Background: Underprovision of food energy within the hospital environment can negatively affect clinical outcomes. Hence, the supply of hospital foods/beverages and the ability to assess their calorie provision is critical. The aim of this study was to directly measure the energy density of foods/beverages supplied to patients by Gold Coast University Hospital (GCUH) foodservice and compare these to caloric values established from nutrition information panels (NIPs) on product packaging. Methods: Bomb calorimetry was used to determine the gross energy density of 58 food/beverage items (similar to 47% of total menu) using standardised procedures. Food items included those from the general menu, in addition to therapeutic menu items. Equivalence between directly measured values and those derived from NIPs was determined by comparing the measured mean and +/- 90% confidence interval (CI) against two pre-defined equivalence bounds (i.e., +/- 10% NIP value [consensus criteria] and +/- 20% NIP value [United States Food and Drug Administration (US FDA) criteria]). Caloric values from NIPs were considered equivalent to measured values when the 90% CI of the measured values fell within these thresholds. Results: Overall, 34 (59%) and 19 (33%) items had measured energy density values not equivalent to those from product NIPs according to the consensus and US FDA thresholds, respectively. When employing the US FDA criteria, 12 (21%) items contained a higher calorie density than that established from the label, while seven (12%) items were lower. While non-equivalent items were identified across all therapeutic menus, food labels from items exclusively prepared for the smooth-pureed menu were particularly inaccurate (similar to 60% non-equivalency). Conclusion: This study found a discrepancy between energy density that was directly measured and that derived from manufacturers' NIPs for many foods and beverages supplied via a hospital foodservice. Given the importance of accurate energy provision for hospitalised patients, this level of inaccuracy is concerning and may warrant a revision of food labelling procedures for items supplied in hospital settings.

Standardised bomb calorimetry methods (sample preparation and combustion techniques) are essential to accurately quantify the caloric value of food and beverages, yet no protocols exist. This study evaluated the influence of various methodological approaches to establish those most reliable for beverage calorie determination. Equivalence testing was used to verify if differences between means (and 90% CI) were within established margins. Standardised test beverages included a low- and high-fat version. Part A determined a coefficient of variation for establishment of equivalence margins; Part B assessed differences between calorimetry methods. Elements evaluated included: initial sample homogenisation, sample dehydration, post-dehydration homogenisation, sample presentation, sample weight, combustion pressure, and sample storage. Aspects that may be critical to reliably determine the gross energy content of beverages include initial agitation, dehydration level (%), post-dehydration homogenisation, pre-combustion sample presentation and sample storage time. Oven-dried high-fat samples had the largest deviations from equivalence, particularly those not agitated prior to dehydration or combustion, or not dehydrated to a constant weight. Some methods do not exhibit differences, such as low-fat sample pre- and post-dehydration homogenisation, dehydration method and temperature, sample weight, and combustion pressure. These findings identify critical aspects of sample preparation and combustion for the caloric determination of beverages.

Malnutrition risk screening is crucial to identify at-risk patients in hospitals; however, screening rates can be suboptimal. This study evaluated the feasibility, acceptability, and potential cost-effectiveness of patient-led, technology-assisted malnutrition risk screening. A prospective multi-methods study was conducted in a 750-bed public hospital in Australia. Patients were recruited from seven wards and asked to complete an electronic version of the Malnutrition Screening Tool (e-MST) on bedside computer screens. Data were collected on feasibility, acceptability, and cost. Feasibility data were compared to pre-determined criteria on recruitment (≥50% recruitment rate) and e-MST completion (≥75% completion rate). Quantitative acceptability (survey) data were analyzed descriptively. Patient interview data were analyzed thematically. The economic evaluation was from the perspective of the health service using a decision tree analytic model. Both feasibility criteria were met; the recruitment rate was 78% and all 121 participants (52% male, median age 59 [IQR 48-69] years) completed the e-MST. Patient acceptability was high. Patient-led e-MST was modeled to save $3.23 AUD per patient and yield 6.5 more true malnutrition cases (per 121 patients) with an incremental cost saving per additional malnutrition case of 0.50 AUD. Patient-led, technology-assisted malnutrition risk screening was found to be feasible, acceptable to patients, and cost-effective (higher malnutrition yield and less costly) compared to current practice at this hospital.

