), which includes the use of SGA. Between 2015 and 2018, interviews were conducted with dietitians at baseline (n = 9), a year after implementation (n = 18), and a year after project completion (n = 6). Thematic analysis was conducted.RESULTS:Themes before SGA adoption included a desire for a malnutrition diagnosis and care planning; lacking comfort in use of SGA; and reflecting on SGA training needs. After a year of implementing INPAC and a year after project completion, themes described becoming a better clinician; allowing dietitians to see the right people, sooner; recognizing the variability in the treatment path for mildly/moderately malnourished (SGA B) patients; improving overall efficiency in delivery of care; and establishing policy and procedures to sustain and spread use of SGA.CONCLUSION:Initially, dietitians were hesitant to use SGA. Adoption through a focused implementation study and experience with implementation of SGA changed these perceptions. Understanding these perceptions before and after use may support adoption of this useful diagnostic tool.

Objective To assess the prevalence, causes, and consequences of malnutrition, as well as the evolution of nutritional status, in Canadian pediatric health care institutions. Study design In this multicenter prospective cohort study, a total of 371 patients were recruited from pediatric hospitals in 5 Canadian provinces. Subjects were aged 1 month to 18 years; admitted to a medical, surgical, or oncology ward; and had a planned hospital stay of > 48 hours. Data on demographics, medical condition, anthropometric measures, and dietary intake were collected. The Screening Tool Risk on Nutritional Status and Growth (STRONG(kids)) and Subjective Global Nutritional Assessment (SGNA) were applied at admission. Malnutrition was defined as a weight-for-age, height-for-age, body mass index-for-age, or weight-for-length/ height z score <-2 SD. Results Among 307 subjects (median age, 5.3 years; median length of stay, 5 days), 19.5% were malnourished on admission. Both STRONG(kids) and SGNA classifications were associated with baseline nutritional status. Mean weight-for-age z score was lower at discharge compared with admission (-0.14 vs -0.09; P < .01), and nearly one-half of all patients lost weight during their hospital stay. Only one-half of the children who were malnourished or screened as high risk of malnutrition were visited by a dietitian during their stay. The percentage of patients who lost weight during hospitalization was significantly greater in the group not visited by a dietitian (76.5 vs 23.5%; P < .01). Conclusion Nutritional status deterioration and malnutrition are common in hospitalized Canadian children. Screening tools, anthropometric measurements, and dietitian consultation should be used to establish adequate nutritional support.

The Integrated Nutrition Pathway for Acute Care (INPAC) is an evidence and consensus based pathway developed to guide health care professionals in the prevention, detection, and treatment of malnutrition in medical and surgical patients. From 2015 to 2017, the More-2-Eat implementation project (M2E) used a participatory action research approach to determine the feasibility, and evaluate the implementation of INPAC in 5 hospital units across Canada. Based on the findings of M2E and consensus with M2E stakeholders, updates have been made to INPAC to enhance feasibility in Canadian hospitals. The learnings from M2E have been converted into an online toolkit that outlines how to implement the key steps within INPAC. The aim of this short report is to highlight the updated version of INPAC, and introduce the implementation toolkit that was used to support practice improvements towards this standard.

Background: Malnutrition at admission, using various parameters, is associated with 30-day readmission. However, the association between 30-day readmission and nutritional parameters at discharge has not been studied.Method: From a large cohort study (n = 1022), 413 patients with a length of stay of >7 days who had information on readmission and discharge location were included into the analysis. Their nutritional status at discharge was assessed by subjective global assessment, body mass index, albumin, nutritional risk index and handgrip strength. Data on demography, diagnoses and Charlson comorbidity index (CCI) were also collected. Missing data was handled using multiple imputations by chained equations. Association of nutrition related measures with 30 day readmission was tested in logistic regression models.Results: Of the 413 patients, 86 (20.8%) were readmitted within 30 days. The proportion of readmitted patients was higher for medical (42.2%) versus surgical patients (25.6%) (p = 0.005) and disease severity was higher in the readmission group with (median (q1, q3) CCI of 3 (2, 6) versus 2(1, 4) for no readmission (p = 0.009). Among the nutritional parameters assessed at discharge, only handgrip strength was significantly associated with 30-day readmission both in unadjusted and adjusted models. Stronger handgrip was associated with decreased chances for readmission where adjusted OR (95% CI) per unit increase were 0.95 (0.92, 0.99). Handgrip strength was not associated with disease severity assessed by CCI (p = 0.14) but was significantly associated with SGA (SGA A and B significantly different from SGA C: both p-values <0.001) after adjusting for age and gender.Conclusion: Lower handgrip at discharge was associated with 30-day readmission. This assessment may be useful to detect patients at risk of readmission to better individualize discharge planning including nutrition care. (C) 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

