Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.

The subjective global assessment (SGA) is a nutrition assessment tool that refers to an overall evaluation of a patient's history and physical examination and uses structured clinical parameters to diagnose malnutrition. The SGA is known to be a reliable and valid tool that predicts morbidity and mortality associated with malnutrition. The objective of SGA is to identify patients likely to benefit from nutrition intervention and therefore to identify persons in whom inadequate nutrition intake or absorption explain features of malnutrition, including body wasting. There are other conditions that cause weight loss, muscle wasting, and fat loss, including cachexia and sarcopenia. Acknowledging that these 2 last conditions differ in their mechanism of body wasting and consequently in the outcomes of nutrition intervention, the practitioner needs a tool to identify when malnutrition is the dominating factor to explain body wasting. The SGA form has been revised to clearly reflect the key concepts behind the diagnosis of malnutrition and help to distinguish this condition from other wasting conditions. This review presents the revised SGA form and guidance document. Using case studies, it illustrates the 3 wasting conditions, their overlap, and how the SGA identifies malnutrition as a dominating factor of body wasting and thus individuals who require nutrition intervention.

BackgroundHandgrip strength (HGS) is a practical measure of strength and physical function that can be used to identify frailty among hospitalized patients, but its utility in this setting is unclear. To be considered useful, any functional measure needs to provide pertinent information on the patient and predict relevant outcomes such as health-care utilization (e.g., length of stay (LOS)) and patient-reported quality of life (QOL). The purpose of this study was to determine if HGS predicted LOS and QOL. A second aim was to examine the best sensitivity (SE) and specificity (SP) for predicting length of stay (>7 or >13 days) using previously published cut-points for HGS.MethodologyHGS was measured on 1136 medical patients shortly after admission with a Lafayette dynamometer. QOL was assessed with the self-reported SF-12 completed with an interviewer during hospitalization and 30- days after discharge via telephone. Physical (PCS) and mental (MCS) component scores of SF-12 were calculated. A variety of covariates were assessed (e.g., nutritional status). Multivariate analyses stratified by sex were completed.ResultsThe mean LOS was 12.71 days (median = 8.00; SD = 13.20), 12.88 days (SD = 13.82) for males, and 12.58 days (SD = 12.68) for females. Lower admission HGS scores were associated with longer LOS (male X2 = 7.85, p < 0.05; female X2 = 14.9, p < 0.0001). The average quality of life scores were as follows: in hospital PCS: 34.66, MCS: 46.49; post discharge PCS: 36.17; MCS: 51.22. HGS predicted PCS during hospitalization (male X2 = 36.22, p < 0.0001; female X2 = 19.87, p < 0.0001) and post hospitalization (male X2 = 6.98, p < 0.01; female X2 = 10.99, p < 0.01). Various reference cut-points for HGS were tested against LOS, with none being considered appropriate (e.g., SE and SP both < 70) when adjusting for age and sex.ConclusionAdmission HGS adds predictive value for both LOS and physical components of QOL and is worth pursuing in practice to identify potential frailty and the need for proactive steps to mitigate further functional decline during hospitalization. However, HGS cut-points for LOS specific to acute care patients need to be defined and tested.

