The prevention and reduction of weight loss in an acute tertiary care setting: Protocol for a pragmatic stepped wedge randomised cluster trial (the PRoWL Project)

Background: Malnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital. Methods/Design: A pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient’s body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool. Discussion: Unplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions.Alison L Kitson, Timothy J Schultz, Leslye Long, Alison Shanks, Rick Wiechula, Ian Chapman and Stijn Soene

Effectiveness of interventions for undernourished older inpatients in the hospital setting

In health care today, undernutrition or malnutrition among elderly hospitalised patients is a widespread problem resulting in serious or adverse health outcomes. Psychosocial factors contribute to the risk of inadequate nutrition or undernourishment in older adults.2 Many older patients live on fixed incomes, have reduced access to food (social isolation), have poor knowledge of nutrition, or are dependent on others (caretakers or institutions) for food preparation. They may also suffer from depression, bereavement, dementia, or alcohol use. Undernutrition is, however, generally not recognised in treating elderly patients who are in the hospital system. There is evidence to suggest that this condition delays recovery and has the effect of lowering resistance to medical complications. Indeed, studies have demonstrated there is a link between undernutrition and lengthened hospital stay, mortality and morbidity. Malnourished older patients consult their general practitioners more frequently, are in hospital more often and for longer periods, and have higher complication and mortality rates

Minimising undernutrition in the older patient

Abstract Background: Malnutrition among elderly hospitalised patients is widespread and has been shown to lead to adverse health outcomes. The effectiveness of interventions to minimise undernutrition in elderly inpatients is not well documented. Objectives: To identify the best available practices, in the hospital setting, that minimise undernutrition or the risk of undernutrition, in the acute care patient especially for the older patient. The review will assesses the effectiveness of a range of interventions designed to promote adequate nutritional intake in the acute care setting, with the aim of determining what practices minimise malnutrition in the elderly inpatients. Search strategy: English language articles from 1980 onwards were sought using Medline, Premedline, Cinahl, Austrom-Australasian Medical Index and AustHealth, Embase and Science Citations Index. Selection criteria For inclusion the study had to include an intervention aiming to minimise undernutrition in hospitalised elderly patients aged 65 years or older. All study designs were included. Data collection and analysis: Two independent reviewers assessed the eligibility of each study for inclusion into the review, critically appraised the study quality and extracted data using standardised tools. For each outcome measure results were tabulated by intervention type and discussed in a narrative summary. Results from randomised controlled trials were pooled in meta-analyses where appropriate. Main results: Twenty-nine studies met the inclusion criteria, with a total of 4021 participants. The focus of 15 interventions was the supplying of oral supplements to the participants, six focused on enteral nutrition therapy, four interventions made changes to the foods provided as part of the hospital diet, one included the services of an additional staff member and three incorporated the implementation of evidence-based guidelines. Ten metaanalyses were conducted from which the main findings were: significant improvements in weight status and arm muscle circumferences with an oral supplement intervention, P < 0.05. Reviewers’ conclusions: The findings of the review support the use of oral supplements to minimise undernutrition in elderly inpatients. The results also emphasise the need for more high-quality research using appropriate outcome measures in the area of minimisation of undernutrition, particularly interventions that make alterations to the hospital diet and address support for feeding patients at the ward level. Key words: aged, inpatient, intervention study, malnutrition, meta-analysis, systematic review