Standardised bomb calorimetry methods are essential to accurately quantify the gross energy within food and beverages, yet no accepted protocols exist. The objective of this review was to synthesise literature on food and beverage sample preparation methods used for conducting bomb calorimetry. This synthesis enhances our understanding of the extent to which methodological variances may currently affect estimates of the caloric values of dietary items. Five electronic databases were searched for peer reviewed literature on food and beverage energy measurement via bomb calorimetry. Data were extracted on seven identified methodological themes, including: (1) initial homogenisation, (2) sample dehydration, (3) post-dehydration homogenisation, (4) sample presentation, (5) sample weight, (6) sample frequency, and (7) equipment calibration. A tabular and narrative approach was used to synthesise the data. Studies that specifically explored the impact of any methodological variance on the energy derived from foods and/or beverages were also considered. In total, 71 documents describing food and beverage sample preparation techniques and processes used for bomb calorimetry were identified. Only 8% of studies described all seven identified sample preparation and calibration processes. The most frequent approaches used included: initial homogenisation – mixing or blending (n = 21); sample dehydration – freeze drying (n = 37); post-dehydration homogenisation – grinding (n = 24); sample presentation – pelletisation (n = 29); sample weight – 1g (n = 14); sample frequency – duplicate (n = 17); and equipment calibration – benzoic acid (n = 30). The majority of studies that have measured food and beverage energy via bomb calorimetry do not describe sample preparation and calibration methods in detail. The extent to which different sample preparation processes influence the energy derived from food and beverage items is yet to be fully elucidated. Use of a bomb calorimetry reporting checklist (described within) may assist with improving the methodological quality of bomb calorimetry studies.

Ensuring inpatients with dysphagia receive and consume the correct texture-modified diet and thickened fluid prescriptions is challenging, and errors can result in significant complications for patients and increased costs to hospitals. The aim of this study was to investigate underlying factors that help or hinder receipt and consumption of correct dietary prescriptions for people with dysphagia in the hospital setting then implement and evaluate a range of strategies to address identified issues. A mixed-methods study design, using an integrated knowledge translation approach, was conducted in three phases. In Phase 1, clinical incident data (i.e., documented incidents of diet/fluid errors, with errors defined as the provision or consumption of any food/fluid not appropriate for a patient's dietary prescription) were analyzed, and staff, patients, and family members were interviewed using the Theoretical Domains Framework to identify factors contributing to errors. In Phase 2, health professionals assisted with the development and implementation of interventions targeted at micro (patient/family), meso (staff), and macro (organizational) levels to address factors identified in Phase 1. In Phase 3, outcomes including the change in number of dietary clinical incidents pre- to post-intervention, meal accuracy error rates from mealtime audits post-intervention, and follow-up interviews were evaluated using quantitative and qualitative measures. Post-intervention, there was a 50% reduction in clinical incidents, and a 2.3% meal accuracy error rate was observed. Staff reported most interventions were acceptable and feasible within their workload, although some interventions were not well embedded in everyday practice. This study highlights the value in using an integrated knowledge translation approach to inform tailored interventions targeting improved dietary accuracy in the hospital setting.