Background & aimsThe Global Leadership Initiative on Malnutrition (GLIM) proposed a new framework for diagnosing malnutrition based on combinations of phenotypic and etiologic criteria. The aim of this study was to compare GLIM criteria to Subjective Global Assessment (SGA) judged to be the most validated standardized assessment of malnutrition.MethodsThis is a retrospective analysis of variables extracted from a prospective cohort study assessing malnutrition at admission, in 18 Canadian hospitals. Based on the available parameters, GLIM was compared to SGA using the following combinations of one phenotypic and one etiologic criteria: A. weight loss and low intake; B. weight loss and high C-reactive protein (CRP); C. low body mass index (BMI) and low intake; D. low BMI, high CRP. Data were not available for fat-free mass. Since all patients had acute or chronic active disease as per GLIM etiologic criterion, CRP was used as a more specific measure to define inflammation. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated. Data are expressed as mean and Clopper-Pearson exact 95% confidence interval (CI).ResultsFrom 1022 patients in the original dataset, 784 had all considered parameters with a prevalence of malnutrition (SGA B or C) of 45.15% (CI 41.60, 48.70), where severe malnutrition (SGA C) was 11.73% (CI 9.57, 14.20). Using the available GLIM parameters with the above combinations of two-criteria, the prevalence of malnutrition was 33.29% (CI 30.00, 36.71) and severe malnutrition was 19.77% (CI 17.00, 22.70). For all criteria combinations of GLIM together versus SGA, sensitivity was 61.30% (CI 56.0, 66.4), specificity was 89.77% (CI 86.5, 92.5) and PPV was 83.14% (CI 78.0, 87.5) while NPV was 73.80 (CI 69.8, 77.5). Sensitivity was improved when only SGA C for severe malnutrition was used as the criterion (82.61%; CI 73.3, 89.7) but PPV was greatly reduced (29.12%; CI 23.7, 35.0). Similarly, when using GLIM criteria for severe malnutrition only, sensitivity improved (76.09%; CI 66.1, 84.4). Any two criteria combinations of GLIM had much poorer sensitivity with the highest being weight loss + high CRP (46.33%) with a specificity of 93.02% (PPV: 84.54%; NPV: 67.80%), while the combination of low BMI + low intake had the highest specificity (98.84%) but with a sensitivity of 15.54% (PPV 91.67%; NPV: 58.70%).ConclusionsBased on the CMTF dataset and using SGA as the most validated tool for diagnosing malnutrition, the two criteria combinations used for GLIM in the present study had fair criterion validity for the diagnosis of malnutrition, regardless of severity status. The best combinations were weight loss and high CRP or weight loss and low intake, both having high specificity at diagnosing malnutrition but unacceptably low sensitivity, and thus were considered poor. There may be potential for the full framework to be used to diagnose malnutrition, but individual combinations of two criteria when used exclusively will miss malnourished patients, as defined by SGA.

Background: Improving the detection and treatment of malnourished patients in hospital is needed to promote recovery. Aim: To describe the change in rates of detection and triaging of care for malnourished patients in 5 hospitals that were implementing an evidence-based nutrition care algorithm. To demonstrate that following this algorithm leads to increased detection of malnutrition and increased treatment to mitigate this condition. Methods: Sites worked towards implementing the Integrated Nutrition Pathway for Acute Care (INPAC), including screening (Canadian Nutrition Screening Tool) and triage (Subjective Global Assessment; SGA) to detect and diagnose malnourished patients. Implementation occurred over a 24-month period, including developmental (Period 1), implementation (Periods 2-5), and sustainability (Period 6) phases. Audits (n = 36) of patient health records (n = 5030) were conducted to identify nutrition care practices implemented with a variety of strategies and behaviour change techniques. Results: All sites increased nutrition screening from Period 1, with three achieving the goal of 75% of admitted patients being screened by Period 3, and the remainder achieving a rate of 70% by end of implementation. No sites were conducting SGA at Period 1, and sites reached the goal of a 75% completion rate or referral for those identified to be at nutrition risk, by Period 3 or 4. By Period 2, 100% of patients identified as SGA C (severely malnourished) were receiving a comprehensive nutritional assessment. In Period 1, the nutrition diagnosis and documentation by the dietitian of 'malnutrition' was a modest 0.37%, increasing to over 5% of all audited health records. The overall use of any Advanced Nutrition Care practices increased from 31% during Period 1 to 63% during Period 6. Conclusion: The success of this multi-site study demonstrated that implementation of nutrition screening and diagnosis is feasible and leads to appropriate care. INPAC promotes efficiency in nutrition care while minimizing the risk of missing malnourished patients. Trial registration: Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016. (C) 2018 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

