Malnutrition in subacute care
thesisposted on 01.03.2017, 02:06 by Collins, Jorja Claire
Malnutrition is a significant problem across all healthcare settings because of its high prevalence and association with adverse outcomes for patients and increased healthcare costs. There is a paucity of research considering subacute patients’ nutritional status and how this changes throughout inpatient stay. Additionally, a stronger evidence base for strategies to prevent and treat malnutrition specifically in this setting is required. This thesis aimed to address these research gaps to contribute to evidence based recommendations for clinical practice, healthcare policy and identify areas for future nutrition research. A series of four related research investigations were conducted. An observational study (n=249) explored change in nutritional status during subacute care. Under usual conditions, nutritional status assessed with the full Mini Nutritional Assessment® improved for 27.7% of participants, did not change for 62.0% and deteriorated for 10.3%, which was associated with discharge to higher level of care. There were inconsistencies in findings using objective indicators and nutrition assessment tools to evaluate change in nutritional status. A systematic literature review identified few (n=10) studies exploring the effect of oral nutrition interventions among subacute patients. There was some evidence in favour of oral nutritional supplements and energy dense meals for increasing dietary intake, but other nutritional and functional outcomes were absent or inconsistent. This prompted the design and evaluation of a novel nutrition intervention integrating a higher energy menu and an enhanced mid-meal delivery. A parallel controlled pilot study (n=122) tested its effects on patient-related outcomes and estimated the cost in comparison to the standard menu and usual foodservice. A complementary process evaluation used qualitative description and theoretical frameworks of behaviour change and implementation research to explore the experiences of foodservice staff (n=15) responsible for delivering the nutrition intervention. It was demonstrated that participants who received the food and service based intervention had greater intake at day 14 of inpatient stay (mean difference (95% CI), 27 (9 – 44) kJ/kg/day, 0.3 (0.0 – 0.5) g protein/kg/day) and no reduction in satisfaction with the foodservice. The additional cost of the intervention was AU$7.47/participant/day. Five themes were identified, describing that implementation of the intervention was influenced by the: foodservice staff, patients, nutrition intervention, environment and implementation process. In particular, foodservice structure, time pressure and patients’ resistance affected perceived sustainability and feasibility of the intervention. Foodservice staff’s knowledge, beliefs and perceptions affected protocol fidelity. Overall this research emphasised the variability in change in nutritional status under usual care or in response to nutrition intervention in the heterogeneous subacute patient group. Adequate multidisciplinary nutritional care, in conjunction with dietetic intervention, are essential to support the nutritional status of all patients throughout subacute inpatient stay. Nursing staff and dietitians need to give greater attention to monitoring patients’ nutritional status during inpatient stay using appropriate tools to detect change. Increased recognition of the role the foodservice system and workforce plays in nutrition care is required. Future clinical and translational research that builds on these findings will assist to shape cost and clinically effective patient care to address malnutrition in subacute care.