ABSTRACT Background: People with aphasia (PWA) may have difficulty accessing information in their environment, including the hospital setting. Prior research has recommended the use of aphasia-friendly text-formatting principles, including using graphics when providing information to PWA. There is limited research into the impact of using such principles for hospital menus. Aims: To evaluate the impact of an aphasia-friendly menu with assistance from a Speech Pathology Therapy Assistant (SPTA) compared with usual hospital menus in PWA on 1) oral intake, 2) self-reported involvement and 3) ease in meal ordering and 4) meal preference. The secondary aim was to investigate the feasibility of implementing the aphasia-friendly menu by exploring staff and caregiver experiences regarding the perceived barriers and facilitators to its implementation, along with time required to assist PWA to order meals. Methods and procedures: This embedded mixed-methods design study was piloted at two hospitals in Queensland, Australia. Hospital inpatients with aphasia due to non-progressive neurological damage, their caregivers and SPTAs participated. Each day PWA received either the 1) aphasia-friendly menu: professional photos of menu items on an iPad with SPTA support, or 2) usual hospital menus provided in random order for up to 15 days during their inpatient stay. Each day, oral intake was measured and PWA rated their perceived involvement and ease with ordering from the menu provided on a 10-point Likert scale. SPTAs recorded time assisted using the menus and reported barriers and facilitators to the use of the menus daily. At the completion of the pilot, the PWA’s preferred menu type was recorded, SPTAs participated in a focus group and caregivers completed a questionnaire. Outcomes and results: There was no significant difference in oral intake between menu types. PWA rated the aphasia-friendly menu more favourably for involvement (p = 0.004) and ease (p = 0.015) when ordering. Nineteen out of 20 PWA who provided a response preferred the aphasia-friendly menu (p = 4 × 10−5). SPTA comments were analysed using qualitative content analysis and outlined their perceived barriers and facilitators to the use of aphasia-friendly menus, experience with usual menus and recommendations for future directions. Meal ordering was approximately 4.4 minutes longer with PWA using the aphasia-friendly menus. Conclusions: The aphasia-friendly menu was positively perceived by PWA, caregivers and SPTAs and may be a viable and preferred option for PWA when ordering food in hospitals. Staff are encouraged to consider the contextual barriers and facilitators identified in the pilot, prior to implementation of such aphasia-friendly menus.

Empowering patients to participate in nutrition care during hospitalisation may improve their dietary intakes and associated outcomes. This study tested the acceptability and feasibility of a technology-based intervention to engage hospital patients in nutrition care at a tertiary teaching hospital in Australia. The hospital used an electronic foodservice system (EFS), by which patients ordered meals via bedside computers. Adults at nutritional risk received the nutrition technology (NUTRI-TEC) intervention, involving nutrition assessment, education on nutrition requirements and training on using the EFS to enter food intakes and monitor nutrition goals. Acceptability was assessed using patient satisfaction and engagement surveys. Feasibility was assessed by evaluating the intervention delivery/fidelity and patient recruitment/retention. Patients’ dietary intakes were observed daily to indicate the intervention’s effects and assess the accuracy of the patient-recorded intakes. Descriptive and inferential statistics were used to analyse the data. Of the 71 patients recruited, 49 completed the study (55% male; median (IQR) age 71 (65–78) years; length of stay 10 (7–14) days). Patient satisfaction with NUTRI-TEC was high. Intervention delivery and fidelity targets were met but recruitment (≥50%) and retention (≥75%) targets were not; only 31% of patients agreed to participate and 69% completed the study (mostly due to unexpected/early discharge). Patient- and researcher-recorded dietary intakes correlated strongly, indicating patients can record food intakes accurately using technology. This study highlights the important role technology is likely to play in facilitating patient engagement and improving care during hospitalisation.

Background Nutrition is vital for health and recovery during hospitalisation, however most patients fail to meet minimum dietary requirements and up to 50% of patients are malnourished in hospital. When patients participate in nutrition care, their dietary intakes are improved. Advances in health information technology (HIT) have broadened the ways by which patients can participate in care. Our team has developed an innovative, HIT-based intervention (called NUTRI-TEC; engaging patients in their nutrition care using technology), facilitating patient participation in their nutrition care in hospital. This paper aims to describe the systematic and iterative process by which the intervention was developed. Methods NUTRI-TEC development was informed by the Medical Research Council guidance for developing complex interventions and underpinned by theoretical frameworks and concepts (i.e. integrated knowledge translation and patient participation in care), existing evidence and a rigorous program of research. The intervention was co-developed by the multidisciplinary research team and stakeholders, including health consumers (patients), health professionals and industry partners. We used an iterative development and evaluation cycle and regularly tested the intervention with hospital patients and clinicians. Results The NUTRI-TEC intervention involves active patient participation in their nutrition care during hospitalisation. It has two components: 1) Patient education and training; and 2) Guided nutrition goal setting and patient-generated dietary intake tracking. The first component includes brief education on the importance of meeting energy/protein requirements in hospital; and training on how to use the hospital’s electronic foodservice system, accessed via bedside computer screens. The second component involves patients recording their food intake after each meal on their bedside computer and tracking their intakes relative to their goals. This is supported with brief, daily goal-setting sessions with a health care professional. Conclusions NUTRI-TEC is a HIT intervention designed to enable patient participation in their nutrition care in hospital. As research on HIT interventions to engage patients in health care in the hospital setting is in its infancy, and as gaps and inconsistencies in the development of such interventions exist, this paper will inform future development of HIT-based interventions in the hospital setting.