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:Decreased physical functioning is associated with malnutrition and common in acute care patients; determining loss of function is often considered part of a comprehensive nutrition assessment. Handgrip strength (HGS) and 5-meter timed walk (5m) are functional measures used in a variety of settings. This analysis sought to determine which functional measure could be added to a hospital nutrition assessment, based on its feasibility and capacity to discriminate patient subgroups.METHODS:Eligible medical patients (no delirium/dementia, admitted from community; n = 1250), recruited from 5 hospitals that participated in a previous multisite action research study, provided data on demographics, HGS, 5m, nutrition status, perceived disability, and other characteristics.RESULTS:Significantly more patients (z = 17.39, P < .00001) were able to complete HGS than 5m (92% versus 43%, respectively). Median HGS was 28.0 kg for men and 14.7 kg for women. Of patients who completed the 5m, mean completion time was 8.98 seconds (median, 6.79 seconds, SD = 6.59). 5m and HGS scores were significantly worse with patient-perceived disability (z = -9.56, t = 10.69, respectively; P < .0001; 95% confidence interval [CI], [7.33, 10.63]; [1.76, 3.18]). HGS was associated with nutrition status (t = 4.13, P < .001; 95% CI [2.02, 5.67]), although it showed poor validity as a single nutrition indicator.CONCLUSIONS:These data indicate that HGS is a more useful functional measure than 5m when added to a hospital nutrition assessment. Determination of HGS cutpoints to identify low strength in acute care patients will promote its use.

Nutrition is an important component of a patient’s overall health, and cases of malnutrition may be more prevalent than realized. This commentary presents a brief overview of an easy-to-use nutrition screening tool created during a Canadian study. In the recent Nutrition Care in Canadian Hospitals (NCCH) Study conducted by the Canadian Malnutrition Task Force, a 45% prevalence of malnutrition on admission was found among 1015 patients admitted to medical and surgical wards of 18 Canadian hospitals. The study was conducted from July 2010 to February 2013 in patients 18 years or older who were admitted to the hospital for more than 2 days. Excluded were those admitted directly to the intensive care unit; obstetric, psychiatry, or palliative units; or medical day units. Malnutrition was independently associated with prolonged length of stay (LOS).1 It is known that malnutrition is also related to detrimental outcomes such as delayed wound healing. Moreover, very few malnourished patients are identified on admission in order to provide prompt nutrition care.2 Nutrition screening remains the process for early identification of patients who are malnourished or at risk for malnutrition. In the hospital setting, nutrition screening should be conducted on admission by the frontline nursing staff.3 The NCCH study included a nursing survey that showed 91% of nurses agreed that 2 or 3 nutrition screening questions could be integrated into patient admission histories.4 An efficient nutrition screening process relies on a simple, valid, and reliable tool. In the NCCH study, the Canadian Nutrition Screening Tool (CNST) was developed (Figure). It initially included 2 questions about weight loss and decreased food intake and the body mass index (BMI) calculation. The first criterion validity and the predictive validity of this tool have been tested in the NCCH study. The Subjective Global Assessment (SGA) was the criterion standard, and the screening tool was completed by the researchers. This first validity assessment of the tool showed promising results: (1) sensitivity, 91.7% (correctly identifies patients at nutrition risk or who are malnourished), and specificity, 74.8% (correctly identifies patients who are not at nutrition risk or malnourished), which indicated good potential of the tool to screen, and (2) the tool could significantly predict clinical outcomes: LOS (P < .001), 30-day readmission (P = .02, odds ratio [OR] = 1.56; 95% confidence interval [CI], 1.07–2.27), and mortality (in hospital or within 30 days of discharge) (P < .001, OR = 5.37; 95% CI, 2.36–12.79).3Figure.: The Canadian Nutrition Screening ToolThe reliability and the second criterion validity of the CNST were assessed in a second study with 150 patients admitted to medical and surgical wards of 3 Canadian hospitals. In this study, the CNST was completed by untrained nursing personnel (n = 160) and 1 nutrition technician to better reflect the real-world hospital setting. To test the interrater reliability of the tool, the CNST was completed by 2 blinded, independent raters for each patient. Reliability results showed a κ coefficient of 0.88 (95% CI, 0.80–0.97), which indicates an almost perfect agreement between the raters. The SGA conducted by the research associates was used to measure the criterion validity of the tool. While using 2 “yes” answers for classifying the patient at nutrition risk, the CNST showed a sensitivity of 73% and a specificity of 86% (rater 1), which is considered adequate performance for a clinical tool. Interestingly, validity results were very similar with or without the inclusion of BMI in the tool. As a result, BMI was removed from the tool to promote ease of use, because calculating the BMI is likely challenging to busy hospital staff.3 Tackling malnutrition in Canadian hospitals requires an interprofessional approach where the first step is nutrition screening. The CNST is the first valid and reliable tool tested by untrained nursing personnel, which represents the reality of a hospital setting. The CNST (Figure) is a simple tool that poses 2 questions, and when the answer is “yes” for both questions, a patient is classified at nutrition risk and will require an evaluation by the dietitian. It is recommended that hospitals include the CNST in the nursing admission questionnaire and the electronic medical record for early recognition of malnourished patients. These steps will help facilitate the appropriate screening and referral process.