BACKGROUND:In hospitals, length of stay (LOS) is a priority but it may be prolonged by malnutrition. This study seeks to determine the contributors to malnutrition at admission and evaluate its effect on LOS.MATERIALS AND METHODS:This is a prospective cohort study conducted in 18 Canadian hospitals from July 2010 to February 2013 in patients ≥ 18 years admitted for ≥ 2 days. Excluded were those admitted directly to the intensive care unit; obstetric, psychiatry, or palliative wards; or medical day units. At admission, the main nutrition evaluation was subjective global assessment (SGA). Body mass index (BMI) and handgrip strength (HGS) were also performed to assess other aspects of nutrition. Additional information was collected from patients and charts review during hospitalization.RESULTS:One thousand fifteen patients were enrolled: based on SGA, 45% (95% confidence interval [CI], 42%-48%) were malnourished, and based on BMI, 32% (95% CI, 29%-35%) were obese. Independent contributors to malnutrition at admission were Charlson comorbidity index > 2, having 3 diagnostic categories, relying on adult children for grocery shopping, and living alone. The median (range) LOS was 6 (1-117) days. After controlling for demographic, socioeconomic, and disease-related factors and treatment, malnutrition at admission was independently associated with prolonged LOS (hazard ratio, 0.73; 95% CI, 0.62-0.86). Other nutrition-related factors associated with prolonged LOS were lower HGS at admission, receiving nutrition support, and food intake < 50%. Obesity was not a predictor.CONCLUSION:Malnutrition at admission is prevalent and associated with prolonged LOS. Complex disease and age-related social factors are contributors.

Background & aim Guidelines promote dietitian consult (DC) for nutrition support. In Canada, dietitians are involved in the assessment of malnutrition and provide specialized dietary counseling. It is unknown however, what leads to a DC for patients fed orally. This study identifies independent predictors for a DC and determines what is the proportion of malnourished patients seeing a dietitian. Methods The Canadian Malnutrition Task Force conducted a prospective cohort study in medical and surgical wards of 18 Canadian hospitals. 947 patients who did not receive enteral or parenteral nutrition were analyzed. At admission, subjective global assessment (SGA), body mass index, patient demography were collected. During hospitalization clinical data, including dietary intake and presence of a DC were obtained. Multivariate logistic regression was completed with dietitian consult ≤ 3 days and 4 + days as the outcome variables. Results The prevalence of malnutrition (SGA B + C) was 45%. Dietitians were consulted for 23% of patients, and of these consults 44% were well nourished (SGA-A), 37% were mildly/moderately malnourished (SGA-B), and 19% were severely malnourished (SGA-C). DC missed 75% of the SGA-B and 60% of SGA-C patients. Predictors of consultation within 3 days of hospitalization were: renal diet (OR 5.75) modified texture diet (OR 5.38), metabolic diagnosis (3.91), ONS use pre-admission (OR 2.33), severe malnutrition (SGA-C, OR 1.88) and age (OR 0.98). Predictors for 4 + days were: dysphagia (OR 11.4), a new medical diagnosis (OR 2.3), severe malnutrition (OR 2.17), constipation (OR 2.16), more than one diagnosis (OR 1.8), antibiotic use (OR 1.6), and male gender (OR 1.6). Consuming < 50% of food in the first week was not a predictor as only 19% of those with low intake had a DC at 4 + days. Conclusions Overall predictors of DC were appropriate but SGA B and C patients and those eating <50% were missed. Screening at admission with algorithms of care that include referral to the dietitian are needed to improve the process of nutrition care.