Hospital-acquired malnutrition is a significant issue with complex aetiology, hence nutrition interventions must be multifaceted and context-specific. This paper describes the development, implementation and process evaluation of a complex intervention for improving nutrition among medical patients in an Australian hospital. An integrated knowledge translation (iKT) approach was used for intervention development, informed by previous research. Intervention strategies targeted patients (via a nutrition intake monitoring system); staff (discipline-specific training targeting identified barriers); and the organisation (foodservice system changes). A process evaluation was conducted parallel to implementation assessing reach, dose, fidelity and staff responses to the intervention using a mixed-methods design (quantitative and qualitative approaches). Staff-level interventions had high fidelity and broad reach (61% nurses, 93% foodservice staff and all medical staff received training). Patient and organisation interventions were implemented effectively, but due to staffing issues, only reached around 60% of patients. Staff found all intervention strategies acceptable with benefits to practice. This study found an iKT approach useful for designing a nutrition intervention that was context-specific, feasible and acceptable to staff. This was likely due to engagement of multiple disciplines, identifying and targeting specific areas in need of improvement, and giving staff frequent opportunities to contribute to intervention development/implementation.

Malnutrition is a common and complex problem in hospitals. This study used an integrated knowledge translation approach to develop, implement, and evaluate a multifaceted, tailored intervention to improve nutrition care, delivery, and intake among acute medical inpatients. This observational, pre-post study was conducted in a medical ward at a public hospital in Australia. The intervention was co-developed with key stakeholders and targeted three levels: individuals (nutrition intake magnets at patient bedsides), the ward (multidisciplinary hospital staff training), and the organisation (foodservice system changes). Observational data were collected pre- and post-intervention on patient demographics, food intakes, and the mealtime environment. Data were entered into SPSS and analysed using descriptive and inferential statistics. Ethical approval was gained through the hospital and university ethics committees. A total of 207 patients were observed; 116 pre- and 91 post-intervention. After intervention implementation, patients' mean energy and protein intakes (in proportion to their estimated requirements) were significantly higher and the number of patients eating adequately doubled (p < 0.05). In summary, a multifaceted, pragmatic intervention, tailored to the study context and developed and implemented alongside hospital staff and patients, seemed to be effective in improving nutrition practices and patient nutrition intakes on an acute medical ward.

Background: People with aphasia (PWA) experience difficulties communicating within our health care system and the National Stroke Guidelines recommend using aphasia-friendly principles to enhance communication access. Inpatient hospital menus are problematic for PWA and provide an opportunity to apply aphasia-friendly principles. This has had limited attention in the literature. Aims: To determine if the use of an aphasia-friendly photo menu tool changed PWA’s behaviours and perceptions related to meal ordering compared to usual menus in the inpatient hospital setting. Additionally, to explore staff perceptions regarding enablers and barriers to its use. Method: Thirty PWA (average age 70.5 years, ∼ 3 weeks post onset), approximately thirteen caregivers and five Speech Pathology Therapy Assistants (SPTAs) participated. Using a random alternating treatment design, PWA ordered their meals daily using either the aphasia-friendly menu with SPTA help or the usual hospital menu. Daily oral intake was recorded and participants reported on their preferred menu type, perceptions of ease and level of participation. Caregivers and SPTA perceptions of the menus were explored through questionnaires and a focus group respectively. Results: Preliminary results suggested that 18 out of 27 PWA preferred the aphasia-friendly menu, with increased food intake for some participants compared to the usual menu. Caregiver perceptions were positive and SPTAs provided patient and environmental considerations for implementation. The final results will be presented. Conclusion: An aphasia-friendly menu may be a viable and preferred option for PWA when ordering food in hospitals. Practical considerations identified regarding continued use of the aphasia-friendly menu will be discussed.