Background & aims: Hospital malnutrition has been established as a critical, prevalent, and costly problem in many countries. Many cost studies are limited due to study population or cost data used. The aims of this study were to determine: the relationship between malnutrition and hospital costs; the influence of confounders on, and the drivers (medical or surgical patients or degree of malnutrition) of the relationship; and whether hospital reported cost data provide similar information to administrative data. To our knowledge, the last two goals have not been studied elsewhere.Methods: Univariate and multivariate analyses were performed on data from the Canadian Malnutrition Task Force prospective cohort study combined with administrative data from the Canadian Institute for Health Information. Subjective Global Assessment was used to assess the relationship between nutritional status and length of stay and hospital costs, controlling for health and demographic characteristics, for 956 patients admitted to medical and surgical wards in 18 hospitals across Canada.Results: After controlling for patient and hospital characteristics, moderately malnourished patients' (34% of surveyed patients) hospital stays were 18% (p = 0.014) longer on average than well-nourished patients. Medical stays increased by 23% (p = 0.014), and surgical stays by 32% (p = 0.015). Costs were, on average, between 31% and 34% (p-values < 0.05) higher than for well-nourished patients with similar characteristics. Severely malnourished patients (11% of surveyed patients) stayed 34% (p = 0.000) longer and had 38% (p = 0.003) higher total costs than well-nourished patients. They stayed 53% (p = 0.001) longer in medical beds and had 55% (p = 0.003) higher medical costs, on average. Trends were similar no matter the type of costing data used.Conclusions: Over 40% of patients were found to be malnourished (1/3 moderately and 1/10 severely). Malnourished patients had longer hospital stays and as a result cost more than well-nourished patients. (C) 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

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.

OBJECTIVES:Since malnutrition is common in Canadian hospitals, physicians frequently encounter patients with significantly impaired nutrition status. The objective of this study was to determine physician attitudes and perceptions regarding the detection and management of malnutrition in Canadian hospitals.MATERIALS AND METHODS:A survey based on a previously developed questionnaire that focused on guidelines for nutrition support of hospitalized patients was completed by Canadian physicians working on wards in the 18 hospitals participating in the Canadian Malnutrition Task Force study. Data were analyzed descriptively and according to ward (medical vs surgical) and hospital type (academic vs community).RESULTS:The survey was completed by 428 of the 1220 physicians who were provided with a questionnaire and asked to participate (response rate 35%). While physicians believe that nutrition assessment should be performed at admission (364/419 [87%]), during hospitalization (363/421 [86%]), and at discharge (327/418 [78%]), most felt that this was not being done on a regular basis (admission, 140/423 [33%]; during hospitalization, 175/423 [41%]; at discharge, 121/424 [29%]). Similarly there was a gap between what was perceived to be the ideal management of hospital-related malnutrition and current practices. Physicians felt that the team's nutrition education and use of dietetic resources could be increased, and although their nutrition knowledge was limited, they felt that hospital-associated malnutrition was very relevant to the care they provided.CONCLUSIONS:A multidisciplinary team is needed to address hospital malnutrition, and educational strategies that target physicians are needed to promote better detection and management throughout the hospital stay.