BACKGROUNDNutritional assessment commonly includes multiple nutrition indicators (NIs). To promote efficiency, a minimum set is needed for the diagnosis of malnutrition in the acute care setting.OBJECTIVEThe objective was to compare the ability of different NIs to predict outcomes of length of hospital stay and readmission to refine the detection of malnutrition in acute care.DESIGNThis was a prospective cohort study of 1022 patients recruited from 18 acute care hospitals (academic and community), from 8 provinces across Canada, between 1 July 2010 and 28 February 2013. Participants were patients aged ≥18 y admitted to medical and surgical wards. NIs measured at admission were subjective global assessment (SGA; SGA A = well nourished, SGA B = mild or moderate malnutrition, and SGA C = severe malnutrition), Nutrition Risk Screening (2002), body weight, midarm and calf circumference, serum albumin, handgrip strength (HGS), and patient-self assessment of food intake. Logistic regression determined the independent effect of NIs on the outcomes of length of hospital stay (<7 d and ≥7 d) and readmission within 30 d after discharge.RESULTSIn total, 733 patients had complete NI data and were available for analysis. After we controlled for age, sex, and diagnosis, only SGA C (OR: 2.19; 95% CI: 1.28, 3.75), HGS (OR: 0.98; 95% CI: 0.96, 0.99 per kg of increase), and reduced food intake during the first week of hospitalization (OR: 1.51; 95% CI: 1.08, 2.11) were independent predictors of length of stay. SGA C (OR: 2.12; 95% CI: 1.24, 3.93) and HGS (OR: 0.96; 95% CI: 0.94, 0.98) but not food intake were independent predictors of 30-d readmission.CONCLUSIONSSGA, HGS, and food intake were independent predictors of outcomes for malnutrition. Because food intake in this study was judged days after admission and HGS has a wide range of normal values, SGA is the single best predictor and should be advocated as the primary measure for diagnosis of malnutrition. This study was registered at clinicaltrials.gov as NCT02351661.

Background & aims: Reducing length of stay (LOS) is a priority for hospitals but patients' decline in nutritional status may have a negative impact. The aims of the study were to assess the change in nutritional status during hospitalization and determine if its decline is associated with prolonged LOS.Methods: This is a prospective cohort study conducted in 18 Canadian hospitals. Subjective global assessment (SGA) and weight measurements were performed at admission and discharge. Patient information was collected at admission and extracted from the chart during hospitalization. Association between LOS and changes in SGA or weight loss >= 5% was tested using multivariate Cox PH approach. Results are expressed as hazard ratios (HR) and their 95% CI.Results: 409 patients (53% male) with a LOS >7 days were analyzed. Patients' median (q1,q3) age was 68 years (58,79) and LOS was 11 days (8,17). At admission, 49% of patients were well nourished (SGA A), 37% were moderately malnourished (SGA B) and 14% were severely malnourished (SGA C). From admission to discharge, 34% remained well-nourished, 29% remained malnourished (SGA B or C), 20% deteriorated and 17% improved. Of the 409 patients, 373 had weight measurements at admission and discharge: 92 (25%) had >= 5% weight loss. Multivariate models showed that after adjusting for covariates, decline in nutritional status from SGA A to B/C or SGA B to C (HR: 0.62, CI: (0.44, 0.87); HR: 0.35, CI: (0.20, 0.62) respectively) and weight loss >= 5% (HR: 0.52; CI: 0.40, 0.69) were significantly associated with longer LOS.Conclusion: In-hospital decline in nutritional status as assessed by SGA or weight loss >= 5% is associated with prolonged LOS independently of factors reflecting demographics, living accommodations and disease severity. This suggests a role for nutrition care in reducing LOS. (C) 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

This prospective cohort study was conducted in eighteen Canadian hospitals with the aim of examining factors associated with nutritional decline in medical and surgical patients. Nutritional decline was defined based on subjective global assessment (SGA) performed at admission and discharge. Data were collected on demographics, medical information, food intake and patients' satisfaction with nutrition care and meals during hospitalisation; 424 long-stay (≥7 d) patients were included; 38% of them had surgery; 51% were malnourished at admission (SGA B or C); 37% had in-hospital changes in SGA; 19·6% deteriorated (14·6% from SGA A to B/C and 5% from SGA B to C); 17·4% improved (10·6% from SGA B to A, 6·8% from SGA C to B/A); and 63·0 % patients were stable (34·4% were SGA A, 21·3% SGA B, 7·3% SGA C). One SGA C patient had weight loss ≥5%, likely due to fluid loss and was designated as stable. A subset of 364 patients with admission SGA A and B was included in the multiple logistic regression models to determine factors associated with nutritional decline. After controlling for SGA at admission and the presence of a surgical procedure, lower admission BMI, cancer, two or more diagnostic categories, new in-hospital infection, reduced food intake, dissatisfaction with food quality and illness affecting food intake were factors significantly associated with nutritional decline in medical patients. For surgical patients, only male sex was associated with nutritional decline. Factors associated with nutritional decline are different in medical and surgical patients. Identifying these factors may assist nutritional care.