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.

Résumé Objectifs La malnutrition des aînés est un problème répandu dans les hôpitaux et les foyers de soins. Cependant, la pratique du dépistage nutritionnel dans ces milieux est peu connue, particulièrement dans les établissements francophones de soins de santé. Cette étude avait pour objectifs de comparer la situation du dépistage nutritionnel des aînés dans les établissements de soins de santé francophones et anglophones du Nouveau-Brunswick, ainsi que les perceptions et les pratiques des professionnels de la santé. Méthodes Les données sur les paramètres de dépistage ont été puisées directement dans les dossiers médicaux des patients/résidents âgés. Les perceptions et les pratiques de dépistage nutritionnel des professionnels de la santé (médecins, infirmiers, diététistes) ont été recueillies au moyen de questionnaires. Résultats Cinq hôpitaux et 31 foyers de soins de longue durée du Nouveau-Brunswick ainsi que 421 patients/résidents et 457 professionnels de la santé ont participé à l’étude. Des différences significatives quant à la disponibilité des paramètres de dépistage furent observées entre les patients/résidents francophones et anglophones; les francophones bénéficiant moins de certains paramètres de dépistage dont le poids à l’admission, la perte d’appétit et la fraction des repas consommés. Les perceptions des professionnels quant au dépistage nutritionnel varient selon la profession et la langue de l’établissement. Plusieurs obstacles au dépistage nutritionnel sont relevés. Conclusion La disponibilité moindre de paramètres de dépistage dans les milieux francophones et la sous-évaluation de la malnutrition par les médecins et les infirmiers sont des barrières pouvant influencer le dépistage nutritionnel en établissements de soins de santé francophones.

OBJECTIVES:Malnutrition among the elderly is a widespread problem in hospitals and nursing homes. However, data on the practice of nutritional screening in these facilities are limited, particularly in Francophone establishments. This study aimed to compare nutritional screening practices among the elderly in Anglophone and Francophone health care facilities in New Brunswick (NB), as well as perceptions and practices of health care professionals. METHODS:Information on screening parameters was taken directly from elderly patients'/residents' medical records. Health care professionals' (doctors, nurses, dietitians) perceptions and practices of nutritional screening were collected through questionnaires. RESULTS:A total of five hospitals and 31 nursing homes in NB took part in the study. Of these, 421 patients/residents and 457 health professionals participated. Significant differences in the availability of screening parameters were observed between Francophone and Anglophone patients/residents. Certain screening parameters, such as weight at admission, loss of appetite and meal fractions consumed were less available in Francophone patients'/residents' records. In addition, health care professionals' perceptions regarding nutritional screening varied by occupation and language of the establishment. Several barriers to screening were also identified. CONCLUSION:Reduced availability of screening parameters in Francophone establishments and the underestimation of malnutrition in elderly patients/residents by doctors and nurses are barriers that can influence nutritional screening in Francophone health care facilities.

We explored the availability of parameters for a nutrition screening system among elderly people in New Brunswick (NB) health care facilities. Patients aged 65 or older were asked to participate in the study; each participant had been admitted to one of four hospitals or lived in one of six nursing homes. Availability of nutrition screening parameters (weight, height, weight change, serum albumin level, appetite, and food intake record) was assessed by auditing the participants' medical charts. When data were not available, the feasibility of obtaining them was determined. Additional data related to nutrition screening were also obtained. In total, 421 participants were recruited for the study: 140 (33.2%) who lived in nursing homes and 281 (66.8%) who were in hospitals. Parameters needed to conduct nutrition screening, such as weight upon admission, were available for 83.6% of participants; usual weight was available for 43.0%, height for 86.0%, and serum albumin level for 47.5%. Our findings show that basic parameters for nutrition screening are available, and that implementation of a nutrition screening system is feasible for patients in NB health care facilities.