The Nutrition Care in Canadian Hospitals (2010–2013) study identified the prevalence of malnutrition on admission to medical and surgical wards as 45%. Nutrition practices in the eighteen hospitals, including diagnosis, treatment and monitoring of malnourished patients, were ad hoc. This lack of a systematic approach has demonstrated the need for the development of improved processes and knowledge translation of practices aimed to advance the culture of nutrition care in hospitals. A narrative review was conducted to identify literature that focused on improved care processes and strategies to promote the nutrition care culture. The key finding was that a multi-level approach is needed to address this complex issue. The organization, staff, patients and their families need to be part of the solution to hospital malnutrition. A variety of strategies to promote the change in nutrition culture have been proposed in the literature, and these are summarized as examples for others to consider. Examples of strategies at the organizational level include developing policies to support change, use of a screening tool, protecting mealtimes, investing in food and additional personnel (healthcare aides, practical nurses and/or diet technicians) to assist patients at mealtimes. Training for hospital staff raises awareness of the issue, but also helps them to identify their role and how it can be modified to improve nutrition care. Patients and families need to be aware of the importance of food to their recovery and how they can advocate for their needs while in hospital, as well as post-hospitalization. It is anticipated that a multi-level approach that promotes being “food aware” for all involved will help hospitals to achieve patient-centred care with respect to nutrition.

Background: Malnutrition is commonly underdiagnosed and undertreated in acute care patients. Implementation of current pathways of care is limited, potentially as a result of the perception that they are not feasible with current resources. There is a need for a pathway based on expert consensus, best practice and evidence that addresses this crisis in acute care, while still being feasible for implementation.Methods: A modified Delphi was used to develop consensus on a new pathway. Extant literature and other resources were reviewed to develop an evidence-informed background document and draft pathway, which were considered at a stakeholder meeting of 24 experts. Two rounds of an on-line Delphi survey were completed (n = 28 and 26 participants respectively). Diverse clinicians from four hospitals participated in focus groups to face validate the draft pathway and a final stakeholder meeting confirmed format changes to make the pathway conceptually clear and easy to follow for end-users. Experts involved in this process were researchers and clinicians from dietetics, medicine and nursing, including management and frontline personnel.Results: 80 % of stakeholders who were invited, participated in the first Delphi survey. The two rounds of the Delphi resulted in consensus for all but two minor components of the Integrated Nutrition Pathway for Acute Care (INPAC). The format of the INPAC was revised based on the input of focus group participants, stakeholders and investigators.Conclusions: This evidence-informed, consensus based pathway for nutrition care has greater depth and breadth than prior guidelines that were commonly based on systematic reviews. As extant evidence for many best practices is absent, the modified Delphi process has allowed for consensus to be developed based on better practices. Attention to feasibility during development has created a pathway that has greater implementation potential. External validation specifically with practitioner groups promoted a conceptually easy to use format. Test site implementation and evaluation is needed to identify resource requirements and demonstrate process and patient reported outcomes resulting from embedding INPAC into clinical practice.

Nutrition in Clinical PracticeVolume 13, Issue 3S p. S42-S45 Preliminary Finding Closed Enteral Systems in the Intensive Care Unit: Evaluating Their Economic Impact Kevin J. Inman MSc, Kevin J. Inman MSc The Richard Ivey Critical Care Trauma Centre, London, Ontario, CanadaSearch for more papers by this authorBridget C. Davidson MHSc, Bridget C. Davidson MHSc The Richard Ivey Critical Care Trauma Centre, London, Ontario, CanadaSearch for more papers by this authorWilliam J. Sibbald MD, William J. Sibbald MD The Richard Ivey Critical Care Trauma Centre, London, Ontario, CanadaSearch for more papers by this authorFrank S. Rutledge MD, Frank S. Rutledge MD The Richard Ivey Critical Care Trauma Centre, London, Ontario, CanadaSearch for more papers by this author Kevin J. Inman MSc, Kevin J. Inman MSc The Richard Ivey Critical Care Trauma Centre, London, Ontario, CanadaSearch for more papers by this authorBridget C. Davidson MHSc, Bridget C. Davidson MHSc The Richard Ivey Critical Care Trauma Centre, London, Ontario, CanadaSearch for more papers by this authorWilliam J. Sibbald MD, William J. Sibbald MD The Richard Ivey Critical Care Trauma Centre, London, Ontario, CanadaSearch for more papers by this authorFrank S. Rutledge MD, Frank S. Rutledge MD The Richard Ivey Critical Care Trauma Centre, London, Ontario, CanadaSearch for more papers by this author First published: 01 June 1998 https://doi.org/10.1177/08845336980130S313Citations: 2 Correspondence and Reprint Requests: Kevin Inman, Msc, Clinical Epidemiology Research Scientist, London Health Science Center - RM N488, Victoria Campus, 375 South Street, P. 0. Box 5375, London, Ontario, Canada N6A 4G5 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume13, Issue3SJune 1998Pages S42-S45 RelatedInformation